IVUS Use during Left Main PCI improve Immediate and Long Term Outcome Where is the Evidence? E Murat...

IVUS Use during Left Main PCI improve IVUS Use during Left Main PCI improve Immediate and Long Term OutcomeImmediate and Long Term Outcome

Where is the Evidence?Where is the Evidence?

E Murat Tuzcu, MD, FACCE Murat Tuzcu, MD, FACCProfessor of MedicineProfessor of Medicine

Vice Chairman Vice Chairman Department of Cardiovascular MedicineDepartment of Cardiovascular Medicine

Cleveland ClinicCleveland Clinic

Does IVUS improve PCI Outcomes 1990 -2000Does IVUS improve PCI Outcomes 1990 -2000

Study Helpful No

SIPS X

CRUISE X

Choi et al X

AVID X

CENIC X

Gaster et al X

RESIST X

TULIP X

OPTICUS X

Role of IVUS in Stenting in the DES EraRole of IVUS in Stenting in the DES Era

Intravascular IVUS-guided DES Placement Associated with Intravascular IVUS-guided DES Placement Associated with Reduced Incidence of Recurrent Clinical EventsReduced Incidence of Recurrent Clinical Events

B. Claessen et al., JACC 2010;56:41

1504 pts, IVUS guidance in 632 (42%), F/U 2 yrs CRF and Amsterdam

Multivariate Analysis for Predicting Death/MIIVUS guidanceAgeCHFRenal impairment

Time in Years

0 0.5 1.0 1.5 2.00

3

6

9

12

15

P=0.004

Non IVUS CohortIVUS Cohort

Park SJ et al., JACC 2005;45:351-356

Comparison of BMS (IVUS 75%) and DES (IVUS 86%) Comparison of BMS (IVUS 75%) and DES (IVUS 86%)

70

60

0

MACE Free Survival (%)

Months0 2 4 6 8 10 12

100

90

80

SES groupBMS group

81.4 ± 3.7%

98.0 ± 1.4%

IVUS in LMCA Stenting IVUS in LMCA Stenting

1.0

.5

0.0

Event-free Survival (%)

Time (days)

0 200 400 600 800 1000

Distal LMNon-Distal LM

IVUS (n=14)No IVUS (n=12)

No IVUS (n=22)IVUS (n=10)

Agostoni et al AJC 2005;95:644-7

IVUS Guidance in DES for LMCA StenosisIVUS Guidance in DES for LMCA Stenosis

Event Free Survival in 24 IVUS+ and 34 IVUS- PatientsEvent Free Survival in 24 IVUS+ and 34 IVUS- Patients

• 975 elective BMS or DES for unprotected LMCA stenosis975 elective BMS or DES for unprotected LMCA stenosis

• IVUS (756), angiography (219) guidance by operator discretionIVUS (756), angiography (219) guidance by operator discretion

• Angiography group was older and sickerAngiography group was older and sicker

• 201 propensity-score matching pairs (DES + BMS)201 propensity-score matching pairs (DES + BMS)

• 145 propensity-score matching pairs of DES patients145 propensity-score matching pairs of DES patients

MAIN COMPARE REGISTRYMAIN COMPARE REGISTRY

Park SJ Circ Cardiovasc Interv 2009;2:167-177

Death Death or MI

Patients at riskIVUS-guidance 201 194 143 88Angiography-guidance 201 191 138 64

0 180 360 540 720 900 1000

Angiography-guidance

IVUS-guidance

P=0.063

40

30

20

10

0

13.6% (8.0-19.24%)

6.0% (2.6-9.4%)

Cumulative Mortality (%)

Days Patients at riskIVUS-guidance 201 178 131 82Angiography-guidance 201 175 128 67

0 180 360 540 720 900 1000


IVUS-guidance

P=0.078

40

30

20

10

0

13.9% (9.1-18.8%)

22.7% (16.2-29.2%)

Cumulative Incidence of Death or MI (%)

Days

IVUS Guidance in Stenting for LMCA StenosisIVUS Guidance in Stenting for LMCA Stenosis

3 year death and MI (K-M) in 201 propensity matched pairs 3 year death and MI (K-M) in 201 propensity matched pairs

Park SJ Circ Cardiovasc Interv 2009;2:167-177

TVR Death/MI/TVR

Patients at riskIVUS-guidance 201 176 125 18Angiography-guidance 201 179 129 70

0 180 360 540 720 900 1080


IVUS-guidance

P=0.056

40

30

20

10

0

11.9% (7.3-16.5%)

8.8% (4.6-12.9%)

Cumulative Incidence of TVR (%)

Days Patients at riskIVUS-guidance 201 164 115 74Angiography-guidance 201 168 129 64

0 180 360 540 720 900 1000

P=0.274

40

30

20

10

0

Cumulative Incidence of Death, MI or TVR (%)

Months


IVUS-guidance28.0%

22.2%


3 year TVR and MACE (K-M) in 201 propensity matched pairs 3 year TVR and MACE (K-M) in 201 propensity matched pairs


Cumulative Mortality (%)

Patients at risk

IVUS-guidance 145 140 98 37Angiography-guidance 145 137 88 29

Months

0

10

20

30

40

0 180 360 540 720 900 1080

4.4%

16.0%

P=0.048


IVUS-guidance

3 year mortality (K-M) in 145 propensity matched pairs 3 year mortality (K-M) in 145 propensity matched pairs

Differences in Patient Outcomes for LMCA PCIDifferences in Patient Outcomes for LMCA PCI

Thoraxcenter vs. Asan Medical Center: Impact of BaselineThoraxcenter vs. Asan Medical Center: Impact of BaselineCharacteristics on Outcomes of DESCharacteristics on Outcomes of DES

Age 65, LVEF 45%Euroscore 4.3, IVUS32%, SYNTAX score 39STEMI 23%, Shock 9%

Age 61, LVEF 59%Euroscore 3.3, IVUS 89%32%, SYNTAX score 39STEMI 0%, Shock 0%

All Cause Mortality 35% versus, 6%

Onuma et al. JACC Int, 2010 Park DW et al., JACC, 2010

Left Main Coronary Artery (LMCA) DiseaseLeft Main Coronary Artery (LMCA) Disease

TTo treat or not to treat?o treat or not to treat?That is the question.That is the question.

IVUS and Left Main DiseaseIVUS and Left Main DiseaseIV

US

ML

D (

mm

)IV

US

ML

D (

mm

)

QCA MLD (mm)QCA MLD (mm)

r=0.364r=0.364

00

11

22

33

44

55

66

77

00 11 22 33 44 55 66 77IV

US

re

f (m

m)

IVU

S r

ef

(mm

)QCA Ref. (mm)QCA Ref. (mm)

001122334455667788

00 11 22 33 44 55 66 77 88

r=0.495r=0.495

Independent predictors of MACEIndependent predictors of MACE

DM (P=0.004) DM (P=0.004)

Any untreated lesion >50% (p=0.04)Any untreated lesion >50% (p=0.04)

IVUS MLD (P=0.005)IVUS MLD (P=0.005) IVU

S D

SIV

US

DS

QCA DSQCA DS

00

2020

4040

6060

8080

100100

00 2020 4040 6060 8080 100100

p=0.106p=0.106

AS Abizaid et al JACC 1999;34:707-15AS Abizaid et al JACC 1999;34:707-15

MACEMACE

IVUS MLD (mm)IVUS MLD (mm)

1.41.4 2.22.2 3.03.0 3.83.8 4.64.6 5.45.41.81.8 2.62.6 3.43.4 4.24.2 5.05.0 5.85.8

1.01.0

0.90.9

0.80.8

0.70.7

0.60.6

0.50.5

0.40.4

0.30.3

0.20.2

0.10.1

0.00.0

DM and DM and 1 untreated 1 untreated vessel with DS vessel with DS 50%50%

DM and no untreated DM and no untreated vesselsvessels

No DM and No DM and 1 untreated 1 untreated vessel with DS vessel with DS 50%50%

No DM and no untreated vesselsNo DM and no untreated vessels

122 patients with moderate LMCA disease, f/u 1 year122 patients with moderate LMCA disease, f/u 1 year

Assessment of Intermediate LMCA Lesions by IVUSAssessment of Intermediate LMCA Lesions by IVUS

354 Patients

MLA ≥6.0 mm2

(N=186)MLA <6.0 mm2

(N=168)

7 revascularized 16 not revascularized

No LMCA revascularization(n=179, 96%)

LMCA revascularization(n=152, 90%)

56% PCI of other vessels55% CABG

45% PCI (+ other vessels in 62%)

LITRO Study – 22 Spanish CentersLITRO Study – 22 Spanish Centers

De La Torre Hernandez et al. ACCi2 2010De La Torre Hernandez et al. ACCi2 2010

Survival free of cardiac death, MI and any Survival free of cardiac death, MI and any revascularizationrevascularizationP=0.22 P=0.22

Defer (n=179)Defer (n=179)

Revascularization (n=152)Revascularization (n=152)

Survival free of cardiac deathSurvival free of cardiac deathP=0.20 P=0.20

DeferDefer

RevascularizationRevascularization



Survival in Revascularized and Deferred PatientsSurvival in Revascularized and Deferred Patients

Time

Defer (medical therapy) with MLA ≥6mm2 (n=179)

100

80

60

40

20

0Survival free of Cardiac Death P=0.02

0 100 200 300 400 500 600 700

Defer (medical therapy) with MLA <6mm2 (n=160)


LITRO Study – Survival in Medically Treated PatientsLITRO Study – Survival in Medically Treated Patients


The Assessment of LMCAThe Assessment of LMCA

Shortfalls of Luminology for Even Experienced CliniciansShortfalls of Luminology for Even Experienced Clinicians

Agreement or Disagreement on Stenosis SeverityAgreement or Disagreement on Stenosis Severity

VisualVisualAssessmentAssessment %% (absolute #)(absolute #)

Reviewer AReviewer A nsns correct correct 53%53% 27/5127/51ss incorrectincorrect 22%22% 11/5111/51uu unsureunsure 25%25% 13/5113/51

Reviewer BReviewer B nsns correctcorrect 49%49% 25/5125/51ss incorrectincorrect 39%39% 20/5120/51uu unsureunsure 12%12% 6/516/51

Reviewer CReviewer C nsns correctcorrect 51%51% 26/5126/51ss incorrectincorrect 49%49% 25/5125/51uu unsureunsure -- 0/510/51

Reviewer CReviewer C nsns correctcorrect 45%45% 23/5123/51ss incorrectincorrect 33%33% 17/5117/51uu unsureunsure 22%22% 11/5111/51

Lindstaedt M et al. Int J Cardiol. 2007;120(2):254-261

Reviewer Assessment ResultsReviewer Assessment Results

51 intermediate LMT assessed by angiography and FFR51 intermediate LMT assessed by angiography and FFR

•4 experienced interventional cardiologist correctly classified lesion severity in 50% of patients.4 experienced interventional cardiologist correctly classified lesion severity in 50% of patients.•Interobserver variability was large resulting in unanimous correct classification in only 29%Interobserver variability was large resulting in unanimous correct classification in only 29%

The Grey Zone of FFRThe Grey Zone of FFR

De Bruyne B et al. Circulation 2001;104:157-162

0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

FFR

100

80

60

40

20

0

Sensitivity

Specificity

FFR = 0.75

Specificity

Sensitivity

0.80

FFR CaveatsFFR Caveats

• Other coronary stenosisOther coronary stenosis

• Distal LMCA stenosisDistal LMCA stenosis

• Variability of hyperemic Variability of hyperemic responseresponse

IVUS shows us so much more!IVUS shows us so much more!

Courtesy of G Mintz (modified)

• Vessel sizeVessel size• RemodelingRemodeling• LengthLength• CalcificationCalcification• OstiumOstium• BifurcationBifurcation

Morphological Assessment of LMCA by IVUSMorphological Assessment of LMCA by IVUS

Maehara A et al., AJC 2001;88:1-4

Ostium Bifurcation p valuen=32 n=55

Plaque burden (%) 62 ± 15 80 ± 9 <0.0001

Max Calcium Arc (°) 78 ± 65 195 ± 101 <0.0001

Eccentric plaque (%) 97 76 0.01

Lesion length (mm) 2.3 ± 2.4 4.5 ± 2.7 0.001

Remodeling index 0.87 ± 0.19 1.01 ± 0.21 0.005

Bifurcation vs Ostium: more calcium and plaque, longer, and more positive remodeling

Distribution of atherosclerosis in LMCA: Ostium vs BifurcationDistribution of atherosclerosis in LMCA: Ostium vs Bifurcation

0%0% 100%100%

Medina 1,1,1Medina 1,1,1(n=21)(n=21)

Medina 1,1,0Medina 1,1,0(n=9)(n=9)


Medina 0,1,1Medina 0,1,1(n=11)(n=11)


Medina 0,1,0Medina 0,1,0(n=14)(n=14)

Medina 0,0,1Medina 0,0,1(n=12)(n=12)

Medina 0,0,0Medina 0,0,0(n=60)(n=60)

All lesionsAll lesions(n=80)(n=80)

OthersOthers

Oviedo Oviedo et al. et al. Circ Cardiovasc Interv. 2010;3:105-12Circ Cardiovasc Interv. 2010;3:105-12

Impact of IVUS on TVR after LMCA StentingImpact of IVUS on TVR after LMCA Stenting

Kang SJ et al., 2011;107:367-373

168 patients with distal LMCA stenosis w/ 42 mo F/U168 patients with distal LMCA stenosis w/ 42 mo F/U

• Pre-PCI MLA at POC was predictor of MACE.Pre-PCI MLA at POC was predictor of MACE.• MLA at POC determined final stent size MLA at POC determined final stent size

POC: Polygon of POC: Polygon of confluanceconfluance

Ostial Left Main StenosisOstial Left Main Stenosis

AA BBAABB

Ostial Left Main StenosisOstial Left Main Stenosis

Why IVUS is Important in LMCA InterventionWhy IVUS is Important in LMCA Intervention

• IVUS improves our understanding of the pathology better and helps to IVUS improves our understanding of the pathology better and helps to plan the strategy of PCI plan the strategy of PCI

• Determination of the extent and distribution of atheroma in distal LMT, Determination of the extent and distribution of atheroma in distal LMT, ostial LAD and Cxostial LAD and Cx

• Location and involvement of the ostium of LMCALocation and involvement of the ostium of LMCA

• True vessel size of LMCATrue vessel size of LMCA

• True vessel size of LAD and CxTrue vessel size of LAD and Cx

• Optimize stent expansion particularly at the osteaOptimize stent expansion particularly at the ostea

• Ensure coverage of the LMCA-ostium when necessaryEnsure coverage of the LMCA-ostium when necessary

• Identify and treat complicationsIdentify and treat complications

IVUS Use during Left Main PCI improve Immediate and Long Term Outcome Where is the Evidence? E Murat...

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