Download collateral flow index (CFI).

What Does Collateral Flow Index
Contribute to PCI in ACS?
Carlo Di Mario, FACC, FESC, FSCAI,FRCP
University Hospital Careggi, Florence
Disclosure Statement of Financial Interest
Carlo Di Mario, MD, PhD, FESC, FACC, FSCAI, FRCP
I received institutional research grants both at the Royal Brompton
Hospital, London -UK and Careggi University Hospital, Florence -IT from
Medtronic, Edwards, Abbott, Shockwave, Philips-Volcano, Amgen
Coronaries Are Not Pure End-Arteries
1600
1700
1669
Richard Lower of
Amsterdam
1757
Albrecht von
Haller
described structural
channels connecting
the right and the left
coronary arteries
demostred
anastomoses
beween coronary
arteries
1800
1900
2000
1912
James Herrik
1940
Prinzmetal
1963
Fulton
observed the
possibility
surviving sudden
thrombotic
coronary
obstruction in the
presence of
intercoronary
anastomoses
functional
studies on
intercoronary
anastomoses
normal human
coronary
circulation
Eurointervention Textbook series, 2010
Scot. med. J., 1963,8: 46
12 studies enrolling 6529 participants
Rentrop classification
Rentrop et al J Am Coll Cardiol 1985 Mar;5(3):587-92.
Werner classification
Werner GS et al Circulation 2003;107 (15) 1972-7
Collateral Flow Derived from Occlusive PostStenotic Pressure
Sailer et al Swiss Med Wkly. 2015;145:w14154
Circulation 1993;86:1354-1367
COLLATERAL FLOW INDEX
Collateral flow index was mesured in 120 consecutive patients during 1 minute coronary
balloon occlusion as indicated by ST-segment elevation
Qc= collateral blood flow
QN= normal maximal perfusion
Pw= coronary wedge pressure
Pv= central venous pressure
Pa= mean arterial pressure
J Am Coll Cardiol 1995 Vol. 25,n°7:1522-8
J Am Coll Cardiol 1995 Vol. 25,n°7:1522-8
Four Variables for Assessing Collateral Extent
Collateral Flow Index Related
With Ischemia
COLLATERAL FLOW INDEX cut off 24%
J Am Coll Cardiol 1995 Vol. 25,n°7:1522-8
845 patients: 106 no CAD, 739 with stable
coronary artery desease
1053 quantitative coronary pressure–
derived collateral measurements
March 1996 and April 2006
Circulation. 2007;116:975-983
Circulation. 2007;116:975-983
Circulation. 2007;116:975-983
1181 patients with stable coronary desease
286 patients had CFI >0.25 (24.2%)
Seiler C,et al. Heart 2013;99:1408–1414
 Collateral blood flow after epicardial coronary occlusion may be sufficient in
some patients to meet myocardial needs at rest, the prevalent view is that
collateral circulation is generally not sufficient to meet myocardial and may not
prevent myocardial ischemia during coronary occlusion
 During acute vessel occlusion, a flow of 20% to 25% is generally regarded as
sufficient to provide the blood supply needed at rest
 One in four patients without coronary artery disease has sufficient collaterals
as compared with one in three patients with coronary artery
Factors can influence collaterals
Meier, Sailer et al. BMC Medicine2013,11:143
Collateral flow in ACS
Potential benefit of collateral circulation:
 smaller infarct size
reduction QT prolungation and fatal arrhythmias
preservation of cardiac function
reduction in post-infarct ventricular dilatation.
Meier, Hemingway et al EHJ 2012 (33);614-621
Meier, Sailer et al. BMC Medicine2013,11:143
Acute Collateral Flow Index
Left Ventricular Mean
Diastolic Pressure
In stable non-ischemic conditions the
central vein pressure (CVP) exceeds
LVMDP.
During STEMI the reverse is true, and
flow into the distal portion of the
occluded artery during diastole is
markedly compromised.
Meisel Shochat, Circ J 2012; 76: 414 – 422)
Meisel Shochat, Circ J 2012; 76: 414 – 422)
70% pts had CFI >25%
only 32% pts have ACFI > 25%
Meisel Shochat, Circ J 2012; 76: 414 – 422)
Cardiac event-free survival (B) and Coronary event-free survival (C) according to
acute collateral flow index (ACFI) tertiles.
Lowest tertile
Middle tertile
Highest tertile
Collateral flow during STEMI
may marginally limit myocardial damage
but had no effect on left ventricular contraction or long-term mortality,
most
likely because of the low flow provided by emerging collaterals
and the high proportion of patients undergoing intervention before the
beneficial effect of collaterals could be realized.
Meisel Shochat, Circ J 2012; 76: 414 – 422)
60 patients treated with primary PCI within 6 hours from symptom
onset receiving Doppler flow measurements post-PCI + H2 15O PET +
cardiac MRI
Teunissen, Circ Cardiovasc Interv 2015
60 patients treated with primary PCI within 6 hours from symptom
onset receiving Doppler flow measurements after primary PCI + H2 15O
PET + cardiac MRI
Teunissen, Circ Cardiovasc Interv 2015
Hyperaemic Myocardial Resistance (HMR): distal pressure/Doppler velocity
Teunissen, Circ Cardiovasc Interv 2015
Teunissen, Circ Cardiovasc Interv 2015
34 patients undergoing Doppler examination during primary PCI, with
HMR and Zero-Flow pressure compared with results of serial cardiac
MRI
Patel et al, JACC 2016
Patel et al, JACC 2016
Collaterals are not sufficient to prevent
ischemia in CTO lesions
Number of patients
10
5
0
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
FFR col
Modified from Werner et al. Eur Heart J 2006;27:2406-12
60 patients with severe coronary stenoses and/or chronic
occlusions undergoing pre-procedural, post-procedural, 24 hour
and 6 month CFI
Pereira et al, Circulation 2007;115:2015-21
60 patients with severe coronary stenoses and/or chronic
occlusions undergoing pre-procedural, post-procedural, 24 hour
and 6 month CFI
Pereira et al, Circulation 2007;115:2015-21
Collateral Flow Index: Conclusions
• CFI is well correlated with experimentally measured collateral flow
• Sufficient collateral flow to avoid ischaemia is present in a minority of lesions,
including CTO
• In stable angina CFI >0.25 is correlated with improved prognosis
• In STEMI correction by LVEDP (ACFI) is likely required to avoid overestimation of
collateral flow
• Pressure/velocity derived indices such as HMR and Pzero pressure have better
correlation with myocardial recovery than CFI
• CFI is an ideal method to assess growth of collaterals stimulating angiogenesis