FFR CT：是否会有美好的未来？

近年来基于冠状动脉CT血管成像的血流储备分数（FFRCT）成为评估冠状动脉生理功能的一项新技术,能同时提供解剖和功能信息,对于冠状动脉疾病的诊疗有望产生积极影响。简要描述了FFRCT的应用现状及本期重点号的内容,以期使更多的读者了解和应用这项新技术,加快其临床转化的进程。      

冠状动脉CTA：斑块特征定量参数与血流储备分数的相关性分析

【摘要】目的：基于冠状动脉CT血管成像（CCTA）探讨斑块特征定量参数值与血流储备分数（FFRCT）测量值的相关性。方法：回顾性分析行CCTA和有创FFR检查的38例患者共50支血管的资料。测量斑块的特征参数（斑块长度、斑块总体积、钙化斑块体积、脂质斑块体积、纤维斑块体积、狭窄程度、最小管腔面积、重塑指数、偏心指数）和FFRCT值,FFRCT≤0.80定义为冠状动脉缺血特异性病变。结合冠状动脉造影和FFR确定的斑块并依据FFRCT值将其分为FFRCT＞0.80组和FFRCT≤0.80组。采用Mann-Whitney非参数检验和两独立样本t检验比较两组中斑块特征参数的差异性。结果：与FFRCT＞0.80组相比,FFRCT≤0.80组中斑块更长［（45.39±14.03） vs （32.51±12.26）mm,P=0.004］,斑块总体积［335.55(209.90,561.74) vs 206.93(147.70,262.84)mm3,P=0.008］、纤维斑块体积［263.13(112.63,436.20) vs 149.71(88.88,177.97)mm3,P=0.013］及脂质斑块体积［23.78(9.84,34.09) vs 3.06(0.89,7.64)mm3,P=0.001］更大。结论：斑块定量特征参数中斑块长度、斑块总体积、脂质斑块体积和纤维斑块体积是影响冠脉血流储备分数的主要因素。     

基于冠状动脉CTA的血流储备分数对冠心病心肌缺血诊断价值的Meta分析

【摘要】目的：采用Meta分析评估基于冠状动脉CTA的血流储备分数（FFRCT）对冠心病心肌缺血的诊断价值。方法：检索Pubmed、Medline、Embase、中国知网、万方、维普数据库中自建库至2018年7月关于FFRCT诊断冠心病心肌缺血的中英文文献。以FFR≤0.8为心肌缺血阈值，按照诊断试验的纳入和排除标准筛选文献，进行质量评价并提取特征信息,数据分析采用Meta-Disc1.4软件和Stata12.0软件，根据异质性检验结果选择相应效应模式，汇总诊断效应量并绘制受试者工作特征曲线（SROC）。结果：共纳入中英文文献10篇，纳入研究的患者共830例，血管1793支，不存在发表偏倚（P＞0.05）。在血管水平汇总后的敏感度、特异度、阳性似然比、阴性似然比、诊断比值比及95%可信区间（95%CI）分别为0.84(0.81~0.87)、0.76（0.74~ 0.79）、3.76(2.69~5.26)、0.22（0.17~0.29）、19.03（10.48~34.54），汇总SROC曲线下面积为0.89；在患者水平汇总后的敏感度、特异度、阳性似然比、阴性似然比、诊断比值比及95%可信区间（95%CI）分别为0.89(0.85~ 0.92)、0.72(0.67~ 0.76)、3.00（2.60~ 3.47）、0.16（0.12~0.22）、19.69 (13.40~ 28.93)，汇总SROC曲线下面积为0.91。结论：以FFR≤0.8为心肌缺血阈值，在血管水平和患者水平上FFRCT诊断冠心病心肌缺血均有较高的诊断准确度，FFRCT可以作为一种无创性筛查冠心病患者心肌缺血的有效手段。     

基于冠状动脉CTA血流储备分数的机器学习对疑似冠状动脉疾病病人的治疗决定和临床结果的影响

正摘要目的本研究旨在通过对比基于冠状动脉CT血管成像(CCTA)的血流储备分数(FFRCT)的机器学习(ML)和有创性冠状动脉造影(ICA),探讨前者对可疑冠心病(CAD)病     

冠状动脉造影临床应用

近年来冠心病的发病率逐年上升,且呈了年轻化趋势,加之城市人口老龄化问题,对冠心病的诊治提出了新的要求。冠状动脉造影(以下简称冠造)作为诊断冠心病的“金标准”是选择冠心病治疗的重要依据,开展该项技术显得尤为重要。于2002年10月开展了冠造,旨在提高冠心病的诊断和治疗水平。1资料和方法1.1一般资料患者73例,其中男63例,女10例,最大年龄79岁,最小年龄32岁,平均年龄59岁。临床诊诊断:急性心肌梗死10例,陈旧性心肌梗死2例,不稳定型心绞痛28例,稳定型心绞痛8例,不典型胸痛者7例,心律失常9例,高血压病6例,其他心脏病行介入治疗时行冠状动…     

CT无创血流储备分数的原理及其临床应用进展

【摘要】CT无创血流储备分数（FFRCT）是一种基于高质量的CCTA图像数据，不需负荷药物，不需额外扫描且无额外辐射剂量的评价冠脉FFR的一种新方法，且逐渐开始应用于临床，在多项国际大规模、多中心的临床试验中开展。本文就FFRCT成像的技术原理、临床应用及其成本效益分析进行综述。     

非体外循环冠状动脉旁路移植术

目的:探讨非体外循环冠状动脉旁路移植术临床疗效。方法:对8例实施非体外循环心脏跳动下冠状动脉旁路移植术的冠心病患者的临床资料、手术方法进行总结分析。结果:本组8例患者无手术死亡,术后随访3个月到1年,所有病人心绞痛症状消失,生活质量明显提高。结论:非体外循环冠状动脉旁路移植术治疗冠心病安全、经济、有效,值得推广。     

冠心病的选择性冠状动脉造影分析（附37例报告）

选择性冠状动脉造影自1958年Sones首先报道之后（1），Judkins于1967年报道了他的改良技术（2），20多年多，国外已普遍应用于临床，但国内报道不多（3）。我院于1984年5月－1986年7月期间共进行了61例选择性冠状动脉造影，其中冠心病37例的临床及造影资料完整，为提高对国人冠心病造影征象的认识，我们进行了回顾性分析，现报告于后。     

CT-心肌灌注成像联合多层螺旋CT冠状动脉成像对冠状动脉粥样硬化性心脏病患者心肌缺血的诊断价值

多层螺旋CT冠状动脉成像(CCTA)属于临床常用冠状动脉粥样硬化性心脏病(冠心病)早期诊断方式,能够对患者冠状动脉狭窄情况进行有效评估,而且诊断准确率较高,但是单纯CCTA技术在心肌缺血预测及评价方面存在一定的局限性[1]。冠心病患者合并冠状动脉狭窄会加大血流动力学紊乱风险并表现出血管重构等表现,因此,了解冠心病患者斑块性质、冠状动脉狭窄状况以及冠状动脉病变对心肌血流灌注情况造成的影响有助于提高诊断准确率并可为临床对患者实际病情以及预后进行准确评估提供依据[2]。此次研究以冠心病心肌缺血患者85例为研究对象,纳入患者自2018年6月至2019年5月接受诊疗,探讨为患者实施CT-心肌灌注成像(CT-MPI)与CCTA联合检测的价值,报告如下。     

以有创性血流储备分数为参照的CTA血流储备分数（CT-FFR）检测心肌缺血：系统评价和Meta分析

正目的 CT血管成像(CTA)衍生的血流储备分数(FFRCT)是一种检测冠状动脉狭窄的血流动力学方法的替代手段。拟通过Meta分析对FFRCT诊断效能进行可靠评估,并     

Assessment of lesion-specific ischemia using fractional flow reserve (FFR) profiles derived from coronary computed tomography angiography (FFRCT) and invasive pressure measurements (FFRINV): Importance of the site of measurement and implications for patient referral for invasive coronary angiography and percutaneous coronary intervention

BackgroundFractional flow reserve (FFR)-derived from computed tomography angiography (CTA; FFRCT) and invasive FFR (FFRINV) are used to assess the need for invasive coronary angiography (ICA) and percutaneous coronary intervention (PCI). The optimal location for measuring FFR and the impact of measurement location have not been well defined.Methods930 patients (age 60.7 + 10 years, 59% male) were included in this study. Normal and diseased coronary arteries were classified into stenosis grades 0–4 in the left anterior descending artery (LAD, n = 518), left circumflex (LCX, n = 112) and right coronary artery (RCA, n = 585). FFRCT (n = 1215 arteries) and FFRINV (n = 26 LAD) profiles were developed by plotting FFR values (y-axis) versus site of measurement (x-axis: ostium, proximal, mid, distal segments). The best location to measure FFR was defined relative to the distal end of the stenosis. FFR ≤0.8 was considered positive for ischemia.ResultsIn normal and stenotic coronary arteries there are significant declines in FFRCT and FFRINV from the ostium to the distal vessel (p < 0.001), due to lesion-specific ischemia and to effects unrelated to the lesion. A reliable location (distal to the stenosis) is 10.5 mm [IQR 7.3–14.8 mm] for FFRCT and within 20–30 mm for FFRINV. Rates of positive FFR (from the distal vessel) reclassified to negative FFR (distal to the stenosis) are 61% (FFRCT) and 33% (FFRINV).ConclusionFFRCT and FFRINV values are influenced by stenosis severity and the site of measurement. FFR measurements from the distal vessel may over-estimate lesion-specific ischemia and result in unnecessary referrals for ICA and PCI.     

基于CCTA对胸痛病人高危斑块成分及血流动力学特征的研究

目的 基于冠状动脉CT血管成像（CCTA）研究伴高危斑块的胸痛病人其斑块成分特征及血流动力学特征。方法 回顾性纳入行CCTA且于2个月内行有创冠状动脉造影检查的43例冠心病病人,男30例,女13例,平均年龄（60.8±8.7）岁。依据病人是否存在高危斑块及胸痛将病人分为2组,组1同时存在胸痛和至少1个高危斑块特征（23例）,组2仅有胸痛或高危斑块特征任意一项（20例）。测量斑块成分特征参数[斑块总体积、钙化斑块体积、纤维斑块体积、脂质斑块体积占比（脂质斑块%）、脂质斑块面积、最小管腔面积、偏心指数]和血流动力学特征参数[基于CCTA的血流储备分数（FFR_CT）,斑块近、远端FFR_CT差值（△FFR_CT）]。采用Mann-Whitney U检验或独立样本t检验比较2组间参数的差异。利用约登指数计算斑块成分特征及血流动力学特征判断高危斑块合并胸痛的临界值,采用受试者操作特征（ROC）曲线分析计算其临界值的敏感度、特异度以及曲线下面积（AUC）。结果 组1的脂质斑块%、脂质斑块面积均高于组2（均P<0.05）,FFR_CT值低于组2（P<0.05）,2组间其他斑块成分特征参数及△FFR_CT差异均无统计学意义（均P>0.05）。分析脂质斑块%、脂质斑块面积及FFR_CT 特征参数的诊断能力,FFR_CT的临界值为0.82时的敏感度最高（61%）、特异度最低（85%）,AUC最高（0.80）。结论 采用CCTA分析高危斑块中脂质斑块成分特征并进行FFR_CT测量,可作为评估高危斑块合并胸痛病人的有效辅助手段,为临床治疗决策提供依据。     

冠状动脉CT血管成像对非心脏手术术前风险评估的价值

术前心脏风险分层有利用改善手术的临床预后、缩短住院时间、减少医疗费用。冠状动脉CT血管成像（CCTA）作为诊断冠状动脉疾病最常应用的无创影像技术在非心脏手术病人的应用中有重要价值。就CCTA在非心脏手术术前风险分层中的潜在适用人群、研究进展和应用前景进行综述，以利于认识其临床价值、解释结果和探讨未来研究方向。     

Incidence and predictors of lesion-specific ischemia by FFRCT: Learnings from the international ADVANCE registry

BackgroundTo date, the clinical utility of coronary computed tomography angiography (CTA)-derived fractional flow reserve (FFRCT) has been limited to trials and single center experiences. We herein report the incidence of abnormal FFRCT (≤0.80) and the relationship of lesion-specific ischemia to subject demographics, symptoms, and degree of stenosis in the multicenter, prospective ADVANCE registry.MethodsOne thousand patients with suspected angina having documented coronary artery disease on coronary CTA and clinically referred for FFRCT were prospectively enrolled in the registry. Patient demographics, symptom status, coronary CTA and FFRCT findings were recorded. Univariate and multivariate analyses were performed to investigate the predictors related to abnormal FFR_CT.ResultsFFR_CT data were analyzed in 952 patients (95.2%). Overall, 51.1% patients had a positive FFR_CT value (≤0.80). Patients with ≥3 risk factors had a significantly higher rate of abnormal FFR_CT than those with <3 risk factors (60.2% vs. 43.9%, p = 0.0001). On multivariate analysis, baseline diabetes (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.04–2.21, p = 0.030) and hypertension (OR 1.56, 95%CI 1.14–2.14, p = 0.005) were both predictive of abnormal FFR_CT. In addition, >70% stenosis was significantly associated with low FFR_CT (OR 31.16, 95%CI 12.25–79.22, p < 0.0001) vs. <30% stenosis. Notably, stenosis 30–49% vs. <30% had an increased likelihood of ischemia (OR 3.74, 95%CI 1.52–9.17, p < 0.0001).ConclusionsIn this real-world registry, CT angiographic stenosis severity in addition to baseline cardiovascular risk factors conferred an increased likelihood of an abnormal FFR_CT. Importantly, however, mild CT angiographic stenoses were noted to have an increased hazard for ischemia and the converse holding true for more severe stenoses as well.     

Quantitation of left ventricular asynchrony on radionuclide angiography phase images

Quantitation of left ventricular (LV) asynchrony is relevant in clinical cardiology, as well as in evaluating LV mechanical properties. Radionuclide angiography (RA) phase images are extensively used, and asynchrony is usually assessed by computing the standard deviation of phase angle distribution (SD). However, SD is dependent on count statistics and does not take into account the spatial distribution of asynchrony. In this study a new index to evaluate asynchrony on phase images is presented (differential uniformity parameter, DUP). DUP is based on the frequency analysis of phase images. Diagnostic accuracy and reproducibility of either SD or DUP were tested. Reproducibility was evaluated in 15 patients studied by RA twice within a few minutes. DUP showed a better reproducibility than SD. Diagnostic accuracy was estimated in 84 patients, divided into four subgroups on the basis of coronary arteriography and contrast ventriculography findings: (a) 25 control subjects, (b) 16 patients with coronary artery disease (CAD) and normal LV wall motion, (c) 23 patients with CAD and LV hypokinesia and (d) 20 patients with CAD and LV dyskinesia. Relative diagnostic ability was assessed by comparing the areas under receiver-operating characteristic curves. DUP's area was larger than SD's when group D was tested against all the other groups (DUP's area=87%±5%, SD's area=76%±7%;P<0.01). Thus, our study indicates that DUP is more reproducible and more accurate than SD in identifying patients with CAD and LV dyskinesia.This work was supported in part by a grant of the Italian Council for Research (CNR) no. 87.00440.56     

Physiologic evaluation of ischemia using cardiac CT: Current status of CT myocardial perfusion and CT fractional flow reserve

Cardiac CT, specifically coronary CT angiography (CTA), is an established technology which detects anatomically significant coronary artery disease with a high sensitivity and negative predictive value compared with invasive coronary angiography. However, the limited ability of CTA to determine the physiologic significance of intermediate coronary stenoses remains a shortcoming compared with other noninvasive methods such as single-photon emission CT, stress echocardiography, and stress cardiac magnetic resonance. Two methods have been investigated recently: (1) myocardial CT perfusion and (2) fractional flow reserve (FFR) computed from CT (FFRCT). Improving diagnostic accuracy by combining the anatomic aspects of coronary CTA with a physiologic assessment via CT perfusion or FFRCT may reduce the need for additional testing to evaluate for ischemia, reduce downstream costs and risks associated with an invasive procedure, and lead to improved patient outcomes. Given a rapidly expanding body of research in this field, this comparative review summarizes the present literature while contrasting the benefits, limitations, and future directions in myocardial CT perfusion and FFRCT imaging.     

Coronary volume to left ventricular mass ratio in patients with diabetes mellitus

BackgroundDiabetes mellitus is a major risk factor for coronary artery disease (CAD) and may provoke structural and functional changes in coronary vasculature. The coronary volume to left ventricular mass (V/M) ratio is a new anatomical parameter capable of revealing a potential physiological imbalance between coronary vasculature and myocardial mass. The aim of this study was to examine the V/M derived from coronary computed tomography angiography (CCTA) in patients with diabetes.MethodsPatients with clinically suspected CAD enrolled in the ADVANCE (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care) registry and known diabetic status were included. Coronary artery volume and left ventricular myocardial mass were analyzed from CCTA and the V/M ratio was calculated and compared between patients with and without diabetes.ResultsOf the 3053 patients (age 66 ?± ?10 years; 66% male) with known diabetic status, diabetes was present in 21.9%. Coronary volume was lower in patients with diabetes compared to those without diabetes (2850 ?± ?940 ?mm³ vs. 3040 ?± ?970 ?mm³, p ?< ?0.0001), whereas the myocardial mass was comparable between the 2 groups (122 ?± ?33 ?g vs. 122 ?± ?32 ?g, p ?= ?0.70). The V/M ratio was significantly lower in patients with diabetes (23.9 ?± ?6.8 ?mm³/g vs. 25.7 ?± ?7.5 ?mm³/g, p ?< ?0.0001). Among subjects with obstructive CAD (n ?= ?2191, 24.0% diabetics) and non-obstructive CAD (16.7% diabetics), the V/M ratio was significantly lower in patients with diabetes compared to those without (23.4 ?± ?6.7 ?mm³/g vs. 25.0 ?± ?7.3 ?mm³/g, p ?< ?0.0001 and 25.6 ?± ?6.9 ?mm³/g vs. 27.3 ?± ?7.6 ?mm³/g, respectively, p ?= ?0.006).ConclusionThe V/M ratio was significantly lower in patients with diabetes compared to non-diabetics, even after correcting for obstructive coronary stenosis. The clinical value of the reduced V/M ratio in diabetic patients needs further investigation.     

Technical challenges of coronary CT angiography: Today and tomorrow

Rapid advancements in multidetector row computed tomography (MDCT) are beginning to revolutionise cardiac imaging applications. As a consequence, coronary CT angiography (CTA) is fast emerging as a highly effective, noninvasive imaging technique for the assessment of coronary artery disease (CAD). Technology is improving at a robust pace, which brings with it the benefits of superior spatial and temporal resolution as well as fast volume coverage, achieved through the development of systems with an increased number of detectors and shorter gantry rotation time, as well as the advent of systems equipped with dual-source X-ray tubes. The main power of CTA was thought to lie in its high negative predictive value in excluding coronary disease with a high degree of accuracy in patients with low probability for CAD. However, this rapid progress has meant that we are also adding to the growing list of additional potential applications of CTA that are possible with the technology. The aim of this review is to present an overview of the technical capabilities of cardiac MDCT relating to coronary CTA and other applications, the limitations of current technologies, as well as discuss political perspectives and how to address these in medical practice.     

PET-CT在冠心病诊断中的临床应用及新进展

PET-CT对冠心病的诊断、治疗方案的选择及预后的判断等具有重要意义,可无创性诊断冠心病、评估动脉粥样硬化斑块性质、指导冠心病治疗方法的选择与疗效监测、判断预后等.该文介绍PET-CT在冠心病中的临床应用及新进展.     

双源CT冠状动脉成像在飞行人员冠心病诊断中的价值

目的 探讨双源CT冠状动脉成像在飞行人员冠心病诊断中的临床应用价值.方法对10名临床怀疑冠心病的飞行人员患者行双源CT冠状动脉成像（computed tomography coronary angiography,CTCA）检查和常规X线冠状动脉血管造影（conventional coronary angiography,CCA）检查,以CCA为金标准比较分析CTCA诊断冠状动脉狭窄的敏感性、特异性及准确性.结果 10例飞行人员患者均成功完成了双源CTCA与CCA 检查,双源CTCA图像优良率为96.3%.CTCA发现不同程度冠状动脉狭窄和斑块形成7例,其中2例同时存在前降支心肌桥;冠状动脉-肺动脉瘘1例;冠状动脉正常2例.7例患者的CTCA图像上15个冠状动脉节段有不同程度狭窄,以CCA为金标准,双源CTCA诊断冠状动脉有狭窄的敏感性、特异性及准确率分别为100.0%、98.2%、98.4%;诊断冠状动脉中度及中度以上狭窄的敏感性、特异性及准确率分别为80.0%、99.2%、98.4%.双源CTCA与CCA显示冠状动脉节段病变的能力无统计学差异（χ2=0.50,P=0.4795）.结论 双源CTCA作为一种无创检查方法,能够准确地评估飞行人员冠状动脉狭窄程度和冠状动脉管壁斑块情况,并能显示冠状动脉先天变异等,对于安全可靠地诊断飞行人员冠心病具有较高的应用价值.