微循环阻力指数(IMR)的临床价值

微循环阻力指数（IMR）的临床价值2023最新整理收集do

something一.IMR的测量方法二.IMR的临床价值MACROvascularCompartmentMICROvascularCompartmentFFRCFR

(andNon-InvasiveTesting)IMR冠脉阻力KaulandJayaweeraEurHeartJ2006;27:2272-74.正常血管的阻力EpicardialVesselArteriolesCapillariesVenulesPressureFFRTemperatureThermodilution

(CFR)

IMR

ABF

(Temperatureoftheplaque)FFR,(CFR)IMR:theCoronaryCirculationFullPictureState-of-the-artPressureWire5andCertus,flowandtemperature.Pressuretransducer

操作方法导引导管注射器冠脉血流压力导丝感受器Transitmeantime/Tmn图示TmnrestTmnhyp1.静息时弹丸式注射2.最大充血状态下弹丸式注射IMR的测量(通过温度稀释法测量)IMR的推导∆Pressure=Pd-Pv=Pd (Pv=0)Flow1/TmnIMR=Pd/(1/Tmn)IMR=PdxTmn (最大充血状态下)

微循环阻力=∆P压力/Flow血流(简单)血流微循环阻力Pd远端压力Pv静脉压力~0IMR的测量IMR= PdxHyperemicTmn= 89x0.37= 33

NormalIMR<25AbnormalIMR>30IMR的确立GuideLADFlowProbeRadio-opaqueOccluderPressureWireCirculation2003;107:3129-3132.动物模型

p=0.002IMR的确立Circulation2003;107:3129-3132破坏微循环后IMR的改变IMRisindependentofepicardialstenosis?

Circulation2004;109:2269-2272AnimalValidationNgetal.Circulation2006;113:2054-61.IMR的重复性血压，心率和心肌收缩力改变后，CFR改变远大于IMRP<0.05准备和手术步骤准备使用6Fguiding三联三通

(压力,生理盐水和造影剂)用带safetyreservoir注射器ContrastMediumSalinePressure如果距离太近，测量的Tmn会太短(特别是最大充血状态下).如果传感器位置变化，对结果会有影响.建议在导引导管放到冠脉远端、基础状态注射结束和充血状态注射结束三个时间点踩X线留图比较传感器位置是否变化把压力导丝传感器放到冠脉远端(离导引导管开口>5cm).在测量中保持传感器在同一位置(给充血药物前和给药中).压力导丝传感器定位PrecautionsforIMRmeasurementCatheterpositioningAvoidunstablepositionorthetemperaturesignalmayfluctuate.Avoid“spilling”saline,positionthecatheterinostiumorthetemperaturesignalmayfluctuate.Avoiddeepengagementortheflowmaybereduced.PressureWire®SensorpositioningPositiontransducer>7cmfromopeningofguidingcatheterorinaccurate

CFR/Tmn(Transitmeantime)valuesmightoccur.TheTmnvaluemaybecometoshortandwillberejectedbythesoftwareHyperemia长效的充血药物!!!

HyperemiaUselong-lastinghyperemicstimulitoattainconstanthyperemiaduringthemeasurements.Ifpossible,verifymaximumhyperemiceffect(byusingPd/Paquota)orIMRwillbeincorrect.PrecautionsforIMRmeasurement校准PressureWire®

，进入CFR模式4.TheCFRscreenlayout手术步骤 注射器抽3ml生理盐水（室温）通过导引导管注射，检查温度是否能够最少下降2℃。手术步骤 注射器抽3ml生理盐水（室温）通过导引导管注射，检查温度是否能够最少下降2℃。注射器抽3ml生理盐水按REC键开始记录,按照屏幕提示.快速稳定的注射生理盐水重复3次基线测量手术步骤通过药物达到并保持最大充血状态按Rec键开始记录，按照屏幕提示快速稳定的注射3次生理盐水

最大充血状态测量手术步骤

ViewFFRandIMRWhenallmeasurementshavebeendonepressSTOP/VIEW

ontheremotecontroltosavetherecordingandviewthe

recordedpressureanddilutioncurvestogetherwiththeFFRvalue.ThevalueofIMRhastobecalculated:IMR=PdxTmnhyp(88x0.50=40)IMR= PdxHyperemicTmn= 89x0.37= 33

NormalIMR<25AbnormalIMR>30手术步骤3. 手工计算错误信息温度下降小于–1℃注射时间长于0.6秒.温度恢复正常的时间超过8秒Tmn小于0,1秒。把传感器放到更远的位置。和错误信息同时出现4.ErrormessagesAsalineinjectionmustpasscertaincriteria'stobeacceptedasanvalidinjection.Iftheinjectiondoesnotpassallcriteria'saninjectionerrorwilloccur.Aninjectionerrorcanbecausedbyanumberofreasonsandanerrormessagedisplayedintheinstructionwindowcontainsinformationonwhatcausedtheproblem.WhenanerrormessageisflashinganINJECTAGAINmessageisalsodisplayed,promptinganewinjection.5.InjectionerrorsTheInstrumentdoesnotrespondtotheinjection Indication Theinstrumentindicates”InjectNow”,thephysicianinjectssalineandtheshaftandsensortemperaturedecreases,buttheinstrumentdoesn'trespondatall. Cause Thedecreaseinsensorshafttemperaturewasnotfastordeepenoughtotriggertheinstrumentsrecordingfunction. SolutionShortanddistinctsalineinjection.Use”one-shot”(3-5cc)syringeforabetterpunch.Increasesalinevolume(3-5cc).Coldersaline(roomtemperature,~20ºC).

10-1-2-3-4-5-6Injectionerrors2. ”SlowInjection”messageIndication:

Afterinjectionthesign”SlowInjection”isdisplayedCause:

Theshafttemperaturedidn'treachitsminimumvaluefastenough.Thismeansthatthe

injectiontime,definedasthetimebetweenstartofinjectionandtheminimumshaft

temperature,wastoolong(>0.6seconds).Theinjectionwastooslow,keepingtheshafttemperaturelowfortoolong.Theinjectionofsalinewasuneven,causinga”bumpy”shaftsignalandalateminima.Theinjectedamountofsalinewastoolarge,keepingtheshafttemperaturelowtoolong.Solution:Shortanddistinctsalineinjection.Use”one-shot”(3-5cc)syringeforabetterpunch.Evenandsteadyinjection-movementLessinjectionvolume(3-5cc)10-1-2-3-4-5-6Injectionerrors5. ”Tmnvaluetoolow”message

Indication:

Afterinjectionthesign”Tmnvaluetoolow”isdisplayed

Cause:ThecalculatedTmnvaluewaslessthan0.1secondsThesensortipisplacedtooclosetothecatheteropening

SolutionAdjustsensorandcatheterpositions10-1-2-3-4-5-6

p=0.002

IMR的确立Circulation2003;107:3129-3132破坏微循环后IMR的改变IMR的测量IMR= PdxHyperemicTmn= 89x0.37= 33

NormalIMR<25AbnormalIMR>30

Circulation2004;109:2269-2272AnimalValidationIMRisindependentofepicardialstenosis?一.微循环阻力指数的测量方法二.微循环阻力指数的临床价值即使PCI联合最佳药物治疗

仍有近30%稳定性冠心病患者反复发作心绞痛Amongthepatientsrandomizedtoinitialstentimplantation,597of2070experiencedpersistentangina(29%)comparedwith669of2052randomizedtomedicaltherapy(33%)(OR,0.80;95%CI,0.60-1.05)(P=.10)(Figure2E).入选TOAT、OAT、COURAGE、BARI-2D等临床随机对照研究2012最新Meta分析持续性心绞痛发作（persistentangina）最佳药物治疗组PCI+最佳药物治疗组ArchInternMed.2012;172(4):312-31933%29%40斑块冠脉多普勒血流显像（Flow-wire）CT血管造影血管腔内超声血流储备分数光学相干断层成像血管造影41严重冠脉狭窄炎症反应血小板和凝血内皮功能障碍微循环障碍血管痉挛心肌缺血“以缺血为中心”假说CMVD的相关临床疾病

1.JournalofCardiovascularMagneticResonance2011,13(Suppl1):P147.2.EuropeanHeartJournal,doi:10.1093/eurheartj/ehl002.3.JThrombHaemost2004;2:1903–07..4.ClinResCardiol(2010)99:475–481.

冠脉慢血流综合症

冠脉微循环障碍（CMVD）的Camici分类Ⅰ.无冠状动脉疾病和心肌病情况下出现CMVD

Lanza建议将此类进一步分为稳定性/慢性和不稳定性/急性两种Ⅱ.存在心肌病情况下出现CMVDⅢ.存在阻塞性心外膜冠状动脉疾病情况下出现CMVDⅣ.医源性CMVDCamiciPL,etal.NEnglJMed

2007,356:830-840LanzaGA,etalCirculation.2010:121:2317-2325IMR的诊断价值Ⅰ.无冠状动脉疾病和心肌病情况下出现CMVD

53岁男性劳力性气促运动平板试验阳性稳定性微血管障碍（X综合征）IMR=37IMR=33IMR=4975岁女性胸痛半小时入院心电图:ST-T改变.B-UCG:LV46mmEF56%

8小时cTnT:0.8ng/ml

CAG正常.

诊断NSTEMIⅠ.无冠状动脉疾病和心肌病情况下出现CMVDLAD：FFR=0.91IMR=39LCX：FFR=0.96IMR=27RCA：FFR=0.97IMR=68不稳定性微血管障碍Ⅱ.存在心肌病情况下出现CMVD反复心绞痛发作，诊断肥厚梗阻性心肌病患者行化学消融术LAD：FFR=0.95IMR=60术前FFR:0.39IMR:50IMRc39cTnT:0.010ng/ml术后FFR:0.97IMR:41cTnT:0.012ng/ml一个月后随访仍有心肌缺血的症状和客观证据Ⅲ.存在阻塞性心外膜冠状动脉疾病情况下出现CMVD术前FFR:0.65IMR:9cTnT:0.006ng/ml

运动平板试验阳性术后FFR:0.82IMR:35cTnT:0.12ng/ml

运动平板试验阳性Ⅳ.医源性CMVDPredictiveValueofIMRafterPCIforSTEMIJAmCollCardiol2008;51:560-5IMRpredictspeakCKinpatientswithSTEMIIMRpredictsLVfunction3monthsafterSTEMIIMR判断预后的价值

胸痛5小时以急性前壁心肌梗死入院，入院30分钟内行急诊PCI治疗。球囊6atm预扩张，植入支架，然后球囊14atm后扩张，前降支TIMI血流2级，再予以FineCorss微导管在前降支远端注射硝普钠200ug，前降支TIMI血流恢复为3级，远端无血栓影残留。

PCI术前PCI术后90分钟IMR＝51PCI术后90分钟复查心电图显示抬高的前壁ST段无明显回落，CK-MB峰值340IU/L，ProBNP4000ug/ml，术后1天超声心动图显示LVd58mm，EF40%，3个月随访LVd60mm，EF45%。持续性胸痛4小时以急性下壁后壁心肌梗死入院，入院50分钟内入心导管室行急诊PCI治疗。抽吸血栓后直接植入支架，TIMI血流3级，远端无血栓影残留PCI术前PCI术后90分钟IMR＝23PCI术后90分钟复查心电图显示抬高的下壁ST段回落＞50%，CK-MB峰值66IU/L，ProBNP91pg/ml，术后1天及3个月访超声心动图LVd48mm，EF54%。IMR判断预后的价值Prospective,LongitudinalIMRpostSTEMIstudyYong,etal.ACC2012IMRmeasuredatthetimeofSTEMIin253patientsIMR的研究价值41patientsrandomizedtoICSKorplaceboafterprimaryPCIforSTEMIIMRwassignificantlylower(16vs.32,p<0.001)intheSKgroupNEnglJMed2007;356:1823-34.IJCA-13092；Noofpages3IMR＜32（n=31）IMR≥32（n=15）PvalueAge64.3±8.759.9±11