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: 10,000Coronary angioplasties: 5,000IVUS use: 70% (AP: 95%)

Organization10 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.

Remodeling in Varying CoronaryLesion Morphologies

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Medial SMCapoptosis

NCMedial SMC loss

Macrophage infiltration

SMC loss

Virmani 2009

Posit Remodeling

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

Positive Remodeling

Intermed. or Negative Remodeling

n= 108 BMS

Plaque Burden and In-Stent Intimal HyperplasiaWHC: 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

1 year MACE

236 patients with mild (<50%) LMCA stenosis by angiography

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

Two attenuated plaques 6.4 mm apart were seen in this RCA.

Shadowing in spite of no visible calcium

Attenuated Plaque in ACS.WHC: SY Lee, Mintz et al. JACC Interv 2009;2:65-72

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.

293 ACS patients: 26% with attenuated plaque ( 40% STEMI, 18% NSTEMI)

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

Plaque Regression by IVUSTardif et al. AJC 2006;98:2327

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.

Intense Lipid Therapy x 2 years in 432 lesions <50%.

Baseline IVUS IVUS at 24 months

Progression of Disease in SVG WHC: YJ Hong JACC 2009;53:1257-64

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Cha

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Statin Therapy and Fibrous Cap ThicknessTakarada et al. Atherosclerosis 2009;202:491-7

Statin Group

Control Group

Statin Group

Statin Therapy and Plaque RuptureChia et al. Cor Art Dis 2008;19:237-42

OCT study in 48 patients.

Statin therapy patients had:

- less plaque rupture (8 vs 36%)

- increased fibrous cap thickness (78 vs 49 microns)

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

5 mm

Different Strategies based on IVUS findings

A

B

Direct Stenting

Roto-Stent

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 up30% MACE

(A) Pathological intimal thickening.

(B) Thin-capped fibroatheroma.

(C) Thick-capped fibroatheroma.

(D) Fibrotic plaque.

(E) Fibrocalcific plaque.

Virtual Histology

IVUS of culprit lesion + 2 non culprit vesselsIVUS of culprit lesion + 2 non culprit vessels

QCA of entire coronary treeQCA of entire coronary tree

IVUS with Virtual histologyIVUS with Virtual histology

Palpography (n=~350)Palpography (n=~350)

Repeat imagingRepeat imagingin pts with events in pts with events

Meds recMeds recAspirinAspirin

Plavix 1yrPlavix 1yrStatinStatin

Repeat biomarkersRepeat biomarkers@ 30 days, 6 months @ 30 days, 6 months

MSCTMSCTSubstudySubstudy

N=50-100N=50-100 F/U: 1 mo, 6 mo,F/U: 1 mo, 6 mo,1 yr, 2 yr,1 yr, 2 yr,±3-5 yrs±3-5 yrs

F/U: 1 mo, 6 mo,F/U: 1 mo, 6 mo,1 yr, 2 yr,1 yr, 2 yr,±3-5 yrs±3-5 yrs

The PROSPECT TrialThe PROSPECT Trial

700 pts with ACS700 pts with ACS

PROSPECT: PROSPECT: MACEMACEM

AC

E (

%)

MA

CE

(%

)

Time in YearsTime in Years00 11 22 33

00

55

1010

1515

2020

2525

Number at riskNumber at risk

ALLALL 697697 557 557 506 506 480480

CL relatedCL related 697697 590590 543543 518518

NCL relatedNCL related 697697 595595 553 553 521521

IndeterminaIndeterminatete 697697 634634 604 604 583583

12.9%12.9%

20.4%20.4%

11.6%11.6%

2.7%2.7%

Culprit Lesion

Non Culprit Les.

All

Indeterminate

Plaque Burden, VH and Outcomes

The same lesions by grayscale IVUS (Plaque Burden ≥ 70%) have dramatically different risk profiles when

looking at VH

• 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

MACE in non Culprit lesions

Stable Progressive

ACTIVE

Dynamic Nature of Plaque by VH. Kubo, Maehara et al. JACC 2010;55:1590-7

Koenig, Margolis, Virmani, Klaus. Nature Clinical Practice 2008 5;4

Stenting and Plaque by VH.Koenig, Margolis, Virmani, Klaus. Nature Clinical Practice 2008 5;4

40%

50%

10%Proximal segmentDistal segment

Stent in AMIDarius Dudek. TCT 2009

NC covered

NC uncovered

Plaque Healing after StentingKubo et al. Am Heart J. 2010;159:271-7.

DES

BMS

DES

BMS

Necrotic Core in contact with stent before and after Stenting

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.

The end