This document discusses the clinical use of optical frequency domain imaging (OFDI) at a cardiac center in Denmark. OFDI is used for final result checks after percutaneous coronary interventions, detecting the culprit lesion, assessing wire position, investigating stent failures, guiding stent sizing and positioning including in bifurcation lesions, and identifying peri-stent staining. The center has experience with over 850 OFDI cases. Future applications include curved catheters, co-registration of OFDI and angiography, and standardization of acquisition and reporting.

1. OCT in clinical practice
Niels R. Holm
Department of the Cardiology
Aarhus Universitetshospital, Skejby
Denmark

2. Disclosure Statement of Financial Interest
Grant/Research Support:
Honoraria/Speaker fees:
Advisory boards/Development
• Terumo, St. Jude Medical, Cordis, Medtronic, Tryton
• Terumo, St. Jude Medical, Acarix, Cook
• Terumo, St. Jude Medical, Medis
Within the past 12 months, I or my spouse/partner have had a financial
interest/arrangement or affiliation with the organization(s) listed below.
Affiliation/Financial Relationship
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk

3. Denmark
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

4. Aarhus University Hospital, Skejby
• Billede af auh
3500 employees now
10.000 employees in 2018
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

5. OFDI: Our center
• 2500 PCI /year
• 4500 CAG /year
• OCT since 2006
• OFDI since 2011
• +850 procedures
• Present clinical use ~100 /year
• Fluctuating study use
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

7. Terumo FastView Imaging Catheter
• 2.6F
• No catheter flush
• 150 mm pullback
• 40 mm/s
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

8. Terumo Lunawave
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

9. guidewire shadow
Technology
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

10. OFDI IVUS
Axial Resolution 15 – 20 µm 100 – 200 µm
Beam Width 20 – 40 mm 200 – 300 mm
Frame Rate 160 frames/s 30 frames/s
Pullback Speed Up to 40 mm/s 0.5 - 1 mm/s
Max. Scan Dia. 10 mm 15 mm
Tissue Penetration 1.0 - 2.0 mm 10 mm
Blood Clearing by flushing Required Not Required
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

11. OFDI: Clinical use
1. Final result check (under-expansion, malapposition)
2. Culprit detection
3. Wire position
4. Target failure (stent thrombosis)
5. Stent sizing and positioning
6. Step wise bifurcation guiding
7. Peri-stent staining (SES)
8. Angiographic ambiguity
Denmark Aarhus, Skejby Clinical OFDI PCI research OFDI research End
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk

12. OFDI: Clinical use
1. Final result check (under-expansion, malapposition)
2. Culprit detection
3. Wire position
4. Target failure (stent thrombosis)
5. Stent sizing and positioning
6. Step wise bifurcation guiding
7. Peri-stent staining (SES)
8. Angiographic ambiguity
Denmark Aarhus, Skejby Clinical OFDI PCI research OFDI research End
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk

13. Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk

14. Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk

15. OFDI: Clinical use
1. Final result check (under-expansion, malapposition)
2. Culprit detection
3. Wire position
4. Target failure (stent thrombosis)
5. Stent sizing and positioning
6. Step wise bifurcation guiding
7. Peri-stent staining (SES)
8. Angiographic ambiguity
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

16. Origin of embolus
• 34 yrs
• Male
• No prehistory of IHD
• No competing risks
• Now acute chest pain
• Admitted for primary PCI due to ST-elevation in
anterior leads.
– Near ST resolution at arrival
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

17. Origin of embolus
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

18. Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

19. Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

20. Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

21. Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

22. Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk

23. OFDI: Clinical use
1. Final result check (under-expansion, malapposition)
2. Culprit detection
3. Wire position
4. Target failure (stent thrombosis)
5. Stent sizing and positioning
6. Step wise bifurcation guiding
7. Peri-stent staining (SES)
8. Angiographic ambiguity
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

24. Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Submitted , Int. Journal

25. Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Submitted , Int. Journal
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

26. Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Submitted , Int. Journal
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

27. Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Submitted , Int. Journal
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

28. Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Submitted , Int. Journal
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

29. Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Submitted , Int. Journal
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

30. OFDI: Clinical use
1. Final result check (under-expansion, malapposition)
2. Culprit detection
3. Wire position
4. Target failure (stent thrombosis)
5. Stent sizing and positioning
6. Step wise bifurcation guiding
7. Peri-stent staining (SES)
8. Angiographic ambiguity
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

31. Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk

32. OFDI: Clinical use
1. Final result check (under-expansion, malapposition)
2. Culprit detection
3. Wire position
4. Target failure (stent thrombosis)
5. Stent sizing and positioning
6. Step wise bifurcation guiding
7. Peri-stent staining (SES)
8. Angiographic ambiguity
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

33. OFDI: Stent sizing and positioning
1. Guiding of predilatation: Cutting balloon, Rotablation
2. Cover the flow limiting part of lesion
3. Cover major dissections
4. Use most healthy looking vessel as references
5. Do not cover SBs if not necessary
6. Do not stent healthy vessel
7. Do not cut lipid plaques in the edges
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

34. OFDI: Clinical use
1. Final result check (under-expansion, malapposition)
2. Culprit detection
3. Wire position
4. Target failure (stent thrombosis)
5. Stent sizing and positioning
6. Step wise bifurcation guiding
7. Peri-stent staining (SES)
8. Angiographic ambiguity
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

35. OFDI: Bifurcation guiding
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

36. OFDI: Clinical use
1. Final result check (under-expansion, malapposition)
2. Culprit detection
3. Wire position
4. Target failure (stent thrombosis)
5. Stent sizing and positioning
6. Step wise bifurcation guiding
7. Peri-stent staining (SES)
8. Angiographic ambiguity
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

37. Coronary Edema
• Cypher hypersensitivity reaction
Holm NR, et al. Circulation Imaging 2013
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

38. Apposed struts Covered struts
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

39. Abolished malapposition
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

40. Aquired Malapposition
– trapped plaque / thrombus
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

41. Apposed struts Evaginations
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

42. OFDI: Clinical use
1. Final result check (under-expansion, malapposition)
2. Culprit detection
3. Wire position
4. Target failure (stent thrombosis)
5. Stent sizing and positioning
6. Step wise bifurcation guiding
7. Peri-stent staining (SES)
8. Angiographic ambiguity
When your angiogram do not provide the answer
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

43. Acquisition technique
• Co-axial guide catheter
– no side holes
• Manual flush or injector (recommended)
– 14 mL, 4 mL/s, 3 - 400 psi
– 100% Visipaque
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

44. Acquisition technique, improve
• Co-axial guide catheter
- Deeper intubation (be careful)
- EBU catheter
- Child catheter
- Increase flow, psi
- Contrast issues
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

45. The Future
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

46. Bended OCT
Tu S, Holm NR, et al. JACC Interventions 2012
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

47. Fusion of angio and OCT
(screen shot of software with landing zones)
Prototype software package (Medis, Leiden, The Netherlands)1
1. Fusion of 3D QCA and IVUS/OCT; Tu et al; International Journal of Cardiovascular Imaging, 2011.
Landing zone
Co-registration of OCT and angiography
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

48. OFDI
The International Working Group on
Standardization and Validation of Intra Vascular
Optical Coherence Tomography (IWG-IVOCT):
Tearney GJ et al. JACC 2012:
“Consensus Standards for Acquisition,
Measurement, and Reporting of Intravascular
Optical Coherence Tomography Studies”
Niels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk
Denmark Aarhus, Skejby Terumo OFDI Clinical OFDI Future OFDI End

49. Thank you very much
niels.holm@ki.au.dkNiels Ramsing Holm, Aarhus University Hospital, Skejby, Denmark. niels.holm@ki.au.dk