1、FFR的基本概念和技术的基本概念和技术阜外医院阜外医院钱杰钱杰冠状动脉血流动力学测定冠状动脉血流动力学测定导管室的特殊运动试验导管室的特殊运动试验冠状动脉造影的补充冠状动脉造影的补充冠状动脉血流量的生理调节epicardial arterial vessels-myocardial microcirculation-venous componentepicardial arterial vessels-myocardial microcirculation-venous componentPhysics Law5.05.03.03.01.01.0Coronary pressureCoronar
2、y pressureMaximum vasodilationMaximum vasodilationCoronary flowCoronary flowCoronary reserveCoronary reserve=FlowFlowdilateddilatedFlowFlowinitialinitial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/QnmaxRstenosisRmyocardialFFRFFRCFR
3、CFR CFR and rCFR:What Do They Investigate?CFR and rCFR:What Do They Investigate?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/PaTHANK YOUSUCCESS2022-11-10Why Flow(Q)=PressureWhy Flow(Q)=PressureEntrance effectsSeparation
4、lossesFriction lossFFR DefinitionFFR DefinitionFFR DefinitionFFR DefinitionFFR DefinitionFFR DefinitionFRACTIONAL FLOW RESERVE:FRACTIONAL FLOW RESERVE:The index FFR(Fractional Flow ReserveFractional Flow Reserve)is based upon the two following principles:It is not resting flow,but maximum achievable
5、 flowmaximum achievable flow which determines the functional capacity(exercise tolerance)of a patient At maximum vasodilation(corresponding with maximum hyperemia or with maximum exercise),blood flow to the myocardium is proportional to myocardial perfusion pressuremyocardial perfusion pressure (hyp
6、eremichyperemic distal coronary pressuredistal coronary pressure)Normal Value of Myocardial Fractional Flow Reserve Normal Value of Myocardial Fractional Flow ReserveNormal FFR =1 Normal FFR =1 P Pa a P Pd dFFRFFR =P Pa a P Pd d0.014”0.014”3 cm3 cmPressure Monitoring Guide WiresPressure Monitoring G
7、uide WiresCoronary Hyperemic StimuliCoronary Hyperemic StimuliPRACTICE OF CORONARY PRESSUREPRACTICE OF CORONARY PRESSUREMEASUREMENT AND FFR MEASUREMENT AND FFR(1 1)1.Verification of equal signals equal signals when sensor at tip of the guiding catheter.Equalization if necessary2.Advance wireAdvance
8、wire,sensor crosses stenosis3.Induce maximum hyperemia maximum hyperemia and measure FFR4.Because sensor is 3 cm from tip,easily pull-back and push-up for exact spatial information.If desirable,perform pull-back pull-back recordingrecordingPRACTICE OF CORONARY PRESSUREPRACTICE OF CORONARY PRESSUREME
9、ASUREMENT AND FFR MEASUREMENT AND FFR(2 2)5.PCI if indicated,with possibility for Pw w measurement for collateral flow assessment6.Followed by FFR measurement to check FFR measurement to check resultresult.If desired,perform hyperemic pull-back recording7.verify absence of drift verify absence of dr
10、ift at the end of procedure,or between measurement in several vesselsLADLADresting adenosine i.v.pull-back across LAD plaquehyperemic pull-back recording2002001001000 02002001001000 0Aortic Pressure=122 Aortic Pressure=122 mm Hgmm HgAortic Pressure=89 Aortic Pressure=89 mm Hgmm HgCoronary Pressure=5
11、2 Coronary Pressure=52 mm Hgmm HgCoronary Pressure=40 Coronary Pressure=40 mm Hgmm Hg P=70 P=70 mmHGmmHG FFR=52/122=0.43 FFR=52/122=0.43 FFR=40/89=0.45 FFR=40/89=0.45 Influence of Systemic Pressure on Transstenotic GradientInfluence of Systemic Pressure on Transstenotic Gradient P=49 P=49 mmHGmmHG 1
12、 1ExerciseExerciseTestTestThalliumThalliumScanScanDobut.Dobut.echoecho0.30.30.40.40.50.50.60.60.70.70.80.80.90.9True Positive Stress TestsTrue Positive Stress TestsNegative Stress TestsNegative Stress TestsFFR and Non-Invasive Stress Testing in FFR and Non-Invasive Stress Testing in Lesions of Inter
13、mediate SeverityLesions of Intermediate SeverityPijls NHJ,de Bruyne B,Peels K et al.New Engl J Med 1996Pijls NHJ,de Bruyne B,Peels K et al.New Engl J Med 1996Ischemic Threshold Values of FFRIschemic Threshold Values of FFR A A A A A A u u u u u ut t t t t th h h h h ho o o o o or r r r r rs s s s s
14、s R R R R R R e e e e e ef f f f f f P P P P P Pa a a a a at t t t t ti i i i i i e e e e e en n n n n nt t t t t ts s s s s s#T T T T T Te e e e e es s s s s st t t t t tT T T T T Th h h h h hr r r r r re e e e e es s s s s sh h h h h ho o o o o ol l l l l l d d d d d dDe Bruyne et al.Circ 19951-VD
15、60Bicycle ECG0.720.72*Pijls et al.Circ 19951-VDpre+post PCI60Bicycle ECG0.740.74*Pijls&De BruyneNEJM 19961-VD,Intermediate Sten45Bicycle ECG+TL+Dobut Echo0.750.75*Bartunek et al.JACC 19961-VD75Dobutamine Echo0.780.78*Chamuleau et al.JACC 2000MVD127MIBI-Spect 0.740.74*Abe et al.Circ 20001-VD46Thallium0.750.75*De Bruyne et alCirc 2001Post MI57MIBI-Spect0.75-0.800.75-0.80*冠状动脉血流动力学测定冠状动脉血流动力学测定导管室的特殊运动试验导管室的特殊运动试验打掉阻力,压力和血流成正比,打掉阻力,压力和血流成正比,压力差反应病变对血流的影响压力差反应病变对血流的影响冠状动脉造影的补充冠状动脉造影的补充ThanksThanksTHANK YOUSUCCESS2022-11-10