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: 10,000 Coronary angioplasties: 5,000 IVUS use: 70% (AP: 95%) Organization 10 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 Coronary Lesion Morphologies IEL-Expected IEL (/plaque area) Erosion Stable Thin cap atheroma Plaque hemorrhage Acute rupture Healed rupture Total occlusion A Medial SMC apoptosis NC Medial 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: Positive Remodeling Intermed. or Negative Remodeling n= 108 BMS

Plaque Burden and In-Stent Intimal Hyperplasia WHC: Shiran et al, AJC 2000; 86: 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: 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: 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: patients. EA: 43.8% in ACS vs. 27.9% in Stable AP, p< 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 IVUS Tardif 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: Change in area (mm2)

Statin Therapy and Fibrous Cap Thickness Takarada et al. Atherosclerosis 2009;202:491-7 Statin Group Control Group Statin Group

Statin Therapy and Plaque Rupture Chia et al. Cor Art Dis 2008;19: 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 mm5 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 ,000 IVUS reviewed 76 perforations found on IVUS. Angio: 21% totally normal 33% dissections 22% mild stenosis 24% perforation suspected 12 months Follow up 30% 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 vessels QCA of entire coronary tree IVUS with Virtual histology Palpography (n=~350) Repeat imaging in pts with events Meds rec Aspirin Plavix 1yr Statin Repeat 30 days, 6 months MSCTSubstudyN= F/U: 1 mo, 6 mo, 1 yr, 2 yr, ±3-5 yrs F/U: 1 mo, 6 mo, 1 yr, 2 yr, ±3-5 yrs The PROSPECT Trial 700 pts with ACS

PROSPECT: MACE MACE (%) Time in Years Number at risk ALL CL related NCL related Indetermina te % 20.4% 11.6% 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

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

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

40%40% 50% 10% Proximal segment Distal segment Stent in AMI Darius Dudek. TCT 2009 NC covered NC uncovered

Plaque Healing after Stenting Kubo et al. Am Heart J. 2010;159: 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.

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