Focus en el diagnóstico y tratamiento de las enfermedades coronarias. Utilidad de las nuevas técnicas de imagen invasivas

1. Focus on the diagnosis and treatment of coronary heart disease: A.Parkhomenko, MD, PhD, FESC, FICA National Scientific Center “Institute of Cardiology”, Kiev, Ukraine Usefulness of New Invasive Imaging Techniques

2. Proposed Determinants of Anatomic and Clinical Natural History of CAD Course Dependent on Atherosclerosis Progression and Remodeling Pattern (Chatzizisis, et al. JACC 2007)

3. 70% of ACS culprit lesions (Naghavi et al. Circulation 2003;108:1664-72) “ Vulnerable Plaque” = thrombosis-prone plaque and plaque with a high probability of undergoing rapid progression

6. Palpography Inactive and non-inflamed plaque Active and inflamed plaque vs. IVUS+Vasa vasorum imaging OCT Morphology IVUS+Virtual histology Physical properties Endothelial shear stress Activity - Chemistry Spectroscopy Thermography IV MRI

8. 3D Coronary Angiography

14. IVUS profile of ruptured plaques: Insights into pre-rupture morphology (n=112 culprit ruptured plaques) (Fujii et al. Am J Cardiol 2006;98:429-35)

15. Effect of Rosuvastatin on Coronary Atheroma in Stable Coronary Artery Disease : COSMOS study Percent change of plaque volume, the primary endpoint, was –5.1±14.1% (P<0.0001). Rosuvastatin exerted significant regression of coronary plaque volume in Japanese patients with stable CAD, including those who had previously used other lipid-lowering drugs. T . Takayama et al. 2009

16. IVUS-Based Therapeutic Decision %DS=52% %CSA=11.0 mm 2 %CSA=6.0 mm 2 AREA STENOSIS=46% CONSERVATIVE TX

17. Impact of IVUS guidance in stent deployment on 6-month restenosis rate : RESIST Study Crossectional areas were larger in IVUS guided group and restenoses rates did not differ significantly F. Schiele et al. 1998 P<0,05 NS P<0,05 P<0,05 Stent restenosis rates Crossectional area

18. Clinical benefits of IVUS-guided vs non-IVUS guided stent implantation? Composite end-point: Cardiac death, MI, revasc., abrupt stent closure Acute vessel closure Intraprocedural cost was significantly higher in the IVUS-guided group, $4142 +/- 1547 vs $3635 +/- 1949 (P = 0 .03) JW Choi et al. 2001 RR, 95% CI 0 0,5 1,0 1,5 RR = 0,49 (0,25 – 0,98), p=0,04 P=0,04

19. In BMS era 10/12 studies supported IVUS-guided PCI Study Angio Better IVUS Better IVUS Also Cheaper Choi et al (AHJ 2001;142:112-8) x CENIC ( JACC 2002;39:54A) X CRUISE ( Circulation 2000;102:523-30) X SIPS ( Circulation 2000;102:2497-502 and AJC 2003;91:143-7) X X AVID ( Circulation 1999;100:I-234) X Gaster et al ( Scan Cardiovasc J 2001;35:80-5 & Heart 2003;89:1043-9) X x RESIST (JACC 1998;32:320-8 & Int J Cardiovasc Intervent 2000;3:207-13) X TULIP ( Circulation 2003;107:62-7) X BEST ( Circulation2003;107:545-551 ) X OPTICUS (Circulation. 2001;104:1343-9) x PRESTO (Am Heart J. 2004;148:501-6) x DIPOL (Am Heart J 2007;154:669-75) X

20. I VUS optimized drug eluting stent implantation: The PRAVIO study Minimum lumen diameter in IVUS-guided vs angio-guided DES implantation P<0,0001 RT Gerber et al. 2009

21. All-Cause Mortality After LMCA DES Implantation: Impact of IVUS Guidance (SJ Park et al. TCT 2007) 1.5 1.0 Years after DES implantation 0.0 0.5 2.5 3.0 70 Cumulative Incidence ( %) 100 80 2.0 IVUS (n=595) No IVUS (n=210) 90 95.2% 85.6% HR=0.43, p=0.019 Other independent predictors were previous CHF, chronic renal failure, COPD, and EUROSCORE>6

23. A display of geometrically correct 3D IVUS using a miniaturized electromagnetic position sensor Reproduced from Y . Honda, P . J. Fitzgerald . 2008

24. IVUS -based temperature monitoring studies normal arterial tissue with the laser illumination photoacoustic response from the region of laser incidence the temperature increase Temperature maps obtained from the arterial tissue Reproduced from S . Sethuraman et al. 2007

25. IVUS elastography/palpography RL Maurice. 2008 Illustration of the vessel wall segmentation LSME radial strain elastogram, superimposed on the IVUS image Palpography- elastography based on rate of radial deformation (strain) due to pressure difference in the artery.

27. Circulation. 2003;108:1664 The 2 nd most common type? Naghavi et al.

28. Gray-scale IVUS uses only the amplitude (echo intensity) in formation of the image Frequency of echo signal can also vary, depending on the tissue… Virtual Histology uses Amplitude and Frequency of Echoes Virtual Histology (VH)

29. Power (dB) Frequency (MHz) Fibrous Calcium Fibrolipidic Necrotic core Virtual Histology (VH)

30. Virtual histilogy IVUS using spectral analysis of radiofrequency data to construct tissue maps Early fibroatheromas (A) thick-cap fibroatheromas (C) thin-cap fibroatheromas (D) extensive calcium (white color) deposition greater fibrous (green color) composition necrotic cores (red color) From Wang-Soo Lee et al. 2009

32. Use of Virtual Histology to predict distal embolization after PCI for STEMI Kanaguchi et al. J Am Coll Cardiol 2007;50:1641 Non-STR case STR case

33. Impact of plaque components on no-reflow phenomenon after stent deployment in patients with ACS: VH-IVUS The only independent predictor of no-reflow in multivariate analysis was necrotic core volume ( OR = 1.126; 95% CI 1.045-1.214, P = 0.002) JL Hong et al. 2009 P=0,001 Necrotic core volumes (mm3) in ACS patients with no-reflow post-stenting P<0,001 % Necrotic core volumes in ACS patients with no-reflow post-stenting

36. 3-vessel imaging post PCI F/U: 1 mo, 6 mo, 1 yr, 2 yr, ±3-5 yrs Culprit artery, followed by non-culprit arteries Angiography (QCA of entire coronary tree) IVUS Virtual histology Palpography (n=~350) Repeat imaging in pts with events Meds rec Aspirin Plavix 1yr Statin Repeat biomarkers @ 30 days, 6 months Proximal 6-8 cm of each coronary artery MSCT Substudy N=50-100

37. PROSPECT Methodology IVUS/VH Core Lab Analysis Lesions are classified into 13 main sub-types based on VH composition 1. Fibrotic 2. Fibrocalcific 3. Pathological intimal thickening 4-9. Thick cap fibroatheroma 10-13. VH-thin cap fibroatheroma (presumed high risk) Single NC, no DC Single NC, +DC - DC outside NC - DC superficial/within NC Multiple NC, no DC Multiple NC, +DC - DC outside NC - DC superficial/within NC Single NC, no DC Single NC, +DC Multiple NC, no DC Multiple NC, +DC

38. VH-TCFA Multiple NC Length 3.7 mm F 35 % FF 1 % NC 52 % DC 12 % MRCA fibroatheroma Stent Angiographically near normal IVUS MLA: 6.4 mm 2

39. 2 nd VH-TCFA Single NC Length 11 mm F 39 % FF 1 % NC 53 % DC 7 % PRCA fibroatheroma Stent Angiographically mild lesion MLA: 6.1 mm 2

40. Expected Correlation with the Anatomy of Vasa Vasorum Note: Pathology pictures are not related to IVUS (taken from Ritman et al.)

41.  IVUS after bubbles at same position and cardiac phase timing IVUS at t=0 Differential Echogenecity (t 0 , P 1 ) (t, P 1 ) Vasa vasorum imaging with IVUS blood wall catheter

43. OCT Imaging of Vulnerable Plaques TCFA Ulcerated plaque + spontaneous rupture Eccentric plaque + TCFA + microcacifications flap Ran Kornowski, CRT 2008

44. Frequency of TCFA Is Greater in Acute Coronary Syndromes (Jang et al. Circulation. 2005;111:1551-5)

45. Intravascular optical coherence tomography imaging Dissection observed with optical coherence tomography (OCT) (A) and IVUS (B) following balloon dilatation. Although the tissue flap can be seen in the IVUS image, it was difficult to determine the depth of dissection. In the OCT image, the bright-dark-bright banding within the flap suggests involvement of the adventitia. In each image, tick marks represent 1.0 mm, and the guide wire location is denoted by an asterisk. BE Bouma. Heart 2003

46. OCT (Immediately Post Stenting) Optimal stent expansion Regional stent mal-apposition Tissue prolapse Ran Kornowski, CRT 2008

47. OCT (Late Post Stenting) Ran Kornowski, CRT 2008

48. Red Thrombus was identified from the high-backscattering protrusions inside the lumen of the artery, with signal-free shadowing in the OCT image. White Thrombus was identified from the low-backscattering projections in the OCT image.

49. 6-Month Results – OCT Data 49.5% 30.2% 17.6% 2.7% Stent Strut Appearance – 6 Mos. F/U J Ormiston, et al, Lancet 2008; 371: 899-907. (738 struts visible at baseline versus 671 at follow up) Dissolved Bright Box Dissolved Black Box Preserved Box Open Box

50. Case Example 24-Month Results – OCT Data P.W.Serruys, TCT 2008 Post Procedure 2 Years

52. Caplan JD et al. J Am Coll Cardiol 2006;47:C92 Near-infrared spectra of various pure substances possibly related to plaque vulnerability NIR absorbance spectra from 4 chemical components. T he regions around 1200 nm separate the cholesterols from the collagens , whereas the regions around 1500 nm provide more discrimination among the cholesterols Spectroscopy - measurement of the amount of electromagnetic radiation that is absorbed or emitted by molecules as they move from one energy level to another.

57. Ishibashi, Waxman et al. Am J Cardiol 2007 Quantitative Colorimetry with Angioscopy High Yellow Color Intensity of Culprit Lesion is Associated with High Risk Features – Plaque Rupture and Thrombosis

58. Number of Yellow Plaques in a Coronary Artery is Associated with Future ACS Marker of disease burden, not predictive of lesion-specific risk Ohtani et al. JACC 2006