Optical Coherence Tomography dr md toufiqur rahman cardiologist

Dr. Md.Toufiqur Rahman MBBS, FCPS, MD, FACC, FESC, FRCP, FSCAI, FCCP,FAPSC, FAPSIC, FAHAAssociate Professor of CardiologyNational Institute of Cardiovascular DiseasesSher-e-Bangla Nagar, Dhaka-1207Consultant, Medinova, Malbagh branch.Honorary Consultant, Apollo Hospitals, Dhaka and Life Care Centre, [email protected] Coherence Tomography

Introduction of OCT James G. Fujimoto, 1991What is OCT:

diagnostic medical imaging techonology Why OCT: better diagnose and treat diseaseMain application areas:

heart disease and [email protected]

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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.

[email protected]

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Michelson [email protected]

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*[email protected]

What is oct

Optical Coherence tomography (OCT) is a light based imaging modality with superior spatial resolution (~ 15Um) compared to other intravascular imaging system. This technology does not use x-ray The acquisition of this image is fast and easy to treat In other hand other type of coronary imaging is difficult to interpret and doesn't have the high resolution

So the high resolution of oct makes it an excellent tool to visualize the vasculature Who that *

fundamental OCT Schematic

SLD

SampleReferenceDemodulatorADComputerDetectorPZTdrtoufiq19711@yahoo.com

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Advantages of OCTBroad dynamic range High resolutionRapid 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.)

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Nowadays and future equipment

Low-coherence Superluminescent diode:800 1300 nm center waveength and severl milliwatts power.

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*Development of [email protected]

200420072009HH20112012M2 SystemM3 SystemC7XR SystemILUMIEN SystemILUMIEN OPTISFirst Commercial OCT System15 fps / 200 linesOcclusion + flush2nd Generation 20 fps / 240 linesOcclusion + flushEurope and US only100 fps / 500 linesOcclusion-freeCommercially available 2011100 fps / 54 mm pullbackCombined FFR and OCTWireless FFRJapan launch 2012180 fps/75 and 54 mm pullbackAdvanced software tools for PCI OptimizationTableside control from DOC

Occlusion balloon + ImageWireTMOcclusion-free FlushFFR and OCT System2nd Gen FFR and OCT System

We have long history of OCT, competition is new to the field*

*OCT Technology from St. Jude MedicalConsoleRapid exchange (Rx) imaging catheterContrast flush; balloon occlusion not requiredFast image acquisition: 7.5cm pullback in 2.5 sec

[email protected]

In order to perform OCT procedures, St. Jude Medical provides a console (C7-XR) and an imaging catheter (Dragonfly).

With the current C7-XR technology, no balloon occlusion is required; rather, the vessel is cleared of blood for imaging by a rapid flush of contrast. The images themselves are acquired extremely quickly: acquiring a 5 cm pullback image takes only 2.5 seconds.*

Physicians MonitorDOCRemovable TrayConnector PanelService Access PanelWheel LocksMain Power Cord ConnectorMain Power SwitchPhysicians Side*ILUMIEN Console [email protected]

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*DRAGON-FLY DUO CATHETER Fiber opticThree radioparque marker Compatible with G.C 6 or 7 Fr without holes G.W 0.14

[email protected]

Long pullback : 75mm ; old one : 55mm

3 markeres : lens marke visible during the pullback ; distal and proximal to guide the phyisican on the best position

The old : only 2 markres : distal and proximal markers ; to help the physician more and more to know where is the good position *

OCT in Nontransparent TissueA epiglottisB arterial layers C atherosclerotic [email protected]

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OCT application A Reduce High False-Negative Rates B Reduce Biopsy Hazardous Applied in guiding microsurgical procedureEsophagus & epithelium & early cancerVulnerable plaqueProstate

[email protected]

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Limitation Penetration: 2-3mm Ideal: 4mmResolution :

catheter/endoscope based image: 10m, noncatheter: 4 m, 1. femtosecond laser is expensive (1 m) 2. transverse resolution needs to be similar to axial resolution, below 10 m need short confocal parameter which results in the focus falling off rapidly.Acquisition rate:

Extention and application of OCT [email protected]

NameWork ResearchApplicationDr. Zhongping ChenUniversity of California, IrvineDoppler OCTstudying blood vessel function and fluid flow, generally in small structures.

Dr. Johannes de BoerMassachusetts General Hospital (MGH)polarization-sensitive OCTdiagnosing burns and guiding appropriate treatmentDr. Brett Bouma and Dr. Guillermo Tierney MGHvery portable, high-performance OCT systems for clinical diagnostic studiesmajor clinical investigations are ongoing in the fields of gastroenterology, dermatology, cardiology, urology, orthopedics, gynecology, and otolaryngology.

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*Application of OCT in [email protected]

The ilumien system incorporat the most advanced oct techology to optmize PCI and visulazie the vessel anatomy How that By *

*Prior to Starting a CaseRequired MaterialsDragonfly 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 [email protected]

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*Turning ON the System Power SwitchesPowerup / Wake-up buttonon upper right of keyboard

.Main Switch next to power cableTech. Procedure [email protected]

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*Entering patient dataTech. Press Add new patient data.

Put all the information's concerning the patient.

Press New OCT Recording.

Procedure [email protected]

Choose existing patient or add new patient, and then choose New OCT Recording. *

*Catheter PreparationPurge with contrast until 3-5 drops exit distal tip.


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*Catheter PreparationRemove the hoop carefully from the catheter


Remove the hoop carefully from the catheter. To avoid damage, grasp the proximal end of the catheter at the side port and hold firmly with your thumb and forefinger.With the other hand, gently twist and pull the hoop to release the catheter. Do not twist and pull the catheter.

While withdrawing it from the hoop, gently wipe the catheter shaft with a compress moistened with heparinized saline. This activates the hydrophilic coating and prevents the catheter from spinning dry, causing possible fiber breaks.

Handle carefully to prevent kinking the catheter.*

*Connect CatheterProcedure [email protected]

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*Connecting Catheter to DOCCounter clockwise clockwise Procedure [email protected]

Once the catheter has been purged, it can be connected to the DOC.

Remove the blue protective cap from the catheter hub by twisting the cap counterclockwise. Open the black connector cover on the front of the DOC.

Align the four catheter hub sprockets inside the DOC connection port; turn clockwise until secure.

Care should be taken not to touch the fiber optic core of the catheter and not to kink or bend the catheter.

Catheter Preparation 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.


Insert the DOC into the sterile bag and place it on the table.

NOTE: This step requires two people, one sterile and one nonsterile.*

*PreparationsWatch the five yellow LEDs light up on the DOC


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*PreparationsProcedure [email protected]

The screen will show the status of the connecting catheter, and the LED on the DOC will light up (see next slide).*

*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


When the catheter is fully connected, this will be indicated on the screen.*

Stop ButtonUnload ButtonLaser Emission SymbolAdvance ButtonPullback ButtonPullback Position LEDsLoad LED

Drive Motor Optical Controller (DOC) Overview

*Procedure [email protected]

This is the DOC, which stands for Drive Motor and Optical Controller.

The controls and indicators are: Load LED Operator can attach or remove catheter when fully lit (not blinking) Unload Press to unload imaging catheter Laser Emission Symbol Illuminated when laser output is switched on Stop Stops the imaging catheter motion and turns off laser output Advance Starts or stops the optical fiber advance sequence Pullback Starts or stops the optical fiber pullback sequence Pullback Position LEDs Relative position of the optical carriage along the pullback range

Once the DOC has been placed in a sterile pouch, it is ready for use together with a sterile Dragonfly imaging catheter.*

*Pullback Preparation Purge the CatheterIf blood enters the catheter lumen, purge with the attached 3 cc contrast syringe.

Blood in catheter lumenPurged catheter lumenProcedure [email protected]

*Preparation of InjectionRecommended 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


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*Performing a case


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*Pullback Preparation Puff into the VesselDuring live scan, puff with the contrast injector to determine guiding catheter position for optimal image clarity.

Suboptimal clearance, blood swirlsOptimal clearanceProcedure [email protected]

*Reviewing an Acquired ImageProcedure [email protected]

Once an image has been acquired, use the toolbar below the image to:

Play, pause, stop, move by frame or move by 1 mm segments Add or delete bookmarks Jump from bookmark to bookmark Export images and bookmark frames of interest

The system will automatically play back at a default speed of 1 mm/sec.The optical fiber automatically advances to the original distal position.

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*Adjusting CalibrationProcedure [email protected]

Once acquisition of a segment is complete, you still have the possibility to adjust calibration. Calibration may be adjusted either to a chosen frame and proximal or to the entire recorded segment.*

*BookmarksProcedure [email protected]

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*Performing Measurements


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*Entering NotesProcedure [email protected]

Click the T icon to add a note to that frame.*

*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 [email protected]

*Ending ProcedurePress Unload to disconnect catheter


When the imaging session is finished, the unload button must be pressed on the DOC to release the catheter. If the Unload button is not pressed before attempting to remove the catheter, part of the catheter will remain locked into the DOC, which can damage the DOC.*

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 [email protected]

Rapture Plaque*[email protected]

Thrombus*White ThrombusRed [email protected]

Stent Malaposition*[email protected]

Progress in coronary imageCoronary angiography CAGIntravascular ultrasound IVUSOptical coherence tomography OCT

IVUS-guided implantation of stent has been showed to improve the outcomes with reduction of restenosis and thrombosisWhat is the role of [email protected]

The most prominent feature of OCT is its high resolution of 10m. It enables real-time, full tomographic, in-vivo of vessel visualization mainly used in the following microstructure:

1. Fibrous cap and evaluate vulnerable plaque2. Strut apposition and stent tissue [email protected]

A very strong correlation between histology and OCT measurementsThin cap fibroatheroma

[email protected]

Classication of strut apposition by OCTTotally embedded strutEmbedded subintimally without disruption of lumen contourCompletely embedded with disruption of lumen contour Partially embedded with extension of strut into lumenComplete strut malapposition (blood able to exist between strut and lumen wall)Type IType IIType IIIaType IIIbType IVGiulio. CCI, 2008, 72:237247 [email protected]@yahoo.com

Different vesselresponses observed in multiple frames Well apposed struts with uniform neointimal coverageWell apposed struts with not-uniform vessel response around some strut. Although fully covered, struts located from 9 to 12 oclock present a signal attenuation of the tissue around them Deeper increase toward the media of the area of signal attenuation inthe proximal cross sectionGiulio. CCI, 2008, 72:237247 [email protected]

New finding with OCT in the recent clinical studies are changing our [email protected]

Novel neointimal formation over sirolimus-eluting stents identied by coronary angioscopy andoptical 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)bMurakami, et al. Journal of Cardiology 2009, 53:[email protected]

Typical findings of angioscopy, and OCT after BMS implantationSix-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 attenuation3.5mm13mmMale, A 43-year-old with SAPBMS in LADJournal of Cardiology , 2009, 53:[email protected]

Novel ndings of angioscopy and OCT after SESs implantationSix-month follow-up angiogram shows no in-stent restenosis 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 LADJournal of Cardiology , 2009, 53:[email protected]

OCT signal patterns of the neointima showed rapid attenuation similar to lipid tissues in atherosclerotic lesionsneointima within the SES is quite different from that of the BMS and may contain atherosclerotic components

Murakami, et al. Journal of Cardiology 2009, 53:[email protected]

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

ODESSA: 6-month OCTlong lesions randomized to multiple SES, PES, ZES and BMS6968 cross-sections53047 struts

malapposed

uncoveredBMSSESPESZESGuagliumi, et al. TCT 2008

[email protected]

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 coveredDistribution of Endeavor Struts ConditionZES= 44 24,076 stent strutsGuagliumi et al. ESC [email protected]

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 OCTOCTAMIGuagliumi, et al. TCT [email protected]

Primary end point% uncovered struts on per patient basisGuagliumi, et al. TCT [email protected]

Secondary end pointmas length of uncovered and incompletely apposed segments (mm) in OCTGuagliumi, et al. TCT [email protected]

Secondary end pointstrut level NIH and net volume obstruction in OCTGuagliumi, et al. TCT [email protected]

OCT image to ACS : 9-year after BMS implantationOCT pullback from mid-proximal LCXTFCA overlying a large lipid-rich [email protected]

Thank you All

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What is oct

Optical Coherence tomography (OCT) is a light based imaging modality with superior spatial resolution (~ 15Um) compared to other intravascular imaging system. This technology does not use x-ray The acquisition of this image is fast and easy to treat In other hand other type of coronary imaging is difficult to interpret and doesn't have the high resolution

So the high resolution of oct makes it an excellent tool to visualize the vasculature Who that **

*

*

We have long history of OCT, competition is new to the field*In order to perform OCT procedures, St. Jude Medical provides a console (C7-XR) and an imaging catheter (Dragonfly).

With the current C7-XR technology, no balloon occlusion is required; rather, the vessel is cleared of blood for imaging by a rapid flush of contrast. The images themselves are acquired extremely quickly: acquiring a 5 cm pullback image takes only 2.5 seconds.*

*Long pullback : 75mm ; old one : 55mm

3 markeres : lens marke visible during the pullback ; distal and proximal to guide the phyisican on the best position

The old : only 2 markres : distal and proximal markers ; to help the physician more and more to know where is the good position **

*

*

*

The ilumien system incorporat the most advanced oct techology to optmize PCI and visulazie the vessel anatomy How that By *

*

*Choose existing patient or add new patient, and then choose New OCT Recording. *

*Remove the hoop carefully from the catheter. To avoid damage, grasp the proximal end of the catheter at the side port and hold firmly with your thumb and forefinger.With the other hand, gently twist and pull the hoop to release the catheter. Do not twist and pull the catheter.

While withdrawing it from the hoop, gently wipe the catheter shaft with a compress moistened with heparinized saline. This activates the hydrophilic coating and prevents the catheter from spinning dry, causing possible fiber breaks.

Handle carefully to prevent kinking the catheter.*

*Once the catheter has been purged, it can be connected to the DOC.

Remove the blue protective cap from the catheter hub by twisting the cap counterclockwise. Open the black connector cover on the front of the DOC.

Align the four catheter hub sprockets inside the DOC connection port; turn clockwise until secure.

Care should be taken not to touch the fiber optic core of the catheter and not to kink or bend the catheter. Insert the DOC into the sterile bag and place it on the table.

NOTE: This step requires two people, one sterile and one nonsterile.*

*The screen will show the status of the connecting catheter, and the LED on the DOC will light up (see next slide).*When the catheter is fully connected, this will be indicated on the screen.*This is the DOC, which stands for Drive Motor and Optical Controller.

The controls and indicators are: Load LED Operator can attach or remove catheter when fully lit (not blinking) Unload Press to unload imaging catheter Laser Emission Symbol Illuminated when laser output is switched on Stop Stops the imaging catheter motion and turns off laser output Advance Starts or stops the optical fiber advance sequence Pullback Starts or stops the optical fiber pullback sequence Pullback Position LEDs Relative position of the optical carriage along the pullback range

Once the DOC has been placed in a sterile pouch, it is ready for use together with a sterile Dragonfly imaging catheter.*

*

*

Once an image has been acquired, use the toolbar below the image to:

Play, pause, stop, move by frame or move by 1 mm segments Add or delete bookmarks Jump from bookmark to bookmark Export images and bookmark frames of interest

The system will automatically play back at a default speed of 1 mm/sec.The optical fiber automatically advances to the original distal position.

*Once acquisition of a segment is complete, you still have the possibility to adjust calibration. Calibration may be adjusted either to a chosen frame and proximal or to the entire recorded segment.*Once acquisition of a segment is complete, you still have the possibility to adjust calibration. Calibration may be adjusted either to a chosen frame and proximal or to the entire recorded segment.*

*

*Click the T icon to add a note to that frame.*When the imaging session is finished, the unload button must be pressed on the DOC to release the catheter. If the Unload button is not pressed before attempting to remove the catheter, part of the catheter will remain locked into the DOC, which can damage the DOC.*

Optical Coherence Tomography dr md toufiqur rahman cardiologist

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Transcript of Optical Coherence Tomography dr md toufiqur rahman cardiologist