Chapters Transcript Video Coronary Physiology Case #1 We'll be talking a little bit about uh coronary imaging and physiology and how we've been using it in the lab. I'm gonna start with a case. Something of a cautionary tale to some extent, 57 year old gentleman with an established history of coronary disease, remote uh an TM I had emergent PC I performed at that time and subsequent stage intervention to non corporate RC A and CERC lesions came in the office with progressive angina refractory to medical therapy. Had uh perfusion imaging which showed inferior ischemia came in for a uh an elective, albeit rather urgent uh invasive evaluation. It's found to have uh inferior, I'm sorry, RC. A territory stenosis. And he had a PC I with 225, 22 Onyx drug looting stents. So pretty routine procedure. We see this every day. He was discharged uneventfully, uh at least in the short term, about 24 hours later came back with crushing chest pain and this was his EKG, he had inferior ST elevations. It's kind of the, the thing that I I know keeps me up at night more than others. Uh More than other things. Uh and probably a lot of us who do procedures is these routine interventions that actually turn out to be um really consequential. Sometimes it's humbling to see how the routine things we do can have severe consequences even more so than some of the things that we do that are more complex. So this turned what was a stable albeit untenable clinical situation into an emergent life-threatening one. So this is stent thrombosis is in his RC A territory. Um So we have clearly an under expanded stent with uh thrombosed RC A here and some pretty aggressive uh intervention was performed to re-establish flow and lesion 30 atmosphere, balloon, inflations, oversized balloon, inflations, balloon rupture. And a great job was done temporizing this and establishing te three flow into the vessel. But you can still see under expansion of the which was felt the nus for his acute repres and needed to be dealt with before he left. So he came over to the heart hospital and, and we were able to use intra coronary imaging to define a little bit better what was going on to help uh target uh therapy in a more tailored fashion to, to hopefully achieve a better result. On the later go around, we decided to use laser atherectomy with multiple passes at maximal pulse frequency and fluency after which we were able to achieve appropriate sten expansion and a better outcome. He is uh not come back. And this is about two years ago. Now So he's been doing quite well in the interval, the final result. So that's a case where subsequent interaction imaging revealed some things that the angiography apparently didn't at first and helped uh remedy a situation that was really um severe. And uh hopefully, um going forward, we'll see routine use of this more heavily implemented to prevent that type of situation. So we know intravascular imaging can be pivotal in achieving good outcomes. This is the adapt uh drug leading stent study. This was a study that examined multiple factors that were felt potentially influential in terms of outcomes in patients who underwent PC I. It was uh a study that was not specifically IVIS directed but had a predefined uh substudy within it that did include examination of IVIS uh use. So it was used at the operator discretion. About 40% of cases in this eight or 9000 person study uh utilized IVIS and among those who received IVIS imaging, 74% of them had revised treatment strategy based on those results generally uh reflected in longer or bigger stents, more intensive uh lesion preparation or post di dilation. And importantly, not only did it change at point of care, the operator's approach to uh treating the lesion, but those who underwent IVIS did better clinically. At one year, there was a 34% reduction in mace, I'm sorry, two years, 34% reduction in mace among patients who underwent IVIS. So you say, well, you know, that left some residual question if it didn't definitively answer it for you. The ultimate trial performed a randomized examination of IVIS use. So in this study, um patients, all comers, about 1500 patients were randomized to either undergo standard and geographically guided PC I or IVIS guided PC I. And I think one of the uh most often CED reasons for not using intravascular imaging in cases is that, you know, I have a lot of experience, I've seen a lot of angiograms. I've used IVIS in the past, I can apply that and I can achieve a good stent result without using it. But the operators in this study performed at minimum 200 PC is per years, these are experienced operators and even in the angiographically guided arm, we're utilizing that experience to achieve the best outcomes they could. And despite uh that experience, they were unable to achieve similar outcomes in those angiographically guided patients as they were in, I was guided patients in whom there was an 86% reduction in target vessel failure at one year. And of course, it wasn't just the IVIS catheter placement that uh led to improved outcomes. It was the use of that information to optimize um you know, stent placement. In this case, defined by appropriate positioning of the distal and proximal edge, satisfactory expansion and the lack of edge dissection at procedure conclusion, among patients who achieved these optimal goals only 1.6% had target vessel failure at one year, which is a considerable improvement and drove that improvement that we saw on IVIS guided outcomes. Published November 14, 2024 Created by Related Presenters Paul Lavigne, M.D. Sentara Cardiology Specialists View full profile
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