Coronary Artery Thermography

Transcription

1 Coronary Artery Thermography The 10th Anniversary, Interventional Vascular Therapeutics Angioplasty Summit 2005 TCT Asia Pacific Christodoulos Stefanadis Professor of Cardiology Athens Medical School

2 In the search for vulnerable plaque What??? Thin cap Lipid core Positive remodeling Reduction of smooth muscle cells Santorini Congress Conclusions Macrophages Eur Heart J 2004;25(12):

3 Inflammation Atheromatosis

4 Can we detect the vulnerable plaque? NO IDEAL METHOD Technique Fibrous cap Lipid core Inflammation Calcium Thrombus VV IVUS Angioscopy OCT MRI IVUS+contrast ? Thermography

5 Thermography The Fire Within

6 Thermal Heterogeneity in Atherosclerotic Plaques Medispes System Thermocore System Casscells et al, Lancet 1996 Volcano System RADI System

7 Plaque Thermography What do we measure?

8 Thermal Heterogeneity Inflammatory In vivo experimental study Control 1.2 o C Atheromatous Ex vivo measurements Verheye et al, Circulation 2002;105(13):

9 Correlation of Histology Temperature Ex Vivo in Carotid Plaques In 27 patients with carotid stenosis: In endarterectomy specimens histology was correlated with temperature measurements Madjid M, Naghavi M, et al. Am J Cardiol 2002;90:36-39

10 Correlation of human coronary plaque temperature measurements with the presence of inflammatory markers in pathology examination C 0% concentration of macrophage marker CD-68 Milan-Athens Experience

11 Correlation of human coronary plaque temperature measurements with the presence of inflammatory markers in pathology examination Patient With Thermal Heterogeneity (TD: 0.08 o C) C 20% concentration of macrophage marker CD-68 Milan-Athens Experience

12 Correlation of human coronary plaque temperature measurements with systemic inflammatory markers 1.8 T ( O C) CRP (mg/dl) Stefanadis et al. J Mol Cell Cardiol 2000

13 Vasa Vasorum Angiogenesis in vasa vasorum Control 2 weeks hyperlipidemic diet 6 weeks No endothelial dysfunction Endothelial dysfunction Vasa vasorum development is observed prior to endothelial dysfunction Herrmann et al. Cardiovasc Res 2001;51:762-6

14 Experimental Protocol Effect of Vasa Vasorum on Plaque Temperature 39 38,8 Temperature ( o C) 38,6 38,4 38, ,8 37,6 Without VV VV Athens Medical School

15 Plaque Thermography What do we measure? Inflammation Neovascularization

16 Thermography Coronary Artery Coronary Sinus

17 Clinical Studies Thermal Heterogeneity and Diabetes Mellitus Type 2 An Increased Inflammatory Activation?

18 Diabetes Mellitus and Temperature Measurements 0,2 P = 0.01 T ( O C) 0,15 0,1 0,05 0 DM non-dm Toutouzas K, et al. Diabetes Care in press

19 Diabetes Mellitus and Temperature Measurements P = 0.02 P = 0.67 Diabetic patients with ACS have higher thermal heterogeneity compared to non diabetic patients Toutouzas K, et al. Diabetes Care in press

20 Prolonged Thermal Heterogeneity Post ACS A Prolonged Inflammatory Activation?

21 Prolonged inflammation Prolonged thermal heterogeneity post MI DT Units ( o C) MI > 2 months Stable Angina DT N=56 AMI SA Toutouzas K et al, Am Heart J 2004

22 Prognostic implication of detection of vulnerable plaque

23 Stenting in Hot Plaques = Cold plaque Hot plaque

24 Temperature and Prognosis post PCI FV 2.0 P < 0.01 Τ ( o C) No Event Event Stefanadis C et al, JACC 2001 April

25 Therapeutic implication of detection of vulnerable plaque

26 Statins and Temperature post AMI.2 0 MI SA Toutouzas et al. Am Heart L 2004

27 DT ACS, 0 ACS, 1 SA, 0 SA, 1 Effect of Atorvastatin on Plaque N=256 pts Temperature.8 No Statins Statins DT ( C) ACS SA Stefanadis et al, submitted

28 What influences local thermal heterogeneity of atheromatic lesions? Prospective clinical study in 256 pts (136 under statins) Multivariate Analysis b- coefficient SEM P-value Atorvastatin -0,13 0,02 < 0,001 Clinical Syndrome -0,13 0,02 < 0,001 Stefanadis et al, submitted

29 Red Light Catheter The possible mechanism includes increased NO synthesis Several previous studies have demonstrated light induced vasorelaxation in vivo and in vitro Kipshidze et al. J Am Coll Cardiol. 1998

30 Red Light Catheter and Vulnerable Plaque 0.16 DT ( O C) N= Before Red Light We applied red light in 3 intermediate lesions. Temperature was immediately decreased. Kipshidze N, Toutouzas K, Stefanadis C

31 Red Light Laser Case 38,0537,8 37, , oC 37,74 37,95 37,72 37,937,7 37,68 37,85 37,66 IVUSLight Catheter Final Stent deployment Thermography Lesion Proximal Red Balloon Catheter 0.08OC 37,64 37,8 Angiographic Result IVUS lesion IVUS proximal distal

32 Coronary Thermography Limitation Effect of Flow

33 The Cooling Effect of Blood Flow Bl GW Th D-GW Without flow With flow With flow Stefanadis C, et al. J Am Coll Cardiol 2003; Febr.

34 Effect of Flow on Thermography Thermocore System Verheye S, Serruys P. Eur Heart J 2004;Jan:158-65

35 Thermography in vivo - Volcano C C With flow Without Flow Dudek et al. TCT 2004

36 Coronary Thermography In vitro model for studying the effect of Flow on heat Heat is transmitted in the direction of coronary flow Weiltz,, Fitzgerald. Cathet Cardiovasc Interv 2004;27:256-61

37 Balloon-Occluded Thermography Catheter Low pressure balloon One thermistor Impairment of flow Measurements in non-significant lesions Thermistor Stefanadis et al. Cathet and Cardiovasc Interv 2003;March

38 Coronary Thermography Effect of Flow in Vivo

39 In Vivo Thermography O o C B Th C Belardi J and O Neil W, TCT 2004

40 In Vivo Thermography 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0 Medispes Thermocore Volcano Imetrx Balloon-Cathet

41 Future Protocols for Detection of Thermal Energy By measurement of thermal energy in a diseased segment : Accurate information regarding regional vulnerability Elimination of cooling effect Estimation of vulnerable arteries rather than local plaque temperature

42 Plaque Thermography Coronary artery Coronary sinus

43 Coronary Sinus Temperature C ±0.10 Temperature Difference (oc) ±0.07 o C 0.15± Control RCA LCA Stefanadis et al, Am J Cardiol 2004 Jan

44 Coronary Sinus Inflammation - Prognosis T (oc) CRP (mg/dl) Cum. Survival T < 0.25 o C T 0.25 o C Time Stefanadis et al, Am J Cardiol 2004;Jan

45 Prospective Multicenter Studies with Thermography

46 Current Multicenter Studies for Evaluation of Vulnerable PLaques Parachute IBIS PROSPECT THERMO CAD

47 PARACHUTE TRIAL

48 IBIS TRIAL Thorax Center, Rotterdam 90patients Evaluation of intermediate lesions by: Angiography IVUS Elastography Virtual histology OCT Thermography

49 PROSPECT: Analysis domains Clinical Age and gender Diabetes (+Metabolic synd) CrCl ACS acuity Virtual Histology Composition Axial and mural distribution Burden QCA Severity Eccentricity Biomarkers Irregularity Burden Necrosis Inflammation Thrombosis Rupture Hemostasis Hemodynamics Palpography Stress/strain relationships Focal or diffuse IVUS Morphology Severity Remodeling Burden Severity (CSN, PA) Thermography Max tempt N, length and circumference of hot spots Thermal burden

50 Thermo CAD study: Preliminary Results Thermo CAD Study Thermography in two vessels (culprit and non-culprit) Multicenter study Preliminary results in 92 lesions and 46 patients from: Hippokration Hospital, Athens Onnaseion Hospital, Piraeus Patra University Hospital, Patra Stefanadis, TCT 2004

51 ACS SA Thermo CAD study: Preliminary Results Widespread thermal heterogeneity.3 P = DT ( C) Co lu m n ACS SA In patients with ACS culprit and non-culprit lesions have increased thermal heterogeneity compared to patients with CSA Stefanadis, TCT 2004

52 Thermo CAD study: Preliminary Results Widespread thermal heterogeneity.4 N = 92 lesions 46 patients T ( O C).3.2 ACS CSA ACS CSA.1 0 Culprit Non-culprit In patients with ACS and CSA culprit and non-culprit lesions have similar thermal heterogeneity. Stefanadis, TCT 2004

53 Temperature and Coronary Artery Disease Ex vivo In vivo First clinical studies Correlation with morphology Prognosis Treatment Cooling Effect of flow Pathophysiology New Technologies Clinical Use?

54 Conclusions Coronary thermography reflects the inflammatory activation in atherosclerotic plaques. Neovascularization may play an additive role. Coronary thermography provides significant clinical information, but still the limitations need to be obviated. Coronary sinus temperature measurement may provide information regarding the vulnerable patient. The ideal scenario would be the combination of thermography and imaging techniques for the identification of the vulnerable plaque.