Percutaneous coronary intervention in patients with impaired left ventricular function

Changes in left ventricular (LV) function are an early manifestation of the ischaemic cascade, and often precede well-recognized markers of ischaemia. Prolonged post-ischaemic myocardial dysfunction can persist for hours or days after bloodflow is restored. Patients with impaired LV function at the outset face potentially hazardous clinical consequences from percutaneous coronary intervention (PCI). This chapter explores the options for optimizing PCI when LV function is impaired, different uses of percutaneous mechanical circulatory support (including intra-aortic balloon counterpulsation and LV assist devices) with the aim of preventing the development of cardiogenic shock, and the impact of revascularization in ischaemic cardiomyopathy and the role of viability testing.

Coronary artery disease: from atherosclerosis to obstructive disease, inducible ischaemia, and the ischaemic cascade

The inclusion or exclusion of coronary artery disease is important for patient management, both from a diagnostic and prognostic view, as well as from a therapeutic view. Various detection techniques are available, including invasive (coronary angiography) or non-invasive imaging techniques. The techniques can also be divided into anatomical imaging or functional imaging, where anatomical imaging detects coronary atherosclerosis and stenosis (invasive coronary angiography, but also non-invasive coronary angiography—performed with multidetector computed tomography), while functional imaging (nuclear imaging, stress echocardiography, and cardiovascular magnetic resonance) detects ischaemia: the haemodynamic consequences of the atherosclerosis/stenosis. The early phase of atherosclerotic coronary artery disease is often asymptomatic (and anatomical imaging can be used to detect/exclude coronary atherosclerosis), whereas with progression of atherosclerotic disease, symptoms occur related to myocardial ischaemia. Non-invasive imaging can facilitate in the detection of both early (asymptomatic) and more advanced (symptomatic, ischaemic) coronary artery disease. The pathophysiological cascade of cardiac abnormalities that occur once ischaemia is induced is referred to as the ischaemic cascade. The ischaemic cascade consists of chronological development of perfusion abnormalities, followed by diastolic dysfunction, then systolic dysfunction, and finally electrocardiographic abnormalities. In this chapter, the variety of the different non-invasive imaging techniques to assess the different phases of the non-ischaemic part and the ischaemic part (ischaemic cascade) of coronary artery disease are described.