Using IVUS to optimize PCI outcome: is it really necessary? 14th Vietnam National Congress of Cardiology Dr Jack Tan Senior Consultant Interventional Cardiologist National Heart Centre Singapore MBBS, MRCP(UK), FAMS(Cardiology), FAsCC Mechanical Transducer – 40 MHz Atlantis Pro (BosSci) Solid-State Transducer – 25 MHz EagleEye (Volcano)  Identify specific disease - left main stem, ostial lesions  Detect angiographically silent disease  Identify plaque morphology  Examine vessel when angiography is inconclusive - transplant vasculopathy -hazy lesions, presence or absence of thrombus or dissection  Measure plaque load  Measure true vessel size IVUS Determination of Atheroma Area Precise Planimetry of EEM and Lumen Borders with Calculation of Atheroma Cross-sectional Area Vessel Area Lumen Diameter Lumen Area Vessel Diameter Atheroma Area ANGIOGRAPHY IVUS dimensional 360º view Planar Tomographic and sagittal Shadow of lumen Visualisation of shape and location Wall structures not imaged Intermittent snapshots or repeat contrast injections necessary QCA measurements prone to magnification errors Visualisation of inner wall structures and morphology Continuous image Precise measurements    Pre-intervention During the intervention Post-intervention Pre-intervention  estimate hemodynamic significance  precise anatomic analysis (type of bifurcation, plaque burden in ostial side branches or left main bifurcation)  reference diameters define normal to normal segments  Type of lesion preparation required e.g atherectomy During Intervention  CTO intervention to guide wires or reentry  Assessment of side branch ostium after predilatation  Adequacy of debulking post atherectomy  Decision making for LM, bifurcation stenting Post Intervention  Stent expansion, stent apposition  Diagnosis of complications (dissection, geographic mismatch, thrombus formation ,plaque protrusion inside the stent  Oversized stents (stent to reference ratio >1.0) result in greater rates of peri-procedural myocardial necrosis and distal embolization without reducing 9-month revascularization rates EEM CSA = 17.6 Lumen CSA = 4.1 ~ 4.3 P+M CSA = 13.1 Max Lumen dia = 2.5 MLD = 2.3 Plaque burden = 74% Fibrous Volume 68.2 mm3 59% Fibro-Fatty volume 6.2 mm3 5% Dense Calcium Volume 11.7 mm3 10% Necrotic Core Volume 28.9 mm3 25% TCFA Independent predictors of lesion level events by Cox Proportional Hazards regression Variable HR [95% CI] P value PBMLA ≥70% 5.03 [2.51, 10.11] 70% and MLA2.4 mm2 may be a useful criterion for excluding intermediate lesions with an FFR [...]... decide on intervention but IVUS to optimize the end result Again if cost is not an issue     Not backed by evidence but good to have if done routinely not just for complex PCI If cost is not an issue A must to do for CTO wire retrograde tracking, SAT Good to do for LM PCI, ISR, diagnostic uncertainty, ASA allergy Ultimately a diagnostic test like IVUS is difficult to show outcome difference, very much... grayscale IVUS and RF backscatter analysis to predict the site of future coronary events 697 patients presenting with ACS were enrolled and underwent PCI of all culprit lesions followed by 3-vessel VH IVUS imaging At 3-year follow-up, nonculprit VH -IVUS defined thin-cap fibroatheromas with a plaque burden >70% and MLA2.4 mm2 may be a useful criterion for excluding intermediate lesions with an FFR