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PET measurement of the coronary flow reserve and microcirculatory function

Messung der Koronarflußreserve und der mikrozirkulatorischen Funktion

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Abstract

This review article discusses some of the potentially beneficial effects of calcium antagonists on the coronary microcirculation. These include their vasodilating action on coronary resistance vessels as well as their effects on extravascular resistance (i.e. intramyocardial pressure).

Examples are presented of how the non-invasive measurement of myocardial blood flow and flow reserve by means of positron emission tomography (PET) can contribute to the understanding of the effects of drug treatment on the coronary microcirculation.

The action of calcium antagonists on the coronary microcirculation can contribute to explain the efficacy, of these drugs against ischemia and ischemia-reperfusion damage.

Zusammenfassung

Kürzlich publizierte klinische Studien haben gezeigt, daß eine Konstriktion der kleinen koronaren Arteriolen eine besondere Rolle in der Pathogenese einer myokardialen Ischämie bei Patienten mit koronarer Herzerkrankung spielen. Zusätzlich können Symptome und Zeichen der myokardialen Ischämie bei Patienten aufgedeckt werden, auch wenn eine koronare Herzerkrankung mit dem Goldstandard der Koronarographie nicht nachgewiesen, werden kann. Pathophysiologisch ist von Bedeutung, daß die kleinen Arteriolen unter 450 μm die Hauptdeterminanten des koronaren Gefäßwiderstands darstellen und ein Abfall um 50% des Perfusionsdrucks relativ zum Aortendruck auftreten kann, wenn die Gefäße einen Durchmesser von 70 bis 440 μm haben. Die weitere Widerstandserhöhung liegt in den Gefäßen unter 100 μm. Diese Gefäße sind auch diejenigen, die für die Autoregulation der Myokarddurchblutung verantwortlich sind.

Verschiedene Verfahren wurden verwendet, um die Myokarddurchblutung zu messen. Experimentell werden die intravitale Mikroskopie und Stroboskopie klinisch die Koronarsinusmodulationsmessung sowie die kürzlich eingeführte intrakoronare Doppler-Untersuchung während der Herzkatheterisierung verwendet.

Die planare Gammaszintigraphie oder auch SPECT-Untersuchung (Single-Photon-Emission-Computed-Tomography) erlaubt für verschiedene Photonemitter die Aufdeckung einer regional unterschiedlichen Aktivitätsverteilung als Zeichen einer unterschiedlichen regionalen Myokarddurchblutung, ohne aber eine Quantifizierung zu erlauben. Die Positronenemissionstomographie dagegen ermöglicht die genaue lokalisierte Perfusionsmessung. Besonders hilfreich scheint die Verwendung von H2 15O und13NH3 zu sein. Dipyridamol wurde verwendet, um die vasodilatorische Flußreserve voll auszunutzen und damit die koronare Flußreserve zu bestimmen. Bei Sportlern wurden ein basaler Blutfluß von 2,7+-1,2 ml/m/g festgestellt sowie eine koronare Flußreserve von 3,6±1,0. Bei Patienten mit sekundärer Linksherzhypertrophie betrug die koronare Flußreserve 2,05±0,61 im Vergleich zu einem entsprechenden Kontrollkollektiv. Auch bei Patienten mit hypertropher Kardiomyopathie lag die Flußreserve mit 2,0±0,7 deutlich unter dem Normalbereich. Im Vergleich fand sich bei diesen Patienten mit dem gepulsten Doppler auch ein signifikanter Unterschied in bezug auf das Verhältnis von E/A im Einstromtrakt des linken Ventrikels. Verschiedene Mechanismen müssen in Betracht gezogen werden, um diese aufgedeckten pathologischen mikrovaskulären Perfusionsstörungen zu erklären. Eine aktive Vasokonstriktion oder Einfluß der vasodilatorischen Dilatation ist möglich. Auch ein Remodeling, der Gefäßwand könnte eine Rolle spielen, ebenso wie ein erhöhter intramyokardialer Druck (extravaskulärer Widerstand).

Die Positronenemissionstomographie erlaubt zum ersten Mal ein nichtinvasive Quantifizierung der myokardialen Perfusion und damit die Aufdeckung einer mikrovaskulären Perfusionsstörung, die bisher nur mittels kathetertechnik möglich gewesen ist. Es ist zu erwarten, daß weitere klinische Studien die Bedeutung dieser neuen Technik unterstreichen werden.

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  1. MRC Cyclotron Unit, Imperial College School of Medicine, Hammersmith Hospital, W12 ONN, London, UK

    Ornella Rimoldi & Paolo G. Camici

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Rimoldi, O., Camici, P.G. PET measurement of the coronary flow reserve and microcirculatory function. Herz 24, 522–530 (1999). https://doi.org/10.1007/BF03044223

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