FFR的基本概念和技术课件

1、FFR的基本概念和技术阜外医院钱杰FFR的基本概念和技术阜外医院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冠状动脉血流量的生理调节The Coronary Circulation-AnatomyAoPaPvCollateralsMyocardiumepicardial arterial vessels - myocardial microcirculation - venous componentThe Coronary Circulation-AnatoPhysics LawPhysics

2、LawKlocke, FJ, Measurement of Coronary Flow Reserve: Defining pathophysiology versus making decisions about patient care; Circulation: 1987; 76: pp 1183-1189The Coronary Circulation-Physiologic RegulationKlocke, FJ, Measurement of Cor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生理调节的指标CFRQsma

3、x /Qsrest冠状动脉血流量的病理调节冠状动脉血流量的病理调节FFR的基本概念和技术课件FFR的基本概念和技术课件FFR的基本概念和技术课件FFR的基本概念和技术课件FFR的基本概念和技术课件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 /QnmaxCFR 还能达到35倍吗？它能反应病变情况吗？不能，RstenosisRmyocardialFFRCFR CFR and rCFR: What Do They Investigate?RstenosisRmyocardialFFRCFR CFR一个假设病例A：狭窄60 DM微血管病变B：狭窄

4、80 没有微血管病变CFRa maybe =CFRb2 or 1.7一个假设病例A：狭窄60 DM微血管病变介入医生关心什么？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介入医生关心什么？为介入服务有没有什么更好的指标？有FFRQsmax /Qnmax=Pd/Pa有没有什么更好的指标？有THANK YOUSUCCESS2022/10/1019可编辑THANK YOUSUCCESS2022/10/91Why Flow (Q) = PressureWhy Flow (Q) = PressureCoronary Stenosis RheologyPressure-Flow Relati

5、onshipPressure drop across stenosis increases with flow in a non-linear fashionEntrance effectsSeparation lossesFriction lossCoronary Stenosis RheologyPresFFR DefinitionFFR DefinitionFFR DefinitionFFR DefinitionFFR DefinitionFFR DefinitionFRACTIONAL FLOW RESERVE:The index FFR (Fractional Flow Reserv

6、e)is based upon the two following principles: It is not resting flow, but maximum 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 propor

7、tional to myocardial perfusion pressure (hyperemic distal coronary pressure) FRACTIONAL FLOW RESERVE:The in Normal Value of Myocardial Fractional Flow ReserveNormal FFR = 1 Pa PdFFR = Pa Pd Normal Value of Myocardial Fr0.014”3 cmPressure Monitoring Guide Wires0.014”3 cmPressure Monitoring Coronary H

8、yperemic StimuliCoronary Hyperemic StimuliPRACTICE OF CORONARY PRESSUREMEASUREMENT AND FFR （1）1. Verification of equal signals when sensor at tip of the guiding catheter. Equalization if necessary2. Advance wire, sensor crosses stenosis3. Induce maximum hyperemia and measure FFR4. Because sensor is

9、3 cm from tip, easily pull-back and push-up for exact spatial information.If desirable, perform pull-back recordingPRACTICE OF CORONARY PRESSUREPRACTICE OF CORONARY PRESSUREMEASUREMENT AND FFR （2）5. PCI if indicated, with possibility for Pw measurement for collateral flow assessment6. Followed by FF

10、R measurement to check result. If desired, perform hyperemic pull-back recording7. verify absence of drift at the end of procedure, or between measurement in several vesselsPRACTICE OF CORONARY PRESSURELADresting adenosine i.v.LADresting pull-back across LAD plaquehyperemic pull-back recordingpull-b

11、ack across LAD plaquehyp20010002001000Aortic Pressure = 122 mm HgAortic Pressure = 89 mm HgCoronary Pressure = 52 mm HgCoronary 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 20010002001000Aortic Pressure 1E

12、xerciseTestThalliumScanDobut.echo0.30.40.50.60.70.80.9True Positive Stress TestsNegative Stress TestsFFR and Non-Invasive Stress Testing in Lesions of Intermediate SeverityPijls NHJ, de Bruyne B, Peels K et al. New Engl J Med 19961ExerciseThalliumDobut.0.30.40Ischemic Threshold Values of FFR AAAuuut

13、tthhhooorrrsss RRReeefff PPPaaatttiiieeennntttsss # TTTeeessstttTTThhhrrreeessshhhooollldddDe Bruyne et al.Circ 19951-VD60Bicycle ECG0.72*Pijls et al.Circ 19951-VDpre+post PCI60Bicycle ECG0.74*Pijls&De BruyneNEJM 19961-VD,Intermediate Sten45Bicycle ECG +TL+Dobut Echo0.75*Bartunek et al.JACC 19961-VD75Dobutamine Echo0.78*Chamuleau et al.JACC 2000MVD127MIBI-Spect 0.74*Abe et al.Circ 20001-VD46Thallium0.75*De Bruyne et alCirc 2001Post MI57MIBI-Spect0.75 - 0.80* 100 % Specificit