IVUS-Guided d Provisional i Stenting: Plaque or Carina Shift. Soo-Jin Kang, MD., PhD.

Transcription

1 Left Main and Bifurcation Summit IVUS-Guided d Provisional i Stenting: ti Plaque or Carina Shift Soo-Jin Kang, MD., PhD. Department of Cardiology, University of Ulsan College of Medicine Asan Medical Center, Seoul, Korea

2 Disclosure I have nothing to disclose

3 IVUS-Guided Provisional Stenting Plaque or Carina Shift Mechanisms of SB Compromise Functional Significance of Jailing Anatomical-Functional Mismatch Pre-PCI Predictors for Functional Jailing

4 Initial Mechanisms of Angiographic SB Jailing Carina Shift After Cross-Over LCX FFR 0.91 Post-stenting

5 Pre-procedural After Cross-Over LCX Carina Shift After cross-over LCX LAD LAD Area Change LCX pullback Lumen -3.4 mm 2 Vessel -3.5 mm 2 LCX pullback Plaque -0.1 mm 2 LCX MLA 7.2 mm 2 LCX MLA 3.8 mm 2 EEM area 9.3 mm 2 EEM area 5.8 mm 2 P+M area 2.1 mm 2 P+M area 2.0 mm 2

6 Mechnisms of Angiographic SB Jaling Plaque Redistribution Pre-procedural Post-stenting After cross-over Area Change Lumen -1.9mm 19mm 2 Vessel -0.4mm 2 LCX MLA 6.9mm 2 Plaque +1.5mm 2 LCX MLA 5.0mm 2 EEM area 9.1mm 2 EEM area 8.7mm 2 P+M 2.2 mm 2 P+M 3.7 mm 2

7 Mechanisms of Angiographic SB Jaliing Stent Strut Artifact Pre-procedural Post-stentingstenting After cross-over over No changes in Lumen or Plaque MLA 8.4mm 2 N MLA 8.3mm 2Novori i

8 Distal MB segment Proximal MB segment Pre Post p Pre Post p Lumen VI 3.5± ±2.1 < ± ±2.0 <0.001 Plaque VI 5.4± ± ± ± Vessel VI 9.0± ±3.1 < ± ±3.5 <0.001 In distal MB, luminal gain is not caused by plaque shift but by vessel enlargement. Carina shift as a result mainly contributes to SB compromise Koo et al. Circ Cardiovasc Interv 2010;3:113-9

9 Changes in LCX Ostial Geometry After a Single Stent Cross-over oeroflmof MLA within LCX Ostium ostium (mm 2 ) LA, LCX M Pre Post-stenting Pre Post % MLA, LCX ostium 5.4mm 2 4.0mm 2 * -20% MLA, LCX carina 6.3mm 2 4.3mm 2 * -31% P+M, LCX ostium 5.2mm 2 5.4mm 2 +4% p=0.009 Eccentricity index * +20% 78% showed >10% reduction in MLA within LCX ostium Kang et al. Circ Cariovasc Interv 2011 Accepted

10 Changes in LCX Ostial Geometry After a Single Stent Cross-over of LM 2 ) EEM area a at the MLA site (mm 2 EEM area at MLA EEM eccentricity P+M area mm 2 9.6mm p=0.048 EE EM eccentric city index at LCX carin na mm 2 5.4mm 2 p< pre post-stenting pre post-stenting 2 ) P+M area a at the ML LA site (mm p=ns pre post-stenting Carina shift is a general mechanism of SB compromise Kang et al. Circ Cariovasc Interv 2011 Accepted

11 Carina Shift Primary Mechanism of SB Compromise MLA, LC CX os (% %) r=0.646 p< MLA, LC CX os (% %) r= p=0.049 % % % EEM area at MLA site(%) Change in EEM eccentricity Kang et al. Circ Cariovasc Interv 2011 Accepted

12 Plaque Redistribution Second Mechanism of SB Compromise P (m mm 2 ) r= p< V / L In minority, P closely plaque correlates redistribution with the may ratio be of superimposed V to L suggesting the larger plaque gain contributes to the greater on carina MLA shift loss to relative lead to to the the further EEM MLA reduction loss Kang et al. Circ Cariovasc Interv 2011 Accepted

13 % LCX carina lum men area a (%) Pre-Procedural Predictor for Anatomical SB Compromise r=0.458 p= Distal carina angle ( ) 160 A narrow distal carina angle between LAD and LCX predicted a greater reduction in MLA as well as EEM area at the LCX ostium Kang et al. Circ Cariovasc Interv 2011 Accepted

14 MACE E-free su urvival α>40 Log-rank p=0.007 α<40 Smaller carina angle predicted higher SB compromise and 1-year MACE rates (also restenosis) Follow-up (months) Gil et al. J Interven Cardiol 2009;22:E1 10

15 IVUS-Guided Provisional Stenting Plaque or Carina Shift Mechanisms of SB Compromise Functional Significance of SB Jailing Anatomical-Functional Mismatch Pre-PCI Predictor for Functional Jailing

16 What is Treatment of Jailed SB Based on, Anatomy or Function? Jailed SB SB intervention 26 lesions 2 lesions No SB intervention 65 lesions 6M Mo f/u No change in SB FFR (0.87± ±0.07) Functional restenosis rate (FFR<0.75) only 8% Koo et al. Eur Heart J 2008;29:726 32

17 No serial changes in SB FFR during 6-month 9-month MACE FFR-guided vs. Conventional FFR-guided provisional SB intervention strategy in bifurcating lesion resulted in a low rate of functional restenosis and 9-month cardiac events Koo et al. Eur Heart J 2008;29:726 32

18 %DS Predicts Neither MLA Nor FFR at the SB Ostium after Cross-overover 2 ) LA of LC CX (mm 2 Post- -stent M 12 r= p= Post-stenting %DS (%) 73% Mismatch Post-stent DS of LCX ostium (%) Kang et al. Circ Cariovasc Interv 2011 Accepted Koo et al. JACC 2005;46: Most lesions (73%) with angiographic g compromise are not functionally significant

19 Anatomical vs. Functional Mismatch SB FFR 0.83 SB MLA 2.6mm 2 SB MLA 1.9mm 2

20 Anatomical vs. Functional Mismatch Pre Post Post-stenting LCX FFR LCX FFR 0.81 LCX-MLA 25mm 2.5mm 2 LCX-MLA 4.2mm 2 LCX-MLA 2.5mm 2

21 Pitfalls of Pre-PCI IVUS vs. FFR of SB Although IVUS assess Anatomical compromise more accurately than QCA, it still has limitations to assess the Functional SB compromise MLA as one of the various anatomical factors FFR is affected by myocardial territory supplied by SB Technical difficulty in obtaining SB-pullback SB FFR?

22 IVUS-Guided Provisional Stenting Plaque or Carina Shift Mechanisms of SB Compromise Functional Significance of Jailing Anatomical-Functional Mismatch Pre-PCI Predictors for Functional Jailing

23 Pre-PCI Angiographic Predictor of Functional Compromise (SB FFR<0.80) OR 95% CI p MB ref MLD MB ref DS SB ref MLD SB %DS Lesion length Carina angle Distal MB MLD Koo et al. Circ Cardiovasc Interv 2010;3:113-9

24 In 90 SB non-lm FFR <0.80: bifurcations 18% post-stenting with SB DS<75%, Independent Predictors for SB FFR β 95% CI p Pre-PCI MLA of SB ostium Pre-PCI PB at SB ostium Pre-PCI PCI MLA of distal MB Maximal balloon pressure Kang et al. Am J Cardiol 2011 in press

25 Pre-procedural IVUS-MLA within SB Ostium Predicts SB FFR <0.80 after MB stenting MLA of SB Ostium Cut-off =2.4mm 2 Sensitivity AUC=0.846 CI p= Specificity it Kang et al. Am J Cardiol 2011 in press SB FFR after cross-ov ver r=0.454 p<0.001 Sensitivity=94% Specificity=68% PPV=40% NPV=98% Pre-PCI MLA within SB ostium (mm 2 ) 32% of SB lesions without functional significance may undergo unnecessary PCI

26 Plaqu ue burden of SB ostium (% %) 80 Only 70 52% FFR< SB FFR<0.80 SB FFR % FFR MLA within SB ostium (mm 2 ) 8 10 Combining pre-pci IVUS-MLA and plaque burden, diagnostic accuracy predicting FFR<0.80 was 83% Kang et al. Am J Cardiol 2011 in press

27 Summary Use of IVUS vs. FFR Pre-procedural Advantage Pitfalls SB-pullback IVUS useful to assess the anatomical severity - MLA, PB, remodeling Predictive value for SB FFR after MB stent MLA-FFR mismatch No IVUS criteria of SB Low feasibility SB FFR functional significance only in isolated SB stenosis, not in true bifurcation Affected by proximal MB or distal SB stenosis SB geometry is usually changed after MB stenting No pre-pci FFR cut-off

28 Summary Use of IVUS vs. FFR After MB Cross-overover Advantage Pitfalls SB-pullback IVUS Mechanism of SB jailing SB MLA MLA-FFR mismatch No IVUS criteria for SB Low feasibility SB FFR Confirm the functional SB compromise Prognostic implication Minority - not feasible Pre-PCI IVUS identifies SB disease and may predict functional SB compromise which is confirmed by post- stenting SB FFR. IVUS provides the precise mechanism