Can IVUS Define Plaque Features that Impact Patient Care? A Pichard L Satler, K Kent, R Waksman, W Suddath, N Bernardo, N Weissman, M Angelo, D Harrington, J Lindsay, J Panza. Washington Hospital Center Washington DC
Conflict of Interest None related to this presentation
IVUS at the WHC Washington Hospital Center in last 12 months: Diagnostic catheterizations: 10,000 Coronary angioplasties: 5,000 IVUS use: 70% (AP: 95%) Organization 10 Labs: 8 Labs have IVUS integrated into the Cath Table (Volcano and Boston). IVUS setup is ready before physician arrives into the room. 2 CV technicians supervise all IVUS cases. 15 CV technicians trained in IVUS. Core Lab analyzes of all IVUS data.
Vessel Size Remodeling.
Positive Remodeling: large plaque mass. plaque is soft. more likely to have thrombus. associated with higher CRP. More common in young people. Very common in acute coronary syndrome. More common no reflow during PCI. Negative Remodeling: less plaque mass plaques are fibrotic. less likely to have thrombus.
Erosion Stable Thin cap atheroma Plaque hemorrhage Acute rupture Healed rupture Total occlusion IEL-Expected IEL (/plaque area) Remodeling in Varying Coronary Lesion Morphologies Macrophage infiltration Posit Remodeling A. 5 4 3 2 1 0-1 -2-3 NC Medial SMC loss SMC loss Medial SMC apoptosis Virmani 2009
Cardiac CT can be as good as IVUS to detect Positive Remodeling
Positive Remodeling and Plaque Composition by OCT. Raffel et al. EHJ 2008;29:1721-8
Positive Remodeling and ISRS Okura et al. JACC 2001, 37: 1031-35 n= 108 BMS Positive Remodeling Intermed. or Negative Remodeling
Plaque Burden and In-Stent Intimal Hyperplasia WHC: Shiran et al, AJC 2000; 86:1318-21 Maximal IH at 6 months angio was at the zone of maximal pre intervention plaque. Pre-intervention plaque area was an independent predictor of IH at follow up.
Remodeling and ISRS in DES. Mintz, Park et al. Circulation. 2003;108:1295-8 ASPECT (ASian Paclitaxel-Eluting Stent Clinical Trial) positive intermed negative Cypher RS 28.6% vs 16.7% for positive and non posit remodeling p=ns. AHA 2009
Mild LMCA Disease and Remodeling. WHC: YJ Hong et al. JIC 2007;19:500-5 236 patients with mild (<50%) LMCA stenosis by angiography 1 year MACE
Positive Remodeling and Outcome in ACS. Okura, Mintz et al. AJC 2009;103:791-5
Prospect. MACE in Non Culprit Lesions
Attenuated Plaque (Black Holes, Echo Signal Attenuation) WHC: SY Lee, Mintz et al. JACC Interv 2009;2:65-72 Shadowing in spite of no visible calcium Two attenuated plaques 6.4 mm apart were seen in this RCA.
Attenuated Plaque in ACS. WHC: SY Lee, Mintz et al. JACC Interv 2009;2:65-72 293 ACS patients: 26% with attenuated plaque ( 40% STEMI, 18% NSTEMI) Attenuated plaque in ACS patients was associated with: - positive remodeling and higher CRP, - more thrombus and complex lesion morphology, - more plaque burden and plaque rupture, - frequent no-reflow after PCI.
Echo Signal Attenuation (EA). Kimura et al. Circ CV Interv. 2009;2:444-54. 687 patients. EA: 43.8% in ACS vs. 27.9% in Stable AP, p<0.001. EA had Positive Remodeling: 55% vs 23 % for lesions without EA. Histology after DCA: higher prevalence of lipid-rich plaque, macrophage infiltration, cholesterol clefts, thrombus, and microcalcification.
No Reflow in SVG s with ACS. WHC: YJ Hong et al. TCT 06
IVUS images of the same cross section of coronary artery at baseline (left) and follow-up (right). The presence of a large branch at 10 o clock and a smaller branch at 7 o clock confirms that the same matched cross section has been studied at the 2 time points. Plaque Regression by IVUS Tardif et al. AJC 2006;98:2327 Intense Lipid Therapy x 2 years in 432 lesions <50%. Baseline IVUS IVUS at 24 months
Change in in area (mm2) Change in area (mm2) Progression of Disease in SVG WHC: YJ Hong JACC 2009;53:1257-64
Summary Positive remodeling with large plaque burden is an important observation that determines clinical and PCI outcomes.
CALCIFIED LESIONS
Patient with Angina and LAD Perfusion Defect Simple PCI?
IVUS of LAD In view of IVUS findings Roto-DES or LIMA need to be chosen
Different Strategies based on IVUS findings Direct Stenting A 5 m m Roto-Stent B
Concealed Vessel Perforation
Most Perforations are Not Seen by Angio. Maehara et al. WHC 2001 15,000 IVUS reviewed 76 perforations found on IVUS. Angio: 21% totally normal 33% dissections 22% mild stenosis 24% perforation suspected 12 months Follow up 30% MACE
Virtual Histology (A) Pathological intimal thickening. (B) Thin-capped fibroatheroma. (C) Thick-capped fibroatheroma. (D) Fibrotic plaque. (E) Fibrocalcific plaque.
The PROSPECT Trial IVUS of culprit lesion + 2 non culprit vessels 700 pts with ACS QCA of entire coronary tree IVUS with Virtual histology Palpography (n=~350) Meds rec Aspirin Plavix 1yr Statin Repeat biomarkers @ 30 days, 6 months F/U: 1 mo, 6 mo, 1 yr, 2 yr, 3-5 yrs MSCT Substudy N=50-100 Repeat imaging in pts with events
MACE (%) PROSPECT: MACE 25 20 All 20.4% 15 10 Culprit Lesion Non Culprit Les. 12.9% 11.6% 5 0 Number at risk 0 1 2 3 Time in Years ALL 697 557 506 480 CL related 697 590 543 518 NCL related 697 595 553 521 Indetermina Indeterminate 2.7%
Plaque Burden, VH and Outcomes MACE in non Culprit lesions A 70% plaque burden lesion by gray scale IVUS has a risk of 9.2% at three years A 70% plaque burden lesion defined as VH TCFA has an elevated risk of 15.3% at three years A 70% plaque burden lesion defined as PIT has a reduced risk of only 2.6% at three years VH Definitions in PROSPECT can swing the risk profile The same lesions by grayscale IVUS (Plaque Burden 70%) have dramatically different risk profiles when looking at VH
Dynamic Nature of Plaque by VH. Kubo, Maehara et al. JACC 2010;55:1590-7 Stable Progressive ACTIVE
Stenting and Plaque by VH. Koenig, Margolis, Virmani, Klaus. Nature Clinical Practice 2008 5;4 Koenig, Margolis, Virmani, Klaus. Nature Clinical Practice 2008 5;4
Stent in AMI Darius Dudek. TCT 2009 40% NC covered 50% NC uncovered 10% Distal segment Proximal segment
Plaque Healing after Stenting Kubo et al. Am Heart J. 2010;159:271-7. Necrotic Core in contact with stent before and after Stenting DES BMS
Conclusions Plaque characterization by IVUS allows for: Better PCI planning and execution. Better PCI outcome. Better prediction of near and long term outcome. Better delineation of need for optimal medical therapy for that lesion. Better understanding of Coronary Atherosclerosis.
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