冠状动脉血流储备分数(FFR)的临床应用课件

冠状冠状动脉血流脉血流储备分数分数（FFR）的）的临床床应用用郭郭 宁宁西安交通大学医学院第一附属医院西安交通大学医学院第一附属医院西安交通大学医学院第一附属医院西安交通大学医学院第一附属医院冠状动脉血流储备分数（FFR）的临床应用郭 宁冠心病检测方法冠心病检测方法冠脉结构检测冠脉结构检测冠脉生理检测冠脉生理检测无创性检测无创性检测磁共振血管成像磁共振血管成像(MRA)磁共振心脏成像磁共振心脏成像(MRI)冠脉血流储备冠脉血流储备(超声多普勒超声多普勒CFR)CTAPET缺血检查缺血检查(运动运动/药物激发试验药物激发试验)心电图心电图 超声心动图超声心动图 放射性核素心肌显像放射性核素心肌显像心导管相关的检测心导管相关的检测冠脉造影冠脉造影冠脉血流流速冠脉血流流速IVUS/VH-IVUS冠脉内压力冠脉内压力Infra-redOCT冠心病检测方法冠脉结构检测冠脉生理检测无创性检测磁共振血管成介入性心脏病学介入性心脏病学冠状动脉疾病的冠状动脉疾病的“专家专家”n充分理解冠脉的充分理解冠脉的结构结构n充分理解冠脉的充分理解冠脉的生理机能生理机能二者缺一不可二者缺一不可!冠状动脉血流储备分数(FFR)的临床应用课件冠状动脉造影的局限性冠状动脉造影的局限性冠状动脉造影的局限性n存在狭窄病变时，血管的最大血流量除以假设不存在狭窄病变时所能获得的最大血流量。nFFR是一个冠脉狭窄的功能性评价指标。Pijls and De Bruyne,Coronary Pressure Kluwer Academic Publishers,2000什么是什么是FFR？存在狭窄病变时，血管的最大血流量除以假设不存在狭窄病变时所能冠状动脉血流储备分数(FFR)的临床应用课件血流血流储备分数分数-FFR10050Pa=Guiding CatheterPd=Pressure Wire血流储备分数-FFR10050Pa=Guiding Ca在最大血管扩张的情况下：在最大血管扩张的情况下：在最大血管扩张的情况下：在最大血管扩张的情况下：冠脉流量冠脉流量冠脉流量冠脉流量 压力压力压力压力 PaPd在最大血管扩张的情况下：PaPd=1PP=FFRadmyoNormal FFR=1.0Pa PdPd=Pa100100=1PP=FFRadmyoNormal FFR=1.0P存在狭窄病变存在狭窄病变存在狭窄病变存在狭窄病变FFRFFRFFRFFRPa PdPd Pa100701PP=FFRadmyo存在狭窄病变FFRPa PdPd Pa100701PPn 心外膜下血管狭窄的严重程度n 心肌灌注面积的范围n 心肌血流量n 可诱导的心肌缺血FFRFFR解释了以下的相互关系：解释了以下的相互关系：心外膜下血管狭窄的严重程度FFR解释了以下的相互关系：FFR-灌注面积的大小灌注面积的大小10060FFR=0.60Large perfusion areaFFR=0.8510085Small perfusion areaFFR-灌注面积的大小10060FFR=0.60LargNormal myocardiumScar tissueNormalmyocardiumFFR=0.80FFR=0.601006010080Normal myocardiumScar tissueNoFFR=0.70PdPv010070Pa100Poorly developed collateralsFFR=0.70PdPv010070Pa100PoorlFFR=0.85PdPv010085100PaWell developed collateralsFFR=0.85PdPv010085100PaWell 54-yo man,PTCA prox LAD 8 years ago,stable angina,occluded distal LCx.48-yo man,aborted sudden death.No other stenosis at angio.54-yo man,PTCA prox LAD 8 yeWhat do I do now?What do I do now?Pijls N,et al.NEJM.1996;334:1703-08.Pijls N,et al.NEJM.1996;334FFRFFR是否具有临床意义？是否具有临床意义？Pijls N,et al;NEJM,1996;334:1703-1708FFR 0.75 心肌缺血(特异度 100%)FFR 0.75 心肌缺血的可能性非常小(敏感度 88%)NOT significant NOT significantSignificantSignificant1.00.8000.75FFR是否具有临床意义？Pijls N,et al;NDEFERDEFER GroupPERFORM GroupREFERENCE GroupBech GJ,et al.Circulation 2001:103;2873-5.RandomizedDEFERBech GJ,et al.CirculatiDEFERn在确定冠脉狭窄病变是否是造成远端心肌缺血的原因，测量FFR具有重要的预示作用。nFFR 90%narrowing,No(%)90%narrowing,No(%)247(18)260(18)Patients with 1 total Patients with 1 total occlusion(%)occlusion(%)7.510.6Fearon WF,et al.Am Heart J,2007;154:1243.Tonino PA,et al.NEJM.2009;360:213-24.FAME1005 patients eligibleFFR-ANGIO-groupn=496FFR-groupn=509P-valueP-valueEvents at 1 year,No(%)Events at 1 year,No(%)Death,MI,CABG,or repeat-PCIDeath,MI,CABG,or repeat-PCI91(18.4)67(13.2)0.020.02DeathDeath15(3.0)9(1.8)0.190.19Death or myocardial infarctionDeath or myocardial infarction55(11.1)37(7.3)0.040.04CABG or repeat PCICABG or repeat PCI47(9.5)33(6.5)0.080.08Total no.of MACETotal no.of MACE113760.020.02Myocardial infarction,specifiedMyocardial infarction,specifiedAll myocardial infarctionsAll myocardial infarctions43(8.7)29(5.7)0.070.07Small periprocedural CK-MB 3-5 x NSmall periprocedural CK-MB 3-5 x N1612Other infarctions(“late or large”)Other infarctions(“late or large”)2717FAME:1 year eventsTonino PA,et al.NEJM.2009;360:213-24.ANGIO-groupFFR-groupP-valueEveAngiography versus FFR in the FAME studyProportions of functionally diseased coronary arteries in patients with angiographic 3-or 2-vessel disease“3-VD”“2-VD”3-VD 3-VD 14%14%1-VD 1-VD 34%34%2-VD 2-VD 43%43%0-VD0-VD9%9%1-VD 1-VD 34%34%2-VD 2-VD 43%43%0-VD 0-VD 12%12%P.Tonino et al Submitted Angiography versus FFR in the LM Disease24 pts,3 yr f/u24 pts,3 yr f/u51 pts,2.5 yr f/u51 pts,2.5 yr f/uBech GJ,et al.Heart 2001;86:547-52Lindstaedt M,et al.Am Heart J 2006;152:156LM Disease24 pts,3 yr f/u51 pDoes stenosis severity of native vessels influence Does stenosis severity of native vessels influence bypass graft patency?A prospective FFR-guided bypass graft patency?A prospective FFR-guided study.study.Botman CJ,et al.Ann Thorac Surg,2007;83:2093-7.n164 patients with at least one intermediate lesion underwent PCI,FFR measured.nSurgeon blinded to FFR results.nSVG patency at 1y follow-up.Does stenosis severity of natiWhen To Use FFR PCI Guideline Recs:PCI Guideline Recs:nAssessment of intermediate stenosis(30 70%)in pts with angina as an alternative to noninvasive functional testing Class IIa,BnAssessment of the success of PCI Class IIa,CnEvaluation of angina in patients without apparent agiographic stenosis Class IIb,C Useful Indications in Useful Indications in Practice:Practice:nDetermination of 1 or more culprit lesion(s)in patients with MVDnEvaluation of left main or ostial lesionsnGuidance for treatment of a vessel with serial lesionsnUse in bifurcation lesion assessmentWhen To Use FFR PCI Guidelinn在考虑对狭窄病变施行血运重建之前，必须找到心肌缺血的证据。n如果一个狭窄病变引起心肌缺血，导致患者出现心绞痛的症状，那么可以通过支架术可以缓解患者的症状、改善生活质量和降低长期心脏事件发生率的风险。对不诱发心肌缺血的狭窄病变进行处理，并不能改善缺血、改善患者的症状和预后。nFFR为证明心肌缺血提供了一种非常好的方法。Pijls N,et al.JACC 2007;49:210511.在考虑对狭窄病变施行血运重建之前，必须找到心肌缺血的证据。PFFRHyperemiaHyperemiaFFRHyperemiaHyperemiaWhat do I do now?FFR with IV adenosine and pullback into the Left Main=0.89 Options:Options:nRepeat and make sure measurement is accuratenIVUSnBelieve it and move onWhat do I do now?FFR with IV abaselinehyperemia中度狭窄病变（中度狭窄病变（中度狭窄病变（中度狭窄病变（40%-60%40%-60%）baselinehyperemia中度狭窄病变（40%-60同一血管多处病变同一血管多处病变同一血管多处病变同一血管多处病变通过对病变进行压力回撤，可以识别出“罪犯”病变。1234同一血管多处病变通过对病变进行压力回撤，可以识别出“罪犯”病通过压力回撤来识别罪犯病变或者揭示血管中的弥漫性病变的情况。弥漫性病变弥漫性病变弥漫性病变弥漫性病变 通过压力回撤来识别罪犯病变或者揭示血管中的弥漫性病变的情况。LADD 1D 2RCA在哪个位置进行介入？在哪个位置进行介入？在哪个位置进行介入？在哪个位置进行介入？LADD 1D 2RCA在哪个位置进行介入？FFR=0.94 0.75FFR=0.89 0.75FFR=0.90 0.75FFR=0.94 0.75FFR=0.89 RCAFFR=0.41 RCAFFR=0.41 FFR=0.67After balloon inflation 3.0 balloon 12 atm(mid-RCA)FFR=0.67After balloon inflAfter stent 3.5 mm(mid-RCA)FFR=0.80Not optimal post stent resultAfter stent 3.5 mm(mid-RCA)FStent 3.5 mm(mid-RCA)+Stent 3.5 mm(prox-RCA)FFR=0.94Optimal post stent resultStent 3.5 mm(mid-RCA)+StentNo inducible ischemiaInducibleischemiaIschemia at rest ornecrosisFFRFFR0.750.800.201.0Gray Zone 评估病变No inducible InducibleIschemiaAfter stent implantationFFR 0.94 =Optimum stent resultAfter balloon angioplastyFFR 0.90 =Excellent result1.00.75interventionalsuccessoptimalsuboptimalno success0.94指导治疗After stent implantationAfter Pijls N,et al.Circulation,2002;105:2950-54评估效果评估效果0.96 4,9%0.91-0.95 6,2%0.86-0.90 16,2%0.81-0.85 22,2%0.75-0.80 29,5%FFR after stent*deploymentTVR(6 ms follow-up)*Bare metal stentsPijls N,et al.Circulation,2FFR 改进了临床的决策改进了临床的决策FFR 改进了临床的决策冠状动脉血流储备分数(FFR)的临床应用课件