冠状动脉内影像学及功能评价.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,卫生部心血管疾病介入诊疗技术培训教材 冠心病分册 第二版,冠状动脉内影像学及功能评价,卫生部心血管疾病介入诊疗技术培训教材 冠心病分册 第二版,冠状动脉内影像学及功能评价,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,卫生部心血管疾病介入诊疗技术培训教材 冠心病分册 第二版,冠状动脉内影像学及功能评价,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,卫生部心血管疾病介入诊疗技术培训教材 冠心病分册 第二版,冠状动脉内影像学及功能评价,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,冠状动脉内,影像学及功能评价,1,QCA DS 40-70%,Coronary angiogram,2,Evaluation of the lesion,Common questions for the intermediate lesion:,As a,physiologist,:whats the effect of this stenosis on coronary blood flow and myocardial function?,As a,clinician,:Is this lesion responsible for the,patients,symptoms?,As an,interventionalist,:Will revascularization of this artery improve the,patients,clinical outcome?,3,Functional test:,Treadmill,SPECT(MPI),UCG,MRI,Evidence of ischemia,4,Functional test:CFR,FFR,VH,Morphology,：,IVUS,OCT,Aortic Pressure=89 mm Hg,FFR=40/89=0.45,Coronary Pressure=40,mm Hg,Intracoronary imaging and functional test in Cath.Lab,5,Atheroma morphology,Soft plaque,Fibrous plaque,Calcified plaque,IVUS classcification of plaque,6,Thrombus,IVUS classcification of plaque,7,Criteria for“significant”lesion of proximal LAD,LCX and RCA:,MLA70%,EEM-csa,=14.2mm,2,Lumen-csa,=3.8mm,2,Plaque burden,=(14.2-3.8)/14.2,=73.2%,Intermediate lesion,8,Characteristics of vulnerable plaue in IVUS,：,Area of echolucent zone,1,mm,2,；,Echolucent area/plaque area,20；,Thickness of fibrous cap,0.7,mm。,Ge et al,Heart,1999,Vulnerable plaque,9,10,baseline,6m FU,Okazaki S,et al.Circulation.;110:1061-68,6m FU,baseline,Control,atorvastatin,ESTABLISH Trial:atorvastatin 20mg,Plaque regression evaluated with IVUS,Ostial lesion,11,Preparation-Lesion Evaluation by IVUS,IVUS guidance is a MUST for left mainsIt helps for building up the strategy and determining the type and size of devices I will need.,Estimate left main length and size(LM always bigger than you think),Give information whether or not there is calcification,Evaluate plaque volume and distribution,!,Use of IVUS in intervention of Left Main Lesion:,12,For LM lesions:,Lcsa,6.0mm,2,or,MLD,3.0mm,For Proximal segment of others(LAD/LCX/RCA),Lcsa,60%,Costa RA.TCT,IVUS,指导介入治疗,23,IVUS,指导,DES,植入改善预后,24,Roy et al.AHA,1296 IVUS-guided,DES-treated lesions in 884 pts vs 1312 matched angio-guided lesions in 884 pts,IVUS,评价,PCI,治疗效果,25,12/15 SES thrombosis lesions has stent CSA 5.0mm,2,(vs 13/45 controls),Fujii et al.J Am Coll Cardiol;45:995-8,Predictors of Cypher Thrombosis within 1 year,Hong Eur HJ,IVUS,评价,PCI,治疗效果,26,Predictors for ISR by IVUS,8m FU,Post-procedure,Detect Late Acquired Stent Malapposition,IVUS,评价,PCI,治疗效果,27,Baseline,Follow-up(9 months),Post-procedure,Follow-up(29 months),Male,32 yrs,Pro-LAD,Cypher Select,3.028mm,Detect Late Acquired Stent Malapposition,28,IVUS,新技术,VH-IVUS,血管弹力图,微血管显像,29,VH IVUS,30,VH:Virtual Histology,虚拟组织,VHIVUS,31,Virtual Histology Four Lesion Types,32,The PROSPECT Trial,33,Lesions are classified into 5 main types,34,The PROSPECT Trial,Methodology:,Virtual histology lesion classification,*Likelihood of one or more such lesions being present per patient.PB=plaque burden at the MLA,35,The PROSPECT Trial,VH-TCFA and Non Culprit Lesion Related Events,血管弹性图（,Palpography,）,36,F,F,SOFT,HARD,Independent predictors of strain were macrophages(p=0.006)and smooth muscle cells(p=0.0001),血管弹性图（,Palpography,）,37,Normal,Hypercholesterolemia,Hypercholesterolemia,+Statin,应用微米及纳米气泡,滋养血管与动脉粥样硬化斑块的进展，炎症以及斑块内出血及活动性有关,比剂与先进的谐振及次谐振,对比剂与先进的谐振及次谐振IVUS结合，将明显地增强显示易损斑块的能力,Vasovasorum Imaging,38,Vasovasorum Imaging,39,Baseline images are acquired for 20 seconds,and regions of interest are assigned,Range of enhancement,Contrast is injected,images are acquired for 120 seconds post-injection,and baseline images are subtracted,Vasovasorum Imaging,40,Vasovasorum Imaging,41,Post-injection,(Frame#800),Peak Injection,(Frame#600),Pre-injection,(Frame#200),Lumen subtracted(microbubble shadow effect is not calculated),The enhancement lasts for at least 25 seconds.,Background motions are cancelled,Optical Coherence Tomography(OCT),42,OCT,成像模式图,43,不一样OCT成像系统与IVUS的特点比较,44,1mm,Signal poor,Sharp border,Fibrocalcific plaque,Signal poor,Diffuse border,Fibro-lipidic plaque,Signal rich,Diffuse border,Attenuation,Fibrous plaque,IVUS,OCT,Plaque characteristics,45,正常血管,内膜增厚,OCT,46,脂质斑块有较高的敏感性(90%)和特异性（92%）,脂质斑块体现为边界不清晰的低信号区，纤维帽体现为均一的高信号区。,OCT,易损斑块,易损斑块,47,均一的高信号区,OCT,纤维性斑块,纤维性斑块,48,OCT诊断钙化斑块的敏感性为96%，特异性为97%。钙化重要体现为边界清晰的、均一的低信号带,OCT,钙化,钙化,49,OCT,夹层,夹层,50,Red&,white thrombus,51,Red thrombus,was identified as high-backscattering protrusions inside the lumen of the artery,with signal-free shadowing in the OCT image.,White thrombus,was identified as low-backscattering projections in the OCT image.,Red Thrombus,White Thrombus,Sensitivity=95%,Specificity=88%,Positive predictive value=86%,Negative predictive value=95%,(Kubo et al.Circulation;114:II-645),Accuracy of intra-coronary OCT for differentiation between red and white thrombus,Thrombus,WT,RT,WT,1mm,WT,RT,1mm,Kubo et al.J Am Coll Cardiol;50:933-9,Incidence=100%,Incidence=100%,Incidence=33%,In vivo comparison of OCT and angioscopy in assessing culprit lesions in 30 AMI patients,52,Floating flap,Related to NIH,Related to malapposed struts,Related to uncovered struts,Abnormal intraluminal tissue,53,Dissections,In-stent Restenosis,But re-endothelialization is below the resolution of even OCT,Stent Malapposition,Compared to IVUS only improves on the identification of small,clinically unimportant edge dissections,stent malapposition,etc.,Superior resolution of OCT,54,Limitations of OCT,Penetration,True vessel sizing,Assessment of plaque burden,Ostial lesion,LM,55,Physiological Testing in Cath.Lab,56,Rationale of Physiological Testing,Coronary lumenology has proven to be an inadequate measure to assess the severity of a lesion,Non-invasive techniques may prove to be time-and money consuming,In-cathlab testing of coronary physiology,has become easy,feasible and cost-effective,can distinguish significant from non-significant lesions,can guide therapeutic interventions,through evaluation of physiologic improvement,57,Regulation of Coronary Blood Flow,Coronary Flow&Pressure,Autoregulation,58,Autoregulation refers to the intrinsic mechanisms which maintain blood flow constant when the perfusion pressure varies(Ranging from 45130 mmHg approximately).,Coronary Flow of Normal or Stenotic Artery,Coronary Flow&Pressure,59,Coronary Flow Reserve,Coronary Flow&Pressure,60,0.014”Flowire,TM,Intracoronary Doppler Measurements of Coronary Flow Reserve,61,“,Normal,”,Coronary Flow Reserve(CFR),Coronary Flow Reserve,62,Kern MJ,et al.JACC 1996;28:1154-60,Components of CFR,Coronary Flow Reserve,63,58,yr old,female,UAP,Pre-intervention,CFVR=1.7,After stenting,CFVR=1.6,Use of CFR in PCI,64,Limitation of CFR,CFR in doubtful anatomy:What is“normal”,what is“good”?,Variability in vasodilatory reserve due to impaired microvascular function,Diabetics,Hypertrophic heart disease,Syndrome X,After myocardial infarction,Rheological flow disturbances,hyperfibrinogenemia,polycythemia,65,Relative Coronary Flow Reserve,Coronary Flow Reserve,66,rCFR=0.95,Coronary Flow Reserve,67,Stenosis Loss of Coronary Pressure,Coronary Pressure,68,Normal artery pressure,Pa,is the same along the length of the vessel.,Resistance=P/Q,Flow,Q=P/R,Qs/Qn=(Pd/Rs)/(Pa/Rn),If Rs=Rn,then Qs/Qn=Pd/Pa,hence,FFR=Qs/Qn=Pd/Pa,FFR vs.CFR:What Do They Investigate?,69,Pressure Monitoring Guide Wires,70,Coronary Hyperemic Stimuli,71,0,100,50,P,distal,=Pressure Wire,P,prox,=Aortic Pressure,Coronary Flow Velocity(Doppler),72,ADENOSINE,Influence of Systemic Pressure on Transstenotic Gradient,73,200,100,0,Aortic Pressure=122 mm Hg,Coronary Pressure=52 mm Hg,P=70 mmHG,FFR=52/122=0.43,Aortic Pressure=89 mm Hg,Coronary Pressure=40 mm Hg,FFR=40/89=0.45,P=49 mmHG,Ischemic Threshold Values of FFR,74,DEFER 5 Year Results,75,327 Pts with Stable Angina and Lesion of Intermediate Severity,FFR-guided,30 days,2.9%,90 days,3.8%,180 days,4.9%,360 days,5.3%,Angio-guided,absolute difference in MACE-free survival,FAME study:Event-free Survival,76,VH,Morphology,：,IVUS,OCT,病变定量、定性评价,指导介入治疗,检测并发症,OCT较IVUS有更高的辨别率，但穿透力下降,Intracoronary imaging Summary,77,CFR&FFR,Aortic Pressure=89,mm Hg,FFR=40/89=0.45,Coronary Pressure=40,mm Hg,Evaluation of myocardial ishemia in Cath.Lab,CFR could be used to assess the microvascular function,but without definite normal value,FFR is the obstruction specific parameter and could be used in the guidance of PCI of intermediate lesion,Functional Test in Cath.LabSummary,78,谢 谢！,79,