Presented on Mar. 4, 2010 at Triple Ring Technologies MedTech Frontiers Series

1. Minimally Invasive
Image-Guided Therapy:
Cardiovascular Applications
Kendall R. Waters, PhD
kendallw@svmii.com
Presented on Mar. 4, 2010
Triple Ring Technologies, Newark, CA
MedTech Frontiers Series
www.tripleringtech.com

2. Original Image from iStockPhoto.com
Minimally Invasive Surgery without Image Guidance is Surgery
Blindfolded

3. Animation from iStockPhoto.com
72 BPM, 100,000 Day, 2.5 Billion Lifetime
CVD: Affect over 86 Million Americans, Estimated direct and indirect
costs for 2010 are $500 Billion

4. A silhouette misses part of the picture
Pilobolus Video from YouTube.com
Pilobulus @ 2007 Oscars

5. Is the standard good enough?
Angiograms are Silhouettes
Contrast Angiography: Shadows hide some details

6. Is the standard good enough?
Poor Soft Tissue Contrast
X-Ray: Poor Tissue Contrast

7. Coronary heart disease is
the largest major killer
Unable to predict
which plaques will
lead to clinical events
Image from Northwest Houston Heart Center (www.houstonheartcenter.com)
CHD: Largest killer, >17M pts
$177B direct/indirect costs 2006
Unable to predict which plaques lead to events

8. Imaging inside the coronary arteries
Image from ShutterStock.com
Catheter-Based Imaging: Retrograde approach

9. Courtesy of Sean Madden, PhD, InfraReDx
Catheter-Based Imaging: Retrograde approach

10. Synthetic Aperture Array Catheter
Mechanically Rotating Catheter
Array Catheter: Ease of Use (No flushing required)
Mechanically Rotating Catheters (US, OCT, NIRS): Image Quality

11. The Watch Child of Vulnerable Plaques
Poster an artery get clogged
Lipid-Rich
or
Necrotic
Core
~25%
Thin Fibrous Cap
Courtesy of Geoff Vince, PhD, Volcano Corp
<65 µm
Normal > Constrictive Remodeling > Core Development > Rupture >
Occlusion > MI
Thin Cap Fibroatheroma: Thin Cap + Necrotic Core Content

12. IVUS this a vulnerable plaque?
Is image ... or Hurricane Map
Zoomed View of a Diseased Vessel with Array Catheter
Modest Spatial Resolution > Poor Tissue Differentiation
Segmentation > Plaque Burden + Lumen Area > Advanced Analysis

13. Do advanced algorithms help?
Volcano VH-IVUSTM BSC iMAP
Fibrosis Necrotic Core Necrotic Fibrotic
Fibro-Fatty Calcification Lipidic Calcified
VH-IVUS > Spectral Parameters > Statistical Classification > 4
Categories > Colorized
iMAP > Spectral Signatures > Statistics Classification > 4 Categories >
Colorized
PROSPECT Trial > Plaque Burden & Necrotic Core & Minimum Lumen
Area

14. Will emerging technologies
find plaques that
lead to clinical events?

15. OCT provides striking detail
Vulnerable ?
but has limited penetration
OCT > 15/30 um resolution > 1-2 mm penetration > Minimum Lumen
Area 0')(.1'2+-
Plaque Characterization > Fibrous (Signal Rich Homogeneous) & Lipid
(Signal Poor with Diffuse Borders)

16. IVUS + OCT Combination
IVUS OCT
Penetration Fine Structural Detail
Courtesy of Dr. Brian Courtney MD and Brian Liang, Sunnybrook Health Sciences Centre,Toronto, CA
Sunnybrook + Colibri > IVUS + OCT > Penetration + Lumen Detail

17. Spectroscopy = Chemical Composition
Pullback Distance
Angle
Limited Spatial Resolution
Courtesy of Sean Madden, PhD, InfraReDx
NIRS > Spectroscopy = Chemical Composition > Lipid Content
Limited Penetration and Resolution
“This is the first device that can help assess the chemical makeup of
coronary artery plaques and help doctors identify those of particular
concern.” -- FDA

18. NIRS + IVUS Combination
NIRS + IVUS Chemogram
IVUS Long View
Chemical Composition + Structural Detail
Courtesy of Sean Madden, PhD, InfraReDx
InfraReDx > NIRS + IVUS > Composition + Structure

19. A Much Better (HD) IVUS
Very Good Structural Detail
Better image quality. IVUS with near-optical resolution. Device simplicity.

20. Some valves become leaky
1% to 5 % mortality rate
Image from Consultants in Cardiology (www.cicmd.com)

21. Can imaging help?
Soft Tissue Imaging
Image from the GE Healthcare Vivid Image Library
Soft Tissue Structure
Color Flow > MVR Jets

22. Can imaging help?
Precision Guidance
Image from Siemens Ultrasound
PFO Closure
mm Length Scale

23. Alignment of Delivery Catheter in LA
Can imaging help?
Real-Time 3D
Image from presentation by J. D. Carroll, MD at TCT 2009
Matrix Array Technology > RT3D
Catheter > Transseptal > MV

24. Can imaging help?
Reduced X-Ray Dose
Procedure Length > X-Rays (Pt & Operator)
US > Non-Ionizing > Reduce X-Ray Need

25. Imaging from inside the heart
Image from ShutterStock.com
Access > Right Side > IVC & SVC

26. Image from Hao and Hongo, EPLab Digest 5(4) (2005). (www.eplabdigest.com)
AcuNav > Steerable > 8-10F > 5-10MHz

27. Imaging from the esophagus
Access > Eso > Proximity

28. Imaging from the esophagus
Images from Toronto General Hospital Department of Anesthesia and Pain Management

29. Figure 6. 2D- and 3D-TEE guidance of percutan
balloon valvuloplasty. (A) 2D-TEE demonstrating
Image From Philips Healthcare (www.medical.philips.com) Image from Hudson et al., J Interv Cardiol 21(6) (2008).
configuration of the anterior mitral valve leaflet (a
typical of rheumatic mitral stenosis. (B) 3D volum
Figure 1. Comparison of echocardiographic transducers. (A) ICE
tion of an en face view of the restricted mitral valv
Steerable > Matrix Array > Multi-plane transducer (AcuNav,TM Siemens, Mountain View, CA, USA). (B)
Conventional two-dimensional multiplane TEE transducer. (C) 3D
the left atrium demonstrating a narrowed mitral o
commissural fusion (arrowheads). (C) 2D X-Plane
matrix array TEE (X7-2t, Philips, Andover, MA, USA) transducer.
atrial septum illustrating “septal tenting” (arrows) d
puncture. (D) Live 3D-TEE guidance of the Inoue
across the rheumatic mitral valve. (E) 3D-TEE view
inflation across the rheumatic mitral valve. (F) 3D
reconstruction demonstrating an enlarged mitral
row) and split commissure (arrowhead). LA = left
ventricle; RA = right atrium; RV = right ventricle
←−−−−−−−−−−−−−−
−−−−−−−−−−−−−−
Figure 4. Percutaneous ASD closure with an Amp
cluder using 2D- and 3D-TEE guidance. (A) 2D-T
small ASD (arrows). (B) Live 3D-TEE displaying
of the ASD (arrow) from the left atrium, reveali
with a long-axis twice the short-axis dimension. (
reconstruction with color Doppler demonstrating l
ing across the ASD (arrow). (D) Live 3D-TEE of
following deployment of the left atrial disk of a 1
Septal Occluder (arrowheads) with excellent vis
delivery cable (arrow) through the ASD. (E) Live
strating good positioning of ASD occluder follo

30. A Leaky Mitral Valve
Normal
Prolapse
Image from Weill Cornell Medical College, Cardiothoracic Surgery (www.cornellheartsurgery.org)
Normal Leaflets > One-way Flow
Prolapse Leaflets > Leaky

31. We can visualize soft tissue and blood flow
Image from Philips Healthcare iE33 Echocardiography System Image Library
Philips xPlane > Biplane TEE
MVR > Mixing of Reds and Blues = Regurgitation

32. 3D Imaging Provides Stunning Detail ...
3D TEE Photograph during Surgery
Images from Ma et al., Chinese Med J 121(20) (2008).
RT3D > Inferior View > Ruptured Chord
Photograph > Ruptured Chord

33. ... and Roadmaps the Repair
Images from Ma et al., Chinese Med J 121(20) (2008).
Quantitative Analysis > 3D Visualization > Specific Area
Roadmap the Intervention

34. Image Guidance Devices are Expensive
Philips X7-2t Probe > Engineering Marvel > many $10Ks > outside CV
system
AcuNav > ~10 yrs old > $2500 disposable > Certified Resterilization

35. A Cardiologist ... and a Cast of Thousands
Images from iStockPhoto.com and ShutterStock.com
Complexity > Echo > Anasthesia > Surgeons

36. “Structural Heart Disease Interventions
are to Cardiac Ultrasound
what
Percutaneous Coronary Interventions
were to X-Ray Coronary Angiography.”
John D. Carroll, MD
Transcatheter Cardiovascular Therapeutics 2009

37. Acknowledgements
All my colleagues at SVMI
Sean Madden, PhD! InfraReDx, Boston, MA
Geoff Vince, PhD! Volcano Corporation, San Diego, CA
Brian Courtney, MD ! Sunnybrook Health Science Center,Toronto, Canada
Chris Daft, PhD! Siemens Ultrasound, Mountain View, CA

38. Thank You
Kendall R. Waters, PhD
kendallw@svmii.com