OCT GUIDED TREATMENT OF CALCIFIED LESIONS RICHARD SHLOFMITZ, MD CHAIRMAN OF DEPT. OF CARDIOLOGY ST. FRANCIS HOSPITAL ROSLYN, NEW YORK

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1 OCT GUIDED TREATMENT OF CALCIFIED LESIONS RICHARD SHLOFMITZ, MD CHAIRMAN OF DEPT. OF CARDIOLOGY ST. FRANCIS HOSPITAL ROSLYN, NEW YORK

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 organization(s) listed below. Affiliation/Financial Relationship Company Consulting Fees/Honoraria Cardiovascular Systems, Inc.

3 WHY IS IMAGING SO IMPORTANT? CALCIUM CAC present in 90% by age 70 Ca underdiagnosed by angio CA detected by angio in 38% pts, 73% by IVUS in same pts IVI sensitivity increased up to % Ca increases underexpansion and MACE GS Mintz et al. Circulation Madhavan et al. Coronary Artery Calcification. JACC 2014 P Genereux et al. Pooled analysis from the HORIZONS-AMI & ACUITY trials. JACC 2014

4 CONSEQUENCE OF NO PRETREATMENT OF CA 2+ AREA 7.77 mm 2 AREA 2.11 mm 2 AREA 8.01 mm 2

5 DIAGNOSE CALCIFIC PLAQUE CALCIUM DEEP DEEP NODULAR SUPERFICIAL NODULAR SUPERFICIAL TRADITIONAL TECHNIQUES (NC BALLOON/ SCORING/CUTTING) ABLATIVE TECHNIQUES (ATHERECTOMY)

6 DESCRIPTION OF DEEP CALCIUM PRESENCE OF THICK FIBROTIC CAP - NON-LUMINAL TRADITIONAL TECHNIQUES (NC BALLOON/ SCORING/CUTTING)

7 DESCRIPTION OF CALCIFIED NODULE SUPERFICIAL CALCIUM - LUMINALLY PROTRUSIVE - ATTENNUATION PRESENT (PROB DUE TO THROMBUS) FROM THROMBOGENIC SURFACE ABLATIVE TECHNIQUES (ATHERECTOMY)

8 DESCRIPTION OF SUPERFICIAL CALCIUM MINIMAL TO NO FIBROTIC LAYER - DEPTH OF CALCIUM LIKELY MEASURABLE ABLATIVE TECHNIQUES (ATHERECTOMY)

9 Approach to Lesion Preparation for Severely Calcified Coronary Lesions E Shlofmitz et al. Expert Rev Med Devices. 2017

10 RISK STRATIFICATION FOR UNDEREXPANSION OCT-based Calcium Volume Index (CVI) Score 90 0 point 1. Maximum Calcium Angle ( ) 90 < Angle point > points 2. Maximum Calcium Thickness (mm) 0.5 mm > 0.5 mm 0 point 1 point 3. Calcium Length (mm) 5.0 mm > 5.0 mm 0 point 1 point Total score 0 to 4 points Hypothesis: There will be a step-wise decrease in stent expansion according to the CVI score 1. Fujino et. al. TCT 2017

11 A SCORING ALGORITHM HELPS US RECOGNIZE WHEN WE NEED HELP GREATER.5mm DEPTH GREATER 180 ARC GREATER THAN 5mm in LENGTH 1. Fujino et. al. TCT 2017

12 AND WHAT DOES ABLATION LOOK LIKE 270 ARC OF CALCIUM OAS ABLATION POST DES FRACTURE

13 ATHERECTOMY CASE EXAMPLE

14 OCT DIAGNOSIS: CALCIFIED NODULE

15 OAS ABLATED CALCIFIED NODULE

16 4.0X28mm DES 4.0X38mm DES

17 FINAL ANGIOGRAM

18 CALCIFIED NODULE ATHERECTOMY MSA MAXIMIZED PRE POST OAS POST DES ABLATION FRACTURE

19 P R E C I S I O N P C I STEP 1 - MORPHOLOGY STEP 2 - LENGTH STEP 3 - SIZE STEP 4 - COREGISTRATION STEP 5 - EDGE DETECTION STEP 6 - APPOSITION STEP 7 - LUMINAL GAIN

20 CASE EXAMPLE

21 DIAGNOSE CALCIFIC PLAQUE CALCIUM DEEP DEEP NODULAR SUPERFICIAL NODULAR SUPERFICIAL TRADITIONAL TECHNIQUES (NC BALLOON/ SCORING/CUTTING) ABLATIVE TECHNIQUES (ATHERECTOMY)

22 STEP 1 MORPHOLOGY CALCIUM DIAGNOSIS OF CALCIUM Low reflectivity Heterogeneous Sharp margins Isolated, strong reflections SUPERFICIAL CALCIUM 323 Arc LOWEST DEGREE OF THICKNESS: 520 μm LENGTH OF CALCIFICATION: 15mm

23 STEP 2 LENGTH 30mm Length 30mm B A A B A B

24 STEP 3 SIZE 2.75mm Diameter LOCATE EEL DISTAL PROX 2.79mm 3.11mm

25 STEP 4 CO-REGISTRATION Eliminates angiographic ambiguity Length 30mm Minimizes geographic miss during stent placement P R O X E D G E D I S T A L E D G E

26 2.25X18 mm DES to D1 OAS of LAD

27 2.75 X 30mm DES to LAD 3.0 X 20mm NC Balloon

28 STEP 5 EDGE DETECTION NO DISSECTION DISTAL PROX SMALL INTIMAL DISSECTIONS

29 STEP 6: APPOSITION IMMEDIATE ASSESSMENT OF APOSITION

30 STEP 7 STENT EXPANSION MLA 1.31mm2 MSA: 4.73mm2 DES EXPANSION: 96.1%

31 EVIDENCE OF CALCIUM FRACTURE

32 FINAL

33 ANGIO UNDERESTIMATES CALCIUM CONCLUSION SEVERE CALCIUM AFFECTS PROCEDURAL SUCCESS - ACUTE ( NOT ACHIEVING LUMINAL GAIN, MULT STENTS, LONG PROCEDURES) - CHRONIC ( RESTENOSIS DUE POOR EXPANSION) IMAGING IMPORTANT FOR PROPER DIAGNOSIS AND CLASSIFICATION OF SEVERITY.) CLASSIFICATION OF SEVERITY ALLOWS FOR STRATEGIC ASSESSMENT FOR TREATMENT STRATEGIES.

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