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Coronary angioscopy: Seeing is believing
BOSTON SPA LS23 7BQ INTERVENTIONAL CAROIOLOGY NEWSLETTER
28-FEB-1995 BL DSC
IHTERV I 11111111111111111.\( ~ CA ~~~
3
PART 1
4557.471853
1/1
/77
/
,-f'~~~
N E
~~X;%I ~~ VOWME 3, NUMBER 1
JANUARY 1995
EXECUTIVE EDITORS David P. Faxon. MD Los Angeles. CA David R. Holmes, Jr., MD Rochester, MN Timothy A. Sanborn, MD New York, NY Richard A. Schatz, MD La Jolla, CA GUEST EDITOR Christopher J. White, MD Clydebank,Scotland
Coronary Angioscopy: Seeing Is Believing Christopher J, White, MD Christopher J. White, MD, is Director of Invasive Cardiology, HCI International Medical Center, Clydebank, Scotland
n this issue of the I ntervent~ona~ Cardiology Newsletter, we will discuss the emerging technology of coronary angioscopy. Since the first reported attempt of a fiberoptic scope introduced through a percutaneous guiding catheter was reported by Dr. Richard Spears in 1985, there has been significant progress in the miniaturization of the angioscope and its ease of use for obtaining in vivo images of coronary artery surface morphology. Coronary angioscopy has allowed us to improve our understanding of
I
the pathophysiology of coronary artery disease by bridging the gap between postmortem analysis and in vivo morphology. Angioscopy is currently an important tool for investigating the accelerated atherosclerosis that develops in some patients following heart transplantation. The ability to examine the surface of the atherosclerotic plaque under direct vision during cardiac catheterization has led to a reexamination of the accuracy of contrast angiography in detecting subtle details of plaque morphology such as plaque rupture, ulceration, and the presence of coronary thrombus. Moreover, many investigators believe that increased accuracy in detecting complex elements of plaque morphology with angioscopy will
Interview with Dr. Stephen R. Ramee Dr. Stephen R. Ramee is Director, Cardiac Catheter Laboratory, Ochsner Clinic, New Orleans, LA
Q: How did you first become interested in percutaneous coronary angioscopy ? A: In the early days of balloon angioplasty it was clinically apparent that coronary artery lesion morphology had a direct bearing on the success or complications of the procedure. The problem was that angiography was proving to be a very insensitive tool for detecting subtle but important characteristics of these coronary atheromatous lesions. In 1986, Dr. Todd Sherman and his associates at Cedars Sinai Medical Center in Los Angeles performed intraoperative !CANEB 3(1)1995,
1~
angioscopy at the time of coronary bypass surgery. They demonstrated that patients with unstable angina had a surprisingly high incidence of intracoronary thrombi that were not detected by angiography. In collaboration with Mike Aita and Gene Sampson, two engineers working for Advanced Cardiovascular Systems (ACS), we began to develop a percutaneous coronary angioscope, employing the latest fiberoptic technology coupled with the new low-profile balloon catheter technology. Our initial investigations provided confirmation that angiography was indeed an insensitive tool for detecting intracoronary thrombus, plaque ulcerations,
lead to an improved outcome in patients treated with balloon angioplasty and other percutaneous devices. One of the major advantages of coronary angioscopy appears to be its superior ability to recognize the presence of intracoronary thrombus. Percutaneous angioscopy studies have confirmed the initial work of Dr. Todd Sherman and his colleagues at Cedars Sinai Medical Center in Los Angelesthey found an unexpectedly high incidence of intracoronary thrombi, which were not detected with angiography, in patients with unstable angina. Intracoronary thrombus has been associated with adverse outcomes during coronary angioplasty, and many investigators feel that improved detection by angioscopy may help to optimize the treatment of coronary lesions containing angiographically undetected thrombus. In a multicen-
Continued on page 2
IN THIS ISS UE Introduction
1
Interview with Dr. Stephen R. Ramee 1 Coronary Angioscopy User Survey Results 4 Summary: The Emerging Technology of Coronary Angioscopy 8
Continued on page 2 C ELSEVIER SCIENCE INC.
1063-4282/95/$0.00 + 9.50
2
IHTERVENnOHAL CARDIOLOGY NEWSLETIER
Coronary Angloscopy: Seeing Is BelievIng ter trial comparing angiography and angioscopy, we were able to show that not only was angioscopy moresensitive in detecting coronary thrombus, but also thatintracoronary thrombus was the only variable, among several clinical and angiographic parameters, that predicted anincreased riskofanin-hospital adverse eventsuch as recurrent ischemia or a major complication of the procedure. Intracoronary angioscopy may also have clinical application in patients with abrupt or threatened coronary occlusion complicating angioplasty. In our experience, angiography correctly identified the causeofcoronary artery occlusion inonly 4 of 17 patients following failed PTCA. Angioscopy, ontheotherhand, wascapableofdefining theetiology of theobstruction, dissection versus thrombosis, in each of the 17 cases. The ability to directly visualize thecause of thecoronary occlusion can improve the treatment directed at reopening theartery. For example,coronary stents may be thetreatment ofchoice inrestoring patency inanartery closed by a dissection, but if intracoronary thrombus was present, lytic therapy would seem to be a more prudent andeffective therapy.
IntervIew with Dr. Stephen R. Ramee continuedfrompage1 and dissections. The next step was to determine thecharacteristics of lesions in native coronary arteries, saphenous vein grafts, patients with restenosis lesions, andinpatients following heart transplantation. In particular, I felt that the ability
We interviewed Dr. Stephen R. Ramee, of the Ochsner Clinic in New Orleans, Louisiana, a pioneer in the development of the percutaneous coronaryangioscope and one of the mostexperienced clinical users of coronary angioscopy in theworld. Theusersurvey addresses the potential clinical utility of theangioscope andpossible areas fordeviceimprovement and future clinical investigation. References 1. Spears JR, Spokojny AM, Marais HI. Coronary angioscopy during cardiac catheterization. J Am CoIl Cardiol 1985;6:9>-97. 2. Sherman CT, Litvack F, Grundfest W, et aL Coronary angioscopy in patients with unstable angina pectoris. N EnglI Moo 1986;315:91~919.
3. Davies MI, Thomas T. The pathological basis and microanatomy of occlusive thrombus formation in human coronary arteries. Philos Trans R Soc Lond Biol 1981;294:225-229. 4. FaIle E. Unstable angina with fatal outcome: Dynamic coronary thrombosisleading to infarction aM/or sudden death. Autopsy evidence of recurrent mural thrombosis with peripheral anbolization culminating in total vascular occlusion. Circulation 1985;71 :699-708. S. Falk E. Plaque rupture with severe preexisting stenosis precipitating coronary
to directly view the surface morphology of plaque would have clinical utility in patients undergoing PTCA. Q: Whatrolehasangioscopy played in understanding the pathophysiology of acutecoronary ischemia? A: AsI mentioned before, theworkof theCedars Sinai group andthepathological studies of Drs. Falkand Davies indicated thatacute coronary ischemia wasa
VOLUME 3, NUMBER 1,1995
thrombosis: Characteristics of coronary atherosclerotic plaques underlying fatal occlusive thrombi. Br Heart 1 1983;50:127-34. 6. White CI, Ramee SR, Collins TJ, et al. Angioscopically detected coronary thrombus correlates with adverse PfCA outcome (abstract). Circulation 1993;88(SuppllV):iv-3206. 7. Ramee SR, White CI, Collins TI, Mesa 1, Murgo JP. Percutaneous angioscopy during percutaneous coronary angioplasty using a steerablc microangioscope, 1 Am CoIl Cardiol
1991;17:1()(}-lOS. 8. WhitcCI,RameeSR,Mesal,CollinsTI. Percutaneous coronary angioscopy in patients with restenosis after coronary angioplasty. 1 Am ColI Cardiol 1991;17:46B-9B. 9. Ramee SR, White CI. Percutaneous angioscopy in assessing coronary atherosclerosis and vascular injury. Am 1 Cardiac Imaging 1992;6:34~3S2. 10. White CI. Ramee SR, Collins RI, Jain A, Mesa IE. Ventura HO. Percutaneous coronary angioscopy: Applications in interventional cardiology. 1 of Interventional Cardiol. 1993;6:61-67. 11. White CI, Ramee SR, Collins rr, Mesa IE, lain A. Percutaneous angioscopy of saphenous vein coronary bypass grafts . 1 Am ColI Cardiol. 1993;21:1181-1185.
resultofatheromatous plaque rupture and intracoronary thrombus formation. The percutaneous angioscope has the advantage of imaging the lesion in vivoat the time or very near the actual time of the inciting clinical event. We have learned thatpatients with unstable angina havea much higher incidence of intraeoronary
Continued on page3
II11~fY~fIlioNJI ClIrdiolo" N_.kttN (lSSN 10634282) is
isauedbimonthly in one indexedvolumeper yearby ElsevierScienceInc., 6SS Avenueof the Americu. New York,NY t0010. Sublcription price per year: $98.00. For .wf.ce airlift add $25.00. Sec:ond·clasa postagepaid .t New York, NY, and at.dditional m.i1ingoffica. Po5tmaster: Send addraa changes to II11~fY~fIlioNJI ClUdiolo" N_6ktr~r. ElaevierScience Inc, 6SS Avenueof the Americas. NewYork,NY 10010. NarE: No responsibility is Illumed by tho Publi&her for an)' injuryand/ordamageto pelSana or propertyI I • matterof productsli.bility, negligenceor otherwise.or from any use or opetationof an)'methods,procludl, instructiona or ideascontainedin the m.terial herein.No lU&&cstcd leat or procedure mould be carriedout unIcsa. in the reader'. judgment,ill risk is justified. Becauao of the npid .dvancca in the medicallCiencea, we recommend that the independent verification of di.gnoses and drug docea should be made. Diacuasiona. view. and recommendationa lito medicalprocedlll'Cll, choiceof drugsand dNg dosagCl.n: the reaponaibility of the .utho....
1063-C28V951$O.OO + 9.50
o ELSEVIER SOENCE INC.
28-FEB-1995 BL DSC
IHTERV I 11111111111111111.\( ~ CA ~~~
3
PART 1
4557.471853
1/1
/77
/
,-f'~~~
N E
~~X;%I ~~ VOWME 3, NUMBER 1
JANUARY 1995
EXECUTIVE EDITORS David P. Faxon. MD Los Angeles. CA David R. Holmes, Jr., MD Rochester, MN Timothy A. Sanborn, MD New York, NY Richard A. Schatz, MD La Jolla, CA GUEST EDITOR Christopher J. White, MD Clydebank,Scotland
Coronary Angioscopy: Seeing Is Believing Christopher J, White, MD Christopher J. White, MD, is Director of Invasive Cardiology, HCI International Medical Center, Clydebank, Scotland
n this issue of the I ntervent~ona~ Cardiology Newsletter, we will discuss the emerging technology of coronary angioscopy. Since the first reported attempt of a fiberoptic scope introduced through a percutaneous guiding catheter was reported by Dr. Richard Spears in 1985, there has been significant progress in the miniaturization of the angioscope and its ease of use for obtaining in vivo images of coronary artery surface morphology. Coronary angioscopy has allowed us to improve our understanding of
I
the pathophysiology of coronary artery disease by bridging the gap between postmortem analysis and in vivo morphology. Angioscopy is currently an important tool for investigating the accelerated atherosclerosis that develops in some patients following heart transplantation. The ability to examine the surface of the atherosclerotic plaque under direct vision during cardiac catheterization has led to a reexamination of the accuracy of contrast angiography in detecting subtle details of plaque morphology such as plaque rupture, ulceration, and the presence of coronary thrombus. Moreover, many investigators believe that increased accuracy in detecting complex elements of plaque morphology with angioscopy will
Interview with Dr. Stephen R. Ramee Dr. Stephen R. Ramee is Director, Cardiac Catheter Laboratory, Ochsner Clinic, New Orleans, LA
Q: How did you first become interested in percutaneous coronary angioscopy ? A: In the early days of balloon angioplasty it was clinically apparent that coronary artery lesion morphology had a direct bearing on the success or complications of the procedure. The problem was that angiography was proving to be a very insensitive tool for detecting subtle but important characteristics of these coronary atheromatous lesions. In 1986, Dr. Todd Sherman and his associates at Cedars Sinai Medical Center in Los Angeles performed intraoperative !CANEB 3(1)1995,
1~
angioscopy at the time of coronary bypass surgery. They demonstrated that patients with unstable angina had a surprisingly high incidence of intracoronary thrombi that were not detected by angiography. In collaboration with Mike Aita and Gene Sampson, two engineers working for Advanced Cardiovascular Systems (ACS), we began to develop a percutaneous coronary angioscope, employing the latest fiberoptic technology coupled with the new low-profile balloon catheter technology. Our initial investigations provided confirmation that angiography was indeed an insensitive tool for detecting intracoronary thrombus, plaque ulcerations,
lead to an improved outcome in patients treated with balloon angioplasty and other percutaneous devices. One of the major advantages of coronary angioscopy appears to be its superior ability to recognize the presence of intracoronary thrombus. Percutaneous angioscopy studies have confirmed the initial work of Dr. Todd Sherman and his colleagues at Cedars Sinai Medical Center in Los Angelesthey found an unexpectedly high incidence of intracoronary thrombi, which were not detected with angiography, in patients with unstable angina. Intracoronary thrombus has been associated with adverse outcomes during coronary angioplasty, and many investigators feel that improved detection by angioscopy may help to optimize the treatment of coronary lesions containing angiographically undetected thrombus. In a multicen-
Continued on page 2
IN THIS ISS UE Introduction
1
Interview with Dr. Stephen R. Ramee 1 Coronary Angioscopy User Survey Results 4 Summary: The Emerging Technology of Coronary Angioscopy 8
Continued on page 2 C ELSEVIER SCIENCE INC.
1063-4282/95/$0.00 + 9.50
2
IHTERVENnOHAL CARDIOLOGY NEWSLETIER
Coronary Angloscopy: Seeing Is BelievIng ter trial comparing angiography and angioscopy, we were able to show that not only was angioscopy moresensitive in detecting coronary thrombus, but also thatintracoronary thrombus was the only variable, among several clinical and angiographic parameters, that predicted anincreased riskofanin-hospital adverse eventsuch as recurrent ischemia or a major complication of the procedure. Intracoronary angioscopy may also have clinical application in patients with abrupt or threatened coronary occlusion complicating angioplasty. In our experience, angiography correctly identified the causeofcoronary artery occlusion inonly 4 of 17 patients following failed PTCA. Angioscopy, ontheotherhand, wascapableofdefining theetiology of theobstruction, dissection versus thrombosis, in each of the 17 cases. The ability to directly visualize thecause of thecoronary occlusion can improve the treatment directed at reopening theartery. For example,coronary stents may be thetreatment ofchoice inrestoring patency inanartery closed by a dissection, but if intracoronary thrombus was present, lytic therapy would seem to be a more prudent andeffective therapy.
IntervIew with Dr. Stephen R. Ramee continuedfrompage1 and dissections. The next step was to determine thecharacteristics of lesions in native coronary arteries, saphenous vein grafts, patients with restenosis lesions, andinpatients following heart transplantation. In particular, I felt that the ability
We interviewed Dr. Stephen R. Ramee, of the Ochsner Clinic in New Orleans, Louisiana, a pioneer in the development of the percutaneous coronaryangioscope and one of the mostexperienced clinical users of coronary angioscopy in theworld. Theusersurvey addresses the potential clinical utility of theangioscope andpossible areas fordeviceimprovement and future clinical investigation. References 1. Spears JR, Spokojny AM, Marais HI. Coronary angioscopy during cardiac catheterization. J Am CoIl Cardiol 1985;6:9>-97. 2. Sherman CT, Litvack F, Grundfest W, et aL Coronary angioscopy in patients with unstable angina pectoris. N EnglI Moo 1986;315:91~919.
3. Davies MI, Thomas T. The pathological basis and microanatomy of occlusive thrombus formation in human coronary arteries. Philos Trans R Soc Lond Biol 1981;294:225-229. 4. FaIle E. Unstable angina with fatal outcome: Dynamic coronary thrombosisleading to infarction aM/or sudden death. Autopsy evidence of recurrent mural thrombosis with peripheral anbolization culminating in total vascular occlusion. Circulation 1985;71 :699-708. S. Falk E. Plaque rupture with severe preexisting stenosis precipitating coronary
to directly view the surface morphology of plaque would have clinical utility in patients undergoing PTCA. Q: Whatrolehasangioscopy played in understanding the pathophysiology of acutecoronary ischemia? A: AsI mentioned before, theworkof theCedars Sinai group andthepathological studies of Drs. Falkand Davies indicated thatacute coronary ischemia wasa
VOLUME 3, NUMBER 1,1995
thrombosis: Characteristics of coronary atherosclerotic plaques underlying fatal occlusive thrombi. Br Heart 1 1983;50:127-34. 6. White CI, Ramee SR, Collins TJ, et al. Angioscopically detected coronary thrombus correlates with adverse PfCA outcome (abstract). Circulation 1993;88(SuppllV):iv-3206. 7. Ramee SR, White CI, Collins TI, Mesa 1, Murgo JP. Percutaneous angioscopy during percutaneous coronary angioplasty using a steerablc microangioscope, 1 Am CoIl Cardiol
1991;17:1()(}-lOS. 8. WhitcCI,RameeSR,Mesal,CollinsTI. Percutaneous coronary angioscopy in patients with restenosis after coronary angioplasty. 1 Am ColI Cardiol 1991;17:46B-9B. 9. Ramee SR, White CI. Percutaneous angioscopy in assessing coronary atherosclerosis and vascular injury. Am 1 Cardiac Imaging 1992;6:34~3S2. 10. White CI. Ramee SR, Collins RI, Jain A, Mesa IE. Ventura HO. Percutaneous coronary angioscopy: Applications in interventional cardiology. 1 of Interventional Cardiol. 1993;6:61-67. 11. White CI, Ramee SR, Collins rr, Mesa IE, lain A. Percutaneous angioscopy of saphenous vein coronary bypass grafts . 1 Am ColI Cardiol. 1993;21:1181-1185.
resultofatheromatous plaque rupture and intracoronary thrombus formation. The percutaneous angioscope has the advantage of imaging the lesion in vivoat the time or very near the actual time of the inciting clinical event. We have learned thatpatients with unstable angina havea much higher incidence of intraeoronary
Continued on page3
II11~fY~fIlioNJI ClIrdiolo" N_.kttN (lSSN 10634282) is
isauedbimonthly in one indexedvolumeper yearby ElsevierScienceInc., 6SS Avenueof the Americu. New York,NY t0010. Sublcription price per year: $98.00. For .wf.ce airlift add $25.00. Sec:ond·clasa postagepaid .t New York, NY, and at.dditional m.i1ingoffica. Po5tmaster: Send addraa changes to II11~fY~fIlioNJI ClUdiolo" N_6ktr~r. ElaevierScience Inc, 6SS Avenueof the Americas. NewYork,NY 10010. NarE: No responsibility is Illumed by tho Publi&her for an)' injuryand/ordamageto pelSana or propertyI I • matterof productsli.bility, negligenceor otherwise.or from any use or opetationof an)'methods,procludl, instructiona or ideascontainedin the m.terial herein.No lU&&cstcd leat or procedure mould be carriedout unIcsa. in the reader'. judgment,ill risk is justified. Becauao of the npid .dvancca in the medicallCiencea, we recommend that the independent verification of di.gnoses and drug docea should be made. Diacuasiona. view. and recommendationa lito medicalprocedlll'Cll, choiceof drugsand dNg dosagCl.n: the reaponaibility of the .utho....
1063-C28V951$O.OO + 9.50
o ELSEVIER SOENCE INC.