左主干病变 PCI 中 IVUS 的指导 作用：是否必需？ 钱杰阜外心血管病医院

术前评价 LM 病变

造影有局限性 1 、短而没有参照 2 、造影剂反流影响开口判断 3 、层流导致假阳性狭窄 4 、弥漫病变低估支架大小 5 、是否需要使用切割技术 6 、钙化时是否使用旋磨 7 、治疗策略的选择

Comparison between percent stenosis assessment from the quality control (QC) lab vs the clinical site in the CASS Study *area of the square is proportional to the number of cases Of all the coronary segments, the LM has the greatest angiographic assessment variability - I QC lab Clinical Site Fisher et al. Cathet Cardiovasc Diagn 1982;8:565-75

Of all the coronary segments, the LM has the greatest angiographic assessment variability - II Cameron et al. Circulation 1983;68: : 0-24% DS 2: 25-49% DS 3: 50-74% DS 4: 75-89% DS 5:90-100%DS 1: 0-24% DS 2: 25-49% DS 3: 50-74% DS 4: 75-89% DS 5:90-100%DS 0:no difference +1 or -1:1 grade difference +2 or -2:2 grades of difference +3 or -3:3 grades of difference +4 or -4:4 grades of difference 0:no difference +1 or -1:1 grade difference +2 or -2:2 grades of difference +3 or -3:3 grades of difference +4 or -4:4 grades of difference Clinical site vs Quality control Clinical site vs Study Group Study Group vs Quality control Five grades of LM severity # of grades of difference in assessment of LM severity

Lindstaedt et al. Int J Cardiol 2007;120: But surely we are better today! 51 intermediate or equivocal LM lesions were evaluated by FFR and angiography. Four experienced interventional cardiologists visually classified lesions as ‘significant’, ‘not significant’, or ‘unsure.’51 intermediate or equivocal LM lesions were evaluated by FFR and angiography. Four experienced interventional cardiologists visually classified lesions as ‘significant’, ‘not significant’, or ‘unsure.’ The 4 experienced interventional cardiologists achieved correct lesion classification in no more than ~50% of each case regardless of the FFR threshold (≤0.75 or ≤0.80).The 4 experienced interventional cardiologists achieved correct lesion classification in no more than ~50% of each case regardless of the FFR threshold (≤0.75 or ≤0.80). Interobserver variability was large, resulting in unanimous correct lesion classification in only 29%!Interobserver variability was large, resulting in unanimous correct lesion classification in only 29%!

IVUS DS QCA DS p=0.106 Abizaid et al. J Am Coll Cardiol 1999;34: DM and ≥1 untreated vessel (DS>50%) DM and no untreated vessels No DM and ≥1 untreated vessel (DS>50%) No DM and no untreated vessels MACE IVUS MLD (mm) Follow-up of 122 patients with moderate LM disease Independent predictors of months: DM (p=0.004), untreated lesion >50% (p=0.037), and IVUS MLD (p=0.005) – but NOT the plaque burden.

IVUS Predictors of the Events Abizaid et al. JACC 1999;34:707 MLD (mm) CSA(mm 2 ) P= P=0.013

Angiographic Predictors of the Events Abizaid et al. JACC 1999;34:707 MLD (mm) P=NS DS(%) P=NS

Abizaid et al. JACC 1999;34:707

Sano et al. Am J Cardiol 2006;98:99M

MLA=12.5 mm 2 MLD=4 mm MLA=22 mm 2 Baseline FFR=0.85

MLA =4.3 mm 2 MLD= 2.3 mm MLA=9.1 mm 2 MLD=3.4 mm Baseline FFR=0.63

mm

Treatment of LMCA Disease

对角支 支架未贴壁

IVUS-guided DES Implantation 102 Pts with LM Disease Treated with Cypher Stents (Park et al. J Am Coll Cardiol 2005;45:351-6) 53 Pts with LM Disease Treated with Taxus Stents (Erglis et al. J Am Coll Cardiol 2007;50:491-7)

“Optimal” MSA and TLR after DES Implantation (n=595) 8.7 Minimum stent area (mm 2 ) (SJ Park et al. TCT 2007) Malaposition and underexpansion

Independent predictors of mortality in 805 patients with LMCA disease treated with DES (SJ Park et al. TCT 2007) HR 95% CI P Previous CHF Previous CHF Chronic Renal Failure Chronic Renal Failure <0.001 COPD COPD Euroscore ≥ 6 Euroscore ≥ IVUS guidance IVUS guidance

Impact of IVUS Guidance on All- Cause Mortality After LMCA DES Implantation (n=805) (SJ Park et al. TCT 2007) Years after DES implantation Cumulative Incidence ( %) IVUS (n=595) No IVUS (n=210) % 85.6% HR=0.43, p=0.019

Using IVUS, most LM lesions show either insignificant disease or critical disease Using IVUS, most LM lesions show either insignificant disease or critical disease Absolute lumen CSA <6.0mm 2 (or MLD <3.0mm) – independent of plaque burden - is the suggested criterion for a significant LMCA stenosis Absolute lumen CSA <6.0mm 2 (or MLD <3.0mm) – independent of plaque burden - is the suggested criterion for a significant LMCA stenosis Correlates with a LMCA FFR<0.75 Correlates with a LMCA FFR<0.75 Murray’s Law ( LMCA r 3 = LAD r 3 + LCX r 3 ) Murray’s Law ( LMCA r 3 = LAD r 3 + LCX r 3 ) Does not depend on finding a disease-free reference segment Does not depend on finding a disease-free reference segment The best available data indicates that IVUS-guidance during LM DES implantation will reduce 3-year mortality; the final MSA should be >8.5mm 2 to minimize TLR. The best available data indicates that IVUS-guidance during LM DES implantation will reduce 3-year mortality; the final MSA should be >8.5mm 2 to minimize TLR. Summary

Is IVUS guidance necessary for the optimal diagnosis and treatment of left main lesions? Is IVUS guidance necessary for the optimal diagnosis and treatment of left main lesions? Given all of this data, the known limitations of angiography, and the risks of making a mistake, how can you possibly argue otherwise? Given all of this data, the known limitations of angiography, and the risks of making a mistake, how can you possibly argue otherwise? Conclusion

THANK YOU !