This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
This is a comprehensive description of coronay lesion assessment from routinely used angiography to advanced imaging modalities like IVUS/OCT including their functional significance by FFR
IVUS may not be clinically warranted in all interventions, and should be seen as an adjunct to angiography. IVUS provides information about vessel morphology, plaque topography, and therapeutic outcomes that is often either equivocal or unavailable in angiographic images.
There are 3 situations in which IVUS has the most clinical utility:
Small vessel stenting: Studies have shown that post-stent restenosis rates are higher in small vessels. This is particularly true for vessels with diameters of 3.0mm or less, wherein small increases in stent diameter have been shown to significantly decrease the rate of restenosis. A study by Moussa et al showed that, as measured by IVUS, the incidence of restenosis has an inverse relationship to the post-procedure in-stent lumen CSA1.
In-Stent restenosis: In these cases, IVUS helps to determine whether the restenosis is due to inadequate stent deployment (underexpansion or incomplete apposition) due to intimal hyperplasia. IVUS will also help you select the proper device size for treatment of the stented area.
Difficult to assess lesions: At times, images of a lesion and the adjacent reference segment are often hazy. IVUS should be used to identify whether the angiographic appearance is due to dissection, thrombus, residual plaque, or is benign.
Intracoronary Imaging – when to use, how to use and how to interpret the imagesEuro CTO Club
Intracoronary Imaging – when to use, how to use and how to
interpret the images
Javier Escaned, Spain
The Experts “Live” Workshop 2017
Saturday, September 16th, 2017
Optical coherence tomography-guided algorithm for percutaneous coronary intervention. Vessel diameter should be assessed using the external elastic lamina (EEL)-EEL diameter at the reference segments, and rounded down to select interventional devices (balloons, stents). If the EEL cannot be identified, luminal measures are used and rounded up to 0.5 mm larger for selection of the devices. Optical coherence tomography (OCT)-guided optimisation strategies post stent implantation per EEL-based diameter measurement and per lumen-based diameter measurement are shown. For instance, if the distal EEL-EEL diameter measures 3.2 mm×3.1 mm (i.e., the mean EEL-based diameter is 3.15 mm), this number is rounded down to the next available stent size and post-dilation balloon to be used at the distal segment. Thus, a 3.0 mm stent and non-compliant balloon diameter is selected. If the proximal EEL cannot be visualised, the mean lumen diameter should be used for device sizing. For instance, if the mean proximal lumen diameter measures 3.4 mm, this number is rounded up to the next available balloon diameter (within up to 0.5 mm larger) for post-dilation. MLA: minimal lumen area; MSA: minimal stent area;NC: non-compliant
IVUS may not be clinically warranted in all interventions, and should be seen as an adjunct to angiography. IVUS provides information about vessel morphology, plaque topography, and therapeutic outcomes that is often either equivocal or unavailable in angiographic images.
There are 3 situations in which IVUS has the most clinical utility:
Small vessel stenting: Studies have shown that post-stent restenosis rates are higher in small vessels. This is particularly true for vessels with diameters of 3.0mm or less, wherein small increases in stent diameter have been shown to significantly decrease the rate of restenosis. A study by Moussa et al showed that, as measured by IVUS, the incidence of restenosis has an inverse relationship to the post-procedure in-stent lumen CSA1.
In-Stent restenosis: In these cases, IVUS helps to determine whether the restenosis is due to inadequate stent deployment (underexpansion or incomplete apposition) due to intimal hyperplasia. IVUS will also help you select the proper device size for treatment of the stented area.
Difficult to assess lesions: At times, images of a lesion and the adjacent reference segment are often hazy. IVUS should be used to identify whether the angiographic appearance is due to dissection, thrombus, residual plaque, or is benign.
Intracoronary Imaging – when to use, how to use and how to interpret the imagesEuro CTO Club
Intracoronary Imaging – when to use, how to use and how to
interpret the images
Javier Escaned, Spain
The Experts “Live” Workshop 2017
Saturday, September 16th, 2017
Optical coherence tomography-guided algorithm for percutaneous coronary intervention. Vessel diameter should be assessed using the external elastic lamina (EEL)-EEL diameter at the reference segments, and rounded down to select interventional devices (balloons, stents). If the EEL cannot be identified, luminal measures are used and rounded up to 0.5 mm larger for selection of the devices. Optical coherence tomography (OCT)-guided optimisation strategies post stent implantation per EEL-based diameter measurement and per lumen-based diameter measurement are shown. For instance, if the distal EEL-EEL diameter measures 3.2 mm×3.1 mm (i.e., the mean EEL-based diameter is 3.15 mm), this number is rounded down to the next available stent size and post-dilation balloon to be used at the distal segment. Thus, a 3.0 mm stent and non-compliant balloon diameter is selected. If the proximal EEL cannot be visualised, the mean lumen diameter should be used for device sizing. For instance, if the mean proximal lumen diameter measures 3.4 mm, this number is rounded up to the next available balloon diameter (within up to 0.5 mm larger) for post-dilation. MLA: minimal lumen area; MSA: minimal stent area;NC: non-compliant
There are two basic IVUS catheter designs: mechanical/rotational and solid state. The mechanical catheters (OptiCross IVUS catheter, Boston Scientific, Santa Clara, California; Revolution IVUS catheter, Volcano, Rancho Cordova, California; ViewIT IVUS catheter, Terumo, Tokyo, Japan; and Kodama HD IVUS catheter, ACIST Medical Systems, Eden Prairie, Minnesota) consist of a single transducer element located at the tip of a flexible drive cable housed in a protective sheath and operated by an external motor drive unit. The drive cable rotates the transducer around the circumference (1800rpm) and the transducer sends and receives the ultrasound signals at 1° increment to form the cross-sectional image. The imaging catheters operate at a central frequency of 40 MHz or 60 MHz and are 5F or 6F compatible [Figure 1]A. In the solid-state catheter design (Eagle Eye Catheter, Volcano), no rotating components are present. There are 64 transducer elements mounted circumferentially around the tip of the catheter. The transducer elements are sequentially activated with different time delays to produce an ultrasound beam that sweeps around the vessel circumference. The catheter works at a central frequency of 20 MHz and is 5F compatible
How to deal with CALCIFIED CORONARY ARTERY LESIONS .Coronary artery calcification (CAC) is highly prevalent in patients with coronary heart disease (CHD) and is associated with major adverse cardiovascular events. There are two recognized type of CAC—intimal and medial calcification, and each of them have specific risk factors. Several theories about the mechanism of vascular calcification have been put forward, and we currently believe that vascular calcification is an active, regulated process. CAC can usually be found in patients with severe CHD, and this asymptomatic phenomenon make early diagnosis of CAC important. Coronary computed tomographic angiography is the main noninvasive tool to detect calcified lesions. Measurement of coronary artery calcification by scoring is a reasonable metric for cardiovascular risk assessment in asymptomatic adults at intermediate risk. To date, effective medical treatment of CAC has not been identified. Several strategies of percutaneous coronary intervention have been applied to CHD patients with CAC, but with unsatisfactory results. Prognosis of CAC is still a major problem of CHD patients. Thus, more details about the mechanisms of CAC need to be elucidated in order to improve the understanding and treatment of CAC.
cardiac bio markers are important diagnostic and prognostic tool in acute coronary syndrome. several new emerging bio markers are coming with more sensitivity and specificity.
differentiating between supraventicular tachycardia and ventricular tachycardia in wide complex rhythm is always confusing and management is totally different. correct diagnosis will make dramatic difference in patient management.
Brugada Syndrome is a inherited sodium channel disorder leading to life threatening ventricular fibrillation in young population. diagnosis and ICD therapy could be life saving.
kawasaki disease is disease of pediatric age group leading to involvement of coronaries in 25% of case. some of presented as fetal complication. early diagnosis and treatment useful measure to prevent complications.
takayasu arteritis is inflammatory disorder of medium sized arteries of unknown etiology, prevent in young female. lead to life threatening complication and long lasting morbidity. early diagnosis and treatment prevent complication and improve quality of life
Trans catheter intervention is emerging field in cardiac intervention. due to complex anatomy of mitral valve understanding of anatomy and three dimensional imaging is most important aspect of successful intervention and could be life saving in high risk surgical candidate
RHD is prevalent in India, many patients requires valve replacement. understanding of prosthetic valve anatomy, morphology and early detection of valve related complication is very important for saving life. TTE and TEE are important tool for identifying these complications.
there are several limitation in VKA,to over come these problem NOACs came in picture but still limited indication for NOACs currently,required further study inter and intra comparison between anticoagulants.
rotablation is procedure used in complex pci with heavily calcified lesion for adequate expansion of stent.if used in indicated case and well aware of contraindication is necessary for achieving good results.
ebstein anomaly is rare congenital disorder,with variable presentation in neonate to adults,early diagnosis and timely take decision make remarkable difference in patients life.
diabetes is most prevalent disease in asia, incidence of heart failure is also increasing in diabetic population, understanding the pathophysiology is very important to deal with these cases.
preop TEE assessment of atrial septal defect is very important for making decision for device closure, properly assessed adequate rims of ASD will reduce risk of device embolization to almost nil.
atherosclerosis is one of most common cause of aortic ds,screening of abdominal aorta in vulnerable population is very useful for prevention and early detection of future omplication.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
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CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
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2. Coronary angiography
Gold standard for evaluating CAD
Guide both PCI and CABG
Provides highly useful picture of the vessel lumen
Indirect information about the arterial wall
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14. Muller et al., The Year in Intracoronary Imaging
J A C C : C A R D I O V A S C U L A R I M A G I N G ,
V O L . 3 , N O . 8 , 2 0 1 0
A U G U S T 2 0 1 0 : 8 8 1 – 9 1
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15. IVUS
Image integrity should be
checked before inserting
No coronary preparation is
needed
Iv Heparin 5000-10000U ;
Ic NTG 100-200 µ
Standard coronary
interventional techniques and
equipment (guiding catheter
and 0.014 inch angioplasty
guidewire)
Automated pullback device
(usually at a rate of 0.5–1.0
mm/s for any length) or by
manual operator pull back
15
16. Characteristic three-layered
appearance (bright-dark-bright)
Spillover effect (blooming)
Normal vessel – intima maynot be
seen
Atherosclerotic vessel – media
may not appear distinct
20-45 MHz
100-200 µ resolution
4-8 mm beam penetration
16
21. Reference segment – most normal looking (largest
lumen with smallest plaque burden) within 10 mm
from the lesion with no intervening side branches
Arterial remodelling (Glagov et al)
-Positive remodelling (adaptive);RI >1
-Negative remodelling(constrictive);RI<1
-Intermediate remodelling
Remodelling Index = EEM surface area (lesion site)
EEM surface area (reference site)
21
23. Gray scale IVUS
Soft plaque – echogenicity less than the
surrounding adventitia
Fibrous plaque – intermediate echogenicity
between those of soft plaques and highly
echogenic calcium plaques
Calcified plaques – high echogenicity with
acoustic shadowing (superficial or deep)
23
30. Plaque rupture
Hypoechoic cavity within the plaque is connected
within the lumen and a remnant of fibrous cap is
observed at the connecting site
Often eccentric, less calcified, large plaque burden,
positively remodelled, and a/w thrombus
Extensive positive remodelling – most consistent
feature reported in GS-IVUS predicting plaque
instability
30
31. Ability of IVUS to predict future coronary events
- PROSPECT trial
Three vessel VH-IVUS in 697 ACS patients
Three baseline IVUS characteristics that
independently predicted future events
1) Plaque burden > 70 %
2) TCFA
3) MLA < 4 mm2
31
32. Safety
Most frequent acute complication – transient
coronary spasm 1-3%
Major complications <0.5% (Dissections,
thrombosis, abrupt closure)
Batkoff BW, Linker DT, Safety of intracoronary ultrasound:
data from a Multicenter European Registry, Cathet
Cardiovasc Diagn, 1996;38:238–41.
32
33. Limitations
Extensive calcification at lesion site leads to large
acoustic shadowing and difficulty in interpreting the
exact size of the vessel
Ghost images - Occurs when structures of high
echogenicity are imaged (eg Calcium, stent struts).
Appear on the side of the transducer that is opposite
the bright structure being imaged.
33
34. A case with spontaneous dissection. Optical coherence
tomography (C) visualized spontaneous dissection that could not
be found with angiography (A) or intravascular ultrasound (B).
34
35. OCT
Optical analogue of IVUS
Significantly higher resolution (10 times more) but
lesser penetration
Uses near infrared rays- 1.3 microns
OCT measures the time delay of the light that is
reflected or backscattered from tissue, and that is
collected by the catheter, by using a technique
known as interferometry.
35
37. TD- OCT FD-OCT
• Injecting continuous saline/
contrast flushes through the
guiding or delivery catheters.
•Proximal balloon occlusion of
the vessel with distal
saline/contrast injection.
•Time-consuming
• Require a high degree of
operator expertise
•FD OCT systems do not require
proximal occlusion
•Bolus injection of saline, contrast, or
other
Solution, injected at rates of 2 to 4
ml/s, and an automated 20 mm/s
pullback within a monorail rapid
exchange catheter allows imaging of a
6-cm-long coronary segment during a
3-s injection
37
41. Ex vivo validations --- OCT superior to conventional and
integrated backscatter IVUS for the characterisation of
coronary atherosclerotic plaque composition.
In vivo, OCT is superior for the identification of lipid
pools
Thin capped fibroatheromas (TCFA) - defined pathologically
by the triad of:
Lipid core.
Fibrous cap with a thickness < 65 micron m.
Cell infiltration of the fibrous cap.
OCT for in vivo assessment of fibrous cap thickness ----
Unique ability to image superficial detail.
OCT can quantify macrophages within the fibrous cap.
41
44. OCT can identify intracoronary thrombus and plaque
rupture with high accuracy.
44
45. OCT AND PCI
Fine resolution at a superficial depth, OCT allows a
uniquely detailed image of the effects of stent
implantation on the vessel wall.
OCT allows:
Examination of the target vessel both pre- and post-
intervention
Defining stent struts readily
Tissue prolapse between stent struts immediately
(97.5%)
Tissue characterization of plaque before and after
stent placement
Intrastent dissection (86.3%)
45
46. 3-point classification defines stent strut
apposition.
Embedded ----- the leading edge is buried
within the intima by more than one-half its
thickness
Protrusion --- stent strut is apposed but not
embedded
Malapposed ---- there is no intimal contact
46
48. Primary imaging modalities for follow-up evaluation of
several bioabsorbable vascular scaffolds (BVS), which are
being studied in clinical trials (ABSORB)
OCT has been increasingly used as an endpoint in clinical
trials of newer generation DES (LEADERS)
OCT helps to predict no reflow post-PCI, based on the
presence of TCFA
48
51. SAFETY
The relatively low energy used in OCT (5.0–8.0 mW)
does not cause functional or structural damage to the
coronary tissue.
Use of a contrast bolus in coronary preparation is a
concern but studies have shown that no patients
suffered contrast-induced nephropathy,
Small risk of coronary spasm and electrocardiogram
(ECG) changes during contrast administration.
51
52. LIMITATIONS
Need to displace blood or dilute the hematocrit, either with
saline or contrast flush injection, or a combination of the two.
Shallow image penetration of 1 to 2.5 mm. This prevents
assessments of cross-sectional plaque area ---- OCT has only
a limited role in the assessment of left main stem and
Saphenous vein graft atherosclerosis severity.
The differentiation of calcific areas from lipid pools can be
problematic . both result in a low attenuation signal.
Imaging of Left main ostium
Imaging in patients with decreased creatinine clearance
Image artifacts
52
55. The 2011(ACCF)/(AHA)/ (SCAI)
guidelines for PCI
1) IVUS for the evaluation of angiographically indeterminate left
main lesions and angiographically indeterminate (50–70 % stenosis)
non-left main coronary lesions (Class IIa LOE B)
2) IVUS to evaluate the aetiology of stent restenosis and stent
thrombosis (Class IIa, Level of Evidence C).
3)The routine use of IVUS for evaluation of lesions when PCI is not
planned was given a Class III recommendation
4) Currently neither the American nor European (ESC) guidelines
provide recommendations for the routine use of OCT in clinical
practice
5) More recent guidelines published in February 2014 by NICE
suggest that the evidence on the safety of OCT to guide PCI showed
no major concerns
IVUS reveals need of postdilatation
55
56. CONCLUSION
IVUS and OCT - useful image guiding tools during stent
implantation.
Intracoronary imaging may prove to be useful in reducing
complications by 1) improving the techniques of stent sizing and
placement, 2) identifying the role of necrotic-core plaque as a cause
of stent complications, and 3) assessing stent coverage and
thrombosis.
OCT - higher resolution and adds more information particularly
distinguishing thrombus formation, coronary dissection and
incomplete stent apposition following implantation.But not clear
whether this additional information helps to improve patient outcome
At present, IVUS remains the more trusted and validated imaging
modality and is the first-choice modality to guide optimal stent
implantation.
56
58. A bend in a mechanical IVUS
catheter due to severely
angulated lesions may cause
unnecessary friction and
generate Non-Uniform
Rotational Distortion
(NURD), which results in a
smeared image
Ring-down artifact -- Caused by
transducer oscillation filling the
area immediately adjacent to the
catheter with noise, making this
area unavailable for imaging. Seen
as bright halo of variable thickness
surrounding the catheter.
58