Κλινική Χρήση IVUS και OCT PERIKLIS A. DAVLOUROS ASSOCIATE PROFESSOR OF CARDIOLOGY INVASIVE CARDIOLOGY & CONGENITAL HEART DISEASE

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1 Κλινική Χρήση IVUS και OCT PERIKLIS A. DAVLOUROS ASSOCIATE PROFESSOR OF CARDIOLOGY INVASIVE CARDIOLOGY & CONGENITAL HEART DISEASE

2 Conflict of interest None to declare

3 While IVUS is the most used intravascular imaging modality in interventional cardiology, it is used in < 20% of cases

4 Ischemia guided PCI PCI for ischemia-inducing coronary stenosis can improve clinical outcome Medical therapy (MT), alone may be preferable for lesions without inducible ischemia

5 Ischemia guided PCI In real-world practice, fewer than 50% of pts are evaluated noninvasively for myocardial ischemia before revascularization therapy Lin GA, et al. Frequency of stress testing to document ischemia prior to elective percutaneous coronary intervention. JAMA. 2008

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8 IVUS, OCT, Angioscopy FFR

9 Advanced Imaging Techniques... A IVUS IVUS-VH VH-IVUS: definition of high-risk plaques and necrotic cores by their ultrasound characteristic D Angioscopy OCT NIRS: detection of lipid-rich plaques by their cholesterol ester composition NIRS

10 Imaging vs. Physiology: Why bother? Pt with recurrent angina and positive ischemia testing in the territory of the target stenosis Does not need FFR or IVUS/OCT unless the operator does not believe the stress test, the patient, or both

11 FFR: The gold standard Patras University Hospital

12 IVUS exchangeable with FFR?

13 IVUS exchangeable with FFR? Intracoronary imaging (IVUS) has a poor correlation with physiological testing for identification of ischemia inducing lesions

14 Can MLA Predict the Functional Significance of Coronary Artery Stenosis? Patras University Hospital

15 Scatterplot showing the relationship between intravascular ultrasound determined minimal lumen area (MLA) and fractional flow reserve (FFR). Patras University Hospital 96% NPV for an MLA 2.4 mm 2

16 The coin toss experiment: implications for risk stratification 96% NPV for an MLA 2.4 mm 2 NPV depends on the pretest probability (21%) An IVUS parameter with no predictive power (AUC = 0.5, equivalent to a coin toss) would have NPV 79%... This comparison makes the reported NPV of 96% for MLA 2.4 mm 2 to seem appropriately less dramatic

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18 Modest correlation of IVUS-FFR in intermediate lesions The new IVUS cutoff for FFR of 0.80 is 2.99 mm 2 The new IVUS cutoff for FFR of 0.75 is 3.16 mm 2 MLA <3.6 mm(2) (AUC = 0.68) for RVD >3.5 mm MLA <2.7 mm(2) (AUC = 0.71) for RVD mm MLA <2.4 mm(2) (AUC = 0.66) for RVD <3.0 mm FFR correlated with plaque burden (r = , p < 0.001) but not with other plaque morphology

19 Q: Why can we not use IVUS/OCT for functional assessment? A: A single cross-sectional area does not mean the same thing everywhere. 5 Ref Diam (mm) < 4 mm² = significant stenosis? % Stenosis for an Cross Sectional Area of 4 mm² 0

20 Small Caliper Vessels Lesions in small-caliber vessels prove especially difficult for IVUS evaluation (no cut-off)... FFR-positive lesions are a minority in small vessels (35-40% in 3 studies) Given the higher rates of restenosis in small vessels even with DES, these studies strongly support FFRselected PCI in small coronaries

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22 If you want to treat a lesion, use IVUS; if you don t, use FFR

23 Outcomes of PCI in Intermediate CAD: FFR Guided Vs. IIVUS Guided Patras University Hospital Chang-Wook Nam, et al. JACC: Cardiovascular Interventions, 2010, Nonrandomized, retrospective study

24 Outcomes of PCI in Intermediate CAD: FFR Guided Vs. IIVUS Guided Patras University Hospital Chang-Wook Nam, et al. JACC: Cardiovascular Interventions, 2010,

25 Outcomes of PCI in Intermediate CAD: FFR Guided Vs. IIVUS Guided IVUS-guided lesion selection resulted in almost 3 times as many treated lesions without any difference in the event rate Patras University Hospital Chang-Wook Nam, et al. JACC: Cardiovascular Interventions, 2010,

26 So when should we use IVUS? Patras University Hospital

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29 LM Disease: 5% of pts with SAP Patras University Hospital

30 LM Disease: 5% of pts with SAP Patras University Hospital

31 Reverse Mismatch Patras University Hospital

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39 OCT vs. standard imaging Patras University Hospital Resolution (log) 1 mm 100 mm High frequency Ultrasound Standard clinical 10 mm 1 mm Confocal microscopy OCT Unprecedented resolution (10 to 15 μm) among intravascular imaging techniques Penetration depth (log) 1 mm 1 cm 10 cm

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41 Prati, F. et al. Eur Heart J 2009 OCT vs. standard imaging OCT penetration vs. plaque composition Penetration max for fibrotic tissue (A) Progressively less for Calcific (B) Lipid (C) Thrombus (D)

42 Will OCT replace IVUS?

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50 Patient with anterior wall ischemia Patras University Hospital Davlouros, P. et al. J Am Coll Cardiol Intv 2011;4:

51 OCT of SVG lesion Patras University Hospital Davlouros, P. et al. J Am Coll Cardiol Intv 2011;4: TCFA at the level of rupture

52 Coronary Angio: LAD filling defect Patras University Hospital

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54 Περιφερικό Κεντρικό

55 Περιφερικό Κεντρικό

56 Περιφερικό Κεντρικό

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58 Clinical use of IVUS-OCT? IVUS More data on ischemic cut-offs Better for PCI planning OCT Better for PCI optimization Better for ambiguous lesions

59 Do what you can do better Patras University Hospital

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61 Algorithm of functional angioplasty... Patras University Hospital Park S et al. Circulation. 2011;124:

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69 Park S et al. Circulation. 2011;124: Theoretical relationships between reference vessel diameter and percentage diameter stenosis and percentage area stenosis for minimal lumen area (MLA) of (A) 4 mm2 and (B) 2.4 mm2. It is generally accepted that >50% diameter stenosis, which corresponds to >75% area stenosis, is significant An MLA of 4 mm 2 is just equivalent to diameter stenoses of 24% and 43% for lesions with reference vessel diameters of 3 and 4 mm, respectively