Index of Microcirculatory Resistance Measured during Intracoronary Adenosine-Induced Hyperemia

Irene Santos-Pardo, Patrik Alström, Nils Witt, Irene Santos-Pardo, Patrik Alström, Nils Witt

Abstract

Background: The index of microcirculatory resistance is an invasive measure of coronary microvascular function that has to be calculated during maximal hyperemia, classically achieved with intravenous adenosine (IV). The aim of this study was to evaluate the use of intracoronary (IC) adenosine for the calculation of IMR.

Methods and results: 31 patients with stable coronary artery disease were included in the study. Coronary pressure and thermodilution measurements were obtained at rest and during maximal hyperemia using a pressure-temperature sensor-tipped coronary guidewire. Duplicate measurements were performed using first IC and then IV adenosine. Dispersion of transit times was comparable for IC and IV adenosine. IMR values based on IC vs IV adenosine showed a high level of agreement and an intraclass correlation coefficient of 0.90. Applying an upper normal limit of 25, misclassification of IMR using IC adenosine was seen in just one patient in whom IC adenosine resulted in a lower value. A simplified procedure based on a single bolus dose of saline did not change the level of agreement or the rate of misclassification.

Conclusions: We found an excellent agreement between IMR values measured during hyperemia induced by IC as compared to IV adenosine. The use of IC adenosine may facilitate invasive assessment of microvascular function and is potentially time- and cost-saving with less patient discomfort as compared to IV infusion. The trail is registered with NCT03369184.

Conflict of interest statement

The authors declare that there are no conflicts of interest regarding the publication of this paper.

Copyright © 2020 Irene Santos-Pardo et al.

Figures

Figure 1
Figure 1
Practical setup for the measurement of IMR with IC adenosine. (a) In order to facilitate administration of IC adenosine and repeated bolus injections of saline, a closed system with a three-way stopcock was used to connect the manifold to a reservoir bag with heparinized saline and a 3 cc syringe, leaving the third connection for administration of IC adenosine. (b) Hyperemia was induced by IC administration of adenosine followed by a quick switch of the three-way stopcock in the direction of the saline reservoir and syringe. (c) Thermodilution curves were obtained by briskly injecting 3 ml of room temperature saline through the guiding catheter. Hyperemia was monitored by visual assessment of the Pd/Pa ratio throughout the procedure. Administration of IC adenosine was repeated if considered necessary to maintain maximal hyperemia. (d) The panel shows the position of the wire's thermistor/pressure sensor in the distal two-thirds of the coronary vessel. The temperature drop following a saline bolus injection is registered by the guide wire shaft as well as the tip sensor, triggering measurement of mean transit time. Abbreviations: IMR, index of microcirculatory resistance; IC, intracoronary adenosine.
Figure 2
Figure 2
Bland Altman diagram for the primary analysis. Legend: Agreement between IMR obtained with IC compared to IV adenosine. Abbreviations: IMR, index of microcirculatory resistance; IC, intracoronary adenosine; IV, intravenous adenosine; SD, standard deviation.
Figure 3
Figure 3
Scatter Plot representing IMR values measured with IC and IV adenosine and their relationship with the cutoff value for each subject. Legend: IMR values higher than 25 are considered pathologic. Abbreviations: IC, intracoronary adenosine; IV, intravenous adenosine; IMR, index of microcirculatory resistance.
Figure 4
Figure 4
Scatter Plot representing IMR calculated with the transit time value obtained from the first injection of saline during IC adenosine-induced hyperemia as compared to the IMR value obtained with Tmn during IV adenosine. Legend: IMR higher than 25 is considered pathologic. Abbreviations: IMR, Index of Microcirculatory Resistance; Tmn, mean transit time; IC, intracoronary adenosine; IV, intravenous adenosine.
Figure 5
Figure 5
Coronary pressure and thermodilution measurements in CoroFlow™ Software (Coroventis Research, Uppsala, Sweden). Legend: Thermodilution measurements performed in the right coronary artery using intracoronary adenosine to achieve hyperemia.

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