In Vivo Validation of a Novel Computational Approach to Assess Microcirculatory Resistance Based on a Single Angiographic View

Yongzhen Fan, Simone Fezzi, Pengcheng Sun, Nan Ding, Xiaohui Li, Xiaorong Hu, Shuang Wang, William Wijns, Zhibing Lu, Shengxian Tu, Yongzhen Fan, Simone Fezzi, Pengcheng Sun, Nan Ding, Xiaohui Li, Xiaorong Hu, Shuang Wang, William Wijns, Zhibing Lu, Shengxian Tu

Abstract

(1) Background: In spite of the undeniable clinical value of the index of microvascular resistance (IMR) in assessing the status of coronary microcirculation, its use globally remains very low. The aim of this study was to validate the novel single-view, pressure-wire- and adenosine-free angiographic microvascular resistance (AMR) index, having the invasive wire-based IMR as a reference standard. (2) Methods: one hundred and sixty-three patients (257 vessels) were investigated with pressure wire-based IMR. Microvascular dysfunction (CMD) was defined by IMR ≥ 25. AMR was independently computed from the diagnostic coronary angiography in a blinded fashion. (3) Results: AMR demonstrated a good correlation (r = 0.83, p < 0.001) and diagnostic performance (AUC 0.94; 95% CI: 0.91 to 0.97) compared with wire-based IMR. The best cutoff value for AMR in determining IMR ≥ 25 was 2.5 mmHg*s/cm. The overall diagnostic accuracy of AMR was 87.2% (95% CI: 83.0% to 91.3%), with a sensitivity of 93.5% (95% CI: 87.0% to 97.3%), a specificity of 82.7% (95% CI: 75.6% to 88.4%), a positive predictive value of 79.4% (95% CI: 71.2% to 86.1%) and a negative predictive value of 94.7% (95% CI: 89.3% to 97.8%). No difference in terms of CMD rate was described among different clinical presentations. (4) Conclusions: AMR derived solely from a single angiographic view is a feasible computational alternative to pressure wire-based IMR, with good diagnostic accuracy in assessing CMD.

Keywords: angiography-derived physiology; coronary physiology; coronary pressure and flow; functional coronary angiography; ischemia with non-obstructed coronary artery disease; microvascular dysfunction; myocardial microcirculation; personalized invasive therapy in coronary artery disease.

Conflict of interest statement

ST is the co-founder of Pulse Medical, and reports research grants and consultancy from Pulse Medical. WW reports grants and consulting fees from MicroPort, outside the submitted work, and is medical advisor of Rede Optimus and co-founder of Argonauts, an innovation facilitator. All other authors report no competing interests.

Figures

Figure 1
Figure 1
Correlation and the linear regression between AMR and IMR. AMR values (y axis) showed good correlation (r = 0.83, p < 0.001) with IMR (x axis). The red dotted line represents the 95% CI of the linear regression equation that was quantified as AMR = 0.90 + 0.07 × IMR. AMR, angio-derived microcirculatory resistance; IMR, index of microvascular resistance.
Figure 2
Figure 2
Receiver-operating characteristic curve analysis of AMR for identifying IMR ≥ 25U. AMR, angio-derived microcirculatory resistance; IMR, index of microvascular resistance.
Figure 3
Figure 3
Sensitivity and specificity of AMR in different vessel types and clinical presentations. LAD, left anterior descending artery; NSTEMI, non-ST-segment elevation myocardial infarction; SA, stable angina; STEMI, ST-segment elevation myocardial infarction; UA, unstable angina.
Figure 4
Figure 4
Reproducibility of AMR analysis. Correlation (A) and agreement (B) of AMR analyzed by two blinded investigators.
Figure 5
Figure 5
Derivation of coronary microvascular resistance from coronary angiography. An illustrative case-example of integrated angiography-derived epicardial and microvascular physiology assessment in a patient presenting with unstable angina: values of the pressure-wire thermodilution-derived index of microvascular resistance (IMR) and angio-derived microcirculatory resistance (AMR) index showed concordance and good agreement. AMR, angio-derived microcirculatory resistance; FFR, fractional flow reserve; IMR, index of microvascular resistance; QFR, quantitative flow ratio.

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