微循環(huán)阻力指數(shù)(IMR)的臨床價(jià)值

微循環(huán)阻力指數(shù)（IMR）的臨床價(jià)值2023最新整理收集do

something一.IMR的測(cè)量方法二.IMR的臨床價(jià)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(dǎo)引導(dǎo)管注射器冠脈血流壓力導(dǎo)絲感受器Transitmeantime/Tmn圖示TmnrestTmnhyp1.靜息時(shí)彈丸式注射2.最大充血狀態(tài)下彈丸式注射IMR的測(cè)量(通過(guò)溫度稀釋法測(cè)量)IMR的推導(dǎo)?Pressure=Pd-Pv=Pd (Pv=0)Flow1/TmnIMR=Pd/(1/Tmn)IMR=PdxTmn (最大充血狀態(tài)下)

微循環(huán)阻力=?P壓力/Flow血流(簡(jiǎn)單)血流微循環(huán)阻力Pd遠(yuǎn)端壓力Pv靜脈壓力~0IMR的測(cè)量IMR= PdxHyperemicTmn= 89x0.37= 33

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

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

Circulation2004;109:2269-2272AnimalValidationNgetal.Circulation2006;113:2054-61.IMR的重復(fù)性血壓，心率和心肌收縮力改變后，CFR改變遠(yuǎn)大于IMRP<0.05準(zhǔn)備和手術(shù)步驟準(zhǔn)備使用6Fguiding三聯(lián)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(cè)量的Tmn會(huì)太短(特別是最大充血狀態(tài)下).如果傳感器位置變化，對(duì)結(jié)果會(huì)有影響.建議在導(dǎo)引導(dǎo)管放到冠脈遠(yuǎn)端、基礎(chǔ)狀態(tài)注射結(jié)束和充血狀態(tài)注射結(jié)束三個(gè)時(shí)間點(diǎn)踩X線(xiàn)留圖比較傳感器位置是否變化把壓力導(dǎo)絲傳感器放到冠脈遠(yuǎn)端(離導(dǎo)引導(dǎo)管開(kāi)口>5cm).在測(cè)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(dǎo)絲傳感器定位PrecautionsforIMRmeasurementCatheterpositioningAvoidunstablepositionorthetemperaturesignalmayfluctuate.Avoid“spilling”saline,positionthecatheterinostiumorthetemperaturesignalmayfluctuate.Avoiddeepengagementortheflowmaybereduced.PressureWire?SensorpositioningPositiontransducer>7cmfromopeningofguidingcatheterorinaccurate

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

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

，進(jìn)入CFR模式4.TheCFRscreenlayout手術(shù)步驟 注射器抽3ml生理鹽水（室溫）通過(guò)導(dǎo)引導(dǎo)管注射，檢查溫度是否能夠最少下降2℃。手術(shù)步驟 注射器抽3ml生理鹽水（室溫）通過(guò)導(dǎo)引導(dǎo)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(kāi)始記錄,按照屏幕提示.快速穩(wěn)定的注射生理鹽水重復(fù)3次基線(xiàn)測(cè)量手術(shù)步驟通過(guò)藥物達(dá)到并保持最大充血狀態(tài)按Rec鍵開(kāi)始記錄，按照屏幕提示快速穩(wěn)定的注射3次生理鹽水

最大充血狀態(tài)測(cè)量手術(shù)步驟

ViewFFRandIMRWhenallmeasurementshavebeendonepressSTOP/VIEW

ontheremotecontroltosavetherecordingandviewthe

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

NormalIMR<25AbnormalIMR>30手術(shù)步驟3. 手工計(jì)算錯(cuò)誤信息溫度下降小于–1℃注射時(shí)間長(zhǎng)于0.6秒.溫度恢復(fù)正常的時(shí)間超過(guò)8秒Tmn小于0,1秒。把傳感器放到更遠(yuǎn)的位置。和錯(cuò)誤信息同時(shí)出現(xiàn)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(huán)后IMR的改變IMR的測(cè)量IMR= PdxHyperemicTmn= 89x0.37= 33

NormalIMR<25AbnormalIMR>30

Circulation2004;109:2269-2272AnimalValidationIMRisindependentofepicardialstenosis?一.微循環(huán)阻力指數(shù)的測(cè)量方法二.微循環(huán)阻力指數(shù)的臨床價(jià)值即使PCI聯(lián)合最佳藥物治療

仍有近30%穩(wěn)定性冠心病患者反復(fù)發(fā)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(jī)對(duì)照研究2012最新Meta分析持續(xù)性心絞痛發(fā)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(nèi)超聲血流儲(chǔ)備分?jǐn)?shù)光學(xué)相干斷層成像血管造影41嚴(yán)重冠脈狹窄炎癥反應(yīng)血小板和凝血內(nèi)皮功能障礙微循環(huán)障礙血管痙攣心肌缺血“以缺血為中心”假說(shuō)CMVD的相關(guān)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(huán)障礙（CMVD）的Camici分類(lèi)Ⅰ.無(wú)冠狀動(dòng)脈疾病和心肌病情況下出現(xiàn)CMVD

Lanza建議將此類(lèi)進(jìn)一步分為穩(wěn)定性/慢性和不穩(wěn)定性/急性?xún)煞NⅡ.存在心肌病情況下出現(xiàn)CMVDⅢ.存在阻塞性心外膜冠狀動(dòng)脈疾病情況下出現(xiàn)CMVDⅣ.醫(yī)源性CMVDCamiciPL,etal.NEnglJMed

2007,356:830-840LanzaGA,etalCirculation.2010:121:2317-2325IMR的診斷價(jià)值Ⅰ.無(wú)冠狀動(dòng)脈疾病和心肌病情況下出現(xiàn)CMVD

53歲男性勞力性氣促運(yùn)動(dòng)平板試驗(yàn)陽(yáng)性穩(wěn)定性微血管障礙（X綜合征）IMR=37IMR=33IMR=4975歲女性胸痛半小時(shí)入院心電圖:ST-T改變.B-UCG:LV46mmEF56%

8小時(shí)cTnT:0.8ng/ml

CAG正常.

診斷NSTEMIⅠ.無(wú)冠狀動(dòng)脈疾病和心肌病情況下出現(xiàn)CMVDLAD：FFR=0.91IMR=39LCX：FFR=0.96IMR=27RCA：FFR=0.97IMR=68不穩(wěn)定性微血管障礙Ⅱ.存在心肌病情況下出現(xiàn)CMVD反復(fù)心絞痛發(fā)作，診斷肥厚梗阻性心肌病患者行化學(xué)消融術(shù)LAD：FFR=0.95IMR=60術(shù)前FFR:0.39IMR:50IMRc39cTnT:0.010ng/ml術(shù)后FFR:0.97IMR:41cTnT:0.012ng/ml一個(gè)月后隨訪仍有心肌缺血的癥狀和客觀證據(jù)Ⅲ.存在阻塞性心外膜冠狀動(dòng)脈疾病情況下出現(xiàn)CMVD術(shù)前FFR:0.65IMR:9cTnT:0.006ng/ml

運(yùn)動(dòng)平板試驗(yàn)陽(yáng)性術(shù)后FFR:0.82IMR:35cTnT:0.12ng/ml

運(yùn)動(dòng)平板試驗(yàn)陽(yáng)性Ⅳ.醫(yī)源性CMVDPredictiveValueofIMRafterPCIforSTEMIJAmCollCardiol2008;51:560-5IMRpredictspeakCKinpatientswithSTEMIIMRpredictsLVfunction3monthsafterSTEMIIMR判斷預(yù)后的價(jià)值

胸痛5小時(shí)以急性前壁心肌梗死入院，入院30分鐘內(nèi)行急診PCI治療。球囊6atm預(yù)擴(kuò)張，植入支架，然后球囊14atm后擴(kuò)張，前降支TIMI血流2級(jí)，再予以FineCorss微導(dǎo)管在前降支遠(yuǎn)端注射硝普鈉200ug，前降支TIMI血流恢復(fù)為3級(jí)，遠(yuǎn)端無(wú)血栓影殘留。

PCI術(shù)前PCI術(shù)后90分鐘IMR＝51PCI術(shù)后90分鐘復(fù)查心電圖顯示抬高的前壁ST段無(wú)明顯回落，CK-MB峰值340IU/L，ProBNP4000ug/ml，術(shù)后1天超聲心動(dòng)圖顯示LVd58mm，EF40%，3個(gè)月隨訪LVd60mm，EF45%。持續(xù)性胸痛4小時(shí)以急性下壁后壁心肌梗死入院，入院50分鐘內(nèi)入心導(dǎo)管室行急診PCI治療。抽吸血栓后直接植入支架，TIMI血流3級(jí)，遠(yuǎn)端無(wú)血栓影殘留PCI術(shù)前PCI術(shù)后90分鐘IMR＝23PCI術(shù)后90分鐘復(fù)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(shù)后1天及3個(gè)月訪超聲心動(dòng)圖LVd48mm，EF54%。IMR判斷預(yù)后的價(jià)值Prospective,LongitudinalIMRpostSTEMIstudyYong,etal.ACC2012IMRmeasuredatthetimeofSTEMIin253patientsIMR的研究?jī)r(jià)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