-
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]
*
-
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]
*
-
Michelson [email protected]
*
-
*[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.)
[email protected]
*
-
Nowadays and future equipment
Low-coherence Superluminescent diode:800 1300 nm center
waveength and severl milliwatts power.
[email protected]
*
-
*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]
*
-
*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
*
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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]
*
-
*Turning ON the System Power SwitchesPowerup / Wake-up buttonon
upper right of keyboard
.Main Switch next to power cableTech. Procedure
[email protected]
*
-
*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.
Procedure [email protected]
*
-
*Catheter PreparationRemove the hoop carefully from the
catheter
Procedure [email protected]
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]
*
-
*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.
Procedure [email protected]
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
Procedure [email protected]
*
-
*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
Procedure [email protected]
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
Procedure [email protected]
*
-
*Performing a case
Procedure [email protected]
*
-
*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.
*
-
*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.*
-
*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]
*
-
*Performing Measurements
Procedure [email protected]
*
-
*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]
-
*Procedure [email protected]
-
*Ending ProcedurePress Unload to disconnect catheter
Procedure [email protected]
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
*
*
*
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.*