VULNERABLE PLAQUES: Pertinent doubts and solutions in interventional cardiology EuroPCR Paris, 16 May 2006

Case 1 ♂ 62 year-old CV risk factors: Diabetes mellitus type 2 Hypercholesterolemia Previous history: NQWMI (1990) > Stenting of prox-RCA NQWMI (2005) > Stenting of prox-LAD Actual symptoms: after an orthopedic operation to the right knee (april 2006), 2 episodes of unstable angina at rest lasting 15’each, with pain referred as the same of the previous NQWMIs without ECG changes but minimal troponine increase Strategy: Coronary angiogram was planned

Case 1 Coronary angiogram: -RCA: Good result of the stent in the proximal part. No further severe stenoses. -LCA: Good result of the stent in the proximal part. 90% stenosis of ostial D1 (covered by the stent in LAD) with TIMI 3 flow, same as just after stenting. No further severe stenoses.

Case 1 After Ventriculography (normal LV function with mild inferior hypokinesia): -New onset retrosternal pain, referred as the same as the 2 previous episodes of unstable angina. New control coronary angiogram: -RCA: same as before. -LCA:…

Pre Post

After 5’ less pain but…

IVUS of LAD

Thrombus in mid-LAD Non “flow-limiting” thrombus, just at the ostium of a small septal branch, superimposed on an eccentric plaque in the anterior descendens artery plaque thrombus

What to do? Pain started increasing again > We decided to stent the lesion The patient could not receive aggressive antithrombotic therapy because of knee hemoarthros after recent surgery. No Abciximab was given, only aspirin and clopidogrel.

In hospital follow up - Residual pain (not improved after stenting) for 3 hours (total occlusion of the small septal branch after stenting) - Increase in post-procedural myocardial enzymes (18 h): - CK: 124 U/l (normal: U/l) - CK-MB: 21 U/l (normal <16 U/l) - Troponine I: 4.78 ng/ml (normal < 0.08 ng/ml) Baseline Thrombus Septal branch After stenting

Case 2 ♂ 51 year-old CV risk factors: Arterial hypertension No previous cardiac hystory Actual symptoms: March 2006:aborted sudden death with VF and out-of- hosptial resuscitation, due to NQWMI Strategy: Stabilization of the neurological situation Coronary angiogram planned 15 days after the acute event

Case 2 Coronary angiogram: -RCA: Non-dominant small vessel without evidence of severe stenoses. -LCA:…

IVUS of mid-LAD Ulcus

Virtual Hystology Non “flow-limiting” ulcerated plaque Predominantly fibrous plaque (stable?)

What to do? Due to the “stable” clinical situation (no cardiac symptoms for 15 days), the “non- flow-limiting” appearance of the lesion at angiography and IVUS, and the “stable” nature of the residual plaque… We treated the patient in a conservative way (aspirin, clopidogrel, statins, B-blockers)

Discussion Non flow-limiting lesions: - “evolving” situation: thrombus formation superimposed on a potentially thrombus-prone “active” plaque Versus - “stable” situation: an ulcus in which the vulnerable part of the plaque (the necrotic core) has already disappeared

Discussion Role of the concomitant pharmacological therapy: - is an aggressive antithrombotic therapy enough to limit thrombus formation and to avoid a complete occlusion of a major epicardial vessel? - what happens if the patient has contraindications to this type of aggressive therapy? Role of the percutaneous treatment of the lesion: - is stenting justifed, exposing the patient to the risk of restenosis and stent thrombosis?

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