Baumann S, Schaefer A C, Hohneck A, Mueller K, Becher T, Behnes M, Renker M, Borggrefe M, Akin I, Lossnitzer D
I. Medizinische Klinik, Abteilung für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg und DZHK (Deutsches Zentrum für Herz-Kreislauf-Forschung), Standort Heidelberg/Mannheim, Heidelberg, Deutschland.
Abteilung für Kardiologie, Pneumologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
Herz. 2018 Nov;43(7):621-627. doi: 10.1007/s00059-017-4608-8. Epub 2017 Aug 23.
Coronary angiography is considered as the gold standard in the morphological representation of coronary artery stenosis. Coronary angiography is often performed without preprocedural non-invasive proof of ischemia and the assessment of the severity of a coronary lesion by morphology is very subjective. Thus, invasive fractional flow reserve (FFR) measurement represents the current standard for estimation of the hemodynamic relevance of coronary artery stenosis and facilitates decision making for percutaneous coronary intervention (PCI) and stenting. The FFR-guided revascularization strategy has been classified as a class IA recommendation in the 2014 ESC/EACTS guidelines on myocardial revascularization. Both the DEFER and the FAME studies showed no treatment advantage of hemodynamically irrelevant stenosis. By use of FFR (and targeted interventions), clinical results could be improved as well as the procedure costs were reduced; however, the use in clinical practice is still limited due to the need of adenosine administration and a significant prolongation of the procedure. Instantaneous wave-free ratio (iFR®) is a new innovative approach for the determination of the hemodynamic relevance of coronary stenosis which can be obtained at rest without the use of vasodilators. Regarding periprocedural complications as well as prognosis, iFR® showed non-inferiority compared to FFR in the SWEDEHEART and DEFINE-FLAIR trials.
冠状动脉造影被认为是冠状动脉狭窄形态学表现的金标准。冠状动脉造影通常在术前未进行缺血的无创证据检查的情况下进行，并且通过形态学对冠状动脉病变严重程度的评估非常主观。因此，有创血流储备分数（FFR）测量是评估冠状动脉狭窄血流动力学相关性的当前标准，并有助于指导经皮冠状动脉介入治疗（PCI）和支架置入的决策。FFR指导的血运重建策略在2014年欧洲心脏病学会/欧洲心胸外科学会心肌血运重建指南中被列为IA类推荐。DEFER研究和FAME研究均表明，血流动力学无关的狭窄没有治疗优势。通过使用FFR（和靶向干预），临床结果可以得到改善，手术成本也可以降低；然而，由于需要使用腺苷且手术时间显著延长其在临床实践中的应用仍然有限。瞬时无波比值（iFR®）是一种用于确定冠状动脉狭窄血流动力学相关性的新的创新方法，无需使用血管扩张剂，在静息状态下即可获得。在瑞典心脏介入注册研究（SWEDEHEART）和DEFINE-FLAIR试验中，就围手术期并发症和预后而言，iFR®与FFR相比显示出非劣效性。
