DID OCT change our experience on coronary arteries?

Transcription

1 DID OCT change our experience on coronary arteries? Istanbul June 2012 F Prati San Giovanni Hospital, Rome Rome Heart Research

2 Use imaging modalities to.. Avoid useless procedures!

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6 MLA of 2.0 mm 2 best correlates with FFR IVUS cut-off Mintz TCT 2010 OCT cut-off Gonzalo et al JACC 2012

7 Use OCT to.. identify culprit lesions in patients with ACS

8 61 years old male with CAD RF: Smoke Unstable angina with transient anterior ST elevation in the anterior leads Angio: Minimal irregularity in the prox LAD. LCx and RCA undiseased

9 OCT: Ruptured plaque with mild thrombus LP Thrombus

10 Vulnerable plaque with high inflammatory cell content RHR dedicated sowtare to address plaque composistion

11 EXPERT REVIEW DOCUMENT ON METHODOLOGY, TERMINOLOGY AND CLINICAL APPLICATIONS OF OCT. F. Prati 1, E. Regar 2, G.S. Mintz 3, E. Arbustini 4, C. Di Mario 5, IK. Jang 6, T. Akasaka 7, M. Costa 8, G. Guagliumi 9, E. Grube 10, Y. Ozaki 11, F. Pinto 12 and P.W.J. Serruys 2 for the Expert s OCT Review Document Clinical Application of OCT: assessment of lesion severity and plaque instability European Heart Journal. 2009

12 Guidance of coronary intervention Use OCT post-intervention to adress the adequacy of stent positioning.

13 Potential use of IVUS to reduce stent thrombosis (Non randomized studies)

14 884 patients undergoing IVUS-guided intracoronary DES implantation Propensity-score matched population undergoing DES implantation with angiographic guidance alone 30 days outcome IVUS No IVUS P MACE 2,8 5, Death TLR 0,7 1, Stent thrombosis 0,5 1, Roy et al Eur Heart J 2008 S.Giovanni H, Rome

15 Fujii et al. JACC 2005

16 OCT represents a new angle of view OCT addresses features that are not easily detected by IVUS Thrombosis Edge dissection Struts malapposition

17 What angiography does not show Examples from the multicenter MOST registry of Subacute Thrombosis TCT 2011

18 Examples of sub-optimal OCT results in pts with Subacute Thrombosis. From the MOST Registry STEMI four days after DES deployment Pt. CA MA Distal stent dissection TCT 2011

19 Examples of sub-optimal OCT results in pts with Subacute Thrombosis. From the MOST Registry STEMI 8 days after DES deployment Pt RE RI Marked proximal stent malapposition TCT 2011

20 N 6 pts with subacute stent thrombosis in the MOST registry Al cases had a STEMI at the time of stenting Pr FU (days) OCT appearance CA MA BMS 4 Edge Dissection TO SE BMS 4 Stent Underex. Reisidual prox plaque. LA 2,5 mm2 RE RI BMS 8 Marked prox stent underexpansion IA AN BMS 18 Prox edge dissection BI GI DES 4 Malapposition and uncoverage MA PA DES 11 Malapposition and uncoverage TCT 2011

21 N 3 pts with subacute stent thrombosis in the S.Giovanni Registry (Years ) Al cases had TD OCT done after intervention Procedures were not OCT guided Pr FU (days) OCT appearance N 1 BMS 7 Intrastent thrombus. Stent positioned x ACS N 2 DES 5 Distal edge dissection. N 3 BMS 3 Large residual plaque at stent edge TCT 2011

22 Guidance of coronary intervention Use OCT pre-intervention to avoid plaque embolization

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24 Clinical case 57 yo, male with inferior STEMI (III h) Previous primary PTCA + 2 DES in LAD Diabetes EFVSx: 40% CFG: distal RCA subocclusion

25 Clinical case

26 After DES Stenting (Xience 3.0 x 15 mm) Stent

27 OCT After Stent Implatation Plaque prolapse at the prox edge Distal edge Proximal edge

28 Missed plaque rupture Further prox DES Stenting (3.0 x 12 mm)

29 Guidance of coronary intervention Use OCT for complex interventions

30 LAD pre PCI Angiography

31 LAD post Stent Stent Resolute integrity 3,5 x 22 mm

32 Postdilatation

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34 After kissing balloon marked stent malapposition at OCT

35 Wrong wire placement in the LCx through the LM stent SB

36 Marked stent malapposition SB SB Wire already outside left main stent

37 Additional LM dilatation n.c balloon 4,5 x10 mm Trek balloon 5 x 12

38 Final Result

39 SB Good stent apposition

40 Angiography alone versus angiography plus optical coherence tomography to guide decision making during percutaneous coronary intervention: the CLI-OPCI study Francesco Prati MD Department of Interventional Cardiology, San Giovanni Hospital, Rome

41 F. Prati, L. Di Vito, G. Biondi-Zoccai, A. La Manna, F. Burzotta, C. Tamburino, C. Trani, V. Ramazzotti, F. Imola, M. Occhipinti, A Manzoli, L. Materia, A Cremonesi and M Albertucci. Dep. of Interventional Cardiology, San Giovanni Hospital, Rome, Italy (FP, VR, FI, AM); Centro per la Lotta contro l Infarto Fondazione Onlus, Rome, Italy (FP, LDV, GBZ, MO, LM, MA); Inst. of Cardiology, University of Catania, Catania, Italy (MO, ALM, CT); Inst. of Cardiology, Catholic University, Rome, Italy (FB, CT); Sansavini Foundation, Cotignola, Italy (AC)

42 Objectives We aimed to compare angiographic guidance alone versus angiographic plus OCT guidance for PCI focusing on: feasibility, procedural safety, early outcomes, long-term outcomes. Submitted Euro-PCR 2012

43 Methods Consecutive patients undergoing PCI with angiographic plus OCT guidance (OCT group) at three high OCT-volume Italian centers between 2009 and 2011 were included. Patients in the OCT group (335 pts) were matched 1:1 with randomly-selected patients undergoing during the same month PCI with angiographic only guidance (Angio group). All patients provided written informed consent, and ethical approval was waived given the observational and retrospective design. Submitted Euro-PCR 2012

44 Definitions of Sub-Optimal results after stenting Submitted Euro-PCR 2012

45 Edge dissection Stent > 200 µ malapposition lenght > 600 µ > 200 µ lenght > 600 µ

46 Under- expansion Stent MLA> 90% Average Ref MLA Prox Stent Edge LA Prox Ref LA Symmetry index Thrombus > 200 µ lenght > 600 µ

47 No residual stenosis adjacent to stent endings (MLA > 4.0 mm 2 ) Distal MSA Prox

48 End-points The primary end-point of the study was the 12-month rate of cardiac death or non-fatal myocardial infarction (MI). Additional end-points were short-term rates of death, cardiac death, and non-fatal MI, and 12-month rates of death, cardiac death, non-fatal MI, target lesion repeat revascularization (TLR) and definite stent thrombosis. All outcomes were defined in keeping with the Academic Research Consortium recommendations. Submitted Euro-PCR 2012

49 Baseline characteristics Angiographic group (N=335) Optical coherence tomography group (N=335) P value Age, years 67.0± ± Female gender 82 (24.5%) 73 (21.8%) Hypertension 244 (73.8%) 253 (75.5%) Diabetes mellitus 97 (29.0%) 81 (24.2%) Current smoking 113 (33.7%) 115 (34.3%) Dyslipidemia 176 (53.3%) 214 (64.5%) Prior myocardial infarction 72 (21.5%) 76 (22.7%) Prior percutaneous coronary intervention 78 (23.5%) 115 (34.3%) Prior coronary artery bypass grafting 29 (8.7%) 22 (6.6%) Admission diagnosis ST-elevation myocardial infarction 123 (36.7%) 86 (25.7%) Non-ST-elevation acute coronary syndrome 85 (25.4%) 112 (33.4%) Stable coronary artery disease 127 (37.9%) 137 (40.9%) Left ventricular ejection fraction, % 52.8± ± Post-procedural serum creatinine (mg/dl) 1.1± ±

50 Procedural results Angiographic guidance group (N=335) Angiographic plus optical coherence tomography guidance group (N=335) P value Number of diseased vessels (47.9%) 122 (36.8%) (32.8%) 144 (43.4%) 3 68 (19.3%) 69 (19.6%) Left main disease 8 (2.4%) 22 (6.6%) American College of Cardiology/American Heart Association type B2/C lesion 287 (86.7%) 244 (72.8%) <0.001 PCI on left anterior descending 179 (53.4%) 204 (60.9%) Multivessel PCI 52 (15.5%) 78 (23.3%) Stent length per patient (mm) 26.0± ± Drug-eluting stent usage 146 (43.6%) 212 (63.3%) <0.001 Stent overlap 25 (7.5%) 49 (14.6%) Maximum balloon diameter (mm) 3.0± ± Maximum dilation pressure (ATM) 16.7± ± Contrast (ml) 220±56 240±

51 Angiography alone versus angiography plus optical coherence tomography to guide decision making during percutaneous coronary intervention: the CLI-OPCI study 40,0 35,0 30,0 25,0 20,0 15,0 10,0 5,0 0,0 335 pts with OCT guidance

52 Results Unadjusted analyses showed that the OCT group had a lower 12-month risk of cardiac death (p=0.010), cardiac death or MI (p=0.006), and the composite of cardiac death, MI, or repeat revascularization (p=0.044). Even at extensive multivariable analysis adjusting for baseline and procedural differences, angiographic plus OCT guidance was associated with a lower risk of cardiac death or MI (OR=0.49 [ ], p=0.037). Finally, even propensity score-adjusted analysis exploiting bootstrap resampling confirmed the association between OCT and the 12-month rate of cardiac death or non-fatal MI (OR=0.37 [ ], p=0.050).

53 Clinical results Angiographic plus optical Angiographic guidance coherence tomography guidance group (N=335) group (N=335) P value In-hospital events Cardiac death 3 (0.9%) 2 (0.6%) Non-fatal myocardial infarction 22 (6.5%) 13 (3.9%) Events at 1-year follow-up Death 23 (6.9%) 11 (3.3%) Cardiac death 15 (4.5%) 4 (1.2%) Myocardial infarction 29 (8.7%) 18 (5.4%) Target lesion repeat revascularization 11 (3.3%) 11 (3.3%) 1.0 Definite stent thrombosis 2 (0.6%) 1 (0.3%) Cardiac death or myocardial infarction 43 (13.0%) 22 (6.6%) Cardiac death, myocardial infarction, or repeat revascularization 50 (15.1%) 32 (9.6%) 0.034

54 Conclusions Use OCT to: Avoid useless interventions Identify culprit lesions in patients with ACS Reduce stent thrombosis identifing suboptimal results Improve results of left main and complex procedures Avoid plaque embolization

55 OCT guided intervention for treatment of LM and proximal LAD 65 years old male with CAD Previous intervention with DES in the LCx (May 09) Stable angina and positive treadmil test at 75 W

56 Is the Left Main significantly diseased?

57 Is the Left Main significantly diseased?

58 3.9 mm mm 2 Aver. Diam. 2.5 mm 2 MID LM Ostial LAD

59 LM treatment with 3.5 x 24 mm Taxus at 12 atm followed by kissing with 2.0 mm balloon and further 4.0 mm balloon inflation in the LM

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61 Angiography after additional deployment of 2.5 x 8 mm Taxus

62 Malapposition of inner 2.5 mm Taxus Plaque prolapse Appropriate expansion

63 Final OCT after further high pressure dilatation with 3.0 mm non compliant baloon Before high pressure dilatation After high pressure dilatation Malapposition of inner 2.5 mm Taxus Well apposed stent

64 Independent predictor of mortality in 805 pts with LMCA disease treated with DES HR 95 % CI P Previous CHF Chronic renal failure < COPD Euroscore > IVUS guidance SJ Park et al TCT 2007 S.Giovanni H, Rome

65 Impact of IVUS guidance on all cause mortality after LMCA DES implantation (805 pt5) Cumulative incidence (%) P= ,5 1 1,5 2 2, IVUS No IVUS Years after DES implantation

66 OCT guided intervention for treatment of in-stent restenosis 51 years old male with CAD Previous intervention with BMS in the LAD (May 2000). No other procedural information Mild effort angina and positive treadmil test at 50W

67 OCT guided intervention for treatment of in-stent restenosis 1. Well expanded stent 2. Marked neointima with non- homogeneous backscatter 3. Short restenosis ( 6,2 mm) 4. Stented segment lenght 18 mm 5. Two overlapped 12mm long BMS

68 1. Well expanded stent 2. Marked neointima with non- homogeneous backscatter 3. Short restenosis ( 6,2 mm) 4. Stented segment lenght 18 mm 5. Two overlapped 12mm long BMS 6. Ruptured LP plaque inside the stent

69 1. Well expanded stent 2. Marked neointima with non- homogeneous backscatter 3. Short restenosis ( 6,2 mm) 4. Stented segment lenght 18 mm 5. Two overlapped 12mm long BMS

70 LP LP Rupture? 1. Well expanded stent 2. Marked neointima with non- homogeneous backscatter 3. Short restenosis ( 6,2 mm) 4. Stented segment lenght 18 mm 5. Two overlapped 12mm long BMS 6. Ruptured LP plaque inside the stent

71 Taxus 3,0 x 12 mm implanted at 18 atm Pre-intervention Final

72 OCT guided intervention in a pt with ACS 50 years old male with Infero-lateral ACS Smoker High cholesterol

73 OCT guided intervention in a pt with ACS

74 Taxus Libertè 3,0 x 20 mm implanted at 16 atm Optimal angiographic result

75 REF Thrombus 1. Well expanded stent 1. area 8,3 mm2 2. MLA > Ref Area 2. Marked in-stent thrombus

76 Taxus implanted at 16 atm Further dilatation with Nc 3,0 balloon at 20 atm for 30 sec Thrombus Mild prolapse

77 OCT use to assess complex intervention The mini-crush technique OCT in the LAD Minimal Crushing OCT in the Diagonal Optimal stent opening (3 mm) Galassi, Prati

78 Safety and Efficacy of Frequency Domain Optical Coherence Tomography for Guidance of Coronary Interventions Imola F *#, Mallus MT *, Ramazzotti V *, Manzoli A *, Pappalardo A *, Albertucci M #, Prati F *# Interventional Cardiology, San Giovanni Addolorata Hospital, Rome Italy # Centro per la Lotta contro l Infarto(CLI) Foundation, Italy Submitted Eurointervention

79 FD-OCT guided interventional procedures planned in 90 patients. In 40 pts OCT was performed for evaluation of ambiguous/intermediate lesions: of these 24 pts were treated with stenting and OCT was done pre and postintervention, in the remaining 16 pts with ambiguous lesions OCT permitted to exclude significant lesions that were left untreated. In a second group of 50 cases we attempted to obtain OCT images only post-intervention to address the adequacy of stent deployment. Therefore a total of seventy-four patients had OCT done post-stenting.

80 Correct stent malapposition (> 200 µ)

81 Treat dissection (> 200 µ) at stent edges S.Giovanni H, Rome

82 Correct insufficient stent expansions Before After high pressure dilatation Distal stent Prox stent

83 Get rid of thrombus Intrastent thrombosis despite optimal angiographic results cambia D

84 Results 74 patients with OCT done post-intervention

85 Clinical Follow-up Clinical follow up (4,6 ± 3,2 m) in 88 patients No death, acute myocardial infarctions and cases of certain, probable or possible stent thrombosis (ARC). New occurrence of chest pain in 3 pts and two revascularizations.

86 IVUS use in the DES Era A large burden of information derives from IVUS. USE IVUS TO: Defer intervention Lend stent edges in relatively undiseased segments Obtain full lesion coverage and complete stent expansion IVUS is a well known and validated technique capable of improving pts outcome S.Giovanni H, Rome

87 OCT use in the DES Era A new angle of view USE OCT to fine tune stent deployment by addressing: Underexpansion, Malapposition, In stent Thrombosis, Dissections OCT is a novel techniques and new clinical strategy of stent guidance need to be corroborated by further studies. S.Giovanni H, Rome