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1、IVUS在LM介入治疗中的应用,首都医科大学附属北京友谊医院 王 雷,LM-PCI面临的特殊挑战:,CAG提供的左主干病变程度、长度欠精确 LMd-LADo-LCXo的斑块分布决定分叉病变干预策略 位于“冠脉树”根部的LM生理特征变异大，纤维组织丰富，弹性强 LM的PCI过程必须迅速精确、支架置入完美 血管内超声提供更多帮助,IVUS Guided LM-PCI,IVUS更清楚显示LM病变部位和程度 IVUS决定LMd病变治疗策略 IVUS改善LMd病变治疗效果,Prevalence of LMSS,IVUS : the most useful intracoronary diagnostic
2、 tool in the cath lab,IVUS-LADo-LMd Lesion distribution,贾三庆，张宇晨，王雷，等.中华实用内科杂志，2002，4（14）7-9.,IVUS-LM Lesion Localization Patients (n=75),Only Ostial 21%,Only Mid Shaft 13.1%,Only Bifurcation 65.5%,From Costantino Costantini et al.,LM Bifurcation-IVUS Classification,CAG 14.89% 4.27% 10.63% 29.78% IVU
3、S 34.04% 6.38% 10.63% 25.53%,CAG 8.51% 17.02% 14.89% IVUS 4.27% 12.76% 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,Oviedo C, Maehara A, Mintz GS,et al.
4、Circulation. 2010 Mar 2. Epub ahead of print,IVUS determinants of LM FFR0.75,Jasti et al.Circulation 2004;110:2831-6,IVUS Criteria for a Significant LMCA Stenosis,Most IVUS LMCA studies show either insignificant disease or critical disease Absolute lumen CSA 6.0mm2 (or MLD 3.0mm) is the suggested cr
5、iterion for a significant LMCA stenosis Correlates with a LMCA FFR0.75 Murrays 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/distal bifurcation lesions and for p
6、ositively vs negatively remodeled lesions,-From Gary S Mintz-TCT2009,Conclusions: IVUS guided stenting reduced long-term mortality rate compared with conventional angiography-guided stenting in DES placement for unprotected LMCA stenosis The differential survival rate between IVUS-versus angiogrphy
7、guidance start to separate and progressively diverged after 1 year Therefore,the reductioin 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 Stenting n=201 pairs (BMS+DES),Effect of IVUS upon D
8、eath 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 Stenting n=145 pairs(DES),对LM进行血运重建的IVUS标准:,最小管腔面积6mm2 管腔面积狭窄率50% 最小腔径(MLD) 2.8mm,LM成功支架置入的IVUS标准:,完全贴壁: 沿支架置入段支架完全帖靠血管壁 对称均匀: 支架最大直径比最小直径0.7 扩张充分: 支架最小腔面积
9、(CSA)比平均参考血管 腔面积0.9,LM-Case Presentation in Recent Work,CASE 01,？,57yrs Man UAP,Case 01,Case01,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 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!,THANKS FOR YOUR ATTENDING,