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
Does IVUS improve PCI Outcomes 1990 -2000
Study
Helpful
SIPS
X
CRUISE
X
Choi et al
X
AVID
X
CENIC
X
Gaster et al
X
RESIST
X
TULIP
X
OPTICUS
No
X
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
12
P=0.004
9
6
3
0
0
0.5
1.0
Time in Years
B. Claessen et al., JACC 2010;56:41
1.5
2.0
Multivariate Analysis for Predicting
Death/MI
IVUS guidance
Age
CHF
Renal impairment
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
SES group
BMS group
60
0
0
Park SJ et al., JACC 2005;45:351-356
2
4
6
8
Months
10
12
IVUS Guidance in DES for LMCA Stenosis
Event Free Survival in 24 IVUS+ and 34 IVUS- Patients
Event-free Survival (%)
1.0
IVUS (n=14)
No IVUS (n=12)
No IVUS (n=22)
IVUS (n=10)
.5
Distal LM
Non-Distal LM
0.0
0
200
400
600
800
1000
Time (days)
Agostoni et al AJC 2005;95:644-7
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
IVUS Guidance in Stenting for LMCA Stenosis
3 year death and MI (K-M) in 201 propensity matched pairs
Death
Death or MI
Cumulative Incidence of Death or MI (%)
Cumulative Mortality (%)
40
40
Angiography-guidance
IVUS-guidance
Angiography-guidance
IVUS-guidance
30
30
P=0.078
P=0.063
22.7% (16.2-29.2%)
20
20
13.6% (8.0-19.24%)
13.9% (9.1-18.8%)
10
10
6.0% (2.6-9.4%)
0
0
180 360 540 720 900 1000
Days
Patients at risk
IVUS-guidance
Angiography-guidance
0
0
201
201
194
191
180 360 540 720 900 1000
Days
Patients at risk
143
138
88
64
IVUS-guidance
Angiography-guidance
201
201
178
175
131
128
82
67
Park SJ Circ Cardiovasc Interv 2009;2:167-177
IVUS Guidance in DES for LMCA Stenosis
3 year TVR and MACE (K-M) in 201 propensity matched pairs
TVR
Death/MI/TVR
Cumulative Incidence of Death, MI or TVR (%)
Cumulative Incidence of TVR (%)
40
40
Angiography-guidance
IVUS-guidance
Angiography-guidance
IVUS-guidance
30
30
28.0%
P=0.274
P=0.056
22.2%
20
20
11.9% (7.3-16.5%)
10
10
8.8% (4.6-12.9%)
0
0
0
0
Patients at risk
IVUS-guidance
201
Angiography-guidance 201
180 360 540 720 900 1080
Days
176
179
125
129
18
70
180 360
900 1000
Months
Patients at risk
IVUS-guidance
Angiography-guidance
540 720
201
201
164
168
115
129
74
64
Park SJ Circ Cardiovasc Interv 2009;2:167-177
IVUS Guidance in DES for LMCA Stenosis
3 year mortality (K-M) in 145 propensity matched pairs
Cumulative Mortality (%)
40
Angiography-guidance
IVUS-guidance
30
P=0.048
20
16.0%
10
4.4%
0
0
180
360
540
720
900
1080
Months
Patients at risk
IVUS-guidance
Angiography-guidance
145
145
140
137
98
88
37
29
Differences in Patient Outcomes for LMCA PCI
Thoraxcenter vs. Asan Medical Center: Impact of Baseline
Characteristics 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
Left Main Coronary Artery (LMCA) Disease
To treat or not to treat?
That is the question.
IVUS and Left Main Disease
7
6
5
4
3
2
1
0
r=0.364
0
1
IVUS ref (mm)
IVUS MLD (mm)
122 patients with moderate LMCA disease, f/u 1 year
2 3 4 5 6 7
QCA MLD (mm)
8
7
6
5
4
3
2
1
0
MACE
1.0
0.9
DM and 1 untreated vessel
with DS 50%
0.8
0.7
r=0.495
0 1 2 3 4 5 6 7 8
QCA Ref. (mm)
DM and no untreated
vessels
0.6
0.5
No DM and 1 untreated
vessel with DS 50%
0.4
100
Independent predictors of MACE
Any untreated lesion >50% (p=0.04)
IVUS MLD (P=0.005)
p=0.106
80
IVUS DS
DM (P=0.004)
0.3
60
0.1
40
0.0
20
0
0
AS Abizaid et al JACC 1999;34:707-15
0.2
20
40 60 80 100
QCA DS
No DM and no untreated vessels
1.4
2.2
3.0
3.8
4.6
5.4
1.8
2.6
3.4
4.2
5.0
5.8
IVUS MLD (mm)
Assessment of Intermediate LMCA Lesions by IVUS
LITRO Study – 22 Spanish Centers
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%)
56% PCI of other vessels
LMCA revascularization
(n=152, 90%)
55% CABG
45% PCI (+ other vessels in 62%)
De La Torre Hernandez et al. ACCi2 2010
Assessment of Intermediate LMCA Lesions by IVUS
Survival in Revascularized and Deferred Patients
Defer
Defer (n=179)
Revascularization
Revascularization (n=152)
Survival free of cardiac death, MI and any
revascularization
P=0.22
Survival free of cardiac death
P=0.20
De La Torre Hernandez et al. ACCi2 2010
Assessment of Intermediate LMCA Lesions by IVUS
LITRO Study – Survival in Medically Treated Patients
100
80
60
40
Defer (medical therapy) with MLA ≥6mm2 (n=179)
Defer (medical therapy) with MLA <6mm2 (n=160)
20
Survival free of Cardiac Death P=0.02
0
0
100
200
300
400
500
600
700
Time
De La Torre Hernandez et al. ACCi2 2010
The Assessment of LMCA
Shortfalls of Luminology for Even Experienced Clinicians
Agreement or Disagreement on Stenosis Severity
51 intermediate LMT assessed by angiography and FFR
Reviewer Assessment Results
Visual
Assessment
Reviewer A
Reviewer B
Reviewer C
Reviewer C
ns
s
u
ns
s
u
ns
s
u
ns
s
u
correct
incorrect
unsure
correct
incorrect
unsure
correct
incorrect
unsure
correct
incorrect
unsure
%
(absolute #)
53%
22%
25%
49%
39%
12%
51%
49%
45%
33%
22%
27/51
11/51
13/51
25/51
20/51
6/51
26/51
25/51
0/51
23/51
17/51
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. 2007;120(2):254-261
The Grey Zone of FFR
100
Specificity
80
FFR Caveats
• Other coronary stenosis
• Distal LMCA stenosis
60
40
Sensitivity
20
0
0.2
0.3
0.4
0.5
0.6
0.7
0.8
FFR
Sensitivity
• Variability of hyperemic
response
Specificity
De Bruyne B et al. Circulation 2001;104:157-162
FFR = 0.75
0.80
0.9
1.0
IVUS shows us so much more!
• Vessel size
• Remodeling
• Length
• Calcification
• Ostium
• Bifurcation
Courtesy of G Mintz (modified)
Morphological Assessment of LMCA by IVUS
Distribution of atherosclerosis in LMCA: Ostium vs Bifurcation
Ostium
n=32
Bifurcation
n=55
p value
Plaque burden (%)
62 ± 15
80 ± 9
<0.0001
Max Calcium Arc (°)
78 ± 65
195 ± 101
<0.0001
Eccentric plaque (%)
97
76
0.01
2.3 ± 2.4
4.5 ± 2.7
0.001
Lesion length (mm)
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 2001;88:1-4
Others
All lesions
(n=80)
Medina 1,1,1
(n=21)
Medina 1,1,0
(n=9)
Medina 1,0,1
(n=6)
Medina 0,1,1
(n=11)
Medina 1,0,0
(n=7)
Medina 0,1,0
(n=14)
Medina 0,0,1
(n=12)
Medina 0,0,0
(n=60)
0%
Oviedo et al. Circ Cardiovasc Interv. 2010;3:105-12
100%
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., 2011;107:367-373
Ostial Left Main Stenosis
Ostial Left Main Stenosis
B
A
A
B
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