Κλινική Χρήση IVUS και OCT PERIKLIS A. DAVLOUROS ASSOCIATE PROFESSOR OF CARDIOLOGY INVASIVE CARDIOLOGY & CONGENITAL HEART DISEASE

Conflict of interest None to declare

While IVUS is the most used intravascular imaging modality in interventional cardiology, it is used in < 20% of cases

Ischemia guided PCI PCI for ischemia-inducing coronary stenosis can improve clinical outcome Medical therapy (MT), alone may be preferable for lesions without inducible ischemia

Ischemia guided PCI In real-world practice, fewer than 50% of pts are evaluated noninvasively for myocardial ischemia before revascularization therapy Lin GA, et al. Frequency of stress testing to document ischemia prior to elective percutaneous coronary intervention. JAMA. 2008

IVUS, OCT, Angioscopy FFR

Advanced Imaging Techniques... A IVUS IVUS-VH VH-IVUS: definition of high-risk plaques and necrotic cores by their ultrasound characteristic D Angioscopy OCT NIRS: detection of lipid-rich plaques by their cholesterol ester composition NIRS

Imaging vs. Physiology: Why bother? Pt with recurrent angina and positive ischemia testing in the territory of the target stenosis Does not need FFR or IVUS/OCT unless the operator does not believe the stress test, the patient, or both

FFR: The gold standard Patras University Hospital

IVUS exchangeable with FFR?

IVUS exchangeable with FFR? Intracoronary imaging (IVUS) has a poor correlation with physiological testing for identification of ischemia inducing lesions

Can MLA Predict the Functional Significance of Coronary Artery Stenosis? Patras University Hospital

Scatterplot showing the relationship between intravascular ultrasound determined minimal lumen area (MLA) and fractional flow reserve (FFR). Patras University Hospital 96% NPV for an MLA 2.4 mm 2

The coin toss experiment: implications for risk stratification 96% NPV for an MLA 2.4 mm 2 NPV depends on the pretest probability (21%) An IVUS parameter with no predictive power (AUC = 0.5, equivalent to a coin toss) would have NPV 79%... This comparison makes the reported NPV of 96% for MLA 2.4 mm 2 to seem appropriately less dramatic

Modest correlation of IVUS-FFR in intermediate lesions The new IVUS cutoff for FFR of 0.80 is 2.99 mm 2 The new IVUS cutoff for FFR of 0.75 is 3.16 mm 2 MLA <3.6 mm(2) (AUC = 0.68) for RVD >3.5 mm MLA <2.7 mm(2) (AUC = 0.71) for RVD 3.0-3.5 mm MLA <2.4 mm(2) (AUC = 0.66) for RVD <3.0 mm FFR correlated with plaque burden (r = -0.220, p < 0.001) but not with other plaque morphology

Q: Why can we not use IVUS/OCT for functional assessment? A: A single cross-sectional area does not mean the same thing everywhere. 5 Ref Diam (mm) < 4 mm² = significant stenosis? 4 3 2 50 25 % Stenosis for an Cross Sectional Area of 4 mm² 0

Small Caliper Vessels Lesions in small-caliber vessels prove especially difficult for IVUS evaluation (no cut-off)... FFR-positive lesions are a minority in small vessels (35-40% in 3 studies) Given the higher rates of restenosis in small vessels even with DES, these studies strongly support FFRselected PCI in small coronaries

If you want to treat a lesion, use IVUS; if you don t, use FFR

Outcomes of PCI in Intermediate CAD: FFR Guided Vs. IIVUS Guided Patras University Hospital Chang-Wook Nam, et al. JACC: Cardiovascular Interventions, 2010, 812-817 Nonrandomized, retrospective study

Outcomes of PCI in Intermediate CAD: FFR Guided Vs. IIVUS Guided Patras University Hospital Chang-Wook Nam, et al. JACC: Cardiovascular Interventions, 2010, 812-817

Outcomes of PCI in Intermediate CAD: FFR Guided Vs. IIVUS Guided IVUS-guided lesion selection resulted in almost 3 times as many treated lesions without any difference in the event rate Patras University Hospital Chang-Wook Nam, et al. JACC: Cardiovascular Interventions, 2010, 812-817

So when should we use IVUS? Patras University Hospital

LM Disease: 5% of pts with SAP Patras University Hospital

Reverse Mismatch Patras University Hospital

OCT vs. standard imaging Patras University Hospital Resolution (log) 1 mm 100 mm High frequency Ultrasound Standard clinical 10 mm 1 mm Confocal microscopy OCT Unprecedented resolution (10 to 15 μm) among intravascular imaging techniques Penetration depth (log) 1 mm 1 cm 10 cm

Prati, F. et al. Eur Heart J 2009 OCT vs. standard imaging OCT penetration vs. plaque composition Penetration max for fibrotic tissue (A) Progressively less for Calcific (B) Lipid (C) Thrombus (D)

Will OCT replace IVUS?

Patient with anterior wall ischemia Patras University Hospital Davlouros, P. et al. J Am Coll Cardiol Intv 2011;4:683-693

OCT of SVG lesion Patras University Hospital Davlouros, P. et al. J Am Coll Cardiol Intv 2011;4:683-693 TCFA at the level of rupture

Coronary Angio: LAD filling defect Patras University Hospital

Περιφερικό Κεντρικό

Clinical use of IVUS-OCT? IVUS More data on ischemic cut-offs Better for PCI planning OCT Better for PCI optimization Better for ambiguous lesions

Do what you can do better Patras University Hospital

Algorithm of functional angioplasty... Patras University Hospital Park S et al. Circulation. 2011;124:951-957

Park S et al. Circulation. 2011;124:951-957 Theoretical relationships between reference vessel diameter and percentage diameter stenosis and percentage area stenosis for minimal lumen area (MLA) of (A) 4 mm2 and (B) 2.4 mm2. It is generally accepted that >50% diameter stenosis, which corresponds to >75% area stenosis, is significant An MLA of 4 mm 2 is just equivalent to diameter stenoses of 24% and 43% for lesions with reference vessel diameters of 3 and 4 mm, respectively