微循環阻力指數（IMR）的臨床價值2023最新整理收集do

something一.IMR的測量方法二.IMR的臨床價值MACROvascularCompartmentMICROvascularCompartmentFFRCFR

(andNon-InvasiveTesting)IMR冠脈阻力KaulandJayaweeraEurHeartJ2006;27:2272-74.正常血管的阻力EpicardialVesselArteriolesCapillariesVenulesPressureFFRTemperatureThermodilution

(CFR)

IMR

ABF

(Temperatureoftheplaque)FFR,(CFR)IMR:theCoronaryCirculationFullPictureState-of-the-artPressureWire5andCertus,flowandtemperature.Pressuretransducer

操作方法導引導管注射器冠脈血流壓力導絲感受器Transitmeantime/Tmn圖示TmnrestTmnhyp1.靜息時彈丸式注射2.最大充血狀態下彈丸式注射IMR的測量(通過溫度稀釋法測量)IMR的推導?Pressure=Pd-Pv=Pd (Pv=0)Flow1/TmnIMR=Pd/(1/Tmn)IMR=PdxTmn (最大充血狀態下)

微循環阻力=?P壓力/Flow血流(簡單)血流微循環阻力Pd遠端壓力Pv靜脈壓力~0IMR的測量IMR= PdxHyperemicTmn= 89x0.37= 33

NormalIMR<25AbnormalIMR>30IMR的確立GuideLADFlowProbeRadio-opaqueOccluderPressureWireCirculation2003;107:3129-3132.動物模型

p=0.002IMR的確立Circulation2003;107:3129-3132破壞微循環后IMR的改變IMRisindependentofepicardialstenosis?

Circulation2004;109:2269-2272AnimalValidationNgetal.Circulation2006;113:2054-61.IMR的重復性血壓，心率和心肌收縮力改變后，CFR改變遠大于IMRP<0.05準備和手術步驟準備使用6Fguiding三聯三通

(壓力,生理鹽水和造影劑)用帶safetyreservoir注射器ContrastMediumSalinePressure如果距離太近，測量的Tmn會太短(特別是最大充血狀態下).如果傳感器位置變化，對結果會有影響.建議在導引導管放到冠脈遠端、基礎狀態注射結束和充血狀態注射結束三個時間點踩X線留圖比較傳感器位置是否變化把壓力導絲傳感器放到冠脈遠端(離導引導管開口>5cm).在測量中保持傳感器在同一位置(給充血藥物前和給藥中).壓力導絲傳感器定位PrecautionsforIMRmeasurementCatheterpositioningAvoidunstablepositionorthetemperaturesignalmayfluctuate.Avoid“spilling”saline,positionthecatheterinostiumorthetemperaturesignalmayfluctuate.Avoiddeepengagementortheflowmaybereduced.PressureWire?SensorpositioningPositiontransducer>7cmfromopeningofguidingcatheterorinaccurate

CFR/Tmn(Transitmeantime)valuesmightoccur.TheTmnvaluemaybecometoshortandwillberejectedbythesoftwareHyperemia長效的充血藥物!!!

HyperemiaUselong-lastinghyperemicstimulitoattainconstanthyperemiaduringthemeasurements.Ifpossible,verifymaximumhyperemiceffect(byusingPd/Paquota)orIMRwillbeincorrect.PrecautionsforIMRmeasurement校準PressureWire?

，進入CFR模式4.TheCFRscreenlayout手術步驟 注射器抽3ml生理鹽水（室溫）通過導引導管注射，檢查溫度是否能夠最少下降2℃。手術步驟 注射器抽3ml生理鹽水（室溫）通過導引導管注射，檢查溫度是否能夠最少下降2℃。注射器抽3ml生理鹽水按REC鍵開始記錄,按照屏幕提示.快速穩定的注射生理鹽水重復3次基線測量手術步驟通過藥物達到并保持最大充血狀態按Rec鍵開始記錄，按照屏幕提示快速穩定的注射3次生理鹽水

最大充血狀態測量手術步驟

ViewFFRandIMRWhenallmeasurementshavebeendonepressSTOP/VIEW

ontheremotecontroltosavetherecordingandviewthe

recordedpressureanddilutioncurvestogetherwiththeFFRvalue.ThevalueofIMRhastobecalculated:IMR=PdxTmnhyp(88x0.50=40)IMR= PdxHyperemicTmn= 89x0.37= 33

NormalIMR<25AbnormalIMR>30手術步驟3. 手工計算錯誤信息溫度下降小于–1℃注射時間長于0.6秒.溫度恢復正常的時間超過8秒Tmn小于0,1秒。把傳感器放到更遠的位置。和錯誤信息同時出現4.ErrormessagesAsalineinjectionmustpasscertaincriteria'stobeacceptedasanvalidinjection.Iftheinjectiondoesnotpassallcriteria'saninjectionerrorwilloccur.Aninjectionerrorcanbecausedbyanumberofreasonsandanerrormessagedisplayedintheinstructionwindowcontainsinformationonwhatcausedtheproblem.WhenanerrormessageisflashinganINJECTAGAINmessageisalsodisplayed,promptinganewinjection.5.InjectionerrorsTheInstrumentdoesnotrespondtotheinjection Indication Theinstrumentindicates”InjectNow”,thephysicianinjectssalineandtheshaftandsensortemperaturedecreases,buttheinstrumentdoesn'trespondatall. Cause Thedecreaseinsensorshafttemperaturewasnotfastordeepenoughtotriggertheinstrumentsrecordingfunction. SolutionShortanddistinctsalineinjection.Use”one-shot”(3-5cc)syringeforabetterpunch.Increasesalinevolume(3-5cc).Coldersaline(roomtemperature,~20oC).

10-1-2-3-4-5-6Injectionerrors2. ”SlowInjection”messageIndication:

Afterinjectionthesign”SlowInjection”isdisplayedCause:

Theshafttemperaturedidn'treachitsminimumvaluefastenough.Thismeansthatthe

injectiontime,definedasthetimebetweenstartofinjectionandtheminimumshaft

temperature,wastoolong(>0.6seconds).Theinjectionwastooslow,keepingtheshafttemperaturelowfortoolong.Theinjectionofsalinewasuneven,causinga”bumpy”shaftsignalandalateminima.Theinjectedamountofsalinewastoolarge,keepingtheshafttemperaturelowtoolong.Solution:Shortanddistinctsalineinjection.Use”one-shot”(3-5cc)syringeforabetterpunch.Evenandsteadyinjection-movementLessinjectionvolume(3-5cc)10-1-2-3-4-5-6Injectionerrors5. ”Tmnvaluetoolow”message

Indication:

Afterinjectionthesign”Tmnvaluetoolow”isdisplayed

Cause:ThecalculatedTmnvaluewaslessthan0.1secondsThesensortipisplacedtooclosetothecatheteropening

SolutionAdjustsensorandcatheterpositions10-1-2-3-4-5-6

p=0.002

IMR的確立Circulation2003;107:3129-3132破壞微循環后IMR的改變IMR的測量IMR= PdxHyperemicTmn= 89x0.37= 33

NormalIMR<25AbnormalIMR>30

Circulation2004;109:2269-2272AnimalValidationIMRisindependentofepicardialstenosis?一.微循環阻力指數的測量方法二.微循環阻力指數的臨床價值即使PCI聯合最佳藥物治療

仍有近30%穩定性冠心病患者反復發作心絞痛Amongthepatientsrandomizedtoinitialstentimplantation,597of2070experiencedpersistentangina(29%)comparedwith669of2052randomizedtomedicaltherapy(33%)(OR,0.80;95%CI,0.60-1.05)(P=.10)(Figure2E).入選TOAT、OAT、COURAGE、BARI-2D等臨床隨機對照研究2012最新Meta分析持續性心絞痛發作（persistentangina）最佳藥物治療組PCI+最佳藥物治療組ArchInternMed.2012;172(4):312-31933%29%40斑塊冠脈多普勒血流顯像（Flow-wire）CT血管造影血管腔內超聲血流儲備分數光學相干斷層成像血管造影41嚴重冠脈狹窄炎癥反應血小板和凝血內皮功能障礙微循環障礙血管痙攣心肌缺血“以缺血為中心”假說CMVD的相關臨床疾病

1.JournalofCardiovascularMagneticResonance2011,13(Suppl1):P147.2.EuropeanHeartJournal,doi:10.1093/eurheartj/ehl002.3.JThrombHaemost2004;2:1903–07..4.ClinResCardiol(2010)99:475–481.

冠脈慢血流綜合癥

冠脈微循環障礙（CMVD）的Camici分類Ⅰ.無冠狀動脈疾病和心肌病情況下出現CMVD

Lanza建議將此類進一步分為穩定性/慢性和不穩定性/急性兩種Ⅱ.存在心肌病情況下出現CMVDⅢ.存在阻塞性心外膜冠狀動脈疾病情況下出現CMVDⅣ.醫源性CMVDCamiciPL,etal.NEnglJMed

2007,356:830-840LanzaGA,etalCirculation.2010:121:2317-2325IMR的診斷價值Ⅰ.無冠狀動脈疾病和心肌病情況下出現CMVD

53歲男性勞力性氣促運動平板試驗陽性穩定性微血管障礙（X綜合征）IMR=37IMR=33IMR=4975歲女性胸痛半小時入院心電圖:ST-T改變.B-UCG:LV46mmEF56%

8小時cTnT:0.8ng/ml

CAG正常.

診斷NSTEMIⅠ.無冠狀動脈疾病和心肌病情況下出現CMVDLAD：FFR=0.91IMR=39LCX：FFR=0.96IMR=27RCA：FFR=0.97IMR=68不穩定性微血管障礙Ⅱ.存在心肌病情況下出現CMVD反復心絞痛發作，診斷肥厚梗阻性心肌病患者行化學消融術LAD：FFR=0.95IMR=60術前FFR:0.39IMR:50IMRc39cTnT:0.010ng/ml術后FFR:0.97IMR:41cTnT:0.012ng/ml一個月后隨訪仍有心肌缺血的癥狀和客觀證據Ⅲ.存在阻塞性心外膜冠狀動脈疾病情況下出現CMVD術前FFR:0.65IMR:9cTnT:0.006ng/ml

運動平板試驗陽性術后FFR:0.82IMR:35cTnT:0.12ng/ml

運動平板試驗陽性Ⅳ.醫源性CMVDPredictiveValueofIMRafterPCIforSTEMIJAmCollCardiol2008;51:560-5IMRpredictspeakCKinpatientswithSTEMIIMRpredictsLVfunction3monthsafterSTEMIIMR判斷預后的價值

胸痛5小時以急性前壁心肌梗死入院，入院30分鐘內行急診PCI治療。球囊6atm預擴張，植入支架，然后球囊14atm后擴張，前降支TIMI血流2級，再予以FineCorss微導管在前降支遠端注射硝普鈉200ug，前降支TIMI血流恢復為3級，遠端無血栓影殘留。

PCI術前PCI術后90分鐘IMR＝51PCI術后90分鐘復查心電圖顯示抬高的前壁ST段無明顯回落，CK-MB峰值340IU/L，ProBNP4000ug/ml，術后1天超聲心動圖顯示LVd58mm，EF40%，3個月隨訪LVd60mm，EF45%。持續性胸痛4小時以急性下壁后壁心肌梗死入院，入院50分鐘內入心導管室行急診PCI治療。抽吸血栓后直接植入支架，TIMI血流3級，遠端無血栓影殘留PCI術前PCI術后90分鐘IMR＝23PCI術后90分鐘復查心電圖顯示抬高的下壁ST段回落＞50%，CK-MB峰值66IU/L，ProBNP91pg/ml，術后1天及3個月訪超聲心動圖LVd48mm，EF54%。IMR判斷預后的價值Prospective,LongitudinalIMRpostSTEMIstudyYong,etal.ACC2012IMRmeasuredatthetimeofSTEMIin253patientsIMR的研究價值41patientsrandomizedtoICSKorplaceboafterprimaryPCIforSTEMIIMRwassignificantlylower(16vs.32,p<0.001)intheSKgroupNEnglJMed2007;356:1823-34.IJCA-13092；Noofpages3IMR＜32（n=31）IMR≥32（n=15）PvalueAge64.3±8.759.9±11