FFR的基本概念和技术.ppt

FFR的基本概念和技术 阜外医院钱杰 冠状动脉血流动力学测定 导管室的特殊运动试验 冠状动脉造影的补充 冠状动脉血流量的生理调节 TheCoronaryCirculation Anatomy epicardialarterialvessels myocardialmicrocirculation venouscomponent PhysicsLaw Klocke FJ MeasurementofCoronaryFlowReserve Definingpathophysiologyversusmakingdecisionsaboutpatientcare Circulation 1987 76 pp1183 1189 TheCoronaryCirculation PhysiologicRegulation 生理调节的指标 CFR Qsmax Qsrest多普勒导丝测量怎么达到最大血流 打掉微循环阻力正常值有变异 冠状动脉血流量的病理调节 CFR还能达到3 5倍吗 它能反应病变情况吗 不能 能 但没有特异性rCFR RFR Qsmax Qn max Rstenosis Rmyocardial FFR CFR CFRandrCFR WhatDoTheyInvestigate 一个假设病例 A 狭窄60 DM微血管病变B 狭窄80 没有微血管病变CFRamaybe CFRb 2or1 7 介入医生关心什么 为介入服务完成导管室的运动试验检查病变是否有可逆缺血做研究 有没有什么更好的指标 有FFR Qsmax Qnmax Pd Pa WhyFlow Q Pressure CoronaryStenosisRheologyPressure FlowRelationship Pressuredropacrossstenosisincreaseswithflowinanon linearfashion Entranceeffects Separationlosses Frictionloss FFRDefinition FFRDefinition FFRDefinition FRACTIONALFLOWRESERVE TheindexFFR FractionalFlowReserve isbaseduponthetwofollowingprinciples Itisnotrestingflow butmaximumachievableflowwhichdeterminesthefunctionalcapacity exercisetolerance ofapatientAtmaximumvasodilation correspondingwithmaximumhyperemiaorwithmaximumexercise bloodflowtothemyocardiumisproportionaltomyocardialperfusionpressure hyperemicdistalcoronarypressure NormalValueofMyocardialFractionalFlowReserve NormalFFR 1 Pa Pd FFR Pa Pd 0 014 3cm PressureMonitoringGuideWires CoronaryHyperemicStimuli PRACTICEOFCORONARYPRESSUREMEASUREMENTANDFFR 1 1 Verificationofequalsignalswhensensorattipoftheguidingcatheter Equalizationifnecessary2 Advancewire sensorcrossesstenosis3 InducemaximumhyperemiaandmeasureFFR4 Becausesensoris3cmfromtip easilypull backandpush upforexactspatialinformation Ifdesirable performpull backrecording PRACTICEOFCORONARYPRESSUREMEASUREMENTANDFFR 2 5 PCIifindicated withpossibilityforPwmeasurementforcollateralflowassessment6 FollowedbyFFRmeasurementtocheckresult Ifdesired performhyperemicpull backrecording7 verifyabsenceofdriftattheendofprocedure orbetweenmeasurementinseveralvessels LAD restingadenosinei v hyperemicpull backrecording 200 100 0 200 100 0 AorticPressure 122mmHg AorticPressure 89mmHg CoronaryPressure 52mmHg CoronaryPressure 40mmHg P 70mmHG FFR 52 122 0 43 FFR 40 89 0 45 InfluenceofSystemicPressureonTransstenoticGradient P 49mmHG 1 ExerciseTest ThalliumScan Dobut echo 0 3 0 4 0 5 0 6 0 7 0 8 0 9 TruePositiveStressTests NegativeStressTests FFRandNon InvasiveStressTestinginLesionsofIntermediateSeverity PijlsNHJ deBruyneB PeelsKetal NewEnglJMed1996 IschemicThresholdValuesofFFR A A A u u u t t t h h h o o o r r r s s s R R R e e e f f f P P P a a a t t t i i i e e e n n n t t t s s s T T T e e e s s s t t t T T T h h h r r r e e e s s s h h h o o o l l l d d d DeBruyneetal Circ1995 1 VD 60 BicycleECG 0 72 Pijlsetal Circ1995 1 VD pre postPCI 60 BicycleECG 0 74 Pijls DeBruyne NEJM1996 1 VD Intermediate Sten 45 BicycleECG TL DobutEcho 0 75 Bartuneketal JACC1996 1 VD 75 DobutamineEcho 0 78 Chamuleauetal JACC2000 MVD 127 MIBI Spect 0 74 Abeetal Circ2000 1 VD 46 Thallium 0 75