目前IVUS对于探查易损斑块的价值

    灰阶IVUS不能探查易损斑块，仅有一个例外（一项小型研究），所有的灰阶IVUS研究：1）比较了ACS与非ACS病变和患者，或2）报道了斑块破裂后和导致的事件结果。但是，我们现在处于IVUS组织学特征时代。最近刚完成的PROSPECT研究显示，联合应用灰阶IVUS和虚拟组织学IVUS能探查易损斑块。但是，这并不意味着要做常规三支血管甚至高危患者有创影像学检查筛查易损斑块。它仅仅意味着：1）我们已经证实了易损斑块（尤其是薄帽纤维粥样硬化）假说，而且2）我们具有探查高危或易损斑块的工具。

    鉴于IVUS对冠脉介入的重要价值，介入医生如何更好地应用这项技术？

    我们知道IVUS尚未得到充分利用，我们也知道IVUS能改善PCI操作。但是，IVUS应用不足存在很多原因，包括费用、教育（或者没有）、易于使用（或者没有）、图像质量等。我认为提高IVUS应用包括如下步骤：1）厂商改善产品——系统与导管——能传输更好更连贯的图像质量。2）医生必须下决心学会IVUS图像信息的判读和运用，这并不难，但确实需要付出时间和精力，不是一个下午或一天、一周就能完成的。3）我们必须灵活掌握何时以及如何应用IVUS，因为它不仅仅可以用于介入术前评估，还可以用于PCI术后评价。

    IVUS指导PCI治疗CTO病变

    IVUS指导在许多方面非常有用，在确定CTO病变的近端入口方面有帮助（在CTO近端有分支的情况下）。它对于确定导引导丝的路径是否良好，即，确定是否在斑块内或者血管内侧或血管外。对置入支架之前CTO远端导引导丝的定位特别有帮助——是否在真腔或假腔。而且对优化支架置入也有帮助——充分覆盖病变和扩张完全。

    您是如何安排TCT2010的影像学专场内容的？大家能看到哪些精彩内容？

    影像学在介入心脏病学领域越来越重要，为此，我们安排了涵盖整个领域的多个影像学专场，包括无创影像学进展（CT、MRI等），有创检查FFR、IVUS、血管内影像新技术（OCT、光谱学等），影像学指导结构性心脏病操作等。但是我们不是自己来做这些事的，我们邀请世界上这些领域的专家来贡献他们的智慧，让这个专场尽可能地具备教育性和先进性。

    许多中国介入医师在IVUS方面得到过您的辅导，您如何评价这些学生的优缺点？

    事实上，这是一种独特的体验，我希望他们能够感激这种经历。我们的IVUS学员能够成为世界上最令人激动的导管室——哥伦比亚大学医学中心导管室——的一员，来观摩介入心脏病学先进技术。他们可以专注地学习IVUS和其他心血管影像学及生理评估技术。不但能通过IVUS了解介入技术，而且能看到一些世界最棒的介入医生的实际操作，使得他们回到中国后自身也得到了提高。曾有几名回国的IVUS学生告诉我，虽然他们一整年都没有摸过导管，但是他们的技术却提高了——仅仅通过观察和学习。我们的IVUS学生曾经进行密集的研究工作，包括数据收集和分析、摘要准备和演示、论文写作。他们能专心地做这些事情而不被临床事务所扰。我真希望我也曾拥有过这样独特的体验。

    CCheart:  Could you please comment on the value of IVUS in detecting vulnerable plaque?

    Dr. Gary Mintz:  Greyscale IVUS cannot detect vulnerable plaque. With only one exception (and that was a small study), all greyscale IVUS studies have (1) compared ACS vs. non-ACS lesions and patients or (2) have reported findings after plaques have already ruptured and caused events. However, we are now in the era of IVUS tissue characterization. The recently completed PROSPECT trial indicates that the combination of greyscale and VH-IVUS can detect vulnerable plaques. However, that does not mean that it makes sense to do routine 3-vessel invasive imaging to screen for vulnerable plaques, even in high-risk patients. It merely means that (1) we have confirmed the vulnerable plaque (especially the thin-cap fibroatheroma) hypothesis and (2) we have the tools to detect high risk or vulnerable plaques.

    CCheart:  Given the important value of IVUS for coronary intervention, how could interventionalist use this technique better?

    Dr. Gary Mintz:  IVUS is underutilized. We know that. IVUS also improves PCI procedures. We also know that. However, there are many reasons why IVUS is underutilized including cost, education (or lack thereof), ease of use (or lack thereof), image quality, etc. To me the steps for increased IVUS use are as follows. (1) The companies have to improve the product - systems and catheters - and deliver better and more consistent image quality. (2) Physicians must decide to learn to interpret and use the information contained in the IVUS images. This is not that difficult, but it does take time and effort and cannot be accomplished in an afternoon or a day or even a week. (3) The IVUS community must become smarter about communicating a single strong message of when and how to use IVUS. IVUS use begins with pre-intervention assessment and ends with optimizing the PCI procedure.

    CCheart:  Could you share with us information about IVUS-guided PCI for CTO?

    Dr. Gary Mintz:  IVUS guidance is useful in many ways. It is useful in identifying the proximal “entrance” into a CTO lesion - although this does require the presence of a sidebranch arising from the proximal stump of the CTO. It is useful to determine whether the course of the guidewire is “good” or not - i.e., whether it is in the plaque or the medial space or even outside the vessel. It is especially useful in determining the position of the guidewire distal to the CTO - whether or not it is in the true or a false lumen - prior to implanting a stent. And it is useful for optimizing stent implantation - length and expansion.

    CCheart:  How do you design the content of Imaging sessions at TCT 2010? What will the attendees expect to see in these sessions?

    Dr. Gary Mintz:  Imaging is increasingly important in interventional cardiology. As a result we create many different types of imaging sessions that cover the entire field. These include non-invasive imaging updates (CT, MRI, etc), invasive physiology using FFR, IVUS, new intravascular imaging techniques (OCT, spectroscopy, etc), imaging to guide structural heart disease procedures, and so on. But we do not just do this ourselves. We involve world experts in each of these areas to contribute their ideas to make the sessions as educational and current as possible.

    CCheart:  Quite a few Chinese interventionalists received IVUS training under your guidance. Would you like to talk about the learners’ advantages and disadvantages?

    Dr. Gary Mintz:  Actually, it is a unique experience - one that I hope they appreciate. Our IVUS fellows become part of one of the world’s most exciting cath labs - the one at Columbia University Medical Center - watching a state of the art practice of interventional cardiology. They can focus on learning IVUS and other intravascular imaging and physiologic assessment techniques, not just IVUS. Understanding intervention through this lens as well as watching some of the world’s best interventionalists makes them better when they return to China. I have been told by several of our returning IVUS fellows that their technical skills progressed without touching a catheter for an entire year - just by watching and learning. Our IVUS fellows get an intense research experience including data collection and analysis, abstract preparation and presentation, and manuscript writing. And they can do this without the burden of patient care. It is a unique experience. One that I wish I had had.