Jose Mª de la Torre Hernandez, MD, PhD, FESC. Cardiologia Valdecilla Hospital Universitario Marques de Valdecilla Santander. SPAIN

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1 Validation and application of IVUS-MLA in LMCA disease Jose Mª de la Torre Hernandez, MD, PhD, FESC Interventional Cardiology Dpt Cardiologia Valdecilla Hospital Universitario Marques de Valdecilla Santander. SPAIN

2 Disclosure Statement of Financial Interest Within the past 12 months, I or my spouse/partner p have had a financial interest/arrangement or affiliation with the organizations listed below. Affiliation/Financial Relationship Company Grant/Research Support Abbott vascular, Cordynamic Consulting Fees/Honoraria Abbott, Boston, Cordis, Medtronic, Biotronik, IHT, Lilly, Daychi Sankio, Astra Zeneca, Volcano, St Jude Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit

3 Washington Heart Center experience 122 pts with intermediate lesions and IVUS with no revascularization. 1 year follow up Indep. predictors IVUS MLD as predictor of events Abizaid et al. J Am Coll Cardiol 1999;34:707-15

4 Proposed MLA cut-off values for LM Kang et al. IVUS vs FFR < mm N= 55 Jasti et al. IVUS vs FFR < mm N= 55 LITRO De la Torre et al. Physics of flow / Jasti et al. 6 mm N = 354 Fassa et al. Epidemiol. inferred 7.5 mm N= 214 Clinical validation

5 Mayo Clinic Experience 1994 to 2002: 214 intermediate LMCA lesions with IVUS MLA cut-off value 7.5 mm 2 Where does 7.5 mm 2 comes from? 121 patients with: angiographically normal or minimally diseased LMCA Mean MLA - 2 SDs = 7.5 mm 2 Fassa et al. J Am Coll Cardiol 2005;45:204 11

6 Mayo Clinic Experience 1994 to 2002: 214 intermediate LMCA lesions with IVUS Fassa et al. J Am Coll Cardiol 2005;45:204 11

7 Mayo Clinic Experience > 7.5 Revasc < 7.5 Revasc > 7.5 Deferred < 7.5 Deferred Fassa et al. J Am Coll Cardiol 2005;45:204 11

8 IVUS FFR in intermediate lesions 55 patients IVUS - FFR Louisville Univ. study Correlation: FFR 0.75 IVUS MLA 5.9 mm 2 Jasti et al. Circulation 2004;110:2831-6

9 Valdecilla Hospital Experience Prospective application of MLA 6 mm 2 as cut-off value 79 pts MACE in a 40±17 months follow up 25-50% LMCA stenosis with IVUS MLA < 6 mm 2 REVASC MLA > 6 mm 2 DEFER Only 2 cases with LM revascularization in 8 years follow up 97.6% free of LM revascularization at 5 years De la Torre Hernandez et al. Rev Esp Cardiol. 2007;60:811-6

10 LMCA MLA = 6 mm 2 Proximal LAD MLA = 4 mm 2 Jasti et al. Circulation 2004;110: Proximal LCx MLA = 4 mm 2 LMCAr 3 = LAD r 3 + LCX r 3

11 Non-LM intermediate lesions: MLA cut-off 4 mm 2 Abizaid, et al. Circulation 1999;100:256, Abizaid et al. Am J Card 1998;82:423.8

12 Correlation IVUS FFR in non-lm Lesions MLA for FFR MLA for FFR < 0.75 < 0.8 Takagi mm 2 Bi Briguori i mm 2 Ben-Dor mm mm Koo mm 2 Kang mm 2 Gonzalo mm 2 F1RST mm 2 VERDICT mm 2

13 Waksman R, et al. FIRST: Fractional Flow Reserve and Intravascular Ultrasound Relationship Study. J Am Coll Cardiol Mar 5;61(9):

14 Clinical outcomes after IVUS and FFR assessment of intermediate coronary lesions. Propensity score matching of large cohorts from two institutions with differential approach. 400 pts with FFR assessment vs. 400 pts with IVUS assessment MLA < 4 mm 2 in vessels >3 mm MLA < 3.5 mm 2 in vessels mm Overall Deferred De la Torre Hernandez et al. Eurointervention (In press)

15 THE FRACTAL NATURE OF VASCULAR TREES Arterial bifurcations have a 3D blood-distribution function

16 Q1 D1 = D major daughter vessel Qo Do = D mother vessel Q2 D2 = D minor daughter vessel Law of flow (mass) conservation Qo = Q1+Q2 Murray s law Do 3 =D1 3 +D2 3 HK 7/3 model Do 7/3 = D1 7/3 + D2 7/3 Linear law (epicardial coronary artery) Do = 0.678*(D1+D2)* * Finet G et al. Eurointervention 2007;3:10-17

17 Finet G et al. Eurointervention 2007;3:10-17 Huo Y et al. EuroIntervention 2012;7:

18 Threshold for MLA in prox. LAD - LCx LAD / LCx MLA Murray`s law LM MLA Linear law LM MLA

19 LMCA MLA = 6 mm 2 Proximal LAD MLA = 3 mm 2 Jasti et al. Circulation 2004;110: Proximal LCx (incl. dominant) MLA = 3 mm 2 Linear law (epicardial coronary artery) Do = 0.678*(D1+D2) D2) Finet G et al Eurointervention Finet G et al. Eurointervention 2007;3:10-17

20 THE CLINICAL VALIDATION for 6 mm 2 22 centers (inclusion in 2007) De la Torre Hernandez, et al. J Am Coll Cardiol 2011; 58:351-8

21 RESULTS Population included 354 pts MLA 6 mm 2 MLA < 6 mm pts 168 pts 7 revascularized 16 no revascularized No Revascularización LM Revascularización LM 179 pts (96%) 152 pts (90%) 56% PCI in other lesions 55% CABG 45% PCI of LMCA (+ other lesions in 62%)

22 Clinical outcome of pts with deferred revascularization (MLA > 6 mm 2 ) l probability (%) Surviva Survival free of cardiac death, MI and LMCA revascularizacion at 2 years: % 1.8% Time

23 Compared clinical outcome in pts with and without LMCA revascularization Defer Revasc Cardiac death P= Time

24 Compared clinical outcome in pts with and without LMCA revascularization Cardiac death, MI and any revascularizacion P= Time Defer Revasc

25 Compared clinical outcome in deferred pts with MLA > 6mm 2 (n=179) and < 6 mm 2 (n=16) > 6D Defer < 6 Defer Cardiac death, MI and any revascularizacion P= Time

26 Patients with deferred LM revascularization MLA 5-6 mm mm 2 Nº pts Events 5 (31.2%) 3 (5.6%)

27 FFR VS. IVUS

28 Stenosis MLD LITRO MLA > 6 MLA<6 MLA > 6 MLA<6

29 MLA > 6 MLA < 6

30 Outcomes in both studies (138) DEF > 0.8 (75) REV < (179) DEF > 6 (152) REV < 6 MACE MACE Time 2 yrs 2 yrs FFR study Hamilos et al. IVUS study De la Torre Hernandez et al.

31 55 pts LM stenosis 30 80% 4.8 mm 2 Kang SJ et al. J Am Coll Cardiol Intv 2011; 4:

32 No follow up provided 71% of lesions with FFR % of lesions with FFR > 0.8 Revascularized

33 Deferring LMCA revascularization: safety concerns Sensitivity 100% 4.8 mm 2 6 mm 2 Kang et al. Jasti et al.

34 Differences between studies Kang et al. Jasti et al. LITRO study MLA, mm PB, % EEM area, mm Method FFR IV adenosine FFR IC adenosine g Clinical validation Cut-off MLA

35 Euro PCR 2012

36 Intravascular ultrasound comparison of left main coronary artery disease between white and asian patients. Rusinova RP, Mintz GS, Choi SY, et al. Am J Cardiol Apr 1;111(7): Cardiovascular Research Foundation, New York, New York; Columbia University Medical Center, New York, New Yor 99 Asian patients (Japan and South Korea) 99 matched control United States white patients with a stable clinical i l presentation ti and >30% LMCA stenosis At the minimum lumen site and over the entire LMCA length Asian patients had a: Smaller lumen area (5.2 18vs mm 2 ; p <0.0001) 0001) Larger vessel area ( vs mm 2 ; p <0.0001) Larger plaque burden (72 10 vs 64 12%: p <0.0001)

37 FFR is more appropriate in assessing intermediate t lesions Why IVUS in ambiguous LM? There is probably more agreement between IVUS and FFR in assessing LM lesion significance than in assessing non-lm lesions Limited it variability in LM length Limited variability in supplied myocardium Large LM size Main limitations for FFR Gray zone or even could be for LM (?) No characterization of LM disease (specially in bifurcations) Not fully reliable in presence of severe LAD / LCx disease IVUS provides anatomic information IVUS provides anatomic information IVUS may be used to guide LM PCI

38 FFR MLA in LM vs non-lm lesions

39 Severe lesions in LAD or LCx: FFR measurement not reliable for LM assessment Differential involvement of LAD / LCx ostium Different FFR readings

40 The double value of IVUS LMCA intermediate lesion IVUS Significant 40 45% FFR CABG (40-45%)* 45%)* PCI (55-60%)* IVUS *National registry RENACIMIENTO (Baz et al ACC 2010) National registry RENACIMIENTO (Baz et al. ACC 2010) 1479 patients with severe LM disease

41 Patients with MLA > 6mm 2 and deferred revascularization in LITRO study Revascularization of LM in follow up No Yes* n= 171 n=8 MLD MLA MLA: % 25% % 25% % 12.5% > % 37.5% * 4 (50%) showed lesion progression at the time of revascularization

42 Average MLA in pts incurring events after deferred revascularization LITRO study Okabe et al. Abizaid et al. 8.4 ± ± ± 4.4 Okabe et al. J Invas Cardiol 2008;20:635-9 Abizaid et al. J Am Coll Cardiol 1999;34: De la Torre, et al. J Am Coll Cardiol 2011; 58:351-8

43 9 months

44 MLA 10.4 mm 2 PB 59% 9 months MLA 5.7 mm 2 PB 75%

45 Plaque burden in LM disease PB > 67% predictor of FFR < 0.75 in LM (in Jasti et al.) PB > 72% predictor of FFR < 0.8 in LM (in Kang et al.) PB was the only predictor of events in deferred LM revascularization after 5 years (in Okabe et al.) Jasti et al. Circulation 2004;110: Kang SJ et al. J Am Coll Cardiol Intv 2011; 4: Okabe et al. J Invas Cardiol 2008;20:635-9

46 MLA cut-off for LM 6mm 2 5mm 2 75mm Small body size Elderly (low physical activity) PB < 60% No positive remodelling Diabetes insulin-dep. Big body size High physical activity (young, sports, job,..) MV disease Positive Remodelling PB > 70% TCFA Symptoms, non-invasive i tests, t...

47 Conclusions IVUS is a safe method to accurately assess the severity of ambiguous LM lesions. An universal definite cutoff value for the LM lumen does not exist. There is a narrow range for the LM MLA around 6 mm 2 and modulation by other factors is required to make an individual case-based decision: Population and patient profile Clinical i l features Angiography: LM and overall coronary tree IVUS PB AS l h l d lli VH IVUS: PB, AS, plaque morphology, remodelling, VH In selected cases, >>> FFR