JasvindarSinghMD,FACCAssociateProfessorofMedicineWashingtonUniversityinSt.LouisDirector,CardiacCatheterization

LabBarnes-JewishHospital

Bifurcation stenting –Physiologic guidance

Novel Tools and Techniques: Co-registration and Resting Indexes

……Novel Tools and Techniques: Co-registration and Resting Indexes

Jasvindar Singh,MD

DisclosureResearch/Grantsupport:VolcanoCorp.,Abbott

Vascular,MedtronicVascular ,Boston-ScientificConsulting:VolcanoCorp,TriremeMedicalBoston-Scientific,AbbottVascular,MedtronicVascular,Spectranetics

Angiography

iFR /iFR Co-registration

IVUS(?OCT)&Co-registration

1.Tonino P,DeBruyneB,etal(2009).FractionalFlowReserveVersusAngiographyforGuidingPercutaneousCoronaryIntervention.NewEnglandJournalofMedicine.Volume360,Number3:213-224.2.ClaessonBE,MehranR,etal,ImpactofIntravascularImagingonEarlyandLateClinicalOutcomeFollowingPCIwithDrug-ElutingStents.J.Am.Coll.Cardiol.Intv.2011;4;974-981

AdvancedImagingAlgorithm

601-0103.109/001 48

Angio +

• Lesscontrast• Lessradiation• Preciseandlessstenting?• Betterpatientoutcomes• Cost-effective

2016------------------

AdvancedImagingSolutionFunctionalityiFR andIVUSCo-RegistrationandAngiographicEnhancement

Angio+EnhancedAngiographyiFR Co-Registration IVUSCo-Registration

• LocalizationofIVUSwithangiography

• Easylength/area/diametermeasurementswithmanualpullback

• iFR dropisdisplayedonangio• Lengthmeasurementwithoutpullbackdevice

• VesselEnhancement• QCA&DeviceDetection

Angio +• DiagnosticPhase

– QCA– VesselEnhancement(VE)

• TherapeuticPhase– StabilizedandEnhancedImageStream– DevicePositioning– MaximumInflation– EnhancedStent

600-0100.144001

Real-timeIVUSCo-registrationwithAngio+simplifiessizing

Easy length measurement with manual pullback

Area & diameter measurements

600-0103.144/0016Volcano, the Volcano logo, Eagle Eye Platinum, Revolution, and SyncVision are registered trademarks of Volcano Corporation. Angioare propert

iFR Co-RegistrationWithiFR co-registrationthereisnoneedforhyperemicdrugs,noneedfortimeconsumingpullbackdevicesandnoneedforguesswork

7

• Makelengthmeasurementswithoutacumbersomepullbackdevice

• Planyourprocedurewithphysiologicguidance

CASE1

JasvindarSinghMDBarnesJewishHospitalofWashingtonUniversity

RK

• 78yearoldwomanwithPMHsignificantfor:– HTN– Hyperlipidemia– DMII– CADs/pMIwithangioplastytothediagonalandOMin1999

• Duringpreoperativeevaluationforbilateralkneereplacement,shecomplainedofrecentchestdiscomfort(squeezingchestdiscomfortwithexertionforseveralweeks,relievedwithrest,similarinnaturetothatofpriorangina).

• GivenherknownhistoryofCADwithtypicalchestpain,shewasbeenreferredforinvasiveassessment.SheunderwentCardiacCatheterization.

Management?

• MedicalRx

• ComplexPCIvsCABGbasedonAngio alone?

• HemodynamicandanatomicassessmentwithiFR/FFRandIVUS?

Hemodynamic&AnatomicAssessments

• Complexcalcified50-60%lesionindistalLeftMainextendingintoproximalLADwith60-70%diseasewhichwashemodynamicallyassessedwithiFR andfoundtobesignificantat0.73.

• iFR pullbackdemonstratedsignificantstepupinboththedistalLMainandprox-midLAD.

• HemodynamicassessmentofOstial CXwithiFR whichwasnon-significant(0.98).

• HowdoesmanagementapproachchangewiththeaddedinformationfromiFR,FFR,andIVUS?

• Whatisthepotentialrevascularizationstrategy?

CircumflexAssessment

Conclusions

• iFR Co-registrationpreciselyprovidedcontributionofeachlesioninthesignificantzones

• IVUScoreg providedsizing,plaquedistributionandcharacteristic,choiceoftherapyandstentoptimization

• PostiFR Circumflex- noaddedstentneeded• Savedtime,lesscontrastuseandradiation,lessstentandexcellentPCIoptimization.

• Samedaydischarge,avoidingCABG,betterpatientsatisfaction