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Update on New Ultrasound andUpdate on New Ultrasound and

Competing Technologies: VH, IB-Competing Technologies: VH, IB-IVUS, OCT, NISIVUS, OCT, NIS

!"i"o #aehara, #$!"i"o #aehara, #$$irector o% Intra&ascular Imaging ' (h)siolog) Core *a+oratories$irector o% Intra&ascular Imaging ' (h)siolog) Core *a+oratories

!ssociate $irector o% #I#$CT Core *a+orator)!ssociate $irector o% #I#$CT Core *a+orator)

Cardio&ascular esearch oundationColum+iaCardio&ascular esearch oundationColum+iaUni&ersit) #edical Center, New .or"Uni&ersit) #edical Center, New .or"

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$isclosure Statement o% inancial Interest

!"i"o #aehara recei&es research grants %or!"i"o #aehara recei&es research grants %or%ellows %rom BSC and Volcano/%ellows %rom BSC and Volcano/

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Plaque Morphology of AMI/SCD w/ThrombiPlaque Morphology of AMI/SCD w/Thrombi

(la0ue upture(la0ue upture

1234%5 6 7234m51234%5 6 7234m5

(la0ue 8rosion(la0ue 8rosion

9234m5 - 234%59234m5 - 234%5

Calci%ied NoduleCalci%ied Nodule

93 - ;393 - ;3

thth

thth

thth

thth

thth

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What is a limitation ofWhat is a limitation of

conentional grayscale I!"S#conentional grayscale I!"S#

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Ultrasound ation

H)po

IsoH)per

H)per with ShadowCalcium

i+ro%att)

i+rous

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!ulnerable Plaque#!ulnerable Plaque#

i+rous Capi+rous Cap Necrotic CoreNecrotic Core

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$etection o% Necrotic Core$etection o% Necrotic Core

(rati , et al ? @ardiol9222

A*ipid necrotic area*ipid necrotic area

A2#H> IVUS2#H> IVUS

AHuman 2 coronar) ' 9 carotid arteries, in &itroHuman 2 coronar) ' 9 carotid arteries, in &itro

2 992 9949D35:49D35:histological lipid poolhistological lipid pool

E99E994135:4135:IVUS lipid poolIVUS lipid pool

Sensiti&it): 1;3Sensiti&it): 1;3Speci%icit): E3Speci%icit): E3

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O+Fecti&e, Guantitati&e 8&aluationO+Fecti&e, Guantitati&e 8&aluation

AIntegrated Bac"scatter 4IB5 IVUSIntegrated Bac"scatter 4IB5 IVUS

AVirtual Histolog) 4VH5 IVUSVirtual Histolog) 4VH5 IVUSAi-#api-#ap

adio%re0uenc) $ataadio%re0uenc) $ata

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8n&elope!mplitude

re0uenc)re0uenc)

VH-IVUSVH-IVUSi-#api-#ap

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(athological IntimalThic"ening 4(IT5

Thic" Capi+roatheroma

VH-IVUSVH-IVUS

=re) Scale=re) Scale

IVUSIVUS

Necrotic Core 4E135

$ense Calcium 4E;35

i+rous 4E35

i+ro%att) 4E35

In &itro $iagnostic!ccurac)

Nair, et al 8urointer& 922;, :-92/

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iMap s$ !% Compare&iMap s$ !% Compare&

i#ap VH

Transducer re0uenc)4esolution5

2#H> 4E2J725 92#H> 4;2JD925

Con%idence *a+els .es None

Characteri>ation%ramesmillimeter

9 rame#illimeter 8C= =ated

i+rotic

*ipidic

Necrotic

Calci%ied

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Integrated Bac"scatter 4IB5-IVUSIntegrated Bac"scatter 4IB5-IVUS

Calci%ication

$ense i+rous

i+rosis

*ipid (ool

O"u+o, @awasa"i, et al Ultrasound #ed Biol 9227, :1DD-1/

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Calci%icationi+rous*ipid (ool

IB-IVUSIB-IVUS

!mplitude

E13E3E23In &itro!ccurac)

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What &o we 'now aboutWhat &o we 'now about

!%( I!"S#!%( I!"S#

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;22 pts with !CS;22 pts with !CSU! 4with 8C=U! 4with 8C=KK55 ororNST8#INST8#I ororST8#I L9hrsST8#I L9hrs

undergoing (CI o% or 9 maFor coronar) arteriesundergoing (CI o% or 9 maFor coronar) arteries

at up to 2 sites in the U/S/ and 8uropeat up to 2 sites in the U/S/ and 8urope

(CI o% culprit lesion4s5(CI o% culprit lesion4s5

Success%ul and uncomplicatedSuccess%ul and uncomplicated

ormall) enrolledormall) enrolled(I: =regg

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Thic"-cap !Thin-cap ! (IT i+rocalci%ici+rous

VH-IVUS Classi%ication

#ore than 23#ore than 23Con%luentCon%luent

Necrotic CoreNecrotic CoreNONO more than 23more than 23Con%luent NecroticCon%luent Necrotic

CoreCore

#ore than#ore than 2323con%luentcon%luentcalciumcalcium

#ore than D3#ore than D3i+ro%att)i+ro%att)

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IndeJ 921IndeJ 921 8&ent 912;8&ent 912;

GC! (*C $S 97/13GC! (*C $S 97/13 GC! (*C $S ;/3GC! (*C $S ;/3

(OS(8CT 79E2-29:(OS(8CT 79E2-29: D9 )oD9 )o

921:921: NST8#I, (CI o% #*!$NST8#I, (CI o% #*!$

912; 4D wee"s later5:912; 4D wee"s later5: NST8#I attri+uted to *CNST8#I attri+uted to *C

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/ ThC!/ ThC!

PO#

D/mm9

*esion*esion

P

proJ

(OS(8CT 79E2-29:(OS(8CT 79E2-29: IndeJ 921IndeJ 921

Baseline (*CBaseline (*C

GC!: V$ 9/79 mm,GC!: V$ 9/79 mm,$S 97/13, length 1/7$S 97/13, length 1/7

mmmm

IVUS: #*! D/ mmIVUS: #*! D/ mm

99

VH: ThC!VH: ThC!

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(OS(8CT:(OS(8CT: #!C8#!C8

#!C

8435

#!C8435

Time in .earsTime in .ears22 99

!ll!ll

Culprit lesion 4C*5 relatedCulprit lesion 4C*5 relatedNon culprit lesion 4NC*5 relatedNon culprit lesion 4NC*5 relatedIndeterminateIndeterminate

22

DD

22

DD

9292

9D9D

Num+er at ris"Num+er at ris"

92/392/3

9/E39/E3

/13/13

9/;39/;3

/93/93

;/E3;/E3

1/31/3

2/E32/E3

7/37/3

/3/3

E/3E/3

/E3/E3

**** 1E;1E; DD;DD; D21D21 7272

* related* related 1E;1E; DE2DE2 DD D7D7

C* relatedC* related 1E;1E; DEDDED DDDD D9D9

ndeterminatedeterminate 1E;1E; 11 1212 D7D7

P)*SP+CTP)*SP+CT !% TC-A & .!% TC-A & .

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P)*SP+CT,P)*SP+CT,!%(TC-A an& .on!%(TC-A an& .on

Culprit esion )elate& +entsCulprit esion )elate& +ents

*esion H*esion H /E2 49/9D, 1/;15 1/DD 4/, 9/D5 2/7 4D/DD, 9/25 /2D 4/E, 9;/795( &alue( &alue Q2/222Q2/222 Q2/222Q2/222 Q2/222Q2/222 Q2/222Q2/222(re&alenceP(re&alenceP 1/;31/;3 D/E3D/E3 2/32/3 /93/93

P*i"elihood o% one or more such lesions +eing present per patient/ (B pla0ue +urden at the #*!P*i"elihood o% one or more such lesions +eing present per patient/ (B pla0ue +urden at the #*!

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Temporal Stability of PlaqueTemporal Stability of Plaque

Morphology by !%( I!"S#Morphology by !%( I!"S#

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!ll Comers =lo+al VH egistr) 4n95

91 Non-Culprit *esions 4(la0ue+urdenL235 in EE patients

Baseline99;; pts!CSnon-!CS

9 months U

!llM non-!CS presentation

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N19N19 N92N92 NENE N99N99 NENE

2323

N7N7 N1N1 N2EN2E N9N9 N92N92

E3E3

1D31D32323

3333

1313

;3;39D39D3

E23E23

(IT TC! ThC! i+rotic i+rocalci%ic

@u+o T, R!CC 922MDD:DE2

793793 223223

Change o% (la0ue T)peChange o% (la0ue T)pe

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HHarmoni>ingarmoni>ing OOutcomes withutcomes with e&asculare&asculari>i>atiationonandand SStents intents in!#I!#I

129 pts with ST8#I with s)mptoms onset129 pts with ST8#I with s)mptoms onsetQ9 hoursQ9 hours

UH=( II+IIIa inhi+itorUH=( II+IIIa inhi+itor

4a+ciJima+ or epti%i+atide54a+ciJima+ or epti%i+atide5Bi&alirudin monotherap)Bi&alirudin monotherap)

44pro&isional =( II+IIIa5pro&isional =( II+IIIa5

:

221 eligi+le %or (rimar) (CI with stent221 eligi+le %or (rimar) (CI with stent

(aclitaJcel-eluting T!US(aclitaJcel-eluting T!US(aclitaJcel-eluting T!US(aclitaJcel-eluting T!US Bare metal 8(8SSBare metal 8(8SSBare metal 8(8SSBare metal 8(8SS

:

722 eligi+le %or month angio %ollow-up722 eligi+le %or month angio %ollow-up

9E T!US9E T!US9E T!US9E T!US ED B#SED B#SED B#SED B#S

E1 41;35 UE1 41;35 UE1 41;35 UE1 41;35 U 19 41D35 U19 41D35 U19 41D35 U19 41D35 U

IVUSIVUS

Su+stud)Su+stud)VH-IVUSVH-IVUS

Su+stud)Su+stud) 2 T!US2 T!US2 T!US2 T!US 7 B#S7 B#S7 B#S7 B#S

E 4;935 UE 4;935 UE 4;935 UE 4;935 U 9 4135 U9 4135 U9 4135 U9 4135 U

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N1N1 NN

E3E3

NN NDND N9N9

33 33

D3D3 D3D37373

;13;137373

(IT TC! ThC!

N2N2

D3D3

HOI?ONS-!#I in 22 non-culprit lesionsHOI?ONS-!#I in 22 non-culprit lesions

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E3 ;3

3

9E3

E3

D23

993

E3

3D3

23

13

93

3

TC!TC!

ThC!ThC!

(IT(IT

i+rousi+rousi+Cali+Cal

BaselineBaseline ollow-upollow-up ollow-upollow-upBaselineBaseline

!CS 4935 ST8#I 42235

$i%%erence o% temporal changes$i%%erence o% temporal changes

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What &o we nee& more#What &o we nee& more#

*CT0 .I)(Spectroscopy*CT0 .I)(Spectroscopy

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Plaque Morphology of AMI/SCD w/ThrombiPlaque Morphology of AMI/SCD w/Thrombi

(la0ue upture(la0ue upture

1234%5 6 7234m51234%5 6 7234m5

(la0ue 8rosion(la0ue 8rosion

9234m5 - 234%59234m5 - 234%5

Calci%ied NoduleCalci%ied Nodule

93 - ;393 - ;3

thth

thth

thth

thth

thth

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Throm+usThrom+us

- !cute Throm+us -- !cute Throm+us -

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Near In%rared

2/; m

OCT 4light5 /m IVUS 42#H>5

7m

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8rosion8rosion

@u+o T, et al R!CC 922;

OCTIVUS !ngioscop)

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*rgani1e& Thrombus*rgani1e& Thrombus

Strong attenuationStrong attenuation

#=H O$I#=H O$IIVUSIVUS

Courtes) o% $r/Tearne)

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.eointimal Coerage.eointimal Coerage

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2

3

42

43

5 6 7 48 89 4#onth54#onth5

435435

ie ., !RC 9227, #atsumoto $, 8ur Heart R 922;, @u+o T R!CCImg 9227, ?hu-hua ., Chin #ed R 9227, Ta"ano #, R!CC 9227

OCT: Neointimal Co&erage and Throm+usOCT: Neointimal Co&erage and Throm+us

3 O&erall 8Jposed Strut3 O&erall 8Jposed StrutCo-eJist Throm+usCo-eJist Throm+us

- C)pher Stent -- C)pher Stent -

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66 years ol&0 male

A Stable AP0 Stage& Proce&ure :AD;A )is' factor, %T0 %0 DM8

A %istory of CA

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(romus Stent D(romus Stent Dmonths agomonths ago

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Old pla0ue rupture with throm+usOld pla0ue rupture with throm+us

Co&ered Strut

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435435

Ota"e H, R!CC Inter& 922EM9:DE, @im R, ! Heart R 922MDE:9;7

OCT: Neointimal Co&erage and Throm+usOCT: Neointimal Co&erage and Throm+us

3 Unco&ered Strut per *esion3 Unco&ered Strut per *esion

(redictor o% throm+us(redictor o% throm+us@im et al/ 4 )ear5@im et al/ 4 )ear5//Stent lengthStent length 97mm97mm9/9/Stent $iemeterStent $iemetermmmm1.1.7 unco&ered strut per stent7 unco&ered strut per stentOta"e et al/ 41 months5Ota"e et al/ 41 months5//Stent lengthStent length9/9/Stent s)mmetr)Stent s)mmetr)

913913

Ota"eOta"e

973973@im@im

33@im@im

33@im@im

Throm+usI

Throm+usI

Thr

om+us-

Throm+us-

Throm

+usI

Throm

+us-

Throm+usI

Throm+usI

Throm+

us-

Throm+

us-

--

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otate

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otate

spectra per per2/mm pull-+ac"

2222 E22E22

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2222 922922 2222 2222 D22D22 122122 ;22;22 722722 E22E22

CholesterolCholesterol

Cholester)lCholester)l *inoleate*inoleate

Cholester)lCholester)l OleateOleate

CollagenCollagen

/2/2

2/72/7

2/12/1

2/2/

2/92/9

!!+sor+a

nce

+sor+ance

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Tissue

/

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low

high

ipiScan ersus %istologyipiScan ersus %istology

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=oldstein et al, R!CC Imaging 922

(rediction o% No-e%low(rediction o% No-e%low

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No %low in arter)

a%ter angioplast)

No %low in arter)

a%ter angioplast)

Balloonin%lationBalloonin%lation

Dilation of Circular ipi& Core PlaqueDilation of Circular ipi& Core Plaque

Complete Heart Bloc"

B( 2

Complete Heart Bloc"

B( 2

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$r/ #anos Brila"is 6 Use o% NI-guided %ilter to pre&ent #I$r/ #anos Brila"is 6 Use o% NI-guided %ilter to pre&ent #I

(eri stenting #I and #a mm *CBILD22 in 19 (atients

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#I No #I

>

>

>

>

>

>

>

>

>

>

>

>

>

>

(eri-stenting #I and #aJ mm *CBILD22 in 19 (atients

CO*O egistr), Su+mitted %or (u+lication

NI Spectroscop)-IVUS

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*C

9

9

9

$istal

9

9

=ra) Scale-IVUS

VH-IVUS

OCT

Chemogram

Bloc"Chemogram

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SummarySummary

=re) Scale=re) ScaleIVUSIVUS

VHVH OCTOCT NINISpectroscop)Spectroscop)

!Jial esolution 4Wm5!Jial esolution 4Wm5 2222 922922 9292 N!N!

(CI(CI -- --TC!TC! -- --Necrotic CoreNecrotic Core --

Throm+usThrom+us -- -- --Stent Co&erageStent Co&erage --

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SummarySummary

4$4$ )ecent progress of )a&iofrequency I!"S may allow)ecent progress of )a&iofrequency I!"S may allowus ob?ectie an& quantitatie assessment of plaqueus ob?ectie an& quantitatie assessment of plaque

characteri1ation$characteri1ation$

8$8$ The higher resolution by *CT can e@amine &etails ofThe higher resolution by *CT can e@amine &etails of

surface such as fibrous cap thic'ness or strutsurface such as fibrous cap thic'ness or strutcoerage which may impact the clinical outcome$coerage which may impact the clinical outcome$

5$5$ The quality of flow is an important clinical questionThe quality of flow is an important clinical questionan& all imaging mo&alities are promising$an& all imaging mo&alities are promising$

9$9$ We nee& to continue to as' ourseles0 when0 how0We nee& to continue to as' ourseles0 when0 how0which imaging mo&ality shoul& be use& thanwhich imaging mo&ality shoul& be use& than

othersB$othersB$