冠狀動脈內

影像學及功能評價1衛(wèi)生部心血管疾病介入診療技術培訓教材冠心病分冊第二版冠心病分冊編寫人員名單主編霍勇方唯一編者(按姓氏筆畫排序)于波于世勇馬長生馬依彤王樂豐王偉民毛懿方唯一石蘊琦曲新凱呂樹錚喬樹賓劉健杜志民李浪李為民李占全李建平李儉強楊峻青楊躍進沈衛(wèi)峰張鉦張大鵬陳明陳紀言陳韻岱周玉杰鄭楊洪濤錢菊英高煒郭麗君黃嵐葛雷葛均波韓雅玲竇克非顏紅兵霍勇學術秘書曲新凱2QCADS40-70%Coronaryangiogram3EvaluationofthelesionCommonquestionsfortheintermediatelesion:Asaphysiologist:what’stheeffectofthisstenosisoncoronarybloodflowandmyocardialfunction?Asaclinician:Isthislesionresponsibleforthepatient’ssymptoms?Asaninterventionalist:Willrevascularizationofthisarteryimprovethepatient’sclinicaloutcome?4Functionaltest:Treadmill,SPECT(MPI),UCG,MRIEvidenceofischemia5Functionaltest:CFR,FFRVHMorphology：IVUS,OCTAorticPressure=89mmHgFFR=40/89=0.45CoronaryPressure=40mmHgIntracoronaryimagingandfunctionaltestinCath.Lab6AtheromamorphologySoftplaqueFibrousplaqueCalcifiedplaqueIVUSclasscificationofplaque7ThrombusIVUSclasscificationofplaque8Criteriafor“significant”lesionofproximalLAD,LCXandRCA:MLA<4mm2Plaqueburden>70%EEM-csa=14.2mm2Lumen-csa=3.8mm2Plaqueburden=(14.2-3.8)/14.2=73.2%Intermediatelesion9CharacteristicsofvulnerableplaueinIVUS：Areaofecholucentzone>1mm2；Echolucentarea/plaquearea>20％；Thicknessoffibrouscap<0.7mm。Geetal,Heart,1999Vulnerableplaque1011baseline6mFUOkazakiS,etal.Circulation.2004;110:1061-686mFUbaselineControlatorvastatinESTABLISHTrial:atorvastatin20mgPlaqueregression

evaluatedwithIVUSOstiallesion12Preparation-LesionEvaluationbyIVUSIVUSguidanceisaMUSTforleftmains

IthelpsforbuildingupthestrategyanddeterminingthetypeandsizeofdevicesIwillneed.Estimateleftmainlengthandsize(LMalwaysbiggerthanyouthink)GiveinformationwhetherornotthereiscalcificationEvaluateplaquevolumeanddistribution!UseofIVUSininterventionofLeftMainLesion:13ForLMlesions:Lcsa<6.0mm2,orMLD<3.0mmForProximalsegmentofothers(LAD/LCX/RCA)Lcsa<4.0mm2

EEMIntimaledgeIVUSCriteriaofsignificantlesionsUseofIVUSininterventionofLeftMainLesion:14Male,57yrs,6mafterstentingofLAD,RCA,StableanginaUseofIVUSinInterventionofLMLesion15MLA7.2mm2Plaqueburden63%MLA5.3mm2Plaqueburden78%MLA2.7mm2Plaqueburden80.6%UseofIVUSinInterventionofLMLesion16MLA13.5mm2UseofIVUSinInterventionofLMLesion17ImpactofIVUSGuidanceonAll-CauseMortality

AfterLMCADESImplantation(n=805)IVUS指導左主干病變介入治療18SJParketal.TCT2007LAD-D1LCXLMFindingtheentrypointofCTOlesion19D1LCXLADD1LCXLADFindingtheentrypointofCTOlesion20CHematomaTLDetectionofcomplication21DESUnderexpansionIVUS指導介入治療2214atm20atmAcuteStentMalappositionIncompleteappositionIVUS指導介入治療23Incomplete“Crush”AppositionPhenomenonfoundin>60%CostaRA.TCT2008IVUS指導介入治療24IVUS指導DES植入改善預后IVUS-guidedAngio-guidedPvalue30dayMACE2.8%5.2%0.01Stentthrombosis0.5%1.4%0.045TLR0.7%1.7%0.0451yearMACE14.5%16.2%0.3Definitestentthrombosis0.7%2.0%0.014Probablystentthrombosis4.0%5.8%0.08TLR5.1%7.2%0.06Latedefinitestentthrombosis0.2%0.7%0.325Royetal.AHA20071296IVUS-guided,DES-treatedlesionsin884ptsvs1312matchedangio-guidedlesionsin884ptsIVUS評價PCI治療效果2612/15SESthrombosislesionshasstentCSA<5.0mm2(vs13/45controls)Fujiietal.JAmCollCardiol2005;45:995-8PredictorsofCypherThrombosiswithin1yearHongEurHJ2006IVUS評價PCI治療效果27PredictorsforISRbyIVUS8mFUPost-procedureDetectLateAcquiredStentMalappositionIVUS評價PCI治療效果28BaselineFollow-up(9months)Post-procedureFollow-up(29months)Male32yrsPro-LADCypherSelect?3.0×28mmDetectLateAcquiredStentMalapposition29IVUS新技術VH-IVUS血管彈力圖微血管顯像30VH–IVUS31VH:VirtualHistology,虛擬組織

VH–IVUS32VirtualHistologyFourLesionTypes33ThePROSPECTTrial34Lesionsareclassifiedinto5maintypes35ThePROSPECTTrialMethodology:Virtualhistologylesionclassification*Likelihoodofoneormoresuchlesionsbeingpresentperpatient.PB=plaqueburdenattheMLA36ThePROSPECTTrialVH-TCFAandNonCulpritLesionRelatedEventsLesionHR3.84(2.22,6.65)6.41(3.35,12.24)10.77(5.53,21.00)10.81(4.30,27.22)Pvalue<0.0001<0.0001<0.0001<0.0001Prevalence*51.2%17.4%11.0%4.6%血管彈性圖（Palpography）37

FFSOFTHARDIndependentpredictorsofstrainweremacrophages(p=0.006)andsmoothmusclecells(p=0.0001)血管彈性圖（Palpography）38NormalHypercholesterolemiaHypercholesterolemia+Statin應用微米及納米氣泡滋養(yǎng)血管與動脈粥樣硬化斑塊的進展，炎癥以及斑塊內出血及活動性有關比劑與先進的諧振及次諧振對比劑與先進的諧振及次諧振IVUS結合，將顯著地增強顯示易損斑塊的能力VasovasorumImaging39VasovasorumImaging40Baselineimagesareacquiredfor20seconds,andregionsofinterestareassignedRangeofenhancementContrastisinjected,imagesareacquiredfor120secondspost-injection,andbaselineimagesaresubtractedVasovasorumImaging41VasovasorumImaging42Post-injection(Frame#800)PeakInjection(Frame#600)Pre-injection(Frame#200)Lumensubtracted(microbubbleshadoweffectisnotcalculated)Theenhancementlastsforatleast25seconds.BackgroundmotionsarecancelledOpticalCoherenceTomography(OCT)43OCT成像模式圖44不同OCT成像系統(tǒng)與IVUS的特點比較451mmSignalpoorSharpborderFibrocalcificplaqueSignalpoorDiffuseborderFibro-lipidicplaqueSignalrichDiffuseborderAttenuationFibrousplaqueIVUSOCTPlaquecharacteristics46正常血管內膜增厚OCT47脂質斑塊有較高的敏感性(90%)和特異性（92%）,脂質斑塊表現(xiàn)為邊界不清晰的低信號區(qū)，纖維帽表現(xiàn)為均一的高信號區(qū)。OCT易損斑塊易損斑塊48均一的高信號區(qū)OCT纖維性斑塊纖維性斑塊49OCT診斷鈣化斑塊的敏感性為96%，特異性為97%。鈣化主要表現(xiàn)為邊界清晰的、均一的低信號帶OCT鈣化鈣化50OCT夾層夾層51Red&

whitethrombus52Redthrombuswasidentifiedashigh-backscatteringprotrusionsinsidethelumenoftheartery,withsignal-freeshadowingintheOCTimage.Whitethrombuswasidentifiedaslow-backscatteringprojectionsintheOCTimage.RedThrombusWhiteThrombus

Sensitivity=95%Specificity=88%Positivepredictivevalue=86%Negativepredictivevalue=95%(Kuboetal.Circulation2006;114:II-645)Accuracyofintra-coronaryOCTfordifferentiationbetweenredandwhitethrombusThrombusWTRTWT1mmWTRT1mmKuboetal.JAmCollCardiol2007;50:933-9Incidence=100%Incidence=100%Incidence=33%InvivocomparisonofOCTandangioscopyinassessingculpritlesionsin30AMIpatients53FloatingflapRelatedtoNIHRelatedtomalapposedstrutsRelatedtouncoveredstrutsAbnormalintraluminaltissue54DissectionsIn-stentRestenosisButre-endothelializationisbelowtheresolutionofevenOCTStentMalappositionComparedtoIVUSonlyimprovesontheidentificationofsmall,clinicallyunimportantedgedissections,stentmalapposition,etc.SuperiorresolutionofOCT55LimitationsofOCTPenetrationTruevesselsizingAssessmentofplaqueburdenOstiallesionLM56PhysiologicalTestinginCath.Lab57RationaleofPhysiologicalTestingCoronarylumenologyhasproventobeaninadequatemeasuretoassesstheseverityofalesionNon-invasivetechniquesmayprovetobetime-andmoneyconsumingIn-cathlabtestingofcoronaryphysiologyhasbecomeeasy,feasibleandcost-effectivecandistinguishsignificantfromnon-significantlesionscanguidetherapeuticinterventions,throughevaluationofphysiologicimprovement58RegulationofCoronaryBloodFlowCoronaryFlow&PressureAutoregulation59Autoregulationreferstotheintrinsicmechanismswhichmaintainbloodflowconstantwhentheperfusionpressurevaries(Rangingfrom45~130mmHgapproximately).CoronaryFlowofNormalorStenoticArteryCoronaryFlow&Pressure60CoronaryFlowReserveCoronaryFlow&Pressure610.014”FlowireTMIntracoronaryDopplerMeasurementsof

CoronaryFlowReserve62“Normal”CoronaryFlowReserve(CFR)CoronaryFlowReserve63KernMJ,etal.JACC1996;28:1154-60ComponentsofCFRCoronaryFlowReserve6458yroldfemaleUAPPre-intervention,CFVR=1.7Afterstenting,CFVR=1.6UseofCFRinPCI65LimitationofCFRCFRindoubtfulanatomy:

Whatis“normal”,whatis“good”?VariabilityinvasodilatoryreserveduetoimpairedmicrovascularfunctionDiabeticsHypertrophicheartdiseaseSyndromeXAftermyocardialinfarctionRheologicalflowdisturbanceshyperfibrinogenemia,polycythemia66RelativeCoronaryFlowReserveCoronaryFlowReserve67

rCFR=0.95CoronaryFlowReserve68

Stenosis→LossofCoronaryPressureCoronaryPressure69Normalarterypressure,Pa,isthesamealongthelengthofthevessel.Resistance=P/QFlow,Q=P/RQs/Qn=(Pd/Rs)/(Pa/Rn)IfRs=Rn,thenQs/Qn=Pd/Pa,henceFFR=Qs/Qn=Pd/PaFFRvs.CFR:WhatDoTheyInvestigate?70PressureMonitoringGuideWires71CoronaryHyperemicStimuli72010050Pdistal=PressureWirePprox=AorticPressureCoronaryFlowVelocity(Doppler)73ADENOSINEInfluenceof