ivus-vh & vulnerable plaque

IVUS-VH & IVUS-VH & Vulnerable PlaqueVulnerable Plaque

IVUS-VH & IVUS-VH & Vulnerable PlaqueVulnerable Plaque

Jang-Ho Bae, MD., PhD.Jang-Ho Bae, MD., PhD.Heart CenterHeart Center

Konyang University HospitalKonyang University HospitalDaejeon City, S. KoreaDaejeon City, S. Korea

CAG 2004.9.2CAG 2004.9.2 Case (48/M), STEMI (ant)

CAG 2004.9.2CAG 2004.9.2 Case (48/M), STEMI (ant)

PCI 2004.9.2PCI 2004.9.2PCI 2004.9.2PCI 2004.9.2

Taxus Express 2, 3.0*24 mm, 10 atm

6 months FU CAG (2005.3.21)6 months FU CAG (2005.3.21)6 months FU CAG (2005.3.21)6 months FU CAG (2005.3.21)

STEMI at 27 months (2006.12.14)STEMI at 27 months (2006.12.14)STEMI at 27 months (2006.12.14)STEMI at 27 months (2006.12.14)

PCI 2006.12.14PCI 2006.12.14PCI 2006.12.14PCI 2006.12.14

Guide wire Thrombectomy

Lumen volume Lumen volume 394.0 mm394.0 mm33

Vessel volume Vessel volume 959.5 mm959.5 mm33

Plaque Volume Plaque Volume 565.5 mm565.5 mm33

Segment lengthSegment length 33.9 mm 33.9 mm

Fibrous volume Fibrous volume 257.1 mm257.1 mm33 63% 63%Fibro-fatty volume Fibro-fatty volume 50.8 mm 50.8 mm33 12% 12%Dense-calcium volume Dense-calcium volume 25.7 mm 25.7 mm33 5%5%Necrotic-core volume Necrotic-core volume 77.8 mm 77.8 mm33 19% 19%

ContentsContentsContentsContents

1.1. VP & TCFAVP & TCFA

2.2. Fate of VP / intermediate lesionFate of VP / intermediate lesion

3.3. Konyang experience with VPKonyang experience with VP

1.1. VP & TCFAVP & TCFA



Underlying Pathologies of Culprit Coronary Lesions Underlying Pathologies of Culprit Coronary Lesions (thrombotic coronary death and ACS)(thrombotic coronary death and ACS)

Ruptured plaques (~70%) Stenotic (~20%) Nonstenotic (~50%)

Nonruptured plaques (~30%) Erosion Calcified nodule Others/Unknown

Naghavi M. et al. Circulation 2003;108:1772-8

Vulnerable PlaqueVulnerable PlaqueVulnerable PlaqueVulnerable Plaque

• Lesions are likely to ruptureLesions are likely to rupture

• Lesions composed of a lipid-rich Lesions composed of a lipid-rich core in the central portion of an core in the central portion of an eccentric plaque with a thin eccentric plaque with a thin friable capfriable cap

• Lesions are likely to ruptureLesions are likely to rupture

• Lesions composed of a lipid-rich Lesions composed of a lipid-rich core in the central portion of an core in the central portion of an eccentric plaque with a thin eccentric plaque with a thin friable capfriable cap

Muller et al. Ann Epidemiol 1992Muller et al. Ann Epidemiol 1992

Libby et al. Circulation1995Libby et al. Circulation1995

Pathologic Definition of VPPathologic Definition of VPIt can not be detectable in clinical practiceIt can not be detectable in clinical practice

Major criteriaMajor criteria• Active inflammation Active inflammation (monocyte/macrophage and sometimes T-cell infiltration)(monocyte/macrophage and sometimes T-cell infiltration)• Thin cap with large lipid coreThin cap with large lipid core• Endothelial denudation with superficial platelet aggregationEndothelial denudation with superficial platelet aggregation• Fissured plaqueFissured plaque• Stenosis > 90% Stenosis > 90%

Minor criteriaMinor criteria• Superficial calcified noduleSuperficial calcified nodule• Glistening yellowGlistening yellow• Intraplaque hemorrhageIntraplaque hemorrhage• Endothelial dysfunctionEndothelial dysfunction• Outward (positive) remodeling Outward (positive) remodeling

Naghavi et al. Circulation 2003;108:1664-72The Center of Vulnerable Plaque Research

70% of ACS 70% of ACS culprit lesionsculprit lesions

30% of ACS culprit lesions30% of ACS culprit lesions

Naghavi et al. Circulation 2003;108:1664-72Gossl M et al. Med Clin N Am 2007;91:573-601

“Vulnerable Plaque” = plaque not only prone to thrombosis/rupture but also at risk for

rapid progression

“Vulnerable Plaque” = plaque not only prone to thrombosis/rupture but also at risk for

rapid progression

Thin Cap Fibroatheroma (TCFA)Thin Cap Fibroatheroma (TCFA)

Lipid CoreFibrous Cap

Intimal Inflammation

• Most common type of VP• Lesion at risk for rupture• Lesion that most resembles the acute plaque rupture• Area narrowing <75% (diameter stenosis <50%) in over 75%

>10% area of the plaque3mm2 in 75% of caseLength; 2-17mm (mean 8mm)

<65 umMean cap thickness+2SDof ruptured plaque

Macrophage infiltration>25 cells/0.3mm diameter

Virmani R et al. J Interven Cardiol 2003;16:267-72Virmani R et al. JACC 2006;47:C13-8

Morphologic Variants of the TCFAMorphologic Variants of the TCFAMorphologic Variants of the TCFAMorphologic Variants of the TCFA

InsignificantInsignificantplaque burdenplaque burden

Large eccentricLarge eccentricnecrotic corenecrotic core

Large concentricLarge concentricnecrotic corenecrotic core

HealedHealedrupture(s)rupture(s)

Most common typeMost common type

Kolodgie FD et al. Curr Opin Cardiol 2001;16:285-92

New Methodologies to Detect VPNew Methodologies to Detect VP

1. MRI2. Coronary CT3. Conventional gray-scale IVUS4. Angiography5. OCT6. Thermography7. VH-IVUS8. NIR, …..

IVUS-RF Data AnalysisIVUS-RF Data AnalysisIVUS-RF Data AnalysisIVUS-RF Data Analysis

ROI lengthROI length480480uumm

LumenLumen

EEMEEM

ROI width=124 scan lines

64 samples along each line

(240 lines/frame)

1 IVUS scan line

Plaque Classification TreePlaque Classification TreeBased on 8 spectral parameterBased on 8 spectral parameter1.1. Maximum powerMaximum power2.2. Corresponding frequencyCorresponding frequency3.3. Minimal powerMinimal power4.4. Corresponding frequencyCorresponding frequency5.5. SlopeSlope6.6. Y-interceptY-intercept7.7. Mid-band fitMid-band fit8.8. Integrated backscatterIntegrated backscatter

Tissue CharacterizationTissue CharacterizationTissue CharacterizationTissue Characterization

MediaMedia

FibrousFibrous

FibrofattyFibrofatty

Dense calciumDense calcium

Necrotic coreNecrotic core

Densely packed Densely packed collagencollagen

Significant lipid Significant lipid in collagenin collagen

Calcium withoutCalcium withoutnecrosisnecrosis

Cholesterol cleft,Cholesterol cleft,foam cells,foam cells,microcalcificationmicrocalcification

IVUSIVUS VH-IVUSVH-IVUS Virmani VHVirmani VH

Calcium = purple

Examples in Tissue CharacterizationExamples in Tissue CharacterizationExamples in Tissue CharacterizationExamples in Tissue Characterization

Predictive Accuracies of VH-IVUSPredictive Accuracies of VH-IVUSPredictive Accuracies of VH-IVUSPredictive Accuracies of VH-IVUS

FibrousFibrous

FibrofattyFibrofatty

CalcifiedCalcified

Necrotic coreNecrotic core

11stst version versionex vivoex vivo79.7%79.7%

81.2%81.2%

92.8%92.8%

85.5%85.5%

2nd version2nd versionin vivo (DCA)in vivo (DCA)

87.1%87.1%

87.1%87.1%

96.5%96.5%

88.3%88.3%

Nasu K. J Am Coll Cardiol 2006;47:2405-12

Nair A. EuroInterv 2007;3:113-120

Histology vs. RF data in gray IVUSHistology vs. RF data in gray IVUS

2nd version2nd versionex vivoex vivo93.5%93.5%

94.1%94.1%

95.8%95.8%

96.7%96.7%

Histology vs. VH-IVUSHistology vs. VH-IVUS

Nair A. Circulation 2002;106:2200-6

Gray scale IVUS vs. VH-IVUSGray scale IVUS vs. VH-IVUS

Lesion ClassificationLesion ClassificationPathological intimal thickeningPathological intimal thickening Fibrocalcific lesionFibrocalcific lesion

Fibrous cap atheromaFibrous cap atheroma Thin-cap fibroatheromaThin-cap fibroatheroma

In at least 3 consecutive frames & PAV 40%In at least 3 consecutive frames & PAV 40%Rodriguez-Granillo et al. Heart 2006;92:388-91

Cap thickness of TCFACap thickness of TCFACap thickness of TCFACap thickness of TCFA

Axial resolution of IVUS-VH; 100-Axial resolution of IVUS-VH; 100-150150uum m

6565uum; based on autopsy and data of m; based on autopsy and data of already ruptured plaquealready ruptured plaque

Cap thickness <250Cap thickness <250uum dramatically m dramatically increases peak circumferential increases peak circumferential stress in the plaquestress in the plaque

Axial resolution of IVUS-VH; 100-Axial resolution of IVUS-VH; 100-150150uum m

6565uum; based on autopsy and data of m; based on autopsy and data of already ruptured plaquealready ruptured plaque

Cap thickness <250Cap thickness <250uum dramatically m dramatically increases peak circumferential increases peak circumferential stress in the plaquestress in the plaque

Virmani R et al. J Interven Cardiol 2003;16:267-72Schaar JA et al. Circulation 2003;108:2636-41


1.1. Definition of VPDefinition of VP






Case (45/M), SACase (45/M), SACase (45/M), SACase (45/M), SA

1 2 3 4 5

Distal Ref.Proximal Ref.

EEM CSA = 17.6Lumen CSA = 4.1 ~ 4.3Lumen CSA = 4.1 ~ 4.3P+M CSA = 13.1Max Lumen dia = 2.5MLD = 2.3Plaque burden = 74%

EEM CSA = 17.8Lumen CSA = 12.2Max Lumen dia = 4.2MLD = 3.7P+M CSA = 5.6Plaque burden = 0.32

EEM CSA = 14.4Lumen CSA = 8.9Max Lumen dia = 3.6MLD = 3.1P+M CSA = 5.5Plaque burden = 0.38

0 4 mm 10 mm 19 mm

1 2 3 4 5

Lumen Volume 174.9 mm3

EEL Volume 361.3 mm3 Plaque Volume 186.4 mm3 Segment Length 19.7 mm

Fibrous Volume 68.2 mm3 59%Fibro-Fatty volume 6.2 mm3 5%Dense Calcium Volume 11.7 mm3 10%Necrotic Core Volume 28.9 mm3 25%

Treatment in this patients ?Treatment in this patients ?Treatment in this patients ?Treatment in this patients ?

EEM CSA = 17.6Lumen CSA = 4.1 ~ 4.3Lumen CSA = 4.1 ~ 4.3P+M CSA = 13.1Max Lumen dia = 2.5MLD = 2.3Plaque burden = 74%

TCFATCFA

Fibrous Volume 68.2 mm3 59%Fibro-Fatty volume 6.2 mm3 5%Dense Calcium Volume 11.7 mm3 10%Necrotic Core Volume 28.9 mm3 25%

Strategies in intermediate lesionStrategies in intermediate lesionStrategies in intermediate lesionStrategies in intermediate lesion

• IVUSIVUS

•FFRFFR

• IVUSIVUS

•FFRFFR

IVUS MLA < 4.0mmIVUS MLA < 4.0mm22IVUS MLA < 4.0mmIVUS MLA < 4.0mm22

357 intermediate lesion in 300 pts357 intermediate lesion in 300 ptsClinical FU >1yrClinical FU >1yr357 intermediate lesion in 300 pts357 intermediate lesion in 300 ptsClinical FU >1yrClinical FU >1yr

31

22

74

0

5

10

15

20

25

30

35

Abizaid AS, et al, Circulation 1999

31

20

4 3

0

5

10

15

20

25

30

35Any event (%)Any event (%) Revascularization (%)Revascularization (%)

2.0-2.92.0-2.9N=17N=17

3.0-3.93.0-3.9N=36N=36

4.0-4.94.0-4.9N=55N=55

55N=193N=193

2.0-2.92.0-2.9N=17N=17

3.0-3.93.0-3.9N=36N=36

4.0-4.94.0-4.9N=55N=55

55N=193N=193

Deferral of PTCA Based on FFRDeferral of PTCA Based on FFR

Bech et al, Circulation 2001

•325 patients referred for PTCA without documented ischemia• If If FFR >0.75FFR >0.75, randomized to Defer (91) or Performance (90) groups, randomized to Defer (91) or Performance (90) groups• If FFR <0.75, PTCA performed, Reference group (144)

0

20

40

60

80

100

Baseline 1 Month 12Months

24Months

DeferPerformanceReference

Patients freefrom angina

(%)

FFR > 0.80 as a cut-off valueFFR > 0.80 as a cut-off valueFFR > 0.80 as a cut-off valueFFR > 0.80 as a cut-off value

Legalery et al, Eur Heat J 2005

Gray zone of FFR by European PCI guidelineGray zone of FFR by European PCI guideline; FFR 0.75 ~ 0.80; FFR 0.75 ~ 0.80

Natural History of Intermediate LesionNatural History of Intermediate LesionNatural History of Intermediate LesionNatural History of Intermediate Lesion

• 10-yrs survival rate10-yrs survival rate 90.1% vs. 85.8% (3342 pts with nor90.1% vs. 85.8% (3342 pts with nor

mal coronary vs. 2184 pts with noncmal coronary vs. 2184 pts with noncritical stenosis (<70%)ritical stenosis (<70%)

• Noncritical stenosis; not significant Noncritical stenosis; not significant independent determinant of survivalindependent determinant of survival

• 10-yrs survival rate10-yrs survival rate 90.1% vs. 85.8% (3342 pts with nor90.1% vs. 85.8% (3342 pts with nor

mal coronary vs. 2184 pts with noncmal coronary vs. 2184 pts with noncritical stenosis (<70%)ritical stenosis (<70%)

• Noncritical stenosis; not significant Noncritical stenosis; not significant independent determinant of survivalindependent determinant of survival

Crenshaw JH. et al. Am J Med Sci 1995

Evolution of Spontaneous Atherosclerotic Evolution of Spontaneous Atherosclerotic Plaque Rupture With Medical TherapyPlaque Rupture With Medical TherapyIn 14 Pts with 28 plaque ruptures, 22 months FUIn 14 Pts with 28 plaque ruptures, 22 months FU

Evolution of Spontaneous Atherosclerotic Evolution of Spontaneous Atherosclerotic Plaque Rupture With Medical TherapyPlaque Rupture With Medical TherapyIn 14 Pts with 28 plaque ruptures, 22 months FUIn 14 Pts with 28 plaque ruptures, 22 months FU

50% healed without significant plaque modificationNo healing-prediction criterion could be found

Rioufol G. et al. Circulation 2004;110:2875-80

Angioscopic F/U of 50 Ruptured Plaques Angioscopic F/U of 50 Ruptured Plaques (30 pts) in Non-culprit Lesions; (30 pts) in Non-culprit Lesions; 13±9 Mo FU13±9 Mo FU

Takano M et al, J Am Coll Cardiol 2005;45:652– 8

• Overall healing; 30% Overall healing; 30%

• Remaining of thrombi in Remaining of thrombi in 35 (70%)35 (70%)

• Thrombus color change Thrombus color change from red (56%) at from red (56%) at baseline to pinkish-white baseline to pinkish-white (83%) at follow-up (83%) at follow-up

• %DS at the healed %DS at the healed plaque (12.3% to 22.7%, plaque (12.3% to 22.7%, p<0.05) p<0.05)

• 1 pt need PCI1 pt need PCIPinkish-white thrombus on the yellow plaque

Smooth white intima without thrombus

DS=35%DS=35% DS=43%DS=43%

Ruptured plaques in nonculprit lesions tend to heal slowly with a progression of angiographic stenosis

Plaque instability frequently occurs days or weeks Plaque instability frequently occurs days or weeks before occlusive coronary thrombosisbefore occlusive coronary thrombosis

Composition of the retrieved material using suction catheter Composition of the retrieved material using suction catheter in 211 pts undergoing 1 PCI within 6 hrs after onset of symptomin 211 pts undergoing 1 PCI within 6 hrs after onset of symptom

Only thrombus54%

Only plaque components5%

Both components45%

van der Wal AC, Koch KT et al, TCT

49

35

9 7

0

10

20

30

40

50

<1day

1-5 days

>5daysboth

%

FreshLytic

OrganizedFresh & organized

Acute coronary occlusion is often the finalStage in a series of successive thromboticEvents that occurred in the preceding days or weeks

1.1. To know clinical outcomes of To know clinical outcomes of intermediate lesion according to tissue intermediate lesion according to tissue type by VH-IVUStype by VH-IVUS

2.2. To identify a lesion, which causes To identify a lesion, which causes angina (needs PCI) in the futureangina (needs PCI) in the future

ObjectivesObjectivesObjectivesObjectives

VH-IVUS for detection a VPVH-IVUS for detection a VPVH-IVUS for detection a VPVH-IVUS for detection a VP

Study DesignStudy DesignStudy DesignStudy Design

Patient population:Patient population:

30%-70% stenosis by CAG30%-70% stenosis by CAG ConsecutiveConsecutive Informed consentInformed consent Good quality of VH-IVUSGood quality of VH-IVUS

Efficacy outcome measure:Efficacy outcome measure: Time to occurrence of a major CV event:Time to occurrence of a major CV event:

– Lesion progression requiring PCILesion progression requiring PCI– Cardiac deathCardiac death– AMIAMI– Fatal or nonfatal strokeFatal or nonfatal stroke– Any eventsAny events

Jan 2007~Jun 2008Jan 2007~Jun 2008

Patients enrollPatients enrollCAG &CAG &

VH-IVUSVH-IVUS

98 lesions in 98 lesions in 94 pts94 pts65 pts eligible65 pts eligible

CAG & VH-IVUS FUCAG & VH-IVUS FU48 lesions (72.7%)48 lesions (72.7%)

FU lossFU lossn=1n=1

Clinical FU Clinical FU 64 pts (98.5%)64 pts (98.5%)

9 months9 months

DeathDeathn=3n=3

98 lesions98 lesions in 94 pts in 94 pts69 – 69 – 33 lesions eligible lesions eligible

8.78.72.9 months2.9 months

Patients Demographics (n=94)Patients Demographics (n=94)Patients Demographics (n=94)Patients Demographics (n=94)

Age, yrsMale, n (%)Hypertension, n (%)Diabetes, n (%)Smoking, n (%)Dyslipidemia, n (%)ACS, n (%)Prior MI, n (%)PCI, n (%)Hs-CRP, mg/dL

61.811.868 (72.3)43 (45.7)27 (28.7)35 (37.2)37 (39.4)42 (44.7)

5 (5.3)78 (83.0)

0.581.22

Angiographic Findings (n=98)Angiographic Findings (n=98)Angiographic Findings (n=98)Angiographic Findings (n=98)

Lesion location, n (%) LAD LCX RCA LM DiagonalMulti-vessel disease, n (%)MLD, mmProximal ref. A diameter, mmDistal ref. A diameter, mm% diameter stenosis, %

53 (54.1)20 (20.4)15 (15.3)

8 (8.2)2 (2.)

58 (59.2)1.790.533.210.712.900.6443.49.05

(30.0 ~ 66.2)

Gray Scale IVUS Findings (n=98)Gray Scale IVUS Findings (n=98)Gray Scale IVUS Findings (n=98)Gray Scale IVUS Findings (n=98)Minimal luminal area EEM area, mm2

Luminal area, mm2

P&M area, mm2

Plaque burden, % Remodeling index Positive remodeling (>1.05), n (%) Luminal area <4.0mm2, n (%)Volumetric analysis EEM volume, mm3

Lumen volume, mm3

P&M volume, mm3

Lesion length, mm

15.25.85.42.19.94.2

63.49.30.960.1323 (23.5)31 (31.6)

215.2128.197.554.2

116.380.513.97.2

IVUS-VH Findings at MLA (n=98)IVUS-VH Findings at MLA (n=98)IVUS-VH Findings at MLA (n=98)IVUS-VH Findings at MLA (n=98)

Fibrous area, mm2

Fibrofatty area, mm2

Dense calcified area, mm2

Necrotic core area, mm2

Fibrous area, %Fibrofatty area, %Dense calcified area, %Necrotic core area, %

3.952.290.921.170.530.521.170.9660.214.112.19.79.18.6

18.711.5

TCFA by IVUS-VHTCFA by IVUS-VH

• In at least three consecutive frames;In at least three consecutive frames;

• 1) necrotic core 1) necrotic core >> 10% without evid 10% without evident overlying fibrous tissue andent overlying fibrous tissue and• 2) percent atheroma area 2) percent atheroma area >> 40% 40%

Rodriguez-Granillo GA et al. JACC 2005;46:2038–42

TCFA ClassificationTCFA Classification

Less vulnerableLess vulnerable Highest vulnerableHighest vulnerable

NC > 20%NC > 20%> 50% Plaque burden> 50% Plaque burdenCa > 5%Ca > 5%Remodeling index > 1.05Remodeling index > 1.05

NC < 20%NC < 20%< 50% Plaque burden< 50% Plaque burden

Proposed by Dr. Mintz G

IVUS-VH Findings at MLA (n=98)IVUS-VH Findings at MLA (n=98)IVUS-VH Findings at MLA (n=98)IVUS-VH Findings at MLA (n=98)

PIT (n=7,7.1%) PIT (n=7,7.1%)

Fibrocalcific AFibrocalcific A(n=17, 17.3%) (n=17, 17.3%)

Fibrous cap AFibrous cap A(n=42, 42.9%)(n=42, 42.9%)

TCFATCFA(n=28, 28.6%)(n=28, 28.6%)

UndeterminedUndetermined(n=4, 4.1%) (n=4, 4.1%)

TCFA, less vulnerableTCFA, less vulnerable(n=13, 46.4%) (n=13, 46.4%)

TCFA, high vulnerableTCFA, high vulnerable(n=15, 53.6%) (n=15, 53.6%)

TCFATCFA According to Diagnosis According to DiagnosisTCFATCFA According to Diagnosis According to Diagnosis

20.0

25.0

30.0

35.0

SA ACS

P=0.021P=0.021

15 (27.3%)15 (27.3%)

13 (30.2%)13 (30.2%)

(n=55)(n=55) (n=43)(n=43)

P=NSP=NS

TC

FA

, %T

CF

A, %

Hig

hes

t vu

lne

rab

le T

CF

A, %

Hig

hes

t vu

lne

rab

le T

CF

A, %

0

20

40

60

80

100

SA ACS

(n=55)(n=55) (n=43)(n=43)

5 (53.6%)5 (53.6%)

10 (76.9%)10 (76.9%)

Medications (n=92 lesions)Medications (n=92 lesions)Medications (n=92 lesions)Medications (n=92 lesions)

AspirinAspirinBeta-blockersBeta-blockersACEIACEIARBARBCCBCCBStatinsStatinsOHAOHAInsulinInsulin

98 (100)98 (100)61 (62.2)61 (62.2)46 (46.9)46 (46.9)15 (15.3)15 (15.3)25 (25.5)25 (25.5)73 (74.5)73 (74.5)20 (20.4)20 (20.4)

2 (2.0)2 (2.0)

6 Mo Clinical outcomes6 Mo Clinical outcomes(64/65 pts, 98.5%)(64/65 pts, 98.5%)

6 Mo Clinical outcomes6 Mo Clinical outcomes(64/65 pts, 98.5%)(64/65 pts, 98.5%)

Death*Death*Myocardial infarctionMyocardial infarctionStrokeStrokeRequiring PCIRequiring PCI

3 (4.7%)3 (4.7%)0 (0)0 (0)0 (0)0 (0)

7 (10.9%)7 (10.9%)8 lesions in 7 pts8 lesions in 7 pts

*; Causes of death; CHF at 1 month, ICH at 4 months, SCD at 5 months

Case, Case, 강 강 0 0 준준 , , SCDSCD at 5 Mo at 5 MoCase, Case, 강 강 0 0 준준 , , SCDSCD at 5 Mo at 5 Mo2007-07-302007-07-30

MLAMLA

Lumen Area 8.5 mm2

EEL Area 28.2 mm2

Plaque Area 19.7 mm2

% Plaque Burden 70 %

Fibrous Area 8.1 mm2 54%Fibro-Fatty Area 5.3 mm2 36%Dense Calcium Area 0.3 mm2 2%Necrotic Core Area 1.2 mm2 8%

Fibrocalcific AtheromaFibrocalcific Atheroma

2008-06-242008-06-24

Case, (65/M), Case, (65/M), 염염 00 철철 , SA, SACase, (65/M), Case, (65/M), 염염 00 철철 , SA, SA

LAD stentingLAD stenting

2007-09-182007-09-18

Lumen Area 3.8 mm2



TCFATCFA

QCA stenosis 35.4% MLD 2.10



Case, (71/M), Case, (71/M), 김김 00 규규 , UA, UACase, (71/M), Case, (71/M), 김김 00 규규 , UA, UA

2007-05-072007-05-07 2008-01-222008-01-22



Lumen Area 2.7 mm2

EEL Area 8.7 mm2

Plaque Area 6.0 mm2

% Plaque Burden 69%

Lumen Area 3.0 mm2

EEL Area 6.8 mm2

Plaque Area 3.7 mm2


Fibrous Area 1.2 mm2 73%Fibro-Fatty Area 0.2 mm2 15%Dense Calcium Area 0.1 mm2 3%Necrotic Core Area 0.1mm2 8%

Fibrous cap atheromaFibrous cap atheroma


Case, (46/M), Case, (46/M), 윤윤 00 선선 , SA, SACase, (46/M), Case, (46/M), 윤윤 00 선선 , SA, SA


IVUS MLA 8.60 mm2


IVUS MLA 6.10 mm2

Lumen Area 8.6 mm2

EEL Area 24.2mm2

Plaque Area 15.7mm2

% Plaque Burden 65%

Lumen Area 6.1 mm2

EEL Area 21.7 mm2




2007-06-062007-06-06 2008-02-142008-02-14TCFATCFA


Case, (57/F), Case, (57/F), 김김 00 순순 , SA, SACase, (57/F), Case, (57/F), 김김 00 순순 , SA, SA

LAD stentingLAD stenting

2007-05-172007-05-17 2008-05-202008-05-20


IVUS MLA 4.70 mm2


IVUS MLA 3.20 mm2

Lumen Area 4.7 mm2

EEL Area 9.7 mm2

Plaque Area 5.0 mm2


Lumen Area 3.2 mm2

EEL Area 10.3 mm2

Plaque Area 7.2 mm2



TCFATCFA



2007-08-092007-08-09 2008-05-302008-05-30

Case, (74/M), Case, (74/M), 김김 00 호호 , UA, UACase, (74/M), Case, (74/M), 김김 00 호호 , UA, UA


IVUS MLA 8.20 mm2


IVUS MLA 5.10 mm2

Lumen Area 8.2 mm2

EEL Area 32.4 mm2


% Plaque Burden 72%

Lumen Area 5.1 mm2

EEL Area 33.7 mm2



Fibrocalcific AtheromaFibrocalcific Atheroma

6 Mo Angiographic Follow Up 6 Mo Angiographic Follow Up (48/66 lesions, 72.7%)(48/66 lesions, 72.7%)

6 Mo Angiographic Follow Up 6 Mo Angiographic Follow Up (48/66 lesions, 72.7%)(48/66 lesions, 72.7%)

BaselineBaseline Ref. Diameter, mmRef. Diameter, mm MLDMLD Follow upFollow up Ref. Diameter, mmRef. Diameter, mm MLDMLD Late Loss, mm Late Loss, mm

3.033.030.610.611.841.840.590.59

2.872.870.54*0.54*1.721.720.600.60

0.120.120.480.48

*;p=0.005 by paried t-test

Comparison between 2 groupsComparison between 2 groupsComparison between 2 groupsComparison between 2 groups

CAGCAG MLDMLD diameter stenosis, %diameter stenosis, %Gray scale IVUSGray scale IVUS MLAMLA Remodeling indexRemodeling index Plaque areaPlaque area Plaque burdenPlaque burden

Need PCINeed PCIn=8n=8

1.91.90.50.543.543.59.19.1

5.85.82.02.00.980.980.10.112.212.25.85.866.366.38.58.5

StationaryStationaryn=40n=40

1.81.80.60.643.243.28.98.9

5.55.52.52.50.950.950.10.19.69.64.24.2

63.163.17.07.0

PP value value

nsnsnsns

nsnsnsnsnsnsnsns

Comparison between 2 groupsComparison between 2 groupsComparison between 2 groupsComparison between 2 groups

VH-IVUSVH-IVUSAt MLA siteAt MLA site Fibrous areaFibrous area Fibrofatty areaFibrofatty area Dense calcified areaDense calcified area Necrotic core areaNecrotic core areaOver the entire lesionOver the entire lesion Fibrous volumeFibrous volume Fibrofatty volumeFibrofatty volume Dense calcified volumeDense calcified volume Necrotic core volumeNecrotic core volume

Need PCINeed PCIn=8n=8

4.914.912.72 (61%)2.72 (61%)1.481.481.84 (15%)1.84 (15%)0.580.580.66 (9%)0.66 (9%)

1.581.581.71 (18%)1.71 (18%)

32.5432.5416.40 (63%)16.40 (63%)8.518.519.41 (15%)9.41 (15%)4.654.656.40 (7%)6.40 (7%)

8.088.087.04 (15%)7.04 (15%)

StationaryStationaryn=40n=40

3.993.992.50 (63%)2.50 (63%)0.750.750.85 (11%)0.85 (11%)0.480.480.45 (9%)0.45 (9%)

1.041.040.81 (18%)0.81 (18%)

42.3442.3430.36 (62%)30.36 (62%)8.358.359.04 (12%)9.04 (12%)6.636.636.62 (9%)6.62 (9%)

10.7810.788.39 (16%)8.39 (16%)

PP value value

nsns0.0770.077

nsnsnsnsnsnsnsnsNsNsnsnsnsns

MLA vs. Lesion progression (need PCI)MLA vs. Lesion progression (need PCI)MLA vs. Lesion progression (need PCI)MLA vs. Lesion progression (need PCI)

0

10

20

30

40

<4mm<4mm22 4mm4mm22

Pro

gres

sion

req

uirin

g P

CI,

%P

rogr

essi

on r

equi

ring

PC

I, %

6 (35.3%)

2 (6.5%)

P=0.010

IVUS criteria is still important

But, 65% of intermediate lesion <4mm2 does not rapidly progress

Lesion types vs. progression (need PCI)Lesion types vs. progression (need PCI)Lesion types vs. progression (need PCI)Lesion types vs. progression (need PCI)P

rogr

essi

on r

equi

ring

PC

I, %

Pro

gres

sion

req

uirin

g P

CI,

%

0 (0%)

2 (20%)

1 (5%)

PIT; pathologic intimal thickening, FCA; fibrocalcific atheroma, CAPA; fibrous cap atheroma, TCFA; thin cap fibroatheroma

Non-TCFA TCFA

3 (8.6%)

P=0.014

(n=3) (n=10) (n=20) (n=13) (n=35) (n=13)

0

10

20

30

40

PIT FCA CAPA TCFA

5 (38.5%)

0

10

20

30

405 (38.5%)

30

32

34

36

38

40

TCFA vulnerability vs. Lesion progressionTCFA vulnerability vs. Lesion progressionTCFA vulnerability vs. Lesion progressionTCFA vulnerability vs. Lesion progression

Less Less vulnerablevulnerable

High High vulnerablevulnerable

Pro

gres

sion

req

uirin

g P

CI,

%P

rogr

essi

on r

equi

ring

PC

I, %

2 (40.0%)3 (37.5%)

P=0.928 TCFA vulnerability was not helpful to identify a real VP, which showed a rapid progression requiring PCI

Different classification is needed

(n=5) (n=8)

MLA < 4.0mmMLA < 4.0mm2 2 & TCFA & TCFA vs. Lesion progression (need PCI)vs. Lesion progression (need PCI)

MLA < 4.0mmMLA < 4.0mm2 2 & TCFA & TCFA vs. Lesion progression (need PCI)vs. Lesion progression (need PCI)

If MLA of intermediate lesion is less than 4.0mm2 as well as TCFA, 67% will rapidly progress

It will be very helpful to see MLA as well as lesion type by VH-IVUS

Variables; MLA < 4.0mm2 & TCFAVariables; MLA < 4.0mm2 & TCFA

1 (4.2%)

3 (16.7%)

P=0.001

0

10

20

30

40

50

60

70

none single double

4 (66.7%)

SummarySummarySummarySummary

1.1. 38.5% of TCFA in intermediate lesion n38.5% of TCFA in intermediate lesion needs an PCI in 6-9 months (vs. 35.3% oeeds an PCI in 6-9 months (vs. 35.3% of lesion <4.0mmf lesion <4.0mm22 by IVUS) by IVUS)

2.2. It will be very helpful to decide a therapIt will be very helpful to decide a therapeutic decision, considering TCFA by Veutic decision, considering TCFA by VH-IVUS as well as MLAH-IVUS as well as MLA

3.3. PIT and fibrous cap atheroma in intermPIT and fibrous cap atheroma in intermediate lesion have a favorable outcomeediate lesion have a favorable outcomess

1.1. 38.5% of TCFA in intermediate lesion n38.5% of TCFA in intermediate lesion needs an PCI in 6-9 months (vs. 35.3% oeeds an PCI in 6-9 months (vs. 35.3% of lesion <4.0mmf lesion <4.0mm22 by IVUS) by IVUS)

2.2. It will be very helpful to decide a therapIt will be very helpful to decide a therapeutic decision, considering TCFA by Veutic decision, considering TCFA by VH-IVUS as well as MLAH-IVUS as well as MLA

3.3. PIT and fibrous cap atheroma in intermPIT and fibrous cap atheroma in intermediate lesion have a favorable outcomeediate lesion have a favorable outcomess

• To evaluate in vivo tissue To evaluate in vivo tissue characteristics of coronary characteristics of coronary plaque with plaque with rupture/ulceration (PRU) in rupture/ulceration (PRU) in culprit lesionculprit lesion

• To evaluate in vivo tissue To evaluate in vivo tissue characteristics of coronary characteristics of coronary plaque with plaque with rupture/ulceration (PRU) in rupture/ulceration (PRU) in culprit lesionculprit lesion

ObjectivesObjectivesObjectivesObjectives

Plaque Rupture & VH-IVUSPlaque Rupture & VH-IVUSPlaque Rupture & VH-IVUSPlaque Rupture & VH-IVUS

MethodsMethodsMethodsMethods

Study PopulationStudy Population

162 consecutive patients undergoing IVUS-VH examination

before PCI or for lesion evaluation were studied prospectively

Exclusion criteriaExclusion criteria

Vessel tortuosity which precluded IVUS-VH examination

History of PCI or CABG

Refuse to study

DefinitionDefinitionDefinitionDefinition• Plaque ulcerationPlaque ulceration; ; a recess in tha recess in th

e plaque beginning at the lumie plaque beginning at the luminal-intimal border, typically witnal-intimal border, typically without enlargement of the EEM chout enlargement of the EEM compared with the ref. segmentompared with the ref. segment

• Plaque rupturePlaque rupture; ; a plaque ulcerata plaque ulceration with a tear detected in a fibion with a tear detected in a fibrous caprous cap

• Plaque ulcerationPlaque ulceration; ; a recess in tha recess in the plaque beginning at the lumie plaque beginning at the luminal-intimal border, typically witnal-intimal border, typically without enlargement of the EEM chout enlargement of the EEM compared with the ref. segmentompared with the ref. segment

• Plaque rupturePlaque rupture; ; a plaque ulcerata plaque ulceration with a tear detected in a fibion with a tear detected in a fibrous caprous cap

JACC 2001;37:1478-92.

• Plaque rupture or ulcerationPlaque rupture or ulceration; ; a cavity in the vessel wall, wia cavity in the vessel wall, with disruption of the intima, and flow observed within the th disruption of the intima, and flow observed within the plaque cavity.plaque cavity.

• Intimal disruption; irregular intimal surface of ulcerated Intimal disruption; irregular intimal surface of ulcerated plaques and visible torn edges.plaques and visible torn edges.

• Blood flow in the vessel wall cavity; contrast injection mBlood flow in the vessel wall cavity; contrast injection may be used to prove and define the communication point.ay be used to prove and define the communication point.

15.4%

26.5%58.0%

Plaque MorphologyPlaque MorphologyPlaque MorphologyPlaque Morphology

Intact (n=94)

Ulcer (n=43)

Rupture (n=25)

Patients DemographicsPatients Demographics

NumberMale, n (%)Age, yHypertension, n (%)Diabetes, n (%)Hyperlipidemia, n (%)Smoking, n (%)Smoking, n (%)Cardiogenic shock, n (%)Cardiogenic shock, n (%)Peak TnI, ng/mLPeak TnI, ng/mLPrior MI, n (%)ACS, n (%)ACS, n (%)Ejection fraction, %Ejection fraction, %Multivessel disease, n (%)LAD/LCX/RCALCX/RCA/Ramus/LMLM%

PRU (-)

9467 (71.3%)60.610.061 (64.9%)31 (33.0%)15 (16.5%)28 (29.8%)

0 (0%)0.723.47 (7.4%)

19 (20.2%)63.910.748 (51.1%)

52/19/16/1/6(55.3/20.2/17.0/1.1/6.4)

PRU (+)

6852 (76.5%)59.514.130 (44.1%)15 (22.1%)15 (22.7%)34 (50.0%)

3 (4.4%)13.710.15 (7.4%)

61 (89.7%)57.410.934 (50.7%)36/8/23/0/1

(53.0/11.8/33.8/0/1.5)

P value

0.4600.5510.0090.1280.3260.0090.040

<0.0000.982

<0.000<0.0000.9680.046

Patients Demographics

NumberHs-CRP, mg/LHs-CRP, mg/LTotal cholesterol, mg/dLTriglyceride, mg/dLHDL-cholesterol, mg/dLHDL-cholesterol, mg/dLLDL-cholesterol, mg/dLBUN, mg/dLCreatinine, mg/dLUric acid, mg/dL

PRU (-)

942.102.61844116582

41.710.011931

16.46.31.21.25.31.5

PRU (+)

683.703.618446

14910445.512.5

1203517.79.91.10.65.71.6

P value

0.0020.9630.2980.0420.8330.3230.4880.214

Lumen volume 204.2 mm3

Vessel volume 425.5 mm3

Plaque Volume 221.3 mm3

Segment length 20.2 mm

FI area 10.7 mm2 71 %FF area 2.5 mm2 16 %DC area 0.2 mm2 1 %NC area 1.7 mm2 11 %

STEMI, M/54, PR(+)PR(+) STEMI, M/56, PR(-)PR(-)





FV 39.0 mm3 36 %FFV 8.7 mm3 8 %DCV 25.7 mm3 24 %NCV 35.2 mm3 32 %



Plaque Rupture

EEM CSA=25.1mm2, RI=1.21EEM CSA=18.7mm2, RI=0.85

STEMI, M/84, Plaque ulceration(+)Plaque ulceration(+) STEMI, M/56, PR(-)PR(-)






EEM CSA=18.7mm2, RI=0.85









Plaque Ulcer

SA, M/77, PR(+)PR(+) SA, F/63, PR(-)PR(-)













Plaque Rupture



0

100

200

300

400

EEL Lumen Plaque PB

Vo

lum

e, m

m3

or

%

0

20

40

60

80

100

FV FFV DCV NCV

P<0.000

P=0.001

P<0.000

P=0.025

P<0.000

P=0.005

P=0.022

P=0.001

Volumetric Analysis (n=162)Volumetric Analysis (n=162)

PRU(-), n=94 PRU(+), n=68

0

1

2

3

4

5

6

7

FA FFA DCA NCA

0

2

4

6

8

10

12

14

16

18

EEL Lumen Plaque

Are

a, m

m2

Lesion Analysis (n=162) at MLALesion Analysis (n=162) at MLA

PRU(-), n=94 PRU(+), n=68

0.88

0.90

0.92

0.94

0.96

0.98

1.00

1.02

RI

P<0.000

P=0.002

P=0.246

P=0.002

P<0.000

P=0.869

P<0.000

P=0.003

Independent Factor for Independent Factor for Plaque Rupture/UlcerationPlaque Rupture/Ulceration

Vessel volumeFibrous volumeFibrofatty volumeNecrotic core volumeRemodeling index

Beta

1.1071.0220.5220.6840.168

P value

0.0350.0210.0080.0050.031

95% CI

0.000 ~ 0.0050.001 ~ 0.0160.003 ~ 0.0210.005 ~ 0.0280.046 ~ 0.915

This model includes IVUS-VH variables showing significance in univariate analysisas a variables

SummarySummarySummarySummary

1.1. Plaque rupture/ulceration is not Plaque rupture/ulceration is not associated with plaque associated with plaque composition at the MLD site, but composition at the MLD site, but those over the entire lesion lengththose over the entire lesion length

2.2. Plaque rupture/ulceration is also Plaque rupture/ulceration is also associated with positive vascular associated with positive vascular remodelingremodeling

1.1. Plaque rupture/ulceration is not Plaque rupture/ulceration is not associated with plaque associated with plaque composition at the MLD site, but composition at the MLD site, but those over the entire lesion lengththose over the entire lesion length

2.2. Plaque rupture/ulceration is also Plaque rupture/ulceration is also associated with positive vascular associated with positive vascular remodelingremodeling

ConclusionsConclusionsConclusionsConclusions

VH-IVUS has a great potential VH-IVUS has a great potential to identify a vulnerble plaqueto identify a vulnerble plaque

Needs clinical correlation witNeeds clinical correlation with VH-IVUS findingsh VH-IVUS findings

VH-IVUS has a great potential VH-IVUS has a great potential to identify a vulnerble plaqueto identify a vulnerble plaque

Needs clinical correlation witNeeds clinical correlation with VH-IVUS findingsh VH-IVUS findings

Thank you for Thank you for your attentionyour attentionThank you for Thank you for your attentionyour attention

Compositional Changes during FUCompositional Changes during FU (32/59, 54.2%) (32/59, 54.2%)

Compositional Changes during FUCompositional Changes during FU (32/59, 54.2%) (32/59, 54.2%)

38.5

40.4

7.5

10.4

6.36.3 10.8

11.7

0

5

10

15

20

25

30

35

40

45

FV FFV DCV NCV

0

5

10

15

20

25

FV FFV DCV NCV

mm

3

P=0.040P=0.040

Total SubjectsTotal Subjects

In 5 Pts Underwent PCIIn 5 Pts Underwent PCI

P=NSP=NS

0

10

20

30

40

50

FV FFV DCV NCV

In 27 Pts In 27 Pts Not Underwent PCINot Underwent PCI

P=0.050P=0.050

6 Mo Gray Scale IVUS FU (33/59, 55.9%)6 Mo Gray Scale IVUS FU (33/59, 55.9%)6 Mo Gray Scale IVUS FU (33/59, 55.9%)6 Mo Gray Scale IVUS FU (33/59, 55.9%)

PCI GroupPCI GroupN=5N=5

No PCI GroupNo PCI GroupN=28N=28

0.860.93

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

1.00

Base FU

0.91

0.97

0.70

0.75

0.80

0.85

0.90

0.95

1.00

Base FU

P=0.008P=0.008P=0.228P=0.228

Remodeling IndexRemodeling Index

6 Mo Gray Scale Volumetric IVUS FU6 Mo Gray Scale Volumetric IVUS FU(33/59, 55.9%)(33/59, 55.9%)

6 Mo Gray Scale Volumetric IVUS FU6 Mo Gray Scale Volumetric IVUS FU(33/59, 55.9%)(33/59, 55.9%)

80.2

70.8

157.3144.8

77.274

0

20

40

60

80

100

120

140

160

LV EEMV PV

BaseFU



103.2108.3

223234.9

115.8126.5

0

50

100

150

200

250

LV EEMV PV

BaseFU

No significant changes in both groupsNo significant changes in both groups

IVUS-VH Findings over entire lesion (n=98)IVUS-VH Findings over entire lesion (n=98)IVUS-VH Findings over entire lesion (n=98)IVUS-VH Findings over entire lesion (n=98)

Fibrous volume, mm3

Fibrofatty volume, mm3

Dense calcified volume, mm3

Necrotic core volume, mm3

Fibrous volume, %Fibrofatty volume, %Dense calcified volume, %Necrotic core volume, %

42.937.49.913.16.06.1

11.69.861.311.212.68.08.87.0

17.39.5

6 Mo Gray Scale IVUS FU (33/59, 55.9%)6 Mo Gray Scale IVUS FU (33/59, 55.9%)6 Mo Gray Scale IVUS FU (33/59, 55.9%)6 Mo Gray Scale IVUS FU (33/59, 55.9%)


P=0.043P=0.043


P=0.011P=0.011

P=0.008P=0.008

5.5

14.6

9.1

11.2

4.2

12.7

8.5

11.7

0

2

4

6

8

10

12

14

16

LALA EEMA PA Length

Base FU15.4

9.8

15.1

5.65.6

15.3

9.1

14.7

0

2

4

6

8

10

12

14

16

18

LA EEMAEEMA PAPA Length

Base FU

3.223.32

2.662.84

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Base FU

PCI

Not PCI

2

1.18

1.841.85

0.0

0.5

1.0

1.5

2.0

2.5

Base FU

PCI

Not PCI

0.82

0.010.0

0.2

0.4

0.6

0.8

1.0

1.2

PCI None

Late Loss, mmLate Loss, mmRef D, mmRef D, mm MLD, mmMLD, mm

P=0.004P=0.004

P=0.016P=0.016

P<0.001P<0.001

6 Mo Angiographic Follow Up 6 Mo Angiographic Follow Up (35/59, 59.3%)(35/59, 59.3%)

6 Mo Angiographic Follow Up 6 Mo Angiographic Follow Up (35/59, 59.3%)(35/59, 59.3%)



ivus-vh & vulnerable plaque

Documents

mm3vessel volume

mm3plaque volume

mmfibrous volume

necroticcore volume

nsecalcium volume

fibrofatty volume

eccentric plaque

vulnerable plaquelesions