1、1 QCA DS 40-70%2u Common questions for the intermediate lesion:1.As a physiologist:whats the effect of this stenosis on coronary blood flow and myocardial function?2.As a clinician:Is this lesion responsible for the patients symptoms?3.As an interventionalist:Will revascularization of this artery im
2、prove the patients clinical outcome?3Functional test:Treadmill,SPECT(MPI),UCG,MRI4Functional test:CFR,FFRVHMorphology：IVUS,OCTAortic Pressure=89 mm HgFFR=40/89=0.45 Coronary Pressure=40 mm Hg5Atheroma morphologySoft plaqueFibrous plaqueCalcified plaque6Thrombus 7Criteria for“significant”lesion of pr
3、oximal LAD,LCX and RCA:p MLA70%EEM-csa=14.2mm2Lumen-csa=3.8mm2Plaque burden=(14.2-3.8)/14.2 =73.2%8Characteristics of vulnerable plaue in IVUS：p Area of echolucent zone1mm2；p Echolucent area/plaque area 20；p Thickness of fibrous cap 0.7mm。Ge et al,Heart,1999910baseline6m FUOkazaki S,et al.Circulatio
4、n.2004;110:1061-686m FUbaselineControlatorvastatinESTABLISH Trial:atorvastatin 20mg11Preparation-Lesion Evaluation by IVUSIVUS guidance is a MUST for left mainsIt helps for building up the strategy and determining the type and size of devices I will need.1.Estimate left main length and size(LM alway
5、s bigger than you think)2.Give information whether or not there is calcification3.Evaluate plaque volume and distribution!12 For LM lesions:Lcsa 6.0mm2,or MLD 3.0mm For Proximal segment of others(LAD/LCX/RCA)Lcsa 60%Costa RA.TCT 200823IVUS-guidedAngio-guidedP value30 day MACE2.8%5.2%0.01 Stent throm
6、bosis0.5%1.4%0.045 TLR0.7%1.7%0.0451 year MACE14.5%16.2%0.3 Definite stent thrombosis0.7%2.0%0.014 Probably stent thrombosis4.0%5.8%0.08 TLR5.1%7.2%0.06Late definite stent thrombosis0.2%0.7%0.324Roy et al.AHA 20071296 IVUS-guided,DES-treated lesions in 884 pts vs 1312 matched angio-guided lesions in
7、 884 pts2512/15 SES thrombosis lesions has stent CSA 5.0mm2(vs 13/45 controls)Fujii et al.J Am Coll Cardiol 2005;45:995-8Predictors of Cypher Thrombosis within 1 yearHong Eur HJ 200626Predictors for ISR by IVUS8m FUPost-procedureDetect Late Acquired Stent Malapposition27BaselineFollow-up(9 months)Po
8、st-procedureFollow-up(29 months)l Malel 32 yrsl Pro-LAD l Cypher Select 3.028mmDetect Late Acquired Stent Malapposition28l VH-IVUSl 血管弹力图l 微血管显像2930VH:Virtual Histology,虚拟组织虚拟组织 313233Lesions are classified into 5 main types34Methodology:Virtual histology lesion classification*Likelihood of one or m
9、ore such lesions being present per patient.PB=plaque burden at the MLA35Lesion HR3.84(2.22,6.65)6.41(3.35,12.24)10.77(5.53,21.00)10.81(4.30,27.22)P value0.00010.00010.00010.0001Prevalence*51.2%17.4%11.0%4.6%36 FFSOFTHARDIndependent predictors of strain were macrophages(p=0.006)and smooth muscle cell
10、s(p=0.0001)37NormalHypercholesterolemiaHypercholesterolemia+Statin应用微米及纳米气泡滋养血管与动脉粥样硬化斑块的进展，炎症以及斑块内出血及活动性有关比剂与先进的谐振及次谐振对比剂与先进的谐振及次谐振IVUS结合，将显著地增强显示易损斑块的能力3839Baseline images are acquired for 20 seconds,and regions of interest are assignedRange of enhancementContrast is injected,images are acquired f
11、or 120 seconds post-injection,and baseline images are subtracted4041Post-injection(Frame#800)Peak Injection(Frame#600)Pre-injection(Frame#200)Lumen subtracted(microbubble shadow effect is not calculated)The enhancement lasts for at least 25 seconds.Background motions are cancelledOptical Coherence T
12、omography(OCT)4243441mmSignal poorSharp borderFibrocalcific plaqueSignal poorDiffuse borderFibro-lipidic plaqueSignal richDiffuse borderAttenuationFibrous plaqueIVUSOCT45正常血管 内膜增厚 46脂质斑块有较高的敏感性(90%)和特异性（92%）,脂质斑块表现为边界不清晰的低信号区，纤维帽表现为均一的高信号区。易损斑块 易损斑块 47均一的高信号区 纤维性斑块 纤维性斑块 48OCT诊断钙化斑块的敏感性为96%，特异性为97%。
13、钙化主要表现为边界清晰的、均一的低信号带钙化钙化49夹层夹层5051 Red thrombus was identified as high-backscattering protrusions inside the lumen of the artery,with signal-free shadowing in the OCT image.White thrombus was identified as low-backscattering projections in the OCT image.Sensitivity=95%Specificity=88%Positive predict
14、ive value=86%Negative predictive value=95%(Kubo et al.Circulation 2006;114:II-645)Accuracy of intra-coronary OCT for differentiation between red and white thrombus Thrombus1mmWT1mmKubo et al.J Am Coll Cardiol 2007;50:933-9Incidence=100%Incidence=100%Incidence=33%52Floating flapRelated to NIHRelated
15、to malapposed strutsRelated to uncovered struts53DissectionsIn-stent RestenosisBut re-endothelialization is below the resolution of even OCTStent MalappositionCompared to IVUS only improves on the identification of small,clinically unimportant edge dissections,stent malapposition,etc.54PenetrationTr
16、ue vessel sizingAssessment of plaque burdenOstial lesionLM55Physiological Testing in Cath.Lab56 Coronary lumenology has proven to be an inadequate measure to assess the severity of a lesion Non-invasive techniques may prove to be time-and money consuming In-cathlab testing of coronary physiologyp ha
17、s become easy,feasible and cost-effectivep can distinguish significant from non-significant lesionsp can guide therapeutic interventions,through evaluation of physiologic improvement57Regulation of Coronary Blood Flow58Autoregulation refers to the intrinsic mechanisms which maintain blood flow const
18、ant when the perfusion pressure varies(Ranging from 45130 mmHg approximately).Coronary Flow of Normal or Stenotic Artery59Coronary Flow Reserve600.014”FlowireTM61“Normal”Coronary Flow Reserve(CFR)62Kern MJ,et al.JACC 1996;28:1154-60Components of CFR63u 58 yr oldu femaleu UAPPre-intervention,CFVR=1.7
19、After stenting,CFVR=1.664 CFR in doubtful anatomy:What is“normal”,what is“good”?Variability in vasodilatory reserve due to impaired microvascular function pDiabeticspHypertrophic heart diseasepSyndrome XpAfter myocardial infarctionpRheological flow disturbances hyperfibrinogenemia,polycythemia65Rela
20、tive Coronary Flow Reserve66rCFR=0.9567Stenosis Loss of Coronary Pressure681.Normal artery pressure,Pa,is the same along the length of the vessel.2.Resistance=P/Q3.Flow,Q=P/R4.Qs/Qn=(Pd/Rs)/(Pa/Rn)If Rs=Rn,then Qs/Qn=Pd/Pa,hence5.FFR=Qs/Qn=Pd/Pa697071010050Pdistal=Pressure WirePprox=Aortic PressureC
21、oronary Flow Velocity(Doppler)72ADENOSINE732001000Aortic Pressure=122 mm HgCoronary Pressure=52 mm Hg P=70 mmHG FFR=52/122=0.43 Aortic Pressure=89 mm HgCoronary Pressure=40 mm HgFFR=40/89=0.45 P=49 mmHG 7475327 Pts with Stable Angina and Lesion of Intermediate SeverityFFR-guided30 days2.9%90 days3.8
22、%180 days4.9%360 days5.3%Angio-guidedabsolute difference in MACE-free survival76VHMorphology：IVUS,OCT 病变定量、定性评价 指导介入治疗 检测并发症 OCT较IVUS有更高的分辨率，但穿透力下降77Aortic Pressure=89 mm HgFFR=40/89=0.45 Coronary Pressure=40 mm HgEvaluation of myocardial ishemia in Cath.LabCFR could be used to assess the microvascular function,but without definite normal valueFFR is the obstruction specific parameter and could be used in the guidance of PCI of intermediate lesion7879
