Effect of Permanent Right Internal Mammary Artery Closure on Coronary Collateral Function and Myocardial Ischemia

Michael Stoller, Christian Seiler, Michael Stoller, Christian Seiler

Abstract

Background: The objective of this study is to test the effect of permanent right internal mammary artery device closure on coronary collateral function and myocardial ischemia.

Methods and results: This was a prospective, open-label clinical trial in 50 patients with coronary artery disease. The primary study end point was coronary collateral flow index as obtained during a 1-minute proximal right coronary artery (RCA) and left coronary artery balloon occlusion at baseline before and at follow-up examination 6 weeks after distal right internal mammary artery device closure. Collateral flow index is the ratio between simultaneously recorded mean coronary occlusive pressure divided by mean aortic pressure, both subtracted by central venous pressure. Secondary study end points were fractional flow reserve during vessel patency, the quantitative intracoronary ECG ST-segment elevation, and angina pectoris during the same 1-minute coronary occlusion. Collateral flow index in the untreated RCA and left coronary artery changed from 0.071±0.082 at baseline to 0.132±0.117 (P<0.0001) at follow-up examination and from 0.106±0.092 to 0.081±0.079 (P=0.29), respectively. RCA fractional flow reserve increased significantly (P=0.0029) from baseline to follow-up examination, despite deferral of coronary intervention in all patients. There was a decrease in intracoronary ECG ST-elevation during RCA occlusion from baseline to follow-up examination (P=0.0015); it did not change in the left coronary artery. Angina pectoris during RCA occlusion tended to occur in fewer patients at follow-up versus baseline examination (P=0.06).

Conclusions: Permanent right internal mammary artery device closure seems to augment extracardiac ipsilateral coronary supply to the effect of reducing ischemia in the dependent myocardial region.

Clinical trial registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02475408.

Keywords: arteriogenesis; collateral circulation; coronary circulation; internal mammary artery; myocardial ischemia.

© 2017 The Authors.

Figures

Figure 1.
Figure 1.
A, Anteroposterior angiogram of the truncus brachiocephalicus (site of the catheter tip) depicting the right internal mammary artery (RIMA) with its pericardiophrenic branch (arrow) taken at the baseline examination. B, RIMA angiography of the same patient as in A taken during follow-up examination. Simultaneous occlusion of the distal RIMA (by vascular occlusion device) and the ostial right coronary artery (RCA, by angioplasty balloon). The pericardiophrenic branch (arrow) and the other RIMA branches are larger than those at baseline (A).
Figure 2.
Figure 2.
Left, Simultaneous recording of phasic and mean aortic pressure (Pao, red curve), ostial right coronary artery (RCA) occlusive pressure (Poccl, black curve), central venous pressure (CVP, blue curve), and intracoronary ECG (bottom, black curve) as obtained during baseline examination. Coronary balloon occlusion starts at ≈2 seconds on the time scale (horizontal axis) and lasts until 79 seconds (up-slope of Poccl). Pao, Poccl, and CVP are taken as temporal mean values between the arrowheads: collateral flow index, CFI=(Poccl−CVP)/(Pao−CVP)=(18.8−12.5)/(92.6−12.5)=0.079. Right, Simultaneous recording of phasic and mean Pao, ostial RCA Poccl, CVP, and intracoronary ECG during follow-up examination in the same patient as in the left panel. CFI=0.190.
Figure 3.
Figure 3.
Individual values of collateral flow index (CFI, vertical axis) as obtained at baseline and follow-up examination in the right and left coronary artery. Error bars indicate mean values and standard deviation.
Figure 4.
Figure 4.
Left, Individual values of fractional flow reserve (FFR, vertical axis) as obtained at baseline and follow-up examination in the right and left coronary artery. Error bars indicate mean values and standard deviation. Right, Individual values of intracoronary ECG ST-segment shift (i.c. ECG ST-segment shift, vertical axis; ST-elevation as positive values) as obtained at baseline and follow-up examination in the right and left coronary artery. Error bars indicate mean values and standard deviation.
Figure 5.
Figure 5.
Number of patients with and without angina pectoris (vertical axis) during the 1-minute proximal right coronary artery (RCA) and left coronary artery (LCA) balloon occlusions at baseline and follow-up examination, which were performed for simultaneous pressure and intracoronary ECG measurements (see also Figure 2).

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