左主干病变左主干病变 PCI PCI 中中 IVUS IVUS 的指的指导作用：是否必需？导作用：是否必需？ 钱杰钱杰阜外心血管病医院阜外心血管病医院

术前评价术前评价 LMLM 病变病变

造影有局限性• 1 、短而没有参照• 2 、造影剂反流影响开口判断• 3 、层流导致假阳性狭窄• 4 、弥漫病变低估支架大小• 5 、是否需要使用切割技术• 6 、钙化时是否使用旋磨• 7 、治疗策略的选择

Comparison between percent stenosis assessment from the Comparison between percent stenosis assessment from the quality control (QC) lab vs the clinical site in the CASS Studyquality control (QC) lab vs the clinical site in the CASS Study

**area of the square is proportional to the number of casesarea of the square is proportional to the number of cases

100

0 1000

Of all the coronary segments, the LM Of all the coronary segments, the LM has the greatest angiographic has the greatest angiographic

assessment variability - Iassessment variability - I

QC lab

Clinical Site

Fisher et al. Cathet Cardiovasc Diagn 1982;8:565-75

Of all the coronary segments, the LM has Of all the coronary segments, the LM has the greatest angiographic assessment the greatest angiographic assessment

variability - IIvariability - II

Cameron et al. Circulation 1983;68:484-489

0

20

40

60

80

100

-3 -2 -1 0 +1 +2 +3 +4

1: 0-24% DS2: 25-49% DS3: 50-74% DS4: 75-89% DS5: 90-100%DS

0: no difference+1 or -1: 1 grade difference+2 or -2: 2 grades of difference+3 or -3: 3 grades of difference+4 or -4: 4 grades of difference

Clinical site vs Clinical site vs Quality controlQuality control

0

20

40

60

80

100

-3 -2 -1 0 +1 +2 +3 +40

20

40

60

80

100

-2 -1 0 +1 +2

Clinical site vs Clinical site vs Study GroupStudy Group

Study Group vs Study Group vs Quality controlQuality control

Five grades of LM severity

# of grades of difference in assessment of LM severity

Lindstaedt et al. Int J Cardiol 2007;120:254-61

But surely we are better today!But surely we are better today!•51 intermediate or equivocal LM lesions were 51 intermediate or equivocal LM lesions were

evaluated by FFR and angiography. Four experienced evaluated by FFR and angiography. Four experienced interventional cardiologists visually classified lesions interventional cardiologists visually classified lesions as ‘significant’, ‘not significant’, or ‘unsure.’as ‘significant’, ‘not significant’, or ‘unsure.’•The 4 experienced interventional cardiologistsThe 4 experienced interventional cardiologists

achieved correct lesion classification in no more than achieved correct lesion classification in no more than ~50% of each case regardless of the FFR threshold ~50% of each case regardless of the FFR threshold (≤0.75 or ≤0.80).(≤0.75 or ≤0.80).•Interobserver variability was large, resulting in Interobserver variability was large, resulting in

unanimous correct lesion classification in only 29%!unanimous correct lesion classification in only 29%!

IVU

S M

LD

(mm

)IV

US

ML

D (m

m)

QCA MLD (mm)QCA MLD (mm)

r=0.36r=0.36440

1

2

3

4

5

6

7

0 1 2 3 4 5 6 7

IVU

S D

SIV

US

DS

QCA DSQCA DS

0

20

40

60

80

100

0 20 40 60 80 100

p=0.10p=0.1066

Abizaid et al. J Am Coll Cardiol 1999;34:707-15Abizaid et al. J Am Coll Cardiol 1999;34:707-15

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1.41.8

2.22.6

3.03.4

3.84.2

4.65.0

5.45.8

DM and ≥1 untreated vessel (DS>50%)

DM and no untreated vessels

No DM and ≥1 untreated

vessel (DS>50%)

No DM and no untreated vessels

MACE

IVUS MLD (mm)

Follow-up of 122 patients Follow-up of 122 patients with moderate LM diseasewith moderate LM disease

Independent predictors of MACE @11.7 months: DM (p=0.004), untreated lesion >50% (p=0.037), and IVUS MLD (p=0.005) – but NOT the plaque burden.

IVUS Predictors of the EventsIVUS Predictors of the Events

2.7

2.75

2.8

2.85

2.9

2.95

EventsNo Events

0

1

2

3

4

5

6

7

8

9

10

CSA

Events

No Events

Abizaid et al. JACC 1999;34:707

MLD (mm)CSA(mm2)

P=0.0003

P=0.013

Angiographic Predictors of the Angiographic Predictors of the EventsEvents

0

0.5

1

1.5

2

2.5

EventsNO events

Abizaid et al. JACC 1999;34:707

MLD (mm)

P=NS

0

5

10

15

20

25

30

35

40

45

50

EventsNo Events

DS(%)

P=NS

1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0

FFR

0.5

0.6

0.7

0.8

0.9

1.0

1.1

1.2

0 2 4 6 8 10 12 14 160.5

0.6

0.7

0.8

0.9

1.0

1.1

1.2

MLDIVUS MLAIVUS

CSNIVUS20 30 40 50 60 70 80 90

FFR

0.5

0.6

0.7

0.8

0.9

1.0

1.1

1.2

FFR

y = 0.1836x + 0.2883r = 0.79

y = 0.0372x + 0.571r = 0.74

Y = -0.008x + 1.3282r = 0.69 r = 0.10

P<0.0001 P<0.0001

P<0.0001

Fig. 10 1 2 3 4 5 6

0.5

0.6

0.7

0.8

0.9

1.0

1.1

y = 0.0498+0.7501r = 0.10 P = 0.016

MLDQCA

FFR

A B

C D

MLAIVUS

0 2 4 6 8 10 12 14

Perc

ent

0102030405060708090

100110

CSNIVUS

20 30 40 50 60 70 80 90

perc

ent

0102030405060708090

100110

MLDIVUS

Sensitivity

SpecificitySensitivity

Specificity

5.9 mm2

67%

93%

90%88%

1 2 3 4 50

102030405060708090

100110

Perc

ent

SensitivitySpecificity

2.8 mm

93%98%

Fig. 2 DSQCA

0 10 20 30 40 50 60 70 80 90

perc

ent

0

10

20

30

40

50

60

70

80

90

100

110

94%

50%

SensitivitySpecificity

86%80%

A B

C D

Abizaid et al. JACC 1999;34:707

Sano et al. Am J Cardiol 2006;98:99M

MLA=12.5 mm2

MLD=4 mm

MLA=22 mm2

Baseline

FFR=0.85

MLA =4.3 mm2

MLD= 2.3 mmMLA=9.1 mm2

MLD=3.4 mm

Baseline

FFR=0.63

0 2.0 8.0mm

Treatment of LMCA DiseaseTreatment of LMCA Disease

对角支

支架未贴壁

IVUS-guided DES ImplantationIVUS-guided DES Implantation

0123456789

10

IVUSMSA

(mm2)

6-mo RS(%)

12-moTLR (%)

102 Pts with LM Disease 102 Pts with LM Disease Treated with Cypher StentsTreated with Cypher Stents

(Park et al. J Am Coll Cardiol 2005;45:351-6)(Park et al. J Am Coll Cardiol 2005;45:351-6)

0123456789

10

IVUSMSA

(mm2)

6-mo RS(%)

6-moTLR (%)

53 Pts with LM Disease 53 Pts with LM Disease Treated with Taxus StentsTreated with Taxus Stents

(Erglis et al. J Am Coll Cardiol 2007;50:491-7)(Erglis et al. J Am Coll Cardiol 2007;50:491-7)

0

20

40

60

80

100

6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5

Sensitivity Specificity

““Optimal” MSA Optimal” MSA and TLR after and TLR after DES Implantation (n=595)DES Implantation (n=595)

8.78.7Minimum stent area (mmMinimum stent area (mm22))

(SJ Park et al. TCT 2007)(SJ Park et al. TCT 2007)

Malaposition and underexpansion

Independent predictors of mortality Independent predictors of mortality in 805 patients with LMCA disease in 805 patients with LMCA disease

treated with DEStreated with DES

(SJ Park et al. TCT 2007)(SJ Park et al. TCT 2007)

HRHR 95% CI95% CI PP

Previous CHFPrevious CHF 2.662.66 1.03-6.851.03-6.85 0.0430.043

Chronic Renal FailureChronic Renal Failure 4.874.87 2.10-11.262.10-11.26 <0.001<0.001

COPDCOPD 2.932.93 1.00-8.531.00-8.53 0.0490.049

Euroscore ≥ 6Euroscore ≥ 6 3.243.24 1.48-7.091.48-7.09 0.0030.003

IVUS guidanceIVUS guidance 0.430.43 0.21-0.870.21-0.87 0.0190.019

Impact of IVUS Guidance on All-Impact of IVUS Guidance on All-Cause Mortality After LMCA DES Cause Mortality After LMCA DES

Implantation (n=805)Implantation (n=805)

(SJ Park et al. TCT 2007)(SJ Park et al. TCT 2007)

Years after DES implantation

Cum

ulat

ive

Inci

denc

e ( %

)

1.51.00.0 0.5 2.5 3.0

70

100

80

2.0

IVUS (n=595)IVUS (n=595)

No IVUS (n=210)No IVUS (n=210)9095.2%95.2%

85.6%85.6%

HR=0.43, p=0.019

• Using IVUS, most LM lesions show either insignificant disease Using IVUS, most LM lesions show either insignificant disease or critical diseaseor critical disease

• Absolute lumen CSA <6.0mmAbsolute lumen CSA <6.0mm22 (or MLD <3.0mm) – (or MLD <3.0mm) – independent of plaque burdenindependent of plaque burden - is the suggested criterion for - is the suggested criterion for a significant LMCA stenosisa significant LMCA stenosis• Correlates with a LMCA FFR<0.75 Correlates with a LMCA FFR<0.75 • Murray’s Law (Murray’s Law (LMCALMCArr33 = = LADLADrr33 + + LCXLCXrr33))• Does not depend on finding a disease-free reference segmentDoes not depend on finding a disease-free reference segment

• The best available data indicates that IVUS-guidance during The best available data indicates that IVUS-guidance during LM DES implantation will reduce 3-year mortality; the final LM DES implantation will reduce 3-year mortality; the final MSA should be >8.5mmMSA should be >8.5mm2 2 to minimize TLR. to minimize TLR.

SummarySummary

• Is IVUS guidance necessary for the optimal Is IVUS guidance necessary for the optimal diagnosis and treatment of left main lesions?diagnosis and treatment of left main lesions?

• Given all of this data, the known limitations of Given all of this data, the known limitations of angiography, and the risks of making a mistake, angiography, and the risks of making a mistake, how can you possibly argue otherwise?how can you possibly argue otherwise?

ConclusionConclusion

THANK YOU !