OCT guidance for distal LM lesions

FRANCESCO BURZOTTA INSTITUTE OF CARDIOLOGY

CATHOLIC UNIVERSITY OF THE SACRED HEART ROME, ITALY

LM suitability for OCT

Parodi G et al. Eurointervention 2010

At FU in stented LM

KEY TECHNICAL POINTS: -  6 F or 6.5 F sheathless GC -  automatic contrast medium injection (dose adjusted to LM size: 4ml/s or

6ml/s in case of large LM >6mm) -  C7 System; C7 Dragonfly; LightLab Imaging Inc/ St Jude Medical

In de novo, non-ostial LM lesions

LM suitability for OCT

Eurointervention 2015

In de novo, non-ostial LM lesions

LM suitability for OCT

Eurointervention 2015

STUDY END-POINT: Nr of artifacted frames (failure of MLA automatic calculation)

In de novo, non-ostial LM lesions

LM suitability for OCT

Eurointervention 2015

STUDY END-POINT: Nr of artifacted frames (failure of MLA automatic calculation)

% artifacted frames

In de novo, non-ostial LM lesions

LM suitability for OCT

Eurointervention 2015

STUDY END-POINT: Nr of artifacted frames (failure of MLA automatic calculation)

% artifacted frames If your doubts are lumen size and morphology

in these areas, OCT is very good option !!!

What can we see with OCT in distal LM?

5 mm

LAD ostium

5 mm

Distal LM POC

Fibrotic plaque Fibrocalcific plaque

Fibroateroma TCFA

Burzotta, Dato et al. Submitted

What can we see with OCT in distal LM?

5 mm

LAD ostium

5 mm

Distal LM POC

Burzotta, Dato et al. Submitted

Mean cap thickness (µm)

LAD ostium Distal LM POC

111 85

109

What can we see with OCT in distal LM?

Burzotta, Dato et al. Submitted

OCT to guide LM management: limits

WHICH PARAMETER ?

<5mm2

<6mm2

WHICH CUT-OFFS?

OCT to guide LM management: limits

WHAT ABOUT MORPHOLOGY?

OCT to guide LM management: limits

Fujino Y et al. Cath Cardiovasc Int 2010

In LM, OCT estimation of MLA is 15% lower compared with IVUS

Looking for cut-offs in intermediate LM disease

Looking for cut-offs in intermediate LM disease

Park et al. JACC-Intv 2014

At IVUS study, MLA value of 4.5 mm2 predicts FFR +

Signficant disease of very large LMs can be undestimated by conservative MLA cut-offs

and recognized by % Area Stenosis

Looking for cut-offs in intermediate LM disease

FFR 0.79

First experience with OCT guidance in angiographically-intermediate LM disease

Angiographically Intermediate LM bifurcation disease (n=84)

OCT assessment

- AS >75% any MLA ?

REVASCULARIZATION (n= 49) (38 PCI, 11 CABG)

DEFER TREATMENT (n=31)

- AS >50%<75% and MLA<4 mm2 ?

- AS >50%<75% and LM ulceration ?

Clinical follow-up (mean: 2 years)

- incomplete imaging of the LM bifurcation (n=2) - poor image quality preventing reliable analyses (n=2)

OCT-guided management (n=80)

LM UCSC criteria:

First experience with OCT guidance in angiographically-intermediate LM disease

CRITERIA PROMPTING FOR REVASCULARIZATION

Revascularized group (n=49)

LM AS >75% any MLA 8 (16%) LM AS >50%<75% and MLA<4 mm2 9 (18%) LM AS >50%<75% and LM ulceration 12 (24%)

LAD or LCX ostium critical stenosis 28 (57%)

First experience with OCT guidance in angiographically-intermediate LM disease

Characteristics Revascularized group (n=49)

Deferred group (n=31)

P

Age 67±10 69±11 0.3 Female sex 10 (20%) 9 (29%) 0.4 Hypertension 37 (76%) 24 (77%) 0.8 Hyperlipidemia 31 (63%) 22 (71%) 0.5 Diabetes 15 (31%) 11 (35%) 0.7 Family history 8 (16%) 7 (23%) 0.5 Current smoking 6 (12%) 3 (10%) 0.7 Chronic renal failure 13 (27%) 8 (26%) 0.9 Clinical presentation Stable CAD NSTE-ACS or recent STEMI

33 (67%) 16 (33%)

19 (61%) 12 (39%)

0.6

Ejection fraction (%) 57 ± 9 56 ± 9 0.8 EuroSCORE (Additive) 5 ± 4 5 ± 4 0.9 Coronary disease beyond LM: 1-vessel disease 2-vessel disease 3-vessel disease

20 (41%) 18 (37%) 11 (22%)

13 (42%) 13 (42%) 5 (16%)

0.8

First experience with OCT guidance in angiographically-intermediate LM disease

TVF

0 6 12 18 24

100

80

60

40

20

0

Time

Sur

viva

l pr

obab

ility

(%)

Event Revascularized group (n=49)

Deferred group (n=31)

Death 1 (2%) 0 MI 1 (2%) 0 TVR 2 (4%) 1 (3%)

Primary endpoint TVF (death-MI-TVR)

REVASCULARIZATION

DEFER TREATMENT

P=0.35

Conclusions

- OCT is able to provide nice characterization of bifurcation disease

- OCT cut-offs to guide decisions on LM are lacking but probably the combination of %AS stenosis, plaque morphology and MLA values (lower than IVUS !!!) should be taken into account

- Preliminary observations suggest the possible safety of OCT-based revascularization deferral when %AS is <75%, MLA is >4 mm2 and LM ulceration is absent

In patients with angiographycally-intermediate distal LM disease:

THANK YOU FOR KIND ATTENTION