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冠状动脉内影像学及功能评价Coronary angiogramQCA DS 40-70%Evaluation of the lesionCommon questions for the intermediate lesion:1.As a physiologist: what’s the effect of this stenosis oncoronary blood flow and myocardial function?2.As a clinician: Is this lesion responsible for the patient’ssymptoms?3.As an interventionalist: Will revascularization of this arteryimprove the patient’s clinical outcome?Functional test:Treadmill, SPECT(MPI), UCG, MRIUpper ：Stress MPI Low：Rest MPI王守忠StressRestStressStressRestRestEvidence of ischemiaFunctional test: CFR, FFR VH Morphology ：IVUS, OCT Aortic Pressure = 89 mm HgFFR = 40/89 = 0.45Coronary Pressure = 40 mm Hg Intracoronary imaging and functional test in Cath. LabAtheroma morphologySoft plaque Fibrous plaque Calcified plaqueThrombusIntermediate lesionCriteria for “significant” lesion of proximal LAD,LCX and RCA:☐MLA<4mm2☐Plaque burden>70%EEM-csa=14.2mm2Lumen-csa=3.8mm2Plaque burden=(14.2-3.8)/14.2=73.2%Vulnerable plaque Characteristics of vulnerable plaue in IVUS：☐Area of echolucent zone>1mm2；☐Echolucent area/plaque area >20％；☐Thickness of fibrous cap <0.7mm 。
Ge et al, Heart, 1999baseline 6m FUOkazaki S, et al. Circulation. 2004; 110: 1061-686m FUbaseline Control atorvastatin ESTABLISH Trial: atorvastatin 20mg Plaque regression evaluated with IVUSOstial lesionPreparation -Lesion Evaluation by IVUS IVUS guidance is a MUST for left mains It helps for building up the strategy and determining the type and size of devices I will need.1.Estimate left main length and size (LM always bigger than you think)2.Give information whether or not there is calcification 3.Evaluate plaque volume and distribution!Lesion:Lesion:IVUS Criteria of significant lesions ➢For LM lesions:Lcsa<6.0mm2, or MLD <3.0mm➢For Proximal segment of others(LAD/LCX/RCA) Lcsa<4.0mm 2EEMIntimal edgeMale, 57 yrs, 6m after stenting of LAD,RCA, Stable anginaUse of IVUS in Intervention of LM LesionMLA 7.2mm 2Plaque burden 63%MLA 5.3mm 2Plaque burden 78%MLA 2.7mm 2Plaque burden 80.6%Use of IVUS in Intervention of LM LesionUse of IVUS in Intervention of LM Lesion MLA 13.5mm 2IVUS指导左主干病变介入治疗Impact of IVUS Guidance on All-Cause MortalityAfter LMCA DES Implantation (n=805)SJ Park et al. TCT 2007Finding the entry point of CTO lesion LMLCXLAD-D1D1LCXLAD D1LCXLAD Finding the entry point of CTO lesionC HematomaTL Detection of complicationDES UnderexpansionAcute Stent Malapposition 14atm20atm Incomplete appositionIncomplete “Crush” AppositionPhenomenon foundin >60% Costa RA. TCT 2008IVUS 指导DES植入改善预后1296 IVUS-guided, DES-treated lesions in 884 pts vs 1312 matched angio-guided lesions in 884 ptsIVUS-guided Angio-guided P value 30 dayMACE 2.8% 5.2%0.01 Stent thrombosis0.5% 1.4%0.045 TLR0.7% 1.7%0.045 1 yearMACE14.5%16.2%0.3 Definite stent thrombosis0.7% 2.0%0.014 Probably stent thrombosis 4.0% 5.8%0.08 TLR 5.1%7.2%0.06 Late definite stent thrombosis0.2%0.7%0.3 Roy et al. AHA 2007IVUS 评价PCI治疗效果Predictors of Cypher Thrombosis within 1 year12/15 SES thrombosis lesions has stent CSA <5.0mm2(vs 13/45 controls) Fujii et al. J Am Coll Cardiol 2005;45:995-8IVUS 评价PCI治疗效果Predictors for ISR by IVUSHong Eur HJ 2006BaselineFollow-up (9 months)Post-Follow-up (29 months)●Male ●32 yrs ●Pro-LAD●Cypher Select ®3.0×28mmDetect Late Acquired Stent MalappositionIVUS 新技术●VH-IVUS●血管弹力图●微血管显像VH: Virtual Histology, 虚拟组织Virtual Histology Four Lesion TypesThe PROSPECT TrialMethodology: Virtual histology lesion classification Lesions are classified into 5 main types*Likelihood of one or more such lesions being present per patient. PB = plaque burden at the MLA VH-TCFA and Non Culprit Lesion Related Events Lesion HR3.84(2.22,6.65) 6.41(3.35,12.24)10.77(5.53,21.00)10.81(4.30,27.22)P value<0.0001<0.0001<0.0001<0.0001Prevalence*51.2%17.4%11.0% 4.6%SOFTHARDIndependent predictors of strain were macrophages (p=0.006) and smooth muscle cells (p=0.0001)Normal Hypercholesterolemia Hypercholesterolemia + Statin应用微米及纳米气泡滋养血管与动脉粥样硬化斑块的进展，炎症以及斑块内出血及活动性有关比剂与先进的谐振及次谐振对比剂与先进的谐振及次谐振IVUS 结合，将显著地增强显示易损斑块的能力Baseline images are acquired for 20 seconds, and regions of interest are assignedRange of enhancementContrast is injected, images are acquired for 120 seconds post-injection, and baseline images are subtractedLumen subtracted(microbubble shadoweffect is notcalculated)The enhancementlasts for at least 25seconds. Background motionsare cancelledOptical Coherence Tomography (OCT)OCT成像模式图不同OCT成像系统与IVUS的特点比较1mmSignal poorSharp border Fibrocalcific plaque Signal poor Diffuse border Fibro-lipidic plaqueSignal rich Diffuse border AttenuationFibrous plaque IVUS OCTPlaque characteristics正常血管内膜增厚易损斑块易损斑块脂质斑块有较高的敏感性(90%)和特异性（92%）,脂质斑块表现为边界不清晰的低信号区，纤维帽表现为均一的高信号区。
