FFR原理及其在不同病变中的应用价值,阜外心血管病医院 冠心病诊治中心 俞梦越,2,病变 缺血,冠脉病变的解剖和功能学评价,Fractional Flow Reserve, FFR,3,4,Fractional Flow Reserve-FFR定义和公式假设,FFR被定义为狭窄存在和正常时 心肌最大血流量（ QS ，QN ）的 比值 （PaPv） （PdPv） QN , QS R R FFR= QS / QN = （Pd-Pv）/（Pa-Pv） Pd/Pa,5,FFR的临界值,FFR0.80提示狭窄无功能意义的敏感性90%,需要测量FFR,65%,20%,6,DEFER STUDYCardiac Death And Acute MI After 5 Years,3.3,7.9,15.7,0,5,10,15,20,%,P=0.20,P 0.03,P 0.005,DEFER PERFORM REFERENCE,FFR 0.75 FFR 0.75,Pijls NHJ, et al. J Am Coll Cardiol 2007;49: 2105 - 2111,7,Angiography-guided PCI,FFR-guided PCI,Measure FFR in all indicated stenoses,Stent all indicated stenoses,Stent only those stenoses with FFR 0.80,Randomization,Indicate all stenoses 50% considered for stenting,Patient with stenoses 50% in at least 2 of the 3 major epicardial vessels,1-year follow-up,FLOW CHART,8,FAME study: 2-year Event-free Survival,p=0.02,9,FAME: Outcome of Deferred Lesions,513 Deferred Lesions in 509 FFR-Guided Patients,2 Years,31 Myocardial Infarctions,22 Peri-procedural,9 Late Myocardial Infarctions,8 Due to a New Lesion or Stent Related,1 Myocardial Infarction due to an Originally Deferred Lesion,Only 1/513 or 0.2% of deferred lesions resulted in a late myocardial infarction,Pijls NHP et al JACC 2010,10,2011 ACCF/AHA/SCAI Guidelines for PCI,11,FFR的适应证,所有与无创检查结果不明显匹配的临界狭窄病变，包括左主干病变； 分叉病变主支支架置入后分支口部DS 70% 的所有分支； ACS患者有疑问的非罪犯病变； 多支血管病变或系列和弥散病变时,指导CABG或PCI仅处理有明显血液动力学意义的血管或病变,即功能血管重建； 评价PCI的即刻结果和预测其中远、期预后。,12,FAME 研究的主要启示,In patients with MVD, a revascularisation strategy based on both angiography + FFR compared to a strategy only based on angiography results in a 30% reduction of MACE and detah/MI rate despite a lower number of stents and less contrast medium. There is no signal to suggest that deferred lesions are likely to be responsible for late myocardial infarctions or to progress and require repeat revascularizations. FAME challenges two important concepts: a. The definition of multivessel disease b. The concept of completeness of revascularisation,13,“多支血管病变（Multi-veseel disease)”,“Presence of at least one stenosis 50% in at least 2 major coronary arteries and/or in the left main stem”,14,FAME Study,Angiographic 3-VD (n=115),造影所示三支血管病变中 有功能学意义的病变血管的比例,P. Tonino et al JACC 2010,15,Melikian N, et al. J Am Coll Cardiol Intv 2010;3:30714,ANGIO vs. SPECT vs. FFR,SPECT vs. FFR,不同方法学对多支血管病变界定的差异,16,PCI的临床价值,直接PCI减少死亡，挽救生命 择期PCI减轻缺血，缓解症状,17,Ischemia Reduction Improves Outcomes,COURAGE Nuclear Substudy,Shaw LJ, et al. Circulation 2008;117:1283-1291,18,Why do We Need Ischemia Assessment in the Cath Lab?, 50% of patients undergo noninvasive stress test prior to coronary angiography Non invasive stress test unreliable in the presence of multivessel CAD Generally “territory” specific, but not “vessel” specific Can be “vessel” specific “ but not “lesion “ specific Coronary Angiography cannot identify the accurate hemodynamic significance of many coronary stenosis,Lin GA et al. JAMA 2008;300:1765-1773 Kern MJ. Cardiol Clin 2011; 29 237267,19,FFR-Guided PCI in MVD,74 year old woman with HTN, hyperlipidemia, diabetes and atrial fibrillation Admitted with unstable angina Stress thallium revealed inferior and lateral reversible ischemia,20,FFR = Pd / Pa during hyperemia = 89 / 108 = 0.82,FFR of the RCA,21,FFR Left Circumflex,FFR = 0.72,22,What about serial lesions?,0.72,23,Across proximal lesion,Across mid disease,Pullback in Circumflex,Most of gradient occurs across proximal lesion,24,After “spot-stenting” proximal circumflex,FFR = 0.97,25,FFR in Acute Coronary Syndromes,Non-Culprit,Culprit,26,Adenosine i. v. infusion 140 g/kg/min.,PCI: LAD,27,FAME Trial: Substudy: ACS versus Stable Angina,FFR,ACS, N= 150Angio ACS, N=178,Data suggest that like the overall population, a 30% reduction in MACE when FFR is used to guide revascularization in ACS,28,Treatment Options for MVD,PCI,CABG,OMT,FAME,SYNTAX,COURAGE,29,FFR-guided SYNTAX Score (FSS) versus Conventional SYNTAX Score (SS),SS,32% of patients moved to a lower-risk group,497 patients of the FFR-arm of FAME I Syntax scored re-calculated by 3 incdependant reviewers Functional ( FFR) Syntax Score : counting only the lesions with FFR 0.80 3 tertiles based on SS,Nam, C.W. et al. JACC 2011,30,Funtctional SYNTAX Score desciminates Risk of Death/MI and Risk of Total MACE,Death / MI,Total MACE,Fearon WF et al , TCT-MD 2011,31,SYNTAX Score = 38,The use of Functional Evaluation ( FFR ) during MVD PCI reduce the number of stents and MACE,32,Angio-driven procedure = 6 stents CABG is preferd . As altervnative :,33,FFR-driven procedure = 3 stents,Functional SYNTAX Score = 17,34,P. Tonino, et al, J Am Coll Cardiol 2010;55:281621,35,Functional Evaluation is not mandatory for every patient,36,FFR assessment in MVD and diffuse disease is technically easy and offers more accurate functional evaluation of coronary stenoses. Defering treatment of intermediate lesions when the FFR0.80 shou