Correlation of Quantitative Angiographic Parameters with Changes in Left Ventricular Diastolic Function After Angioplasty of the Left Anterior Descending Coronary Artery Wing-Hung Leung, MB, MRCP, and Chu-Pak Lau, MD
This study evaluates the changes in left ventrkuiar (LV) diastolk filling after penwtaneous transhmlinal coronaryangkpiastyandthereiationof such changes to quantMfve angiographic measurements of the sevedty of coronary narrowings. Puked Doppkr echecardiographic measurements were performed in 40 patiis with ringle left anterior descending artefy narrowing before, and 10 and 30 days after angioplasty. Minimal luminal diameter and percent diameter stenosis of coromuylesionsweremeasuredby computer-assisted quantitation. The ratio of early to late diastolic flow velocities (E/A ratio), time veiocity integrai of eariy diastolk fi#ing period (Ei) and the ratio of early and late diastdk filling periods (Ei/Ai ratio) increased gradually after angioplasty. Minimal lumi~l diameter correlated signifkantiy with the percent changes in E/A ratio (r = 0.59 at 10 days, r = 0.57 at 30 days), Ei (r = OS3 at 10 days, r = 0.55 at 30 days) and Ei/Ai ratio (r = 0.41 at 10 days, r = 0.49 at 30 days). Percent diameter stenosis showed overall weaker convrlations than minimal diameter with the percent changes in E/A ratio (r = 0.39 at 10 days, r = 0.32 at 30 days) and Ei (r = 0.36 at 10 days, r = 0.31 at 30 days). Thus, l.V diastdic fiMng improves serially after coronary angioplasty in patients with l-vessel disease. The magnitude of improvement in diastdic filling correlates better with midmal iuminal diameter than percent diameter stenosis. Therefore, minimal luminal diameter is a better predktor of changes in Doppler transmitral flow parameters after angioplasty than percent diameter stenosis. (Am J Cardid 1991;67:1061-1066)
ecently, pulsed Doppler echocardiography has been shown to be useful in evaluating left ventricular (LV) diastolic filling dynamics because Doppler-derived transmitral flow velocities reflect the rate of LV volume change.le5By using such noninvasive Doppler techniques, abnormal LV diastolic function has been found in patients with ischemic heart disease,6-9LV hypertrophy,lO acpte cardiac allograft rejection, I l diabetic cardiomyopathy,l 2 doxorubicin cardiotoxicity l 3 and connective tissue diseases.14,15A previous study showed that Doppler-derived LV diastolic filling abnormalities improved within 2 days after percutaneous transluminal coronary angioplasty and continued to improve up to 9 days.16However, it remains unknown whether the improvement wiU continue in longer term. Although quantitative angiographic measurementshave been found to correlate with impaired LV systolic function,” there is no study to date to assessthe relation betweenquantitative angiographic variables and LV diastolic dysfunction. The present study determines the temporal changesin Doppler-derived indexes of LV diastolic filling up to 30 days after angioplasty in patients with l-vessel coronary artery disease.In addition, the relation betweenthese changes in LV diastolic function and quantitative angiographic measurementsof narrowing severity was evaluated.
R
METHODS
Patients: Forty-five consecutivepatients with stable exertional angina pectoris were considered. All were candidates for angioplasty of a significant (>75% diameter stenosis)isolated proximal left anterior descending artery narrowing. Patients with total occlusion of the left anterior descendingartery, heavily calcified lesions or extensivecollateral arteries were excluded. Patients with atria1 fibrillation, valvular heart disease,congenital heart disease,cardiomyopathy, systemic hyperFrom the Cardiology Divisions, Stanford University School of Medi- tension, history of acute myocardial infarction, and cine, Stanford, California and the Department of Medicine, University of Hong Kong, Hong Kong. Manuscript received November 9, 1990; reduced angiographic or echocardiographic LV ejection revised manuscript received January 15, 1991, and accepted January fraction (60%) were also excluded. Three patients 21. were excluded because of unsatisfactory Doppler reAddress for reprints: Wing-Hung Lung, MD, Cardiology Division, Falk Cardiovascular Research Building, Stanford University cordings, 2 because of inadequate coronary angiograms. Hence, the study group consistedof 40 patients Medical Center, Stanford, California 94305. ANGlOGRAPHIC MEASUREMENTS AND DIASTOLIC FILLING
1061
(31 men and 9 women aged 40 to 69 years [mean age subsequent analysis. Catheters of known diameters f standard deviation 58 f 121). were used for calibration.19 Cardacm&WdaUmand Doppler echocardiography: Doppler examination -mW=b: was performed at baselinewithin 48 hours before angiSelective coronary arteriography was performed using the percutaneous femoral approach. Coronary angio- oplasty and was repeated 10 and 30 days after angiograms were obtained after administration of intracoro- plasty. Calcium antagonistsand ~-blocking agentswere nary nitroglycerin just before and immediately after discontinued 72 hours and nitrates were discontinued coronary angioplasty. Nitroglycerin was given to mini- 12 hours before all Doppler examinations. mize the effect of varying vasomotor tone on vesselluPulsed Doppler studies of LV diastolic filling were men diameters. All angiograms were reviewed as suit- performed through an apical 4-chamber view with the able for analysis by quantitative coronary arteriogra- Doppler cursor oriented parallel to the long-axis plane phy. Multiple projections including cranial and caudal of the left ventricle and the sample volume placed just angulated views were obtained for all patients. All pa- below the level of the mitral anulus. The position of the tients had given written informed consentfor the study. samplevolume was adjusted to render the highest early Coronary angioplasty was performed in a routine velocity peak of the transmitral flow signal at baseline. fashion using appropriately sized balloon catheters.Bal- The position and depth of the sample volume were reloon inflations were maintained for a period of 30 to 90 corded and used for subsequent studies. All patients secondsat pressuresof 4 to 9 atm. Before angioplasty, were examined in the left lateral position. The study nitrates were given to 40 patients, calcium antagonists was performed with a Hewlett-Packard model 7702OA to 29 patients and @blockers to 8 patients. Doses of echocardiographic system with a 2.5-MHz transducer. these medications were unchanged after angioplasty in Pulsed Doppler images were recorded on paper at a order to minimize the effects of alteration in medica- speedof 100 mm/s for subsequentmeasurement. tions on LV filling dynamics. Analysis of the Doppler transmitral inflow velocity Quantitative coronary arteriography: Coronary recording was performed as previously described.2aJ cineangiographic films were analyzed by computer-as- The Doppler velocity curve of 4 consecutivecardiac cysistededge-detectionusing a 35-mm tine film transport cles was digitized through the darkest gray scale and mechanism mounted on a movable stage (Vanguard the variables obtained were averaged.Variables of LV Instruments, Melville, New York). l8 End-diastolic tine diastolic function used in this study included: (1) peak frames, which clearly demonstrated the stenotic seg- early diastolic flow velocity (E); (2) peak late diastolic ment, were selectedand magnitied (X 3.5). Coronary flow velocity that is due to atrial contraction (A); (3) segmentswere centered in the image field, and the im- ratio of peak early and late diastolic flow velocities (E/ age was digitized with a video processor(model 5524 A); (4) time velocity integral of the early diastolic fillDe Anza Systems,Fremont, California) controlled by a ing period (E); (5) time velocity integral of the late Hewlett Packard 2100 computer (Andover, Massachu- diastolic filling period (Ai); (6) ratio of early and late setts). The digitized image was displayed on a graphic diastolic filling periods (EJAi); and (7) time velocity computer terminal linked to a light pen. The margins of integral of transmitral flow during the first third of either the catheter or coronary segment were traced diastole (% filling fraction [ % FF]). manually using the light pen. Using theselines as initial StaWkal w All data are expressedas mean search locations, the automatic edge-finding algorithm f standard deviation. Analysis of variance for repeated drew and smoothedthe edges,defining the edge as the measureswas used to compare data before and after peak of the first derivative of the gray-scaledensity gra- coronary angioplasty. Liiear regression analysis was dient, perpendicular to the long axis of the catheter or performed on percent changes in Doppler parameters vessel as estimated from the initial manual tracings. of LV diastolic filling after angioplasty and quantitative When the computer algorithm was unable to resolve angiographic measurements.Differences were considvesselboundaries in areas of noise or vesselcrossings, ered significant when the confidence limits exceeded manual editing of short segmentsof boundary with the 95% (p
This study evaluates the changes in left ventrkuiar (LV) diastolk filling after penwtaneous transhmlinal coronaryangkpiastyandthereiationof such changes to quantMfve angiographic measurements of the sevedty of coronary narrowings. Puked Doppkr echecardiographic measurements were performed in 40 patiis with ringle left anterior descending artefy narrowing before, and 10 and 30 days after angioplasty. Minimal luminal diameter and percent diameter stenosis of coromuylesionsweremeasuredby computer-assisted quantitation. The ratio of early to late diastolic flow velocities (E/A ratio), time veiocity integrai of eariy diastolk fi#ing period (Ei) and the ratio of early and late diastdk filling periods (Ei/Ai ratio) increased gradually after angioplasty. Minimal lumi~l diameter correlated signifkantiy with the percent changes in E/A ratio (r = 0.59 at 10 days, r = 0.57 at 30 days), Ei (r = OS3 at 10 days, r = 0.55 at 30 days) and Ei/Ai ratio (r = 0.41 at 10 days, r = 0.49 at 30 days). Percent diameter stenosis showed overall weaker convrlations than minimal diameter with the percent changes in E/A ratio (r = 0.39 at 10 days, r = 0.32 at 30 days) and Ei (r = 0.36 at 10 days, r = 0.31 at 30 days). Thus, l.V diastdic fiMng improves serially after coronary angioplasty in patients with l-vessel disease. The magnitude of improvement in diastdic filling correlates better with midmal iuminal diameter than percent diameter stenosis. Therefore, minimal luminal diameter is a better predktor of changes in Doppler transmitral flow parameters after angioplasty than percent diameter stenosis. (Am J Cardid 1991;67:1061-1066)
ecently, pulsed Doppler echocardiography has been shown to be useful in evaluating left ventricular (LV) diastolic filling dynamics because Doppler-derived transmitral flow velocities reflect the rate of LV volume change.le5By using such noninvasive Doppler techniques, abnormal LV diastolic function has been found in patients with ischemic heart disease,6-9LV hypertrophy,lO acpte cardiac allograft rejection, I l diabetic cardiomyopathy,l 2 doxorubicin cardiotoxicity l 3 and connective tissue diseases.14,15A previous study showed that Doppler-derived LV diastolic filling abnormalities improved within 2 days after percutaneous transluminal coronary angioplasty and continued to improve up to 9 days.16However, it remains unknown whether the improvement wiU continue in longer term. Although quantitative angiographic measurementshave been found to correlate with impaired LV systolic function,” there is no study to date to assessthe relation betweenquantitative angiographic variables and LV diastolic dysfunction. The present study determines the temporal changesin Doppler-derived indexes of LV diastolic filling up to 30 days after angioplasty in patients with l-vessel coronary artery disease.In addition, the relation betweenthese changes in LV diastolic function and quantitative angiographic measurementsof narrowing severity was evaluated.
R
METHODS
Patients: Forty-five consecutivepatients with stable exertional angina pectoris were considered. All were candidates for angioplasty of a significant (>75% diameter stenosis)isolated proximal left anterior descending artery narrowing. Patients with total occlusion of the left anterior descendingartery, heavily calcified lesions or extensivecollateral arteries were excluded. Patients with atria1 fibrillation, valvular heart disease,congenital heart disease,cardiomyopathy, systemic hyperFrom the Cardiology Divisions, Stanford University School of Medi- tension, history of acute myocardial infarction, and cine, Stanford, California and the Department of Medicine, University of Hong Kong, Hong Kong. Manuscript received November 9, 1990; reduced angiographic or echocardiographic LV ejection revised manuscript received January 15, 1991, and accepted January fraction (60%) were also excluded. Three patients 21. were excluded because of unsatisfactory Doppler reAddress for reprints: Wing-Hung Lung, MD, Cardiology Division, Falk Cardiovascular Research Building, Stanford University cordings, 2 because of inadequate coronary angiograms. Hence, the study group consistedof 40 patients Medical Center, Stanford, California 94305. ANGlOGRAPHIC MEASUREMENTS AND DIASTOLIC FILLING
1061
(31 men and 9 women aged 40 to 69 years [mean age subsequent analysis. Catheters of known diameters f standard deviation 58 f 121). were used for calibration.19 Cardacm&WdaUmand Doppler echocardiography: Doppler examination -mW=b: was performed at baselinewithin 48 hours before angiSelective coronary arteriography was performed using the percutaneous femoral approach. Coronary angio- oplasty and was repeated 10 and 30 days after angiograms were obtained after administration of intracoro- plasty. Calcium antagonistsand ~-blocking agentswere nary nitroglycerin just before and immediately after discontinued 72 hours and nitrates were discontinued coronary angioplasty. Nitroglycerin was given to mini- 12 hours before all Doppler examinations. mize the effect of varying vasomotor tone on vesselluPulsed Doppler studies of LV diastolic filling were men diameters. All angiograms were reviewed as suit- performed through an apical 4-chamber view with the able for analysis by quantitative coronary arteriogra- Doppler cursor oriented parallel to the long-axis plane phy. Multiple projections including cranial and caudal of the left ventricle and the sample volume placed just angulated views were obtained for all patients. All pa- below the level of the mitral anulus. The position of the tients had given written informed consentfor the study. samplevolume was adjusted to render the highest early Coronary angioplasty was performed in a routine velocity peak of the transmitral flow signal at baseline. fashion using appropriately sized balloon catheters.Bal- The position and depth of the sample volume were reloon inflations were maintained for a period of 30 to 90 corded and used for subsequent studies. All patients secondsat pressuresof 4 to 9 atm. Before angioplasty, were examined in the left lateral position. The study nitrates were given to 40 patients, calcium antagonists was performed with a Hewlett-Packard model 7702OA to 29 patients and @blockers to 8 patients. Doses of echocardiographic system with a 2.5-MHz transducer. these medications were unchanged after angioplasty in Pulsed Doppler images were recorded on paper at a order to minimize the effects of alteration in medica- speedof 100 mm/s for subsequentmeasurement. tions on LV filling dynamics. Analysis of the Doppler transmitral inflow velocity Quantitative coronary arteriography: Coronary recording was performed as previously described.2aJ cineangiographic films were analyzed by computer-as- The Doppler velocity curve of 4 consecutivecardiac cysistededge-detectionusing a 35-mm tine film transport cles was digitized through the darkest gray scale and mechanism mounted on a movable stage (Vanguard the variables obtained were averaged.Variables of LV Instruments, Melville, New York). l8 End-diastolic tine diastolic function used in this study included: (1) peak frames, which clearly demonstrated the stenotic seg- early diastolic flow velocity (E); (2) peak late diastolic ment, were selectedand magnitied (X 3.5). Coronary flow velocity that is due to atrial contraction (A); (3) segmentswere centered in the image field, and the im- ratio of peak early and late diastolic flow velocities (E/ age was digitized with a video processor(model 5524 A); (4) time velocity integral of the early diastolic fillDe Anza Systems,Fremont, California) controlled by a ing period (E); (5) time velocity integral of the late Hewlett Packard 2100 computer (Andover, Massachu- diastolic filling period (Ai); (6) ratio of early and late setts). The digitized image was displayed on a graphic diastolic filling periods (EJAi); and (7) time velocity computer terminal linked to a light pen. The margins of integral of transmitral flow during the first third of either the catheter or coronary segment were traced diastole (% filling fraction [ % FF]). manually using the light pen. Using theselines as initial StaWkal w All data are expressedas mean search locations, the automatic edge-finding algorithm f standard deviation. Analysis of variance for repeated drew and smoothedthe edges,defining the edge as the measureswas used to compare data before and after peak of the first derivative of the gray-scaledensity gra- coronary angioplasty. Liiear regression analysis was dient, perpendicular to the long axis of the catheter or performed on percent changes in Doppler parameters vessel as estimated from the initial manual tracings. of LV diastolic filling after angioplasty and quantitative When the computer algorithm was unable to resolve angiographic measurements.Differences were considvesselboundaries in areas of noise or vesselcrossings, ered significant when the confidence limits exceeded manual editing of short segmentsof boundary with the 95% (p
