8 th European Bifurcation Club October Barcelona

Transcription

1 8 th European Bifurcation Club October Barcelona 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 have had a financial interest/arrangement or affiliation with the organizations listed below. Affiliation/Financial Relationship Grant/Research Support Consulting Fees/Honoraria Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit Company Abbott vascular, Cordynamic Abbott, Boston, Cordis, Biotronik, IHT, Lilly, Daychi Sankio, Astra Zeneca

3 LMCA angiography LMCA: difficult segment for angiographic evaluation - Frequent atherosclerosis (89%) with angio N 1 - Poor correlation QCA & IVUS 1,2 - Diffuse disease, no reference (short shaft) - Opacification coronary sinus, ostial angulation - Bifur LAD-LCX distal LMCA: complex angio - Intraluminal defects?? - Association with other lesions - ischemia? 3 Variability intra- interobserver 4,5 - Intravascular ultrasound (IVUS) may overcome these angiographic limitations 1 Hermiller et al. Am J Card 1993;71: Abizaid et al. Am J Cardiol 1999;34: El-Menyar et al. Curr Probl Cardiol 2007;32: Cameron et al. Circulation 1983:68: Fisher et al. Catheter Cardiovasc Diagn 1982;8: Ricciardi et al. Am Heart J 2003;146:507-12

4 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

5 Proposed MLA cut-off values for LM Kang et al. IVUS vs FFR <0.8 MLA 4.8 mm N= 55 Jasti et al. IVUS vs FFR < 0.75 MLA 5.9 mm N= 55 LITRO De la Torre et al. Physics of flow / Jasti et al. MLA 6 mm N = 354 Fassa et al. Epidemiol. inferred MLA 7.5 mm N= 214 Legutko et al. IVUS vs FFR < 0.75 / SPECT MLA 8 mm N=44 Clinical follow-up

6 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

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

8 Mayo Clinic Experience > 7.5 Revasc < 7.5 Revasc > 7.5 Deferred < 7.5 Deferred Best cut-off MLA by ROC = 9.6 mm2 Fassa et al. J Am Coll Cardiol 2005;45:204 11

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

10 22 centers De la Torre, et al. J Am Coll Cardiol 2011; 58:351-8

11 Valdecilla Hospital Experience Prospective application of MLA 6 mm 2 as cut-off 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 et al. Rev Esp Cardiol. 2007;60:811-6"

12 LMCA MLA = 6 mm 2 Proximal LAD MLA = 3 mm 2 Proximal LCx MLA = 3 mm 2 Linear law (epicardial coronary artery) Do = 0.678*(D1+D2)

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

14 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

15 Finet G et al. Eurointervention 2007;3:10-17

16 Correlation IVUS FFR: non LM MLA cut off Lesions MLA for FFR < 0.75 Takagi mm 2 Briguori mm 2 MLA for FFR < 0.8 Ben-Dor mm mm 2 Koo mm 2 Kang mm 2 F1RST mm 2 Gonzalo mm 2 2 mm 2 (OCT)

17 Threshold for MLA in prox. LAD - LCx Correlation FFR-IVUS in non-lm lesions in vessels of mm in diameter LAD / LCx MLA Murray`s law LM MLD LM MLA Linear law LM MLD LM MLA

18 LITRO study 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%)

19 Visual stenosis Compared angiographic parameters between IVUS groups > 6 MAYOR grupo < 6 MENOR QCA stenosis 4,0 MLD DLM (mm) 3,5 3,0 2,5 30 2,0 20 1,5 10 grupo 1,0 MENOR MAYOR MENOR < 6 < 6 grupo MAYOR > 6 > 6

20 Clinical outcome of pts with deferred revascularization (MLA > 6 mm 2 ) 100 MC+MI+RTC Survival free of cardiac death, MI and LMCA revascularizacion at 2 years: 94.2 ± 1.8% Time

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

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

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

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

25 55 pts LM stenosis 30 80% 4.8 mm 2 72% Kang SJ et al. J Am Coll Cardiol Intv 2011; 4:

26 No clinical follow up 71% of lesions with FFR % of lesions with FFR > 0.8 Revascularized

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

28 Differences between studies Kang et al. Jasti et al. LITRO study Fassa et al. MLA, mm PB, % EEM area, mm Method FFR IV adenosine FFR IC adenosine µg Clinical validation From Normal population- Clinical validation Cut-off MLA

29 Euro PCR 2012

30 MLA cut-off for LM 5 mm 2 6 mm mm 2 Very small body size Octogenarians (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 tests,...

31 The double value of IVUS LMCA intermediate lesion IVUS Significant 40 45% FFR CABG (45-50%)* PCI (50-55%)* IVUS *National registry RENACIMIENTO (Baz et al. ACC 2010) 1,479 patients with severe LM disease (year 2008) 53% PCI 47% CABG

32 The Corean experience Mortality Outcomes in 145 propensity-matched pairs of patients receiving DES with and without IVUS guidance IVUS guidance decreased mortality Death + MI TVR Park S et al. Circ Cardiovasc Interv 2009;2:

33 Distal-LM subset and IVUS Propensity score matched groups MCIAMTLR Survival free of c.death, MI and TLR P=0.1 IVUS No IVUS MuertecardiacaIAM 100 RevascTCpcicabg Survival free of c.death and MI Survival free of TLR 60 P= P= ESTROFA LM multicenter study

34 Borderline Left Main Stenosis The use of FFR Author Reference n= FFR >0,75 <0,75 Bech G, et al.. Heart Jasti V, et al Circulation Jimenez-Navarro, et al. J Invasive Cardiol Suemaru S, et al. Heart Vesels Legutko J, et al Polish Heart Journal Lindstaedt M, et al American Heart Journal >0,8 <0,8 Hamilos M, et al Circulation

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

36 IVUS FFR in intermediate lesions Louisville Univ. study

37 Hamilos et al. Circulation 2009;120:

38 LMCA intermediate lesions: Evaluation with FFR 138 pts FFR > 0.8 Medical Tx 75 pts FFR < 0.8 CABG Death MACE Hamilos et al. Circulation 2009;120:

39 VS.

40 Hamilos et al. Stenosis MLD LITRO MLA > 6 MLA<6 MLA > 6 MLA<6

41 MLA > 6 MLA < 6 46% 35%

42 Comparative outcomes IVUS - FFR (138) DEF > 0.8 (75) REV < (179) DEF > 6 (152) REV < 6 MACE MACE Time 2 yrs 2 yrs Hamilos et al. Circulation 2009;120: LITRO De la Torre et al.

43 FFR is more appropriate in assessing intermediate 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 variability in LM length Limited variability in supplied myocardium Large LM size Potential limitations for FFR LAD and/or LCx significant disease (frequent 30-40%) Collaterals to an occluded (sub-occluded) RCA Inter-individual variation in hyperemic response is varied Gray zone (?) IVUS provides anatomic information not possible with FFR Characterization of disease (LAD / LCx ostial involvement,...) IVUS may be used to guide LM PCI

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

45 FFR = Non-significant LM+LCx FFR = 0.72 Significant LM + LAD

46 LM < - - LCX LM < LAD Prox LM Distal LM MLA = 6.2 mm2 PB = 75% Ostial LCx Ostial LAD MLA = 3.8 mm2 PB = 73%

47 The nature of narrowing EEM area Lumen area 11 5,8 14 7,5

48 LAD ostial LAD prox LM proximal LM distal Calcium in nodules PCI feasible Cx prox LCx ostial

49 Calcium 360º Complex PCI (Rotablator) +CABG

50 PREINTERVENTION ASSESSMENT FFR Isolated ostial or midshaft lesions in pts more appropriate candidates to CABG IVUS Distal-bifurcation lesions Diffuse-distal coronary artery disease Likely candidates to PCI (extent, distribution, morphology, Ca, lumen,...) Puri R et al. J Am Coll Cardiol Intv 2012;5:

51 Conclusions IVUS and FFR are both safe methods to accurately assess the severity of ambiguous LM lesions. IVUS : 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 Useful in case of LM PCI FFR : Definite cut-off value (0.8). (Suggested gray zone ) No characterization of LM disease (specially in bifurcations) Not fully reliable in presence of severe LAD / LCx disease

52 My personal approach In isolated equivocal LM lesions: IVUS/FFR In serial lesions to determine the isolated LM component: IVUS Severe lesions in LAD and/or LCx Collaterals to a totally occluded RCA With high likelihood of PCI: IVUS

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54 IVUS assessment of LCX ostium from the LAD-LM (or vice versa) plaque burden Evaluation of the LAD from the LM-LCX pullback Evaluation of the LCX from the LM-LAD pullback Sensitivity Specificity Sensitivity Specificity Plaque burden >40% 59% 45% Plaque burden >40% 67% 55% Plaque burden >70% 78% 42% Plaque burden >70% 88% 42% If you want to quantify the plaque burden, you must image the daughter branches directly. Oviedo et al. Am J Cardiol 2010;105:948-54

55

56 Some patients may metabolize adenosine faster than others No hyperemic response use a multipurpose catheter to deliver adenosine into the right atrium

57 MLA cut-off value for ischemia in non-lm lesions Abizaid, et al. Circulation 1999;100:256, )

58 If you want to stent... DO IVUS 83 pts 94 pts Chang Wook N et al. JACC Intv 2010;3:812-7

59 MLA cut-off depends on vessel size 92 lesions (84 pts) in vessels > 2.5 mm FFR < 0.75 RVD > 3.5 mm MLA = 3.7 mm 2 RVD mm MLA = 2.9 mm 2 Ben-Dor I, et al. Eurointervention 2011;7: RVD mm MLA = 2.6 mm 2

60

61 FFR-center vs. IVUS-center (TCT De la Torre, Lopez Palop, et al.) FFR < 0.75 MLA < 3-4 mm 2 (based on vessel size) and PB > 50% 100 FFR 12 months % 47% No PCI PCI TLR 2% No MI lesion related Other revasc. 2.3% IVUS 0 FFR IVUS FFR IVUS 471 pts 352 pts 545 les 429 les TLR 1% No MI lesion related Other revasc. 2.8%

62 IVUS examination

63 Stone et al. N Engl J Med 2011;364:226-35

64 Plaque composition by IVUS-VH in LM Absence of TCFA in LMCA Mercado N et al. Eurointervention 2011;7: Minimal Necrotic Core in the LM Valgimigli et al. J Am Coll Cardiol 2007;49:23-31 Low incidence of LM-STEMI in clinical practice But,... Selection bias as complete LM occlusion as a result of plaque rupture is much more often fatal

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66 Comparison with previous study with IVUS (114) Def > 7.5 (12) Def < (179) Def > 6 (16) Def < 6 MACE MACE Time 2 yrs 2 yrs Fassa et al. J Am Coll Cardiol 2005;45:204 11

67 In 25% of patients, the left main MLA differed by 1mm 2 when imaged from a pullback beginning in the LAD vs a pullback beginning in the LCX. Since IVUS can artificially increase, but not decrease lumen dimensions, the smallest MLA is always the most accurate

68 There is probably more agreement between IVUS and FFR in assessing LMCA lesion significance than in assessing non-lmca lesion significance Limited variability in LMCA length Limited variability in amount of supplied myocardium Large LMCA size However, IVUS provides anatomic information not possible with FFR

69 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

70 MLA cut-off for LM 5 mm 2 6 mm mm 2 Very small body size Octogenarians (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 tests,...

71 FFR MLA in LM vs non-lm lesions

72 The case for the LMCA -Lesions in LMCA are prognostically relevant. -Angiographic assessment of the severity of disease in the LMCA remains elusive in many cases: -Measurements at this level are the least reproducible of any coronary segment (Fisher et al. Cathet Cardiovasc Diagn 1982;8:565-75) -Autopsy studies have demonstrated significant discrepancies between angiography and histology at this level (Arnett et al. Ann Intern Med 1979;91:350-6) -Inadequate severity evaluation may lead to defer revascularization of really severe lesions or lead to the unnecessary revascularization of nonsignificant lesions

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74 Patients with MLA > 6mm 2 and deferred revascularization Revascularization of LM in follow up No Yes* n= 171 n=8 MLD 2.9 ± ± 0.7 MLA 9.3 ± ± 2.1 MLA: % 25% % 25% % 12.5% > % 37.5% * 4 (50%) showed lesion progression at the time of revascularization

75 MLA + Plaque burden Plaque burden beyond 40% predicts further luminal narrowing PB > 70% predictor of lesion-events in PROSPECT trial PB > 72% predictor of FFR < 0.8 in LM in Kang et al. PB > 67% predictor of FFR < 0.75 in LM in Jasti et al. PB was the only predictor of events in deferred LM revascularization after 5 years in Okabe et al. Glagov et al, NEJM 1987; 316: Stone et al. N Engl J Med 2011;364: 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

76 Finet G et al. Eurointervention 2007;3:10-17

77 71% of lesions with FFR % of lesions with FFR > 0.8 Revascularized