Update on New Ultrasound and

Update on New Ultrasound and

Competing Technologies: VH, IB-
Competing Technologies: VH, IB-
IVUS, OCT, NIS
IVUS, OCT, NIS
!"i"o #aehara, #$
!"i"o #aehara, #$
$irector o% Intra&ascular Imaging ' (h)siolog) Core *a+oratories $irector o% Intra&ascular Imaging ' (h)siolog) Core *a+oratories
!ssociate $irector o% #I,#$CT Core *a+orator) !ssociate $irector o% #I,#$CT Core *a+orator)
Cardio&ascular esearch -oundation,Colum+ia
Cardio&ascular esearch -oundation,Colum+ia
Uni&ersit) #edical Center, New .or"
Uni&ersit) #edical Center, New .or"
$isclosure Statement o% -inancial Interest
!"i"o #aehara recei&es research grants %or
!"i"o #aehara recei&es research grants %or
%ellows %rom BSC and Volcano/
%ellows %rom BSC and Volcano/
Plaque Morphology of AMI/SCD w/Thrombi
Plaque Morphology of AMI/SCD w/Thrombi
(la0ue upture (la0ue upture
1234%5 6 7234m5 1234%5 6 7234m5
(la0ue 8rosion (la0ue 8rosion
9234m5 - :234%5 9234m5 - :234%5
Calci%ied Nodule Calci%ied Nodule
93 - ;3 93 - ;3
th th
th
th
th
th
th th
th th
What is a limitation of
What is a limitation of
conentional grayscale I!"S#
conentional grayscale I!"S#
Ultrasound <a&e Ultrasound <a&e
(atholog) (atholog)
=re) Scale =re) Scale
=re) Scale IVUS Tissue Characteri>ation
=re) Scale IVUS Tissue Characteri>ation
H)po
Iso,H)per
H)per with Shadow
Calcium
-i+ro%att)
-i+rous
!ulnerable Plaque#
!ulnerable Plaque#
-i+rous Cap -i+rous Cap Necrotic Core Necrotic Core
$etection o% Necrotic Core
$etection o% Necrotic Core
(rati -, et al ? @ardiol
9222
A
*ipid necrotic area
*ipid necrotic area
A
:2#H> IVUS
:2#H> IVUS
A
Human B2 coronar) ' 9 carotid arteries, in &itro
Human B2 coronar) ' 9 carotid arteries, in &itro
C2 ,B99
C2 ,B99
49D35:
49D35:
histological lipid pool
histological lipid pool
BE,B99
BE,B99
4B135:
4B135:
IVUS lipid pool
IVUS lipid pool
Sensiti&it): 1;3
Sensiti&it): 1;3
Speci%icit): E:3
Speci%icit): E:3
O+Fecti&e, Guantitati&e 8&aluation
O+Fecti&e, Guantitati&e 8&aluation
A
Integrated Bac"scatter 4IB5 IVUS
Integrated Bac"scatter 4IB5 IVUS
A
Virtual Histolog) 4VH5 IVUS
Virtual Histolog) 4VH5 IVUS
A
i-#ap
i-#ap
adio%re0uenc) $ata
adio%re0uenc) $ata
8n&elopeH!mplitude
-re0uenc)
-re0uenc)
I
I
H
H
VH-IVUS
VH-IVUS
i-#ap
i-#ap
(athological Intimal
Thic"ening 4(IT5
Thic" Cap
-i+roatheroma
VH-IVUS
VH-IVUS
=re) Scale
=re) Scale
IVUS
IVUS
Necrotic Core 4E135
$ense Calcium 4E;35
-i+rous 4E:35
-i+ro%att) 4E:35
In &itro $iagnostic
!ccurac)
Nair, et al 8urointer& 922;, C:BBC-B92/
iMap s$ !% Compare&
iMap s$ !% Compare&
i#ap VH
Transducer -re0uenc)
4esolution5
:2#H> 4E2J:725 92#H> 4B;2JD925
Con%idence *a+els .es None
Characteri>ation
%rames,millimeter
9 -rame,#illimeter 8C= =ated
-i+rotic
*ipidic
Necrotic
Calci%ied
Integrated Bac"scatter 4IB5-IVUS
Integrated Bac"scatter 4IB5-IVUS
Calci%ication
$ense -i+rous
-i+rosis
*ipid (ool
O"u+o, @awasa"i, et al Ultrasound #ed Biol 9227, C::1DD-
1C/
Calci%ication -i+rous *ipid (ool
IB-IVUS
IB-IVUS
!mplitude
E13
EC3
E23
In &itro
!ccurac)
What &o we 'now about
What &o we 'now about
!%( I!"S#
!%( I!"S#
;22 pts with !CS
;22 pts with !CS
U! 4with 8C=
U! 4with 8C=
K
K
5
5
or
or
NST8#I
NST8#I
or
or
ST8#I L9:hrs
ST8#I L9:hrs
undergoing (CI o% B or 9 maFor coronar) arteries
undergoing (CI o% B or 9 maFor coronar) arteries
at up to :2 sites in the U/S/ and 8urope
at up to :2 sites in the U/S/ and 8urope
(CI o% culprit lesion4s5
(CI o% culprit lesion4s5
Success%ul and uncomplicated
Success%ul and uncomplicated
-ormall) enrolled
-ormall) enrolled
(I: =regg </ Stone (I: =regg </ Stone
Sponsor: !++ott VascularM (artner: Volcano Sponsor: !++ott VascularM (artner: Volcano
The
The
P)*SP+CT
P)*SP+CT
Trial
Trial
Thic"-cap -!
Thin-cap -! (IT
-i+rocalci%ic
-i+rous
VH-IVUS Classi%ication
#ore than B23 #ore than B23
Con%luent Con%luent
Necrotic Core Necrotic Core
NO NO more than B23 more than B23
Con%luent Necrotic Con%luent Necrotic
Core Core
#ore than #ore than B23 B23
con%luent con%luent
calcium calcium
#ore than BD3 #ore than BD3
-i+ro%att) -i+ro%att)
IndeJ 9,BC,21
IndeJ 9,BC,21
8&ent 9,1,2;
8&ent 9,1,2;
GC! (*CN $S 97/13
GC! (*CN $S 97/13
GC! (*CN $S ;B/C3
GC! (*CN $S ;B/C3
(OS(8CT 79EB2-2B9:
(OS(8CT 79EB2-2B9:
D9 )oO
D9 )oO
9,BC,21:
9,BC,21:
NST8#I, (CI o% #*!$
NST8#I, (CI o% #*!$
9,1,2; 4DB wee"s later5:
9,1,2; 4DB wee"s later5:
NST8#I attri+uted to *CN
NST8#I attri+uted to *CN
C7
B/ ThC-! B/ ThC-!
PO#
D/C
mm
9
*esion *esion
P
B
proJ
(OS(8CT 79EB2-2B9:
(OS(8CT 79EB2-2B9:
IndeJ 9,BC,21
IndeJ 9,BC,21
Baseline (*CN
Baseline (*CN
GC!: V$ 9/79 mm,
GC!: V$ 9/79 mm,
$S 97/13, length 1/7
$S 97/13, length 1/7
mm
mm
IVUS: #*! D/C mm
IVUS: #*! D/C mm
9 9
VH: ThC-!
VH: ThC-!
(OS(8CT:
(OS(8CT:
#!C8
#!C8
#
!
C
8

4
3
5
#
!
C
8

4
3
5
Time in .ears Time in .ears
2 2 B B 9 9 C C
!ll !ll
Culprit lesion 4C*5 related Culprit lesion 4C*5 related
Non culprit lesion 4NC*5 related Non culprit lesion 4NC*5 related
Indeterminate Indeterminate
2 2
D D
B2 B2
BD BD
92 92
9D 9D
Num+er at ris" Num+er at ris"
92/:3 92/:3
B9/E3 B9/E3
BB/13 BB/13
9/;3 9/;3
BC/93 BC/93
;/E3 ;/E3
1/:3 1/:3
2/E3 2/E3
B7/B3 B7/B3
BB/:3 BB/:3
E/:3 E/:3
B/E3 B/E3
!** !** 1E; 1E; DD; DD; D21 D21 :72 :72
C* related C* related 1E; 1E; DE2 DE2 D:C D:C DB7 DB7
NC* related NC* related 1E; 1E; DED DED DDC DDC D9B D9B
Indeterminate Indeterminate 1E; 1E; 1C: 1C: 12: 12: D7C D7C
P)*SP+CT,
P)*SP+CT,
!%(TC-A an& .on
!%(TC-A an& .on
Culprit /esion )elate& +ents
Culprit /esion )elate& +ents
*esion H *esion H C/E2 49/9D, 1/;15 1/DD 4C/:C, B9/DB5 B2/7C 4D/DD, 9B/B25 BB/2D 4:/CE, 9;/795
( &alue ( &alue Q2/222B Q2/222B Q2/222B Q2/222B Q2/222B Q2/222B Q2/222B Q2/222B
(re&alenceP (re&alenceP :1/;3 :1/;3 BD/E3 BD/E3 B2/B3 B2/B3 :/93 :/93
P*i"elihood o% one or more such lesions +eing present per patient/ (B H pla0ue +urden at the #*! P*i"elihood o% one or more such lesions +eing present per patient/ (B H pla0ue +urden at the #*!
Temporal Stability of Plaque
Temporal Stability of Plaque
Morphology by !%( I!"S#
Morphology by !%( I!"S#
!ll Comers =lo+al VH egistr) 4nHCC9B5
9B1 Non-Culprit *esions 4(la0ue
+urdenL:235 in EE patients
Baseline
99,;; ptsH!CS,non-!CS
B9 months -U
!llM non-!CS presentation
NH19 NH19 NH92 NH92 NHEC NHEC NH99 NH99 NHBE NHBE
B23 B23
NH:7 NH:7 NHB1 NHB1 NHB2E NHB2E NH9C NH9C NH92 NH92
BE3 BE3
1D3 1D3
B23 B23
B3 B3
C3 C3
13 13
;B3 ;B3
9D3 9D3
E23 E23
(IT TC-! ThC-! -i+rotic -i+rocalci%ic
@u+o T, R!CC 92B2MDD:BDE2
793 793
B223 B223
Change o% (la0ue T)pe
Change o% (la0ue T)pe
H Harmoni>ing armoni>ing O Outcomes with utcomes with e&ascular e&asculari> i>ati ation on and and S Stents in tents in !#I !#I
C129 pts with ST8#I with s)mptoms onset C129 pts with ST8#I with s)mptoms onset
QB9 hours QB9 hours
U-HI=( II+,IIIa inhi+itor U-HI=( II+,IIIa inhi+itor
4a+ciJima+ or epti%i+atide5 4a+ciJima+ or epti%i+atide5
Bi&alirudin monotherap) Bi&alirudin monotherap)
4 4 pro&isional =( II+,IIIa5 pro&isional =( II+,IIIa5

B:B
C221 eligi+le %or (rimar) (CI with stent C221 eligi+le %or (rimar) (CI with stent
(aclitaJcel-eluting T!NUS (aclitaJcel-eluting T!NUS (aclitaJcel-eluting T!NUS (aclitaJcel-eluting T!NUS
Bare metal 8N(8SS Bare metal 8N(8SS Bare metal 8N(8SS Bare metal 8N(8SS

C:B
B722 eligi+le %or BC month angio %ollow-up B722 eligi+le %or BC month angio %ollow-up
9E: T!NUS 9E: T!NUS 9E: T!NUS 9E: T!NUS
ED B#S ED B#S ED B#S ED B#S
BE1 41;35 -U BE1 41;35 -U BE1 41;35 -U BE1 41;35 -U
19 41D35 -U 19 41D35 -U 19 41D35 -U 19 41D35 -U
IVUS
IVUS
Su+stud)
Su+stud)
VH-IVUS
VH-IVUS
Su+stud)
Su+stud)
BC2 T!NUS BC2 T!NUS BC2 T!NUS BC2 T!NUS
C7 B#S C7 B#S C7 B#S C7 B#S
E: 4;935 -U E: 4;935 -U E: 4;935 -U E: 4;935 -U
9: 41C35 -U 9: 41C35 -U 9: 41C35 -U 9: 41C35 -U
NHB1 NHB1
NH:C NH:C
BE3 BE3
NHBB NHBB
NHD: NHD:
NHC9 NHC9
:C3 :C3
B:3 B:3
D3 D3
:D3 :D3
C73 C73
;13 ;13
:73 :73
(IT
TC-! ThC-!
NH:2 NH:2
D3 D3
HOI?ONS-!#I in B22 non-culprit lesions
HOI?ONS-!#I in B22 non-culprit lesions
E3
;3
:C3
9E3
BE3
D23
993
BE3
:C3
D:3
:23
B13
C93
BB3
TC-! TC-!
ThC-! ThC-!
(IT (IT
-i+rous -i+rous
-i+Cal -i+Cal
Baseline Baseline -ollow-up -ollow-up -ollow-up -ollow-up Baseline Baseline
!CS 49C35 ST8#I 4B2235
$i%%erence o% temporal changes
$i%%erence o% temporal changes
What &o we nee& more#
What &o we nee& more#
*CT0 .I)(Spectroscopy
*CT0 .I)(Spectroscopy
Plaque Morphology of AMI/SCD w/Thrombi
Plaque Morphology of AMI/SCD w/Thrombi
(la0ue upture (la0ue upture
1234%5 6 7234m5 1234%5 6 7234m5
(la0ue 8rosion (la0ue 8rosion
9234m5 - :234%5 9234m5 - :234%5
Calci%ied Nodule Calci%ied Nodule
93 - ;3 93 - ;3
th th
th
th
th
th
th th
th th
Throm+us
Throm+us
- !cute Throm+us - - !cute Throm+us -
Near In%rared
2/; SCTm
OCT 4light5 B/CTm
IVUS 4:2#H>5
C7Tm
<a&e length Increase
<a&e length Increase
esolution Increase
esolution Increase
BDTm
B22Tm
8rosion
8rosion
@u+o T, et al R!CC 922;
OCT IVUS
!ngioscop)
<T
T
<T
Bmm
T
T
Bmm
@u+o T, et al R!CC 922;
OCT IVUS
!ngioscop)
!cute Throm+us
!cute Throm+us
*rgani1e& Thrombus
*rgani1e& Thrombus
Strong attenuation
Strong attenuation
#=H O-$I
#=H O-$I IVUS
IVUS
Courtes) o% $r/Tearne)
.eointimal Coerage
.eointimal Coerage
2
3
42
43
5 6 7 48 89 4#onth5 4#onth5
435 435
Nie ., !RC 9227, #atsumoto $, 8ur Heart R 922;, @u+o T R!CC
Img 9227, ?hu-hua ., Chin #ed R 9227, Ta"ano #, R!CC 9227
OCT: Neointimal Co&erage and Throm+us
OCT: Neointimal Co&erage and Throm+us
3 O&erall 8Jposed Strut 3 O&erall 8Jposed Strut
Co-eJist Throm+us Co-eJist Throm+us
- C)pher Stent - - C)pher Stent -
66 years ol&0 male
A Stable AP0 Stage& Proce&ure :/AD;
A )is' factor, %T0 %/0 DM8
A %istory of CA<=0 PCI :)CA;
Case
Case
(romus Stent D (romus Stent D
months ago months ago
Old pla0ue rupture with throm+us
Old pla0ue rupture with throm+us
Co&ered Strut
435 435
Ota"e H, R!CC Inter& 922EM9::DE, @im R, ! Heart R 92B2MBDE:9;7
OCT: Neointimal Co&erage and Throm+us
OCT: Neointimal Co&erage and Throm+us
3 Unco&ered Strut per *esion
3 Unco&ered Strut per *esion
(redictor o% throm+us (redictor o% throm+us
@im et al/ 4B )ear5 @im et al/ 4B )ear5
B/ B/Stent length Stent length 97mm 97mm
9/ 9/Stent $iemeter Stent $iemeter Cmm Cmm
1. 1. 7 unco&ered strut per stent 7 unco&ered strut per stent
Ota"e et al/ 41 months5 Ota"e et al/ 41 months5
B/ B/Stent length Stent length
9/ 9/Stent s)mmetr) Stent s)mmetr)
913 913
Ota"e Ota"e
973 973
@im @im
BB3 BB3
@im @im
B3 B3
@im @im
T
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-

I I - -
In%rae$J NI S)stem
In%rae$J NI S)stem
A
Three Components
Three Components

Console
Console

(ull-+ac" de&ice
(ull-+ac" de&ice

$isposa+le Catheter
$isposa+le Catheter
otate
B spectra per BU per
2/Bmm pull-+ac"
BB22 BB22
BE22 BE22
<a&elength <a&elength
4nm5 4nm5
Original <a&e
!+sorption
eturned <a&e
BB22 BB22
B922 B922 BC22 BC22 B:22 B:22 BD22 BD22 B122 B122 B;22 B;22 B722 B722 BE22 BE22
Cholesterol Cholesterol
Cholester)l Cholester)l *inoleate *inoleate
Cholester)l Cholester)l Oleate Oleate
Collagen Collagen
B/2 B/2
2/7 2/7
2/1 2/1
2/: 2/:
2/9 2/9
! !
+
s
o
r
+
a
n
c
e
+
s
o
r
+
a
n
c
e
<a&elength <a&elength
NI Spectroscop)
NI Spectroscop)
A
Necrotic CoreL2/9mm thic", L12
Necrotic CoreL2/9mm thic", L12

, CapQ2/:Dmm
, CapQ2/:Dmm
Tissue
B/ <hat "ind
o% tissueV
Tissue
9/ Near In%rared
C/ !+sorption
(attern %rom this
tissue
:/ How similarV
Necrotic Core
Collagen
D/ (ro&a+ilit) %or
Necrotic Core
NN3
NN3
(rocess o% NI Spectroscop)
(rocess o% NI Spectroscop)
low
high
/ipiScan ersus %istology
/ipiScan ersus %istology
=oldstein et al, R!CC Imaging 92B2
(rediction o% No-e%low
(rediction o% No-e%low
No %low in arter)
a%ter angioplast)
No %low in arter)
a%ter angioplast)
Balloon
in%lation
Balloon
in%lation
Dilation of Circular /ipi& Core Plaque
Dilation of Circular /ipi& Core Plaque
Complete Heart Bloc"
B( C2
Complete Heart Bloc"
B( C2
$r/ #anos Brila"is 6 Use o% NI-guided %ilter to pre&ent #I $r/ #anos Brila"is 6 Use o% NI-guided %ilter to pre&ent #I
#I No #I
>
>
>
>
>
>
>
>
>
>
>
>
>
>
(eri-stenting #I and #aJ :mm *CBILD22 in 19 (atients
CO*O egistr), Su+mitted %or (u+lication
*CN
B 9
9
B
9 B
$istal
NI Spectroscop)-IVUS
9 B
9
B
=ra) Scale-IVUS
VH-IVUS
OCT
Chemogram
Bloc"
Chemogram
Summary
Summary
=re) Scale =re) Scale
IVUS IVUS
VH VH OCT OCT NI NI
Spectroscop) Spectroscop)
!Jial esolution 4Wm5 !Jial esolution 4Wm5
B22 B22 922 922 92 92 N! N!
(CI (CI
II
II
I,-
I,-
I
I
-
-
TC-! TC-!
I,-
I,-
I
I
II
II
I,-
I,-
Necrotic Core Necrotic Core
I,-
I,-
I
I
I
I
II
II
Throm+us Throm+us
I,-
I,-
-
-
II
II
-
-
Stent Co&erage Stent Co&erage
I
I
I
I
II
II
-
-
Summary
Summary
4$
4$ )ecent progress of )a&iofrequency I!"S may allow )ecent progress of )a&iofrequency I!"S may allow
us ob?ectie an& quantitatie assessment of plaque us ob?ectie an& quantitatie assessment of plaque
characteri1ation$ characteri1ation$
8$
8$ The higher resolution by *CT can e@amine &etails of The higher resolution by *CT can e@amine &etails of
surface such as fibrous cap thic'ness or strut surface such as fibrous cap thic'ness or strut
coerage which may impact the clinical outcome$ coerage which may impact the clinical outcome$
5$
5$ The quality of flow is an important clinical question The quality of flow is an important clinical question
an& all imaging mo&alities are promising$ an& all imaging mo&alities are promising$
9$
9$ We nee& to continue to as' ourseles0 Awhen0 how0 We nee& to continue to as' ourseles0 Awhen0 how0
which imaging mo&ality shoul& be use& than which imaging mo&ality shoul& be use& than
othersB$ othersB$