Coronary flow capacity and survival prediction after revascularization: physiological basis and clinical implications

• Published in: European heart journal Vol. 45; no. 3; pp. 181 - 194
• Main Authors: Gould, K Lance, Johnson, Nils P, Roby, Amanda E, Bui, Linh, Kitkungvan, Danai, Patel, Monica B, Nguyen, Tung, Kirkeeide, Richard, Haynie, Mary, Arain, Salman A, Charitakis, Konstantinos, Dhoble, Abhijeet, Smalling, Richard, Nascimbene, Angelo, Jumean, Marwan, Kumar, Sachin, Kar, Biswajit, Sdringola, Stefano, Estrera, Anthony, Gregoric, Igor, Lai, Dejian, Li, Ruosha, McPherson, David, Narula, Jagat
• Format: Journal Article
• Language: English
• Published: US Oxford University Press 14.01.2024
• Subjects: Coronary Angiography - methods; Coronary Artery Disease; Fast Track Clinical Research; Humans; Positron-Emission Tomography - methods; Prospective Studies; Rubidium Radioisotopes; Myocardial ischaemia; Coronary bypass surgery; Coronary flow reserve; PET imaging; Myocardial perfusion; Coronary artery disease
• ISSN: 0195-668X; 1522-9645; 1522-9645
• DOI: 10.1093/eurheartj/ehad579

Abstract Background and Aims Coronary flow capacity (CFC) is associated with an observed 10-year survival probability for individual patients before and after actual revascularization for comparison to virtual hypothetical ideal complete revascularization. Methods Stress myocardial perfusion (mL/min/g) and coronary flow reserve (CFR) per pixel were quantified in 6979 coronary artery disease (CAD) subjects using Rb-82 positron emission tomography (PET) for CFC maps of artery-specific size-severity abnormalities expressed as percent left ventricle with prospective follow-up to define survival probability per-decade as fraction of 1.0. Results Severely reduced CFC in 6979 subjects predicted low survival probability that improved by 42% after revascularization compared with no revascularization for comparable severity (P = .0015). For 283 pre-and-post-procedure PET pairs, severely reduced regional CFC-associated survival probability improved heterogeneously after revascularization (P < .001), more so after bypass surgery than percutaneous coronary interventions (P < .001) but normalized in only 5.7%; non-severe baseline CFC or survival probability did not improve compared with severe CFC (P = .00001). Observed CFC-associated survival probability after actual revascularization was lower than virtual ideal hypothetical complete post-revascularization survival probability due to residual CAD or failed revascularization (P < .001) unrelated to gender or microvascular dysfunction. Severely reduced CFC in 2552 post-revascularization subjects associated with low survival probability also improved after repeat revascularization compared with no repeat procedures (P = .025). Conclusions Severely reduced CFC and associated observed survival probability improved after first and repeat revascularization compared with no revascularization for comparable CFC severity. Non-severe CFC showed no benefit. Discordance between observed actual and virtual hypothetical post-revascularization survival probability revealed residual CAD or failed revascularization. Structured Graphical Abstract Structured Graphical Abstract Coronary flow capacity (CFC) and survival prediction after revascularization: physiological basis and clinical implications. CFC maps in one view before (upper row) and after revascularization (lower row) show residual diffuse coronary artery disease (CAD), stenosis, and incomplete or inappropriate revascularization as examples from 283 pre-post-revascularization positron emission tomography (PET) pairs. The 10-year survival probability is determined as a fraction of one for normal CFC (all red) by the proportional distribution of regional size-severity CFC abnormalities. The individual observed survival probabilities for each CFC map before and after actual coronary revascularization are listed below each CFC map. The virtual survival probability predicted for the baseline CFC map after virtual theoretical ideal complete revascularization is listed in the lowest (3rd) row for each case. The plots show the observed survival probability of 6979 PET cases with and without severely reduced CFC with and without non-randomized revascularization followed over 12 years as the database from which individual survival probability is determined by multi-variable CFC components by Cox regression modelling. LAD, left anterior descending coronary artery; LCx, left circumflex artery; RCA, right coronary artery.