Instantaneous Wave-Free Ratio for Evaluation of Circumflex Artery Compression During Indirect Mitral Annuloplasty

Figures

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  Visual Summary. Use of iFR for Evaluation of Circumflex Artery Compression During Indirect Mitral Annuloplasty (A) Reduction of functional mitral regurgitation by indirect mitral annuloplasty visualized by intraprocedural transesophageal echocardiography. (B) Coronary angiography showing coronary artery compression of the left circumflex artery by the proximal anchor of the Carillon Mitral Contour System (white arrow and white circle). (C) Left: a Verrata pressure wire (Philips) positioned in the distal Cx for evaluation of coronary flow influenced by the Carillon device. Right: possible approach for the usage of iFR in indirect mitral annuloplasty. CSp = proximal coronary sinus; Cx = circumflex artery; FMR = functional mitral regurgitation; GCV = great cardiac vein; iFR = instantaneous wave-free ratio.

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  Figure 1. Diagnostic Workflow Prior to Indirect Mitral Annuloplasty (A) Transthoracic echocardiography for grading FMR. Quantification of FMR using vena contracta (“MR radius” 1, left), PISA (“MR radius” 2, left), effective regurgitant orifice area (“MR ERO,” middle), regurgitant volume (“MR Volumen,” middle) and mitral annulus diameter (right). (B) Transesophageal echocardiography to confirm FMR. (C) Cardiac CT scan for evaluation of coronary sinus and mitral annulus topography. (D) Run-through angiography showing the relation of coronary sinus and left circumflex artery. Left: Left coronary artery angiography. Middle: After Cx angiography, coronary sinus passively filled by contrast agent. Right: Second left coronary artery angiography for parallel visualization of coronary sinus and Cx. CT = computed tomography; Cx = circumflex artery; FMR = functional mitral regurgitation; PISA = proximal isovelocity surface area.

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  Figure 2. Evaluation for Cx Compression Using iFR During Indirect Mitral Annuloplasty With the Carillon Mitral Contour System (A) CS angiography via a marker catheter (spacing: 1 mm) for Carillon device sizing. (B) Left coronary angiography with marker catheter in CS for visualization of Cx to CS topography. (C) Deployment of the proximal anchor of the Carillon Mitral Contour System in the proximal CS and applying tension to the device (tension length 6 cm). (D) Reduction of FMR from moderate-to-severe to mild (vena contracta: 3 mm), indicating good procedural result. (E) Deployment of the distal Carillon device anchor in the distal CS, fixing the applied tension. (F) Left coronary angiography revealing device-related compression of the proximal Cx. (G) Measurement of iFR in the distal Cx for hemodynamic evaluation of Cx impingement showing an iFR of 1.00, excluding hemodynamic compromise. (H) Right coronary angiography excluding an interaction of the device and the right coronary artery. (I) Deployment of the Carillon Mitral Contour System. CS = coronary sinus; Cx = circumflex artery; FMR – functional mitral regurgitation; iFR = instantaneous wave-free ratio.

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  Figure 3. Usage of iFR in a Case of Coronary Artery Compression by the Carillon Device (A) Proximal position of the proximal Carillon device anchor leading to Cx compromise with TIMI flow grade II. (B) After repositioning the Carillon Mitral Contour System, Cx impingement results in intermediate stenosis. An iFR pressure wire (Verrata, Philips) is introduced into the Cx and placed distal in the coronary artery. The iFR measurement revealed a value of 0.88, indicating hemodynamic compromise. (C) Again, the Carillon device is repositioned to a more distal position. In this location, no reduction in FMR was obtained. Therefore, the device was recaptured and the procedure was terminated given Cx compromise. Cx = circumflex artery; FMR = functional mitral regurgitation; iFR = instantaneous wave-free ratio.

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  Figure 4. Recapture of the Carillon Mitral Contour System (A to D) The Carillon Mitral Contour System is recaptured by reintroducing it into the guiding catheter.

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  Figure 5. Characteristics of Patients With Left Circumflex Artery Occlusion Due to Carillon Device Implantation The CS length is the distance from junction of the great cardiac vein and CS to the CS ostium. The tension length is the CS length minus the length of the Carillon device. CS = coronary sinus; Cx = left circumflex artery; iFR = instantaneous wave-free ratio; LCA = left coronary angiography; MR = mitral regurgitation; MVA = mitral valve annulus.

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  Figure 6. Flow Chart of 92 Patients With FMR Treated Between January 2019 and December 2021 CS = coronary sinus; FMR = functional mitral regurgitation; Cx = circumflex artery; iFR = instantaneous wave-free ratio.