Cardiovascular Research Foundation

Cardiovascular Research Foundation

New York, NY
New York, NY
Pre-Intervention IVUS
Pre-Intervention IVUS
Gary S. Mintz, MD
Gary S. Mintz, MD

Weigh otential ro!le"s #i$e$ %& disease, signi'icant Weigh otential ro!le"s #i$e$ %& disease, signi'icant
ro(i"al or distal disease) ro(i"al or distal disease)

*ssess lesion severit+ *ssess lesion severit+

*ssess unusual lesion "orholog+ #i$e$, aneur+s"s, *ssess unusual lesion "orholog+ #i$e$, aneur+s"s,
calciu", thro"!i, high-risk "orholog+, in-stent calciu", thro"!i, high-risk "orholog+, in-stent
restenosis, etc$) restenosis, etc$)

&easure vessel si,e &easure vessel si,e

&easure lesion length &easure lesion length

-eter"ine and 'ine-tune the results -eter"ine and 'ine-tune the results

*ssess co"lications *ssess co"lications

&ost o' the concets used in IVUS-guided intervention are &ost o' the concets used in IVUS-guided intervention are
no di''erent 'ro" those used in angiograh+-guided no di''erent 'ro" those used in angiograh+-guided
intervention$ .owever, unlike angiograh+, IVUS is actuall+ intervention$ .owever, unlike angiograh+, IVUS is actuall+
a!le to "ake recise "easure"ents and assess lesion a!le to "ake recise "easure"ents and assess lesion
"orholog+$ "orholog+$
/ /
0"" 0"" 12"" 12""
Pro(i"al Pro(i"al
Re'erence Re'erence
%esion %esion
Site Site
-istal -istal
Re'erence Re'erence
33& CS* 4 21$5 33& CS* 4 21$5
%u"en CS* 4 6$7 %u"en CS* 4 6$7
&a(i"u" lu"en dia"eter 4 02$8 &a(i"u" lu"en dia"eter 4 02$8
&%- 4 2$0 &%- 4 2$0
P9& CS* 4 33&-%u"en 4 1:$1 P9& CS* 4 33&-%u"en 4 1:$1
3ccentricit+ 4 &a(i"u";"ini"u" P9& 4 0$/;/$1 3ccentricit+ 4 &a(i"u";"ini"u" P9& 4 0$/;/$1
Pla<ue !urden 4 P9&;33& 4 :=> Pla<ue !urden 4 P9&;33& 4 :=>
*rea stenosis 4 re'erence-lesion;re'erence lu"en area 4 72> *rea stenosis 4 re'erence-lesion;re'erence lu"en area 4 72>
0 10 50mm
b
a
c
76% 74%
69%
67%
a
b
c
Mintz et al. J Am Coll Cardiol 1995;25:1479-85 Mintz et al. J Am Coll Cardiol 1995;25:1479-85
In 886 native coronar+ arteries, the la<ue !urden in the
angiograhicall+ ?nor"al@ re'erence seg"ent was 71A10>
and :2A12> o' la<ue volu"e #range 65-85>) is in non-stenotic
seg"ents
Tinana et al. Am J Cardiol 2002;89:757-60 Tinana et al. Am J Cardiol 2002;89:757-60
Coronar+ Re"odeling .+othesis
Coronar+ Re"odeling .+othesis
Co"enator+ 3(ansion
&aintains Consistant %u"en
3(ansion
Bverco"eC
%u"en Narrows
Nor"al
Vessel
&ini"al
C*-
&oderate
C*-
Severe
C*-
* D
- 3
'
'E
C
F
distal
%u"en
e
!
eE
!E
%u"en
Positive Re"odeling Positive Re"odeling
Negative Re"odeling Negative Re"odeling
c
cE
distal
33& 33&
33& 33&
Re"odeling is not Fust acade"ic$
Re"odeling is not Fust acade"ic$
Positive re"odeling is associated with
Positive re"odeling is associated with

Acute coronary syndrome at presentation Acute coronary syndrome at presentation

CK-MB elevation after percutaneous coronary intervention CK-MB elevation after percutaneous coronary intervention

No reflow in primary infarct angioplasty No reflow in primary infarct angioplasty

Recurrent ischemia within one month after thrombolysis Recurrent ischemia within one month after thrombolysis
for acute myocardial infarction for acute myocardial infarction

arget lesion revasculari!ation in patients undergoing arget lesion revasculari!ation in patients undergoing
nonstent intervention and intimal hyerplasia in patients nonstent intervention and intimal hyerplasia in patients
undergoing bare metal stent intervention undergoing bare metal stent intervention

Ma"or adverse coronary events in patients with unstable Ma"or adverse coronary events in patients with unstable
angina undergoing any form of revasculari!ation angina undergoing any form of revasculari!ation

#n-hospital complications$ ma"or adverse coronary events$ #n-hospital complications$ ma"or adverse coronary events$
restenosis$ and new lesion formation in patients with restenosis$ and new lesion formation in patients with
stable angina undergoing single vessel intervention% stable angina undergoing single vessel intervention%
%esion Calci'ication #n41177)
%esion Calci'ication #n41177)
Calci'ication
&

o
f

a
n
g
i
o
g
r
a
p
h
i
c

l
e
s
i
o
n
s
#'() *uadrants of calcium
Suer'icial calci'ication
&

o
f

a
n
g
i
o
g
r
a
p
h
i
c

l
e
s
i
o
n
s
#'() *uadrants of
superficial calcium
Mintz et al. Circlation1995;91:1959-65. Mintz et al. Circlation1995;91:1959-65.
Ghe onl+ redictor o' IVUS calciu" was angiograhic calci'ication Ghe onl+ redictor o' IVUS calciu" was angiograhic calci'ication
elsewhere in the coronar+ tree$ elsewhere in the coronar+ tree$ +u!cu et al% , AM Coll Cardiol -../0123451-46 +u!cu et al% , AM Coll Cardiol -../0123451-46
0
5
1 0
1 5
2 0
2 5
3 0
N o n eO n e T w o T h r e e F o u r
S e v e r e
M o d e r a t e
N o n e / M i l d
0
5
1 0
1 5
2 0
2 5
3 0
3 5
4 0
N o n eO n e T w o T h r e e F o u r
S e v e r e
M o d e r a t e
N o n e / M i l d
%esion 3ccentricit+ #n41665)
%esion 3ccentricit+ #n41665)
Mintz et al. Circlation 1996;9!:924-9!1 Mintz et al. Circlation 1996;9!:924-9!1
0
1 0
2 0
3 0
4 0
5 0
6 0
1 . 0 - 3. 0 3 . 0 - 5. 0 5 . 0 - 7. 0 > 7 . 0
Y e s
N o
3ccentricit+
&

o
f

a
n
g
i
o
g
r
a
p
h
i
c

l
e
s
i
o
n
s
#'() Ma78Min
9:M hic;ness
&a(i"u" la<ue thickness sares the 'low divider in
&a(i"u" la<ue thickness sares the 'low divider in
nearl+ all cases and la<ue deosition is usuall+
nearl+ all cases and la<ue deosition is usuall+
oosite the side!ranch$
oosite the side!ranch$
"imra et al. J Am Coll Cardiol 1996;27:825-!1 "imra et al. J Am Coll Cardiol 1996;27:825-!1
Unusual %esion &orholog+
Unusual %esion &orholog+

*ngiograhic 'illing de'ects *ngiograhic 'illing de'ects

Ghro"!i Ghro"!i

Calci'ied nodules Calci'ied nodules

*ngiograhic aneur+s"s *ngiograhic aneur+s"s

Grue aneur+s"s Grue aneur+s"s

Pseudoaneur+s"s Pseudoaneur+s"s

Co"le(;rutured la<ues Co"le(;rutured la<ues

Nor"al seg"ents adFacent to one or "ore stenoses Nor"al seg"ents adFacent to one or "ore stenoses

*cute coronar+ s+ndro"es *cute coronar+ s+ndro"es

Pla<ue rutures Pla<ue rutures

*ttenuated la<ues *ttenuated la<ues

Calci'ied nodules Calci'ied nodules

Sontaneous dissections Sontaneous dissections

*ngiograhic ha,+ lesions *ngiograhic ha,+ lesions

B
<ong et al , Am Coll Card 1==>0?/31/--> <ong et al , Am Coll Card 1==>0?/31/-->
@istance from coronary ostium +mm6 @istance from coronary ostium +mm6
A of ruptured pla*ues A of ruptured pla*ues
IVUS Classi'ication o'
*ngiograhic *neur+s"s
B' :: angiograhic aneur+s"s

21 #2:>) true aneur+s"

0 #6>) seudoaneur+s"

12 #15>) co"le( la<ues or unhealed dissections

61 #70>) nor"al seg"ent adFacent to one or "ore

stenoses
Grue
*neur+s"
PS* Co"le(
Pla<ue
Nor"al Site with
*dFacent Stenoses
No prior 9C# -= = / 1/
9rior 9C# -- 5 / ->
#Mae$ara et al Am J Cardiol 2001;88:!65-70% #Mae$ara et al Am J Cardiol 2001;88:!65-70%
0 2.5 10.0mm
0 3.5 17.5mm
0 1.5 7.5mm
Ghree Vessel IVUS I"aging in 26
Ghree Vessel IVUS I"aging in 26
Pts with *CS and Positive Gn
Pts with *CS and Positive Gn

7/ rutured la<ues 7/ rutured la<ues

= culrit lesion = culrit lesion

61 nonculrit lesion 61 nonculrit lesion

1= ts had at least 1 1= ts had at least 1

nonculrit la<ue ruture nonculrit la<ue ruture
#:=>) #:=>)

1: ts had 1 la<ue ruture 1: ts had 1 la<ue ruture

in a second arter+ in a second arter+

0 ts had la<ue rutures in 0 ts had la<ue rutures in

all 0 arteries all 0 arteries
Rioufol et al Circulation 2002;106:804-808 Rioufol et al Circulation 2002;106:804-808
%
# of Ruptured Plaques
Rutured la<ues in atients with
Rutured la<ues in atients with
&I and sta!le angina
&I and sta!le angina
Number of ruptured plaques per patient
% of patients
(Hong et al Circulation 2004;110:928-33) (Hong et al Circulation 2004;110:928-33)
In &I, the onl+ indeendent redictor o' la<ue
ruture was elevated CRP #4/$/07, BR42$10=)$
In sta!le angina, the onl+ indeendent redictor
was dia!etes "ellitus #4/$/06, BR42$770)$
%ocation o' 2:0 rutured la<ues in 178 atients
%ocation o' 2:0 rutured la<ues in 178 atients
with *CS and 68 atients with sta!le angina and
with *CS and 68 atients with sta!le angina and
three vessel IVUS
three vessel IVUS
-istance 'ro" coronar+ ostiu" #"") -istance 'ro" coronar+ ostiu" #"")
H o' rutured la<ues H o' rutured la<ues
%ength o' arter+ i"aged !eginning at the coronar+ ostiu" #"") %ength o' arter+ i"aged !eginning at the coronar+ ostiu" #"")
H o' arteries H o' arteries
#&on' et al J Am Coll Card 2005;46:261-5% #&on' et al J Am Coll Card 2005;46:261-5%
Co"arison o' Culrit I Non-Culrit Ruture Sites in
Co"arison o' Culrit I Non-Culrit Ruture Sites in
*CS Patients and Ruture Sites in Non-*CS Patients
*CS Patients and Ruture Sites in Non-*CS Patients
4/$//1 4/$//1
4/$//1 4/$//1
ACS Culprit Plaque ACS Culprit Plaque
Ruptures (N=35) Ruptures (N=35)
ACS NonCulprit Plaque ACS NonCulprit Plaque
Ruptures (N=!") Ruptures (N=!")
NonACS Plaque NonACS Plaque
Ruptures (N=!#) Ruptures (N=!#)
(mm
!
)
(nde)endent )redictor* o+ AC, -ere M.A and t$rom/* #/ot$ )00.01% (nde)endent )redictor* o+ AC, -ere M.A and t$rom/* #/ot$ )00.01%
Fuji et al. Circulation 2003;108:2473-8 Fuji et al. Circulation 2003;108:2473-8
2"" 2"" 5"" 5"" / /
0 0 1.0 1.0 6.0mm 6.0mm
What is the 'ate o' non-'low-li"iting
What is the 'ate o' non-'low-li"iting
rutured la<ues
rutured la<ues

16 ts with 28 la<ue rutures with &%* J6$/"" 16 ts with 28 la<ue rutures with &%* J6$/""
2 2
treated with treated with
statins and dual antilatelet thera+ statins and dual antilatelet thera+

*t 22A10 "onths, hal' had healed with no clincal events *t 22A10 "onths, hal' had healed with no clincal events

#Rio'ul et al$ Circulation 2//6K11/C28:7-8/) #Rio'ul et al$ Circulation 2//6K11/C28:7-8/)

28 ts with non-culrit la<ue rutures #onl+ hal' treated with 28 ts with non-culrit la<ue rutures #onl+ hal' treated with
statins) were 'ollowed 'or 11$=A1$0 "onths statins) were 'ollowed 'or 11$=A1$0 "onths

Statin-treated atients had a decrease in la<ue area o' /$5A/$8"" Statin-treated atients had a decrease in la<ue area o' /$5A/$8""
2 2

#vs an increase o' /$0A/$:"" #vs an increase o' /$0A/$:""
2 2
in controls, 4/$//7)$ in controls, 4/$//7)$

Co"lete healing was o!served in 6 #2=>) statin-treated vs no Co"lete healing was o!served in 6 #2=>) statin-treated vs no
control atients #4/$/6=)$ control atients #4/$/6=)$

Garget lesion revasculari,ation was er'or"ed in 0 control #21>) vs Garget lesion revasculari,ation was er'or"ed in 0 control #21>) vs
no statin-treated atient #4/$11)$ no statin-treated atient #4/$11)$

%esions re<uiring revasculari,ation had a decrease in lu"en area #- %esions re<uiring revasculari,ation had a decrease in lu"en area #-
1$:A1$6"" 1$:A1$6""
2 2
vs /$1A/$8"" vs /$1A/$8""
2 2
, 4/$//1) as well as an increase in la<ue , 4/$//1) as well as an increase in la<ue
area #1$1A1$/"" area #1$1A1$/""
2 2
vs -/$0A/$:"" vs -/$0A/$:""
2 2
, 4/$/6)$ , 4/$/6)$

#.ong et al$ *therosclerosis$ 2//:K1=C1/:-16) #.ong et al$ *therosclerosis$ 2//:K1=C1/:-16)

Su!clinical la<ue rutures heal and
have a role in lesion rogression

In 162 "en with sudden cardiac death, the "echanis" o' death
was resu"ed to !e acute la<ue ruture

with acute
thro"!us in 66, acute la<ue erosion with acute thro"!us
in 20, sta!le la<ue with healed &I in 61, and sta!le la<ue
without &I in 06
Ghere were 18= healed ruture sites$ .ealed rutures were resent
in :7> o' hearts

with acute la<ue ruture and 8/> o' hearts with
sta!le la<ue

and healed &I
B' the 66 acute ruture sites, = showed 1 healed

revious ruture
site, = showed 2 healed revious ruture sites,

= showed 0 healed
revious ruture sites, and 5 showed 6 healed

revious ruture
sites$
*cute rutures at sites o' L0 healed revious rutures

de"onstrated greater underl+ing la<ue !urden #=6A6>)

than
those without healed revious ruture #:6A12>)$
#1r2e et al. Circlation 2001;10!;9!4-40% #1r2e et al. Circlation 2001;10!;9!4-40%
0 3.0 12.0mm
0 8 40mm
The HCI SCAD Registry
)CA@ NB15
Med R7 without stent or CABC
NB-?
#nitial 9C# attempted
NB5
Coronary stenting without CABC
NB5
#nitial med R7 attempted
NB-4
#nitial CABC
NB5
9C# after initial med R7
NB1
CABC after 9C# attempt
NB-
CABC after initial med R7
NB-
Med R7 after failed
thrombectomy
NB-
CABC
NB/
9C# attempted otal
NB>
hrombolysis NB1
Coronary Angiograms
NB15
#(to et al. JACC Cardio3a*clar (nter3ention*4 in )re**% #(to et al. JACC Cardio3a*clar (nter3ention*4 in )re**%
Wrinkling
Wrinkling
0 1.5 9.0mm
Attenuated 9la*ue
Attenuated 9la*ue
Dee et al% ,ACC Cardiovasc #nterv% 1==.013/>-21
Eu et al$ Am , Cardiol 1=-=0-=>3?4->5
Attenuated pla*ues were observed in 5.%/& of )FM#$ -2%/& of N)FM#$ and =&
of stable angina%
Attenuate pla*ues were associated with more fibroatheromas and a larger necrotic
core +on '<-#'()6%
#n AC) patients with attenuated pla*ues +-6 the level of CR9 was higher$ +16
angiographic thrombus and initial coronary flow G#M# 1 were more common$ and +56
no-reflow or flow deterioration post-9C# were more common%
Validation o' IVUS assess"ent o' ische"ia-
Validation o' IVUS assess"ent o' ische"ia-
roducing stenoses #-oler FloWire,
roducing stenoses #-oler FloWire,
SP3CG, and Pressure Wire)
SP3CG, and Pressure Wire)
? ? 5. 5. CHR CHR 1%= 1%=
12 12 1 1 CHR G 1%= CHR G 1%=
#'() MDA
G?%=mm
1
#'() MDA
I?%=mm
1
@iagnostic accuracy B .1&% @iagnostic accuracy B .1&%
Abi!aid et al% Am , Cardiol -..40413?1-4 Abi!aid et al% Am , Cardiol -..40413?1-4
- - 1= 1= - )pect - )pect
?1 ?1 ? ? J )pect J )pect
#'() MDA
G?%=mm
1
#'() MDA
I?%=mm
1
@iagnostic accuracy B .5&% @iagnostic accuracy B .5&%
Nishio;a et al% , Am Coll Cardiol -...0553-42=-4 Nishio;a et al% , Am Coll Cardiol -...0553-42=-4
a;agi$ et al% Circulation a;agi$ et al% Circulation
-...0-==31>=-> -...0-==31>=->
85 ts
Nishioka G,
M*CC 1===
Gakagi et al
Cir$ 1===
*!i,aid et al
*MC 1==8
:/ lesions

62 ts
&%* #""
2
) 0$092$0 0$=A2$/ 6$6A2$/
&V* #""
2
) 10$2A6$6
*rea stenosis> 77A26 60A26
Cut-o'' o' &%*
#""
2
)
N6$/
#Ghalliu" 9)
N0$/
#FFR N/$:7)
J 6$/
#CFR J2$/)
OC* V- #"")
-S #>)

Sensitivit+4=/>
Seci'icit+45/>
PPV40:>
NPV4=5>
*ccurac+458>
IVUS vs FFR in 2/1 ts #205
inter"ediate lesions)
= 1= ?= /= 4= -==
-==-)pecificity
-==
4=
/=
?=
1=
=
)
e
n
s
i
t
i
v
i
t
y
Cut-o'' 42$62""
2
A(CB=%4==
.>& C#B=%2?1-=%4?4
"an' et al. Circlation Cardio3a*clar (nter3ention*4 in )re**
&%* ""
2
/ > ? 5 1 - =
=%4
FFR J/$8

2$6 ""
2
FFR N/$8

V3R-ICG Pilot
V3R-ICG Pilot
9rospective$ multicenter$ non-randomi!ed$ non-blinded study in
5== intermediate coronary lesions
+@) K?=& - G4=&$ R'@ 1%2> L ?%= mm6
HHR and '<-#'() assessment of all lesions
-= sites in () and F(0 )ponsor3 'olcano Corp%
9rospective$ multicenter$ non-randomi!ed$ non-blinded study in
5== intermediate coronary lesions
+@) K?=& - G4=&$ R'@ 1%2> L ?%= mm6
HHR and '<-#'() assessment of all lesions
-= sites in () and F(0 )ponsor3 'olcano Corp%
-% F7amine concordance between HHR and '<-#'() parameters
1% Fstablish #'() values for MDA8length8volume to predict ischemia +RMC6
5% N #ncremental correlative value of fibroatheromas for ischemia
?% #nform a large-scale$ randomi!ed trial
-% F7amine concordance between HHR and '<-#'() parameters
1% Fstablish #'() values for MDA8length8volume to predict ischemia +RMC6
5% N #ncremental correlative value of fibroatheromas for ischemia
?% #nform a large-scale$ randomi!ed trial
'ascular Fvaluation for Revasculari!ation3
@efining #ndications for Coronary herapy
)tudy Fndpoints and Mb"ectives3


C$ Mctober -? th $ 1==4
C$ Mctober -? th $ 1==4
Nico <%,%9i"ls$ M@$ 9h@ Nico <%,%9i"ls$ M@$ 9h@
Catharina <ospital$ Findhoven Catharina <ospital$ Findhoven
he Netherlands$ he Netherlands$
on behalf of the HAMF investigators on behalf of the HAMF investigators
HAMF3 HRAC#MNAD HDME RF)FR'F
HAMF3 HRAC#MNAD HDME RF)FR'F
versus ANC#MCRA9<O
versus ANC#MCRA9<O
HMR C(#@#NC 9C# #N 9A#FN) E#<
HMR C(#@#NC 9C# #N 9A#FN) E#<
M(D#'F))FD CMRMNARO ARFRO @#)FA)F
M(D#'F))FD CMRMNARO ARFRO @#)FA)F


Date Brea;ing rial at
Date Brea;ing rial at

*NPIB-grou
N46=5
FFR-grou
N47/=
9-value 9-value
# indicated lesions per patient # indicated lesions per patient
2$: A /$= 2$8 A 1$/ =%5? =%5?
FFR results FFR results
Desions succesfully measured$ Desions succesfully measured$ No +&6 No +&6 - 102= #=8>) - -
Desions with HHR I =%4=$ Desions with HHR I =%4=$ No +&6 No +&6 - 8:6 #50>) - -
Desions with HHR P =%4=$ Desions with HHR P =%4=$ No +&6 No +&6 - 710 #0:>) - -
Stents per patient Stents per patient
2$: A 1$2 1$= A 1$0 G=%==- G=%==-
Desions succesfully stented Desions succesfully stented +&6 +&6 =2> =6> - -
@F)$ total$ @F)$ total$ No No 107= =8/ - -
HAMF study3
HAMF study3
9rocedural Results
9rocedural Results
HHR-guided
5= days
1%.&
.= days
5%4&
-4= days
?%.&
5/= days
>%5&
Angio-guided
absolute difference in MACF-free survival
HAMF study3
HAMF study3
Fvent-free )urvival
Fvent-free )urvival
Hisher et al% Cathet Cardiovasc @iagn -.41043>/>-2>
Comparison between percent stenosis Comparison between percent stenosis
assessment from the *uality control +QC6 lab vs assessment from the *uality control +QC6 lab vs
the clinical site in the CA)) )tudy the clinical site in the CA)) )tudy
Rarea of the s*uare is proportional to the number of cases Rarea of the s*uare is proportional to the number of cases
QC lab QC lab
Clinical site Clinical site
-== -==
= = -== -==
= =
B' all the coronar+ seg"ents, the %&C* has
B' all the coronar+ seg"ents, the %&C* has
the greatest angiograhic assess"ent
the greatest angiograhic assess"ent
varia!ilit+ - I
varia!ilit+ - I
B' all the coronar+ seg"ents, the %& has
B' all the coronar+ seg"ents, the %& has
the greatest angiograhic assess"ent
the greatest angiograhic assess"ent
varia!ilit+ - II
varia!ilit+ - II
Cameron et al% Circulation -.450/43?4?-?4.
Hive grades of DM Hive grades of DM
severity severity
-3 -3 =-1?& @) =-1?& @)
13 13 1>-?.& @) 1>-?.& @)
53 53 >=-2?& @) >=-2?& @)
?3 ?3 2>-4.& @) 2>-4.& @)
>3 >3 .=--==&@) .=--==&@)
A of grades of difference in assessment A of grades of difference in assessment
of DM severity of DM severity
=3 =3 no difference no difference
J- or --3 J- or --3 - grade difference - grade difference
J1 or -13 J1 or -13 1 grades of difference 1 grades of difference
J5 or -53 J5 or -53 5 grades of difference 5 grades of difference
J? or -?3 J? or -?3 ? grades of difference ? grades of difference
Clinical site vs Clinical site vs
Quality control Quality control
Clinical site vs Clinical site vs
)tudy Croup )tudy Croup
)tudy Croup vs )tudy Croup vs
Quality control Quality control
Lindstaedt et al. Int J Cardiol 200!"20#2$%&'"
Dut surel+ we are !etter toda+ - IQ
Dut surel+ we are !etter toda+ - IQ

>- intermediate or e*uivocal DM lesions were evaluated by >- intermediate or e*uivocal DM lesions were evaluated by
HHR and angiography% Hour e7perienced interventional HHR and angiography% Hour e7perienced interventional
cardiologists visually classified lesions as SsignificantT$ Snot cardiologists visually classified lesions as SsignificantT$ Snot
significantT$ or Sunsure%T significantT$ or Sunsure%T

he ? e7perienced interventional cardiologists achieved he ? e7perienced interventional cardiologists achieved

correct lesion classification in no more than correct lesion classification in no more than U U>=& of each >=& of each
case regardless of the HHR threshold +I=%2> or I=%4=6% case regardless of the HHR threshold +I=%2> or I=%4=6%

#nterobserver variability was large$ resulting in unanimous #nterobserver variability was large$ resulting in unanimous
correct lesion classification in only 1.&V correct lesion classification in only 1.&V
Which o' these %&C* lesions is
Which o' these %&C* lesions is
signi'icant and, there'ore, should !e
signi'icant and, there'ore, should !e
treatedR *nd which is notRR
treatedR *nd which is notRR
0 1.5 6.0mm
0 3.0 9.0mm
0 2.0 5.0mm
&%*46$5""
2
0 2.0 8.0mm
0 1.0 4.0mm
IVUS deter"inants o' %&C* FFR
IVUS deter"inants o' %&C* FFR
N/$:7
N/$:7
,asti ,asti et al% Circulation et al% Circulation 1==?0--=3145--/ 1==?0--=3145--/
IVUS Criteria 'or a
IVUS Criteria 'or a
SSigni'icantT %&C*
SSigni'icantT %&C*
Stenosis
Stenosis

&ost IVUS %&C* studies show either insigni'icant disease &ost IVUS %&C* studies show either insigni'icant disease
or critical disease or critical disease

*!solute lu"en CS* N5$/"" *!solute lu"en CS* N5$/""

2 2
#or &%- N0$/"") is the #or &%- N0$/"") is the
suggested criterion 'or a signi'icant %&C* stenosis suggested criterion 'or a signi'icant %&C* stenosis

Correlates with a %&C* FFRN/$:7 Correlates with a %&C* FFRN/$:7

-oes not deend on 'inding a disease-'ree re'erence -oes not deend on 'inding a disease-'ree re'erence
seg"ent seg"ent

%ong ter" data #%IGRB registr+) %ong ter" data #%IGRB registr+)

It is not clear whether the sa"e criteria should !e used 'or It is not clear whether the sa"e criteria should !e used 'or
ostial %& lesions as 'or "id-sha't;distal !i'urcation lesions ostial %& lesions as 'or "id-sha't;distal !i'urcation lesions
and 'or ositivel+ vs negativel+ re"odeled lesions and 'or ositivel+ vs negativel+ re"odeled lesions
9la*ue burden +9:M8FFM6 B /4& 9la*ue burden +9:M8FFM6 B /4&
MDAB2%1mm MDAB2%1mm
1 1
#'() assessment of DM disease
#'() assessment of DM disease
significance is based on lumen
significance is based on lumen
dimensions$ not pla*ue burden
dimensions$ not pla*ue burden
?
?
S"all@ %& 4 -i''use %&C* disease
S"all@ %& 4 -i''use %&C* disease

&urra+ &urra+Ts %aw Ts %aw

%&C* %&C*
r r
0 0
4 4
%*- %*-
r r
0 0
9 9
%CU %CU
r r
0 0

Fractal Peo"etr+ Fractal Peo"etr+

%&C* %&C*
- 4 /$5:8 # - 4 /$5:8 #
%*- %*-
- 9 - 9
%CU %CU
-) -)
(C) DS *+,
Fractal (C) DS *+,
/
2/
:/
/
2/
:/
Matreff et al% Furointervention 1=-=0>32=.-->
-rospecti.e application o/ prede/ined I01S criteria /or -rospecti.e application o/ prede/ined I01S criteria /or
re.ascularization o/ inter2ediate le/t 2ain coronary artery re.ascularization o/ inter2ediate le/t 2ain coronary artery
lesions# Results at 2 years /ro2 t3e LI4R5 study lesions# Results at 2 years /ro2 t3e LI4R5 study
5>? patients 5>? patients
MDA MDA K/%=mm K/%=mm
1 1
+nB-4/6 +nB-4/6
MDA G/%=mm MDA G/%=mm
1 1
+nB-/46 +nB-/46
2 revasculari!ed 2 revasculari!ed
No DMCA revasculari!ation No DMCA revasculari!ation
+nB-2.$ ./&6 +nB-2.$ ./&6
DMCA revasculari!ation DMCA revasculari!ation
+nB->1$ .=&6 +nB->1$ .=&6
-/ not revasculari!ed -/ not revasculari!ed
>/& 9C# of other vessels >/& 9C# of other vessels
>>& CABC >>& CABC
?>& 9C# +J other vessels in /1& ?>& 9C# +J other vessels in /1&
@e Da orre <ernande! et al% C 1=-= @e Da orre <ernande! et al% C 1=-=
Clinical outco2e o/ patients 6it3 de/erred Clinical outco2e o/ patients 6it3 de/erred
re.ascularization *ML) 7'22 re.ascularization *ML) 7'22
2 2
, ,
Sur.i.al /ree o/ cardiac
deat3, MI and any
re.ascularization
-80.22
De/er *n8"9,
Re.ascularization *n8"$2,
Sur.i.al /ree o/ cardiac
deat3
-80.20
De/er
Re.ascularization
Sur.i.al /ree o/ cardiac
deat3, MI and LMC)
re.ascularization at 2
years# 9%.2+
Sur.i.al /ree o/ LMC)
re.ascularization at 2
years# 9'.$+
Sur.i.al /ree o/ cardiac
deat3 at 2 years# 9.++
@e Da orre <ernande! et al% C 1=-= @e Da orre <ernande! et al% C 1=-=
Clinical outco2e o/ patients 6it3 .s 6it3out re.ascularization Clinical outco2e o/ patients 6it3 .s 6it3out re.ascularization
@e Da orre <ernande! et al% C 1=-= @e Da orre <ernande! et al% C 1=-=
g
mas
nn
= -== 1== 5== ?== >== /== 2== 4== .==
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2
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De/er *2edical t3erapy, 6it3 ML) ;'22
2<
*n8"',
Sur.i.al /ree o/ cardiac deat3
-80.02
IVUS vs FFR in %&C* -isease
IVUS vs FFR in %&C* -isease

here is probably more agreement between #'() and HHR in here is probably more agreement between #'() and HHR in
assessing DMCA lesion significance than in assessing non- assessing DMCA lesion significance than in assessing non-
DMCA lesion significance DMCA lesion significance

Dimited variability in DMCA length Dimited variability in DMCA length

Dimited variability in amount of supplied myocardium Dimited variability in amount of supplied myocardium

Darge DMCA si!e Darge DMCA si!e

Both have theoretical and practical limitations Both have theoretical and practical limitations

DA@ and8or DCW disease L HHR DA@ and8or DCW disease L HHR

#t is necessary to image the DM from both the DA@ and #t is necessary to image the DM from both the DA@ and
DCW - #'() DCW - #'()

<owever$ #'() provides anatomic information not possible <owever$ #'() provides anatomic information not possible
with HHR with HHR

#n 1>& of patients$ the left main MDA differed

#n 1>& of patients$ the left main MDA differed
by -mm
by -mm
1 1
when imaged from a pullbac;
when imaged from a pullbac;
beginning in the DA@ vs a pullbac; beginning
beginning in the DA@ vs a pullbac; beginning
in the DCW%
in the DCW%

)ince #'() can artificially increase$ but not

)ince #'() can artificially increase$ but not
decrease lumen dimensions$ the smallest MDA
decrease lumen dimensions$ the smallest MDA
is always the most accurate
is always the most accurate
0 0 1.0 1.0
4.0mm 4.0mm
0 0 1.0 1.0 5.0mm 5.0mm
LC= LC=
L)D L)D
3valuation o' the %*- 'ro"
the %&-%CU ull!ack
3valuation o' the %CU 'ro"
the %&-%*- ull!ack
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#'() assessment of DCW ostium from the DA@-
#'() assessment of DCW ostium from the DA@-
DM +or vice versa6 - MD@
DM +or vice versa6 - MD@
Mviedo et al% Am , Cardiol 1=-=0-=>3.?4->?
#f you want to *uantify the degree of lumen compromise$ you
must image the daughter branches directly%
Sensitivit+ Seci'icit+
9la*ue
burden
P?=&
>.& ?>&
9la*ue
burden
P2=&
24& ?1&
3valuation o' the %*- 'ro"
the %&-%CU ull!ack
Sensitivit+ Seci'icit+
9la*ue
burden
P?=&
/2& >>&
9la*ue
burden
P2=&
44& ?1&
3valuation o' the %CU 'ro"
the %&-%*- ull!ack
#'() assessment of DCW ostium from the
#'() assessment of DCW ostium from the
DA@-DM +or vice versa6 L pla*ue burden
DA@-DM +or vice versa6 L pla*ue burden
#f you want to *uantify the pla*ue burden$ you must image the
daughter branches directly%
Mviedo et al% Am , Cardiol 1=-=0-=>3.?4->?
%CU #1) %*- #1)
%&C* #1;1)
52> 16> 16>
6> 0> 2> 1>
%CU #1) %*- #1) %CU #/) %*- #1)
%CU #1) %*- #1) %CU #/) %*- #1) %CU #1) %*- #1) %CU #1) %*- #/)
%&C* #1;/) %&C* #1;/)
%&C* #/;1) %&C* #/;/) %&C* #/;/) %&C* #/;1)
1;1,1,1 1;/,1,1 1;/,1,/
/;1,1,1 /;/,1,/ /;/,1,1 /;1,/,1
IVUS la<ue distri!ution in 16/ distal %&C* !i'urcation lesions
Mviedo et al% Circ Cardiovasc #nterv% 1=-=053-=>--1
=&
-==&
&edina 1,1,1
#n421)
&edina 1,1,/
#n4=)
&edina 1,/,1
#n45)
&edina /,1,1
#n411)
&edina 1,/,/
#n4:)
&edina /,1,/
#n416)
&edina /,/,1
#n412)
&edina /,/,/
#n45/)
*ll lesions
#n48/)
Bthers
Mviedo et al% Circ Cardiovasc #nterv% 1=-=053-=>--1
Inter"ediate in-stent restenosis lesions V II
Inter"ediate in-stent restenosis lesions V II
=-"onth "ini"u" lu"en area that redicts 0-+ear &*C3- =-"onth "ini"u" lu"en area that redicts 0-+ear &*C3-
'ree survival in atients 'ro" G*UUS IV, V, and VI 'ree survival in atients 'ro" G*UUS IV, V, and VI
n4068
n4068
D&S
D&S
C-statistic
C-statistic
Cuto''
Cuto''
&ini"u" lu"en area
&ini"u" lu"en area
/$:0
/$:0
6$/""
6$/""
2 2
n4071
n4071
Ga(us
Ga(us
C-statistic
C-statistic
Cuto''
Cuto''
&ini"u" lu"en area
&ini"u" lu"en area
/$:7
/$:7
6$2""
6$2""
2 2
+@oi et al Circulation #nterventions 1==40-3------4% %
3
diastole systole diastole
D
-
*
C
0 0 2.5 2.5 12.5mm 12.5mm
0 5.0 15.0mm
0 0 2.5 2.5 10.0mm 10.0mm
/ 2$7"" 1/$/""
Pro(i"al Pro(i"al
0 1.5 6.0mm
0 1.5 6.0mm