European Heart Journal Advance Access originally published online on June 16, 2008
European Heart Journal 2008 29(14):1714-1720; doi:10.1093/eurheartj/ehn248
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The correlation between lipid volume in the target lesion, measured by integrated backscatter intravascular ultrasound, and post-procedural myocardial infarction in patients with elective stent implantation
1 Department of Cardiology, Chubu Rosai Hospital, 1-10-6, Komei, Minato-ku, Nagoya 465-8530, Japan
2 Department of Internal Medicine, Aichi-Gakuin School of Dentistry, Nagoya, Japan
3 Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
Received 3 September 2007; revised 16 May 2008; accepted 23 May 2008; online publish-ahead-of-print 16 June 2008.
* Corresponding author. Tel: +81 52 6525511, Fax: +81 52 6533533, Email: uetani{at}med.nagoya-u.ac.jp
See page 1701 for the editorial comment on this article (doi:10.1093/eurheartj/ehn053)
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Abstract |
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Aims: The aim of this study was to perform quantitative analysis of the plaques of target lesions by integrated backscatter intravascular ultrasound (IB-IVUS) and to investigate the association between these data and the risk of post-procedural myocardial injury after stenting.
Methods and results: One hundred and fourteen consecutive patients who received elective stent implantations following IB-IVUS analysis were enrolled. The volume of each plaque component (lipid, fibrous, and calcified) was calculated for the target lesion. Creatine kinase-MB (CK-MB) and troponin-T (TnT) were also evaluated 18 h after procedure. We defined a post-procedural TnT level higher than three times the normal limit as a post-procedural myocardial injury. Lipid, fibrous, and calcified volumes were greater in patients with myocardial injury than in those without myocardial injury. Lipid and fibrous volumes correlated with post-procedural cardiac biomarkers, and the lipid volume fraction (lipid volume/total plaque volume) also correlated with post-procedural TnT and CK-MB. The fibrous volume fraction for plaques was found to be inversely correlated with post-procedural TnT and CK-MB. Hence, lipid volume and volume fraction were concluded to be independent predictors of post-procedural myocardial injury.
Conclusion: A larger plaque volume and lipid-rich plaque may be indicative of embolic events after stent implantation, resulting in myocardial injury.
Key Words: Intravascular ultrasound • Integrated backscatter intravascular ultrasound • Myocardial injury • Stent
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Introduction |
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A post-procedural increase in cardiac biomarkers has been recognized as a relatively common event following apparently successful percutaneous coronary interventions (PCIs).1–3 Contrast-enhanced magnetic resonance imaging (MRI) provides evidence that a post-procedural elevation in the levels of cardiac biomarkers is associated with micro-infarction of myocardial regions sourced from the target vessel.4 Clinical, lesion, and procedural characteristics that related to post-procedural myocardial injury were indicated in various analyses.5–7 A previous study using a thrombectomy device demonstrated that no-reflow during PCI is not just attributable to the thrombus burden but also to components of the plaques in the atheromatous lesions.8 Thus, it is presumed that plaque characteristics may also be important contributory factors in embolic complications during PCI. However, details of the lesion characteristics that correlate with myocardial infarction after PCI are unclear.
Recently, the integrated backscatter intravascular ultrasound (IB-IVUS) system, which provides two-dimensional colour-coded maps for the tissue characterization of coronary plaques, has been developed.9,10 A good correlation was reported between the maps obtained by IB-IVUS and histological findings, the differentiation of vulnerable plaques, and the prediction of acute coronary events.9–11 Therefore, it was hypothesized that IB-IVUS would be able to provide volumetric data for the plaques characteristics of target lesions in patients undergoing elective stenting. The aim of this study was hence to evaluate the relationship between the quantitative analysis of target lesions and the incidence of post-procedural myocardial injury.
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Study population
From September 2005 to October 2006, 139 consecutive patients who underwent elective coronary stent implantations following IB-IVUS examination of target lesion at the Chubu Rosai hospital were enrolled in this study, which was approved by the Ethics Committee of the hospital. All had angina, documented myocardial ischaemia, or both, and gave their informed consent for participation in this study. The exclusion criteria of this study were patients with chronic total occlusion (six patients), elevated pre-procedural cardiac biomarkers (four patients), angioplasty with atherectomy (two patients), obvious occlusion of a side branch originated from stented segment (one patient), multi-vessel stenting in a single procedure (10 patients), and IB-IVUS imaging of unassessable quality (two patients). Thus, the study comprised a total of 114 patients.
Percutaneous coronary intervention procedure
All patients underwent coronary stent implantation with or without pre-dilatation. All patients received treatment with anti-platelet agents for at least 24 h prior to the procedure. Furthermore, 10 000 IU of heparin was administered before stenting and an additional bolus of 1000–2000 IU was given every hour if the procedure lasted for >1 h. No patient received glycoprotein IIb/IIIa receptor inhibitors, which are not approved for use in Japan. All procedures were performed using six or seven French guiding catheters by either the radial or the femoral approach. The operator decided on the position and length of the angioplasty and stent implantation according to angiography and conventional IVUS findings. Successful PCI, defined as <50% residual stenosis with no occlusion of the large branch and final grade 3 flow in the Thrombolysis in the Myocardial Infarction Trial (TIMI) grading system, was achieved in all enrolled patients. We started administration of clopidgrel (75 mg/day) or ticlopidine (200 mg/day) to prevent thrombosis after stent implantation in patients who were not already receiving thienopyridine derivatives.
Angiography and conventional intracoronary ultrasound analysis
Angiography, IVUS, and IB-IVUS were evaluated by an independent investigator who was not involved in procedures and was unaware of the final outcomes. A computerized quantitative analysis system (QCA-CMS system version 6.0.39.0, MEDIS, Leiden, the Netherlands) was employed with the guiding catheter for calibration. Angiographic measurements included reference diameter, minimum lumen diameter (MLD), per cent diameter stenosis, and lesion length.
IVUS studies were performed with a mechanical sector scanner (Atlantis® SR Pro, Boston Scientific Corp, Natick, MA, USA) and a motorized transducer pullback system (0.5 mm/s) following the administration of intracoronary injections of 1000 µg isosorbide dinitrate. Image slices of minimum lumen, proximal reference, and distal reference sites were analysed according to previously described methods.12 The external elastic membrane (EEM) cross-sectional area (CSA), lumen CSA, and plaque plus media CSA (EEM CSA minus lumen CSA) of these slices were measured. The target lesion EEM CSA divided by the average of the proximal and distal reference EEM CSA was defined as the remodelling index. Total plaque volume was calculated as the sum of plaque plus media in each CSA at 1 mm axial intervals for the IVUS images from the target lesion.
Integrated backscatter intravascular ultrasound analysis
A personal computer (Windows XP Professional, CPU 3.4 GHz) equipped with custom software (IB-IVUS, YD Co., Ltd, Nara, Japan) was connected to the IVUS imaging system (Galaxy, Boston Scientific, Natick, MA, USA) in order to obtain radio frequency signal output, signal trigger output, and video image output. Ultrasound backscattered signals were acquired using a 40 MHz mechanically rotating IVUS catheter in order to be digitized and subjected for spectral analysis. IB values for each tissue component were calculated as an average power using a fast Fourier transform, measured in decibels, of the frequency component of the backscattered signal from a small volume of tissue. We applied the manufacturer’s default setting on the basis of previous data9,10 to define a range of IB value for each plaque component (lipid, fibrous, and calcified). A total of 256 vector lines per image (1.4 grade/line) and a set of 20 regions of interest (ROIs) for each 100 µm depth on each vector line (total 5120 ROIs/image) were used for IB analysis. Polar coordinates were transformed into Cartesian coordinates (64 x 64pixels) using computer software.10 We then manually excluded the vessel lumen and area outside of the intima in the two-dimensional IB IVUS images. Colour-coded maps were constructed for each 1 mm slice to illustrate the tissue characteristics in the target lesions (Figure 1). The percentage of the plaque area that was fibrous (fibrous area/plaque area), calcified (calcified area/plaque area), and lipid-rich (lipid area/plaque area) was automatically calculated. Three-dimensional analysis of IB-IVUS images was performed to calculate fibrous, lipid, and calcified volumes from the sum of fibrous, lipid, and calcified areas in each CSA at 1 mm axial intervals for the IB-IVUS images of the target lesion, respectively. The fibrous (fibrous volume/plaque volume), lipid-rich (lipid volume/plaque volume), and calcified (calcified volume/plaque volume) volume fractions were then calculated.
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Evaluation of cardiac biomarkers
Blood was sampled prior to and 18 h after the procedure. Serum troponin-T (TnT) was measured using an enzyme immunoassay kit (Roche Diagnostics, Tokyo, Japan). The detection limit of this system is 0.03 ng/mL, and linearity is achieved from 0.1 to 2 ng/mL. A level of TnT <0.03 ng/mL was considered as a negative result and any reading from 0.03 up to 0.1 ng/mL was considered as 0.1 ng/mL. A TnT level >2 ng/mL was considered as 2 ng/mL. We defined a post-procedural TnT level >0.3 ng/mL, which was three times the normal limit (manufacturers’ clinical cut-off value 0.1 ng/mL), as a post-procedural myocardial injury. Creatine kinase-MB (CK-MB) activity was measured using an immunoinhibition assay kit (Sysmex, Kobe, Japan).
Statistics
All data are expressed as mean ± SD values. A comparison of continuous variables was achieved with the unpaired Student’s t-test and of categorical variables using 
2 analysis or Fisher’s exact probability test. No adjustment was made to the significance level owing to the exploratory nature of the study. Linear regression analysis was performed to assess the association between quantitative plaque characteristics, as assessed using IB-IVUS, and an increase in cardiac biomarkers. To identify predictors of myocardial injury, simple and multiple regression analyses were performed. Variables with a significance level of <0.1 in the simple regression analysis were considered to be candidate variables for the inclusion in the multivariable regression analysis. A total plaque volume measured by the conventional IVUS was not introduced in the multivariable model because of a strong correlation with the volume of lipid and fibrous components, as measured by IB-IVUS. A receiver-operating characteristic curve analysis was performed to assess the ability of lipid volume to predict post-procedural myocardial injury, which was defined as post-procedural TnT elevation >0.3 ng/mL. To validate cut-off point of lipid volume in this study, we performed IB-IVUS analysis before PCI in 105 patients who matched the including criteria of this study (January 2007 to February 2008). Differences were considered significant at P < 0.05. All P-values were derived from two-sided significance tests.
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Baseline clinical, lesion, and procedural characteristics
Clinical variables for the total study population are given in Table 1. Of this study population, 25 patients (21.9%) have a history of acute coronary syndrome (recent unstable angina or myocardial infarction). The level of serum low-density lipoprotein (LDL) cholesterol was higher in patients with myocardial injury than without myocardial injury. Lesion and procedural characteristics are given in Table 2. In angiography (quantitative coronary angiography, QCA) measurements, lesion length was significantly greater in patients with myocardial injury, and the MLD was smaller in patients with myocardial injury. The number of stents used, incidence of direct stent implantation (without prior balloon dilatation), maximum pressure of inflation, and total inflation time were similar for the two groups.
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Volumetric plaque measurements using integrated backscatter intravascular ultrasound
A total of 30 randomly selected lesions were measured by two observers. To evaluate interobserver agreement, 95% limits of agreement were determined with Bland–Altman approach (Figure 2). Mean differences in the volume were –0.12 ± 23.19 (mm3) for lipid and –1.81 ± 18.04 (mm3) for fibrous. Limits of agreement for lipid were between –46.3 [mm3, 95% confidence interval (CI) –61.6 to –31.1] and 46.1 (mm3, 95% CI 30.9 to –61.3). There was a good correlation between the measurements taken by the two separate observers for total plaque (r = 0.87, P < 0.01), lipid (r = 0.82, P < 0.01), and fibrous volumes (r = 0.85, P < 0.01). The measurements for each of the plaque components recorded using IB-IVUS are shown in Figure 2. Lipid, fibrous, and calcified volumes were significantly larger in patients with myocardial injury. The difference in the lipid content of patient with or without history of ASC was not observed (58.2 ± 49.6 vs.53.2 ± 44.8 mm3, P = 0.64). In addition, a significantly greater lipid volume fraction and smaller fibrous volume fraction were demonstrated in patients with myocardial injury (Figure 3). A correlation between quantitative plaque characteristics and an increase in the levels of the CK-MB and TnT is given in Table 3. Plaque volume and lipid, fibrous, and calcified volumes were significantly correlated with the post-procedural cardiac biomarkers. However, whereas the lipid volume fraction correlated positively with TnT and CK-MB, fibrous volume fraction was found to be inversely correlated with both biomarkers.
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Predictors of post-procedural troponin elevation
The results of simple and multiple regression analyses with post-procedural TnT are given in Table 4. Multivariable linear regression analysis demonstrated that the lipid volume was independently associated with post-procedural TnT. We also found lipid volume fraction (%) is significantly associated with post-procedural TnT even after adjusting for significant confounding factors (P < 0.1 in the simple regression analysis). The results of receiver-operating characteristic analysis of the ability of lipid volume to predict myocardial injury are given in Table 5. Best discriminate value of lipid volume was 45.6 mm3 (sensitivity 100%, specificity 67.3%).
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To validate cut-off point of lipid volume, we re-evaluated lipid volume measured by IB-IVUS before PCI in 105 patients who matched the including criteria of this study (January 2007 to February 2008). In the additional study population, the cut-off point of lipid volume (45.6 mm3) showed that the sensitivity of myocardial injury was 100% (95% CI 69.0–100) and specificity was 68.4% (95% CI 58.1–77.6). Receiver-operating characteristic analysis of additional study population showed that the best discriminate value of lipid volume was 52.1 mm3 (sensitivity 100%, specificity 73.7%).
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Discussion |
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Predicting percutaneous coronary intervention complications by lipid volume measurement
This study demonstrated that total plaque volume, lipid volume, and fibrous volume were larger in patients who incurred myocardial injury following stent implantation. Fibrous volume correlated positively with increased levels of biomarkers, whereas the fibrous volume fraction was found to be inversely correlated. In contrast, both the lipid volume and volume fraction of lipid correlated positively with TnT and CK-MB. These findings suggest that fibrous volume alone did not contribute to a post-procedural elevation in cardiac biomarkers. Therefore, multivariable analysis identified lipid volume and fraction of lipid (%) as independent predictors of post-procedural myocardial injury.
Mechanism of embolization after stent implantation
Although it is apparent that occlusion of a large side branch, flow-limiting dissection, or large embolization would cause significant post-procedural infarction, which is associated with a worse clinical outcome, it is reported that even minor embolism with no clinical symptoms or surface ECG abnormality may lead to microvascular obstruction and myocardial necrosis.4 Coronary stents may increase the risk of distal embolisms resulting in myocardial injury when compared with balloon angioplasty.7 Recently, a remarkably low restenosis rate was demonstrated for drug-eluting stents, and the usage of coronary stents thus increased rapidly.
Larger stent expansion to reduce restenosis is associated with a higher level of post-procedural CK-MB, suggesting a trade-off between optimal stent implantation and myocardial injury.13 Distal embolization detected by an enhanced MRI was associated with a decrease in plaque volume after PCI.14 When the stent was expanded within the lesion, the stent strut grated up plaques and microembolic debris was released into the bloodstream (the so-called ‘cheese grater effect’).15 Therefore, plaques that contain larger lipid-rich components may be more prone to being broken down, generating greater amounts of atherosclerotic particles following stent expansion. These hypotheses are strongly supported by the finding that a considerable amount of the lumen enlargement obtained after stenting is attributable to plaque reduction, and the amount of plaque reduction after stenting is significantly correlated with a post-procedural release of CK-MB.16 Although we did not quantify the post-procedural reduction in plaque volume, the finding that target lesion lipid volume correlated better with post-procedural CK-MB and TnT than lipid volume fraction (%) supports the hypothesis that the volume of plaque reduction was associated with the extent of post-procedural myocardial injury.
Clinical significance of post-procedural elevation of cardiac biomarkers
In large clinical trials of PCI with abciximab, the relationship between the extent of the post-procedural elevation in CK-MB and mortality rate was demonstrated.17 Another clinical trial also showed similar correlations between the post-procedural levels of CK or CK-MB and clinical outcome.18 An increase in post-procedural troponin to greater than between three and eight times the normal limit was also found to be associated with worse mid-term or long-term clinical outcomes.19–21 Troponin may be too sensitive for the detection of minor myocardial necrosis; hence some multiple of the cut-off for acute myocardial infarction may be appropriate for the prediction of adverse clinical events after PCI.22 In this study, there were only three patients with a TnT level >0.5 ng/mL (five times the normal limit). We therefore defined any TnT level >0.3 ng/mL (13 patients) as being indicative of myocardial injury. However, we also demonstrated a linear correlation between the lipid volume or volume fraction and post-procedural cardiac biomarkers.
Recent studies demonstrated that the baseline plaque characteristics evaluated by virtual histology are associated with embolic complication during coronary intervention.24,25 Our findings may provide additional information about the association between volumetric assessment of plaque characteristics and the amount of myocardial TnT release after coronary intervention.
Study limitations
Thrombus and lipid-rich tissues had similar IB values and it is difficult to differentiate between these tissue components by IB-IVUS.9 Our definition of lipid may contain a certain amount of thrombus; however, no emergency PCI cases were included in this study and the incidence of thrombus formation in the target lesion may therefore be relatively small. In most cases, thrombus-like findings such as intra-lumen mobile mass or intra-plaque channels were not observed by conventional IVUS images.
Post-procedural stent expansion, longitudinal plaque shift, and reduction in plaque volume in the target lesion are important factors affecting post-procedural distal embolization.13,14 We did not evaluate an association between a change in plaque distribution in the target lesion and an elevation in post-procedural enzymes. Therefore, the mechanism of myocardial injury in this study seems to be somewhat speculative. Procedural profiles such as stent/artery and balloon/artery ratios were not documented in this study. However, there was no difference in the maximum ballooning pressure between patients with and without myocardial injury.
We obtained post-procedural blood samples only once, at 18 h after PCI. It may be impractical to collect blood from patients without any apparent complications several times in daily practice. However, 100% of the peak TnT elevations and 92% of the peak CK-MB were observed 12–20 h (mean 17.9 ± 0.46 h) after procedure in patients who underwent elective PCI without pre-procedural elevation of cardiac biomarkers.23 Therefore, we evaluated cardiac biomarkers obtained from single blood samples at 18 h after PCI.
Relatively small sample size and arbitrary definition of post-procedural myocardial injury are also study limitations. To avoid this arbitrariness, we assessed multivariable analysis using troponin T as a continuous variable.
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Conclusions |
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We have demonstrated a significant correlation between the volume of lipid-rich plaque within target lesions, as measured by IB-IVUS, and a post-procedural elevation in the levels of cardiac biomarkers. The volume of the lipid plaque was found to be an independent predictor of post-procedural myocardial injury after elective stenting.
Clinical implication
Distal protection devices and several pharmacological methods may decrease myonecrosis after PCI. However, indication of these interventions has not been established. Measurement of the lipid volume by IB-IVUS was expected to identify high-risk lesion of post-procedural myocardial injury and indication of these interventions for myocardial protection.
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No funding was received in respect of this research.
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Acknowledgement |
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We would like to thank Messrs Ito Katsumi, Yamamoto Keiichi, Mori Masahito, Takahiko Matsumoto, Hiroyuki Furuta, and Shinji Watanabe for collecting and analysing the IB-IVUS data.
Conflict of interest: none declared.
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