在lm介入治疗中的应用课件幻灯

IVUS在LM介入治疗中的应用 首都医科大学附属北京友谊医院 王 雷 LM-PCI面临的特殊挑战: CAG提供的左主干病变程度、长度欠精确 LMd-LADo-LCXo的斑块分布决定分叉病变干 预策略 位于“冠脉树”根部的LM生理特征变异大 ，纤维组织丰富，弹性强 LM的PCI过程必须迅速精确、支架置入完美 血管内超声提供更多帮助 IVUS Guided LM-PCI nIVUS更清楚显示LM病变部位和程度 nIVUS决定LMd病变治疗策略 nIVUS改善LMd病变治疗效果 Prevalence of LMSS IVUS : the most useful intracoronary diagnostic tool in the cath lab IVUS-LADo-LMd Lesion distribution 贾三庆，张宇晨，王雷，等.中华实用内科杂志，2002，4（14）7-9. IVUS-LM Lesion Localization Patients (n=75) Only Ostial 21% Only Mid Shaft 13.1% Only Bifurcation 65.5% From Costantino Costantini et al. LM Bifurcation-IVUS Classification CAG 14.89% 4.27% 10.63% 29.78% IVUS 34.04% 6.38% 10.63% 25.53% CAG 8.51% 17.02% 14.89% IVUS 4.27% 12.76% 6.38% From Costantino Costantini et al. 47 Bifurcations IVUS-LM Plaque Distribution Oviedo C, Maehara A, Mintz GS,et al.Circulation. 2010 Mar 2. Epub ahead of print IVUS-LM Plaque Distribution Oviedo C, Maehara A, Mintz GS,et al.Circulation. 2010 Mar 2. Epub ahead of print IVUS determinants of LM FFR0.75 Jasti et al.Circulation 2004;110:2831-6 IVUS Criteria for a Significant LMCA Stenosis lMost IVUS LMCA studies show either insignificant disease or critical disease lAbsolute lumen CSA 6.0mm2 (or MLD 3.0mm) is the suggested criterion for a significant LMCA stenosis Correlates with a LMCA FFR0.75 Murrays Law (LMCAr3 = LADr3 + LCXr3) Does not depend on finding a disease-free reference segment It is not clear whether the same criteria should be used for ostial LM lesions as for mid-shaft/distal bifurcation lesions and for positively vs negatively remodeled lesions -From Gary S Mintz-TCT2009 Conclusions: lIVUS guided stenting reduced long-term mortality rate compared with conventional angiography-guided stenting in DES placement for unprotected LMCA stenosis lThe differential survival rate between IVUS-versus angiogrphy guidance start to separate and progressively diverged after 1 year lTherefore,the reductioin of the risk of very late stent thrombosis by IVUS- guidance might play a role in improving survival after DES placement Effect of IVUS upon Mortality of LM Stenting n=201 pairs (BMS+DES) Effect of IVUS upon Death or MI of LM Stenting n=201 pairs (BMS+DES) Effect of IVUS upon TVR of LM Stenting n=201 pairs (BMS+DES) Effect of IVUS upon Mortality of LM Stenting n=145 pairs(DES) 对LM进行血运重建的IVUS标准: 最小管腔面积6mm2 管腔面积狭窄率50% 最小腔径(MLD) 2.8mm LM成功支架置入的IVUS标准: 完全贴壁: 沿支架置入段支架完全帖靠血管壁 对称均匀: 支架最大直径比最小直径0.7 扩张充分: 支架最小腔面积(CSA)比平均参考血管 腔面积0.9 LM-Case Presentation in Recent Work CASE 01 ？ 57yrs Man UAP Case 01 Case01 Case 01 Case 01-Final Result Case02 54yrs Man STEMI (Anterior Wall) Post infarction agina Case02 Case02 Case02 Case 02 Case02-Final Result Conlcusions l Pre intervention IVUS is mandatory if technically possible 1.Important qualitative and quantitative information permit best approach. 2.Det