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[Coronary disease: should images be treated?]
1Unité d'Hémodynamique et de Cardiologie interventionnelle, CHU Henri Mondor, Créteil.
Insights
Coronary artery imaging now combines anatomy and function. Measuring coronary artery flow and pressure alongside detailed images improves diagnosis and treatment decisions for coronary artery disease.
Area of Science:
- Cardiovascular Imaging
- Interventional Cardiology
- Medical Diagnostics
Background:
- Coronarography and angioscopy provide detailed anatomical views of coronary artery stenosis, revealing plaque characteristics and pathophysiological mechanisms.
- Endocoronary echography offers histological-like views of the artery wall layers without biopsy, enhancing understanding of stenosis.
- Current imaging excels at anatomical detail but requires functional assessment for comprehensive diagnosis.
Discussion:
- Anatomical imaging alone is insufficient for therapeutic decisions; functional assessment of coronary circulation is crucial.
- Measuring coronary artery flow velocity and pressure across stenoses provides critical data on the impact of disease.
- Integrating anatomical and functional imaging provides a holistic view of coronary artery disease.
Key Insights:
- Doppler signals from a catheter-tip sensor quantify blood flow velocity, revealing diastolic/systolic patterns and coronary vascular reserve.
- Transstenotic pressure measurements complement flow data, offering a complete hemodynamic assessment.
- Therapeutic strategies should be guided by both precise anatomical visualization and functional flow dynamics.
Outlook:
- Optimizing current imaging techniques is essential for improving patient outcomes.
- Developing treatments with the best benefit-risk-cost ratio for coronary artery disease is a key goal.
- Future research should focus on refining integrated anatomical and functional imaging for personalized patient care.
Abstract:
Precise digitized images of the coronary arteries displaying the dimensions of high risk stenoses and giving objective measurements of their contours and density can be provided by coronarography. On-line angioscopic images of tissue flaps floating in the lumen, recent or structured thrombi, artery wall dissections, plaque ruptures, deep fissurations and sub-intimal haemorrhages demonstrate, in live colour, the pathophysiological mechanisms of coronary artery stenosis. Histological sections of the artery wall, without biopsy, can be visualized with endocoronary echography offering a global view of the wall and differentiating all the physiological layers including the intima and the internal elastic lamina, the blood-wall interface, the media and the adventitia. Our technical imaging capacity is impressive, but is anatomic imaging synonymous with coronary circulation? Certainly not. Sophisticated imaging techniques have led us to associate the severity of the stenosis with its effect on myocardial irrigation, but today therapeutic decisions require not only considering coronary anatomy but also downstream consequences which can be evaluated by measuring coronary artery flow on both sides of the stenosis. Carried on the tip of the angioplasty guide, a piezo-electric crystal emits and receives a Doppler signal. The data is processed in real time giving a complete pattern of blood flow velocity and describing diastolic and systolic flow, differences between upstream and downstream flow, and the effect of pharmacological or physiological tests such as maximal dilatation to measure coronary vascular reserve. Transstenosic pressure measurements complete the diagnostic armentorium. Thus therapeutic decisions can now be made not only on the basis of precise anatomic imaging, but also on functional imaging, giving a complete view of the pathophysiology of the coronary arteries and the effect of disease on myocardial blood supply. It is now up to us to optimize these imaging techniques and to propose treatments which provide patients with coronary artery disease with the best benefit-risk-cost ratio.