Optical Coherence Tomography dr md toufiqur rahman cardiologist

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
drtoufiq19711@yahoo.com
Optical Coherence Tomography

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

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.

Michelson interferometer

fundamental OCT Schematic
SLD
Sample
Reference
Demodulator AD
Computer
Detector
PZT

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

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.

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

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

Physician’s
Monitor
DOC
Removable Tray
Connector
Panel
Service Access
Panel
Wheel Locks Main Power
Cord Connector
Main Power Switch
Physician’s Side
11
ILUMIEN™ – Console Overview
Operator’s
Monitor
Keyboard
CD/DVD Drive
Fan Filter
Hibernate/
wake-up
button
Mouse
Chart
Holder
Operator’s Side

12
DRAGON-FLY DUO CATHETER
• Fiber optic
• Three radioparque marker
• Compatible with G.C 6 or 7
Fr without holes
• G.W 0.14”

OCT in Nontransparent Tissue
A epiglottis
B arterial layers
C atherosclerotic plaques

OCT application
A Reduce High False-Negative
Rates
B Reduce Biopsy Hazardous
Applied in guiding microsurgical
procedure
Esophagus & epithelium & early cancer
Vulnerable plaque
Prostate

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

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.

17
Application of OCT in Cardiology
Pre-
PCI
PCI
POS-
PCI

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

19
Turning ON the System – Power Switches
Powerup / Wake-up button
on upper right of keyboard
.
Main Switch
next to power cable
Tech.
Procedure

20
Entering patient data
Tech.
 Press Add new patient data.
 Put all the information's concerning the
patient.
 Press New OCT Recording.
Procedure

21
Catheter Preparation
• Purge with contrast until 3-5 drops exit distal tip.
Procedure

22
• Remove the hoop carefully from the catheter
Procedure

23
Connect Catheter Procedure

24
Connecting Catheter to DOC
Counter clockwise
clockwise
Procedure

 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

26
Preparations
• Watch the five yellow LEDs light up on the DOC
Procedure

27
Preparations Procedure

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

Stop
Button
Unload
Button
Laser Emission
Symbol
Advance
Button
Pullback
Button
Pullback
Position LEDs
Load
LED
Drive Motor Optical Controller (DOC) – Overview
29
Procedure

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

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

32
Performing a case Procedure

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

34
Reviewing an Acquired Image Procedure

35
Adjusting Calibration Procedure

36
Adjusting Calibration Procedure

37
Bookmarks Procedure

38
Performing MeasurementsProcedure

39
Entering Notes Procedure

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

41
Procedure

42
Ending Procedure
• Press “Unload” to disconnect catheter
Procedure

• 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

Rapture Plaque
44

Thrombus
45
White Thrombus Red Thrombus

Stent Malaposition
46

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

• 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

A very strong correlation between
histology and OCT measurements
Lipid-rich plaque
Fibrous plaque
Thin cap fibroatheroma

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

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

New finding with OCT in the recent
clinical studies are changing our views

Novel neointimal formation over sirolimus-
eluting stents identiﬁed by coronary angioscopy
and
optical coherence tomography
Daisuke Murakami (MD)a
, Masamichi Takano (MD)b,∗
,
Masanori Yamamoto (MD)a
, Shigenobu Inami (MD)a
,
Takayoshi Ohba (MD)a
, Yoshihiko Seino (MD, FJCC)a
,
Kyoichi Mizuno (MD, FJCC)b
Murakami, et al. Journal of Cardiology
2009, 53:311—313

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

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

• 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

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

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

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

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

Primary end point
% uncovered struts on per patient basis

Secondary end point
mas length of uncovered and incompletely apposed
segments (mm) in OCT

Secondary end point
strut level NIH and net volume obstruction in OCT
Guagliumi, et al. TCT 2009drtoufiq19711@yahoo.com

OCT image to ACS : 9-year after BMS
implantation
OCT pullback from
mid-proximal LCX
TFCA overlying a
large lipid-rich plaque

Optical Coherence Tomography dr md toufiqur rahman cardiologist

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