1. TAVOLA ROTONDA Quale Ruolo Clinico e Quale Rimborso per la Franctional Flow Reserve? Correlazioni anatomo-funzionali FFR vs IVUS Luigi Vignali, Parma Bologna 21 Aprile 2011

2. IVUS guidance in PCI Indications

3. IVUS in evaluation for Post dilatation needs Post-dilatation strategy: With non-compliant balloon shorter than stent in presence of vessel remodelling or uncompleted- apposition Pre Stent Posdil Under expansion Stent Mal apposition IVUS reveals need of postdilatation

4. IVUS-guided stent implantation may be considered for unprotected left main PCI CLASS IIb EVIDENCE C Recommendations for specific percutaneous coronary intervention devices

5. IVUS in ISR Beware that expected ISR might reveal under expanded stent during previous intervention. Because the vessel and plaque and stents became visible, IVUS guidance clarify substrate in failure or previous PCI, and frequently discover under expanded stents IVUS reveals stent underexpansion in ISR

9. Performance Comparison, OCT vs IVUS Spazial Resolution 12 - 15  m100 - 200  m Acquisition Time20 mm/s0.5 - 1 mm/s Tissue Penetration1.0 - 2.0 mm10 mm Contrast enjection during acquisition Every imagesNo contrast IVUS C7 XR

10. Image Comparison 10 Edge dissection during stent implantation  Neointimal growth on previously implanted stent at follow-up ???

11. Validation of IVUS Assessment of Ischemia-producing Stenoses (Doppler FloWire, SPECT, and Pressure Wire) 439 CFR  2.0 272 CFR < 2.0 IVUS MLA <4.0mm 2 IVUS MLA  4.0mm 2 Diagnostic accuracy = 92%. Abizaid et al. Am J Cardiol 1998;82:42-8 120 - Spect 424 + Spect IVUS MLA <4.0mm 2 IVUS MLA  4.0mm 2 Diagnostic accuracy = 93%. Nishioka et al. J Am Coll Cardiol 1999;33:1870-8 Takagi, et al. Circulation 1999;100:250-5

12. IVUS in intermediate assessment Proximal LAD, CX, RCA Takagi, et al. Circulation 1999;100:250-5 Intermediate stenosis assessment: If in Proximal LAD, CC or RCA, the stenosis MLA ≤ 4 mm 2 then is cause isquemia; and must be treated IVUS reveals significance of intermediate lesions, with morphological assessment

13. Clinical follow-up in 357 Intermediate Lesions in 300 Pts with Deferred Intervention after IVUS Imaging Death/MI/TLR @ (mean) 13 mos = 8% overall (2% death/MI and 6% TLR) Death/MI/TLR @ (mean) 13 mos = 8% overall (2% death/MI and 6% TLR) Death/MI/TLR @ (mean) 13 mos = 4.4% in lesions with MLA >4.0mm 2 Death/MI/TLR @ (mean) 13 mos = 4.4% in lesions with MLA >4.0mm 2 Only independent predictor of death/MI/TLR was IVUS MLA (p=0.0041) Only independent predictor of death/MI/TLR was IVUS MLA (p=0.0041) Independent predictors of TLR were DM (p=0.0493) and IVUS MLA (p=0.0042) Independent predictors of TLR were DM (p=0.0493) and IVUS MLA (p=0.0042) IVUS MLD (mm) QCA MLD (mm) 0 0 1 1 2 2 3 3 4 4 0 0 1 1 2 2 3 3 4 4 r=0.339 IVUS MLA (mm 2 ) Death/MI/TLR 2-33-44-5 5555 IVUS MLA (mm 2 ) TLR DM no-DM 2-33-44-5 5555 Abizaid et al. Circulation 1999;100:256-61

14. Confidential information of Boston Scientific Corporation. Do not copy or distribute. In Intermediate stenosis assessment: Event Free Survival is better for the IVUS Criteria vs. the FFR >0.75 Criteria.

15. Follow-up of 122 patients with moderate LEFT MAIN disease Indipendent predictors of MACE @11.7 Months:DM (p=0.004) and IVUS MLD (p=0.005)- but NOT the palque burden Abizaid, et al. J Am Coll Cardiol 1999;34:707-715

17. Intermediate Main Left stenosis assessment: If Main Left MLA ≤ 6 mm 2 cause isquemia and must be treated IVUS in intermediate assessment in Left Main IVUS assess significance of Main Left lesions, where angio fails

18. IVUS determinants of LMCA FFR<0.75 Jasti et al Circulation 2004; 110;2831-6

21. Months Cumulative proportion surviving 01224 Logrank test: p = 0.04 REV 93.4% DEF 98.1% Kaplan-Meier survival free from mortality and infarction 331 Patients 179 pt MLA>6 mm 2 (DEF group) 152 pt MLA<6 mm 2 (REV group) PCI 44% CABG 55% MULTICENTERDED LITRO STUDY INTERMEDIATE LEFT MAIN CORONARY ARTERY LESION Jose’ M de la torre Hernandez et al.JACC 2010;vol55

22. Absolute lumen CSA <5.9 mm 2 (or MLD < 2.8 mm) is the suggested criterion for significant LMCA stenosis IVUS Criteria for a “significant” LMCA stenosis

23. FFR= 0,70 LA= 5,5 LA= 4,5 LA= 8,0

24. Chang-Wook Nam et al 2010;JACC interventions vol 3 :812-7 FFR vs IVUS in Intermediate Coronary Lesions 167 consecutive patients 0 25 50 75 100 FFR guided IVUS guided 91.5% 33,7% The rate of performing PCI according to guiding device 100 90 80 70 60 100200 300 400 Time to event (days) Event Free Survaival (%) P>0.05 Cutoff value FFR 0.80 Cutoff value IVUS MLA >4mm2 (FFR-guided,83 lesion vs IVUS-guided,94 lesion)

25. CORRELATION BETWEEN FFR AND IVUS LUMEN AREA IN 150 INTERMEDIATE CORONARY STENOSIS Itsik Ben-Dior, Ron Waksman et al 2011.JACC For lesion with vessel reference diameters of 2.5-3 mm, 3-3.5 mm and >3.5 mm, the MLA threshold for FFR <0.8 were 2.5,2.8 and 3.7 mm 2 respectively

27. FFR= 0,74

28. COMPLEMENTARY ROLE IVUS FFR OCT PRE INTERVENTION IVUS vessel size lesion lenght FFR Severity lesion POST INTERVENTION ExpansionAppositionCoverageComplication Underexpansion Edge problems IVUS OCT INDICATION Immediatelly after stent implantation 1 Year after DES Implantation Implantation 1 Year after BMS Implantation Implantation Delayed healing; new intimal growth

29. Thank you for your attention For any correspondence: gbiondizoccai@gmail.com For these and further slides on these topics feel free to visit the metcardio.org website: http://www.metcardio.org/slides.html gbiondizoccai@gmail.com http://www.metcardio.org/slides.html