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How can we identify the plaque at risk of rupture or thrombosis

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SHAPE Society

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How can we identify the plaque at risk of rupture or thrombosis

  1. 1. Hypothesis
  2. 2. r = -0.63 p = 0.0001
  3. 3. Flexible guide wire Collapsed basket Shaft A penny! 0.014” Diameter
  4. 4. Basket CatheterBasket Catheter Wires with built-in Thermocouples 0.0014” Flexible Guide wire
  5. 5. PRESSURE WIRE HUMAN STUDY
  6. 6. CLINICAL: RISK FACTORS: 59Y Female with Cardiomyopathy and Angina Smoker Family history of CAD LAD Thermal Mapping in RCA Using Pressure Wire 39.65 39.66 39.67 39.68 39.69 39.7 39.71 39.72 39.73 1 26 51 76 101 126 151 176 201 226 251 276 301 326 351 376 401 426 451 476 501 526 # of Measurements Temperature(C) DISTAL END STENOSES 90% OSTIUM
  7. 7. stenosis Distal end CLINICAL: 39 y male with MI RISK FACTORS: Hypertension DM Family history Thermal Mapping of LCX using Pressure Wire 38.765 38.775 38.785 38.795 38.805 38.815 38.825 38.835 38.845 1 126 251 376 501 626 751 876 1001 1126 # of Measurements Temp(C) STENOSI S
  8. 8. CLINICAL: RISK FACTORS: 44y male Angina Kidney insuff Smoker DM Hypertension Obesity normal normal 1 cm Temperature Mapping in LAD (William Flusche) 38.32 38.33 38.34 38.35 38.36 38.37 38.38 38.39 38.4 1 119 237 355 473 591 709 827 945 1063 1181 1299 1417 1535 No of Measurements Temp(C)
  9. 9. LAD:100% PROXIMAL OCCLUSION LCA:70% MID STENOSIS RCA:SMALL ,NON DOMINANT CLINICAL: RISK FACTORS: 68 MALE Angina MI HYPERTENSION OBESITY DM 0.5 cm
  10. 10. RANGE OF TEMPERATURE 0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 0.16 1 2 3 4 5 6 7 8 9 10 o C
  11. 11. of Atherosclerotic Plaques and its Correlation with •Morteza Naghavi MD, •Reji John MD, Said Siadaty MD, •Sameh Naguib MD, Roxana Grasu MD, •KC Kurian MD, Mohammad Madjid MD, •James T. Willerson MD, Ward Casscells MD, The University of Texas-HoustonTexas Heart Institute pH HeterogeneitypH Heterogeneity Temperature HeterogeneityTemperature Heterogeneity
  12. 12. pH 9.00 8.88 8.75 8.63 8.50 8.38 8.25 8.13 8.00 7.88 7.75 7.63 7.50 7.38 7.25 7.13 7.00 6.88 6.75 6.63 Noofpointswiththesameph 140 120 100 80 60 40 20 0 pH Distribution in 48 Human Carotid Plaques This histogram demonstrates distribution of pH measured in 858 points in 48 carotid plaques of 48 patients. A marked variation ranging from 6.5 to 8.9 is seen.
  13. 13. Watanabe Rabbit Aorta pH 9.5 9.0 8.5 8.0 7.5 7.0 6.5 6.0 5.5 pH Heterogeneity in 9 Watanabe Rabbit Aortas
  14. 14. 2220231717191026252428N = 11 human umbilical artery pH 9.5 9.3 9.1 8.9 8.7 8.5 8.3 8.1 7.9 7.7 7.5 7.3 7.1 6.9 6.7 6.5 6.3 6.1 5.9 5.7 5.5 pH Heterogeneity in 11 Human Umbilical Arteries
  15. 15. calcified&thrombosedLipid Rich pH 9.0 8.5 8.0 7.5 7.0 6.5 pH in Lipid Rich Yellow Areas vs. Calcified areas Areas with large lipid core exhibit higher temperature and lower pH p < 0.01
  16. 16. Correlation of pH and Temperature in Human Carotid Plaques Varied by the Areas We see a marked inverse correlation between temperature and pH of plaques that varies by macroscopic characteristics of plaques. p < 0.01
  17. 17. Fluorescence Single-Emission Imaging Microscopy of a Predominantly Lipid Rich Plaque Shows Significant Microscopic pH Heterogeneity Mostly Acidic
  18. 18. Catheter Tipped with a Side Looking Silvered Conical 0.5 mm Mirror cm 0.5mm
  19. 19. Conclusions 1.1. Temperature at the lumen of living carotid plaquesTemperature at the lumen of living carotid plaques correlates with density of inflammatory cells, andcorrelates with density of inflammatory cells, and inversely with cap thickness.inversely with cap thickness. 2.2. Differences of more than 0.3 C were seen in allDifferences of more than 0.3 C were seen in all specimens but only a minority had differences of 2specimens but only a minority had differences of 2oo C orC or more.more. 3.3. Large differences in temperatures were more oftenLarge differences in temperatures were more often found in patients who were younger, symptomatic,found in patients who were younger, symptomatic, female, and not taking aspirin.female, and not taking aspirin.
  20. 20. Conclusions continued 4.4. These temperature differences can be detectedThese temperature differences can be detected by infrared cameras.by infrared cameras. 5.5. Compared to normal arteries, inflamed andCompared to normal arteries, inflamed and lipid-rich plaques are acidic, while calcified andlipid-rich plaques are acidic, while calcified and thrombosed plaques are alkaline.thrombosed plaques are alkaline. 6.6. Plaque pH correlates moderately and inverselyPlaque pH correlates moderately and inversely with plaque temperature.with plaque temperature.
  21. 21. Conclusions continued 7.7. Stefanadis and colleagues have reported that hotStefanadis and colleagues have reported that hot plaques confer higher risk; it will be important toplaques confer higher risk; it will be important to determine whether plaque prognosis is best determineddetermine whether plaque prognosis is best determined by T,by T, ∆∆T, pH,T, pH, ∆∆pH or a combination.pH or a combination. 8.8. Heating to 41Heating to 41oo C decreases expression of pro-C decreases expression of pro- inflammatory genes.inflammatory genes. 9.9. Heating to 42-43Heating to 42-43oo C causes apoptosis, mainly ofC causes apoptosis, mainly of macrophages.macrophages.
  22. 22. Conclusions continued 10.10. Near-IR Spectroscopy can estimate plaqueNear-IR Spectroscopy can estimate plaque protein/lipid ratios and may also provideprotein/lipid ratios and may also provide inferences as to concentrations of plaque Hinferences as to concentrations of plaque H++ ,, NO, glucose, ONO, glucose, O22 and oxidants.and oxidants. 11.11. IR and near IR may predict plaque behaviourIR and near IR may predict plaque behaviour alone or in combination with ultrasound,alone or in combination with ultrasound, angioscopy, magnetic resonance orangioscopy, magnetic resonance or immunoscintigraphyimmunoscintigraphy

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