Near Infrared Spectroscopy: Case Studies and Clinical Relevance Sergio Waxman, M.D. Lahey Clinic, Burlington, MA Tufts University School of Medicine, Boston, MA

Sergio Waxman, MD DISCLOSURES I have no real or apparent conflicts of interest to report.

Potential Relevance of LCP Detection in the Cath Lab Progression of Non-stented Site (VP) Later Trouble With the Stent: Restenosis/LST Place Stent Periprocedural MI

NIRS: From the Bench to the Clinic Ex Vivo Autopsy Study SPECTACL Clinical Study In Vivo Clinical Spectra Ex Vivo Autopsy Spectra = Histology Waxman et al. JACC Imaging 2009;2:858-868

A 71y, M BMI 28.3 kg/m2 MI (<72 hrs) HTN Pre-dilatation NIRS Start NIRS End 71y, M BMI 28.3 kg/m2 MI (<72 hrs) HTN Pre-dilatation A Beth Israel Deaconess Med. Ctr., Boston, MA

A B NIRS Start NIRS End A B William Beaumont Hospital, Royal Oaks, MI

Predicting periprocedural complications/MI 62 year old man, stable angina Confidential Goldstein et al, JACC Imaging, Dec, 2009 Right Coronary Artery 7

Dilation of Circular Lipid Core Plaque Balloon inflation No flow in artery after angioplasty Complete Heart Block BP 30 Confidential 8

Circumferential LCP: Histopathological-chemographic correlates 48 year old man, sudden cardiac death Goldstein et al, JACC Imaging, Dec, 2009

Could this information affect management? Courtesy Dr. Manos Brilakis, Dallas VA.

LCP and Periprocedural MI: Chemograms in 28 Patients Undergoing Stenting, 4 Pts Developed Peri-stenting MI 1 8 15 22 LCP Very Distal in LAD 2 9 16 23 MI Chemogram Post PCI unchanged 3 10 17 24 4 11 18 25 MI 5 12 19 26 6 13 20 27 MI 7 14 21 28 MI Maini et al, ACC, March 2010 11

Major Decrease in Lipid Core Plaque Peri-stenting MI and Changes in Chemograms NIR COLOR Registry (PI: Morton Kern, MD) Pre PCI Pre PCI Post PCI Post PCI Pre PCI There are leads being generated to the mechanism behind the enzymatic elevations. Promising lead but still anectodal. The three subjects shown here had a LipiScan performed prior to angioplasty and post treatment. Note the remarkable reduction in LCP in the case that exhibited enzyme elevation. Major Decrease in Lipid Core Plaque Post PCI Peri-stenting MI Small Change in Lipid Core Plaque No Peri-stenting MI

Determining target lesion borders: Angiographic vs morphologic lesion margins NIR End Culprit NIR Start 59y, F Atypical Chest Pain T.O. LCX (opened) Diseased RCA HTN,  Chol +Family Hx Pre-dilatation SPECTACL Study. Case from William Beaumont Hospital Pullback (mm) Culprit

SPECTACL subanalysis: Angiographic (luminal stenosis) vs NIR-Spectroscopic (morphologic) lesion margins: Implications for Stent Coverage Pre-PCI Post-PCI Dixon et al. TCT 2008

NIR Findings and Temporal Stability or Progression of Coronary Artery Disease B Maini, MD COLOR Registry 141 Days Later Baseline Chemogram Post-stent 55 yo m SR Dixon, MD/JA Goldstein, MD Beaumont LipiScan Registry 171 Days Later Unstable Angina Chemogram Pre-Stent “Stable” LCP Negative Plaque This subject participating in the COLOR Chemogram Registry underwent 3 vessel intervention at day 0, with treatment in the LAD, LCX, and Ramus and LipiScan imaging of the treatment result in the LAD. The chemogram shows low lipid content in the arterial wall in the LAD following treatment. 141 Days later the subject was cath-ed again for recurrent angina symptoms. The LCX and Ramus were restented, the LAD imaged at baseline was virtually unchanged, angiographically, right down to the nearly occluded jailed diagonals and septals. Due to the excellent appearance of the LAD no follow up Chemogram was obtained. Less “Stable” LCP Positive Plaque This subject from the William Beaumont Hospital LipiScan Registry shows a high grade lesion, proximal to the second diagonal, that shows a strong positive signal for LCP or lipid content. This vessel was imaged by angiography 171 days prior during an intervention in the RCA. The vessel shows mild plaque burden almost 6 months prior to near total occlusion. Unfortunately there is not a chemogram from the LAD at the earlier time point to study the LCP progression during this critical period. Pre-Stent 59 yo m

First Pair of Baseline and 6 Month Follow-Up Chemograms Stability of Disease: First Pair of Baseline and 6 Month Follow-Up Chemograms A B A B Baseline Baseline shows very little lipid-core A B A B 180 Day COLOR Registry 0107-023-007 Gender: Male Age: 54 6 mo shows no new stenosis, and similar chemogram Dr. David Rizik, Scottsdale Hospital, Scottsdale AZ.

Multimodality Coronary Imaging: A Glimpse of the Future? Garg et al, EuroIntervention, 2010;5:755-756

NIR Spectroscopy Clinical Relevance Summary NIR data to detect LCP can be obtained rapidly and safely through blood with a single pullback. Experience from ongoing multicenter registries will identify areas of potential use. Anecdotal evidence regarding: Assessment of risk of distal embolization/periprocedural MI Determination of the appropriate length of stent Stability or progression of disease (target and remote) Plaque shift in bifurcation lesions Co-registration with IVUS (composition and structure) is feasible. Future studies of NIR assessment of LCP to improve outcomes are needed.

Plaque Shift at site of LCP as detected by LipiScan™: an Observation from the SPECTACL Study Ostium 2nd Diag 2nd Diag LCP Weisz G., Columbia University Medical Center

Plaque Shift at site of LCP as detected by LipiScan™: an Observation from the SPECTACL Study Weisz G., Columbia University Medical Center

Plaque Shift at site of LCP as detected by LipiScan™: an Observation from the SPECTACL Study Ostium 2nd Diag 2nd Diag LCP Weisz G., Columbia University Medical Center