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

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

3. 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

4. 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:

5. 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

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

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

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

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

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

11. 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

12. 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

13. 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

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

15. 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 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

16. 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
Gender:
Male
Age: 54
6 mo shows no new stenosis,
and similar chemogram
Dr. David Rizik, Scottsdale Hospital, Scottsdale AZ.

17. Multimodality Coronary Imaging: A Glimpse of the Future?
Garg et al, EuroIntervention, 2010;5:

18. 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.

19. 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

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

21. 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