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: [email protected]
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