OCT and Stent Thrombosis Ik-Kyung Jang, MD, PhD Professor of Medicine Harvard Medical School

Disclosure Research grant: LLI/St Disclosure Research grant: LLI/St. Jude medical, Medtronic, Abbott Vascular, JNJ Consultant: LLI/St. Jude medical

Stent Thrombosis Acute: BMS, DES Intermediate: DES up to 2 years Chronic: BMS after 5 years DES after 2 years

Stent Thrombosis Acute: BMS, DES Intermediate Chronic

Stent Thrombosis Acute: BMS, DES Malapposition (underexpansion) Edge dissection Thrombus

Stent Thrombosis Acute Intermediate: DES up to 2 years Chronic

Stent Struts Coverage/Apposition A: well apposed and covered B: well apposed, not covered C: malapposed, not covered D: malapposed, but covered (A) (B) (C) (D) Takano.. Jang, Mizuno. AJC 2007

OCT for SES Takano Matsumoto Yao Chen F/U 3 mo 6 mo 8.6 mo 12 mo 24 mo NIH thickness 29 53 42 120/40 88 71 Exposed (%) 15 11 9.2 17 6.6 5 Malapp (%) 16 1.3 2 1.4 Expo+Mala (%) 6 1 Thrombus (%) 14 Takano, Mizuno. AJC 2007, Matsumoto, Shite. EHJ 2007, Chen. Heart 2008, Xie, Takano, Mizuno. AJC 2008, Takano, Mizuno. JACC 2008, Yao, Suzuki. Chinese Med J 2008.

OCT for SES Takano (BMS) Matsumoto Yao Chen F/U 3 mo 6 mo 8.6 mo NIH thickness 29 351 53 42 120/40 590/200 88 71 Exposed (%) 15 0.1 11 9.2 17 0.3 6.6 5 Malapp (%) 16 1.1 1.3 2 1.4 Expo+Mala (%) 6 1 Thrombus (%) 14

SES v PES: 9 mo F/U 14 12 SES 10 PES 8 6 4 2 % exposed strut 12.5 12 SES 10 PES 8 P =0.067 P=0.037 5.4 6 4 2.6 2.6 1.5 1.7 2 % exposed strut % Malapposition % exposed + malapposition Kim JS. Int J Card 2011 10

SES v PES v ZES: 9 mo F/U Kim JS. JACC CV Interv 2009

Stent Thrombosis Acute Intermediate Chronic: BMS after 5 years DES after 2 years

Evolution following BMS PCI 6mo 3Y 5Y Angio (MLD, mm) Histology OCT Thrombus +++ mφ α-actin - cells ECM +++ α-actin +SMCs + mφ, +vWF vWF + mφ microvessels Neoatheroma? Signal-rich homogenous neointima ??

Late changes of Neointima: BMS Takano, Mizuno. JACC 2010

Late changes of Neointima: BMS

OCT for Neointima inside BMS < 6 mo (n=20) > 5 yrs (n=21) Lipid laden intima 67% < 0.05 Intimal disruption 38% Thrombus 5% 25% Intraintimal neovascularization 62% 0.01 Takano, Mizuno. JACC 2010

JB Hou. , H Qi. , JY Kong. , MM Zhang. , LJ Ma. , HM Liu. , CY LB Meng JB Hou*, H Qi*, JY Kong*, MM Zhang*, LJ Ma*, HM Liu*, CY LB Meng*, SA Yang*, SS Zhang*, B Yu*, and IK Jang** Collaboration between: Harbin Medical University*, and Massachusetts General Hospital**

Lipid-rich plaque inside BMS - 39 pts with 6.5 yr f/u - 20/60 (33%) stents, 16/39 (41%) patients - Fibrous cap thickness: 56.7 ± 5.8 µm - Lipid arc: 173 ± 57.7° - Plaque disruption: 6/20 (30%) - Thrombus: 1/20 (5%) - Macrophage: 7/20 (35%) Heart 2010;96:1187

Comparison between patients with vs without LRP Patients with in-stent lipid-rich plaque (n=16) Patients without in-stent lipid-rich plaque (n=23) P Follow-up period, (years) 6.6±1.4 6.5±1.2 Age (years) 61.1±7.5 60.1±10.5 0.752 Male, n (%) 14 (87.5%) 16 (69.6%) 0.357 Hypertension, n (%) 13 (81.3%) 9 (39.1%) 0.009 Diabetics, n (%) 4 (25%) 1 (4.3%) 0.139 Smoking, n (%) 9 (56.3%) 5 (21.7%) 0.027 Hyperlipidemia, n (%) 13(81.3%) 15(65.2%) 0.464

Characterization of Neointima inside SES using Quantitative Tissue Property Analysis Program Collaboration between Harbin Medical University and Massachusetts General Hospital

Aims of the study - To evaluate the nature of neointima tissue inside SES - To compare the evolution of tissue property over time - To identify associated vascular changes

Tissue Property Analysis

Tissue Property Analysis

Results 136 SES in 96 patients: Group 1: < 24 mo (98 stents in 71 pts) Group 2: > 24 mo (35 stents in 25 pts)

OCT assessment of neointima Group 1 (98) Group 2 (35) P Cross sections (n) 1857 644 Cross sections with NIT>100um (n) 687 277 Covered cross sections (n,%) 1256(67.6%) 472(73.3%) 0.007 Average NIT (mm) 0.13±0.11 0.16±0.14 0.001 Neointima area (mm2) 1.13±0.93 1.25±1.13 0.006 Microchannel (n,%) 48(2.6%) 46(7.1%) Lipid plaque (n,%) 5(0.8%)

Tissue property analysis Group 1 (n=687) Group 2 (n=277) P Attenuation 0.841±1.690 0.791±1.966 0.727 backscatter 6.467±0.757 6.584±0.723 0.019 Correlation Coefficient -0.355±0.498 -0.367±0.538 0.204 Min intensity 5.191±0.762 5.176±0.719 0.973 Max intensity 7.867±0.701 7.893±0.645 0.528 Mean intensity 6.686±0.668 6.716±0.649 0.518 Variance 0.386±0.094 0.387±0.091 0.766 Heterogeneous neointima (n,%) 82（11.9%） 51（18.4%） 0.008

Conclusion (1) Neointima characteristics change over time after SES. The incidence of heterogenous neointima was higher in the longer f/u group. The heterogenous group had higher incidence of angiogenesis and lipid-rich plaque.

Conclusion (2) Neointimal heterogeneity may be an important factor for late stability of SES First study to quantitatively analyze the tissue property of neointima after SES using the new off line tissue property analysis system

Percentage of Patients With Atherosclerotic Change in DES Versus BMS in Relation to Duration of Implant at Autopsy Nakazawa, G. et al. J Am Coll Cardiol Img 2009;2:625-628 Copyright ©2009 American College of Cardiology Foundation. Restrictions may apply.

Summary Acute: BMS, DES malapposition, dissection, thrombus Intermediate: DES up to 2 years Strut surface coverage Chronic: BMS after 5 years DES after 2 years Neoatherosclerosis

Limitation Lack of correlation between OCT finding and clinical outcome!

MGH OCT Registry http://www.massgeneral.org/octregistry Target 3000 patients x 3 years 20 sites from Australia, China, Singapore, Japan, Korea, USA Data collection started in 6/2010 As of 2/25/2011, 335 patients enrolled http://www.massgeneral.org/octregistry

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