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Intravascular Ultrasound Imaging: Tips and tricks on lesion assessment Ramesh Daggubati, MD FACC FSCAI Associate Chief of Cardiology Director of Interventional Cardiology Fellowship Program Winthrop University Hospital Mineola NY USA Do all patients require IVUS? 2014 ESC Guidelines on myocardial revascularization Post Benefits of IVUS TLR Stent Thrombosis Mortality Reasons for lack of IVUS use/adoption No good clinical data  “My patients fine”  IVUS use is associated with a high rate of complications  Vocal anti-IVUS statements by some prominent interventionalists  Live demonstration courses and public posturing vs actual practice  Image interpretation – not understanding the image and how to use the information  Too much information – don’t know what is/is not important  Lack of consensus among experts  Guidelines not give Class I indication  Inertia – especially among senior interventionalists  Lack of education – especially for junior interventionalists • Poor image quality or inconsistency – often requires expert interpretation and inhibits confidence in new users • Intimidation by experts • OCT is better  • • • • • • • • • • • • • • • Ambivalence among stent companies Rapidly changing PCI landscape Procedural inefficiency Resistance from staff Past history and experience Poor catheter performance and recalls Chronic, nagging hardware problems Poor marketing strategies both domestically and internationally – no “magic bullet”; and every country is different Cost Limited reimbursement Catheter re-use – a necessary evil in some countries Competition – when the real competition is angiography and not other intravascular imaging companies and technologies No open interface Mature technology No new advances in IVUS despite major investments ADAPT-DES - Current Cohort Assessment of Dual AntiPlatelet Therapy with Drug-Eluting Stents 8582 pts prospectively enrolled No clinical or anatomic exclusion criteria 11 sites in US and Germany PCI with ≥1 non-investigational DES Successful and uncomplicated IVUS Use: 3361 pts No IVUS: 5221 pts Clinical FU at 30 days, year, years clinicaltrials.gov NCT00638794 Stone et al Lancet 2013; 382: 614–23 Relationship Between IVUS Use and MACE (Definite/Probable ST, Cardiac Death, MI) Within 2Yrs 10 MACE (%) HR: 0.65 [95% CI: 0.54, 0.78] P < 0.001 7.4% No IVUS Used 4.9% IVUS Used 0 12 18 24 Time in Months Number at risk: IVUS Used 3361 3206 3117 2988 1739 No IVUS Used 5221 4912 4740 4537 2177 Witzenbichler et al Circulation 2014;129:463-470 Association of IVUS Use with MACE (Definite/Probable ST, Cardiac Death, MI) in Relation to Lesion Complexity Event Rate (n) HR [95%CI] IVUS vs Angio P-Value All 4.9% (158) vs 7.5% (373) 0.65 [0.54, 0.78] MSA of 6.0 mm2) Step 4: PCI Optimization Post PCI Criteria for optimal Full lesion:coverage with minimal residual plaque burden stent deployment No stent related complications ( such as edge dissection, stent fracture, thrombus, or others) Guidelines for use of IVUS No Class I Recommendation Class II A : Mechanism of ISR, ST, Assessment of indeterminate LMCA PCI of Unprotected LMCA Post stent Optimization Post transplant allograft vasculopathy Class III : Routine lesion assessment without PCI Conclusions Routine use of IC Imaging results in Safer, faster, Optimal Procedure Prevents Complications Improves Outcomes : Less ST, Less Restenosis, less MACE No stress for the operator: no unknown to deal with Summary Before reviewing IVUS images, please imagine what you should expect in relation to angiography and procedure Expect and Learn!  "Any intelligent fool can make things bigger, more complex, and more violent It takes a touch of genius and a lot of courage -to move in the opposite direction." Albert Einstein