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TCTAP 2013 Fellowship CourseL ft M i d Bif ti PCI Bif ti PCILeft Main and Bifurcation PCI: Bifurcation PCI

Plaque Shift vs Carina ShiftLeft Main and Bifurcation PCI: Bifurcation PCI

Plaque Shift vs Carina ShiftPlaque Shift vs. Carina ShiftPrevalence and ImplicationPlaque Shift vs. Carina ShiftPrevalence and Implication

S Ji K MD PhD

pp

Soo-Jin Kang, MD., PhD.

Department of Cardiology, University of Ulsan College of MedicineAsan Medical Center Seoul KoreaAsan Medical Center, Seoul, Korea

Disclosure

I h hi di lI have nothing to disclose

Mechanisms of Angiographic SB JailingStent Strut ArtifactStent Strut Artifact

Post-stentingPre-procedural

After cross-over

NoboriMLA 8.4mm2 MLA 8.3mm2

Nobori

Pre-procedure After Cross-Over

SBCarina Shift

SB

∆V/∆L >1

MBMB∆P <0

A ChArea Change∆L -3.4 mm2

MBMB

∆V -3.5 mm2

∆P 0 1 mm2

SB pullbackSB pullback

SB MLA 7.2 mm2 SB MLA 3.8 mm2

∆P -0.1 mm2

EEM area 9.3 mm2

P+M area 2.1 mm2EEM area 5.8 mm2

P+M area 2.0 mm2

After MB stentingPre-procedure

Plaque ShiftPlaque Shift

∆V/∆L <1∆V/∆L <1∆P >0

SB FFR 0.77

Area ChangePB 52% PB 70%

g∆L -1.0mm2

∆V 0 3mm2∆V -0.3mm2

∆P +0.7mm2

SB MLA 2.3 mm2

EEM 5 0 2SB MLA 1.4 mm2

EEM area 5.0 mm2

P+M 2.7 mm2EEM area 4.7 mm2

P+M 3.3 mm2

Plaque Shift vs. Carina Shift

Prevalence of Carina vs. Plaque Shift Impact on Functional Significance

Distal MB segment Proximal MB segmentDistal MB segment Proximal MB segmentPre Post p Pre Post p

Lumen VI 3 5±1 5 6 1±2 1 <0 001 4 0±2 0 6 7±2 0 <0 001Lumen VI 3.5±1.5 6.1±2.1 <0.001 4.0±2.0 6.7±2.0 <0.001

Plaque VI 5.4±1.8 5.3±1.7 0.227 9.1±3.0 8.4±2.4 0.001

V l VI 9 0±2 5 11 3±3 1 0 001 13 2±3 6 15 1±3 5 0 001Vessel VI 9.0±2.5 11.3±3.1 <0.001 13.2±3.6 15.1±3.5 <0.001

Luminal gain is not caused by plaque shift but by EEMLuminal gain is not caused by plaque shift but by EEM expansion, leading to carina shift and SB compromise

Koo et al. Circ Cardiovasc Interv 2010;3:113-9

( 23 LM bif ti l i )(n=23 LM bifurcation lesions)

Kang et al. Circ Cardiovasc Interv 2011;4:355-61

Hemodynamic Impact of Changes in Geometry of Non LM Bifurcation Geometry of Non-LM Bifurcation Non-LM bifurcation lesions with SB ostial DS<50%

SB MLA (mm2)3 5±1 32 8±1 2

EEM (mm2)6 3±1 95 5±1 7

P+M (mm2)2 8±1 52 7±1 3

Eccentricity1 1±1 11 4±0 2

6 0

7.0 12.0

1 8

2.0

7.0

8.0

3.5±1.32.8±1.2 6.3±1.95.5±1.7

p<0.001

2.8±1.52.7±1.31.1±1.11.4±0.2

p<0.001 p=0.215p<0.001

5.0

6.0

8.0

10.0

1.6

1.8

5 0

6.0

7.0

3.0

4.06.0

1.2

1.4

3 0

4.0

5.0

1 0

2.0

2.0

4.0

0 8

1.0 2.0

3.0

1.0

pre post

2.0

pre post

0.8

pre post

1.0

pre postp p p p p p p pKang et al. Catheter Cardiovasc Interv 2013 in press

Plaque Shift + Carina Shift

1.0

Plaque Shift Carina Shift

45%0.5

45%+M 0.0

∆P+

-0.5

-1.0Isolated

Carina Shift55%

3 02 52 01 51 00 50

Carina Shift

∆V/∆L3.02.52.01.51.00.50

Kang et al. Catheter Cardiovasc Interv 2013 in press

Plaque Shift vs. Carina Shift

Prevalence of Carina vs. Plaque Shift Impact on Functional Significance

SB ostium with pre-procedural DS<50%p p48% were angiographically jailed (DS>50%) after MB stenting while 15% had FFR<0 80after MB stenting, while 15% had FFR<0.80

After MBstentingstenting

AMC preliminary

How Often Functional SB Compromise?

50

40 38%0

(%)

20

3020%

R<0

.80

20 13%10FF

R

<30% 30-50% 50-75%

Pre-procedural SB %DS

30% 30 50% 50 75%

Kang et al. Am J Cardiol 2011;107:1787-93

How to TreatHow to TreatAngiographic Jailing of SB?

FFR 0 75 i f f d f l f j il d SBFFR >0.75 is safe for deferral of jailed SBFFR guided provisional SB interventionFFR-guided provisional SB intervention resulted in a low rate of 9-month MACE

Koo et al. Eur Heart J 2008;29:726–32

Mismatch Between QCA vs. FFR

Post-stenting DS 70%SB FFR 0 83

Post-stenting DS 80%SB FFR 0 88SB FFR 0.83 SB FFR 0.88

Discordance BetweenP t t ti QCA DS SB FFRPost-stenting QCA-DS vs. SB FFR

73% 74%

FFR

FFR

SB

SB

Post-stenting DS (%) Post-stenting DS (%)

K l JACC 2005 46 633 Ah t l JACC I t i PKoo et al. JACC 2005;46:633 Ahn et al. JACC Interv in Press

Why Mismatch?Angiography and SB FFR

Lesion eccentricity of SB Negative remodeling of ostium Negative remodeling of ostium Various size of myocardium

St t tif t Strut artifacts

Sachdeva et al. Am J Cardiol 2011;107:1794-5

Is Post-stenting SB-IVUS Useful gto Assess Jailed SB?

SB MLA <2.25mm2

1.0

0 9To Predict FFR<0.80

0.9

0.8FFR Sensitivity 100%

S ifi it 71%0.7S

B Specificity 71%

PPV 38%r=0.516p=0.001

0.6 NPV 100%6.05.04.03.02.01.0

Post-PCI MLA of SB (mm2)0

Kang et al. Catheter Cardiovasc Interv 2013 in press

Why Mismatch?IVUS-MLA vs. FFR

After MB Stenting

Small myocardial territory The general mechanism of SB jailing is focal The general mechanism of SB jailing is focal

carina shift rarely causing functional stenosis

Why Does the Isolated Carina Shift R l R d FFR?Rarely Reduce FFR?

N t b l i b t b l d f tiNot by plaque gain, but by vessel deformationThe luminal change is extremely focalg y

Hemodynamic ImpactCarina vs Plaque Shift

1.0

Carina vs. Plaque Shift

0.9R

0.8

B F

FR

0.7

0 6

S CS onlyPS+CS

6 05 04 03 02 01 0

0.6

0

PS+CS

6.05.04.03.02.01.0

Post-PCI MLA of SB (mm2)

0

Plaque shift may be a prerequisiteto the hemodynamically significant SB stenosisy y g

Kang et al. Catheter Cardiovasc Interv 2013 in press

Predictor for Plaque Shift

m2 )

m (m

m 1.0

0.5 MB carinar=0.341p=0.031

ostiu

m

0.0

MB carinap, S

B o

-0.5

1 0

9080706050403020∆P+M

-1.0

Plaque burdenat MB carina (%)r p

Lumen area MB carina 0 137 0 399

9080706050403020∆ ( )

Lumen area, MB carina -0.137 0.399Plaque burden, MB carina 0.341 0.031Plaque burden distal MB 0 299 0 061Plaque burden, distal MB 0.299 0.061Plaque burden, proximal MB -0.039 0.813Plaque burden SB ostium -0 218 0 176Plaque burden, SB ostium 0.218 0.176

Kang et al. Catheter Cardiovasc Interv 2013 in press

Impact of Carina Angle 0

-10rea

(%)

10

-20

-30umen

a

30

-40

-50carin

a l

r=0.458

16014012010080604020

-50

-60

%∆

LCX

p=0.028

Distal carina angle (°)

%

A narrow distal carina angle predicted a greater reduction in MLA and EEM area at the LCX ostiumreduction in MLA and EEM area at the LCX ostium

Kang et al. Circ Cardiovasc Interv 2011;4:355-61

Summary

Carina shift is a general mechanism of SB Carina shift is a general mechanism of SBjailing, occurs in almost all lesions

Plaque shift is less frequent, but moreaggressive mechanism of the functional SBcompromisecompromise

Considering the frequent visual functional Considering the frequent visual–functionalmismatch, treatment of the jailed SB shouldbe based on post-stenting SB FFR