冠狀動(dòng)脈內(nèi)影像學(xué)及功能評(píng)價(jià)

1、冠狀動(dòng)脈內(nèi)影像學(xué)及功能評(píng)價(jià),1,衛(wèi)生部心血管疾病介入診療技術(shù)培訓(xùn)教材冠心病分冊(cè) 第二版,冠心病分冊(cè)編寫(xiě)人員名單,主　　編　霍　勇　方唯一編　　者　(按姓氏筆畫(huà)排序)于　波　于世勇　馬長(zhǎng)生　馬依彤　王樂(lè)豐　王偉民毛　懿　方唯一　石蘊(yùn)琦　曲新凱　呂樹(shù)錚　喬樹(shù)賓劉　健　杜志民　李　浪　李為民　李占全　李建平李儉強(qiáng)　楊峻青　楊躍進(jìn)　沈衛(wèi)峰　張　鉦　張大鵬陳　明　陳紀(jì)言　陳韻岱　周玉杰　鄭 楊 洪　濤　錢(qián)菊英 高

2、　煒　郭麗君　黃　嵐　葛　雷　葛均波　韓雅玲 竇克非　顏紅兵　霍　勇學(xué)術(shù)秘書(shū)　曲新凱,2,QCA DS 40-70%,Coronary angiogram,3,Evaluation of the lesion,Common questions for the intermediate lesion:As a physiologist: what’s the effect of this stenosis on coronary

3、 blood flow and myocardial function?As a clinician: Is this lesion responsible for the patient’s symptoms?As an interventionalist: Will revascularization of this artery improve the patient’s clinical outcome?,4,Functio

4、nal test: Treadmill, SPECT(MPI), UCG, MRI,Evidence of ischemia,5,,Functional test: CFR, FFR,VH,Morphology：IVUS, OCT,Intracoronary imaging and functional test in Cath. Lab,6,Atheroma morphology,Soft plaque,Fibrous

5、plaque,Calcified plaque,IVUS classcification of plaque,7,Thrombus,IVUS classcification of plaque,8,,Criteria for “significant” lesion of proximal LAD,LCX and RCA:MLA70%,EEM-csa=14.2mm2Lumen-csa=3.8mm2,Plaque burden=(1

6、4.2-3.8)/14.2 =73.2%,Intermediate lesion,9,,,Characteristics of vulnerable plaue in IVUS：Area of echolucent zone>1mm2；Echolucent area/plaque area >20％；Thickness of fibrous cap <0.7mm。

7、,Ge et al, Heart, 1999,Vulnerable plaque,10,11,baseline,6m FU,Okazaki S, et al. Circulation. 2004; 110: 1061-68,6m FU,baseline,Control,atorvastatin,ESTABLISH Trial: atorvastatin 20mg,Plaque regression evaluated with IV

8、US,,,Ostial lesion,12,,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 len

9、gth and size (LM always bigger than you think)Give information whether or not there is calcificationEvaluate plaque volume and distribution,!,,Use of IVUS in intervention of Left Main Lesion:,13,For LM lesions: Lc

10、sa <6.0mm2, or MLD <3.0mmFor Proximal segment of others(LAD/LCX/RCA) Lcsa <4.0mm2,IVUS Criteria of significant lesions,Use of IVUS in intervention of Left Main Lesion:,14,,,,Male, 57 yrs, 6m after stenting of

11、LAD,RCA, Stable angina,Use of IVUS in Intervention of LM Lesion,15,,,,MLA 7.2mm2Plaque burden 63%,MLA 5.3mm2Plaque burden 78%,MLA 2.7mm2Plaque burden 80.6%,Use of IVUS in Intervention of LM Lesion,16,,,,MLA 13.5mm2,Us

12、e of IVUS in Intervention of LM Lesion,17,Impact of IVUS Guidance on All-Cause Mortality After LMCA DES Implantation (n=805),IVUS指導(dǎo)左主干病變介入治療,18,SJ Park et al. TCT 2007,,,LAD-D1,LCX,LM,Finding the entry point of CTO lesi

13、on,19,,,D1,LCX,LAD,D1,LCX,LAD,Finding the entry point of CTO lesion,20,,,Detection of complication,21,DES Underexpansion,IVUS指導(dǎo)介入治療,22,14atm,20atm,,,Acute Stent Malapposition,,Incomplete apposition,IVUS指導(dǎo)介入治療,23,Incomple

14、te “Crush” Apposition,Phenomenon found in >60%,Costa RA. TCT 2008,IVUS指導(dǎo)介入治療,24,IVUS指導(dǎo)DES植入改善預(yù)后,25,Roy et al. AHA 2007,1296 IVUS-guided, DES-treated lesions in 884 pts vs 1312 matched angio-guided lesions in 884 pts,I

15、VUS評(píng)價(jià)PCI治療效果,26,12/15 SES thrombosis lesions has stent CSA <5.0mm2 (vs 13/45 controls),Fujii et al. J Am Coll Cardiol 2005;45:995-8,Predictors of Cypher Thrombosis within 1 year,Hong Eur HJ 2006,IVUS評(píng)價(jià)PCI治療效果,27,Predi

16、ctors for ISR by IVUS,8m FU,Post-procedure,,,,,Detect Late Acquired Stent Malapposition,IVUS評(píng)價(jià)PCI治療效果,28,Baseline,Follow-up (9 months),Post-procedure,Follow-up (29 months),Male32 yrsPro-LAD Cypher Select® 3.0

17、5;28mm,Detect Late Acquired Stent Malapposition,29,IVUS 新技術(shù),VH-IVUS血管彈力圖微血管顯像,30,VH– IVUS,31,VH: Virtual Histology, 虛擬組織,VH–IVUS,32,Virtual Histology Four Lesion Types,33,The PROSPECT Trial,34,Lesions are classified in

18、to 5 main types,35,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,36,The PROSPECT Trial,VH-TCFA a

19、nd Non Culprit Lesion Related Events,血管彈性圖（Palpography）,37,,,,,Independent predictors of strain were macrophages (p=0.006) and smooth muscle cells (p=0.0001),血管彈性圖（Palpography）,38,Normal,Hypercholesterolemia,Hypercholest

20、erolemia+ Statin,應(yīng)用微米及納米氣泡,滋養(yǎng)血管與動(dòng)脈粥樣硬化斑塊的進(jìn)展，炎癥以及斑塊內(nèi)出血及活動(dòng)性有關(guān),比劑與先進(jìn)的諧振及次諧振,對(duì)比劑與先進(jìn)的諧振及次諧振IVUS結(jié)合，將顯著地增強(qiáng)顯示易損斑塊的能力,Vasovasorum Imaging,39,Vasovasorum Imaging,40,Baseline images are acquired for 20 seconds, and regions of inte

21、rest are assigned,Range of enhancement,Contrast is injected, images are acquired for 120 seconds post-injection, and baseline images are subtracted,Vasovasorum Imaging,41,Vasovasorum Imaging,42,Post-injection (Frame #80

22、0),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 Coherenc

23、e Tomography (OCT),43,OCT成像模式圖,44,不同OCT成像系統(tǒng)與IVUS的特點(diǎn)比較,45,Plaque characteristics,46,正常血管,內(nèi)膜增厚,OCT,47,,,脂質(zhì)斑塊有較高的敏感性(90%)和特異性（92%）,脂質(zhì)斑塊表現(xiàn)為邊界不清晰的低信號(hào)區(qū)，纖維帽表現(xiàn)為均一的高信號(hào)區(qū)。,OCT,易損斑塊,易損斑塊,48,均一的高信號(hào)區(qū),OCT,纖維性斑塊,纖維性斑塊,49,OCT診斷鈣化斑塊的敏感性為9

24、6%，特異性為97%。鈣化主要表現(xiàn)為邊界清晰的、均一的低信號(hào)帶,OCT,鈣化,鈣化,50,OCT,夾層,夾層,51,Red &　white thrombus,52,Red thrombus was identified as high-backscattering protrusions inside the lumen of the artery, with signal-free shadowing in the OCT

25、image.White thrombus was identified as low-backscattering projections in the OCT image.,Sensitivity = 95%Specificity = 88%Positive predictive value = 86%Negative predictive value =95%,(Kubo et al. Circulation 2006;1

26、14:II-645 ),Accuracy of intra-coronary OCT for differentiation between red and white thrombus,,,,,,,,Thrombus,Kubo et al. J Am Coll Cardiol 2007;50:933-9,Incidence=100%,Incidence=100%,Incidence=33%,In vivo comparison of

27、 OCT and angioscopy in assessing culprit lesions in 30 AMI patients,53,Floating flap,Related to NIH,Related to malapposed struts,Related to uncovered struts,Abnormal intraluminal tissue,54,Dissections,In-stent Restenosis

28、,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.,Superi

29、or resolution of OCT,55,Limitations of OCT,PenetrationTrue vessel sizingAssessment of plaque burdenOstial lesionLM,56,Physiological Testing in Cath. Lab,57,,Rationale of Physiological Testing,Coronary lumenology has

30、proven to be an inadequate measure to assess the severity of a lesionNon-invasive techniques may prove to be time- and money consumingIn-cathlab testing of coronary physiologyhas become easy, feasible and cost-effecti

31、vecan distinguish significant from non-significant lesionscan guide therapeutic interventions, through evaluation of physiologic improvement,58,Regulation of Coronary Blood Flow,Coronary Flow & Pressure,Autoregulat

32、ion,59,Autoregulation refers to the intrinsic mechanisms which maintain blood flow constant when the perfusion pressure varies (Ranging from 45~130 mmHg approximately).,Coronary Flow of Normal or Stenotic Artery,Coronary

33、 Flow & Pressure,60,Coronary Flow Reserve,Coronary Flow & Pressure,61,0.014” FlowireTM,Intracoronary Doppler Measurements of Coronary Flow Reserve,62,“Normal” Coronary Flow Reserve (CFR),Coronary Flow Reserve,63

34、,Kern MJ, et al. JACC 1996;28:1154-60,Components of CFR,Coronary Flow Reserve,64,58 yr oldfemaleUAP,Pre-intervention, CFVR=1.7,After stenting, CFVR=1.6,Use of CFR in PCI,65,Limitation of CFR,CFR in doubtful anatomy: W

35、hat is “normal”, what is “good”?Variability in vasodilatory reserve due to impaired microvascular function DiabeticsHypertrophic heart diseaseSyndrome XAfter myocardial infarctionRheological flow disturbanceshyper

36、fibrinogenemia, polycythemia,66,Relative Coronary Flow Reserve,Coronary Flow Reserve,67,,,rCFR=0.95,Coronary Flow Reserve,68,,Stenosis → Loss of Coronary Pressure,Coronary Pressure,69,Normal artery pressure, Pa, is the s

37、ame along the length of the vessel.Resistance=P/QFlow, Q=P/RQs/Qn = (Pd/Rs)/(Pa/Rn) If Rs=Rn, then Qs/Qn = Pd/Pa, henceFFR= Qs/Qn = Pd/Pa,,,,,FFR vs.CFR: What Do They Investigate?,70,Pressure Monitoring Guide Wi

38、res,71,Coronary Hyperemic Stimuli,72,0,100,50,,,Pdistal = Pressure Wire,Pprox = Aortic Pressure,Coronary Flow Velocity (Doppler),73,ADENOSINE,,,Influence of Systemic Pressure on Transstenotic Gradient,74,Ischemic Thresho

39、ld Values of FFR,75,DEFER 5 Year Results,76,327 Pts with Stable Angina and Lesion of Intermediate Severity,FAME study:Event-free Survival,77,VH,Morphology：IVUS, OCT,病變定量、定性評(píng)價(jià)指導(dǎo)介入治療檢測(cè)并發(fā)癥OCT較IVUS有更高的分辨率，但穿透力下降,Intracoro

40、nary imaging Summary,78,,CFR& FFR,Evaluation of myocardial ishemia in Cath. LabCFR could be used to assess the microvascular function, but without definite normal valueFFR is the obstruction specific parameter and