Plaque Shift vs. Carina Shift Prevalence and Implication

Transcription

1 TCTAP 2013 Fellowship Course Left Main and Bifurcation PCI: Bifurcation PCI Plaque Shift vs. Carina Shift Prevalence and Implication 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 Mechanisms of Angiographic SB Jailing Stent Strut Artifact Pre-procedural After cross-over Post-stenting MLA 8.4mm 2 Nobori MLA 8.3mm 2Nobori

4 Pre-procedure After Cross-Over SB MB Carina Shift V/ L >1 P <0 SB MB MB SB pullback Area Change L -3.4 mm 2 V -3.5 mm 2 P mm MB SB pullback SB MLA 7.2 mm 2 SB 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

5 Pre-procedure After MB stenting Plaque Shift V/ L <1 P >0 PB 52% PB 70% Area Change L -1.0mm 2 V -0.3mm 03mm 2 P +0.7mm 2 SB FFR 0.77 SB MLA 2.3 mm 2 SB MLA 1.4 mm 2 EEM area 5.0 mm 2 EEM area 4.7 mm 2 P+M 2.7 mm 2 P+M 3.3 mm 2

6 Plaque Shift vs. Carina Shift Prevalence of Carina vs. Plaque Shift Impact on Functional Significance

7 Distal MB segment Proximal MB segment Pre Post p Pre Post p Lumen VI < < Plaque VI Vessel VI < < Luminal gain is not caused by plaque shift but by EEM expansion, leading to carina shift and SB compromise Koo et al. Circ Cardiovasc Interv 2010;3:113-9

8 Kang et al. Circ Cardiovasc Interv 2011;4: (n=23lm bifurcation lesions)

9 Hemodynamic Impact of Changes in Geometry of Non-LM Bifurcation SB MLA (mm 2 ) Non-LM bifurcation lesions with SB ostial DS<50% EEM (mm 2 ) p< p<0.001 Eccentricity p<0.001 P+M (mm 2 ) p=0.215 pre post pre post pre post pre post Kang et al. Catheter Cardiovasc Interv 2013 in press 1.0

10 Plaque Shift + Carina Shift % 0.5 P+ +M % Isolated Carina Shift V/ L Kang et al. Catheter Cardiovasc Interv 2013 in press

11 Plaque Shift vs. Carina Shift Prevalence of Carina vs. Plaque Shift Impact on Functional Significance

12 SB ostium with pre-procedural p DS<50% 48% were angiographically jailed (DS>50%) after MB stenting, while 15% had FFR<0.80 After MB stenting AMC preliminary

13 How Often Functional SB Compromise? 50 FFR R< (%) 40 38% % 13% <30% 30-50% 50-75% Pre-procedural SB %DS Kang et al. Am J Cardiol 2011;107:

14 How to Treat Angiographic Jailing of SB? FFR >0.75 is safe for deferral of jailed SB FFR-guided provisional SB intervention resulted in a low rate of 9-month MACE Koo et al. Eur Heart J 2008;29:726 32

15 Mismatch Between QCA vs. FFR Post-stenting DS 70% Post-stenting DS 80% SB FFR SB FFR

16 Discordance Between Post-stenting QCA-DS vs. SB FFR 73% 74% SB FFR SB FFR Post-stenting DS (%) Post-stenting DS (%) Koo et al. JACC 2005;46: Ahn et al. JACCInterv in Press

17 Why Mismatch? Angiography and SB FFR Lesion eccentricity of SB Negative remodeling of ostium Various size of myocardium Strut t artifacts t Sachdeva et al. Am J Cardiol 2011;107:1794-5

18 Is Post-stenting SB-IVUS Useful to Assess Jailed SB? SB MLA <2.25mm 2 FFR SB To Predict FFR<0.80 Sensitivity 100% 0.8 Specificity it 71% 0.7 PPV 38% 0.6 NPV 100% r=0.516 p= Post-PCI MLA of SB (mm 2 ) Kang et al. Catheter Cardiovasc Interv 2013 in press

19 Why Mismatch? IVUS-MLA vs. FFR After MB Stenting Small myocardial territory The general mechanism of SB jailing is focal carina shift rarely causing functional stenosis

20 Why Does the Isolated Carina Shift Rarely Reduce FFR? Not by plaque gain, but by vessel deformation The luminal change is extremely focal

21 Hemodynamic Impact 1.0 Carina vs. Plaque Shift 0.9 B FFR S CS only PS+CS Post-PCI MLA of SB (mm 2 ) Plaque shift may be a prerequisite to the hemodynamically y significant SB stenosis Kang et al. Catheter Cardiovasc Interv 2013 in press

22 , SB ostium (mm m 2 ) P+M 1.0 Predictor for Plaque Shift r= p=0.031 MB carina Plaque burden at MB carina (%) r p Lumen area, MB carina Plaque burden, MB carina Plaque burden, distal MB Plaque burden, proximal MB Plaque burden, SB ostium Kang et al. Catheter Cardiovasc Interv 2013 in press

23 Impact of Carina Angle carina lumen a rea (%) % LCX r=0.458 p=0.028 Distal carina angle ( ) A narrow distal carina angle predicted a greater reduction in MLA and EEM area at the LCX ostium Kang et al. Circ Cardiovasc Interv 2011;4:355-61

24 Summary Carina shift is a general mechanism of SB jailing, occurs in almost all lesions Plaque shift is less frequent, but more aggressive mechanism of the functional SB compromise Considering the frequent visual functional mismatch, treatment of the jailed SB should be based on post-stenting SB FFR