Internal imaging of blood vessels in the field of coronary heart disease diagnosis and treatment progress progress
Expert introduction:
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Jia Haibo
Chief physician, professor, doctoral supervisor, winner of the National Outstanding Youth Science Fund (2017), currently the Deputy Director of the Cardiology Ward of the Second Hospital of Harbin Medical University.
He graduated from Harbin Medical University. He studied with Professor Yu Bo from the famous cardiovascular disease expert in my country and studied at Harvard Medical College for 3 years. It is mainly engaged in clinical, teaching and scientific research on coronary intervention diagnosis and internal imaging and functional science.
The rapid development of imaging technology in the cavity has greatly promoted the improvement of the level of coronary intervention diagnosis and treatment, and has become an indispensable part of the cardiovascular field. In the past 2018, the internal imaging of vascular imaging has occurred in the study of coronary heart disease mechanisms, treatment guidance and strategy optimization, and many hot events that may change future clinical practice have been invested in the latest annual incident of vascular imaging.
(1) The first internal intravascular clinical application experts jointly formulated by the European Cardiovascular Intervention Association (EAPCI) and the Chinese Medical Association Cardiovascular Disease Branch (CSC)
In the past, many consensus on OCT (optical coexistence layer imaging) and IVUS (ultrasound in the blood vessels) have made detailed specifications for the application of the two technologies, but mainly based on theory. The actual question is authorized to answer the authority, and this consensus is based on a large number of evidence -based medical evidence and combined with the opinions of the expert group to answer the five questions that are most concerned about clinical intervention doctors.
1. Can intravascular images improve the clinical ending after PCI?
The consensus expert group comprehensive evidence -based medical evidence, and believes that IVUS and OCT are not weaker or even better than the “gold standard” coronary angiography in guiding and optimizing PCI treatment. Both intra -cavity imaging technology can identify the advantages and disadvantages of stent implantation (bracket expansion, paste and complications, etc.), and can conduct in -depth research from the mechanism of failed to place the bracket.
2. Which type of patients and lesions should be performed in PCI in the PCI?
The optimization of the treatment strategy and stent in the effect of intra -cavity is the main basis for clinical application of imaging. This is the main guiding significance of the current application and is also generally recognized by experts at home and abroad. Consensus opinion: Patients diagnosed with ACS, left -main stem disease, bifurcation lesions with dual bracket technology, biological absorption bracket implantation, and renal insufficiency patients are the main adaptation signs of intra -intra -intra -intra -intra -imaging examination.
3. What are the standards of IVUS and OCT when guiding and optimizing the grid implantation?
Consensus from PCI, during the multi -angle of the operation, and postoperative multi -direction, the use of the use of the use of intra -stent in the stent implantation and optimization of the intra -cavity, including: 1) the identification of plaques before PCI; 2) Evaluation of the best stent size when intervention; 3) evaluation of postoperative stent implantation effect
4. How to evaluate the reason for the failure of the bracket?
Analysis of the reasons for reenginer and thrombosis in the bracket in the vascular imaging is the key to clarify the stent failure (high recommendation); OCT is the first choice for clarifying the stenosis and bracket thrombosis mechanism; When the reasons are not clear, you should consider the internal imaging of the application, and it must be applied, and it is recommended to evaluate the failure of any new DES or BRS bracket. The OCT results of the registered research on the bracket of the bracket indicate that the following reasons for the failure of the bracket can be prevented: the bracket paste wall is poor, the stent edge plaques have a large load, and the expansion and bracket expansion is poor.
5. What are the limitations of images in the cavity?
One of the main limitations of vascular imaging is that the imaging itself also takes additional time. The cost of IVUS and OCT is also worthy of attention. This is also the limitations of most interventional experts. In a large -scale study, more than 3600 PCIs under the guidance of OCT or IVUS were selected. The results showed that the complications related to imaging examination were very rare (0.6 %), self -limiting, or after simple process It will not cause severe adverse blood vessels.
The consensus is based on the most controversial clinical problems, based on the existing evidence -based medical evidence, and answered the actual questions as a clinical practitioner. It has a clinical reference and guidance value.
(2) Forecast of plaques erosion of EROSION series of research: smoking, age <50 years old, female patients, no other coronary heart disease risk factors
For patients with myocardial infarction caused by plaques erosion (PE), those who have no obstructive lesions after the blood flow is opened, and the non -stent treatment strategy is initially confirmed to be safe and reliable. The clinical trial further confirmed, but the individual precision and precise treatment model of non -stent plaques eroded patients broke the treatment concept of conventional stent implantation of myocardial infarction patients, which fits contemporary precision individualized therapy concepts. Whether plaques erosion patients have predictable crowd characteristics, and the transformation of secondary prevention to first -level prevention is still a problem that needs to be solved clinically.
Our team conducted an OCT examination before intervention through 822 patients who were selected for forward -looking. Under the diagnostic criteria established in the past, 209 PE (25.4%) and 564 cases of PR (68.6%) were divided into. Higher rate (P = 0.009), men also have similar but not obvious trends (P = 0.011). PE has a high incidence in smoking patients and has a lower risk of coronary heart disease. In the onset part, LAD (61.2%) Most of them, and plaque rupture mainly occurs in LAD (47%) and right crowns (43.3%). Despite the length of similar lesions, the plaques have been ruptured in the bifurcation (P <0.001). Through multiple factors regression analysis, the first time in the crowd confirmed that 1/4 ACS was caused by plaques erosion. Age <50, smoking, no other coronary heart disease risk factors, single vascular lesions, mild lesions, residual lumen area Large, lesions close to branches are significantly correlated with plaques erosion; for male patients, smoking and lesions close to branches are the most important factors for plaques erosion. Among female patients, age <50 years old (before menopause) predict the value of plaque erosion the highest value. Essence
Big sample analysis of PE patients clinical, angiography and OCT features, found that PE is a predictable crowd in ACS patients, so as to establish a precise PE warning model, so that the prevention and treatment of PE patients move forward. The precision treatment system for diagnosis and treatment has the transformation from clinical manifestations to pathological mechanisms based on clinical manifestations.
(3) OCT, IVUS and traditional coronary angiography, the three guidance of PCI is good or bad
Traditional coronary angiography is still the gold standard of coronary heart disease diagnosis, but with the continuous development of medical science and technology levels, the continuous strengthening of the implementation of individualized and precise treatment concepts, coronary angiography has gradually revealed only the shortcomings of the two -dimensional image of coronary blood vessels. And intra -cavity imaging technology can accurately evaluate the fine structure of the coronary arterial tube cavity, which can not only evaluate the degree of lumen stenosis, but also evaluate other refined structures such as the degree of load and damage of plaques to explore coronary heart disease diseases such as coronary heart disease The pathogenesis and optimization guidance of coronary heart disease intervention have important clinical significance. Oct and IVUS, as the two most promising intra -cavity imaging technologies, have their own advantages and disadvantages in scientific research and clinical applications. Essence
A queue study based on Pan-London (UK) PCI was included in 12374 patients with PCI in PCI from 2005 to 2015 from 2005 to 2015. After excluding patients receiving emergency PCI, 87 166 patients were eventually selected. The main research end is due to the mortality rate (medium follow -up 4.8 years). 1149 patients (1.3 %) patients used OCT, 10 971 (12.6 %) patients used intraevioles (IVUS), and the remaining 75046 patients used blood vessels separately. The total OCT utilization rate increases with time (P <0.0001), and the growth rate of different centers is different (P = 0.002). The average bracket length angiography guidance group is the shortest, the IVUS guidance group is long, and the OCT guidance group is the longest. OCT's surgery, its surgical success rate is high, and can reduce the MACE rate in the courtyard. Oct -guided PCI patients (7.7 %) and IVUS guidance (12.2 %) or vascular angiography (15.7 %; P <0.0001) patients with PCI have a significant difference in mortality rates.
Overall, this difference in multiple variable Cox analysis (HR = 0.48; 95 % CI: 0.26 ~ 0.81; P = 0.001) and tendency matching (HR = 0.39; 95 % CI: 0.21 ~ 0.77; P = 0.0008; Oct; Oct; Oct; Oct; Oct; Oct; Oct; Oct; Oct; VS. vascular angiography still exists, and there is no difference in matching OCT and IVUS groups (HR = 0.88; 95 % CI: 0.61 ~ 1.38; P = 0.43). This large -scale observation research reminds that compared with the PCI guidance of standard blood vessels, the PCI guided by OCT is related to the improvement of surgical ending, intra -hospital events and long -term survival.
Another Ultimate studied for 1,448 patients, with 1; 1 of 1; 1 randomly divided into the IVUS guidance group and coronary angiography guidance group. After 12 months of follow -up, 60 cases of TVFS (4.2%), 21 cases (2.9%) in IVUS group, 39 cases (5.4%) (HR: 0.530, 95%CI: 0.312 -0.901; P = 0.019). In the IVUS group, 1.6%of patients with successful surgery recorded TVF. In contrast, 4.4%of patients who failed to reach all best standards recorded TVF (HR: 0.349; 95%CI: 0.135-0.898; P = 0.029). Based on the analysis of IVUS at the level of lesions, the target lesion reconstruction (TLR) or clear stent thrombosis caused by clinical factors (HR: 0.407; 95%CI: 0.188-0.880; P = 0.018)
The results show that within a larger population range, the PCI treatment guided by IVUS has reduced the incidence of bad events after surgery, and is better than coronary angiography, providing evidence of evidence -based medical evidence for IVUS’s wider clinical applications. Whether the intra -cavity imaging technology can ultimately replace coronary angiography, or only as supplementary diagnosis and treatment methods, will be further answered by future clinical trials. In addition, as a follow -up study of the iLumien series, the Ilumien IV test began to enter patients this year. This research will be the largest randomized trial in the field of imaging in the cavity to guide the clinical PCI field. The clinical application provides evidence -based medical evidence. Previous studies have shown that IVUS auxiliary guidance PCI can effectively reduce severe cardiovascular adverse incidents (MACE) after PCI, and has been widely used in clinical clinical. Oct has a higher resolution than IVUS, can analyze the more fine structure gold, whether it has a better clinical guidance effect, and will give an answer through further clinical trials in the future.
(4) LRP Study: The prospect of NIRS in predicting ACS prognosis is broad
At the TCT 2018 conference, Professor Ron Waksman announced the latest research results of LRP, which proved that the existence of undetectable non-blood flow-rich lipid plaques detected by the NIRS-IVUS imaging, which occurred with the major unconcerned vascular incident (MACE) (MACE) Related. Coronary arteries are rich in lipid plaques. It may be related to subsequent cardiovascular events. It can effectively improve the clinical prognosis of PCI patients by identifying high -risk population and lipid -rich prone plaque. NIRS-IVUS has a dual-mode imaging catheter that can simultaneously evaluate the lipid composition and plaques load of plaques at the same time, thereby making danger layers and judgment on the patients.
The study was included in from February 2014 to March 2016. A total of 1,563 patients with a cardiac inspection of 44 centers in the United States and Europe conducted a total of 1,563 patients with suspected coronary disease. And observed the level of patients and plaques within 2 years. At least one Maxlcbi 4 mm segment ≥250 and 50 % of patients with MAXLCBI 4 mm segments ≥250 <250.
In the analysis of susceptible patients, every 100 units of Maxlcbi 4 mm increased, the risk of MACE incidents in non -criminal diseases in 24 months was higher than 18 %. The MAXLCBI 4 mm ≥ 400 patient MACE rate was 12.6 %, while MaxlCBI 4 mm <400 patients were 6.3 %. In the analysis of the horizontal analysis of damaged plaques, every 100 units increased by MaxlCBI 4 mm, and the risk of incidents in the coronary arterial section within 24 months was higher than 45 %. The MAXLCBI 4 mm ≥ 400 plaque's MACE rate is 3.7 %, while MaxlCBI 4 mm? 400 plaques are 0.8 %.
Professor Ron Waksman, MEDSTAR Cardiovascular Diseases, Washington, said that multi -blood vessel NIRS can be easily carried out to evaluate and identify patients with susceptibility and damaged plaques. Obstructive coronary arteries and non -criminal arterial examination tools should consider patients who are used for PCI cardiac custody examination.
(5) MINOCA (non -obstructive myocardial infarction) Inquiry: The first use of OCT combined with MRI to reveal its pathogenesis
At present, many studies are mainly concentrated in the prognosis and treatment of MINOCA patients, but the research on the MINOCA mechanism is still lacking. In fact, MINOCA is a heterogeneous disease, with many potential causes, and atherosclerosis is one of the important pathogenesis. But the specific pathogenesis of MINOCA is still an unknown field. OCT is based on its high resolution, or a imaging technology that can effectively identify the cause of MINOCA.
The study was eventually incorporated into 38 patients (average age of 62 ± 13 years, 55%was female, and 39%were raised myocardial infarction in ST segments). Among them, the most important relationship between coronary lesions was 35%of stenosis, and 5 patients (13%) coronary angiography results were normal. There were 9 cases (24%) of plaques (PLAQUE DISRUPTION) [including plaque rupture (PR) and calcification nodules (CN)], 7 cases (18%), and coronary thrombosis. 16 of the 31 patients (52%) had LGE, and 7 (23%) had ischemic LGE. Ischemic LGE is more common among patients with spots destruction (50% vs. 13%, P = 0.053) and coronary thrombosis (67% vs. 12%, P = 0.014). Compared with the non -IRA plaques (40% vs. 6%, P = 0.02), thrombosis (50% vs. 4%, P = 0.014), and thin fiber cap (70% vs. 30%, 30%, 30% P = 0.03) The incidence is higher.
This study found that 24%and 18%of MINOCA patients had plaques damage and thrombosis. In addition, it is found that the damage and thrombosis formation of plaques is related to smoking and higher degree of maximum lumen stenosis. This provides clues for the pathogenic mechanism of some MINOCA patients, and prompts that smoking and mild to medium -degree CAD can be used as whether it can be used as whether It is necessary to further clarify the important signs of the existence of plaques and/or thrombosis. At present, CMR has high diagnostic value for detection of myocardial fibrosis, and has also become a gold standard for detecting myocardial infarction. In addition, based on the precise positioning of the CMR infarction area, CMR can directly establish the connection between the vascular and myocardial infarction areas. This study found that patients with plaques destruction or thrombosis are more likely to have ischemia LGE. The latter has statistically significant significance. In addition, compared with non -IRA, plaques in Ira (caused by PR), thrombosis and thrombosis and Changing of thin fiber hat porridge -like hardened diseases is common, which indicates that atherosclerosis may be the pathological basis of MINOCA.
However, it is worth noting that the number of this experiment has fewer cases and less statistical persuasion.
(6) New application in the field of heart transplantation: Early early warning early prevention and control
Heart transplantation has become an effective way to rescue the heart failure of the end, saving tens of thousands of lives. However, heart transplantation still faces many difficulties and has a failure rate that cannot be ignored. For example, CAV cardiac migration vascular disease (CAV), CAV, 5 years after transplantation reaches more than 50 %, affects patients. The main factors of the prognosis. Due to the desertification of the transplantation heart, CAV patients lack typical symptoms. Therefore, clinically use coronary arterials to regularly screen CAV and give timely treatment. However, due to the limitations of the method itself, the coronary angiography has a poor diagnosis of early stages or mild CAVs, so it has been looking for a technology that can effectively detect the early CAV of coronary angiography to effectively detect the early CAV. The recognition of the minor structure of the lumen wall is expected to stand out in many intra -cavity imaging technology.
Research and analyzed 110 OCT images from 76 patients. 26 of the 110 cases were thickened, of which 11 were severely thickened (0.4 mm). It is worth noting that 8 cases of angiography were normal. Five patients with I/M CSA (ratio of endometrium and mid -membrane cross -sectional area) ≥ 2 are normal. The maximum endometrium thickness ≥0.25 mm is 24%, and the maximum endometrium thickness ≥0.40 mm is 10%. The average I/M CSA ≥ 1 in 80%of the cases. The ratio of the I / M CSA in the heinet therapy group is significantly lower than that of unattended treatment group (P = 0.03). 17%of cases changed clinical treatment strategies due to OCT discovery.
OCT provides an important information lack of coronary angiography. It may effectively detect the early signs of CAV. This is the early warning of CAV. It provides an opportunity to prevent early early warning of CAV. The incidence of CAV improves the quality of survival of patients with heart failure. However, the statistical persuasiveness of this study is insufficient, changing the early forecast of CAV’s early forecast to reduce the failure rate of heart transplantation, whether it is widely used, and still requires future large -scale clinical trials to confirm.
Cardiogenic imaging technology has gone through the development process from ordinary two -dimensional imaging to three -dimensional imaging, from macro, general imaging to micro, molecular imaging, from simply display forms to providing functional information.随着应用的规范化和普及化，其对疾病机制研究，优化临床诊治策略的作用日渐凸显，除此之外，在其它心血管领域腔内影像学也扮演着重要的角色，例如心脏移植，心Fatting and so on. In the future, the continuous advancement of image technology in the cavity will further promote modern cardiovascular imaging to a higher level of development. The use of intra -cavity imaging guidance clinical treatment will further promote the improvement of cardiovascular disease diagnosis and treatment, and better serve the majority of patients.
(7) A new field with promising prospects: OCT combined with IVUS
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With the rapid economic development, the change of lifestyle, and the arrival of population aging, the proportion of coronary calcification of the residents of my country has also increased. Vascular calcifications lead to increased vascular stiffness and decrease in compliance, leading to increased compression and pulse pressure. The strategy of calcification from the occurrence mechanism and the diagnosis and treatment strategy is a major problem of controversial clinical clinical, and there is no unified conclusion. The previous perspective believes that vascular calcification is a passive, degenerative calcium salt dominated by calcium and phosphorus metabolic imbalance in the end of the vessel wall deposition. Research in recent years has found that vascular calcification is an active, multi -factor participation in regulatory biological processes. Among them, inflammation, metabolic disorders, oxidation stress, hormone interference, and chronic pressure affect the composition of vascular micro -environment. This greatly improves the understanding of calcification mechanism. So what exactly is the evolution of calcification?
Studies include 72 basis lines and follow-up cross-section IVUS-virtual tissue imaging and OCT matching matching. During the follow -up, there were 46 calcification plaque, 33 cases inside the bracket, 13 cases outside the bracket, and the progress of calcification (52.2%) or newborn calcification (47.8%). In October, the calcification volume increased by 2.3-2.4 mm3 (p = 0.001) from the baseline to follow -up. The baseline virtual tissue -based pre -tissue pre -tissue necrotic nucleus accounted for 73.9%, and fiber or fiber fat plaques accounted for 10.9%. 15.2%of patients have existed on the baseline. 71.2%of the calcification preparation on OCT is a lipid pool, 4.3%is fibrous plaques, and 23.9%is fibrobalized plaques. OCT combined with IVUS in the body to detect a process of calcification evolution. The necrotic stove is the most common calcified precursor, and the bracket will cause a layer of tissue to cover the calcified lesion. Compared with clinical trial significance, it is more significant in the OCT combination of IVUS to explore a new field of clinical trials. IVUS has strong penetration and can show the full picture of vascular lesions.负性重构，用以定量分析某种治疗手段对斑块负荷的影响；而OCT分辨率高，可清晰显示内膜下的病变或斑块，识别易损斑块、稳定斑块、血栓、 The endometrium hyperplasia of calcification, mezzanine, brackets, and brackets is narrow in the bracket. Therefore, in the future, the clinical research and efficacy evaluation of damaged plaques, intervention therapy, and re -narrow mechanisms will have important application value.
