IVUS Use during Left Main PCI IVUS Use during Left Main PCI improve Immediate and Long Term improve Immediate and Long Term Outcome Outcome Where is the Evidence? Where is the Evidence? E Murat Tuzcu, MD, FACC E Murat Tuzcu, MD, FACC Professor of Medicine Professor of Medicine Vice Chairman Vice Chairman Department of Cardiovascular Department of Cardiovascular Medicine Medicine Cleveland Clinic Cleveland Clinic
25
Embed
IVUS Use during Left Main PCI improve Immediate and Long Term Outcome Where is the Evidence? E Murat Tuzcu, MD, FACC Professor of Medicine Vice Chairman.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
IVUS Use during Left Main PCI improve IVUS Use during Left Main PCI improve Immediate and Long Term OutcomeImmediate and Long Term Outcome
Where is the Evidence?Where is the Evidence?
E Murat Tuzcu, MD, FACCE Murat Tuzcu, MD, FACCProfessor of MedicineProfessor of Medicine
Vice Chairman Vice Chairman Department of Cardiovascular MedicineDepartment of Cardiovascular Medicine
Role of IVUS in Stenting in the DES EraRole of IVUS in Stenting in the DES Era
Intravascular IVUS-guided DES Placement Associated with Intravascular IVUS-guided DES Placement Associated with Reduced Incidence of Recurrent Clinical EventsReduced Incidence of Recurrent Clinical Events
B. Claessen et al., JACC 2010;56:41
1504 pts, IVUS guidance in 632 (42%), F/U 2 yrs CRF and Amsterdam
Multivariate Analysis for Predicting Death/MIIVUS guidanceAgeCHFRenal impairment
Time in Years
0 0.5 1.0 1.5 2.00
3
6
9
12
15
P=0.004
Non IVUS CohortIVUS Cohort
Park SJ et al., JACC 2005;45:351-356
Comparison of BMS (IVUS 75%) and DES (IVUS 86%) Comparison of BMS (IVUS 75%) and DES (IVUS 86%)
70
60
0
MACE Free Survival (%)
Months0 2 4 6 8 10 12
100
90
80
SES groupBMS group
81.4 ± 3.7%
98.0 ± 1.4%
IVUS in LMCA Stenting IVUS in LMCA Stenting
1.0
.5
0.0
Event-free Survival (%)
Time (days)
0 200 400 600 800 1000
Distal LMNon-Distal LM
IVUS (n=14)No IVUS (n=12)
No IVUS (n=22)IVUS (n=10)
Agostoni et al AJC 2005;95:644-7
IVUS Guidance in DES for LMCA StenosisIVUS Guidance in DES for LMCA Stenosis
Event Free Survival in 24 IVUS+ and 34 IVUS- PatientsEvent Free Survival in 24 IVUS+ and 34 IVUS- Patients
• 975 elective BMS or DES for unprotected LMCA stenosis975 elective BMS or DES for unprotected LMCA stenosis
• IVUS (756), angiography (219) guidance by operator discretionIVUS (756), angiography (219) guidance by operator discretion
• Angiography group was older and sickerAngiography group was older and sicker
3 year mortality (K-M) in 145 propensity matched pairs 3 year mortality (K-M) in 145 propensity matched pairs
Differences in Patient Outcomes for LMCA PCIDifferences in Patient Outcomes for LMCA PCI
Thoraxcenter vs. Asan Medical Center: Impact of BaselineThoraxcenter vs. Asan Medical Center: Impact of BaselineCharacteristics on Outcomes of DESCharacteristics on Outcomes of DES
51 intermediate LMT assessed by angiography and FFR51 intermediate LMT assessed by angiography and FFR
•4 experienced interventional cardiologist correctly classified lesion severity in 50% of patients.4 experienced interventional cardiologist correctly classified lesion severity in 50% of patients.•Interobserver variability was large resulting in unanimous correct classification in only 29%Interobserver variability was large resulting in unanimous correct classification in only 29%
The Grey Zone of FFRThe Grey Zone of FFR
De Bruyne B et al. Circulation 2001;104:157-162
0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
FFR
100
80
60
40
20
0
Sensitivity
Specificity
FFR = 0.75
Specificity
Sensitivity
0.80
FFR CaveatsFFR Caveats
• Other coronary stenosisOther coronary stenosis
• Distal LMCA stenosisDistal LMCA stenosis
• Variability of hyperemic Variability of hyperemic responseresponse
IVUS shows us so much more!IVUS shows us so much more!
Morphological Assessment of LMCA by IVUSMorphological Assessment of LMCA by IVUS
Maehara A et al., AJC 2001;88:1-4
Ostium Bifurcation p valuen=32 n=55
Plaque burden (%) 62 ± 15 80 ± 9 <0.0001
Max Calcium Arc (°) 78 ± 65 195 ± 101 <0.0001
Eccentric plaque (%) 97 76 0.01
Lesion length (mm) 2.3 ± 2.4 4.5 ± 2.7 0.001
Remodeling index 0.87 ± 0.19 1.01 ± 0.21 0.005
Bifurcation vs Ostium: more calcium and plaque, longer, and more positive remodeling
Distribution of atherosclerosis in LMCA: Ostium vs BifurcationDistribution of atherosclerosis in LMCA: Ostium vs Bifurcation
0%0% 100%100%
Medina 1,1,1Medina 1,1,1(n=21)(n=21)
Medina 1,1,0Medina 1,1,0(n=9)(n=9)
Medina 1,0,1Medina 1,0,1(n=6)(n=6)
Medina 0,1,1Medina 0,1,1(n=11)(n=11)
Medina 1,0,0Medina 1,0,0(n=7)(n=7)
Medina 0,1,0Medina 0,1,0(n=14)(n=14)
Medina 0,0,1Medina 0,0,1(n=12)(n=12)
Medina 0,0,0Medina 0,0,0(n=60)(n=60)
All lesionsAll lesions(n=80)(n=80)
OthersOthers
Oviedo Oviedo et al. et al. Circ Cardiovasc Interv. 2010;3:105-12Circ Cardiovasc Interv. 2010;3:105-12
Impact of IVUS on TVR after LMCA StentingImpact of IVUS on TVR after LMCA Stenting
Kang SJ et al., 2011;107:367-373
168 patients with distal LMCA stenosis w/ 42 mo F/U168 patients with distal LMCA stenosis w/ 42 mo F/U
• Pre-PCI MLA at POC was predictor of MACE.Pre-PCI MLA at POC was predictor of MACE.• MLA at POC determined final stent size MLA at POC determined final stent size
POC: Polygon of POC: Polygon of confluanceconfluance
Ostial Left Main StenosisOstial Left Main Stenosis
AA BBAABB
Ostial Left Main StenosisOstial Left Main Stenosis
Why IVUS is Important in LMCA InterventionWhy IVUS is Important in LMCA Intervention
• IVUS improves our understanding of the pathology better and helps to IVUS improves our understanding of the pathology better and helps to plan the strategy of PCI plan the strategy of PCI
• Determination of the extent and distribution of atheroma in distal LMT, Determination of the extent and distribution of atheroma in distal LMT, ostial LAD and Cxostial LAD and Cx
• Location and involvement of the ostium of LMCALocation and involvement of the ostium of LMCA
• True vessel size of LMCATrue vessel size of LMCA
• True vessel size of LAD and CxTrue vessel size of LAD and Cx
• Optimize stent expansion particularly at the osteaOptimize stent expansion particularly at the ostea
• Ensure coverage of the LMCA-ostium when necessaryEnsure coverage of the LMCA-ostium when necessary
• Identify and treat complicationsIdentify and treat complications