leimbach march cotm 17mar2014 1811
TRANSCRIPT
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NIRS-IVUS TVC Imaging of LCX Reveals 4 New
Findings Not Detected by Coronary Angiography
Dr. Wayne LeimbachOklahoma Heart Center
Hillcrest Healthcare System
Tulsa, Oklahoma
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Case Report
72 y/o male, unstable angina
Nuclear imaging stress test positive forinferior-lateral wall ischemia
Prior stents in proximal LCX and proximal LAD
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Angiographic examination to locate the
culprit lesion is not conclusive.
RCA and LAD showed no
significant narrowing.
Pre-existing stent in theproximal LCX is widely
patent.
A moderate narrowing ispresent at the origin of the
first circumflex marginal.
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1) NIRS-IVUS TVC Imaging Clarifies Severity of Stenosis
IVUS reveals the vessel issignificantly narrowed with an
MLA of 1.48 mm2
Lesion also shows signs of
plaque vulnerability with a
plaque burden = 81% and
maximum lipid core burden
index in 4mm of 427
(maxLCBI4mm427)
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2) In the present case, there is marked lipid accumulation
at the bifurcation.
Pre-stent Post-stent
Plaque Shift at site of LCP as detected by NIR Spectroscopy:
Plaque
shift?
LCP
2ndDiag
In a previous
case with lipid
at a bifurcation,plaque shift was
observed.
Courtesy of Dr. Giora Weisz Columbia University NY, NY and Shaare Zedek Medical Center, Jerusalem, Israel
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Because plaque shiftand possible sidebranch closure wereanticipated, a wire
was placed in thedistal LCX.
In the present case, detection of lipid at the bifurcation
changed management
Bifurcation
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Post
After balloon dilation in the marginal,
a new stenosis appeared in the LCX
Pre
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Treatment of new LCX narrowing
With the use of
the pre positioned
guide wire,the new stenosis
was treated with
balloon dilation.
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3) NIRS-IVUS imaging reveals pre-existing stent is
patent, fully apposed and no lipid is present.
Pre-existing
LCX stent
Stents that remain patent
have less lipid by NIRS at
time of stenting than do
stents that fail.
Dohi et al, TCT Abstract, JACC 2013
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4) NIRS-IVUS reveals a large non-obstructive lipid-
rich plaque in the left main coronary artery.
The maxLCBI 4 mm is 491 .
The plaque burden is 67%.
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The left main lesion supports the need for
intensive medical management
The patient wasplaced on intensivelipid-lowering andanti-thrombotictherapy
atorvastatin 80 mg &extended dual anti-platelet therapy
2 months post-PCIthe patient remainsasymptomatic
LM Lesion
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Summary of the 4 findings of NIRS-IVUS TVC imaging
not revealed by angiography
Diagnosis Management Implications
1) IVUS confirms narrowing in LCXStent required, and documentation
obtained for AUC criteria.
2) NIRS shows lipid at stenosis and
adjacent bifurcationWire placed in side branch.
3) NIRS shows no lipid in prior stent,
IVUS shows good stent patency and
apposition of prior stent
Stent considered to be low risk for future
events.
4)NIRS shows lipid in left main, IVUS
shows large plaque, with preserved
lumen
No stent required, intensive medical
therapy initiated.