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Can IVUS Define Plaque Features that Impact Patient Care?. A Pichard L Satler, K Kent, R Waksman, W Suddath, N Bernardo, N Weissman, M Angelo, D Harrington, J Lindsay, J Panza. Washington Hospital Center Washington DC. Conflict of Interest. None related to this presentation. - PowerPoint PPT Presentation
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Can IVUS Define Plaque Features that Impact Patient Care?
A Pichard
L Satler, K Kent, R Waksman, W Suddath,
N Bernardo, N Weissman, M Angelo, D Harrington,
J Lindsay, J Panza.
Washington Hospital Center
Washington DC
Conflict of Interest
• None related to this presentation
IVUS at the WHC
Washington Hospital Center in last 12 months:Diagnostic catheterizations: 10,000Coronary angioplasties: 5,000IVUS use: 70% (AP: 95%)
Organization10 Labs: 8 Labs have IVUS integrated into the Cath
Table (Volcano and Boston).IVUS setup is ready before physician arrives into the
room.2 CV technicians supervise all IVUS cases. 15 CV
technicians trained in IVUS.Core Lab analyzes of all IVUS data.
Vessel Size Remodeling.
Positive Remodeling: large plaque mass.
plaque is soft.
more likely to have thrombus.
associated with higher CRP.
More common in young people.
Very common in acute coronary syndrome.
More common no reflow during PCI.
Negative Remodeling: less plaque mass
plaques are fibrotic.
less likely to have thrombus.
Remodeling in Varying CoronaryLesion Morphologies
IEL
-Exp
ecte
d IE
L(/
pla
qu
e ar
ea)
Ero
sio
n
Sta
ble
Th
in c
ap a
ther
om
a
Pla
qu
e h
emo
rrh
age
Acu
te r
up
ture
Hea
led
ru
ptu
re
To
tal
oc
clu
sio
n
A.5
4
3
2
1
0
-1
-2
-3
Medial SMCapoptosis
NCMedial SMC loss
Macrophage infiltration
SMC loss
Virmani 2009
Posit Remodeling
Cardiac CT can be as good as IVUS to detect Positive Remodeling
Positive Remodeling and Plaque Composition by OCT.Raffel et al. EHJ 2008;29:1721-8
Positive Remodeling and ISRS Okura et al. JACC 2001, 37: 1031-35
Positive Remodeling
Intermed. or Negative Remodeling
n= 108 BMS
Plaque Burden and In-Stent Intimal HyperplasiaWHC: Shiran et al, AJC 2000; 86:1318-21
Maximal IH at 6 months angio was at the zone of maximal pre intervention plaque. Pre-intervention plaque area was an
independent predictor of IH at follow up.
Remodeling and ISRS in DES.Mintz, Park et al. Circulation. 2003;108:1295-8
ASPECT (ASian Paclitaxel-Eluting Stent Clinical Trial)
positive
intermed
negative
Cypher RS 28.6% vs 16.7% for positive and non posit remodeling p=ns. AHA 2009
Mild LMCA Disease and Remodeling.WHC: YJ Hong et al. JIC 2007;19:500-5
1 year MACE
236 patients with mild (<50%) LMCA stenosis by angiography
Positive Remodeling and Outcome in ACS.Okura, Mintz et al. AJC 2009;103:791-5
Prospect. MACE in Non Culprit Lesions
Attenuated Plaque(Black Holes, Echo Signal Attenuation)
WHC: SY Lee, Mintz et al. JACC Interv 2009;2:65-72
Two attenuated plaques 6.4 mm apart were seen in this RCA.
Shadowing in spite of no visible calcium
Attenuated Plaque in ACS.WHC: SY Lee, Mintz et al. JACC Interv 2009;2:65-72
Attenuated plaque in ACS patients was associated with:- positive remodeling and higher CRP,- more thrombus and complex lesion morphology, - more plaque burden and plaque rupture,- frequent no-reflow after PCI.
293 ACS patients: 26% with attenuated plaque ( 40% STEMI, 18% NSTEMI)
Echo Signal Attenuation (EA).Kimura et al. Circ CV Interv. 2009;2:444-54.
687 patients.
EA: 43.8% in ACS vs. 27.9% in Stable AP, p<0.001.
EA had Positive Remodeling: 55% vs 23 % for lesions without EA.
Histology after DCA:
higher prevalence of lipid-rich plaque, macrophage infiltration, cholesterol clefts, thrombus, and microcalcification.
No Reflow in SVG’s with ACS.WHC: YJ Hong et al. TCT 06
Plaque Regression by IVUSTardif et al. AJC 2006;98:2327
IVUS images of the same cross section of coronary artery at baseline (left) and follow-up (right). The presence of a large branch at 10 o’clock and a smaller branch at 7 o’clock confirms that the same matched cross section has been
studied at the 2 time points.
Intense Lipid Therapy x 2 years in 432 lesions <50%.
Baseline IVUS IVUS at 24 months
Progression of Disease in SVG WHC: YJ Hong JACC 2009;53:1257-64
Cha
nge
in a
rea
(mm
2)C
hang
e in
are
a (m
m2)
Cha
nge
in a
rea
(mm
2)
Statin Therapy and Fibrous Cap ThicknessTakarada et al. Atherosclerosis 2009;202:491-7
Statin Group
Control Group
Statin Group
Statin Therapy and Plaque RuptureChia et al. Cor Art Dis 2008;19:237-42
OCT study in 48 patients.
Statin therapy patients had:
- less plaque rupture (8 vs 36%)
- increased fibrous cap thickness (78 vs 49 microns)
Summary
Positive remodeling with large plaque burden is an important observation that determines clinical and PCI outcomes.
CALCIFIED LESIONS
Patient with Angina and LAD Perfusion Defect
Simple PCI ?
IVUS of LAD
In view of IVUS findings Roto-DES or LIMA need to be chosen
5 mm
Different Strategies based on IVUS findings
A
B
Direct Stenting
Roto-Stent
Concealed Vessel Perforation
Most Perforations are Not Seen by Angio. Maehara et al. WHC 2001
15,000 IVUS reviewed
76 perforations found on IVUS.
Angio: 21% totally normal
33% dissections
22% mild stenosis
24% perforation suspected
12 months Follow up30% MACE
(A) Pathological intimal thickening.
(B) Thin-capped fibroatheroma.
(C) Thick-capped fibroatheroma.
(D) Fibrotic plaque.
(E) Fibrocalcific plaque.
Virtual Histology
IVUS of culprit lesion + 2 non culprit vesselsIVUS of culprit lesion + 2 non culprit vessels
QCA of entire coronary treeQCA of entire coronary tree
IVUS with Virtual histologyIVUS with Virtual histology
Palpography (n=~350)Palpography (n=~350)
Repeat imagingRepeat imagingin pts with events in pts with events
Meds recMeds recAspirinAspirin
Plavix 1yrPlavix 1yrStatinStatin
Repeat biomarkersRepeat biomarkers@ 30 days, 6 months @ 30 days, 6 months
MSCTMSCTSubstudySubstudy
N=50-100N=50-100 F/U: 1 mo, 6 mo,F/U: 1 mo, 6 mo,1 yr, 2 yr,1 yr, 2 yr,±3-5 yrs±3-5 yrs
F/U: 1 mo, 6 mo,F/U: 1 mo, 6 mo,1 yr, 2 yr,1 yr, 2 yr,±3-5 yrs±3-5 yrs
The PROSPECT TrialThe PROSPECT Trial
700 pts with ACS700 pts with ACS
PROSPECT: PROSPECT: MACEMACEM
AC
E (
%)
MA
CE
(%
)
Time in YearsTime in Years00 11 22 33
00
55
1010
1515
2020
2525
Number at riskNumber at risk
ALLALL 697697 557 557 506 506 480480
CL relatedCL related 697697 590590 543543 518518
NCL relatedNCL related 697697 595595 553 553 521521
IndeterminaIndeterminatete 697697 634634 604 604 583583
12.9%12.9%
20.4%20.4%
11.6%11.6%
2.7%2.7%
Culprit Lesion
Non Culprit Les.
All
Indeterminate
Plaque Burden, VH and Outcomes
The same lesions by grayscale IVUS (Plaque Burden ≥ 70%) have dramatically different risk profiles when
looking at VH
• A ≥ 70% plaque burden lesion by gray scale IVUS has a risk of 9.2% at three years
• A ≥ 70% plaque burden lesion defined as VH TCFA has an elevated risk of 15.3% at three years
• A ≥ 70% plaque burden lesion defined as PIT has a reduced risk of only 2.6% at three years
• VH Definitions in PROSPECT can swing the risk profile
MACE in non Culprit lesions
Stable Progressive
ACTIVE
Dynamic Nature of Plaque by VH. Kubo, Maehara et al. JACC 2010;55:1590-7
Koenig, Margolis, Virmani, Klaus. Nature Clinical Practice 2008 5;4
Stenting and Plaque by VH.Koenig, Margolis, Virmani, Klaus. Nature Clinical Practice 2008 5;4
40%
50%
10%Proximal segmentDistal segment
Stent in AMIDarius Dudek. TCT 2009
NC covered
NC uncovered
Plaque Healing after StentingKubo et al. Am Heart J. 2010;159:271-7.
DES
BMS
DES
BMS
Necrotic Core in contact with stent before and after Stenting
Conclusions
Plaque characterization by IVUS allows for:
Better PCI planning and execution.
Better PCI outcome.
Better prediction of near and long term outcome.
Better delineation of need for optimal medical therapy for that lesion.
Better understanding of Coronary Atherosclerosis.
The end