leimbach march cotm 17mar2014 1811

8/12/2019 Leimbach March COTM 17Mar2014 1811

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NIRS-IVUS TVC Imaging of LCX Reveals 4 New

Findings Not Detected by Coronary Angiography

Dr. Wayne LeimbachOklahoma Heart Center

Hillcrest Healthcare System

Tulsa, Oklahoma


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Case Report

72 y/o male, unstable angina

Nuclear imaging stress test positive forinferior-lateral wall ischemia

Prior stents in proximal LCX and proximal LAD


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Angiographic examination to locate the

culprit lesion is not conclusive.

RCA and LAD showed no

significant narrowing.

Pre-existing stent in theproximal LCX is widely

patent.

A moderate narrowing ispresent at the origin of the

first circumflex marginal.


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1) NIRS-IVUS TVC Imaging Clarifies Severity of Stenosis

IVUS reveals the vessel issignificantly narrowed with an

MLA of 1.48 mm2

Lesion also shows signs of

plaque vulnerability with a

plaque burden = 81% and

maximum lipid core burden

index in 4mm of 427

(maxLCBI4mm427)


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2) In the present case, there is marked lipid accumulation

at the bifurcation.

Pre-stent Post-stent

Plaque Shift at site of LCP as detected by NIR Spectroscopy:

Plaque

shift?

LCP

2ndDiag

In a previous

case with lipid

at a bifurcation,plaque shift was

observed.

Courtesy of Dr. Giora Weisz Columbia University NY, NY and Shaare Zedek Medical Center, Jerusalem, Israel


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Because plaque shiftand possible sidebranch closure wereanticipated, a wire

was placed in thedistal LCX.

In the present case, detection of lipid at the bifurcation

changed management

Bifurcation


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Post

After balloon dilation in the marginal,

a new stenosis appeared in the LCX

Pre


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Treatment of new LCX narrowing

With the use of

the pre positioned

guide wire,the new stenosis

was treated with

balloon dilation.


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3) NIRS-IVUS imaging reveals pre-existing stent is

patent, fully apposed and no lipid is present.

Pre-existing

LCX stent

Stents that remain patent

have less lipid by NIRS at

time of stenting than do

stents that fail.

Dohi et al, TCT Abstract, JACC 2013


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4) NIRS-IVUS reveals a large non-obstructive lipid-

rich plaque in the left main coronary artery.

The maxLCBI 4 mm is 491 .

The plaque burden is 67%.


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The left main lesion supports the need for

intensive medical management

The patient wasplaced on intensivelipid-lowering andanti-thrombotictherapy

atorvastatin 80 mg &extended dual anti-platelet therapy

2 months post-PCIthe patient remainsasymptomatic

LM Lesion


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Summary of the 4 findings of NIRS-IVUS TVC imaging

not revealed by angiography

Diagnosis Management Implications

1) IVUS confirms narrowing in LCXStent required, and documentation

obtained for AUC criteria.

2) NIRS shows lipid at stenosis and

adjacent bifurcationWire placed in side branch.

3) NIRS shows no lipid in prior stent,

IVUS shows good stent patency and

apposition of prior stent

Stent considered to be low risk for future

events.

4)NIRS shows lipid in left main, IVUS

shows large plaque, with preserved

lumen

No stent required, intensive medical

therapy initiated.

leimbach march cotm 17mar2014 1811

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