IVUS, FFR, OCT- Which Should I Use For PCI? Ramesh Daggubati, MD FACC FSCAI Director of Interventional Cardiology East Carolina University

Nothing to disclose

Angiogram is gold standard for imaging It provides 2 dimensional information similar to a roadmap

Angiography Has Major Limitation in Assessing in Complicated Lesions

IVUS IVUS provides 3 dimensional detail of what lies ahead It provides additional information not visualized on the angio map

IVUS: Pre PCI indication When IVUS? Decide strategy & sizing Why IVUS? Vessel reference & % stenosis Length of lesion Plaque composition

IVUS: Post PCI Indication When IVUS? Evaluate stent result Why IVUS? Final lumen Expansion Apposition Dissection or plaque shift

IVUS Guided LMCA Stenting Assessment of lesion Selection of PCI technique Optimization of technique Assessment of DES failure

Treat or Not Treat EEM=14.04 sq mm Lumen= 4.0 sq mm Area stenosis=71.5%

Plaque Characterization Lesion preparation: need of rotablation Fibrous plaque Plaque rupture Thrombus Calcification

How IVUS Helps?

Significant LMCA ostial disease Mild LCX ostial disease Normal- LAD, bifurcation, shaft

Post Stenting

No Malapposition, No Touch on Ostial LAD or LCX

Impact of IVUS on all Cause Mortality With LMCA DES

Procedural Optimization

Unstable Angina, Significant LMCA, LAD, Mild LCX Ostial Disease

SB Assessment

Final Result After Crush

Final IVUS After Crush Ostial LCX 6.2 mm2 Ostial LAD 7 mm2 Distal LMCA

Other Uses of IVUS DES failure: In-stent restenosis & thrombosis (under expansion, incomplete apposition, strut fracture) Vulnerable plaque

IVUS: Impacts Clinical Outcomes IVUS improves clinical outcomes (Zhang et al, EuroIntervention 2012. Reduces stent thrombosis & mortality For LMCA stenosis, IVUS is an important adjunct pre and post intervention

FFR Threshold For Ischemia No ischemia Yes ischemia FFR 1.00 0.75 0.00 Bovendien is er een drempewaarde van 0.75 die onderscheid maakt tussen wel of geen induceerbare ischaemie. FFR < 0.75  inducible ischemia (spec. 100 % ) FFR > 0.75  no inducible ischemia (sens. 90 % ) Pijls, De Bruyne et al, NEJM 1996

Event – free Survival (%) 100 75 78.8 72.7 64.4 50 Defer p=0.52 Perform p=0.03 p=0.17 25 Reference (FFR < 0.75) 1 2 3 4 5 Years of Follow-up No. at risk Defer group 90 85 82 74 73 72 Perform group 88 78 70 67 65 Reference gr 135 105 103 96

Cardiac Death And Acute MI After 5 Years P< 0.03 % 20 P< 0.005 15.7 15 P=0.20 10 7.9 5 3.3 DEFER PERFORM REFERENCE FFR > 0.75 FFR < 0.75

FAME FFR allowed elimination of a third of the lesions that might have been stented Outcomes at 1yr for the FFR group showed a 28% lower incidence of MACE

FAME: 2Yr Surival Free of MACE (Death, MI, Repeat Revascularization) FFR Guided Angio Guided Tonino et al NEJM 2008

Only 35% of lesions with 50-70% stenosis have FFR< .80 Tonino JACC 2010

Anatomic vs Functional Revascularization Only 14% Anatomical 3 VD are Functional 3 VD Tonino JACC 2010

Only 27% Lesions With Angiographically Stenosis of > 75% Are Significant by FFR Koo et al. Euro Heart J 2008

FFR Guided Provisional SB PCI

FFR Guided LMCA Crossover Stenting (FILM) Real functional status of LCX could be widely different from that apparent by angiography : NAM CW

FILM Study

Ostial and Shaft LMCA PCI FFR is crucial FFR works Akiko Maehara

FFR with Concomitant LAD and LCx Disease FFR LM apparently rises with severe downstream lesion A downstream FFR of 0.6 is associated with a 0.05 overestimation of FFR LM true. Daneils, et al. J Am Coll Cardiol Intv 2012;5:1021–5

Single Stent Cross-Over IVUS Guided Stent cross over based on LCX disease status , stent size selection, stent optimization. FFR Guided decision making for further treatment about the side branch.

LMCA: 2 Stent Technique IVUS guided stent optimization is needed irrespective of any 2 stent technique used

FFR vs IVUS: LMCA Stenosis FFR has better correlation with IVUS in LM stenosis due to limited variability in length, diameter, and amount of supplied myocardium.

FFR vs IVUS MLA IVUS MLA < 6 sq mm is matched with FFR <0.75 Jasti V et al. Circulation 2004

Angiographic 30-60% diameter stenosis (Intermediate LMCA Stenosis) MLA≥ 6.0 mm2 MLA<6.0 mm2 FFR or non-invasive stress test Defer revascularization J Am Coll Cardiol Interv 2011

Angiographic 40-70% diameter stenosis ( Intermediate non-LMCA Stenosis) MLA≥ 4.0 mm2 MLA<4.0 mm2 FFR or non-invasive stress test If unavailable consider revasc if: Area stenosis≥60-70% Plaque burden ≥80% Lesionl ength ≥20 mm Defer revascularization J Am Coll Cardiol Interv 2011

OCT Plaque Characterization Normal arterial wall with mild intimal thickening Fibro fatty plaque Calcified plaque

OCT Plaque Characterization: TCFA

Plaque Erosion

OCT Post PCI Immediately post: Malapposition, dissection, thrombus Intermediate F/U: DES Strut surface coverage Chronic F/U: BMS after 5 years DES after 2 years Neoatherosclerosis

OCT- Immediately Post PCI

Stent Strut Coverage. Apposition A: well apposed and covered B: well apposed, not covered C: malapposed, not covered D: malapposed, but covered D Takano, Jang AJC 2007

Comparison of IVUS & OCT Grey Scale IVUS VH OCT Axial Resolution (µm) 100 200 20 PCI ++ +/- + TCFA Necrotic Core Thrombus - Stent Coverage

Comparison of OCT and IVUS Findings Post Stenting 35 29 30 Number of stents 25 18 18 20 OCT 15 IVUS 12 Comparison of OCT and IVUS finding post stenting, obtained in 39 patients including 42 stents. 10 8 7 3 5 2 Dissection Tissue Incomplete Irregular prolapse apposition struts Bouma, Jang, Heart 2003

Will OCT Replace IVUS? It has limitations (penetration, true vessel sizing, assessment of plaque burden, etc) and really does not add important information. A good IVUS study provides all the information needed to optimize stenting . OCT only will have a niche role. There is simply not enough data to say for sure.

Why OCT Would Succeed? The images are seductive. OCT provides additional information in specific situations . . . ?Follow-up imaging – especially in clinical trials – may belong to OCT

Conclusion (1) I will choose the right tool for the right job None of the tools is a single, all-in-one solution IVUS, FFR & OCT have complementary role All of them are important in specific situations.

Conclusion (2) I would use FFR to know if PCI is indicated & beneficial (Shift from anatomical revascularization to physiological revascularization) Targeted PCI/CABG rather than conventional would be of focus in 2014-15 based on FFR IVUS is useful for optimization of stenting IVUS could be used to apprise of significance of LMCA stenosis.

Conclusion (3) OCT determines optimal stent deployment (sizing, apposition, and lack of edge dissection) with improved resolution However, clinical implications need to be determined ?Follow-up imaging – especially in clinical trials – may belong to OCT

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