Ischemia guided myocardial revascularization

Ischemia guided myocardial revascularization

Ischemia guided myocardial revascularization is an important aspect to be considered when myocardial revascularization is undertaken in the absence of significant symptoms. Disabling symptoms are often recognized as a definite reason for myocardial revascularization. In the absence of significant symptoms, unequivocal demonstration of ischemia would be the main reason for revascularization. The role of stress testing is to demonstrate ischemia and thereby the need for coronary angiography and revascularization if the vascular anatomy is suitable.

Myocardial perfusion imaging is often considered as the gold standard for demonstration of ischemia. This is because it gives the region of ischemia in addition to documentation of the severity of ischemia. In multi-vessel disease and post infarction scenarios, this may help in deciding which vessel to treat and which vessel to leave alone, especially in the presence of chronic total occlusions.

Fractional flow reserve or FFR, estimated using Doppler guide wires under maximal hyperemia induced by adenosine injections or infusions is a popular modality for ischemia guided myocardial revascularization [1]. Various protocols for FFR have been developed including methods for assessing the significance of multiple stenotic lesions in the same vessels and the influence of stenoses in branch vessels on the parent vessel. Unless absolute care is taken in ensuring maximal hyperemia and in the finer details of measurement techniques, FFR values can also give erroneous guidance.

Reference

  1. Tonino PA, De Bruyne B, Pijls NH, Siebert U, Ikeno F, van’ t Veer M, Klauss V, Manoharan G, Engstrøm T, Oldroyd KG, Ver Lee PN, MacCarthy PA, Fearon WF; FAME Study Investigators. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009; 360:213–224.