阜外FFR原理及临床应用

病变≠缺血冠脉病变的解剖和功能学评价FractionalFlowReserve,FFRFractionalFlowReserve-FFR

定义和公式假设FFR被定义为狭窄存在和正常时心肌最大血流量（QS

，QN

）的比值

（Pa－Pv）（Pd－Pv）

QN

＝,QS

＝

RR

FFR=QS

/

QN

=

（Pd-Pv）/（Pa-Pv）

≈Pd/PaFFR的临界值FFR<0.75提示狭窄有功能意义的特异性100%FFR>0.80提示狭窄无功能意义的敏感性90%需要测量FFR~65%~20%DEFERSTUDY

CardiacDeathAndAcuteMIAfter5Years

3.37.915.705101520%P=0.20P<0.03P<0.005DEFER

PERFORM

REFERENCEFFR>0.75FFR<0.75PijlsNHJ,etal.JAmCollCardiol2007;49:2105-2111Angiography-guidedPCIFFR-guidedPCIMeasureFFRinallindicatedstenosesStentallindicatedstenosesStentonlythosestenoseswithFFR≤0.80RandomizationIndicateallstenoses≥50%consideredforstentingPatientwithstenoses≥50%inatleast2ofthe3majorepicardialvessels1-yearfollow-upFLOWCHARTFAMEstudy:

2-yearEvent-freeSurvival

p=0.02FAME:OutcomeofDeferredLesions513DeferredLesionsin509FFR-GuidedPatients2Years31MyocardialInfarctions22Peri-procedural9LateMyocardialInfarctions8DuetoaNewLesionorStentRelated1MyocardialInfarctionduetoanOriginallyDeferredLesionOnly1/513or0.2%ofdeferredlesionsresultedinalatemyocardialinfarctionPijlsNHPetalJACC20102011ACCF/AHA/SCAIGuidelinesforPCIFFR的适应证所有与无创检查结果不明显匹配的临界狭窄病变，包括左主干病变；分叉病变主支支架置入后分支口部DS>70%的所有分支；ACS患者有疑问的非罪犯病变；多支血管病变或系列和弥散病变时,指导CABG或PCI仅处理有明显血液动力学意义的血管或病变,即功能血管重建；评价PCI的即刻结果和预测其中远、期预后。FAME研究的主要启示InpatientswithMVD,arevascularisationstrategybasedonbothangiography+FFRcomparedtoastrategyonlybasedonangiographyresultsina~30%reductionofMACEanddetah/MIratedespitealowernumberofstentsandlesscontrastmedium.Thereisnosignaltosuggestthatdeferredlesionsarelikelytoberesponsibleforlatemyocardialinfarctionsortoprogressandrequirerepeatrevascularizations.FAMEchallengestwoimportantconcepts: a.Thedefinitionofmultivesseldiseaseb.Theconceptofcompletenessofrevascularisationwww.cardio-aalst.beFAME,SYNTAX,COURAGE,...“多支血管病变（Multi-veseeldisease)”RCA:0.51LCx:0.89LAD:0.45“Presenceofatleastonestenosis>50%inatleast2majorcoronaryarteriesand/orintheleftmainstem”3-VD14%1-VD34%2-VD43%0-VD9%FAMEStudyAngiographic3-VD(n=115)造影所示三支血管病变中有功能学意义的病变血管的比例P.ToninoetalJACC2010MelikianN,etal.JAmCollCardiolIntv2010;3:307–14ANGIOvs.SPECTvs.FFRSPECTvs.FFR不同方法学对多支血管病变界定的差异PCI的临床价值直接PCI——减少死亡，挽救生命择期PCI——减轻缺血，缓解症状

IschemiaReductionImprovesOutcomes

CumulativeEvent-freeSurvivalTimetoFollow-up(inyears)1.522.533.544.5500.10.20.30.40.50.60.70.80.91Unadjustedp=0.001Risk-adjustedp=0.082>5%reductioninischemic

myocardium(n=68)Nosignificantreductionin

ischemia(n=37)COURAGENuclearSubstudyShawLJ,etal.Circulation2008;117:1283-1291WhydoWeNeedIschemiaAssessmentintheCathLab?LinGAetal.JAMA2008;300:1765-1773KernMJ.CardiolClin2011;29237–267FFR-GuidedPCIinMVD74yearoldwomanwithHTN,hyperlipidemia,diabetesandatrialfibrillationAdmittedwithunstableanginaStressthalliumrevealedinferiorandlateralreversibleischemiaFFR

=Pd/Paduringhyperemia =89/108 =

0.82FFRoftheRCAFFRLeftCircumflexFFR=0.72Whataboutseriallesions?0.72AcrossproximallesionAcrossmiddiseasePullbackinCircumflexMostofgradientoccursacrossproximallesionAfter“spot-stenting”proximalcircumflexFFR=0.97FFRinAcuteCoronarySyndromesNon-CulpritCulpritMinimumLumenArea(MLA)2.50mm²PercentPlaqueBurden75%PlaquetypePITAdenosinei.v.infusion140µg/kg/min.PCI:LADFAMETrial:Substudy:ACSversusStableAnginaFFR,ACS,N=150 AngioACS,N=178Datasuggestthatliketheoverallpopulation,a30%reductioninMACEwhenFFRisusedtoguiderevascularizationinACSwww.cardio-aalst.beFAME,SYNTAX,COURAGE,...TreatmentOptionsforMVD

PCICABGOMTFAMESYNTAXCOURAGEFFR-guidedSYNTAXScore(FSS)versusConventionalSYNTAXScore(SS)LOWrisk33%MEDIUMrisk33%HIGHrisk33%LOWrisk59%MEDIUMrisk21%HIGHrisk21%FSSSS32%ofpatientsmovedtoalower-riskgroup

497patientsoftheFFR-armofFAMEISyntaxscoredre-calculatedby3incdependantreviewersFunctional(FFR)SyntaxScore:countingonlythelesionswithFFR<0.803tertilesbasedonSSNam,C.W.etal.JACC2011FuntctionalSYNTAXScoredesciminatesRiskofDeath/MIandRiskofTotalMACEDeath/MITotalMACEFearonWFetal,TCT-MD2011SYNTAXScore=38TheuseofFunctionalEvaluation(FFR)duringMVDPCIreducethenumberofstentsandMACE

Angio-drivenprocedure=6stentsCABGispreferd.Asaltervnative:

FFR-drivenprocedure=3stents

FunctionalSYNTAXScore=17

P.Tonino,etal,JAmCollCardiol2010;55:2816–2165%20%4%35%80%96%FunctionalEvaluationisnotmandatoryforeverypatientFFRassessmentinMVDanddiffusediseaseistechnicallyeasyandoffersmoreaccuratefunctionalevaluationofcoronarys