Background

1
IVUS Use during Left Main PCI improve Immediate
and Long Term Outcome Where is the Evidence? E
Murat Tuzcu, MD, FACC Professor of Medicine Vice
Chairman Department of Cardiovascular
Medicine Cleveland Clinic
2
Does 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
3
Role of IVUS in Stenting in the DES Era
Intravascular IVUS-guided DES Placement
Associated with Reduced Incidence of Recurrent
Clinical Events
1504 pts, IVUS guidance in 632 (42), F/U 2 yrs
CRF and Amsterdam
15
Non IVUS Cohort IVUS Cohort
Multivariate Analysis for Predicting
Death/MI IVUS guidance Age CHF Renal impairment
12
P0.004
9
6
3
0
0
0.5
1.0
1.5
2.0
Time in Years
B. Claessen et al., JACC 20105641
4
IVUS in LMCA Stenting
Comparison of BMS (IVUS 75) and DES (IVUS 86)
MACE Free Survival ()
100
98.0 1.4
90
80
81.4 3.7
70
60
SES group BMS group
0
0
2
4
6
8
10
12
Months
Park SJ et al., JACC 200545351-356
5
IVUS Guidance in DES for LMCA Stenosis
Event Free Survival in 24 IVUS and 34 IVUS-
Patients
Agostoni et al AJC 200595644-7
6
MAIN COMPARE REGISTRY

• 975 elective BMS or DES for unprotected LMCA
  stenosis
• IVUS (756), angiography (219) guidance by
  operator discretion
• Angiography group was older and sicker
• 201 propensity-score matching pairs (DES BMS)
• 145 propensity-score matching pairs of DES
  patients

7
IVUS Guidance in Stenting for LMCA Stenosis
3 year death and MI (K-M) in 201 propensity
matched pairs
Park SJ Circ Cardiovasc Interv 20092167-177
8
IVUS Guidance in DES for LMCA Stenosis
3 year TVR and MACE (K-M) in 201 propensity
matched pairs
Park SJ Circ Cardiovasc Interv 20092167-177
9
IVUS Guidance in DES for LMCA Stenosis
3 year mortality (K-M) in 145 propensity matched
pairs
10
Differences in Patient Outcomes for LMCA PCI
Thoraxcenter vs. Asan Medical Center Impact of
BaselineCharacteristics on Outcomes of DES
Age 65, LVEF 45 Euroscore 4.3, IVUS 32, SYNTAX
score 39 STEMI 23, Shock 9
Age 61, LVEF 59 Euroscore 3.3, IVUS 89 32,
SYNTAX score 39 STEMI 0, Shock 0
All Cause Mortality 35 versus, 6
Onuma et al. JACC Int, 2010
Park DW et al., JACC, 2010
11
Left Main Coronary Artery (LMCA) Disease
To treat or not to treat? That is the question.
12
IVUS and Left Main Disease
122 patients with moderate LMCA disease, f/u 1
year
MACE
7
8
6
7
1.0
DM and ?1 untreated vessel with DS ?50
6
5
0.9
5
4
IVUS MLD (mm)
IVUS ref (mm)
4
0.8
3
3
DM and no untreated vessels
2
0.7
2
1
r0.364
1
r0.495
0.6
0
0
0
1
2
3
4
5
6
7
No DM and ?1 untreated vessel with DS ?50
0
1
2
3
4
5
6
7
8
0.5
QCA MLD (mm)
QCA Ref. (mm)
0.4
Independent predictors of MACE DM (P0.004) Any
untreated lesion gt50 (p0.04) IVUS MLD (P0.005)
100
0.3
p0.106
80
0.2
60
0.1
IVUS DS
40
0.0
No DM and no untreated vessels
20
1.4
2.2
3.0
3.8
4.6
5.4
1.8
2.6
3.4
4.2
5.0
5.8
0
IVUS MLD (mm)
0
20
40
60
80
100
QCA DS
AS Abizaid et al JACC 199934707-15
13
Assessment of Intermediate LMCA Lesions by IVUS
LITRO Study 22 Spanish Centers
De La Torre Hernandez et al. ACCi2 2010
14
Assessment of Intermediate LMCA Lesions by IVUS
Survival in Revascularized and Deferred Patients
De La Torre Hernandez et al. ACCi2 2010
15
Assessment of Intermediate LMCA Lesions by IVUS
LITRO Study Survival in Medically Treated
Patients
De La Torre Hernandez et al. ACCi2 2010
16
The Assessment of LMCA
Shortfalls of Luminology for Even Experienced
Clinicians
17
Agreement or Disagreement on Stenosis Severity
51 intermediate LMT assessed by angiography and
FFR
Reviewer Assessment Results

• Visual
• Assessment (absolute )
• Reviewer A ns correct 53 27/51
• s incorrect 22 11/51
• u unsure 25 13/51
• Reviewer B ns correct 49 25/51
• s incorrect 39 20/51
• u unsure 12 6/51
• Reviewer C ns correct 51 26/51
• s incorrect 49 25/51
• u unsure - 0/51
• Reviewer C ns correct 45 23/51
• s incorrect 33 17/51
• u unsure 22 11/51

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

Lindstaedt M et al. Int J Cardiol.
2007120(2)254-261
18
The Grey Zone of FFR
FFR Caveats

• Other coronary stenosis
• Distal LMCA stenosis
• Variability of hyperemic response

De Bruyne B et al. Circulation 2001104157-162
19
IVUS shows us so much more!

• Vessel size
• Remodeling
• Length
• Calcification
• Ostium
• Bifurcation

Courtesy of G Mintz (modified)
20
Morphological Assessment of LMCA by IVUS
Distribution of atherosclerosis in LMCA Ostium
vs Bifurcation
Ostium Bifurcation p value n32 n55 Plaque
burden () 62 15 80 9 lt0.0001 Max Calcium Arc
() 78 65 195 101 lt0.0001 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
Maehara A et al., AJC 2001881-4
21
Oviedo et al. Circ Cardiovasc Interv.
20103105-12
22
Impact of IVUS on TVR after LMCA Stenting
168 patients with distal LMCA stenosis w/ 42 mo
F/U
POC Polygon of confluance

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

Kang SJ et al., 2011107367-373
23
Ostial Left Main Stenosis
24
Ostial Left Main Stenosis
B
B
A
A
25
Why IVUS is Important in LMCA Intervention

• IVUS improves our understanding of the pathology
  better and helps to plan the strategy of PCI
• Determination of the extent and distribution of
  atheroma in distal LMT, ostial LAD and Cx
• Location and involvement of the ostium of LMCA
• True vessel size of LMCA
• True vessel size of LAD and Cx
• Optimize stent expansion particularly at the
  ostea
• Ensure coverage of the LMCA-ostium when necessary
• Identify and treat complications