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Vuln shape aha 2005

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Vuln shape aha 2005

  1. 1. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Perspective: Vulnerable Plaque …or vessels, patients or ?? Robert S. Schwartz, MD Minneapolis Heart Institute
  2. 2. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute How to Cure Human Disease 1. Define the Disease 2.Associate it reliably 3.Find the Disease 4. Deliver the ‘Fix’
  3. 3. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute
  4. 4. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Arterial Inflammation
  5. 5. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Find the Disease Imaging Technology
  6. 6. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute 3 Autopsy Derived Groups Acute MI 18 patients/337 segments Stable Angina 5 Patients/76 segments Controls (no CAD) 9 Patients/111 segments Coronary Inflammation Is Diffuse
  7. 7. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Inflammatory Cell Count Macrophages/Monocytes CD-68 Positivity T-Lymphocytes CD-3 Positivity Coronary Inflammation Is Diffuse
  8. 8. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute IRA Segments AMI Non-IRA segments of AMI group Controls CD68 positive cells monocytes/macrophag es 38.0 + 7.9% 35.3 + 4.7% 1.0 + 2.9% CD3 positive cells (T-lymphocytes) 17.7 + 3.5% 20.9 + 4.1% 7.6 + 1.6% Coronary Artery Inflammation Is Diffuse JACC April 2005 Mauriello, Sangiorgi, Fratoni, Palmieri, Bonanno, Anemona Schwartz, Spagnoli
  9. 9. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Coronary Inflammation Is Diffuse 0 5 10 15 20 25 30 35 40 IRA Non-IRA Control Macrophages Lymphocytes JACC April 2005 Mauriello, Sangiorgi, Fratoni, Palmieri, Bonanno, Anemona Schwartz, Spagnoli
  10. 10. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Vulnerable Plaque: Detection
  11. 11. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Thermography Will Thermography will easily detect and localize vulnerable plaque?
  12. 12. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Thermography
  13. 13. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Porcine Proximal LCX 10 days Histopathology: Chronic, superficial inflammation, mainly mononuclear cells ¾ of the lumen circumflex Temperature: Circumferential and significantly increased vessel wall temperature above 1.0°C
  14. 14. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Caveat: Thermography and thermal heterogeneity measures appear highly flow dependent. The methods and devices can be technically challenging. Major differences exist across published studies.
  15. 15. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute MRI Imaging
  16. 16. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Self-contained portable MRI catheter Catheter Based MRI Imaging
  17. 17. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Ex-vivo MR imaging: human coronary arteries Adaptive intimal thickening LAD atheroma
  18. 18. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute
  19. 19. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Vulnerability Better Detection Methods MSCTA
  20. 20. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Coronary Ruptured Plaque (CTA) Aortic Penetrating Ulcer (MRA)
  21. 21. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Is Not ‘Soft Plaque” MSCTA visualizes well Questions:  Prevalence of isolated Uncalcified Plaque (no associated calcified plaque)  Risk Factors associated CTA and Uncalcified Plaque
  22. 22. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute 506 unselected patients scanned for chest pain  16-Slice MSCTA CTA and Uncalcified Plaque
  23. 23. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute 30% (124/506 patients) had no calcification CTA and Uncalcified Plaque 30% 70% No Calcification Calcification
  24. 24. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute 44% (55/124 patients) had no plaque CTA and Uncalcified Plaque 30% 70% No Calcification Calcification
  25. 25. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute 51% (63/124patients) had uncalcified plaque without severe stenosis CTA and Uncalcified Plaque 51% 49% No Stenosis Stenosis
  26. 26. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute 5% (6/124 patients) of Uncalcified Plaque had significant stenosis CTA and Uncalcified Plaque 5% 95% Significant Stenosis No Signficiant Stenosis
  27. 27. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Risk Factors and all uncalcified plaque 83% Smokers (former/current) 98% of patients with 0-3 Risk factors had no plaque or <50% Stenosis 86% of patients with > 4 Risk factors had UCP and/or significant stenosis No patient with <2 Risk Factors had uncalcified plaque
  28. 28. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Uncalcified plaque is prevalent in patients with chest pain Smoking may have significant impact on UCP formation. UCP prevalence is highly dependent on aggregate coronary risk. MSCTA appears useful for detecting both calcified and noncalcified coronary plaque. MSCTA and Uncalcified Plaque
  29. 29. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Observation: Significant technical developments are needed for MRI. Problems of Spatial and Temporal Resolution, and Acquistion remain a major impediment to clinical coronary imaging in living patients.
  30. 30. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Optical Coherence Tomography
  31. 31. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Culprit Lesion M-OA M-LC A-WJ Unstable E-KK M-UM E-IM E-JS A-MK RECENT MI UNSTABLE ANGINA UNSTABLE ANGINA Just proximal to stented lesion
  32. 32. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Caveat Intravascular Imaging can localize thin-cap fibroadenoma and lipid- laden regions of vulnerability. But what does it mean?
  33. 33. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Raman Spectroscop Scepanvic O, Galindo LH, Feld MS
  34. 34. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Now that we aren’t certain about diagnoses, what about therapy? Perspective: Imaging Vulnerable Plaque
  35. 35. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute %% withwith EvenEven tt 00 33 1818 2121 2424 2727 303066 99 1212 1515 2020 1515 1010 55 00 Months of Follow-up All-Cause Death, Non-Fatal MI, or Urgent Revascularization Pravastatin 40mgPravastatin 40mg 16.7%16.7% Atorvastatin 80mgAtorvastatin 80mg 12.9%12.9% 25% RR25% RR P = 0.0004P = 0.0004
  36. 36. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute 16.7 20.5 33.3 16.7 6.4 3.9 1.3 1.3 0 0 0 0 0 0 5 10 15 20 25 30 35 Percent(%) 10 20 30 40 50 60 70 80 90 100 110 120 130 millimeters (mm) Prox Mid Distal p = 0.003 Distribution of Acute Coronary Occlusions Left Anterior Descending Artery (Normalized Segment Analysis)
  37. 37. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute 0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100 110 120 130 millimeters (mm) Percent(%)Acute Coronary Occlusions by Distance from Left Anterior Descending Artery Ostium
  38. 38. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute How to Cure Human Disease 1. Define the Disease Not Yet 2.Associate it reliably Not Yet 3.Find the Disease Not Yet 4. Deliver the ‘Fix’ Not Yet
  39. 39. The Minneapolis Heart Institute Foundation The Minneapolis Heart Institute Perspective: Vulnerable Plaque …or vessels, patients or ?? Robert S. Schwartz, MD Minneapolis Heart Institute

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