FFR的基本概念和技术

1、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,The Coronary Circulation-Anatomy,epicardial arterial vessels - myocardial microcirculation - venous component,Physics Law,Klocke, FJ, Measurement of Coronary Flow Reserve: Defining pathophysiology versus making decisions about patient

2、 care; Circulation: 1987; 76: pp 1183-1189,The Coronary Circulation-Physiologic Regulation,生理调节的指标,CFRQsmax /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35倍吗？它能反应病变情况吗？,不能， 能，但没有特异性 rCFR(RFR)=Qsmax /Qnmax,Rstenosis,Rmyocardial,FFR,CFR,CFR and rCFR: What Do They Investigate?,一个假设病例,A

3、：狭窄60 DM微血管病变 B：狭窄80 没有微血管病变 CFRa maybe =CFRb2 or 1.7,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 FFRQsmax /Qnmax =Pd/Pa,Why Flow (Q) = Pressure,Coronary Stenosis Rheology Pressure-Flow Relationship,Pressure drop across stenosis increases with flow in a non-linear fashion,Entrance effec

4、ts,Separation losses,Friction loss,FFR Definition,FFR Definition,FFR Definition,FRACTIONAL FLOW RESERVE:,The index FFR (Fractional Flow Reserve) is based upon the two following principles: It is not resting flow, but maximum achievable flow which determines the functional capacity (exercise toleranc

5、e) of a patient At maximum vasodilation (corresponding with maximum hyperemia or with maximum exercise), blood flow to the myocardium is proportional to myocardial perfusion pressure (hyperemic distal coronary pressure),Normal Value of Myocardial Fractional Flow Reserve,Normal FFR = 1,Pa,Pd,FFR =,Pa

6、,Pd,0.014”,3 cm,Pressure Monitoring Guide Wires,Coronary Hyperemic Stimuli,PRACTICE OF CORONARY PRESSUREMEASUREMENT AND FFR （1）,1. Verification of equal signals when sensor at tip of the guiding catheter. Equalization if necessary 2. Advance wire, sensor crosses stenosis 3. Induce maximum hyperemia

7、and measure FFR 4. Because sensor is 3 cm from tip, easily pull-back and push-up for exact spatial information. If desirable, perform pull-back recording,PRACTICE OF CORONARY PRESSUREMEASUREMENT AND FFR （2）,5. PCI if indicated, with possibility for Pw measurement for collateral flow assessment 6. Fo

8、llowed by FFR measurement to check result. If desired, perform hyperemic pull-back recording 7. verify absence of drift at the end of procedure, or between measurement in several vessels,LAD,resting adenosine i.v.,hyperemic pull-back recording,200,100,0,200,100,0,Aortic Pressure = 122 mm Hg,Aortic P

9、ressure = 89 mm Hg,Coronary Pressure = 52 mm Hg,Coronary Pressure = 40 mm Hg,P = 70 mmHG,FFR = 52/122 = 0.43,FFR = 40/89 = 0.45,Influence of Systemic Pressure on Transstenotic Gradient,P = 49 mmHG,1,Exercise Test,Thallium Scan,Dobut. echo,0.3,0.4,0.5,0.6,0.7,0.8,0.9,True Positive Stress Tests,Negati

10、ve Stress Tests,FFR and Non-Invasive Stress Testing in Lesions of Intermediate Severity,Pijls NHJ, de Bruyne B, Peels K et al. New Engl J Med 1996,Ischemic Threshold Values of FFR,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,De Bruyne et al.,Circ 1995,1-VD,60,Bicycle ECG,0.72*