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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 care;Ci
2、rculation: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：狭窄60 DM微血管病变B：狭窄80 没
3、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 RheologyPressure-Flow Relationship,Pressure drop across stenosis increases with flow in a non-linear fashion,Entrance effects,Separation losses,Friction loss
4、,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 tolerance)of a patient At maximum vasodilation(
5、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,Pd,0.014”,3 cm,Pressure Monitoring Guide Wire
6、s,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 necessary2.Advance wire,sensor crosses stenosis3.Induce maximum hyperemia and measure FFR4.Because sensor is 3 cm from tip,easil
7、y 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 assessment6.Followed by FFR measurement to check result.If desired,perform hyp
8、eremic pull-back recording7.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 Pressure=89 mm Hg,Coronary Pressure=52 mm Hg,Coronary Pressure=40 mm Hg,
9、P=70 mmHG,FFR=52/122=0.43,FFR=40/89=0.45,Influence of Systemic Pressure on Transstenotic Gradient,P=49 mmHG,1,ExerciseTest,ThalliumScan,Dobut.echo,0.3,0.4,0.5,0.6,0.7,0.8,0.9,True Positive Stress Tests,Negative Stress Tests,FFR and Non-Invasive Stress Testing in Lesions of Intermediate Severity,Pijl
10、s 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 1
11、995,1-VD,60,Bicycle ECG,0.72*,Pijls et al.,Circ 1995,1-VD,pre+post PCI,60,Bicycle ECG,0.74*,Pijls&De Bruyne,NEJM 1996,1-VD,Intermediate,Sten,45,Bicycle ECG+TL,+,Dobut Echo,0.75*,Bartunek et al.,JACC 1996,1-VD,75,Dobutamine Echo,0.78*,Chamuleau et al.,JACC 2000,MVD,127,MIBI-,Spect,0.74*,Abe et al.,Circ 2000,1-VD,46,Thallium,0.75*,De Bruyne et al,Circ 2001,Post MI,57,MIBI-,Spect,0.75-0.80*,*100%Specificity;*Optimal Cutoff Value,0.75,冠状动脉血流动力学测定,导管室的特殊运动试验打掉阻力，压力和血流成正比，压力差反应病变对血流的影响,冠状动脉造影的补充,Thanks,
