1. When I Use IVUS Neal Uren MD FRCP Consultant Cardiologist Royal Infirmary Edinburgh

2. MY CONFLICTS OF INTEREST ARE Travel, Accomodation & Registration  PCR - May 2006 (BosSci)  TCT - October 2006 (BosSci) Travel & Accomodation  Guidant Institute visit, Brussels - February 2006 (Abbott)  Emerging Technologies Symposium -March 2006 (BosSci)  Annual SpR training, Malaga – June 2006 (BosSci)

3. IVUS Transducers Mechanical Transducer – 40 MHz Atlantis Pro (BosSci) Solid-State Transducer – 25 MHz EagleEye (Volcano)

4. Diagnostic Applications of IVUS  Identify specific disease - left main stem, ostial lesions  Detect angiographically silent disease - transplant vasculopathy  Identify plaque morphology  Examine vessel when angiography is inconclusive - hazy lesions, presence or absence of thrombus or dissection  Measure plaque load  Measure true vessel size

5. Lumen Area Vessel Area Atheroma Area IVUS Determination of Atheroma Area Precise Planimetry of EEM and Lumen Borders with Calculation of Atheroma Cross-sectional Area Vessel Diameter Lumen Diameter

6. Angiography versus IVUS ANGIOGRAPHY 2 dimensional Planar Shadow of lumen Wall structures not imaged Intermittent snapshots or repeat contrast injections necessary QCA measurements prone to magnification errorsIVUS 360º view Tomographic and sagittal Visualisation of shape and location Visualisation of inner wall structures and morphology Continuous image Precise measurements

7. In-Stent Restenosis

9. Interventional Indications of IVUS PRE-INTERVENTION  Accurate quantitation  Assessment of reference segment disease  Interventional strategy & device selection  In-stent restenosisPOST-INTERVENTION  Recognition of an ambiguous appearance  Optimal balloon angioplasty  IVUS-guided stenting

10. IVUS & Stent Expansion

11. Minimum Stent Area & Restenosis 0 5 10 15 20 25 30 35 40 <66-7.98-9.9>10 Angio restenosis TVR Minimum Stent Area (mm 2 ) % After Moussa et al, Mintz et al, CRUISE 2000

12. Stent Malapposition

13. The POST Registry Predictors and Outcomes of Stent Thrombosis 0 10 20 30 40 50 60 Percentage Expansion <80% %DS>0 Malapposition Inflow-outflow disease Thrombus Filling defect Edge tear/ dissection Plaque protrusion IVUS Angio Uren et al, EHJ 2002 53 stent thromboses

14. The POST Registry The POST Registry Comparison with other trials 0 10 20 30 40 50 60 70 80 90 Expansion Edge Tears Malapposition In-Stent Thrombus POST STRUT CRUISE AVID * * * * p<0.05 Percentage Uren et al, EHJ 2002

15. Wijns et al, TCT 2006

16. Left Main Stenting PRE-INTERVENTION  Confirm length of left main stem = pullback time (0.5 mm/s) ÷ 2  Confirm lesion length  Assess for ostial disease in LAD or CFX  Measure true vessel size = [maximum + minimum vessel diameter] ÷ 2

17. IVUS & Left Main Stenting POST-INTERVENTION  Confirm optimal stent deployment  Recognition of an ambiguous appearance  Maximise stent expansion - clinical experience MLA ≥ 7 mm 2 - parent vessel MLA should be 1.5x daughter (4mm 2 )

20. Costa et al, TCT 2006

21. Cosat et al, TCT 2006

22. IVUS & Unprotected LMS Stenting  18 LMS vs. 60 non-LMS PCI  Additional high-pressure or larger size balloon dilatations were more frequently performed in LMS stenting vs. non-LMS stenting (p <0.05)  After IVUS-guided stent implantation, MLA was ≥9 mm 2 in 88% of LMS patients vs. 19% of non-LMS (p<0.001) Hong MK et al, AJC 1998;82:670-3

23. IVUS & Unprotected LMS Stenting 0 5 2.5 15 5 25 MLD (mm) Debulk/Stent Stent 0 10 20 Angiographic Restenosis (%) p<0.05 p<0.01 4.2 4.0 Reference artery size = only independent predictor (not IVUS) 99.2% procedural success, 97% 2 year survival 8.3 25.0 IVUS Angio n=127 non-randomised 7750 4087 Park SJ et al, JACC 2001;38:1054-60

24. When I Use IVUS CLINICAL PRACTICE  Diagnostic uncertainty  Assessment of in-stent restenosis  Left main stenting  Atherosclerosis research

25. Prior Coronary IVUS Progression Trials -1.2 -0.6 0 0.6 1.2 1.8 1.251.51.752.02.252.52.753.0 Median Change In Percent Atheroma Volume (%) Mean LDL-C (mmol/l) REVERSAL pravastatin REVERSAL atorvastatin CAMELOT placebo A-Plus ACTIVATE Relationship between LDL-C and Progression Rate Unexplored Region Unexplored Region

26. Baseline IVUS Exam Follow-up IVUS 24 months rosuvastatin Atheroma Area 10.16 mm 2 Lumen Area 6.16 mm 2 Atheroma Area 5.81 mm 2 Lumen Area 5.96 mm 2

27. -10 -8 -6 -4 -2 0 2 Prava40 Atorva80 Rosuva40 Median  PAV (%) Median  TAV in most diseased subsegment (%) Median  TAV (%) REVERSAL & ASTEROID Trials 1.6 Percent Change 0.2 -0.8 -1.2 -4.2 -9.1 2.6 -0.4 -6.8 NS ** * NS *p<0.05, **p  0.001, NS = non significant vs. baseline ** REVERSAL: atorvastatin 80 mg vs pravastatin 40 mg reduced LDL-C to 2.1 mmol/l ASTEROID: rosuvastatin 40 mg reduced LDL-C to 1.5 mmol/l and raised HDL-C by 15%