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Optical Coherence Tomography dr md toufiqur rahman cardiologist
1. Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI,
FCCP,FAPSC, FAPSIC, FAHA
Associate Professor of Cardiology
National Institute of Cardiovascular Diseases
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova, Malbagh branch.
Honorary Consultant, Apollo Hospitals, Dhaka and
Life Care Centre, Dhanmondi
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Optical Coherence Tomography
2. Introduction of OCT
• James G. Fujimoto, 1991
• What is OCT:
diagnostic medical imaging techonology
• Why OCT: better diagnose and treat disease
• Main application areas:
heart disease and cancer
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3. What is OCT(Optical Coherence
Tomography)?
• OCT use low-coherence interferometry to
produce a two or three dimensional image
of optical scattering from internal tissue
microstructures.
• Michelson interferometer is used to
perform low-coherence interferometry
• OCT measures intensity of reflected
infrared light.
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7. Advantages of OCT
• Broad dynamic range
• High resolution
• Rapid data acquisition rate,
• Small inexpensive catheter/endoscope design
• Compact portable structure
(fiber optically based, making possible the
development of small catheters and endoscopes)
• The frame rate for OCT systems are four to eight
frames per second.(assume an image size of 256 by
512 pixels.) drtoufiq19711@yahoo.com
8. Nowadays and future equipment
DISPLAY
AND
KEYBOARD
INTEROMETER
ELECTRONICS
AND
OPTICS
+COMPUTER
FIBEROPTIC PROBE
•Low-coherence
Superluminescent
diode:800 –1300 nm
center waveength and
severl milliwatts power.
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9. 9
Development of OCT
2004 2007 2009H H2011 2012
M2 System M3 System C7XR™
System ILUMIEN™
System ILUMIEN™
OPTIS™
First Commercial OCT
System
15 fps / 200 lines
Occlusion + flush
2nd
Generation
20 fps / 240 lines
Occlusion + flush
Europe and US only
100 fps / 500 lines
Occlusion-free
Commercially available 2011
100 fps / 54 mm pullback
Combined FFR and OCT
Wireless FFR
Japan launch 2012
180 fps/75 and 54 mm pullback
Advanced software tools for PCI
Optimization
Tableside control
from DOC
Occlusion balloon + ImageWireTM
Occlusion-free Flush FFR and OCT System 2nd
Gen FFR and OCT System
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10. 10
OCT Technology from St. Jude Medical
• Console
• Rapid exchange (Rx) imaging catheter
• Contrast flush; balloon occlusion not required
• Fast image acquisition: 7.5cm pullback in 2.5 sec
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12. 12
DRAGON-FLY DUO CATHETER
• Fiber optic
• Three radioparque marker
• Compatible with G.C 6 or 7
Fr without holes
• G.W 0.14”
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13. OCT in Nontransparent Tissue
A epiglottis
B arterial layers
C atherosclerotic plaques
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14. OCT application
A Reduce High False-Negative
Rates
B Reduce Biopsy Hazardous
Applied in guiding microsurgical
procedure
Esophagus & epithelium & early cancer
Vulnerable plaque
Prostate
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15. Limitation
• Penetration: 2-3mm Ideal: 4mm
• Resolution :
catheter/endoscope based image: 10μm,
noncatheter: 4 μm,
1. femtosecond laser is expensive (1 μm)
2. transverse resolution needs to be similar to
axial resolution, below 10 μm need short confocal
parameter which results in the focus falling off
rapidly.
• Acquisition rate: <10franes/second
• Lack of large-scale clinical trials
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16. Extention and application of OCT
Name Work Research Application
Dr. Zhongping Chen University of
California, Irvine
Doppler OCT studying blood vessel function and fluid
flow, generally in small structures.
Dr. Johannes de
Boer
Massachusetts
General Hospital
(MGH)
polarization-sensitive
OCT
diagnosing burns and guiding appropriate
treatment
Dr. Brett Bouma
and Dr. Guillermo
Tierney
MGH very portable, high-
performance OCT
systems for clinical
diagnostic studies
major clinical investigations are ongoing in
the fields of gastroenterology, dermatology,
cardiology, urology, orthopedics, gynecology,
and otolaryngology.
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18. 18
Prior to Starting a Case
Required Materials
– Dragonfly™ Duo imaging catheter
– Sterile DOC cover
– 3 ml purge syringe
– Contrast media indicated for coronary use
– 0.014" guidewire
– Guide catheter (6-7 F, with no sideholes)
PROCEDURE OF OCT
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19. 19
Turning ON the System – Power Switches
Powerup / Wake-up button
on upper right of keyboard
.
Main Switch
next to power cable
Tech.
Procedure
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20. 20
Entering patient data
Tech.
Press Add new patient data.
Put all the information's concerning the
patient.
Press New OCT Recording.
Procedure
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25. Catheter Preparation
Insert the DOC into the sterile bag.
Scrub Tech Fix the DOC by her hand and the Technician pull the
sterile cover.
Place it on the table.
Procedure
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28. 28
Preparations Of Calibaration
Press Live View
Ask the physician to put his 2 fingers to calibrate the catheter
Press Auto-Calibrate , The system is calibrated automatically
Procedure
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30. 30
Pullback Preparation – Purge the Catheter
• If blood enters the catheter lumen, purge with the attached 3 cc
contrast syringe.
Blood in catheter lumen Purged catheter lumen
Procedure
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31. 31
Preparation of Injection
Recommended Settings:
• Injection by hand
• Left coronary, Right coronary arteries: (16----20) ml ;
• We can use 12-20 ml syring In your Cath. (Depend on operator)
• When the operator is ready to inject contrast,
click the “Enable Pullback ” button.
• Ask the Physician to inject, 3 sec from the injection and when the
image is clear press ”Start Pullback”
Procedure
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33. 33
Pullback Preparation – Puff into the Vessel
• During live scan, puff with the contrast injector to determine guiding
catheter position for optimal image clarity.
Suboptimal clearance,
blood swirls
Optimal clearance
Procedure
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40. 40
New Recording for the same patient
Press New Recording
Ask again the physician to put his 2 fingers to do calibration
Repeat the same step of the Injection
Procedure
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43. • Detect the Thrombus , not detected with Angio – Image
• Rapture Plaque
• Differentiate between the Red and white Thrombus
• Stent Thrombosis and Malappositon
Post Procedure
Findings of OCT
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47. Progress in coronary image
• Coronary angiography CAG
• Intravascular ultrasound IVUS
• Optical coherence tomography OCT
IVUS-guided implantation of stentIVUS-guided implantation of stent
has been showed to improve thehas been showed to improve the
outcomes with reduction of restenosisoutcomes with reduction of restenosis
and thrombosisand thrombosis
What is the role of OCTWhat is the role of OCT
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48. • The most prominent feature of OCT is its high
resolution of 10µm. It enables real-time, full
tomographic, in-vivo of vessel visualization
mainly used in the following microstructure:
1. Fibrous cap and evaluate vulnerable plaque1. Fibrous cap and evaluate vulnerable plaque
2. Strut apposition and stent tissue coverage2. Strut apposition and stent tissue coverage
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49. A very strong correlation between
histology and OCT measurements
Lipid-rich plaque
Fibrous plaque
Thin cap fibroatheroma
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50. Classification of strut apposition by OCT
Totally embedded strut
Embedded subintimally
without disruption of
lumen contour
Completely embedded
with disruption of
lumen contour
Partially embedded
with extension of
strut into lumen
Complete strut
malapposition
(blood able to exist
between strut and
lumen wall)
Type I
Type II
Type IIIa
Type IIIb
Type IV
Giulio. CCI, 2008, 72:237–247
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51. Different vessel
responses observed in multiple frames
Well apposed struts
with uniform
neointimal coverage
Well apposed struts
with not-uniform
vessel response around
some strut. Although
fully covered, struts
located from 9 to 12
o’clock present a
signal attenuation of
the tissue around them
Deeper increase
toward the media of the
area of signal
attenuation in
the proximal cross
section
Giulio. CCI, 2008, 72:237–247drtoufiq19711@yahoo.com
52. New finding with OCT in the recent
clinical studies are changing our views
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54. Typical findings of angioscopy, and OCT
after BMS implantation
(A)Six-month follow-up angiogram shows no in-stent restenosis
(B) Angioscopy shows white neointima covers completely over the
BMS and the struts are invisible
(C) Circumferential stent struts with strong signals are identified by
cross-sectional image of OCT. Neointima inside the struts has
uniform signals without their attenuation
3.5mm×13mm
Male, A 43-year-old
with SAP
BMS in LAD
Journal of Cardiology , 2009, 53:311—313
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55. Novel findings of angioscopy and OCT
after SESs implantation
(A)Six-month follow-up angiogram shows no in-stent restenosis
(B) Angioscopy shows yellow neointima covers over the SES , whereas some of the
struts are uncovered in the proximal overlapping segment.
(C) In this overlapping segment, thin membranous structure inside the struts of
inner stent is partially recognized by optimal coherence tomography.
Neointima has strong signalswith their rapid attenuation similar to a lipid
plaque. Although struts of inner stent are clearly seen, those of outer stent are
not visible owing to backscattering of the neointima.
SESs deployed
in LAD
Journal of Cardiology , 2009, 53:311—313
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56. • OCT signal patterns of the neointima
showed rapid attenuation similar to lipid
tissues in atherosclerotic lesions
• neointima within the SES is quite different
from that of the BMS and may contain
atherosclerotic components
Murakami, et al. Journal of Cardiology
2009, 53:311—313
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57. OCT and intravascular ultrasound imaging was performed at corresponding
sites in patients undergoing catheterization. OCT plaque characteristics for lipid
content, fibrous cap thickness, and macrophage density were derived using
previously validated criteria. Thin-cap fibroatheroma (TCFA) was defined as
lipid-rich plaque (two or more quadrants) with fibrous cap thickness <65 µm.
Remodelling index (RI) was calculated as the ratio of the lesionto the reference
external elastic membrane area. A total of 54 lesions from 48 patients were
imaged.Positive remodelling compared with absent or negative remodelling was
more commonly associated with lipid-rich plaque (100 vs. 60 vs. 47.4%, P = 0.01),
a thin fibrous cap (median 40.2 vs. 51.6 vs. 87 µm, P = 0.003) and the presence of
TCFA (80 vs. 38.5 vs. 5.6%, P < 0.001). Fibrous cap macrophage density was also
higher in plaques with positive remodelling showing a positive linear correlation
with the RI (r = 0.60, P < 0.001).
Eur Heart J. 2008, 29: 1721–1728
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58. ODESSA: 6-month OCT
long lesions randomized to multiple SES, PES, ZES and
BMS
6968 cross-sections6968 cross-sections
53047 struts53047 struts
malapposedmalapposed uncovereduncovered
BMSBMSSESSES PESPES ZESZES
Guagliumi, et al. TCT 2008Guagliumi, et al. TCT 2008
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59. Human OCT Study
100% of Endeavor Stent Struts Covered at 6 Months
Stent struts are apposed to vessel wall with uniform stent coverage
100%
24,076 Endeavor struts were uniformly covered
Distribution of Endeavor Struts Condition
ZES= 44 24,076 stent struts
Guagliumi et al. ESC 2008
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60. Six-month strut coverage and vessel wall
response of the zotarolimus eluting stent
compared with driver bare mental stent
implanted in AMI
A prospective, randomized, controlled study
proformed with OCT
OCTAMI
Guagliumi, et al. TCT 2009
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61. Primary end point
% uncovered struts on per patient basis
Guagliumi, et al. TCT 2009
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62. Secondary end point
mas length of uncovered and incompletely apposed
segments (mm) in OCT
Guagliumi, et al. TCT 2009
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63. Secondary end point
strut level NIH and net volume obstruction in OCT
Guagliumi, et al. TCT 2009drtoufiq19711@yahoo.com
64. OCT image to ACS : 9-year after BMS
implantation
OCT pullback from
mid-proximal LCX
TFCA overlying a
large lipid-rich plaque
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What is oct
Optical Coherence tomography (OCT) is a light based imaging modality with superior spatial resolution (~ 15Um) compared to other intravascular imaging system.
This technology does not use x-ray
The acquisition of this image is fast and easy to treat
In other hand other type of coronary imaging is difficult to interpret and doesn&apos;t have the high resolution
So the high resolution of oct makes it an excellent tool to visualize the vasculature
Who that
We have long history of OCT, competition is new to the field
In order to perform OCT procedures, St. Jude Medical provides a console (C7-XR™) and an imaging catheter (Dragonfly™). With the current C7-XR technology, no balloon occlusion is required; rather, the vessel is cleared of blood for imaging by a rapid flush of contrast. The images themselves are acquired extremely quickly: acquiring a 5 cm pullback image takes only 2.5 seconds.
Long pullback : 75mm ; old one : 55mm
3 markeres : lens marke visible during the pullback ; distal and proximal to guide the phyisican on the best position
The old : only 2 markres : distal and proximal markers ; to help the physician more and more to know where is the good position
The ilumien system incorporat the most advanced oct techology to optmize PCI and visulazie the vessel anatomy
How that
By ……
Choose existing patient or add new patient, and then choose New OCT Recording.
Remove the hoop carefully from the catheter. To avoid damage, grasp the proximal end of the catheter at the side port and hold firmly with your thumb and forefinger.
With the other hand, gently twist and pull the hoop to release the catheter. Do not twist and pull the catheter.
While withdrawing it from the hoop, gently wipe the catheter shaft with a compress moistened with heparinized saline. This activates the hydrophilic coating and prevents the catheter from spinning dry, causing possible fiber breaks.
Handle carefully to prevent kinking the catheter.
Once the catheter has been purged, it can be connected to the DOC.Remove the blue protective cap from the catheter hub by twisting the cap counterclockwise. Open the black connector cover on the front of the DOC.
Align the four catheter hub sprockets inside the DOC connection port; turn clockwise until secure.
Care should be taken not to touch the fiber optic core of the catheter and not to kink or bend the catheter.
Insert the DOC into the sterile bag and place it on the table.
NOTE: This step requires two people, one sterile and one nonsterile.
The screen will show the status of the connecting catheter, and the LED on the DOC will light up (see next slide).
When the catheter is fully connected, this will be indicated on the screen.
This is the DOC, which stands for Drive Motor and Optical Controller.
The controls and indicators are:
Load LED – Operator can attach or remove catheter when fully lit (not blinking)
Unload – Press to unload imaging catheter
Laser Emission Symbol – Illuminated when laser output is switched on
Stop – Stops the imaging catheter motion and turns off laser output
Advance – Starts or stops the optical fiber advance sequence
Pullback – Starts or stops the optical fiber pullback sequence
Pullback Position LEDs – Relative position of the optical carriage along the pullback range
Once the DOC has been placed in a sterile pouch, it is ready for use together with a sterile Dragonfly imaging catheter.
Once an image has been acquired, use the toolbar below the image to:
Play, pause, stop, move by frame or move by 1 mm segments
Add or delete bookmarks
Jump from bookmark to bookmark
Export images and bookmark frames of interest
The system will automatically play back at a default speed of 1 mm/sec.
The optical fiber automatically advances to the original distal position.
Once acquisition of a segment is complete, you still have the possibility to adjust calibration. Calibration may be adjusted either to a chosen frame and proximal or to the entire recorded segment.
Once acquisition of a segment is complete, you still have the possibility to adjust calibration. Calibration may be adjusted either to a chosen frame and proximal or to the entire recorded segment.
Click the T icon to add a note to that frame.
When the imaging session is finished, the unload button must be pressed on the DOC to release the catheter.
If the Unload button is not pressed before attempting to remove the catheter, part of the catheter will remain locked into the DOC, which can damage the DOC.