International Circulation:  Dr. Hodgson， how is the specificity and sensitivity of Fractional Flow Reserve compared to IVIS?
　　国际循环：冠脉血流储备与血管内超声相比，其特异性和敏感性如何？
　　Prof. Hodgson: Specificity and sensitivity is difficult to use as a good measure for the relative benefit of a particular technology.   The reason being it is very dependant of the prevalence of disease， it is dependant on the characteristics of the test， its dependant on the criteria that you use to decide significance;  I don not think there is a great gold-standard other than routine stress testing and clinical symptoms.  We have known since early ‘90s when Dr. Pills and his colleagues validated FFR that there is a very difficult correlation between a low FFR and a positive stress test.  That was further validated by angioplasty removing the stenosis， then FFR and the stress test returning to normal; that is sort of a complete Pasteur’s hypothesis of proof.  So， I really do not put any weight on specificity and sensitivity， and the predictive accuracy is never shown because the predictive accuracy is horrible.
　　Hodgson教授：对一种特定技术而言，将特异性和敏感性作衡量相对优势的工具是很困难的。这是由于其非常依赖疾病的患病率，测试的特点以及判断测试意义的标准；我认为与其他常规心肌负荷试验和临床症状相比，这不是一项优秀的黄金标准。我们都知道，当90年代初Pill博士和他的同事们验证冠脉血流储备时，验证冠脉血流储备低和阳性心肌负荷试验之间的相关性很困难。采用血管成形术消除狭窄后，冠脉血流储备和心肌负荷试验回归了正常，使其得到了进一步验证；这可以说是巴斯德假说的铁证。所以，我真的不认为特异性和敏感性有多重要，预测的准确性没有报告过，因为预测的准确性很糟糕。
　　International Circulation:  What do you think is the primary measurement between those two techniques?
　　国际循环：您认为这两种技术主要测量的是什么呢？
　　Prof. Hodgson: Cleary if the question is: ‘Is the lesion I am seeing on the angiogram causing ischemia in this patient， right now?’ the only tool for that is Fractional Flow Reserve because IVIS can not assess that in stable patients without thrombus， ruptured plaques or other complications.  However IVIS is the cornerstone of the vast amount of intervention that we do， guiding the intervention for the physician who has already based the decision on an FFR， or more commonly on a lesion that looks severe or a previous positive stress test that matches with that area.  We don’t do FFR in every lesion to figure it out.  We do it in intermediate lesions where it is not clear， or we do not have some other measure or point to suggest it is important.
　　We use IVIS routinely for guiding the intervention.  We also believe IVIS is well suited for assessing the left mail coronary， largely because its short， its easy to get to， usually it is about the same size in most patients， and its much easier to get a uniform cut-point.  So the predictive accuracy oif IVIS in left mains is considerably better.
　　Hodgson教授：如果问题是：“该患者的缺血是由血管造影上看到的这个病变引起的吗？”答案就更清楚了。血流储备分数是惟一的识别工具，因为血管内超声不能用于评估那些没有血栓，破裂斑块或其他并发症的稳定患者。然而，血管内超声是我们做过的大量介入治疗的基石，在医师已经根据冠脉血流储备，或在一般情况下，根据看起来严重的病变或之前做的与病变位置吻合的阳性心肌负荷试验做出了决定的基础上，为医师的介入手术进行指导。我们不会为了查明病变给每一个病变做冠脉血流储备，除非病变不明确，或没有其他测试方法或有指征显示采用冠脉血流储备很重要。
　　我们常规使用血管内超声指导介入。我们也相信血管内超声非常适合评估左冠状动脉，这主要是因为它短且易进入，通常与大多数患者尺寸相同，而且获得均匀的分割点非常容易。所以血管内超声对左主干的预测性准确度相当不错。
　　International Circulation: Both FFR guided and IVIS guided PCI strategies have been reported to be safe and effective in intermediate coronary lesions.  What is the best choice of those two methods when applied to PCI and LMCA?
　　国际循环：冠脉血流储备功能检查和血管内超声引导下的对于中度狭窄的动脉的PCI手术具有安全性和有效性。您在左主干病变中对于这两项检查是如何选择的？
　　Prof. Hodgson: People have suggested either to evaluate whether a patient needs intervention.   There are very limited studies that actually use FFR to actually guide the intervention as to where to place the stent.  The last one those was a registry that Dr. Pills did with bare metal stents.  It is clear that is the stent is adequately implanted that the FFR should go back to normal.  But you do not have to have fill stent expansion or full stent apposition to get rid of the bulk of the flow limitation.  But leaving the stent that is under expanded or mal-opposed may set up the patient for other problems.  The FFR can not detect that.  So most people would argue that IVIS is the correct tool for guiding the procedure， and I think currently data suggests that IVIS is imperative for guiding left main stenting.
　　Hodgson教授：有人建议评估患者是否需要接受介入治疗。事实上，采用冠脉血流储备指导介入治疗在哪里安置支架的研究非常有限。最近一个注册试验是Pill博士采用裸金属支架的研究。很明显，冠脉血流储备恢复正常时，才能充分植入支架。但是解决大部分的血流受限并不需要充分的支架扩张或良好的支架安置。但是，如果支架扩张不充分或安置不良可能会给患者带来其他问题。冠脉血流储备检查无法检测到这一点。所以，大部分人认为血管内超声才是引导手术的正确工具，我认为，当前的数据显示，血管内超声引导左主干支架植入是势在必行。
　　International Circulation: One interventional expert has said ‘if you want to treat， use IVIS， if you don’t use FFR’ - what is your opinion about that?
　　国际循环：对于介入心脏病学医师而言，“如果你想处理这个病变就用血管内超声吧，如果不想处理，就用冠脉血流储备检查!” 如何理解这句话？
　　Prof. Hodgson: I have said that many times myself， and I think Bill Ferrion’s resent paper confirmed that.  The problem is in the lack of understanding of the physiology by most Interventionalists.  It’s a little like sending a carpenter to pile of wood with some nails and a hammer - they are probably going to start nailing stuff together; send a guy with a backhoe there and he will probably start lifting stuff up.  So， an Intervetionalist with a stent and show him an obvious lesion and he wants to figure out how he can do something - and that’s kind of fun… not to mention that’s how we get paid.  The problem is， the data does not support that.  In fact in many trials now it shows that lesions that were not significant that were treated with a stent actually do worse than when left alone.  So of the necessities is to get that information out to people and have them become more comfortable with that and comfortable with the concept of telling Mrs. Jones:
　　‘Yes， we did find narrowing， but good news: you do not need a stent-we measured it carefully and stenting is not important right now-we can treat this with medicine.  And guess what?  You don’t have to stay overnight in the hospital， you don’t have to be on plavix for a year， and we’re just going to work with your primary care doctor to make sure you don’t have any more problems’.
　　Most people like that news.  If you believe that， it is a pretty easy sell to use FFR routinely in your practice to make these important decisions， and it is very evidence based.
　　Hodgson教授：我自己也经常说这句话，我认为Bill Ferrion最近的文章证实了这一观点。问题是，大多数介入医学的专家们缺乏对生理学的认识。这就有点像给一个木匠一堆木材，一些钉子和一个锤子，可能他们就开始把东西钉起来；给一个人起重机，可能他就开始吊东西了。所以，给一个拿着支架的介入医学专家看一个明显的病变，他就开始想弄清楚他究竟能做什么，这是很有意思的，更别说这是我们获取报酬的方式了。问题是这一行为没有得到研究数据的支持。事实上，现在许多试验表明，对于并不严重的病变，采用支架治疗事实上要比其自行发展更糟糕。所以，了解患者的信息并让他们更舒适是必要的，应该自在的接受这个观点并告诉琼斯太太：“是的，我们确实发现了狭窄处，但是好消息是：你不需要支架植入--我们慎重衡量过，现在植入支架还并不必要--我们可以进行药物治疗。还有一个好消息，你不需要在医院里留宿查看，也不需要接受为其一年的氯吡格雷治疗，我们正准备与您的初级保健医生商讨如何确保你不出现其他问题。”
　　大部分人都乐意听到这个消息。如果您认可这一点，在您的实践中常规使用冠脉血流储备检查来做出上述重要决定就很容易了，而且这也是有证据支持的。
　　International Circulation: In your talked you emphasized that some doctors will move automatically to a stent when they see some sort of lesion， but that is not always what they should do.  Could you talk more about thyat?
　　国际循环：在您的谈话中，您强调有些医生看到某种病变就会下意识地想去植入支架，而这并不总是他们应该做的。您能再谈谈上述问题吗？
　　Prof. Hodgson:  Since the very beginning of angioplasty in the late 70’s， the reason it is attractive is that it allows the patient to become free of their symptoms.  Now there are some subsets of patients with very critical lesions with only-remaining-vessel kind of case examples where stenting that lesion would be important， but there is absolutely no data that senting anything g less than that makes one live longer or less likely to have complications， or anything else.  You are really just doing plastic surgery.
　　Hodgson教授：自从70年代后期开始，血管成形术极具吸引力的原因在于他能够让患者免于症状的困扰。现在有一组患者在仅存的血管上出现了非常危险的病变，此时该病变的支架置入就变得非常重要，但是完全没有相关数据证明支架植入能够让患者活得更长或是更不容易出现并发症或是其他情况。你真的只是在做整形手术。
　　International Circulation: Very good sir， thank you very much.
　　国际循环：很好，非常感谢您。