From a cellular standpoint, the term ‘myocardial viability’ refers to a myocyte that has no irreparable damage. From a clinical standpoint, it refers to areas with myocardial contractile dysfunction at rest that are expected to improve with correct revascularization.
There are specific vessel ischemia and viability indexes that may help identify hibernation areas that could be treated. Different tests derived from this, such as the coronary wave intensity analysis (cWIA) that simultaneously uses pressure and Doppler to measure energy flow in myocardial perfusion, which can be done via antegrade waves (from the aorta ) or retrograde waves (from microcirculation), such as the backward compression wave (BCW).
This study aims at researching whether cWIA can accurately determine viability on patients with stable ischemic heart disease who receive optimal medical treatment (with or without revascularization).
Enrolled patients included patients from UK centers with ejection fraction ≤40% and extensive coronary artery disease, according to the British Cardiovascular Interventional Society. Exclusion criteria were acute coronary syndrome within 4 weeks, contraindication for cardiac magnetic resonance (CMR), severe valvular heart disease, and hard-to-assess anatomies (total occlusion or severe lesions). Measurements were taken using Combowire or Philips Volcano guidewires.
Forty patients were recruited. Sixty one vessels were studied. Median stenosis was 72%. Baseline echocardiography and LGE-CMR were performed in all participants. Myocardial viability was observed in 50 % of the cases. Based on echocardiogram results, the change in wall motion score index (WMSI) was -0.75 (-0.55 to -1.13) in viable territories versus 0 in nonviable territories (P ≤ 0.001).
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BCW had good overall accuracy for the prediction of viability (area under the curve = 0.812) with a -2500 W m-2 s-1 threshold. Compared with a viability index validated as the scar area via LGE-CMR, BCW had a similar area under the curve (P = 0.588).
A multivariate analysis demonstrated that BCW and enhanced medical treatment were the only predictors of functional recovery during follow-up.
Conclusions
In the recently published REVIVED-BCIS2 trial, viability-guided angioplasty (detected via CMR or dobutamine stress echo) did not improve outcomes for stable patients when compared with optimal medical therapy alone.
However, the study published by Ryan et al. highlights vessel-driven invasive analysis (instead of a region-driven one). This study also demonstrates that there are indexes with the appropriate amount of sensitivity to allow for the assessment of viability, which can be useful when combined with coronary angiography during treatment. The long-term clinical consequences of this treatment on such difficult disease are yet to be observed during the follow-up period.
Dr. Omar Tupayachi.
Member of the editorial board of SOLACI.org.
Original Title: Coronary Wave Intensity Analysis as an Invasive and Vessel-Specific Index of Myocardial Viability.
Reference: Ryan M, De Silva K, Morgan H, O’Gallagher K, Demir OM, Rahman H, Ellis H, Dancy L, Sado D, Strange J, Melikian N, Marber M, Shah AM, Chiribiri A, Perera D. Coronary Wave Intensity Analysis as an Invasive and Vessel-Specific Index of Myocardial Viability. Circ Cardiovasc Interv. 2022 Dec;15(12):e012394. doi: 10.1161/CIRCINTERVENTIONS.122.012394. Epub 2022 Dec 20. PMID: 36538582; PMCID: PMC9760472.
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