Paradigm Shift to Functional PCI - summitmd.comsummitmd.com/pdf/pdf/1145_Funtional...
Transcript of Paradigm Shift to Functional PCI - summitmd.comsummitmd.com/pdf/pdf/1145_Funtional...
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Seung-Jung Park, MD, PhDProfessor of Medicine, University of Ulsan College of Medicine
Asan Medical Center, Heart Institute, Seoul, Korea
Paradigm Shift to Functional PCI
Coronary Intervention ;Future Perspective
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Smart In-corporation of recent Evidencesinto Clinical Practice.
Functional PCI
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Treat or Not treat :FFR guided - Decision making(Physiologic assessment)
How to treat : IVUS guided - Optimizing procedure(Anatomical optimization)
Functional PCI
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Treat or Not treat :FFR guided - Decision making(Physiologic assessment)
Functional PCI
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A Case
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M/58, Atypical chest pain, Hyperlipidemia, Ex-smoker
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Visual Estimation 80%
Treat or Not treat ?
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QCA ; 56%QCA ; 56%
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MLA : 3.2 mm2
Ref. VD : 4.5 mmPlaque Burden :80.2%
IVUS
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Visual Estimation: 80%IVUS: MLA 3.2 mm2
Plaque Burden: 80.2%
Treat or Not treat ?
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FFR(intravenous adenosine, 140 µg/kg/min)
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Stage 4 - NegativeStage 4 - NegativeTMT
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Thallium Spect ; NormalThallium Spect ; Normal
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Visual Estimation : 80%IVUS : MLA 3.2 mm2
FFR : 0.91Treadmill test : NegativeThallium spect : Normal
Do you still want to treat ?
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A Case
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M/74, Multiple stenosis on Coronary CT,Silent ischemia, Hypertension, DM, Hyperlipidemia, Ex-smoker,
Visual Estimation: 60%Ruptured Plaque
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IVUS (LAD pullback)IVUS (LAD pullback)
MLA : 3.8 mm2
MLA 3.2 mm2
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Thrombi
Exclude thrombi Exclude thrombi& plaque rupture
Plaque rupture withorganizing thrombi
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Treat or Not treat ?
Visual Estimation: 60%IVUS: MLA 3.8-3.2mm2
VH-IVUS: Ruptured Plaque with large necrotic core
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FFR(intravenous adenosine, 140 µg/kg/min)
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Thallium Spect ; Normal PerfusionThallium Spect ; Normal Perfusion
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Visual Estimation: 60%IVUS: MLA 3.8-3.2mm2
VH-IVUS: Ruptured Plaque with large necrotic coreThallium scan : Normal
Do you want to treat ?
M/74,
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What you see may not be everything.Looks can be deceiving.
FFR > 0.8 is a really perfect surrogate for absence of clinical ischemia.(Specificity 100%, Sensitivity 88%)
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Milestone Study
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DEFER 5 Year ResultsDEFER 5 Year Results
Event Free Survival Cardiac Death and MI
Pijls et al. J am Coll Cardiol 2007;49:2105-11
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FAMEFAME
FFractional Flow Reserve ractional Flow Reserve VS VS AAngiography ngiography for for MMultivessel ultivessel EEvaluationvaluation
New Engl J Med 2009;360:213-24
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ANGIO-groupN=496
FFR-groupN=509 PP--valuevalue
# indicated lesions per patient# indicated lesions per patient 2.7 ± 0.9 2.8 ± 1.0 0.340.34
FFR resultsFFR resultsLesions succesfully measured, Lesions succesfully measured, No (%)No (%) - 1329 (98%) --
Lesions with FFR ≤ 0.80, Lesions with FFR ≤ 0.80, No (%)No (%) - 874 (63%) --Lesions with FFR > 0.80, Lesions with FFR > 0.80, No (%)No (%) - 513 (37%) --
Stents per patientStents per patient 2.7 ± 1.2 1.9 ± 1.3 <0.001<0.001
Lesions succesfully stented Lesions succesfully stented (%)(%) 92% 94% --
DES, total, DES, total, NoNo 1359 980 --
FAME : Procedural Results
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2 Year Survival Free of MACE2 Year Survival Free of MACE
Late Breaking Trial, TCT 2009
FFR-Guided (n=509)
Angio-Guided (n=496)730 days730 days
4.5%4.5%
30 days2.9%
90 days3.8% 180 days
4.9%
365 days5.1%
MACE : Composite of Death, Myocardial Infarction, or Repeat Revascularization
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• Avoid unnecessary procedures• Avoid unnecessary surgery• Minimize MACE• Maximize clinical outcomes• Save money • Save lives
Why FFR guided ?
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How to treat : IVUS guided - Optimizing procedure(Anatomical optimization)
Functional PCI
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Why IVUS guided ?
IVUS guidance Saves Lives !!
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Usefulness of IVUS studyUsefulness of IVUS studyIn the era of BMS
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p=0.5
Combined Endpoints (Death & MI) at 6 MoMeta-analysis (N=2972)
Casella et al. Cathet Cardiovasc Intervent 2003;59:314-21
1.13 (0.79-1.61)60/1,448 (4.1%)69/1,524 (4.5%)Total
1.37 (0.74-2354)17/483 (3.5%)28/606 (4.6%)Subtotoal
1.01 (0.51-2.01)16/229 (7%)19/270 (7%)CRUISE. 2000
2.28 (0.25-20.65)1/100 (1%)4/178 (2.2%)Choi et al. 1997
11.07 (0.61-201.97)0.15 (0%)5/18 (3.1%)Albiero et al. 1995
Registries
1.02 (0.65-1.57)43/965 (4.4%)41/918 (4.4%)Subtotal
0.20 (0.02-1.75)5/77 (6.5%)1/73 (1.3%)TULIP. 2001
1.57 (0.83-2.95)17/387 (4.4%)25/372 (6.7%)AVID. 1999
0.91 (0.36-2.28)10/277 (3.6%)9/273 (3.3%)OPTICUS.1998
0.96 (0.06-15.65)1/76 (1.3%)1/79 (1.2%)RESIST. 1997
0.59 (0.20-1.79)0/148 (6.7%)5/121 (4.1%)SIPS,1996
Radnomizedtrials
OR and 95% CIOdds ratios and 95% CI FixedAngio-guidedIVUS-guidedStudy
0.01 0.2 1 5 10
IVUS-guided better Angio-guded better
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Substantial 25% reduction of binary restenosis in IVUS-guided stenting
Binary Restenosis at 6 MoMeta-analysis (N=2972)
Casella et al. Cathet Cardiovasc Intervent 2003;59:314-21
0.75 (0.60-0.94)239/829 (28.8%)186/802 (23%)Total
Randomized trials
0.63 (0.42-0.95)72/261 (27.5%)51/263 (19%)Subtotal
0.62 (0.33-1.16)32/107 (29.9%)22/105 (20.9%)Blasini et al,1995
0.64 (0.37-1.10)40/154 (26%)29/158 (18.3%)Albiero et al, 1995
Registries
0.81 (0.62-1.06)167/568 (29%)135/539 (25%)Subtotal
0.45 (0.22-0.94)28/77 (36.4%)15/73 (20.5%)TULIP, 2001
1.10 (0.71-1.69)52/228 (22.8%)56/229 (24.4%)OPTICUS, 1998
0.72 (0.34-1.53)21/73 (28.7%)17/71 (22.5%)RESIST, 1997
0.76 (0.49-1.20)66/190 (34.7%)48/166 (29%)SIPS, 1996
OR and 95% CIAngio-guidedIVUS-guidedStudy
IVUS-guided better Angio-guded better
p=0.01
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Usefulness of IVUS studyUsefulness of IVUS studyIn the era of DES
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IVUS-guidance vs. Angio-guidance (Propensity–Matched) in DES-Treated LesionsIVUS-guidance vs. Angio-guidance (Propensity–Matched) in DES-Treated Lesions
Roy et al. EHJ 2008;29:1851-7
0.1600.7%0.2%Late ST0.0707.2%5.1%TLR0.0805.8%4.0%Probab ST0.0142.0%0.7%Definite ST0.33016.2%14.5%MACE
1-year
0.0501.7%0.7%TLR0.0461.4%0.5%ST0.0105.22.8%MACE
30-day
p value
Angio-guided
IVUS-guided Stent Thrombosis
Free Survival (%)100
Months1261
90
95
IVUS
No-IVUS
P=0.013
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IVUS-Guided (n=952) vs. Angio-Guided (n=398)in the era of DES
IVUS-Guided (n=952) vs. Angio-Guided (n=398)in the era of DES
IVUSIVUS--guidedguided AngioAngio--guidedguided pp
AgeAge 63.463.4±±0.36 yrs0.36 yrs 63.563.5±±0.42 yrs0.42 yrsDiabetesDiabetes 27%27% 35%35% 0.0070.007ACSACS 26%26% 27%27% NSNSMultivessel diseaseMultivessel disease 54%54% 45%45% 0.0010.001LADLAD 46%46% 15%15% <0.001<0.001Stents/lesionStents/lesion 1.011.01 1.041.04 NSNS%DES%DES 93%93% 81%81% <0.01<0.01Stent diameter (mm)Stent diameter (mm) 3.03.0±±0.40.4 2.92.9±±0.50.5 <0.001<0.001Stent length (mm)Stent length (mm) 24.024.0±±7.47.4 22.922.9±±7.87.8 <0.0001<0.0001
Costantini et al. TCT 2008
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Thrombosis Free Survival at 3 year F/U
TVF Free Survival
Costantini et al. TCT 2008
100.0%
95.0%
90.0%
Tempo em dias
Log-Rank Test p=0.04
IVUS (N=952)Angio (N=398)
0 180 360 540 720 900 1080 1260 1440 1620 1800
100.%
90%
70%
Tempo em dias
Log-Rank Test p=0.02
IVUS (N=952)
0 180 360 540 720 900 1080 1260 1440 1620 1800
80% ANGIO (n=398)
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IVUS guided procedureIVUS guided procedurein the era of DES – Matched registry data
Survival Benefit !
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Unselected “Real World” PCI Registry IVUS guided vs. Angio-guided
(n=8371, 2 centers registry)
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Overall population N=8371
DES2003-2006
BMS1998-2003
IVUS guidanceN=4627
Angio guidanceN=3744
N = 2765 N = 1816
N = 1928N = 1862
All cause death, MI, TVR, Stent thrombosis, MACE
DES PopulationDES PopulationN=4581N=4581
BMS PopulationBMS PopulationN=3790N=3790
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DeathDeath
98.697.3 96.5
97.095.3
93.8
Log-Rank test, p<0.001
IVUS guidance PCIAngiography guidance PCI
Overall PopulationOverall Population
0 12 24 36
80
85
90
95
100
Months after Initial Procedure
Even
t-fr
ee S
urvi
val (
%)
Unadjusted K-M Curves
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0 12 24 360
80
85
90
95
100
Months after Initial Procedure
Even
t-fr
ee S
urvi
val (
%)
Cardiac DeathOverall PopulationOverall Population
99.2 98.7 98.4
98.2 97.7 97.1
Log-Rank test, p<0.001
IVUS guidance PCIAngiography guidance PCI
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Hazard Ratios of Clinical OutcomesIVUS guidance vs. Angiography guidance
Overall Population
Multivariate Adjusted Adjusted for PropensityHR (95% CI) p HR (95% CI) p
DeathDeath 0.49 (0.34-0.71) <0.01 0.66 (0.53-0.83) <0.01
CardiacCardiac deathdeath 0.46 (0.28-0.76) <0.01 0.58 (0.41-0.81) <0.01
MIMI 1.01 (0.65-1.58) 0.96 1.08( 0.71-1.63) 0.73
TVRTVR 0.97 (0.83-1.13) 0.66 1.05 (0.90-1.22) 0.54
STST 0.87(0.60-1.27) 0.48 0.83 (0.58-1.17) 0.29
MACEMACE 0.89 (0.77-1.02) 0.09 0.92 (0.81-1.05) 0.21
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DES PopulationDES PopulationN = 4581 PatientsN = 4581 Patients
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0 12 24 36
80
85
90
95
100
Months after Initial Procedure
Even
t-fr
ee S
urvi
val (
%)
DeathDeath
99.297.8 97.4
97.695.9
94.9
Log-Rank test, p<0.001
IVUS guidance PCIAngiography guidance PCI
DES PopulationDES Population
Unadjusted K-M Curves
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0 12 24 360
80
85
90
95
100
Months after Initial Procedure
Even
t-fr
ee S
urvi
val (
%)
Cardiac DeathDES PopulationDES Population
99.5 99.0 98.7
98.5 98.0 97.2
Log-Rank test, p=0.003
IVUS guidance PCIAngiography guidance PCI
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0 12 24 360
1
2
3
4
5
Months after Initial Procedure
Even
t Rat
e (%
)
DeathDeathDES PopulationDES Population
p<0.001 p=0.284 p=0.01
IVUS guidance PCIAngiography guidance PCI
2.4
0.80.3
1.7
0.4
1.1
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0 12 24 360
1
2
3
4
5
Months after Initial Procedure
Even
t Rat
e (%
)
Cardiac DeathCardiac DeathDES PopulationDES Population
p<0.001 p=0.90 p=0.01
IVUS guidance PCIAngiography guidance PCI
1.47
0.47 0.540.57
0.42
1.10
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Hazard Ratios of Clinical OutcomesIVUS guidance vs. Angiography guidance
DES Population
Multivariate Adjusted Adjusted for PropensityHR (95% CI) p HR (95% CI) p
DeathDeath 0.52 (0.37-0.73) <0.01 0.50 (0.36-0.70) <0.01CardiacCardiac deathdeath 0.46 (0.28-0.76) <0.01 0.47 (0.29-0.75) <0.01
MIMI 0.43 (0.16-1.14) 0.09 0.21 (0.28-1.32) 0.21
TVRTVR 1.00 (0.75-1.34) 0.99 1.04 (0.80-1.35) 0.79
MACEMACE 0.75 (0.60-0.95) 0.01 0.78 (0.64-0.95) 0.01STST 0.87 (0.52-1.47) 0.61 0.77 (0.48-1.23) 0.28
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Although we have the limitation of registry data, 45-50 % relative reduction of cardiac mortality in IVUS guided procedure is very substantial in the era of DES.
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BMS PopulationBMS PopulationN = 3790 PatientsN = 3790 Patients
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Hazard Ratios of Clinical OutcomesIVUS guidance vs. Angiography guidance
BMS Population
Multivariate Adjusted Adjusted for PropensityHR (95% CI) p HR (95% CI) p
DeathDeath 0.88 (0.64-1.21) 0.42 0.85 (0.62-1.16) 0.31
CardiacCardiac deathdeath 0.96 (0.58-1.58) 0.86 1.42 (0.88-2.33) 0.16
MIMI 1.43 (0.87-2.36) 0.16 1.36 (0.83-2.24) 0.22
TVRTVR 1.14 (0.95-1.38) 0.15 1.13 (0.94-1.36) 0.18
MACEMACE 1.09 (0.92-1.30) 0.31 1.08 (0.91-1.28) 0.38STST 0.98 (0.57-1.67) 0.93 0.96 (0.56-1.63) 0.87
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Paradigm Shift in the era of DESParadigm Shift in the era of DES
0.5
1.0
1.5
2.0
2.5
0.0
Complexity
Dea
th o
r M
I
Complicated PatientsComplicated PatientsComplex LesionsComplex Lesions
Complex ProceduresComplex Procedures
DES
BMS
%
No Survival Benefit
Survival Benefit
IVUS Guidance gives…
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IVUS guided procedureIVUS guided procedurein the era of DES -Various Registry data-
Constantly reduced long-term mortality !
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IVUS guided procedures haveBetter Survival…
IVUS guided procedures haveBetter Survival…
Can you explain this ?
Small difference made by IVUS guidance can make a big differencein the late clinical outcomes.
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How can we make a small difference using the IVUS guidance in real practice ?
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• Treat or not treat (Intermediate lesion evaluation, Ostial lesion assessment, LM bifurcation PCI)
• Measurement of MLA, lesion length, reference VD, degree of remodeling
• Plaque characterization• Procedure Optimization
Usefulness of IVUS studyWe can make a small difference
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EEM : 14.04 mm2
Lumen : 3.2 mm2
Area stenosis : 71.5%
Big discrepancy !Treat or not Treat
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0 1.0 4.0mm
Big discrepancy !Treat or not Treat
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2 stent or 1 stent ?
Treat or not Treat
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LCX
LAD
IVUS evaluation before stenting showed Minimal-disease on the LCX OS…
LAD Ostium LCX Ostium
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Cypher 3.5 ´ 23 mm Additional high pressureInflation with 4.0 mmNon-compliant balloon
Single Stenting Cross-Overwith minimal-disease at LCX OSSingle Stenting Cross-Overwith minimal-disease at LCX OS
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Perfect Result !
Single Stenting Cross-Overwith minimal-disease at LCX OSSingle Stenting Cross-Overwith minimal-disease at LCX OS
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I can avoid two stents technique under the IVUS guidance.
I can make a small difference !!
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TLR at 4 yearTLR at 4 year
5.1
17.119.4
12.5
0
5
10
15
20
25
Cross Crush T Kissing or V -Over
14/267 14/82 6/31 7/56
%P=0.005
Data from MAIN COMPARE Registry
P=NS
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• Treat or not treat (Intermediate lesion evaluation, Ostial lesion assessment, LM bifurcation PCI)
• Measurement of MLA, lesion length, reference VD, degree of remodeling
• Plaque characterization• Procedure Optimization
Usefulness of IVUS studyWe can make a small difference
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Proximal reference
Real estimation of the reference vessel diameter, MLA, lesion length and degree of remodeling are important to choose appropriate stent size.
Stenotic lesion
Distal reference
Negative Remodeling
>4 mm
4 mm
<3 mm
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Prediction of FFR (0.75) with IVUS parameter Prediction of FFR (0.75) with IVUS parameter
Jasti V et al. Circulation 2004;110:2831-6
2.8mm 5.9mm2
67% 50%
Left Main disease MLA < 6.0 mm2
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439CFR ³ 2.0
272CFR < 2.0
IVUS MLA <4.0mm2
IVUS MLA ³4.0mm2
Diagnostic accuracy = 92%. Abizaid et al. Am J Cardiol 1998;82:42-8
120- Spect
424+ Spect
IVUS MLA <4.0mm2
IVUS MLA ³4.0mm2
Diagnostic accuracy = 93%. Nishioka et al. J Am Coll Cardiol 1999;33:1870-8
Takagi, et al. Circulation 1999;100:250-5
Epicardial Artery disease MLA < 4.0 mm2
IVUS MLA <4.0mm2
FFR
< 0
.75
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• Treat or not treat (Intermediate lesion evaluation, Ostial lesion assessment, LM bifurcation PCI)
• Measurement of MLA, lesion length, reference VD, degree of remodeling
• Plaque characterization
Usefulness of IVUS studyWe can make a small difference
![Page 72: Paradigm Shift to Functional PCI - summitmd.comsummitmd.com/pdf/pdf/1145_Funtional PCI-TCTAP-10-F.pdf · Treat or Not treat : FFR guided -Decision making (Physiologic assessment)](https://reader034.fdocuments.in/reader034/viewer/2022051321/5abe418a7f8b9aa15e8c97d3/html5/thumbnails/72.jpg)
Plaque rupture ThrombiFibrous plaque Calcification
Plaque characterization is important.We need some plaque modification for calcific lesions and some pre-treatment for vulnerable plaque.
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• Treat or not treat (Intermediate lesion evaluation, Ostial lesion assessment, LM bifurcation PCI)
• Measurement of MLA, lesion length, reference VD, degree of remodeling
• Plaque characterization• Procedure Optimization
Usefulness of IVUS studyWe can make a small difference
![Page 74: Paradigm Shift to Functional PCI - summitmd.comsummitmd.com/pdf/pdf/1145_Funtional PCI-TCTAP-10-F.pdf · Treat or Not treat : FFR guided -Decision making (Physiologic assessment)](https://reader034.fdocuments.in/reader034/viewer/2022051321/5abe418a7f8b9aa15e8c97d3/html5/thumbnails/74.jpg)
IVUS predictorsof Angiographic Restenosis
Stent CSATotal stent length
odds ratio=0.584, 95% CI 0.385–0.885, p=0.011odds ratio=1.028, 95% CI 1.002–1.055, p=0.038
Hong MK, Eur Heart J, 2006:27:1305, AMC data Park, DW. AJC 2006;98:353-356, AMC data
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How Long stented Length and How Big stent CSA would be good for the long-term outcomes in real practice ?
How Long stented Length and How Big stent CSA would be good for the long-term outcomes in real practice ?
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0
10
20
30
40
50
60
70
80
90
100
10 15 20 25 30 35 4040 45 50 55 60 65 70
Stent length (mm) by IVUS
(%) SpecificitySpecificitySensitivitySensitivity
Hong MK, Eur Heart J, 2006:27:1305,
AMC Cypher Registry
Epicardial Artery diseaseTotal stent length < 40 mm
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SpecificitySpecificitySensitivitySensitivity
0
10
2030
40
50
60
7080
90
100
3.5
4.0
4.5
5.0
5.55.5
6.0
6.5
7.0
7.5
8.0
(%)
Hong MK, Eur Heart J, 2006:27:1305
AMC Cypher Registry
Epicardial Artery diseaseStent CSA > 5.5 mm2
Stent CSA (mm2)
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Restenosis Rate according to Stented Length and Stent CSA by IVUS
11/62 (17.7%)< 5.5> 406/ 70 (8.6%)³ 5.5> 40
3/127 (2.4%)< 5.5£ 40P <0.001
1/284 (0.4%)³ 5.5£ 40
P valueRestenosis RateStent area (mm2)Stent length (mm)
and or
or
AMC Cypher Registry
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90 (86.5%)14 (13.5%)Stented length ≥ 46 mm
No Restenosis (n=257)
Restenosis(n=20)
167 (96.5%)6 (3.5%)Stented length < 46 mm
Sensitivity = 70%, Specificity = 65%, Positive predictive value = 14%,Negative predictive value = 97%
Restenosis Rate according to Stented Length by QCA
AMC Cypher Registry
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How Big stent CSA : > 5.5 mm2How Long stented length : <50 mm
< 5% TLR rate
IVUS Guidance in Real Practice (Rule of 5)
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Why IVUS guided ?Why IVUS guided ?
A small difference made by IVUS guidance can make a big difference in late clinical outcomes – SURVIVAL BENEFIT !
![Page 82: Paradigm Shift to Functional PCI - summitmd.comsummitmd.com/pdf/pdf/1145_Funtional PCI-TCTAP-10-F.pdf · Treat or Not treat : FFR guided -Decision making (Physiologic assessment)](https://reader034.fdocuments.in/reader034/viewer/2022051321/5abe418a7f8b9aa15e8c97d3/html5/thumbnails/82.jpg)
Old Issue but New Insight !
![Page 83: Paradigm Shift to Functional PCI - summitmd.comsummitmd.com/pdf/pdf/1145_Funtional PCI-TCTAP-10-F.pdf · Treat or Not treat : FFR guided -Decision making (Physiologic assessment)](https://reader034.fdocuments.in/reader034/viewer/2022051321/5abe418a7f8b9aa15e8c97d3/html5/thumbnails/83.jpg)
439CFR ³ 2.0
272CFR < 2.0
IVUS MLA <4.0mm2
IVUS MLA ³4.0mm2
Diagnostic accuracy = 92%. Abizaid et al. Am J Cardiol 1998;82:42-8
120- Spect
424+ Spect
IVUS MLA <4.0mm2
IVUS MLA ³4.0mm2
Diagnostic accuracy = 93%. Nishioka et al. J Am Coll Cardiol 1999;33:1870-8
Takagi, et al. Circulation 1999;100:250-5
Epicardial Artery disease MLA < 4.0 mm2
IVUS MLA <4.0mm2
FFR
< 0
.75
No doubt about it ?
![Page 84: Paradigm Shift to Functional PCI - summitmd.comsummitmd.com/pdf/pdf/1145_Funtional PCI-TCTAP-10-F.pdf · Treat or Not treat : FFR guided -Decision making (Physiologic assessment)](https://reader034.fdocuments.in/reader034/viewer/2022051321/5abe418a7f8b9aa15e8c97d3/html5/thumbnails/84.jpg)
We need reWe need re--validation of IVUS MLA for validation of IVUS MLA for assessment of significant coronary stenosis; assessment of significant coronary stenosis; Comparison with Stress Myocardial Comparison with Stress Myocardial Perfusion ImagingPerfusion Imaging
Old Issue but New Insight !
Comparison study of IVUS and Thallium scanAMC prospective cohort registry
Preliminary analysis, 2010 TCTAP
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Distributions of MLA in all lesions (n=193 lesions, 156 pts)
Distributions of MLA in all lesions (n=193 lesions, 156 pts)
P<0.01
2.32±1.1mm21.65±0.6mm2
N=41 N=152
0
1
2
3
4
5
6
Thallium(+) Thallium(-)
Min
imal
Lum
inal
Are
a, m
m2
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N=41 N=152
0
1
2
3
4
5
6
Thallium(+) Thallium(-)
Min
imal
Lum
inal
Are
a, m
m2
Distributions of MLA in all lesions (n=193 lesions, 156 pts)
Distributions of MLA in all lesions (n=193 lesions, 156 pts)
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ROC curves for MLA measured by IVUS to discriminate thallium scan (+) and (-)
ROC curves for MLA measured by IVUS to discriminate thallium scan (+) and (-)
AUC 0.707±0.041, p<0.01
0 10 20 30 40 50 60 70 80 90 1000
10
20
30
40
50
60
70
80
90
100
1-specificity
Sens
itivi
tu
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Plots for the sensitivity & specificity of MLA
Plots for the sensitivity & specificity of MLA
Best cut off value : 2.125mm2
Sensitivity 87.8%
Specificity 49.3%
-1 0 1 2 3 4 5 60
20
40
60
80
100SensitivitySpecificity
Minimal Luminal Area, mm2
Perc
ent
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Abizaid et al1998,AJC
Takaki et al1999,Circ
Briguori et al2001,AJC
AMC2010,preliminary
43±2455±2465±1865±16Area stenosis %
75±10Plaque burden %
13.2±4.412.0±4.610.9±4.5MVA, mm2
4.4±2.03.9±2.03.9±2.52.5±1.0MLA, mm2
4.0(CFR<2.0)
3.0(FFR<0.75)
4.0(FFR<0.75)
1.86 (FFR<0.8)
Cut-off of MLAmm2
0.85 ± 0.09FFR
4253142No.
If you compared the baseline IVUS findings, you may understand why previous cut-off values are so big.
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Can MLA measured by IVUS be used as a surrogate for clinical ischemia defined with FFR <0.8 ?
Can MLA measured by IVUS be used as a surrogate for clinical ischemia defined with FFR <0.8 ?
Comparison study of FFR, IVUS, TMT, and Thallium scanAMC prospective cohort registry
Preliminary analysis, 2010 TCTAP
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Mean±SD Range
FFR, baseline 0.95 ± 0.65 0.4 - 1.0
FFR, adenosine 0.85 ± 0.89 0.4 - 1.0
MLA, mm2 2.54 ± 1.01 0.8 - 5.9
MVA, mm2 10.97 ± 4.00 2.6 - 22.1
Length of lumen area <3.0 mm2, mm
4.89 ± 6.11 0 - 25.9
Plaque burden,% 75 ± 10 34 - 94
Vessel
LAD 95 (67%)
LCX 15 (11%)
RCA 32 (22%)
Intermediate LesionsN=142
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Can MLA cut-off value by IVUS predict FFR <0.8 ? Can MLA cut-off value by IVUS predict FFR <0.8 ?
IVUS-MLA (mm2)
6543210
FFR
, Pos
t-Ade
nosi
n
1.1
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0 20 40 60 80 100100-Specificity
100
80
60
40
20
0
Sen
sitiv
ity
r=0.511p<0.001
(95% CI = 0.722 - 0.861)
Sensitivity 64%Specificity 88%PPV 53%NPV 92%
MLA=1.63 mm2
AUC=0.798
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Treat or Not treat :FFR guided –
Decision making
Functional PCI
How to treat : IVUS guided –Optimizing procedure
Do we have to choose only one ?
At this stage, these two are complementary for good clinical outcomes.
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FFR guided - Decision makingIVUS guided - Optimizing procedure
You Can Save Lives !!
Functional PCI
Coronary Intervention ;Future Perspective
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Thank You !!
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