TRANSTHORACIC COLOR (DOPLER) ULTRASOUND OF LEFT ANTERIOR DESCENDING ARTERY AS ALTERNATIVE TO IMMEDIATE INSTANT WAVE­FREE RATIO FOR PERCUTANEOUS CORONARY INTERVENTION IN ELDERLY PATIENTS

The modern doctrine of treating ischemic heart disease (IHD) is aimed to choose a method, which maximizes the effectiveness and safety for patients. Currently there are three approaches for treatment of stable IHD: optimal medical therapy, percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG). Each approach has own indications and contraindications, based on international recommendations. Separate controversial group of patients are the elderly and senile patients. Limited physical activity, comorbidities, high complications risk in post-PCI double antiplatelet therapy and after CABG, requires strongly individualized approach and proved treatment method. Surgery is possible only after myocardial ischemia is proved by noninvasive imaging methods, assessment of fractional flow reserve (FFR) or its alternative – instant wave-free ratio (iFR) during the coronary angiography. Determination of hemodynamically significant stenosis helps interventional cardiologists to avoid unreasonable revascularization and PCI-related complications.

1. Kochanov IN. Efficiency of treatment with coronary angioplasty and stenting in elderly and senile patients with coronary heart disease: The abstract of Cand. Med. Sci. Diss. St. Petersburg; 2007. In Russian.

2. Patel MR, Dehmer GJ, Hirshfeld JW, et al.. ACCF/ SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization. Circulation. 2009; 119 (9): 1330-1352.

3. 2014 ESC/EACTS Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur. Heart J. 2014; 35 (37): 2541-2619.

4. Lin GA, Dudley RA, Lucas FL, et al. Frequency of stress testing to document ischemia prior to elective percutaneous coronary intervention. JAMA. 2008; 300 (15): 1765-1773.

5. Lindstaedt M, Spiecker M, Perings C, et al. How good are experienced interventional cardiologists at predicting the functional significance of intermediate or equivocal left main coronary artery stenoses? Int. J. Cardiol. 2007; 120 (21): 254-261.

6. Brueren BR, ten Berg JM, Suttorp MJ, et al. How good are experienced cardiologists at predicting the hemodynamic severity of coronary stenoses when taking fractional flow reserve as the gold standard. Int. J. Cardiovasc. Imaging. 2002; 18 (2): 73-76.

7. Tonino PA, De Bruyne B, Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N. Engl. J. Med. 2009; 360 (3): 213-224.

8. Tonino PA, Fearon WF, De Bruyne B, et al. Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation. J. Am. Coll. Cardiol. 2010; 55 (25): 2816-2821.

9. Escaned J, Echavarría-Pinto M, Garcia-Garcia HM, et al. Prospective Assessment of the Diagnostic Accuracy of Instantaneous Wave-Free Ratio to Assess Coronary Stenosis Relevance. JACC Cardiovasc Interv. 2015; 8 (6): 824-833.

10. Lindner JR. The Physiologic Evaluation of Stenosis by Transthoracic Doppler: A Bit of Theory, a Lot of Practice. J. Am. Soc. Echocardiogr. 2011; 24 (4): 382–384.

11. Boshchenko A. Transthoracic coronary flow reserve in the left anterior and posterior descending arteries as an additional option to stress echocardiography with wall motion analysis. Eur. Heart J. Cardiovasc. Imaging. 2013; 14, suppl. 2: ii1-ii2.

12. European Society of Hypertension-European Society of Cardiology guidelines for the management of arterial hypertension. J. Hypertens. 2003; 21 (6): 1011–1053.

13. Sen S, Asrress KN, Nijjer S, et al. Diagnostic classification of the instantaneous wave-free ratio is equivalent to fractional flow reserve and is not improved with adenosine administration. Results of CLARIFY (Classification Accuracy of Pressure- Only Ratios Against Indices Using Flow Study). J Am Coll Cardiol. 2013;61:1409–1420.

14. Corban MT, Hung OY, Eshtehardi P, et al. Myocardial bridging: contemporary understanding of pathophysiology with implications for diagnostic and therapeutic strategies. J Am Coll Cardiol 2014;63:2346–2355.

15. Srinivasan M, Prasad A. Metal fatigue in myocardial bridges: stent fracture limits the efficacy of drug-eluting stents. J Invasive Cardiol 2011;23:E150–2.