Minimally Invasive Image Guided Therapy
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Minimally InvasiveImage-Guided Therapy:
Cardiovascular ApplicationsKendall R. Waters, PhD
Presented on Mar. 4, 2010Triple Ring Technologies, Newark, CA
MedTech Frontiers Serieswww.tripleringtech.com
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Original Image from iStockPhoto.com
Minimally Invasive Surgery without Image Guidance is Surgery Blindfolded
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Animation from iStockPhoto.com
72 BPM, 100,000 Day, 2.5 Billion LifetimeCVD: Affect over 86 Million Americans, Estimated direct and indirect costs for 2010 are $500 Billion
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A silhouette misses part of the picture
Pilobolus Video from YouTube.com
Pilobulus @ 2007 Oscars
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Angiograms are Silhouettes
Is the standard good enough?
Contrast Angiography: Shadows hide some details
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Poor Soft Tissue Contrast
Is the standard good enough?
X-Ray: Poor Tissue Contrast
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Unable to predict which plaques will
lead to clinical events
Coronary heart disease is the largest major killer
Image from Northwest Houston Heart Center (www.houstonheartcenter.com)
CHD: Largest killer, >17M pts$177B direct/indirect costs 2006Unable to predict which plaques lead to events
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Imaging inside the coronary arteries
Image from ShutterStock.com
Catheter-Based Imaging: Retrograde approach
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Courtesy of Sean Madden, PhD, InfraReDx
Catheter-Based Imaging: Retrograde approach
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Mechanically Rotating Catheter
Synthetic Aperture Array Catheter
Array Catheter: Ease of Use (No flushing required)Mechanically Rotating Catheters (US, OCT, NIRS): Image Quality
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Watch an artery get cloggedThe Poster Child of Vulnerable Plaques
Thin Fibrous Cap<65 µm
Lipid-Richor
NecroticCore~25%
Courtesy of Geoff Vince, PhD, Volcano Corp
Normal > Constrictive Remodeling > Core Development > Rupture > Occlusion > MIThin Cap Fibroatheroma: Thin Cap + Necrotic Core Content
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IVUS image ... or Hurricane MapIVUS image ...Is this a vulnerable plaque?
Zoomed View of a Diseased Vessel with Array CatheterModest Spatial Resolution > Poor Tissue DifferentiationSegmentation > Plaque Burden + Lumen Area > Advanced Analysis
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Do advanced algorithms help?
Necrotic Fibrotic
Lipidic Calcified
BSC iMAPVolcano VH-IVUSTM
Fibro-Fatty Calcification
Necrotic CoreFibrosis
VH-IVUS > Spectral Parameters > Statistical Classification > 4 Categories > ColorizediMAP > Spectral Signatures > Statistics Classification > 4 Categories > ColorizedPROSPECT Trial > Plaque Burden & Necrotic Core & Minimum Lumen Area
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Will emerging technologies find plaques that
lead to clinical events?
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OCT provides striking detail
Vulnerable ?
but has limited penetration
OCT > 15/30 um resolution > 1-2 mm penetration > Minimum Lumen AreaPlaque Characterization > Fibrous (Signal Rich Homogeneous) & Lipid (Signal Poor with Diffuse Borders)
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IVUS OCT
Fine Structural Detail
IVUS + OCT Combination
Courtesy of Dr. Brian Courtney MD and Brian Liang, Sunnybrook Health Sciences Centre, Toronto, CA
Penetration
Sunnybrook + Colibri > IVUS + OCT > Penetration + Lumen Detail
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Spectroscopy = Chemical Composition
Limited Spatial ResolutionCourtesy of Sean Madden, PhD, InfraReDx
Pullback Distance
Ang
le
NIRS > Spectroscopy = Chemical Composition > Lipid ContentLimited 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
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Chemical Composition + Structural Detail
NIRS + IVUS Chemogram
IVUS Long View
NIRS + IVUS Combination
Courtesy of Sean Madden, PhD, InfraReDx
InfraReDx > NIRS + IVUS > Composition + Structure
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Very Good Structural Detail
A Much Better (HD) IVUS
Better image quality. IVUS with near-optical resolution. Device simplicity.
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Some valves become leaky
1% to 5 % mortality rateImage from Consultants in Cardiology (www.cicmd.com)
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Can imaging help?
Soft Tissue Imaging
Image from the GE Healthcare Vivid Image Library
Soft Tissue StructureColor Flow > MVR Jets
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Can imaging help?
Precision Guidance
Image from Siemens Ultrasound
PFO Closuremm Length Scale
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Alignment of Delivery Catheter in LACan imaging help?
Real-Time 3D
Image from presentation by J. D. Carroll, MD at TCT 2009
Matrix Array Technology > RT3DCatheter > Transseptal > MV
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Can imaging help?
Reduced X-Ray Dose
Procedure Length > X-Rays (Pt & Operator)US > Non-Ionizing > Reduce X-Ray Need
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Image from ShutterStock.com
Imaging from inside the heart
Access > Right Side > IVC & SVC
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Image from Hao and Hongo, EPLab Digest 5(4) (2005). (www.eplabdigest.com)
AcuNav > Steerable > 8-10F > 5-10MHz
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Imaging from the esophagus
Access > Eso > Proximity
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Imaging from the esophagus
Images from Toronto General Hospital Department of Anesthesia and Pain Management
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HUDSON, ET AL.
Figure 1. Comparison of echocardiographic transducers. (A) ICEtransducer (AcuNav,TM Siemens, Mountain View, CA, USA). (B)Conventional two-dimensional multiplane TEE transducer. (C) 3Dmatrix array TEE (X7-2t, Philips, Andover, MA, USA) transducer.
Figure 6. 2D- and 3D-TEE guidance of percutaneous mitral valveballoon valvuloplasty. (A) 2D-TEE demonstrating a “hockey-stick”configuration of the anterior mitral valve leaflet (arrowhead) proto-typical of rheumatic mitral stenosis. (B) 3D volumetric reconstruc-tion of an en face view of the restricted mitral valve as viewed fromthe left atrium demonstrating a narrowed mitral orifice (arrow) andcommissural fusion (arrowheads). (C) 2D X-Plane view of the inter-atrial septum illustrating “septal tenting” (arrows) during transseptalpuncture. (D) Live 3D-TEE guidance of the Inoue balloon catheteracross the rheumatic mitral valve. (E) 3D-TEE view of Inoue ballooninflation across the rheumatic mitral valve. (F) 3D-TEE volumetricreconstruction demonstrating an enlarged mitral valve orifice (ar-row) and split commissure (arrowhead). LA = left atrium; LV = leftventricle; RA = right atrium; RV = right ventricle.
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Figure 4. Percutaneous ASD closure with an Amplatzer Septal Oc-cluder using 2D- and 3D-TEE guidance. (A) 2D-TEE suggesting asmall ASD (arrows). (B) Live 3D-TEE displaying an en face viewof the ASD (arrow) from the left atrium, revealing its oval shapewith a long-axis twice the short-axis dimension. (C) 3D volumetricreconstruction with color Doppler demonstrating left to right shunt-ing across the ASD (arrow). (D) Live 3D-TEE of an en face viewfollowing deployment of the left atrial disk of a 12 mm AmplatzerSeptal Occluder (arrowheads) with excellent visualization of thedelivery cable (arrow) through the ASD. (E) Live 3D-TEE demon-strating good positioning of ASD occluder following right atrialdisk (arrowheads) deployment. (F) 2D X-plane with color Dopplerdemonstrating final device positioning without evidence of residualshunting from two simultaneous planes of view. LA = left atrium;RA = right atrium; # = septum primum; ## = septum secundum.
540 Journal of Interventional Cardiology Vol. 21, No. 6, 2008
Image From Philips Healthcare (www.medical.philips.com) Image from Hudson et al., J Interv Cardiol 21(6) (2008).
Steerable > Matrix Array > Multi-plane
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A Leaky Mitral Valve
Image from Weill Cornell Medical College, Cardiothoracic Surgery (www.cornellheartsurgery.org)
Normal
Prolapse
Normal Leaflets > One-way FlowProlapse Leaflets > Leaky
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We can visualize soft tissue and blood flow
Image from Philips Healthcare iE33 Echocardiography System Image Library
Philips xPlane > Biplane TEEMVR > Mixing of Reds and Blues = Regurgitation
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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 ChordPhotograph > Ruptured Chord
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... and Roadmaps the Repair
Images from Ma et al., Chinese Med J 121(20) (2008).
Quantitative Analysis > 3D Visualization > Specific AreaRoadmap the Intervention
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Image Guidance Devices are Expensive
Philips X7-2t Probe > Engineering Marvel > many $10Ks > outside CV systemAcuNav > ~10 yrs old > $2500 disposable > Certified Resterilization
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A Cardiologist ... and a Cast of Thousands
Images from iStockPhoto.com and ShutterStock.com
Complexity > Echo > Anasthesia > Surgeons
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“Structural Heart Disease Interventions are to Cardiac Ultrasound
what
Percutaneous Coronary Interventions were to X-Ray Coronary Angiography.”
John D. Carroll, MDTranscatheter Cardiovascular Therapeutics 2009
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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