Coronary interventions
and imaging
Petr Kala
Dpt of Internal Medicine and Cardiology
Medical Faculty of Masaryk University
University Hospital Brno
Czech Republic
v. 2020
Fascination by HEART… for a long time
Image source: https://leonardodavinci.stanford.edu/projects/anatomy/heart1.jpg
Foam
Cells
Fatty
Streak
Intermediate
Lesion Atheroma
Fibrous
Plaque
Complicated lesion
Erosion/Rupture
From 1st Decade From 3rd Decade From 4th Decade
Growth Mainly by Lipid Accumulation Smooth Muscle
& Collagen
Thrombosis,
Hematoma
Adapted From Stary HC et al. Circulation. 1995;92:1355-1374
Endothelial Dysfunction
Life
threatening
Mostly
symptom
generating
The Evolution of Atherosclerosis
Mostly asymptomatic
Mechanism of plaque formation
Bentzon JF et al. Circulation Research. 2014;114:1852–1866
Coronary artery disease (CAD)
• Myocardial ischemia mainly due to the atherosclerosis
• Definition is based on the angiography
− Stenoses ≥50% (i.e. the „old“ definition though still broadly accepted)
 respecting the limitations of angiography, more appropriate is to divide
the lesions in two groups
− 40-70% moderate or borderline lesions
− >70% significant lesions (..mostly)
− Total occlusions
 Acute
 Chronic (>3 months)
- 3VD, normal LVEF –> HEARTteam -> FAME 3 trial -> patient was randomized in FFR-guided PCI
(cut-off for revascularization 0.80)
Woman, 71yo
CAD for 3 months with progression in Unstable angina, NYHA II-III
Risk factors: Hypertension, Hyperlipidemia
LAD LCX - OM RCA –„culprit“ lesion
Intravascular ultrasound - IVUS
MLA - Minimal lumen area of the Left main
stem (LM) = 7,1 mm2 = conservative Tx
(cut-off for revascularization of LM ≤6mm2)
Woman, 68yo
CAD w/o angina, dyspnea NYHA III, LVEF 67%, history of PCI + DES of
LAD, LCx, RCA
Sones - 1958
Gruentzig - 1977
History of PCI/PTCA
(PCI = percutaneous coronary intervention;
PTCA = percutaneous transluminal coronary angioplasty)
• 1958 - selective coronary angiography
• 1977 - balloon angioplasty (POBA)
• 1983 – mechanical reperfusion in acute myocardial infarction (AMI)
• 1986 – intracoronary stenting
• 1995 – stenting in AMI
• 2001 – drug-eluting stents
Coronary stenting
Courtesy: myoclinic.org
Coronary interventions
Types of lesions and techniques
1-3 diseased coronary arteries may be
treated by PCI
Types of lesions:
A, B1, B2, C (i.e. from simple, discrete to long,
diffuse and/or chronic total occlusions)
CAD forms:
Chronic Coronary Syndrome - stable angina,
silent ischemia
Acute Coronary Syndrome (ACS) - unstable
angina (UA), acute myocardial infarction (AMI)
with or without ST elevations = STEMI or
NSTEMI
• Stenting (>90-95%)
• Ballooning
• Atherectomy
− Rotational
− Direct
• Laser, ultrasound
Coronary interventions
Pharmacotherapy
Antiplatelet Tx
• acetylosalicylic acid (ASA) (chronic+acute..)
• P2Y12 blockers for oral administration
− Ticlopidin
− Clopidogrel (chronic..)
− Prasugrel (acute..)
− Ticagrelor (acute..)
• P2Y12 blocker for i.v. administration
− Cangrelor (acute..)
• Gp IIb/IIIa i.v. platelet blockers (complications..)
Anticoagulation
• Heparin
− Unfractionated
− Low-mollecular weight
• Bivalirudin
PCI - Primary success rate
and complications
• Primary success in the cathlab = at the end of the procedure
− Stenoses > 90%
− Acute occlusions > 85-90%
− Chronic occlusions > 50% (up to 90% in dedicated centres)
• Complications (more often in acute patients)
− Local 0.5 - 5% (radial vs. femoral approach)
− Cardiac 0.5 - 2%
PCI - Cardiac complications
Acute (relatively rare and mostly well managable in the cathlab)
 Distal embolization
 Slow-flow, no-reflow phenomenon
 Thrombosis
 Coronary vessel closure
 Arterial wall dissection
Late
 Restenosis
 clinically 10-50% after POBA, 5-30% after bare-metal stenting and
around 5% after DES)
 anatomic rate is higher (based on the detection of ≥50% stenosis)
Coronary dissection
Courtesy: M. Gibson
Coronary dissection
OCT – optical coherent tomography: cross-sectional view
false
lumen
true
lumen
OCT
probe
coronary
wires
Acute in-stent thrombosis on OCT
Stent Struts
Thrombus
Lumen
OCT
cathetr
Optimal result after stenting
avoids restenosis
Romagnoli E, 2008
Angiography and IVUS OCT
Incomplete vs. complete
stent apposition on OCT
ACS - Acute Coronary Syndrome
Typy nestabilního plátu
VP diagnostics
Jacob Fog Bentzon. Circulation Research. Mechanisms of Plaque Formation
and Rupture, Volume: 114, Issue: 12, Pages: 1852-1866, DOI:
(10.1161/CIRCRESAHA.114.302721) © 2014 American Heart Association, Inc.
Thrombosis caused by plaque rupture
Plaque rupture and healing
Plaque erosion
Coronary thrombus
Coronary angiography IVUS
Ronen Jaffe et al. JCIN 2013;6:e43-e44
UA and NSTE-ACS
Unstable Angina and non-STE
Acute Coronary Syndrome
NSTE-ACS Risk stratification scores
STE-ACS = STEMI
ST-Elevation Acute Myocardial
Infarction
F, 71 yo, AW STEMI
• STEMI as first presentation of CAD
− Symptom onset: Time 0
− EMS call: 63 mins
 Lifenet telemedicine – AW STEMI
 UFH 5000 IU + ASA 250mg i.v.,
 Fentanyl 2cc i.v.
− Transport to CCU: 47 mins
− Catlab+20mins! puncture +8mins; wire+17min
− End of primary PCI in 70 mins from the CCU admission
− Killip III … progression in Killip IV in the cathlab =
Cardiogenic shock
− History: Hypertension on ACEI + BB
• RADIAL approach – 6F
• MANUAL THROMBOASPIRATION
• DES
• HIGH-PRESSURE POSTDILATATION
• STENTING of LAD and LCx during the index procedure in patient with multivessel
disease who was scheduled for staged non-culprit PCI of RCA in several weeks
• Adjunctive pharmacotherapy – Ticagrelor LD 180mg, GPI (abciximab bolus i.v.),
furosemid, Noradrenalin
• Patient was discharged home after 5 days in good clinical status
• Further Qs during the acute phase
− Mechanical circulatory support? Timing? (IABP vs Impella vs ECMO?)
− Imaging?
F, 71 yo, AW STEMI
Primary PCI vs. fibrinolysis
ESC guidelines on STEMI
Algorithm of reperfusion Tx and the time intervals
Non-stop (24/7) PCI centres
in the Czech Republic
Třinec
22 centres per 10.6M population = 460.000 / centre
Reperfusion Therapies and Mortality Differ
among Countries
92
86
81 81
75 75 72 70
66 64
59
49
45 45
35 33 30 30 28 24 23 19 19
9 8 5
1
0 7
2 12
5
3
15
8 10
31
15
15
40
35
28
26
35
30
55
25
44
33
41
29
45
7
14 12
17 13
20
25
15
26 26
10
36
40
15
30
39
44
35
42
21
52
37
48 50
63
50
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
CZ SLO DE CH NO DK PL HR SE HU BE IL IT FIN AT FR SK ES LAT UK BG PO SRB GR TR RO
P-PCI Thrombolysis No reperfusion
Widimsky P....Kala P. et al. Eur. Heart.J. 2010. doi:10.1093/eurheartj/ehp492
23
57
33
64
9
32
19
44
30
50
8
78
25
9
28
14
41
40
33
26
35
40
29
19
52
34
39
22
50
28
48
30
35
9
63
3
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percentage of reperfusion therapy utilization in the SFL6 countries,
development from 2008 to 2011
No
reperfusion
Bulgaria France parts Greece Serbia Spain Turkey parts
2008 2008 2008 2008 2008 20082011 2011 2011 2011 2011 2011
SFL Impact on Access to PPCI – what
can be achieved within several years..
Kristensen SD,..Kala P et al. EHJ 2014. doi: 10.1093/eurheartj/eht529. Epub 2014 Jan 12.
21 countries from 5 continents were
actively participating in SFL Initiative
SFL Member Countries
Belarus, Bosnia and Herzegovina,, Bulgaria,
Cyprus, Egypt, France,
Greece, Italy, Portugal, Romania,
Russia, Serbia, Spain, Tunisia,
Turkey, Ukraine
SFL Affiliate Organizations
Argentine Society of Cardiology
Saudi Heart Association
SOCIME (Mexico)
South African Heart Association
STEMI INDIA
Male, 51 yo in Cardiogenic Shock
due to the anterior wall STEMI with chronic occlusion of RCA
RCA chronic occlusion
LCA with acute LAD
and chronic LCx
occlusion
LAD recanalisation with
the wire
Balloon inflation
Final result after stenting
Post ballooning
Severe Left ventricle dysfunction with Ejection Fraction of 22%
Chronic CAD
newly known as CCS = Chronic Coronary
Syndrome
ESC Guidelines on Revascularization
PCI vs CABG
From morphology to coronary
physiology
Two-Compartment Model
of the Coronary Circulation
Courtesy to B. de Bruyne
Only 5% of coronary circulation can be
visualized by angiography!
Coronary morphology - summary
• Coronary angiography = luminography – the gold standard
in ACS patients though suffering several limitations.
• IVUS and virtual histology provide better knowledge of the
artery and plaque distribution/composition.
• OCT provides the highest resolution at present and becomes
an important imaging technique complementary to IVUS.
but…there is a BUT
3VD
(14%)
0VD
(9%)
1VD (34%)
2VD (43%)
Anatomic vs. Functional CAD
Tonino et al., JACC 2010 (submitted)
Tonino et al., JACC 2010
Angiographic
3 Vessel
Disease
3VD
(14%)
0VD
(9%)
1VD (34%)
2VD (43%)
Anatomic vs. Functional CAD
Tonino et al., JACC 2010 (submitted)
Tonino et al., JACC 2010
Fractional flow reserve - FFRmyo
1993 – Dr. Nico Pijls, Catharina Hospital, Eindhoven
Dr. Bernard De Bruyne, Cardiovascular Center, Aalst
- 3VD, normal LVEF –> HEARTteam -> FAME 3 trial -> patient was randomized in FFR-guided PCI
(cut-off for revascularization 0.80)
Woman, 71yo
CAD for 3 months with progression in Unstable angina, NYHA II-III
Risk factors: Hypertension, Hyperlipidemia
FFR 0,75
FFR 0,85
FFR 0,86
„FFR – Pd/Pa“ = 0,30
without hyperemia
LAD LCX - OM RCA
final FFR 0,92
final FFR 0,90
Woman, 71yo, FINAL RESULT after STENTING of LAD and RCA
Enjoy your healthy, full-sized aortic pump 
Source: cz.pinterest.com