ivus在lm介入治療中的應用,

1、IVUS在LM介入治療中的應用,首都醫(yī)科大學附屬北京友誼醫(yī)院王 雷,LM-PCI面臨的特殊挑戰(zhàn):,CAG提供的左主干病變程度、長度欠精確LMd-LADo-LCXo的斑塊分布決定分叉病變干預策略位于“冠脈樹”根部的LM生理特征變異大，纖維組織豐富，彈性強LM的PCI過程必須迅速精確、支架置入完美　　　　　　 血管內超聲提供更多幫助,IVUS Guided LM-PCI,IVUS更清楚顯示LM病變部位和程度IVUS決定LMd病變

2、治療策略IVUS改善LMd病變治療效果,Prevalence of LMSS,IVUS : the most useful intracoronary diagnostic tool in the cath lab,,IVUS-LADo-LMd Lesion distribution,賈三慶，張宇晨，王雷，等.中華實用內科雜志，2002，4（14）7-9.,,IVUS-LM Lesion LocalizationPatients

3、 (n=75),,,,,,,Only Ostial21%,Only Mid Shaft13.1%,Only Bifurcation65.5%,,,From Costantino Costantini et al.,,LM Bifurcation-IVUS Classification,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,CAG 14.89% 4.27%

4、 10.63% 29.78%IVUS 34.04% 6.38% 10.63% 25.53%,CAG 8.51% 17.02% 14.89%IVUS 4.27% 12

5、.76% 6.38%,From Costantino Costantini et al.,47 Bifurcations,IVUS-LM Plaque Distribution,Oviedo C, Maehara A, Mintz GS,et al.Circulation. 2010 Mar 2. [Epub ahead of print],IVUS-LM Plaque Distribution,

6、Oviedo C, Maehara A, Mintz GS,et al.Circulation. 2010 Mar 2. [Epub ahead of print],IVUS determinants of LM FFR<0.75,Jasti et al.Circulation 2004;110:2831-6,,IVUS Criteria for a ‘Significant’ LMCA Stenosis,Most IVUS L

7、MCA studies show either insignificant disease or critical diseaseAbsolute lumen CSA <6.0mm2 (or MLD <3.0mm) is the suggested criterion for a significant LMCA stenosis ? Correlates with a LMCA FFR<0.75

8、 ? Murray’s Law (LMCAr3 = LADr3 + LCXr3) ? Does not depend on finding a disease-free reference segment? It is not clear whether the same criteria should be used for ostial LM lesions as for mid-shaft/

9、distal bifurcation lesions and for positively vs negatively remodeled lesions,------From Gary S Mintz-TCT2009,,Conclusions:IVUS guided stenting reduced long-term mortality rate compared with conventional angiograph

10、y-guided stenting in DES placement for unprotected LMCA stenosisThe differential survival rate between IVUS-versus angiogrphy guidance start to separate and progressively diverged after 1 yearTherefore,the re

11、ductioin of the risk of very late stent thrombosis by IVUS- guidance might play a role in improving survival after DES placement,Effect of IVUS upon Mortality of LM Stentingn=201 pairs (BMS+DES),,,Effect of IVUS upo

12、n Death or MI of LM Stenting n=201 pairs (BMS+DES),Effect of IVUS upon TVR of LM Stenting n=201 pairs (BMS+DES),,Effect of IVUS upon Mortality of LM Stentingn=145 pairs(DES),,對LM進行血運重建的IVUS標準:,最小管腔面積≥6mm2管腔面積狹窄率＞50%最

13、小腔徑(MLD) ≤2.8mm,LM成功支架置入的IVUS標準:,完全貼壁: 沿支架置入段支架完全帖靠血管壁對稱均勻: 支架最大直徑比最小直徑≥0.7擴張充分: 支架最小腔面積(CSA)比平均參考血管 腔面積≥0.9,LM-Case Presentation in Recent Work,CASE 01,,,,,,,？,57yrs Man UAP,Case 01,,,,,,,,Case01,,,,,,

14、Case 01,Case 01-Final Result,Case02,,,,,,54yrs Man STEMI (Anterior Wall) Post infarction agina,Case02,Case02,,,Case02,Case 02,Case02-Final Result,Conlcusions,Pre intervention IVUS is mandatory if technically possible

15、 1.Important qualitative and quantitative information permit best approach. 2.Determine whether or not and how to do.Post intervention IVUS is mandatory as possible as you can It decreases mortality!,