1、LM-PCI面臨的特殊挑戰面臨的特殊挑戰: CAGCAG提供的左主干病變程度、長度欠精確提供的左主干病變程度、長度欠精確 LMd-LADo-LCXoLMd-LADo-LCXo的斑塊分布決定分叉病變干預策略的斑塊分布決定分叉病變干預策略 位于位于“冠脈樹冠脈樹”根部的根部的LMLM生理特征變異大，纖維組織豐富，彈性強生理特征變異大，纖維組織豐富，彈性強 LMLM的的PCIPCI過程必須迅速精確、支架置入完美過程必須迅速精確、支架置入完美 血管內超聲提供更多幫助血管內超聲提供更多幫助第1頁/共33頁IVUS Guided LM-PCI nIVUS更清楚顯示更清楚顯示LM病變部位和程度病變部位和程度

2、nIVUS決定決定LMd病變治療策略病變治療策略nIVUS改善改善LMd病變治療效果病變治療效果第2頁/共33頁Prevalence of LMSS第3頁/共33頁IVUS : the most useful intracoronary diagnostic tool in the cath lab第4頁/共33頁IVUS-LADo-LMd Lesion distribution賈三慶，張宇晨，王雷，等賈三慶，張宇晨，王雷，等. .中華實用內科雜志，中華實用內科雜志，20022002，4 4（1414）7-9.7-9.第5頁/共33頁IVUS-LM Lesion LocalizationPat

3、ients (n=75)Only Ostial21%Only Mid Shaft13.1%Only Bifurcation65.5%From Costantino Costantini et al.第6頁/共33頁LM Bifurcation-IVUS ClassificationCAG 14.89% 4.27% 10.63% 29.78%IVUS 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第7頁/

4、共33頁IVUS-LM Plaque DistributionOviedo C, Maehara A, Mintz GS,et al.Circulation. 2010 Mar 2. Epub ahead of print第8頁/共33頁IVUS-LM Plaque DistributionOviedo C, Maehara A, Mintz GS,et al.Circulation. 2010 Mar 2. Epub ahead of print第9頁/共33頁IVUS determinants of LM FFR0.75Jasti et al.Circulation 2004;110:28

5、31-6第10頁/共33頁IVUS Criteria for a Significant LMCA StenosislMost IVUS LMCA studies show either insignificant disease or critical diseaselAbsolute lumen CSA 6.0mm2 (or MLD 3.0mm) is the suggested criterion for a significant LMCA stenosis Correlates with a LMCA FFR0.75 Murrays Law (LMCAr3 = LADr3 + LCX

6、r3) 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 positively vs negatively remodeled lesions-From Gary S Mintz-TCT2009第11頁/共33頁Conclusions:lIVUS guided ste

7、nting reduced long-term mortality rate compared with conventional angiography-guided stenting in DES placement for unprotected LMCA stenosislThe differential survival rate between IVUS-versus angiogrphy guidance start to separate and progressively diverged after 1 yearlTherefore,the reductioin of th

8、e risk of very late stent thrombosis by IVUS- guidance might play a role in improving survival after DES placement第12頁/共33頁Effect of IVUS upon Mortality of LM Stentingn=201 pairs (BMS+DES) 第13頁/共33頁Effect of IVUS upon Death or MI of LM Stenting n=201 pairs (BMS+DES) 第14頁/共33頁Effect of IVUS upon TVR

9、of LM Stenting n=201 pairs (BMS+DES) 第15頁/共33頁Effect of IVUS upon Mortality of LM Stentingn=145 pairs(DES)第16頁/共33頁對對LMLM進行血運重建的進行血運重建的IVUSIVUS標準標準: : 最小管腔面積6mm2 管腔面積狹窄率50% 最小腔徑(MLD) 2.8mm第17頁/共33頁LMLM成功支架置入的成功支架置入的IVUSIVUS標準標準: : 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

10、腔面積0.9第18頁/共33頁LM-Case Presentation in Recent Work第19頁/共33頁CASE 01？57yrs Man UAP第20頁/共33頁Case 01第21頁/共33頁Case01第22頁/共33頁Case 01第23頁/共33頁Case 01-Final Result第24頁/共33頁Case0254yrs Man STEMI (Anterior Wall) Post infarction agina第25頁/共33頁Case02第26頁/共33頁Case02第27頁/共33頁Case02第28頁/共33頁Case 02第29頁/共33頁Case02-Final Result第30頁/共33頁ConlcusionslPre intervention IVUS is mandatory if technically possible 1.Important qualitative and quantitative information permit best approach. 2.Determine whet