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• W4379742198 abstract "Aortic regurgitation (AR) represents the quintessential left ventricular volume overload state. In contrast to mitral regurgitation, where the left ventricle (LV) ejects blood into both the relatively low pressure left atrium and higher-pressure aorta, in AR, the entirety of LV stroke volume is ejected into the relatively higher pressure aorta. The severity of AR is obviously related to the regurgitant volume ejected into the LV during diastole. When severe, the forward stroke volume available for tissue perfusion represents a minority of the cardiac output. Determinants of the degree of the regurgitant volume includes the size of the regurgitant orifice, the difference in pressure between the aorta and the LV, the compliance of the LV and the duration of diastole. Chronic AR has complex, yet predictable physiologic consequences. Over time, the regurgitant volume leads to a rise in LV mass and ultimately in LV end diastolic pressure (LVEDP). The consequent increase in LV stroke volume leads to an elevation in systolic pressure. As a consequence of Laplace's law, the augmentation in LVEDP and systolic pressure eventuates in an increase in myocardial oxygen consumption. A decrease in aortic diastolic pressure, coupled with reductions in forward stroke volume and diastolic filling time act in concert to reduce myocardial oxygen supply. Consequently, chronic AR afflicts patients with increased myocardial oxygen consumption in the setting of diminished supply. This physiologic framework explains how patients with chronic AR can experience symptoms of angina pectoris in the absence of epicardial coronary artery disease. In the case under discussion, Tabrizi and colleagues describe a case of a high-risk patient with mixed aortic valve disease who underwent transcatheter aortic valve replacement (TAVR), utilizing axillary access under transesophageal echocardiographic (TEE) guidance [1]. TEE demonstrated reversal of coronary blood flow with retrograde diastolic flow out of the left main coronary artery. Following TAVR, this abnormal flow resolved. In mixed valvular disease, virtually always, one entity predominates. In this case, it is likely that the regurgitant lesion is predominant given the apparent LV dilation in the absence of LVH. Patients such as the one described frequently experience anginal symptoms. The cited causes for this usually involve the enhanced demand/diminished supply imbalance. In my decades of experience as an interventional cardiologist in the catheterization laboratory, reversal of coronary blood flow is an uncommon finding. It is most often seen during coronary angiography in patients with some form of hypertrophic cardiomyopathy or aortic stenosis where reversal of flow in unlikely to have clinical sequelae as it occurs in systole. [2,3] In this case, reversal of coronary flow is likely due to the combination of profoundly reduced aortic diastolic pressure (perhaps with associated sinus-Venturi forces) and elevated LV diastolic pressure. As both of these elements are instantaneously improved by placement of the competent aortic prosthesis, abnormal flow out of the left main coronary artery abates. Why has coronary flow reversal not been noted more frequently? Perhaps it has not been looked for, been missed, or not being the focus of the primary procedure, been ignored. In addition, TAVR practitioners have quickly moved away from utilizing TEE guidance during procedures. Tabrizi, et al [1] are to be congratulated for bringing an interesting if not dramatic case of coronary flow reversal to our attention. This constitutes the rheolytic analogy of driving the wrong way on a one-way street. As is often the case, their observation has made us think about the underlying physiology allowing this observation to be made. This linkage between an imaging observation and appreciation of pathophysiology allows us to better understand how and why we treat patients. 1Tabrizia NS, Ramadan R, Musuku SR, Shapeton AD. Diastolic left main coronary artery flow reversal. J Cardiothorac Vasc Anesth2Yoshikawa J, Akasaka T, Yoshida K, Takagi T. Systolic coronary flow reversal and abnormal diastolic flow patterns in patients with aortic stenosis: assessment with an intracoronary Doppler catheter. J Am Soc Echocardiogr 1993; 6:516-24.3Ferreiro DE, Cianciulli TF, Saccheri MC, Lax JA, Celano L, Beck MA, Gagliardi JA, Kazelián LR, Neme RO. Assessment of coronary flow with transthoracic color Doppler echocardiography in patients with hypertrophic cardiomyopathy. Echocardiography 2013; 30:1156-63. I, Carey Kimmelstiel, have no financial interests to disclose relative to this work. Diastolic Left Main Coronary Artery Flow ReversalJournal of Cardiothoracic and Vascular AnesthesiaPreviewIn patients undergoing percutaneous cardiac interventions, perioperative transesophageal echocardiography is used routinely, often revealing an unusual pathology that was not previously detected with transthoracic echocardiography. In this e-challenge, the authors present a patient undergoing percutaneous transcatheter aortic valve replacement, with preprocedural transesophageal echocardiography revealing an abnormal color Doppler signal near the left main coronary artery during diastole. Full-Text PDF" @default.
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• W4379742198 date "2023-06-01" @default.
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• W4379742198 title "Driving the wrong way on a one-way street. Reversal of coronary flow in aortic regurgitation" @default.
• W4379742198 doi "https://doi.org/10.1053/j.jvca.2023.06.004" @default.
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