DID OCT change our experience on coronary arteries fileDID OCT change our experience on coronary...

F Prati San Giovanni Hospital, Rome

DID OCT change our experience on coronary

arteries ?

Rome Heart Research

Istanbul June 2012

Avoid useless procedures!

Use imaging modalities to……..

IVUS cut-off Mintz TCT 2010

OCT cut-off Gonzalo et al JACC 2012

MLA of 2.0 mm2 best correlates with FFR

Use OCT to…….. identify culprit lesions in patients with ACS

Angio: Minimal irregularity in the prox LAD. LCx and RCA undiseased

•61 years old male with CAD •RF: Smoke •Unstable angina with transient anterior ST elevation in the anterior leads

OCT: Ruptured plaque with mild thrombus

LP

Thrombus

Vulnerable plaque with high inflammatory cell

content RHR dedicated sowtare to address plaque composistion

EXPERT REVIEW DOCUMENT ON METHODOLOGY, TERMINOLOGY

AND CLINICAL APPLICATIONS OF OCT.

European Heart Journal. 2009

Clinical Application of OCT: assessment of lesion severity and plaque instability

F. Prati1, E. Regar2, G.S. Mintz3, E. Arbustini4, C. Di Mario5, IK. Jang6, T. Akasaka7, M. Costa8, G. Guagliumi9, E. Grube10, Y. Ozaki11, F. Pinto12 and P.W.J. Serruys2 for the Expert’s OCT Review Document

Guidance of coronary intervention

•Use OCT post-intervention to adress the adequacy of stent positioning.

Potential use of IVUS to reduce stent thrombosis (Non randomized studies)

30 days outcome IVUS No IVUS P MACE 2,8 5,2 0.01 Death 1.7 3.3 0.03 TLR 0,7 1,7 0.045 Stent thrombosis 0,5 1,4 0.046

•884 patients undergoing IVUS-guided intracoronary DES implantation •Propensity-score matched population undergoing DES implantation with angiographic guidance alone

Roy et al Eur Heart J 2008 S.Giovanni H,

Rome

Fujii et al. JACC 2005

OCT represents a new angle of view OCT addresses features that are not easily detected by IVUS

Edge dissection

Thrombosis

Struts malapposition

What angiography does not show Examples from the multicenter MOST registry of Subacute Thrombosis

TCT 2011

Pt. CA MA

Distal stent dissection

Examples of sub-optimal OCT results in pts with Subacute Thrombosis. From the MOST Registry

TCT 2011

STEMI four days after DES deployment

Marked proximal stent malapposition

Pt RE RI

Examples of sub-optimal OCT results in pts with Subacute Thrombosis. From the MOST Registry

TCT 2011

STEMI 8 days after DES deployment

N 6 pts with subacute stent thrombosis in the MOST registry Al cases had a STEMI at the time of stenting

Pr FU (days) OCT appearance

CA MA BMS 4 Edge Dissection

TO SE BMS 4 Stent Underex. Reisidual prox plaque. LA 2,5 mm2

RE RI BMS 8 Marked prox stent underexpansion

IA AN BMS 18 Prox edge dissection

BI GI DES 4 Malapposition and uncoverage

MA PA DES 11 Malapposition and uncoverage

TCT 2011

N 3 pts with subacute stent thrombosis in the S.Giovanni Registry (Years 2006-2008) Al cases had TD OCT done after intervention Procedures were not OCT guided

Pr FU (days) OCT appearance

N 1 BMS 7 Intrastent thrombus. Stent positioned x ACS

N 2 DES 5 Distal edge dissection.

N 3 BMS 3 Large residual plaque at stent edge

TCT 2011

Guidance of coronary intervention

• Use OCT pre-intervention to avoid plaque embolization

Clinical case

57 yo, male with inferior STEMI (III h) Previous primary PTCA + 2 DES in LAD Diabetes EFVSx: 40% CFG: distal RCA subocclusion

Clinical case

After DES Stenting (Xience 3.0 x 15 mm)

Stent

OCT After Stent Implatation Plaque prolapse at the prox edge

Distal edge Proximal edge

Missed plaque rupture Further prox DES Stenting (3.0 x 12 mm)

Guidance of coronary intervention

Use OCT for complex interventions

LAD pre PCI Angiography

LAD post Stent Stent Resolute integrity 3,5 x 22 mm

Postdilatation

After kissing balloon marked stent malapposition at OCT

SB

Wrong wire placement in the LCx through the LM stent

SB Wire already outside left main stent

Marked stent malapposition

SB

Additional LM dilatation

n.c balloon 4,5 x10 mm Trek balloon 5 x 12

Final Result

Good stent apposition

SB

Angiography alone versus angiography plus optical coherence tomography to

guide decision making during percutaneous coronary intervention: the

CLI-OPCI study

Francesco Prati MD

Department of Interventional Cardiology, San Giovanni Hospital, Rome Email: fprati@hsangiovanni.roma.it

F. Prati, L. Di Vito, G. Biondi-Zoccai, A. La Manna, F. Burzotta, C. Tamburino, C. Trani, V. Ramazzotti, F. Imola, M. Occhipinti, A Manzoli, L. Materia, A Cremonesi and M Albertucci. Dep. of Interventional Cardiology, San Giovanni Hospital, Rome, Italy (FP, VR, FI, AM); Centro per la Lotta contro l’Infarto – Fondazione Onlus, Rome, Italy (FP, LDV, GBZ, MO, LM, MA); Inst. of Cardiology, University of Catania, Catania, Italy (MO, ALM, CT); Inst. of Cardiology, Catholic University, Rome, Italy (FB, CT); Sansavini Foundation, Cotignola, Italy (AC)

Objectives We aimed to compare angiographic guidance alone

versus angiographic plus OCT guidance for PCI focusing on: feasibility, procedural safety, early outcomes, long-term outcomes.

Submitted Euro-PCR 2012

Methods Consecutive patients undergoing PCI with

angiographic plus OCT guidance (OCT group) at three high OCT-volume Italian centers between 2009 and 2011 were included.

Patients in the OCT group (335 pts) were matched 1:1 with randomly-selected patients undergoing during the same month PCI with angiographic only guidance (Angio group).

All patients provided written informed consent, and ethical approval was waived given the observational and retrospective design.

Submitted Euro-PCR 2012

Definitions of Sub-Optimal results after

stenting

Submitted Euro-PCR 2012

Stent malapposition

• > 200 µ • lenght > 600 µ

Edge dissection • > 200 µ • lenght > 600 µ

Under- expansion

Stent MLA> 90% Average Ref MLA

Prox Stent Edge LA Prox Ref LA

Symmetry index

Thrombus • > 200 µ • lenght > 600 µ

No residual stenosis adjacent to stent endings (MLA > 4.0 mm2)

Distal Prox MSA

End-points The primary end-point of the study was the 12-month

rate of cardiac death or non-fatal myocardial infarction (MI).

Additional end-points were short-term rates of death, cardiac death, and non-fatal MI, and 12-month rates of death, cardiac death, non-fatal MI, target lesion repeat revascularization (TLR) and definite stent thrombosis.

All outcomes were defined in keeping with the Academic Research Consortium recommendations.

Submitted Euro-PCR 2012

Angiographic

group (N=335)

Optical coherence

tomography group (N=335) P value

Age, years 67.0±11.5 64.8±11.5 0.016

Female gender 82 (24.5%) 73 (21.8%) 0.409

Hypertension 244 (73.8%) 253 (75.5%) 0.427

Diabetes mellitus 97 (29.0%) 81 (24.2%) 0.162

Current smoking 113 (33.7%) 115 (34.3%) 0.063

Dyslipidemia 176 (53.3%) 214 (64.5%) 0.002

Prior myocardial infarction 72 (21.5%) 76 (22.7%) 0.709

Prior percutaneous coronary intervention 78 (23.5%) 115 (34.3%) 0.002

Prior coronary artery bypass grafting 29 (8.7%) 22 (6.6%) 0.308

Admission diagnosis 0.005

ST-elevation myocardial infarction 123 (36.7%) 86 (25.7%)

Non-ST-elevation acute coronary syndrome 85 (25.4%) 112 (33.4%)

Stable coronary artery disease 127 (37.9%) 137 (40.9%)

Left ventricular ejection fraction, % 52.8±10.4 53.8±10.2 0.303

Post-procedural serum creatinine (mg/dL) 1.1±0.4 1.1±0.3 0.954

Baseline characteristics

Procedural results Angiographic

guidance group

(N=335)

Angiographic plus optical

coherence tomography

guidance group (N=335)

P value

Number of diseased vessels 0.007

1 159 (47.9%) 122 (36.8%)

2 108 (32.8%) 144 (43.4%)

3 68 (19.3%) 69 (19.6%)

Left main disease 8 (2.4%) 22 (6.6%) 0.009

American College of Cardiology/American Heart

Association type B2/C lesion 287 (86.7%) 244 (72.8%) <0.001

PCI on left anterior descending 179 (53.4%) 204 (60.9%) 0.050

Multivessel PCI 52 (15.5%) 78 (23.3%) 0.011

Stent length per patient (mm) 26.0±15.6 29.0±16.6 0.024

Drug-eluting stent usage 146 (43.6%) 212 (63.3%) <0.001

Stent overlap 25 (7.5%) 49 (14.6%) 0.003

Maximum balloon diameter (mm) 3.0±0.5 3.1±0.4 0.037

Maximum dilation pressure (ATM) 16.7±2.5 16.7±2.8 0.823

Contrast (mL) 220±56 240±74 0.784

335 pts with OCT guidance

0,05,0

10,015,020,025,030,035,040,0

Angiography alone versus angiography plus optical coherence tomography to guide decision making during percutaneous coronary intervention: the CLI-OPCI study

Results • Unadjusted analyses showed that the OCT group had a

lower 12-month risk of cardiac death (p=0.010), cardiac death or MI (p=0.006), and the composite of cardiac death, MI, or repeat revascularization (p=0.044).

• Even at extensive multivariable analysis adjusting for baseline and procedural differences, angiographic plus OCT guidance was associated with a lower risk of cardiac death or MI (OR=0.49 [0.25-0.96], p=0.037).

• Finally, even propensity score-adjusted analysis exploiting bootstrap resampling confirmed the association between OCT and the 12-month rate of cardiac death or non-fatal MI (OR=0.37 [0.10-0.90], p=0.050).

Clinical results

Angiographic guidance

group (N=335)

Angiographic plus optical

coherence tomography guidance

group (N=335)

P value

In-hospital events

Cardiac death 3 (0.9%) 2 (0.6%) 0.010

Non-fatal myocardial infarction 22 (6.5%) 13 (3.9%) 0.096

Events at 1-year follow-up

Death 23 (6.9%) 11 (3.3%) 0.035

Cardiac death 15 (4.5%) 4 (1.2%) 0.010

Myocardial infarction 29 (8.7%) 18 (5.4%) 0.096

Target lesion repeat revascularization 11 (3.3%) 11 (3.3%) 1.0

Definite stent thrombosis 2 (0.6%) 1 (0.3%) 0.624

Cardiac death or myocardial infarction 43 (13.0%) 22 (6.6%) 0.006

Cardiac death, myocardial infarction, or

repeat revascularization 50 (15.1%) 32 (9.6%) 0.034

Conclusions

Use OCT to: Avoid useless interventions Identify culprit lesions in patients with ACS Reduce stent thrombosis identifing sub-

optimal results Improve results of left main and complex

procedures Avoid plaque embolization

•65 years old male with CAD •Previous intervention with DES in the LCx (May 09) •Stable angina and positive treadmil test at 75 W

OCT guided intervention for treatment of LM and proximal LAD

Is the Left Main significantly diseased ?

Is the Left Main significantly diseased ?

3.9 mm2

3.0 mm2

Ostial LAD MID LM

Aver. Diam. 2.5 mm2

LM treatment with 3.5 x 24 mm Taxus at 12 atm followed by kissing with 2.0 mm balloon and further

4.0 mm balloon inflation in the LM

Angiography after additional deployment of 2.5 x 8 mm Taxus

Malapposition of inner 2.5 mm Taxus

Plaque prolapse

Appropriate expansion

Malapposition of inner 2.5 mm Taxus

Well apposed stent

Before high pressure dilatation

After high pressure dilatation

Final OCT after further high pressure dilatation with 3.0 mm non compliant baloon

HR 95 % CI P Previous CHF 2.66 1.03-6.85 0.043 Chronic renal failure 4.87 2.10-11.26 < 0.001 COPD 2.93 1.00-8.53 0.049 Euroscore > 6 3.24 1.48-7.09 0.003 IVUS guidance 0.43 0.21-0.87 0.019

Independent predictor of mortality in 805 pts with LMCA disease treated with DES

SJ Park et al TCT 2007 S.Giovanni H, Rome

6065707580859095

100

0 0,5 1 1,5 2 2,5 3

IVUSNo IVUS

95

Years after DES implantation

Cum

ulat

ive

inci

denc

e (%

)

Impact of IVUS guidance on all cause mortality after LMCA DES implantation (805 pt5)

85

95

P=0.019

•51 years old male with CAD •Previous intervention with BMS in the LAD (May 2000). No other procedural information •Mild effort angina and positive treadmil test at 50W

OCT guided intervention for treatment of in-stent restenosis

1. Well expanded stent 2. Marked neointima with

non- homogeneous backscatter

3. Short restenosis ( 6,2 mm)

4. Stented segment lenght 18 mm

5. Two overlapped 12mm long BMS

OCT guided intervention for treatment of in-stent restenosis

1. Well expanded stent 2. Marked neointima with

non- homogeneous backscatter

3. Short restenosis ( 6,2 mm)

4. Stented segment lenght 18 mm

5. Two overlapped 12mm long BMS

6. Ruptured LP plaque inside the stent

1. Well expanded stent 2. Marked neointima with

non- homogeneous backscatter

3. Short restenosis ( 6,2 mm)

4. Stented segment lenght 18 mm

5. Two overlapped 12mm long BMS

1. Well expanded stent 2. Marked neointima with

non- homogeneous backscatter

3. Short restenosis ( 6,2 mm)

4. Stented segment lenght 18 mm

5. Two overlapped 12mm long BMS

6. Ruptured LP plaque inside the stent

LP Rupture?

LP

•Taxus 3,0 x 12 mm implanted at 18 atm

Pre-intervention Final

•50 years old male with Infero-lateral ACS Smoker High cholesterol

OCT guided intervention in a pt with ACS

OCT guided intervention in a pt with ACS

Optimal

angiographic result

•Taxus Libertè 3,0 x 20 mm implanted at 16 atm

1. Well expanded stent 1. area 8,3 mm2 2. MLA > Ref Area

2. Marked in-stent thrombus

Thrombus

REF

Taxus implanted at 16 atm Further dilatation with Nc 3,0 balloon at 20 atm

for 30 sec

Thrombus Mild prolapse

OCT in the Diagonal

Optimal stent

opening

Galassi, Prati

OCT in the LAD

Minimal

Crushing

(3 mm)

OCT use to assess complex intervention The mini-crush technique

Safety and Efficacy of Frequency Domain Optical Coherence Tomography for Guidance of Coronary Interventions Imola F *#, Mallus MT*, Ramazzotti V *, Manzoli A* , Pappalardo A *, Albertucci M # , Prati F *#

•Interventional Cardiology, San Giovanni Addolorata Hospital, Rome Italy • # Centro per la Lotta contro l’Infarto(CLI) Foundation, Italy

Submitted Eurointervention

•FD-OCT guided interventional procedures planned in 90 patients.

•In 40 pts OCT was performed for evaluation of ambiguous/intermediate lesions: of these 24 pts were treated with stenting and OCT was done pre and post-intervention, •in the remaining 16 pts with ambiguous lesions OCT permitted to exclude significant lesions that were left untreated.

•In a second group of 50 cases we attempted to obtain OCT images only post-intervention to address the adequacy of stent deployment. Therefore a total of seventy-four patients had OCT done post-stenting.

Correct stent malapposition (> 200 µ)

S.Giovanni H, Rome

Treat dissection (> 200 µ) at stent edges

Before After high pressure dilatation

Prox stent

Distal stent

Correct insufficient stent expansions

cambia

D

Intrastent thrombosis despite optimal angiographic results

Get rid of thrombus

02468

101214161820

Results 74 patients with OCT done post-intervention

•Clinical follow up (4,6 ± 3,2 m) in 88 patients •No death, acute myocardial infarctions and cases of certain, probable or possible stent thrombosis (ARC). •New occurrence of chest pain in 3 pts and two revascularizations.

Clinical Follow-up

A large burden of information derives from IVUS.

USE IVUS TO:

• Defer intervention

• Lend stent edges in relatively undiseased segments

• Obtain full lesion coverage and complete stent expansion

IVUS use in the DES Era

IVUS is a well known and validated technique capable of improving pts outcome

S.Giovanni H, Rome

A new angle of view

USE OCT to fine tune stent deployment by addressing:

Underexpansion, Malapposition, In stent Thrombosis, Dissections

OCT use in the DES Era

OCT is a novel techniques and new clinical strategy of stent guidance need to be corroborated by further studies.

S.Giovanni H, Rome