OCT guidance for distal LM lesions

Transcription

1 OCT guidance for distal LM lesions FRANCESCO BURZOTTA INSTITUTE OF CARDIOLOGY CATHOLIC UNIVERSITY OF THE SACRED HEART ROME, ITALY

2 LM suitability for OCT At FU in stented LM Parodi G et al. Eurointervention 2010

3 LM suitability for OCT In de novo, non-ostial LM lesions KEY TECHNICAL POINTS: - 6 F or 6.5 F sheathless GC - automatic contrast medium injection (dose adjusted to LM size: 4ml/s or 6ml/s in case of large LM >6mm) - C7 System; C7 Dragonfly; LightLab Imaging Inc/ St Jude Medical Eurointervention 2015

4 LM suitability for OCT In de novo, non-ostial LM lesions STUDY END-POINT: Nr of artifacted frames (failure of MLA automatic calculation) Eurointervention 2015

5 LM suitability for OCT In de novo, non-ostial LM lesions STUDY END-POINT: Nr of artifacted frames (failure of MLA automatic calculation) % artifacted frames Eurointervention 2015

6 LM suitability for OCT In de novo, non-ostial LM lesions STUDY END-POINT: Nr of artifacted frames (failure of MLA automatic calculation) If your doubts are lumen size and morphology in areas, OCT is very good option!!! % these artifacted frames Eurointervention 2015

7 What can we see with OCT in distal LM? Fibrotic plaque LAD ostium 5 mm POC Fibrocalcific plaque Distal LM 5 mm Fibroateroma TCFA Burzotta, Dato et al. Submitted

8 What can we see with OCT in distal LM? LAD ostium 5 mm POC Distal LM 5 mm Mean cap thickness (µm) 85 Distal LM POC LAD ostium Burzotta, Dato et al. Submitted

9 What can we see with OCT in distal LM? Burzotta, Dato et al. Submitted

10 OCT to guide LM management: limits WHICH PARAMETER?

11 OCT to guide LM management: limits <5mm2 <6mm2 WHICH CUT-OFFS?

12 OCT to guide LM management: limits WHAT ABOUT MORPHOLOGY?

13 Looking for cut-offs in intermediate LM disease In LM, OCT estimation of MLA is 15% lower compared with IVUS Fujino Y et al. Cath Cardiovasc Int 2010

14 Looking for cut-offs in intermediate LM disease At IVUS study, MLA value of 4.5 mm2 predicts FFR + Park et al. JACC-Intv 2014

15 Looking for cut-offs in intermediate LM disease FFR 0.79 Signficant disease of very large LMs can be undestimated by conservative MLA cut-offs and recognized by % Area Stenosis

16 First experience with OCT guidance in angiographically-intermediate LM disease Angiographically Intermediate LM bifurcation disease (n=84) OCT assessment OCT-guided management (n=80) - incomplete imaging of the LM bifurcation (n=2) - poor image quality preventing reliable analyses (n=2) LM UCSC criteria: - AS >75% any MLA? - AS >50%<75% and MLA<4 mm 2? - AS >50%<75% and LM ulceration? REVASCULARIZATION (n= 49) (38 PCI, 11 CABG) DEFER TREATMENT (n=31) Clinical follow-up (mean: 2 years)

17 First experience with OCT guidance in angiographically-intermediate LM disease CRITERIA PROMPTING FOR REVASCULARIZATION Revascularized group (n=49) LM AS >75% any MLA 8 (16%) LM AS >50%<75% and MLA<4 mm 2 9 (18%) LM AS >50%<75% and LM ulceration 12 (24%) LAD or LCX ostium critical stenosis 28 (57%)

18 First experience with OCT guidance in angiographically-intermediate LM disease Characteristics Revascularized group (n=49) Deferred group (n=31) Age 67±10 69± Female sex 10 (20%) 9 (29%) 0.4 Hypertension 37 (76%) 24 (77%) 0.8 Hyperlipidemia 31 (63%) 22 (71%) 0.5 Diabetes 15 (31%) 11 (35%) 0.7 Family history 8 (16%) 7 (23%) 0.5 Current smoking 6 (12%) 3 (10%) 0.7 Chronic renal failure 13 (27%) 8 (26%) 0.9 Clinical presentation Stable CAD NSTE-ACS or recent STEMI 33 (67%) 16 (33%) 19 (61%) 12 (39%) Ejection fraction (%) 57 ± 9 56 ± EuroSCORE (Additive) 5 ± 4 5 ± Coronary disease beyond LM: 1-vessel disease 2-vessel disease 3-vessel disease 20 (41%) 18 (37%) 11 (22%) 13 (42%) 13 (42%) 5 (16%) P

19 First experience with OCT guidance in angiographically-intermediate LM disease 100 Primary endpoint TVF (death-mi-tvr) TVF DEFER TREATMENT P=0.35 REVASCULARIZATION 40 Event Revascularized group (n=49) Deferred group (n=31) 20 0 Death 1 (2%) 0 MI 1 (2%) 0 TVR 2 (4%) 1 (3%) Time

20 Conclusions In patients with angiographycally-intermediate distal LM disease: - OCT is able to provide nice characterization of bifurcation disease - OCT cut-offs to guide decisions on LM are lacking but probably the combination of %AS stenosis, plaque morphology and MLA values (lower than IVUS!!!) should be taken into account - Preliminary observations suggest the possible safety of OCT-based revascularization deferral when %AS is <75%, MLA is >4 mm2 and LM ulceration is absent

21 K N A TH FO U YO D N I RK N O I T N E ATT