The authors are grateful to the patients, colleagues and institutions that have contributed to the body of knowledge in this field. No specific funding was received for this work.

The following protocol adheres to the guidelines of our institution&#39;s human research ethics committee. Methods from this protocol have been included within ethics committee-approved research studies in our institution17,18.
1. Coronary angiography
<ol>
	<li>Before starting, have the catheter laboratory team undertake a &#39;huddle&#39; to review the clinical case and plan the procedure. This includes preparation for medication and/or equipment should adverse events occur (for instance the need for pacing).</li>
	<li>Consider adopting the following checklist: written informed consent, including the off-label use of acetylcholine, indication and potential risks of the procedure, history of allergy, and plan for procedural thromboprophylaxis, sedation and/or pain-control.</li>
	<li>Obtain arterial access using standard Seldinger technique. Radial artery access is recommended as per contemporary guidelines.</li>
	<li>Administer intra-arterial nitrate to reduce propensity to radial artery spasm. Modest doses of short-acting nitrate (e.g., 200 &#181;g of GTN) are recommended. Avoid calcium channel antagonists.</li>
	<li>Give unfractionated heparin 5000 IU and actively manage the activated clotting time (ACT) to ~250 seconds.</li>
	<li>Perform standard coronary angiography to obtain orthogonal views of all main coronary artery branches.</li>
	<li>Record left ventricular end diastolic pressure (LVEDP), if feasible, to provide information on possible alternative explanations for symptoms (e.g., heart failure).</li>
	<li>Size the guide catheter selection according to the patient stature, e.g., 6 Fr and 3.5 size for the standard patient, or 5Fr and 3.0 size for those of smaller stature. 
	&#8203;NOTE: Careful attention to the aortic pressure waveform will inform the operator about &#39;pressure damping&#39; and the risk of coronary dissection. An &#39;Extra Back-Up&#39; catheter may secure a more stable position in the left main coronary artery, but care is needed during manipulation to avoid vessel injury.</li>
</ol>
2. Diagnostic guidewire test (FFR, CFR, IMR, RRR)
<ol>
	<li>Engage the coronary artery with a guide catheter of choice.</li>
	<li>With the guide catheter engaged and co-axial, administer 200 &#181;g of GTN to attenuate any epicardial coronary spasm.</li>
	<li>Ensure that the ACT is ~250 seconds before instrumentation of the coronary artery.</li>
	<li>While avoiding handling the diagnostic guidewire sensor, advance the sensor to the tip of the guide catheter.</li>
	<li>Flush the guide catheter to avoid contrast pressure damping. Allow 30 seconds for resting conditions to return before &#39;equalizing&#39; pressure with the invasive aortic root pressure. Ensure that the catheter system is fully closed (e.g., introducer needle fully removed) and &#39;pressure damping&#39; is not present. Meticulous setup reduces the risk of subsequent errors from &#39;signal drift&#39;.</li>
	<li>Advance the diagnostic guidewire to the distal 1/3 of the coronary artery. In the absence of a clinical indication to select a specific coronary artery, select the left anterior descending (LAD) artery as the default due to the volume of myocardium subtended.</li>
	<li>If encountering difficulty advancing the diagnostic guidewire, consider use of a standard workhorse coronary guidewire as a &#39;buddy-wire&#39;. Alternatively, a different coronary artery may be selected if vascular injury remains a concern.</li>
	<li>With the diagnostic guidewire in appropriate position within the vessel, flush the guide catheter with room-temperature normal saline and allow 30 seconds for resting physiology to return.</li>
	<li>Store a fluoroscopy image of the diagnostic guidewire to document position within the coronary artery.</li>
	<li>Record resting pressure indices, including resting Pd/Pa and RFR.</li>
	<li>Before recording resting thermodilution transit times, flush the guide catheter with room temperature saline to displace saline within the catheter that has been warmed by the patient&#39;s body temperature.</li>
	<li>Using a dedicated 3 mL syringe (or 5 mL syringe in large left dominant coronary arteries), administer brisk 3 mL boluses of room-temperature normal saline via the guide catheter. 
	CAUTION: Care should be taken to avoid injection of air into the coronary artery. Ensure guide catheter is co-axially intubated during injections to avoid hydro trauma.</li>
	<li>Repeat the 3 mL boluses of room-temperature normal saline as required. Inspect the recorded transit times and replace any artefactual and/or outlier readings.</li>
	<li>Set up the linked diagnostic software to prepare for hyperemic measurements. 
	NOTE: For the coronary pressure/flow relationship to become linear, resistance should be minimized and stable. This can be achieved with IV adenosine (140-210 &#181;g/kg/min). Contrast-FFR (ischemic threshold 0.83) is an alternative to FFR with IV adenosine but does not provide the stable hyperemic conditions necessary for thermodilution measurement.</li>
	<li>Inform the patient of potential adenosine side-effects (transient dyspnea, flushing and chest discomfort).</li>
	<li>Commence IV adenosine (140 &#181;g/kg/min) infusion via a large peripheral venous cannula.</li>
	<li>Keep manifold manipulation to a minimum to avoid movement-induced pressure trace artefacts.</li>
	<li>Monitor for signs of hyperemia: &#39;ventriculization&#39; and disappearance of the dicrotic notch in the distal pressure waveform, separation of the aortic and distal pressure waveforms, and symptoms (chest discomfort, dyspnea). Changes in heart rate and blood pressure are less reliable indicators of hyperemia.</li>
	<li>If the initial adenosine infusion fails to achieve steady-state hyperemia, consider increasing the rate to 210 &#181;g/kg/min.</li>
	<li>Document FFR at stable hyperemia. An FFR reading of &#8804;0.80 is taken as significant for flow-limiting epicardial disease.</li>
	<li>With the adenosine infusion still running, switch the linked diagnostic software to complete the hyperemic thermodilution measurements.</li>
	<li>Repeat rapid 3 mL boluses of room-temperature normal saline via the guide catheter to record hyperemic thermodilution transit times.</li>
	<li>Perform the same data quality assurance checks as for the resting readings. Replace any artefactual or outlier data.</li>
	<li>Stop the IV adenosine infusion. The total duration of adenosine infusion will be approximately 2-3 minutes.</li>
	<li>Review data recordings to ensure the software-selected readings are free from artefact. Manual fine-tuning may be required. CFR &#60;2.0 (&#39;grey zone&#39; 2.0-2.5), IMR &#8805;25 and RRR &#60;2.0 are indicative of coronary microvascular dysfunction.</li>
</ol>
3. Pharmacological reactivity test
<ol>
	<li>Keep the pre-prepared acetylcholine from pharmacy at 4 &#176;C in the catheterization laboratory until use. Product shelf life is 30 hours from manufacture. The expiry date/time should be detailed on the label. Acetylcholine will be prepared at three doses: 
	Solution 1 Acetylcholine Chloride 0.182 &#181;g/mL (10-6M) 
	Solution 2 Acetylcholine Chloride 1.82 &#181;g /mL (10-5M) 
	Solution 3 Acetylcholine Chloride 18.2 &#181;g /mL (10-4M)</li>
	<li>Choose an angiographic projection that allows visualization of the coronary artery with minimal foreshortening and overlap. Acquire a resting angiogram.</li>
	<li>Check that the guide catheter is still co-axially intubated for the acetylcholine infusion. 
	NOTE: If choosing to infuse using a dedicated intracoronary microcatheter, position at this stage with the aid of a coronary guidewire. We advocate direct infusion via the guide catheter to minimize coronary instrumentation and procedural cost.</li>
	<li>Connect a long, sterile IV line to a 3-way tap and flush the system with normal saline. Connect the sterile IV line to the acetylcholine syringe which will be administered using an automated infusion pump. 
	CAUTION: Acetylcholine can temporarily interrupt cardiac conduction. Keep atropine 1 mg and alternative means of pacing available. This is more relevant for dominant coronary arteries. Coughing is effective for heart rate recovery. Inform the patient that this may be needed.</li>
	<li>Connect Solution 1 (60 mL syringe; 10-6M).
	<ol>
		<li>Purge the IV line and guide catheter with 4 mL of acetylcholine solution to minimize any &#39;dead space&#39; effect when the infusion is commenced.</li>
		<li>With the guide catheter still co-axial, commence the infusion at 2 mL/min for 2 minutes.</li>
		<li>Have the cardiac catheterization laboratory physiologist start the digital stopwatch on the monitor to ensure accurate time keeping.</li>
		<li>Monitor the patient, vital signs and ECG for effects of acetylcholine. If encountering any safety concerns, stop the acetylcholine infusion immediately.</li>
		<li>After the 2 minute infusion is complete, acquire an ECG and assess the patient for symptoms.</li>
		<li>Gently purge the guide catheter system with contrast to avoid a sudden bolus of acetylcholine with next contrast injection.</li>
		<li>Repeat the coronary angiogram in the same projection as at rest. This should be sufficiently long to assess myocardial blush and TIMI frame counts, i.e., &#62;3 heart beats.</li>
	</ol>
	</li>
	<li>Connect Solution 2 (60 mL syringe; 10-5&#160;M).
	<ol>
		<li>Purge the IV line and guide catheter with 4 mL of acetylcholine solution to minimize any &#39;dead space&#39; effect when the infusion is commenced.</li>
		<li>With the guide catheter still co-axial, commence the infusion at 2 mL/min for 2 minutes.</li>
		<li>Have the cardiac catheterization laboratory physiologist start the digital stopwatch on the monitor to ensure accurate time keeping.</li>
		<li>Monitor the patient, vital signs and ECG for effects of acetylcholine. If encountering any safety concerns, stop the acetylcholine infusion immediately.</li>
		<li>After the 2 minute infusion is complete, acquire an ECG and assess the patient for symptoms.</li>
		<li>Gently purge the guide catheter system with contrast to avoid a sudden bolus of acetylcholine with next contrast injection.</li>
		<li>Repeat the coronary angiogram in the same projection as at rest. This should be sufficiently long to assess myocardial blush and TIMI frame counts, i.e., &#62;3 heart beats.</li>
	</ol>
	</li>
	<li>Connect Solution 3 (60 mL syringe; 10-4M).
	<ol>
		<li>Purge the IV line and guide catheter with 4 mL of acetylcholine solution to minimize any &#39;dead space&#39; effect when the infusion is commenced.</li>
		<li>With the guide catheter still co-axial, commence the infusion at 2 mL/min for 2 minutes.</li>
		<li>Have the cardiac catheterization laboratory physiologist start the digital stopwatch on the monitor to ensure accurate time keeping.</li>
		<li>Monitor the patient, vital signs and ECG for effects of acetylcholine. If encountering any safety concerns, stop the acetylcholine infusion immediately.</li>
		<li>After the 2 minute infusion is complete, acquire an ECG and assess the patient for symptoms.</li>
		<li>Gently purge the guide catheter system with contrast to avoid a sudden bolus of acetylcholine with next contrast injection.</li>
		<li>Repeat the coronary angiogram in the same projection as at rest. This should be sufficiently long to assess myocardial blush and TIMI frame counts, i.e., &#62;3 heart beats.</li>
	</ol>
	</li>
	<li>Manual administration (bolus) of acetylcholine. The dose is usually 100 &#181;g (5.5 mL of Solution 3) into a left coronary artery. This should be halved if infusing into a dominant coronary artery.
	<ol>
		<li>With the guide catheter still co-axial, commence manual infusion of the desired dose over 20 seconds.</li>
		<li>Have the cardiac catheterization laboratory physiologist start the digital stopwatch on the monitor to ensure accurate time keeping.</li>
		<li>Monitor the patient, vital signs and ECG for effects of acetylcholine. If encountering any safety concerns, stop the acetylcholine infusion immediately.</li>
		<li>After the infusion is complete, acquire an ECG and assess the patient for symptoms.</li>
		<li>Gently purge the guide catheter system with contrast to avoid a sudden bolus of acetylcholine with next contrast injection.</li>
		<li>Repeat the coronary angiogram in the same projection as at rest. This should be sufficiently long to assess myocardial blush and TIMI frame counts, i.e., &#62;3 heart beats.</li>
	</ol>
	</li>
	<li>Administer 300 mcg of intracoronary GTN and allow 30 seconds to take effect.
	<ol>
		<li>Acquire an ECG and assess the patient for symptoms.</li>
		<li>Repeat the coronary angiogram in the same projection as at rest. This should be sufficiently long to assess myocardial blush and TIMI frame counts, i.e., &#62;3 heart beats.</li>
	</ol>
	</li>
	<li>Finally, perform a &#39;pullback&#39; of the diagnostic guidewire and ensure &#39;signal drift&#39; &#8804;0.03. Consider a final angiogram to exclude distal guidewire injury.</li>
</ol>
4. Multivessel assessment
<ol>
	<li>Coronary function may vary between different coronary territories. The variation reflects differences in heart muscle mass subtended by individual coronary arteries, as well as disease (e.g., fibrosis). Therefore, while the IDP is usually performed in a single coronary artery, repeat testing or investigation of additional coronary arteries may be undertaken as felt to be clinically appropriate. A typical scenario would be when the initial test results are normal despite a strong clinical history; hence, assessing a second artery would be intended to avoid a false negative result. Similarly, vasospasm may vary between coronary arteries, so multi-vessel pharmacological testing may be considered if a high index of suspicion persists despite an initial negative response.</li>
</ol>

<ol>
	<li>Patel, M. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Low+Diagnostic+Yield+of+Elective+Coronary+Angiography.">Low Diagnostic Yield of Elective Coronary Angiography.</a> Engl J Med. 362 (10), 886-895 (2010).</li><li>Ford, T. J., Corcoran, D., Berry, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stable+coronary+syndromes:+Pathophysiology,+diagnostic+advances+and+therapeutic+need.">Stable coronary syndromes: Pathophysiology, diagnostic advances and therapeutic need.</a> Heart. 104 (4), 284-292 (2018).</li><li>Tavella, R., Cutri, N., Tucker, G., Adams, R., Spertus, J., Beltrame, J. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Natural+history+of+patients+with+insignificant+coronary+artery+disease.">Natural history of patients with insignificant coronary artery disease.</a> European Heart Journal - Quality of Care and Clinical Outcomes. 2 (2), 117-124 (2016).</li><li>Maddox, T. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Nonobstructive+coronary+artery+disease+and+risk+of+myocardial+infarction.">Nonobstructive coronary artery disease and risk of myocardial infarction.</a> JAMA - Journal of the American Medical Association. 312 (17), 1754-1763 (2014).</li><li>Jespersen, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stable+angina+pectoris+with+no+obstructive+coronary+artery+disease+is+associated+with+increased+risks+of+major+adverse+cardiovascular+events.">Stable angina pectoris with no obstructive coronary artery disease is associated with increased risks of major adverse cardiovascular events.</a> European Heart Journal. 33 (6), 734-744 (2012).</li><li>Ang, D. T. Y., Berry, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=What+an+Interventionalist+Needs+to+Know+About+INOCA.">What an Interventionalist Needs to Know About INOCA.</a> Interventional Cardiology: Reviews, Research, Resources. 16, (2021).</li><li>Ong, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=International+standardization+of+diagnostic+criteria+for+microvascular+angina.">International standardization of diagnostic criteria for microvascular angina.</a> International Journal of Cardiology. 250, 16-20 (2018).</li><li>Neumann, F. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=ESC+Guidelines+for+the+diagnosis+and+management+of+chronic+coronary+syndromes.">ESC Guidelines for the diagnosis and management of chronic coronary syndromes.</a> European Heart Journal. 41 (3), 407-477 (2020).</li><li>Kunadian, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=An+EAPCI+Expert+Consensus+Document+on+Ischaemia+with+Non-Obstructive+Coronary+Arteries+in+Collaboration+with+European+Society+of+Cardiology+Working+Group+on+Coronary+Pathophysiology+&amp;+Microcirculation+Endorsed+by+Coronary+Vasomotor+Disorders+International.">An EAPCI Expert Consensus Document on Ischaemia with Non-Obstructive Coronary Arteries in Collaboration with European Society of Cardiology Working Group on Coronary Pathophysiology &amp; Microcirculation Endorsed by Coronary Vasomotor Disorders International.</a> European heart journal. 41 (37), 3504-3520 (2020).</li><li>. Stratified medicine methodology framework - Research - Medical Research Council Available from: <a target="_blank" href="https://mrc.ukri.org/research/initiatives/precision-medicine/stratified-medicine-methodology-framework/">https://mrc.ukri.org/research/initiatives/precision-medicine/stratified-medicine-methodology-framework/</a> (2018)</li><li>Ford, T. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Stratified+Medical+Therapy+Using+Invasive+Coronary+Function+Testing+in+Angina:+The+CorMicA+Trial.">Stratified Medical Therapy Using Invasive Coronary Function Testing in Angina: The CorMicA Trial.</a> Journal of the American College of Cardiology. 72 (23), 2841-2855 (2018).</li><li>Ford, T. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=1-Year+Outcomes+of+Angina+Management+Guided+by+Invasive+Coronary+Function+Testing+(CorMicA).">1-Year Outcomes of Angina Management Guided by Invasive Coronary Function Testing (CorMicA).</a> JACC: Cardiovascular Interventions. 13 (1), 33-45 (2020).</li><li>Williams, R. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Doppler+Versus+Thermodilution-Derived+Coronary+Microvascular+Resistance+to+Predict+Coronary+Microvascular+Dysfunction+in+Patients+With+Acute+Myocardial+Infarction+or+Stable+Angina+Pectoris.">Doppler Versus Thermodilution-Derived Coronary Microvascular Resistance to Predict Coronary Microvascular Dysfunction in Patients With Acute Myocardial Infarction or Stable Angina Pectoris.</a> The American Journal of Cardiology. 121, 1-8 (2017).</li><li>Okumura, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sensitivity+and+specificity+of+intracoronary+injection+of+acetylcholine+for+the+induction+of+coronary+artery+spasm.">Sensitivity and specificity of intracoronary injection of acetylcholine for the induction of coronary artery spasm.</a> Journal of the American College of Cardiology. 12 (4), 883-888 (1988).</li><li>Sueda, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=complications+during+spasm+provocation+tests+with+an+intracoronary+injection+of+acetylcholine.">complications during spasm provocation tests with an intracoronary injection of acetylcholine.</a> The American journal of cardiology. 85 (3), 391-394 (2000).</li><li>Stygall, J., Kong, R., Walker, J. M., Hardman, S. M. C., Harrison, M. J. G., Newman, S. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cerebral+Microembolism+Detected+by+Transcranial+Doppler+During+Cardiac+Procedures.">Cerebral Microembolism Detected by Transcranial Doppler During Cardiac Procedures.</a> Stroke. 31 (10), 2508-2510 (2000).</li><li>Ford, T. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rationale+and+design+of+the+British+Heart+Foundation+(BHF)+Coronary+Microvascular+Angina+(CorMicA)+stratified+medicine+clinical+trial.">Rationale and design of the British Heart Foundation (BHF) Coronary Microvascular Angina (CorMicA) stratified medicine clinical trial.</a> American Heart Journal. 201, 86-94 (2018).</li><li>Sidik, N. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Rationale+and+design+of+the+British+Heart+Foundation+(BHF)+Coronary+Microvascular+Function+and+CT+Coronary+Angiogram+(CorCTCA)+study.">Rationale and design of the British Heart Foundation (BHF) Coronary Microvascular Function and CT Coronary Angiogram (CorCTCA) study.</a> American Heart Journal. 221, 48 (2020).</li><li>Japanese Circulation Society. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Guidelines+for+diagnosis+and+treatment+of+patients+with+vasospastic+angina+(Coronary+Spastic+Angina)+(JCS+2013).">Guidelines for diagnosis and treatment of patients with vasospastic angina (Coronary Spastic Angina) (JCS 2013).</a> Circulation journal: official journal of the Japanese Circulation Society. 78 (11), 2779-2801 (2014).</li><li>. Glyceryl Trinitrate 5 mg/ml Sterile Concentrate - Summary of Product Characteristics (SmPC) - (etc) Available from: <a target="_blank" href="https://www.medicines.org.uk/emc/product/3792/smpc#gref">https://www.medicines.org.uk/emc/product/3792/smpc#gref</a> (2022)</li></ol>

Drs Berry, Ang, Sidik, Morrow and Sykes are employed by the University of Glasgow which holds consultancy and research agreements with Abbott Vascular, AstraZeneca, Auxilius Pharma, Boehringer Ingelheim, Causeway Therapeutics, Coroventis, Genentech, GSK, HeartFlow, Menarini, Neovasc, Siemens Healthcare, and Valo Health.
Dr Berry receives research funding from the British Heart Foundation grant (RE/18/6134217), Chief Scientist Office, EPSRC (EP/R511705/1, EP/S030875/1), European Union (754946-2), Medical Research Council (MR/S018905/1) and UKRI (MC/PC/20014).
Dr McEntegart has no competing interests to declare.

Nitrate administration after radial artery cannulation reduces the propensity towards peripheral vasospasm that might hamper catheter manipulation. Intracoronary nitrates prior to diagnostic guidewire testing serves to negate any confounding epicardial spasm. Bearing the subsequent pharmacological provocation test in mind, only short-acting nitrates (e.g., GTN) are used. With a short half-life of approximately 2 minutes, the majority of this drug is metabolized prior to the later commencement of acetylcholine infusion20. In our experience, this has not led to false negative pharmacological test results. 
Guide catheter choice should be personalized to achieve the best balance between support and patient tolerability. The benefits of good catheter support include: reduced variation in volume delivered from each saline bolus, reduced risk of vessel injury due to less recoil of the catheter during rapid saline injections, and reduced transit time variability by stabilizing the diagnostic guidewire position within the vessel. 'Balloon-tracking', or alternatively 'catheter-assisted tracking' by advancing a 5 Fr diagnostic pigtail catheter within a 6 Fr guide, can help overcome issues with shearing injury and radial spasm6.
Provision of a dedicated 3 mL syringe may assist with thermodilution injections. When inspecting results for artefact and outliers, a &#8804;10% (or &#8804;0.1 s) variation between thermodilution transit times represent good consistency. Thermodilution deflection waveforms should be of similar shape and overlap.
If significant signal drift repeatedly occurs during measurement, check that all elements within the catheter and manifold system are secure. 'Pressure bleed' can occur from loose connections to the pressure transducer.

Approximately 40% of patients undergoing invasive coronary angiography for investigation of suspected angina are found to have no obstructive coronary artery disease (ANOCA)1. Anatomical imaging in coronary angiography has a spatial resolution of approximately 0.3 mm, which lacks sensitivity in visualizing the resistance arterioles that help to govern myocardial blood flow2. Supply/demand mismatch of myocardial blood flow relative to requirements may induce ischemia and drive angina symptom burden.
Coronary function testing provides information on the health of the coronary circulation, the presence and nature of abnormal coronary function. The goal of testing is therefore to aid in the diagnosis of coronary vasomotion disorders. These include coronary endothelial dysfunction, microvascular angina, vasospastic angina, post-percutaneous coronary intervention (PCI) angina and myocardial infarction with non-obstructive coronary arteries (MINOCA). These conditions are associated with impaired quality of life, higher morbidity and healthcare resource utilization3,4,5.
Coronary function tests are performed either as an adjunctive interventional diagnostic procedure (IDP) at the time of invasive coronary angiography, or non-invasively by cardiac MRI or transthoracic Doppler echocardiography. Its role within the diagnostic pathway has been discussed elsewhere6. Diagnostic criteria and linked therapy for the different endotypes of coronary vasomotion disorders are now established by expert consensus7 and clinical guidelines8,9.
Despite the advent of guidelines and objective testing, there remains variation in clinical practice for the diagnosis and management of this heterogenous group of patients. An alternative approach to coronary function testing is to institute a trial of therapy in all patients. Proponents of this approach cite a shorter procedural duration and reduced upfront cost from the procedural diagnostic guidewires and pharmacological testing agents.
However, stratifying patients by the differing disease mechanisms and personalizing their therapies is an approach that better aligns with the concept of precision medicine10. Indeed, the CorMicA trial served evidence that this approach may improve angina and quality of life in patients with ANOCA11,12.
Here, we present a protocol for an IDP to assess coronary vasomotor function. It is intended to enhance diagnostic power in the cardiac catheterization laboratory for patients with ANOCA.
General considerations for the IDP 
The IDP includes two distinct components6: a diagnostic guidewire test and a pharmacological coronary reactivity test. A common approach is to perform these tests in sequence, with acetylcholine administered before the diagnostic guidewire is withdrawn. The benefit of this approach is that the guidewire will stabilize the guide catheter, which in turn helps to ensure selective intracoronary infusion of acetylcholine and GTN.
The multidisciplinary team should involve an interventional cardiologist with prior experience of the acetylcholine test protocol, supported by the catheter laboratory team, including nurses, a physiologist, and a radiographer. Involving a second cardiologist may be helpful. The tests last approximately 5 minutes for the diagnostic guidewire component and 10-15 minutes for the pharmacological component.
Patient selection 
The IDP is performed at the time of invasive coronary angiography, either as a planned procedure or as an ad-hoc &#34;follow-on&#34; if no obstructive coronary artery disease is found, with the condition that informed consent has been obtained. The patient should be aware of the additional risks and benefits of the adjunctive interventional diagnostic procedure. Unless contraindicated, most patients undergoing investigation for possible angina may be considered. This is particularly helpful in patients who have had previous anatomical imaging (invasive or otherwise) to suggest the possibility of ANOCA.
Advanced renal dysfunction, where contrast media administration may be detrimental to renal function, is a relative contraindication to invasive angiography. Relative contraindications to acetylcholine testing include severe chronic obstructive pulmonary disease (COPD) and obstructive coronary artery disease (CAD). Vasoactive medications (such as beta-blockers, calcium channel blockers, and nitrates) and caffeine-containing drinks should be withheld for at least 24 hours pre-procedure.
The diagnostic guidewire 
Current diagnostic guidewires utilize a combined technology of a pressure sensor with either: 1) a temperature sensor to estimate flow based on the principles of thermodilution, or 2) an ultrasound sensor to estimate flow based on the Doppler principle. Thermodilution-based wires are safe and straightforward to use11. Doppler/pressure wires may have higher accuracy and better correlation with non-invasive testing results, but at the expense of wire maneuverability13. This review focuses on thermodilution-based guidewires.
The pharmacological reactivity test 
Pharmacological tests of coronary reactivity involve intracoronary infusion of acetylcholine and glyceryl trinitrate (GTN), to assess the vasodilator potential and propensity to vasospasm of the main coronary arteries and microcirculation. Vasodilatation is the normal, expected response to infusion of physiological concentrations of acetylcholine. Vascular spasm represents an abnormal response, which would support the diagnosis of vasospastic angina. Okumura et al. demonstrated that intracoronary acetylcholine had 90% sensitivity and 99% specificity for diagnosing epicardial spasm14.
Safety considerations 
The half-life of acetylcholine is 1-2 seconds. Any physiological responses will cease within 5-10 seconds. More than three decades of experience with intracoronary acetylcholine tests support overall procedural safety. Self-limiting bradycardia and heart block are to be expected. These effects may be more profound if acetylcholine is infused into the dominant coronary artery, but should nonetheless be transient.
Atropine should be at hand, ready for administration, however the short half-life of acetylcholine means that it is rarely required. A simple cough maneuver by the patient is usually sufficient to restore sinus rhythm. Shortening of the atrial refractory period and increased propensity to atrial fibrillation (&#60;10%) can occur, but this is typically short lived.
A review by Sueda et al. found a rate of 0.6% for major complications, such as ventricular tachycardia, cardiac tamponade and shock with intracoronary acetylcholine15. More recent experience in the CorMicA study11 did not reveal any serious adverse events secondary to the IDP. Together, these findings reinforce the importance of informed consent. Acetylcholine should be pre-ordered by a cardiologist on a named patient basis from the pharmacy.
Thromboprophylaxis and loading with antiplatelet therapy 
Standard coronary angiography is associated with a small risk of thromboembolism. Subclinical micro-emboli may occur, as revealed by transcranial Doppler studies16. Further, guidewire-based coronary instrumentation carries a very small risk of vascular injury, which may in turn necessitate PCI. Therefore, platelet inhibition may be considered for thromboprophylaxis at the time of the procedure, and to optimize patient safety. Indeed, the pre-procedural clinical plan for some of these patients may already include antiplatelet therapy, due to the possibility of obstructive coronary artery disease and/or PCI at the time of angiography. Since radial artery access is routinely used, the risks of bleeding are considered minimal. There is no interaction anticipated between dual antiplatelet therapy, including a loading dose of aspirin and clopidogrel, and the coronary response to acetylcholine.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Coroflow software</td>
			<td>Coroventis</td>
			<td>N/A</td>
			<td>https://www.coroventis.com/coroflow/measurements-indepth/</td>
		</tr>
		<tr>
			<td>Miochol-E, 20 mg, Powder and Solvent for instillation solution for intraocular use.</td>
			<td>Bausch &#38; Lomb U.K Limited</td>
			<td>Unlicensed for parenteral use</td>
			<td>https://www.medicines.org.uk/emc/product/4795/smpc#gref</td>
		</tr>
		<tr>
			<td>PressureWire Receiver</td>
			<td>Abbott Vascular</td>
			<td>C17040</td>
			<td>https://www.cardiovascular.abbott/us/en/hcp/products/percutaneous-coronary-intervention/pressurewireX-guidewires-physiology/ht-tab/ordering-info.html</td>
		</tr>
		<tr>
			<td>PressureWire X Guidewire, 175 cm</td>
			<td>Abbott Vascular</td>
			<td>C12059</td>
			<td>https://www.cardiovascular.abbott/us/en/hcp/products/percutaneous-coronary-intervention/pressurewireX-guidewires-physiology/ht-tab/ordering-info.html</td>
		</tr>
	</tbody>
</table>

interventional diagnostic procedure: a practical guide for the assessment of coronary vascular function

Approximately 40% of patients undergoing invasive coronary angiography for investigation of angina are found to have no obstructive coronary artery disease (ANOCA). Abnormal coronary function underlies coronary vasomotion syndromes including coronary endothelial dysfunction, microvascular angina, vasospastic angina, post-PCI angina and myocardial infarction with no obstructive coronary arteries (MINOCA). Each of these endotypes are distinct subgroups, characterized by specific disease mechanisms. Diagnostic criteria and linked therapy for these conditions are now established by expert consensus and clinical guidelines.
Coronary function tests are performed as an adjunctive interventional diagnostic procedure (IDP) in appropriately selected patients during coronary angiography. This aids differentiation of patients according to endotype. The IDP includes two distinct components: a diagnostic guidewire test and a pharmacological coronary reactivity test. The tests last approximately 5 minutes for the former and 10-15 minutes for the latter. Patient safety and staff education are key.
The diagnostic guidewire test measures parameters of coronary flow limitation (fractional flow reserve [FFR], coronary flow reserve [CFR], microvascular resistance [index of microvascular resistance (IMR)], basal resistance index, and vasodilator function [CFR, resistive reserve ratio (RRR)]).
The pharmacological coronary reactivity test measures the vasodilator potential and propensity to vasospasm of both the main coronary arteries and the micro-vessels. It involves intra-coronary infusion of acetylcholine and glyceryl trinitrate (GTN). Acetylcholine is not licensed for parenteral use and is therefore prescribed on a named-patient basis. Vasodilatation is the normal, expected response to infusion of physiological concentrations of acetylcholine. Vascular spasm represents an abnormal response, which supports the diagnosis of vasospastic angina.
The purpose of this practical guide is to provide information on the preparation and administration of the IDP in clinical practice. It discusses some key preparation and safety considerations, as well as tips for procedural success. The IDP supports stratified medicine for a personalized approach to health and wellbeing.

The ultimate goal of the IDP is to be able to differentiate patients according to their respective clinical endotypes and institute appropriate management. The main endotypes to consider are: microvascular angina, vasospastic angina, mixed (both), or non-cardiac symptoms. The individual endotypes and diagnostic criteria are summarized in Table 1. Figure 1 further illustrates how these criteria are applied at each step of the IDP, with examples of abnormal results.
Diagnostic guidewire test 
The diagnostic guidewire test measures parameters of coronary flow limitation (fractional flow reserve [FFR], coronary flow reserve [CFR], microvascular resistance [index of microvascular resistance (IMR)], basal resistance index, and vasodilator function [CFR, resistive reserve ratio (RRR)]). Abnormal results are defined below:
FFR &#8804;0.80 is indicative of obstructive epicardial disease.
CFR &#60;2.0 (2.0-2.5 = &#39;grey zone&#39;) in the absence of obstructive epicardial disease is indicative of microvascular angina.
IMR &#8805;25 is indicative of microvascular angina.
RRR&#60;2.0 is indicative of microvascular angina.
Acetylcholine provocation test 
A clinical response is reflected by concomitant symptoms (i.e., chest pain), changes on the ECG (i.e., ST-segment deviation) and/or angiogram (Figure 1). Abnormalities on the coronary angiogram include: reduction in coronary artery diameter when assessed visually or measured by quantitative coronary analysis (QCA), transient impairment in antegrade coronary flow (TIMI flow), and a reduced myocardial blush.
Vasospastic angina symptoms typically occur at rest, may exhibit marked diurnal variation, and may be precipitated by hyperventilation19. The European Association of Percutaneous Cardiovascular Interventions (EAPCI)9 and Japanese Circulation Society (JCS)19 have proposed standardized criteria for the diagnosis of vasospastic angina. These are summarized in Table 1. Recognition of vasospastic angina is important due to its associated increased risk of myocardial infarction19.
Vasospastic angina is diagnosed when there is &#8805;90% reduction in coronary luminal diameter, along with reproduction of anginal symptoms and ischemic ECG changes.
Microvascular spasm is diagnosed with the reproduction of angina, ST-segment deviation, &#60;90% change in epicardial lumen diameter, and/or TIMI flow reduction.
Table 1: Diagnostic criteria for each endotype (disease sub-group). <a href="https://www.jove.com/files/ftp_upload/62265/Table1.xlsx" target="_blank">Please click here to download this Table.</a>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/62265/62265fig01.jpg" /> 
Figure 1: Summary flow-chart for interpretation of IDP results, with illustrative examples. IMR, index of microvascular resistance; CFR, coronary flow reserve. <a href="https://www.jove.com/files/ftp_upload/62265/62265fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function at JoVE.com

Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function

The purpose of this practical guide is to provide information on the preparation and administration of an interventional diagnostic procedure in clinical practice. It discusses some key preparation and safety considerations, as well as tips for procedural success.

Approximately 40% of patients undergoing invasive coronary angiography for investigation of angina are found to have no obstructive coronary artery ...

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4.6K Views.  Golden Jubilee National Hospital. The purpose of this practical guide is to provide information on the preparation and administration of an interventional diagnostic procedure in clinical practice. It discusses some key preparation and safety considerations, as well as tips for procedural success.

Video: Interventional Diagnostic Procedure: A Practical Guide for the Assessment of Coronary Vascular Function

Dual-mode Imaging of Cutaneous Tissue Oxygenation and Vascular Function

Accurate assessment of cutaneous tissue oxygenation and vascular function is important for appropriate detection, staging, and treatment of many health disorders such as chronic wounds. We report the development of a dual-mode imaging system for non-invasive and non-contact imaging of cutaneous tissue oxygenation and vascular function. The imaging system integrated an infrared camera, a CCD camera, a liquid crystal tunable filter and a high intensity fiber light source. A Labview interface was programmed for equipment control, synchronization, image acquisition, processing, and visualization. Multispectral images captured by the CCD camera were used to reconstruct the tissue oxygenation map. Dynamic thermographic images captured by the infrared camera were used to reconstruct the vascular function map. Cutaneous tissue oxygenation and vascular function images were co-registered through fiduciary markers. The performance characteristics of the dual-mode image system were tested in humans.

A dual-mode imaging system was developed for non-contact assessment of cutaneous tissue oxygenation and vascular function.

Accurate assessment of cutaneous tissue oxygenation and vascular function is important for appropriate detection, staging, and treatment of many health ...

Guide Wire Assisted Catheterization and Colored Dye Injection for Vascular Mapping of Monochorionic Twin Placentas

Monochorionic (MC) twin pregnancies are associated with significantly higher morbidity and mortality rates than dichorionic twins. Approximately 50% of MC twin pregnancies develop complications arising from the shared placenta and associated vascular connections1. Severe twin-to-twin syndrome (TTTS) is reported to account for approximately 20% of these complications2,3. Inter-twin vascular connections occur in almost all MC placentas and are related to the prognosis and outcome of these high-risk twin pregnancies. The number, size and type of connections have been implicated in the development of TTTS and other MC twin conditions. Three types of inter-twin vascular connections occur: 1) artery to vein connections (AVs) in which a branch artery carrying deoxygenated blood from one twin courses along the fetal surface of the placenta and dives into a placental cotyledon. Blood flows via a deep intraparenchymal capillary network into a draining vein that emerges at the fetal surface of the placenta and brings oxygenated blood toward the other twin. There is unidirectional flow from the twin supplying the afferent artery toward the twin receiving the efferent vein; 2) artery to artery connections (AAs) in which a branch artery from each twin meets directly on the superficial placental surface resulting in a vessel with pulsatile bidirectional flow, and 3) vein to vein connections (VVs) in which a branch vein from each twin meets directly on the superficial placental surface allowing low pressure bidirectional flow. In utero obstetric sonography with targeted Doppler interrogation has been used to identify the presence of AV and AA connections4. Prenatally detected AAs that have been confirmed by postnatal placental injection studies have been shown to be associated with an improved prognosis for both twins5. Furthermore, fetoscopic laser ablation of inter-twin vascular connections on the fetal surface of the shared placenta is now the preferred treatment for early, severe TTTS. 
Postnatal placental injection studies provide a valuable method to confirm the accuracy of prenatal Doppler ultrasound findings and the efficacy of fetal laser therapy6. Using colored dyes separately hand-injected into the arterial and venous circulations of each twin, the technique highlights and delineates AVs, AAs, and VVs. This definitive demonstration of MC placental vascular anatomy may then be correlated with Doppler ultrasound findings and neonatal outcome to enhance our understanding of the pathophysiology of MC twinning and its sequelae. Here we demonstrate our placental injection technique.

Vascular mapping of monochorionic (MC) twin placentas after birth provides a means for detailed demonstration of vascular connections between the twins&#x2019; circulations. 
Imbalance of these connections is thought to play a pivotal role in the development of complications of MC twinning including twin-to-twin transfusion syndrome.

Monochorionic (MC) twin pregnancies are associated with significantly higher morbidity and mortality rates than dichorionic twins. Approximately 50% of MC ...

Dual-phase Cone-beam Computed Tomography to See, Reach, and Treat Hepatocellular Carcinoma during Drug-eluting Beads Transarterial Chemo-embolization

The advent of cone-beam computed tomography (CBCT) in the angiography suite has been revolutionary in interventional radiology. CBCT offers 3 dimensional&#160;(3D) diagnostic imaging in the interventional suite and can enhance minimally-invasive therapy beyond the limitations of 2D angiography alone. The role of CBCT has been recognized in transarterial chemo-embolization (TACE) treatment of hepatocellular carcinoma (HCC). The recent introduction of a CBCT technique: dual-phase CBCT (DP-CBCT) improves intra-arterial HCC treatment with drug-eluting beads (DEB-TACE). DP-CBCT can be used to localize liver tumors with the diagnostic accuracy of multi-phasic multidetector computed tomography (M-MDCT) and contrast enhanced magnetic resonance imaging (CE-MRI) (See the tumor), to guide intra-arterially guidewire and microcatheter to the desired location for selective therapy (Reach the tumor), and to evaluate treatment success during the procedure (Treat the tumor). The purpose of this manuscript is to illustrate how DP-CBCT is used in DEB-TACE to see, reach, and treat HCC.

Dual-phase cone-beam computed tomography (DP-CBCT) is a useful intraprocedural imaging technique for transarterial chemo-embolization treatment with drug-eluting beads of hepatocellular carcinoma. DP-CBCT has been used to perform three major steps in oncologic interventional radiology: tumor localization (see), navigation and intraprocedural catheter guidance (reach), and intraprocedural evaluation of treatment success (treat).

The advent of cone-beam computed tomography (CBCT) in the angiography suite has been revolutionary in interventional radiology. CBCT offers 3 ...

Diagnostic Ultrasound Imaging of Mouse Diaphragm Function

Function analysis of rodent respiratory skeletal muscles, particularly the diaphragm, is commonly performed by isolating muscle strips using invasive surgical procedures. Although this is an effective method of assessing in vitro diaphragm activity, it involves non-survival surgery. The application of non-invasive ultrasound imaging as an in vivo procedure is beneficial since it not only reduces the number of animals sacrificed, but is also suitable for monitoring disease progression in live mice. Thus, our ultrasound imaging method may likely assist in the development of novel therapies that alleviate muscle injury induced by various respiratory diseases. Particularly, in clinical diagnoses of obstructive lung diseases, ultrasound imaging has the potential to be used in conjunction with other standard tests to detect the early onset of diaphragm muscle fatigue. In the current protocol, we describe how to accurately evaluate diaphragm contractility in a mouse model using a diagnostic ultrasound imaging technique.

Diagnostic ultrasound imaging has proven to be effective in diagnosing various respiratory diseases in human and animal subjects. We demonstrate a comprehensive ultrasound protocol utilized by Dr. Zuo's lab to analyze diaphragm kinetics specifically in mouse models. This is also a non-invasive research technique which can provide quantitative information on mouse respiratory muscle function.

Function analysis of rodent respiratory skeletal muscles, particularly the diaphragm, is commonly performed by isolating muscle strips using invasive ...

Assessment of Vascular Function in Patients With Chronic Kidney Disease

Patients with chronic kidney disease (CKD) have significantly increased risk of cardiovascular disease (CVD) compared to the general population, and this is only partially explained by traditional CVD risk factors. Vascular dysfunction is an important non-traditional risk factor, characterized by vascular endothelial dysfunction (most commonly assessed as impaired endothelium-dependent dilation [EDD]) and stiffening of the large elastic arteries. While various techniques exist to assess EDD and large elastic artery stiffness, the most commonly used are brachial artery flow-mediated dilation (FMDBA) and aortic pulse-wave velocity (aPWV), respectively. Both of these noninvasive measures of vascular dysfunction are independent predictors of future cardiovascular events in patients with and without kidney disease. Patients with CKD demonstrate both impaired FMDBA, and increased aPWV. While the exact mechanisms by which vascular dysfunction develops in CKD are incompletely understood, increased oxidative stress and a subsequent reduction in nitric oxide (NO) bioavailability are important contributors. Cellular changes in oxidative stress can be assessed by collecting vascular endothelial cells from the antecubital vein and measuring protein expression of markers of oxidative stress using immunofluorescence. We provide here a discussion of these methods to measure FMDBA, aPWV, and vascular endothelial cell protein expression.

The degree of vascular dysfunction and contributing physiological mechanisms can be assessed in patients with chronic kidney disease by measuring brachial artery flow-mediated dilation, aortic pulse-wave velocity, and vascular endothelial cell protein expression.

Patients with chronic kidney disease (CKD) have significantly increased risk of cardiovascular disease (CVD) compared to the general population, and this ...

Permanent Ligation of the Left Anterior Descending Coronary Artery in Mice: A Model of Post-myocardial Infarction Remodelling and Heart Failure

Heart failure is a syndrome in which the heart fails to pump blood at a rate commensurate with cellular oxygen requirements at rest or during stress. It is characterized by fluid retention, shortness of breath, and fatigue, in particular on exertion. Heart failure is a growing public health problem, the leading cause of hospitalization, and a major cause of mortality. Ischemic heart disease is the main cause of heart failure.
Ventricular remodelling refers to changes in structure, size, and shape of the left ventricle. This architectural remodelling of the left ventricle is induced by injury (e.g., myocardial infarction), by pressure overload (e.g., systemic arterial hypertension or aortic stenosis), or by volume overload. Since ventricular remodelling affects wall stress, it has a profound impact on cardiac function and on the development of heart failure. A model of permanent ligation of the left anterior descending coronary artery in mice is used to investigate ventricular remodelling and cardiac function post-myocardial infarction. This model is fundamentally different in terms of objectives and pathophysiological relevance compared to the model of transient ligation of the left anterior descending coronary artery. In this latter model of ischemia/reperfusion injury, the initial extent of the infarct may be modulated by factors that affect myocardial salvage following reperfusion. In contrast, the infarct area at 24 hr after permanent ligation of the left anterior descending coronary artery is fixed. Cardiac function in this model will be affected by 1) the process of infarct expansion, infarct healing, and scar formation; and 2) the concomitant development of left ventricular dilatation, cardiac hypertrophy, and ventricular remodelling.
Besides the model of permanent ligation of the left anterior descending coronary artery, the technique of invasive hemodynamic measurements in mice is presented in detail.

Heart failure is the leading cause of hospitalization and a major cause of mortality. A model of permanent ligation of the left anterior descending coronary artery in mice is applied to investigate ventricular remodelling and cardiac dysfunction post-myocardial infarction. The technique of invasive hemodynamic measurements in mice is presented.

Heart failure is a syndrome in which the heart fails to pump blood at a rate commensurate with cellular oxygen requirements at rest or during stress. It ...

Chronic Thromboembolic Pulmonary Hypertension and Assessment of Right Ventricular Function in the Piglet

An original piglet model of Chronic Thromboembolic Pulmonary Hypertension (CTEPH) associated with chronic Right Ventricular (RV) dysfunction is described. Pulmonary Hypertension (PH) was induced in 3-week-old piglets by a progressive obstruction of the pulmonary vascular bed. A ligation of the left Pulmonary Artery (PA) was performed first through a mini-thoracotomy. Second, weekly embolizations of the right lower pulmonary lobe were done under fluoroscopic guidance with n-butyl-2-cyanoacrylate during 5 weeks. Mean Pulmonary Arterial Pressure (mPAP) measured by ritght heart catheterism, increased progressively, as well as Right Atrial pressure and Pulmonary Vascular Resistances (PVR) after 5 weeks compared to sham animals. Right Ventricular (RV) structural and functional remodeling were assessed by transthoracic echocardiography (RV diameters, RV wall thickness, RV systolic function). RV elastance and RV-pulmonary coupling were assessed by Pressure-Volume Loops (PVL) analysis with conductance method. Histologic study of the lung and the right ventricle were also performed. Molecular analyses on RV fresh tissues could be performed through repeated transcutaneous endomyocardial biopsies. Pulmonary microvascular disease in obstructed and unobstructed territories was studied from lung biopsies using molecular analyses and pathology. Furthermore, the reliability and the reproducibility was associated with a range of PH severity in animals. Most aspects of the human CTEPH disease were reproduced in this model, which allows new perspectives for the understanding of the underlying mechanisms (mitochondria, inflammation) and new therapeutic approaches (targeted, cellular or gene therapies) of the overloaded right ventricle but also pulmonary microvascular disease.

Chronic Thromboembolic Pulmonary Hypertension (CTEPH) and Right Ventricular (RV) dysfunction were induced in piglets by progressive obstruction of the pulmonary arteries. Consequences were remarkably similar to those observed in CTEPH patients. This animal model would be a very useful tool for pathophysiology and therapeutic experiments on CTEPH and RV failure.

An original piglet model of Chronic Thromboembolic Pulmonary Hypertension (CTEPH) associated with chronic Right Ventricular (RV) dysfunction is described. ...

Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide

Time is of the essence when caring for an acute stroke patient. The ultimate goal is to restore blood flow to the ischemic brain. This can be&#160;achieved by either&#160;thrombolysis with recombinant tissue-plasminogen activator (rt-PA), the standard therapy for stroke patients who present within the first hours of symptom onset without contraindications, or by an endovascular approach, if a proximal brain vessel occlusion is detected. As the efficacy of both therapies declines over time, every minute saved along the way will improve the patient&#39;s outcome.
This critical situation requires thorough work and precise communication with the patient, the family and colleagues from different professions to acquire all relevant information and reach the right decision while carefully monitoring the patient. This is a high fidelity situation. In nonmedical high-fidelity environments such as aviation, Crew Resource Management (CRM) is used to enhance safety and team efficiency.
This guide shows how a Stroke Team algorithm, which is transferable to other hospital settings, was established and how regular simulation-based trainings were performed. It requires determination and endurance to maintain these time-consuming simulation trainings on a regular basis over the course of time. However, the resulting improvement of team spirit and excellent door-to-needle times will benefit both the patients and the work environment in any hospital.
A dedicated Stroke Team of 7 persons who are notified 24/7 by a collective call via speed dial and run a binding algorithm that takes approximately 20 min, was established. To train everybody involved in this algorithm, a simulation-based team training for all new Stroke Team members was conceived and conducted at monthly intervals. This led to a relevant and sustained reduction of the mean door-to-needle time to 25 min, and enhanced the feeling of stroke readiness especially in junior doctors and nurses.

Every min counts in acute stroke care. This guide shows how to establish a Stroke Team algorithm and enhance its performance with regular simulation training. The principles of Crew Resource Management (CRM) facilitate a straight workflow, reduce door-to-needle times and increase staff satisfaction.

Time is of the essence when caring for an acute stroke patient. The ultimate goal is to restore blood flow to the ischemic brain. This can ...

Oral Health Assessment by Lay Personnel for Older Adults

Oral health is an often-undervalued contributor to overall health. The literature, however, underscores the myriad of systemic diseases influenced by oral health, including type II diabetes, heart disease, and atherosclerosis. Thus, assessments of oral health, called oral screenings, have a significant role in assessing risk of disease, managing disease, and even improving disease by oral care. Here we present a method to assess oral health quickly and consistently across time. The protocol is simple enough for non-oral health professionals such as students, family, and caregivers. Useful for any age of patient, the method is particularly key for older individuals who are often at risk of inflammation and chronic disease. Components of the method include existing oral health assessment scales and inventories, which are combined to produce a comprehensive assessment of oral health. Thus, oral characteristics assessed include intraoral and extraoral structures, soft and hard tissues, natural and artificial teeth, plaque, oral functions such as swallowing, and the impact this oral health status has on the patient&#39;s quality of life. Advantages of this method include its inclusion of measures and perceptions of both the observer and patient, and its ability to track changes in oral health over time. Results acquired are quantitative totals of questionnaire and oral screening items, which can be summed for an oral health status score. The scores of successive oral screenings can be used to track the progression of oral health across time and guide recommendations for both oral and overall health care.

The goal of this protocol is to enable non-dental professionals to assess oral health status for research or health-screening purposes. Aspects assessed include lips, tongue, soft and hard tissues, natural and artificial teeth, oral cleanliness, plaque, swallowing, and impact of oral health on quality of life.

Oral health is an often-undervalued contributor to overall health. The literature, however, underscores the myriad of systemic diseases influenced by oral ...

Intrathecal Application of a Fluorescent Dye for the Identification of Cerebrospinal Fluid Leaks in Cochlear Malformation

In cases of cerebrospinal fluid (CSF) leaks, reliable detection of their origins is needed to seal the leak sufficiently and prevent complications, such as meningitis. A method is presented here using intrathecal administered fluorescein in a clinical case of bilateral congenital ear malformation. A fluorescent dye is administered intrathecally to achieve intraoperative visualization of CSF leaks. The dye is applied 20 min before surgery, and concentration of 5% is used. Per every 10 kg of body weight, 0.1 mL of the fluid is applied intrathecally. The fluorescein is visualized using a fully digital microscope. The origin of the fluid leak is identified in the stapes footplate. During primary surgery, it is sealed, and cochlea implantation is performed for hearing restoration. In this specific case, 6 weeks later, the implant was explanted due to acute meningitis, and the electrode array was left as a spacer. Postoperatively, in the aural smear, &#946;-transferrin was detected. During a revision mastoidectomy, dislocated coverage of the leak was found. The stapes was removed and oval window sealed. Five days after revision surgery, no &#946;-transferrin was detected in the aural smear. During the revision of cochlea implantation 6 months later, intact coverage of the oval niche was observed. Thus, intrathecal fluorescein application proves to be a reliable tool for the detection of CSF leaks. It facilitates the orientation in malformations and complicated or unknown surgical situs. In the literature, its use is described for CSF fistulas in endonasal surgery but is rarely described in skull base and mastoid surgeries. The method has been used successfully in several cases with CSF leaks, and the results confirm the feasibility of safely accessing the origin of the leak.

Intrathecally applied fluorescein is used to achieve intraoperative visualization of CSF leaks. This protocol describes a lumbar puncture, the application of 5% fluorescein, and intraoperative visualization using a fully digital microscope.

In cases of cerebrospinal fluid (CSF) leaks, reliable detection of their origins is needed to seal the leak sufficiently and prevent complications, such ...