Coronary Microcirculation in Aortic Stenosis: Pathophysiology, Invasive Assessment, and Future Directions

Figure 5

Clinical case of simultaneous aortic and coronary stenosis assessment: as detailed in the text, this 82-year-old man with exertional dyspnea underwent coronary evaluation before transcatheter aortic valve implantation. Three pressures were measured simultaneously: aortic (via the guide catheter), coronary (via a distal pressure wire), and left ventricular (via a pigtail catheter). Intravenous papaverine induced coronary hyperemia with a fractional flow reserve (FFR) of 0.54. Both the severe aortic stenosis (baseline mean gradient 51 mmHg) and the severe in-stent coronary lesion imbalance myocardial demand (systolic pressure time integral, or SPTI) and diastolic coronary supply (diastolic pressure time integral, or DPTI). This figure allows for a visual understanding of the additive effects of the tandem aortic valve and coronary stenosis.