FFR-临床应用.ppt

What can be learned and achievedfrom“FFR-guided PCI”?,FFR(血流储备分数）临床应用,FFR=,存在狭窄病变时血管所能获得的最大血流量,正常状态下时血管所能获得的最大血流量,什么是FFR?,（pa：主动脉压）,冠脉,FFR=,Qs,QN,max,max,Rmyo,Q,Pv,Rmyo,Q,Pv,Pa,Pd,Pa,Pd,当使用腺苷等微循环扩张类药物的情况下,什么是FFR?,正常值 FFR=1.0,Pa,Pd,Pd=Pa,100,100,存在狭窄病变FFR 1,Pa,Pd,Pd Pa,100,70,什么是FFR?,是否具有临床意义？,“Measurement of Fractional Flow Reserve to asses the Functional Severity of Coronary Artery Stenoses”,Pijls et al;The New England Journal of Medicine;Vol 334:1703-1708(1996),FFR 0.75 心肌缺血的可能性非常小(敏感度 88%),NOT significant,Significant,1.0,0.80,0.75,0,什么是FFR?,是否行介入治疗？,最佳的药物治疗,PCI/血运重建,1.0,0.80,0.75,0,加大血管扩张药物的剂量，再重新测定FFR；结合其他的指标及临床情况，综合判断；,目前常用的FFR临界值为0.8,什么是FFR?,FFR真正的意义在于告诉我们这个病变是否需要PCI。FFR已经成为冠脉狭窄功能性评价的金标准。,欧洲ESC指南规定：FFR为IA级临床证据。ESC指南建议：对于未经无创功能试验检查的病人，造影显示狭窄程度在50-90%的，建议进行FFR检查，根据检查结果决定是否进行PCI治疗，或者转到外科搭桥。无论患者是单支血管病变，多支病变，左主干或前降支近端病变。,FFR 压力导丝的临床应用,临界病变或模糊病变多支病变串联病变弥漫病变左主干病变分叉病变支架内再狭窄介入后再评价急性冠脉综合征,Where can we use pressure wire?,临界病变或模糊病变多支病变串联病变弥漫病变左主干病变分叉病变支架内再狭窄介入后再评估急性冠脉综合征,临界病变,Mismatched Case,临界病变,Matched Case,临界病变,Topol and Nissen Circulation 1995;92:2333-42,冠脉造影的局限,Pijl NH,JACC 2007;49:2105,对没用功能学意义（即FFR0.75）的中度狭窄进行PCI，并不能改善心绞痛的症状，同时也不会减少相关药物的使用量。,DEFER 研究,50-70%狭窄：仅凭造影会有35%的缺血病人被忽略治疗。70%狭窄：仅凭造影会有20%的没有缺血的病人被过度治疗,Angiographic Versus Functional Severity of Coronary Artery Stenoses in the FAME StudyFractional Flow R versus Angiography in Multivessel Evaluation.JACC.Jan.15.2010,FAME分析（FFR与造影对比）,Nam CW,et al.JACC interv 2010:3:812,临界病变PCI:FFR vs IVUS,Where can we use pressure wire?,临界病变或模糊病变多支病变串联病变弥漫病变左主干病变分叉病变支架内再狭窄介入术后再评估急性冠脉综合征,多支病变（串联的和/或弥漫的多点病变）,需要回答的问题是哪个或哪些狭窄引起缺血？这些狭窄都需要通过PCI治疗吗？哪些点或部分是最佳的PCI位置？需要多少支架？是多长的支架？该病人是不是搭桥的适应症？是不是药物治疗是他最好的选择？,Normal Myocardium,MLD,Cross-sectional area and stenosis resistance are identical,but physiologic severity is different!,normal myocardium,灌注面积的主要性:,MLD=1.9 mmCSA=4.5 mm2,Normal Myocardium,MLD,Cross-sectional area,and stenosis resistance areidentical,but physiologic severity is different!,相同狭窄，正常心肌面积不同。,100,100,85,60,normal myocardium,FFR=0.60,FFR=0.85,Normal Myocardium,Normal Myocardium,Anatomic stenosis severity and resistance is identical,but physiologic severity is different!,Identical%stenosis but different physiologic significance,SCAR,Normal Myocardium,Normal Myocardium,Scar,Anatomic stenosis severity remains unchanged but physiologic severity has decreased.FFR accounts for those changes!,Previous myocardial infarction(decreased perfusion territory):,60,80,100,100,FFR=0.60,FFR=0.80,26 col-schema fcf(figuur),Coron flow30 ml/min,Poor collaterals,inducibleischemia,Pd,相同狭窄,同程度的侧枝循环。,Myocardial flow35 ml/min,collat flow5 ml/min,26 col-schema fcf(figuur),Coron flow30 ml/min,Well-developed collaterals,No inducible ischemia,Pd,Myocardial flow55 ml/min,collat flow25 ml/min,相同狭窄，不同程度的侧枝循环,26 col-schema fcf(figuur),Poor collaterals low FFR,100,Poor collaterals:FFR=0.40,Pd,40,“One identical stenosis,but.”,0,26 col-schema fcf(figuur),Good collaterals higher FFR,100,Good collaterals:FFR=0.80,Pd,80,“An identical stenosis,but.”,0,100,FFR 0.87,FFR 0.89,FFR 0.88,FFR 0.50,在造影认为的3支病变中，经FFR测量 14%是 3-VD 43%是 2-VD 34%是 1-VD 9%是 0-VD,FAME分析（FFR与造影对比）,多支病变FFR的应用,1、需要对每支病变血管进行FFR测定2、建议静脉给予扩血管药物3、根据FFR结果，决定是否PCI。,Where can we use pressure wire?,临界病变或模糊病变多支病变串联病变弥漫病变左主干病变分叉病变支架内再狭窄介入术后再评估急性冠脉综合征,0.70,0.70,串联病变,0.95,0.95,1.00,1.00,在最大充血状态下进行PULL-BACK 1、把导丝放置于病变冠脉的远端。2、静脉连续滴注ATP或腺苷，诱导最大充血状态。3、如果FFR0.8，则串联病变可诱发缺血，PCI是合适的。4、在透视状态缓慢回撤导丝，发现有突然压力改变的点或节段。如果局部压力阶差10mmHg，可以考虑在这个部位放置支架。5、优先处理压力阶差大的病变，如果病变压力相似，优先处理远端病变。,串联病变FFR应用:Pressure Pull-back Curve（压力回撤曲线）,在最大充血状态下进行PULL-BACK 6、最严重的病变放置支架后，需要再次做PULLBACK，需要理解的一点，在最严重的病变放完支架，与术前比，其他病变的压力阶差会上升。重要规律：一个严重的远端病变可以掩盖近端病变的压力阶差，反之亦然。,串联病变FFR应用:Pressure Pull-back Curve（压力回撤曲线）,7、支架节段的压力阶差10mmHg，就不需要进一步处理。,1,2,3,4,4,1,2,3,Where can we use pressure wire?,临界病变或模糊病变多支病变串联病变弥漫长病变左主干病变分叉病变支架再狭窄介入术后再评估急性冠脉综合征,弥漫长病变,How to Distinguish Focal from Diffuse?,在充血状态下进行导丝PULLBACK,Hennico Walter85621,H.W.(85621)57-y-o manUnstable Angina,Hennico Walter85621,Sensor Left in Distal LAD,Hennico Walter85621,H.W.(85621)57-y-o man Unstable Angina,Hennico Walter85621,H.W.(85621)57-y-o man:Unstable Angina,Pullback of Sensor from Distal LAD to LM,Hennico Walter85621,H.W.(85621)57-y-o man:Unstable Angina,Pullback of Sensor from Distal LAD to LM,压力的测量和弥漫病变,Pullback pressure tracings obtained under steady state maximal hyperemia is presently the only available means to localize and to quantify the abnormal resistance along an epicardial vessel.,弥漫病变压力测量,1.动脉粥样硬化大多为弥漫性的。2.弥漫的病变一般也会存在压力阶差。3.将导丝放置最远端，在最大充血状态，测定所有狭窄构成FFR值。4.通过一个狭窄压力阶差往往被第二个狭窄所掩盖，尤其是第二个狭窄位于远端的时候。5.当一个狭窄进行PCI术后，另一个狭窄的压力阶差也明显起来。,Pressure Measurements in Diffuse Disease,1.弥漫病变无局灶点病变把导丝放到最远端IV ATP 诱导最大充血状态。透视下手动回撤导丝。(one eye on the fluoro,one eye on the pressure tracing)当压力阶差10mmHg，PCI,Multiple stenoses and diffuse disease:In some patients,focal or segmental pressuredrops can be detected and stenting in the right way is beneficial,like in the patient above.Sometimes,however,there are no focal or segmental pressure drops,but decline of pressure is homogeneously distributed all along the artery,In such cases,PCI is not possible and has no sense and stenting is only a cosmetic Treatment.,Where can we use pressure wire?,临界病变或模糊病变多支病变串联病变弥漫长病变左主干病变分叉病变支架内再狭窄介入术后评价急性冠脉综合征,左主干开口狭窄,50%Area Stenosis,7 F Guiding Catheter,3 mm RCA,Ostial Lesions,开口和左主干病变,左主干和开口病变的FFR临界值it is safe to defer a LM stenosis With a FFR 0.75(confirmed by many papers)b.For the LM 0.80 seems reasonnable(even though there are no data to do so.),左主干狭窄,213 patients with angiographically equivocal LM CAD,Assessment of moderate LM stenosis,Hamilos,M et al.Circ 2009;120:1505,左主干狭窄的评估,Courtesy to Dr Yun-Kyeong Cho,Where can we use pressure wire?,临界病变或模糊病变多支病变串联病变弥漫长病变左主干病变分叉病变支架内再狭窄介入后再评估急性冠脉综合征,Various size,various amount of supplying myocardiumSide branch ostial lesion is uniqueUnderlying plaque Eccentric plaqueRemodeling Negative remodelingMechanisms of luminal narrowingCarina shift,plaque shift,stent struts,thrombus.,Why discrepancy between anatomy and physiology?,Koo BK.et al,Circ Cardiovasc Intv 2010:3:113,Fractional Flow Reserve,FFR vs.%diameter stenosis in Jailed side branches,Percent Stenosis(%),影像学是否能预测受累边支功能学的意义？,Courtesy to Dr Koo,FFR=0.67,FFR=0.93,FFR=0.95,FFR=0.74,Courtesy of Dr Colombo and Dr Airoldi,FFR=0.92,Is FFR needed or useful?,Seoul National University Cardiovascular Center,58,介入前主要分支PCI术后边支球囊扩张后边支支架后,in non-left main bifurcation stenting,59,59,FFR应用的时机,分叉病变采用FFR指导（从开始到结束）整个过程是可行的。FFR指导下的分叉病变可减少不必要的介入以及介入产生的并发症。复杂的分叉病变FFR的操作需要注意技巧。,Use of FFR in non-left main bifurcation stenting,60,Where can we use pressure wire?,临界病变或模糊病变多支病变串联病变弥散长病变左主干病变分叉病变支架内再狭窄介入术后再评估急性冠脉综合征,支架内再狭窄,50 ISR lesions,Nam CW,et al.AJC 2011:107:1783,29%False positive,FFR指导下的支架内再狭窄的干预,50 ISR lesions,51%False negative,Nam CW,et al.AJC 2011:107:1783,FFR指导下的支架内再狭窄的干预,FFR指导下的支架内再狭窄的干预,Nam CW,et al.AJC 2011:107:1783,Where can we use pressure wire?,临界病变或模糊病变多支病变串联病变弥散长病变左主干病变分叉病变支架再狭窄介入术后再评估急性冠脉综合征,支架术后评估,(%),P 0.01,Nam CW.et al,Am J Cardiol 2011:107:1763,支架术后评估,80 patients(99 DESs)after successful PCI with DES,Nam CW.et al,Am J Cardiol 2011:107:1763,支架术后评估,Where can we use pressure wire?,临界病变或者模糊病变多支病变串联病变弥散长病变左主干病变分叉病变支架内再狭窄介入术后评估急性冠脉综合征,Where can we use pressure wire?,临界病变或模糊病变多支病变串联病变弥漫病变左主干病变分叉病变支架内再狭窄介入手术后再评价急性冠脉综合征,最大充血药的选择,静脉给药（推荐肘正中静脉、股静脉）-腺苷(或者ATP）140 g/kg/min 浓度1mg/ml 高流量输注泵（剂量=体重*8.4 ml/小时）冠脉给药-腺苷或者ATP 40-60 g 浓度为40 g/ml.,73,剂量和起效时间,74,FFR真正的意义在于告诉我们这个病变是否需要PCI。FFR已经成为冠脉狭窄功能性评价的金标准。,欧洲ESC指南规定：FFR为IA级临床证据。ESC指南建议：对于未经无创功能试验检查的病人，造影显示狭窄程度在50-90%的，建议进行FFR检查，根据检查结果决定是否进行PCI治疗，或者转到外科搭桥。无论患者是单支血管病变，多支病变，左主干或前降支近端病变。,FFR优化PCI,