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How to apply intracoronary diagnostic tools for clinical decision making

Invasive Coronary Imaging and Hemodynamics


This session addressed an important practical topic: how to use intracoronary diagnostic techniques in the “cath lab” for clinical decision making. The value of the two most frequently used intracoronary diagnostic techniques (namely intracoronary ultrasound and intracoronary pressure) was reviewed in detail, stressing clinical and practical issues.

In the first presentation, Dr G Finet (Lyon, FR) reviewed the clinical information supporting the value of intravascular ultrasound (IVUS) in patients with coronary artery disease. He emphasized the limitations of angiography in this setting, well recognized for a long period of time. Many examples were presented showing how ambiguous angiographic images may be unmasked using IVUS. He also stressed the accuracy of IVUS to provide precise anatomic information before coronary interventions. The value of IVUS to identify severe lesions was discussed. However, he further emphasized the usefulness of IVUS to achieve unique anatomic insights after interventions. Data suggesting that this imaging technique may indeed help to optimize the results of coronary stenting were presented. The use of IVUS to ensure adequate expansion of drug-eluting stents was also discussed.

In particular, the presence of malapposition was considered to be a major anatomic information readily provided by IVUS (not recognized by angiography)  that potentially may be related with the risk of stent thrombosis. A recent study by Park et al (Circulation Interv) suggesting the value of IVUS guidance during the implantation of drug-eluting stents to reduce “mortality” was analyzed. Finally, the value of virtual histology was also reviewed. Dr Finet, however, was more critical with this technique. Although the use of the complete signal of radiofrequency is very appealing to characterize tissue, this technique has many limitations in this regard. In particular, some illustrative examples where virtual histology erroneously classified calcium or thrombus, were shared with the audience. The diagnosis of thrombus remains elusive to this technology. Dr Finet concluded that virtual histology was neither virtual, nor histology.

In the second talk Dr E Barbato (Aalst, BE) addressed the topic of the use of intracoronary pressure measurement to guide clinical decisions. Fractional flow reserve (FFR) is considered as the “gold standard” to assess lesion severity. In fact, the limitations of anatomic data (either angiographic or IVUS-derived) to assess the functional significance of coronary lesions were emphasized. In addition, the importance of ischemia in general in the prognosis of patients with coronary artery disease was reviewed. Data from the COURAGE trial also suggested that ischemia was a major determinant of prognosis.

Subsequently Dr Barbato presented multiple clinical examples on how to use the FFR in many lesion subsets. The value of FFR in patients with left main disease, multiple lesions, tandem lesions etc was reviewed from a practical perspective. Tips and tricks regarding NTG administration, the use of IV adenosine, and how to avoid pressure damping with the guiding catheter were discussed. The results of the FAME trial, recently published in the NEJM, were revisited. The value and limitations of FFR in unstable patients was recognized. He further discussed a paper (Circulation, still in press) where his group demonstrated that FFR can be readily use in patients with unstable angina to evaluate “non-culprit” lesions.

Many examples and practical considerations were discussed with the audience. These comments were also complemented with interesting insights from the chairman of the session (Dr N Pijls) pioneer in the use and development of this technique.

References


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SessionTitle:

How to apply intracoronary diagnostic tools for clinical decision making

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.