New OCT Slides for revascularisation and decision making

Optical coherence tomography
Vs intravascular ultrasound

1. OCT Optical Coherence Tomography Advanced Imaging to guide complex interventions

2. Basics of OCT OCT System overview OCT Catheter OCT Procedure OCT Image Interpretation Clinical Trials Case Based Discussion on Demo OCT Laptop What is in store for the day…

3. OCT BASICS

4. Time for High resolution imaging

5. What is OCT? Optical Coherence Tomography (OCT) is an optical imaging modality that uses near-infrared light to create high-resolution images of tissue microstructure. Optical  of or relating to light (visual) Coherence  a measure of the correlation between phases of a wave or waves Tomography  method of producing images from a series of single planes or slices (Greek “TOMOS=Slice”) 5

6. What Is Intravascular OCT? OCT is an optical imaging modality that uses near-infrared light (1250-1350nm) for high-resolution imaging of vessel anatomy, tissue microstructure and stents. Key Features: Uses light, not sound Does not use X-ray Image acquisition is fast Images acquired are sharp, detailed and easy to interpret 6

7. Intravascular OCT Flexible fiber-optic catheter used for light delivery Fiber rotates to create image frames Fiber pulls back to map vessel segment The more frames per mm, or high frame density, the higher the resolution 7

8. Michelson Interferometer 1881 Albert Michelson (1852-1931) Nobel Prize Physics 1907

9. Time Domain OCT (TD-OCT): (older generation) Non-Commercially available for cardiovascular use 2001 to the present Moderate image quality slower imaging speeds (full pullback 30s) and made it necessary to totally block the blood flow in the vessel using an occlusion balloon Frequency Domain OCT (FD-OCT): Commercially available for cardiovascular use 2010 to the present Exceptional image quality Fast imaging (full pullback 3s) : 10 to 100x increase in speed Rapid contrast flush instead of balloon occlusion Time vs. Frequency Domain Intravascular OCT C7-XR system: FD-OCT 100 fps, 20 mm/s pullback M3 system: TD-OCT 20 fps, 1 mm/s pullback Gonzalo, N . Optical Coherence Tomography for the Assessment of Coronary Atherosclerosis and Vessel Response after Stent Implantation . Rotterdam, the Netherlands: Optima Grafische Communicatie; 2010. improved image quality

10. Light is too fast for direct echo measurement  interferometry Compares path length between known reference arm and sample arm Mechanical reference arm motion limits imaging speed Time Domain OCT (M2/M2x/M3) intensity axial distance Demod Amp Broadband Source D Tissue Mirror Reflections (moving)

11. Time Domain OCT: fixed laser signal, moving mirror

12. Measurement of interference pattern spectrum + Fourier transform Signal generated from all depths simultaneously Faster image acquisition without loss of quality greater penetration depth Frequency Domain OCT (C7-XR TM and ILUMIEN TM ) Swept Laser D λ intensity intensity distance FFT Amp

13. Frequency Domain OCT: sweeping laser signal, fixed mirror

14. OCT IMAGE ACQUISITION

15. OCT CATHETER MOVEMENT – REAL TIME

16. Pullback Generation One pullback  270 – 540 frames 16

17. Image Display 17 “L-Mode” longitudinal view “B-Mode” cross-sectional view

18. Intravascular OCT Rotate a sensor & Pullback distal proximal Catheter with fiber-optic core used for light delivery Fiber rotates to create image frames Fiber-optic core pulls back to map vessel segment During the pullback, blood clearing is required to get a good image quality. Sensor Lens Optic fiber OCT catheter Better image quality by: Faster rotation Slower pullback

19. Principle of catheter based intravascular imaging 1 st line A-Line distal proximal Sensor

20. A-Line acquisition 2 nd line 3rd 4th 5th 1st 2nd 3rd 1 2 3 4 5 6 7 ………………………………………………………………………………………………..…n depth

21. R-Theta Conversion (Frame) 1 2 3 4 5 6 7 ……………………………………………………………………………………………..…n 1,2,3 4,5,6 One frame  560 axial lines Computer make lines to circle

22. A pulse of light is sent out that bounces off the different layers of tissue and returns back to be analyzed by the system. The catheter can be seen in the middle of the image, with the optical fiber at its core. Measure echo time delay of reflected light waves Ilumien each frames = 504 A lines Optis and optis integrated each frame = 560 A limes Image (Frame)

23. Difference of resolution . Direction of beam High resolution Low resolution Unable to distinguish. Distinguishable each component

24. Axial direction Lateral direction 2 types of Resolution(Axial/Lateral) Axial: parallel to the beam = along the vessel Lateral: perpendicular to both the beam and the catheter = cross-section of vessel ※JACC vol.37, No.5, 2001 1478-92(IVUS consensus report) The ability of an imaging system to resolve detail in the object that is being imaged

25. IVUS/OCT: smaller beam size & larger number of A-Lines To get better resolution (Lateral Resolution) Lateral resolution is around With OCT 20 to 40 µ m

26. Resolution 400 pix 600 pix 200 pix 130 pix

27. Resolution 400 pix 600 pix 200 pix 130 pix

28. OCT SYSTEM OVERVIEW

29. OCT Evolution 29 1999-2001 PTCA balloon + ImageWire TM R&D prototypes Not commercially available Inside PTCA balloon ‘Snapshot’ flush imaging 2007 M3 System CE mark 20 fps / 240 lines Occlusion + flush 2004 Soft occlusion balloon + ImageWire TM M2 System CE mark 15 fps / 200 lines Occlusion + flush 2009 C7 XR ™ System CE mark, FDA cleared 100 fps / 500 lines NO occlusion Occlusion-free Dragonfly TM

30. 30 2011-12 2013-15 2016 ILUMIEN ™ System ILUMIEN ™ OPTIS™ System OPTIS™ Integrated System OPTIS™ Mobile System Commercially available 2011 100 fps / 54 mm pullback Combined FFR and OCT Wireless FFR 180 fps/75 and 54 mm pullback Advanced software tools Real time 3D reconstruction Pullback initialization from DOC Integrated in the Cath lab Angio Co-Registration With tableside FFR/ OCT controller Integrates with Multiple Cath labs Angio Co-Registration With tableside FFR/ OCT controller FFR and OCT System 2 nd Gen FFR and OCT System Cath lab integrated FFR and OCT system Latest system with 3D OCT, FFR, ACR & MSO 2015 Current Generation PCI Optimization Systems

31. 31 2016/17 OCT product launches OPTIS™ Mobile System OPTIS™ Mobile Upgrade Kit (Ilumien™ OPTIS™ Systems only ) OPTIS™ Metallic Stent Optimization Software-MSO (Software Version E.4) OPTIS™ Mobile Workstation (Accessory for OPTIS™ Integrated System) Mobile System integrated into Cath lab during procedure to offer angio co-registration Angio Co-registration Wireless Tableside Controller Mobile cart connect into Cath Lab during procedure Enables the use in multiple labs Will include E.4 after LMR Enables angio co-registration function on Ilumien™ OPTIS System Angio Co-registration (ACR) Wireless Tableside Controller Mobile cart connect into Cath Lab during procedure Enables the use of OCT-ACR and FFR in multiple labs Leverage options to include E.4 New clinically relevant software enhancements for pre and post PCI Stent roadmap on angio co-registration New default view with automated measurements from lumen profile Acute Stent detection and apposition assessment Expanded 3D imaging Standard available for bug fixes only Offered as another point of control to operate the OPTIS Integrated system Optional control point for non-sterile personnel to perform all input/viewing functions available on OPTIS Integrated System Note: All systems having MSO must be updated to E.4.1 version by Service team.

32. OPTICAL COHERENCE TOMOGRAPHY - SYSTEM OVERVIEW

33. DOC (Drive Motor & Optical Controller) CPU (Central Processing Unit) ENGINE (Infrared Light Source) Physician and Operator Monitors Monitors

34. DOC ( Drive Motor and Optical Controller ) 1 Emergency shutoff – stops rotation, pullback and scanning 2 Enable scanning; second push will start pullback in manual trigger mode 3 Toggle between Live and Standby 4 Unload catheter 1 2 3 4

35. Dragonfly TM Duo / Dragonfly TM Optis OCT Catheter OCT ILUMIEN / ILUMIEN Optis ™ / Optis ™ range – both oct & ffr PressureWire TM Aeris TM PressureWire TM X ILUMIEN™ Console Ilumien Optis Console Wireless FFR

36. Comparison to ILUMIEN Engine ILUMIEN ILUMIEN OPTIS/ OPTISi & Mobile Parameter Nominal Settings Long Pullback High-resolution Pullback Engine speed 100 frames/sec 180 frames/sec 180 frames/sec Pullback speed 20 mm/sec 36 mm/sec 18 mm/sec Frame density 5 frames/mm 5 frames/mm 10 frames/mm Pullback length 54 mm 75 mm 54 mm Pullback time 2.7 sec 2.1 sec 3.0 sec Contrast (Max) 14 ml at 4 ml/sec 10 ml at 4 ml/sec 14 ml at 4 ml/sec File size 271 frames 270 MB 375 frames 375 MB 540 frames 540 MB Key Features of Abbott - OCT More Information Same Time Same Contrast

37. Ilumien Optis & MSO Software Reviewing an acquired Image Entering note Bookmark Calibration Performing the Measurements Lumen Profile MLA /AS% / DS% Mean Diameter Dynamic stent planning Automated Measurements Stent Roadmap Apposition Indicator 3D Bifurcation Mode Side-branch detection Carina view Expanded 3D Navigation 3D flythrough view Object segmentation 37 OPTIS™ Stent Optimization Software broadens the clinical utility for OCT to guide daily decision making for complex PCI both pre and post stenting though:

38. Clinical applications of oct 38

39. OCT CATHETER OCT Dragonfly Range Of Catheters

40. 40

41. Usable length: 135 cm Outer diameter: 2.7 F (distal) Wire lumen: 0.014” Hydrophilic Coating Dragonfly™ DUO Imaging Catheter Specifications Lens

42. INTRODUCING LATEST OCT CATHETER Dragonfly TM OPTIS TM Simplifies the OCT procedure TIP MARKER DUAL LUMEN for GUIDEWIRE EXIT Easier loading ; reduce potential for lens damage and kinking Lens Marker Facilitates Angio Co-Registration ©2018 Abbott. All Rights Reserved. IN CP0007-EN 02/18

43. Dragonfly Duo Dragonfly OPTIS Dragonfly™ OPTIS™ changes vs. Dragonfly™ Duo Catheters Dual lumen Smoother transition zone Shorter rail Dedicated purge exit Tip Design Dragonfly™ OPTIS catheter

44. Duo vs optis Lens DUO OPTIS

45. Catheter design changes: Rapid exchange tip Improves catheter performance Reduces risk of damage and kinking Support for continuous calibration* Reduces steps necessary during calibration Shaft guide marker at 90 cm Aids in understanding distal tip position during radial procedures Gray hub Differentiates Dragonfly OPTIS catheter from previous Dragonfly catheters Dragonfly™ OPTIS™ Imaging Catheter *Refer to D.2 or E.2 Software Note: The Dragonfly OPTIS imaging catheter is designed for use with the ILUMIEN OPTIS PCI Optimization and OPTIS integrated systems equipment. It should not be used with older model OCT systems. ILUMIEN™, ILUMIEN™ OPTIS™ PCI Optimization and OPTIS™ integrated systems software Dragonfly™ OPTIS™ imaging catheter

46. OCT PROCEDURE Performing an OCT Procedure

47. OCT Procedure CONFIDENTIAL – FOR INTERNAL USE ONLY P reparation Console / Catheter / Contrast P osition Catheter P urge P uff P ullback Troubleshooting The 4 P’s

48. Performing an OCT exam - REQUIREMENTS Required Material and Equipment • ILUMIEN™ or Optis System • Dragonfly™ or Dragonfly Duo Imaging Catheter • Sterile DOC Cover • 3 ml purge syringe • Contrast media indicated for coronary use, for purging and flush (allow 15 mL for each run planned) • 0.014 inch guidewire (with torque device if desired) • Guide catheter (6 French, 0.068 inch ID or larger, with no side holes) • Sheath introducer (to match guide catheter) • Hemostatic Y-Adapter/Connector • Heparinized , physiologic saline solution, for hydrophilic catheter preparation • Power injector pump for coronary angiography (capable of injecting 4.0 ml/sec for a total of 14 ml in 3.5 second) CONFIDENTIAL – FOR INTERNAL USE ONLY

49. Large Lumens increase device compatibility and allow more dye flow for better visualization FFR is strongly recommended in 6F OCT dragonfly is compatible with 6F large Lumen ID > 0.068” Guide catheter Inner lumen Mach 1 Boston Runway BSC Vista Brite Cordis Sherpa Active / Balanced MDT Launcher MDT Heartrail Climber Terumo 5F .058” .058” .058” .059” 6F .070” .070" .067” .070” .070” .071” .071” 7F .081” .078” .081” .081” .081” 8F .091” .088” .090” .090”

50. Allows for antegrade flow through the holes and out through the distal tip. Drawbacks: Decrease arterial visualization. Increase use of contrast Media Systemic drug delivery NB: GUIDE CATHETER WITH SIDE HOLES SHOULD NOT BE USED WITH FFR and OCT Side Holes in Guides

51. OCT procedure – Required materials 51 DOC – Bedside control to initiate pullback, able to run at fast speed Dragonfly Duo Imaging Catheter DOC Cover Ilumien / Optis Console Non Sterile Devices Sterile Devices 3ml Syringe

52. P reparation : STARTING Up THE OCT SYSTEM CONFIDENTIAL – FOR INTERNAL USE ONLY

53. Preparation : Add a new patient CONFIDENTIAL – FOR INTERNAL USE ONLY

54. Preparation : Patient data CONFIDENTIAL – FOR INTERNAL USE ONLY

55. Preparation : Step by step on the screen CONFIDENTIAL – FOR INTERNAL USE ONLY

56. Preparation DOC Cover Give the DOC Cover to the physician Pass the DOC through the DOC cover Pull the DOC cover “Telescoping style” fold DOC Cover Tab labeled “Insert DOC Here” DOC cover length increased from 60 inches to 96 inches Sterile blue cover wrapped around DOC cover Plastic ring around the DOC cover opening CONFIDENTIAL – FOR INTERNAL USE ONLY

57. P reparation: Catheter preparation Remove catheter from hoop Wipe shaft to activate hydrophilic coating Gently purge catheter with 3ml syringe filled with 100% contrast PRIOR to connection Inject until 3 drops exit tip Leave syringe attached for repeat purging in vivo CONFIDENTIAL – FOR INTERNAL USE ONLY

58. Don’t touch inner fiber optics! Preparation: Connect the catheter to the DOC CONFIDENTIAL – FOR INTERNAL USE ONLY

59. Preparation: Test Image To Test the Image hold the catheter CONFIDENTIAL – FOR INTERNAL USE ONLY

60. Preparation Summary Add a new patient Data Pass the doc through the DOC cover Activate catheter hydrophilic coating of Catheter Gently purge catheter with 3ml syringe filled with 100% contrast Connect the catheter to the DOC Test The image Auto-calibrate Prepare and Connects Automatic injector pump to the manifold CONFIDENTIAL – FOR INTERNAL USE ONLY

61. Procedure-Ready Automatic injector pump connects to manifold 3 cc contrast syringe remains connected DOC 6-7 F guide catheter (no side holes) 0.014" standard guidewire Dragonfly catheter loaded with guidewire Y should not be tighten too much CONFIDENTIAL – FOR INTERNAL USE ONLY

62. Backloading the Dragonfly DUO onto the Guidewire Entry portal is blue. Exit portal for guidewire is distal to proximal marker. Tortuous Anantomy or Long stent : Disconnect the DOC and the catheter / Or use 2 guide wires Proximal marker Lens located at end of torque wire CONFIDENTIAL – FOR INTERNAL USE ONLY When manipulating the catheter the system must be in Standby mode

63. Insertion and Positioning Dragonfly Optis CONFIDENTIAL – FOR INTERNAL USE ONLY Lens Guidewire is prevented from going down image core and wall improves kink resistance Pinhole to reduce blood ingress Simplifies the OCT procedure

64. P ositioning Dragonfly Duo/ Optis Distance from the Distal marker to Lens Marker = 26mm Distance from Lens Marker to the proximal Marker= 50mm Frame the specific region of interest in the High-resolution Mode Distance from lens to Lens marker is = 2 mm Proximal and Lens markers are on the torque wire and then the markers move during the pullback Markers 26 mm apart Pullback length: 54mm Or 75mm Lens 2 mm Distal Marker Lens Marker Proximal Marker Markers 50 mm apart POI 54MM POI 75MM Insertion and positioning of the Dragonfly catheter should be done in the “Stand by” Mode CONFIDENTIAL – FOR INTERNAL USE ONLY

65. Pullback Prep: P urging Blood Purged If blood creeps into catheter lumen, purge with attached contrast syringe. CONFIDENTIAL – FOR INTERNAL USE ONLY To purge the catheter the system must be in Standby mode

66. Pullback Prep: P uff Marginal, Blood Swirls Optimal Clearance During live scan, use a puff of contrast to evaluate clarity. CONFIDENTIAL – FOR INTERNAL USE ONLY

67. Blood Clearance CONFIDENTIAL – FOR INTERNAL USE ONLY

68. RBC mixed into flush fluid Flush contrast diluted with saline, less viscous, does not flush all RBC Data on file at LLI Blood Speckle

69. Turbulent flow between flush and blood Flush not filling lumen, perhaps going into other arteries OR End of flush bolus Blood swirls CONFIDENTIAL – FOR INTERNAL USE ONLY

70. P ullback : Automatic trigger When the Trigger Type is set to Automatic Press Live View, Press the “Enable Pullback” button to allow the system to detect initiation of the imaging flush. Inject Flush Now.” The imaging pullback will start automatically when clear image frames are detected. Note that the Enabled state lasts for 15 seconds. CONFIDENTIAL – FOR INTERNAL USE ONLY

71. P ullback : Manual trigger When the Trigger Type is set to Manual Press Live View, => The Enable Pullback button changes to Start Pullback Inject Flush Media Press start Pullback or F5 or Button on the DOC when blood is cleared from the vessel lumen Note that the Enabled state lasts for 15 seconds. When the Trigger Type is set to Pressure , the DOC motor does not speed up until a signal is received from the pressure transducer. CONFIDENTIAL – FOR INTERNAL USE ONLY

72. For a New & PROPER acquisition FOLLOW The 5 P’s P REPARATION of the system & catheter P OSITION the catheter relative to target lesion/stent P URGE blood from catheter lumen, if present P UFF of contrast to evaluate clearance P ULLBACK! Image acquisition CONFIDENTIAL – FOR INTERNAL USE ONLY

73. OCT IMAGE INTERPRETATION

74. TIPS for Image interpretation BACTE-RIA B - Backscatter A - Attenuation C - Composition T - Texture E - Edge RIA July 8, 2019 Enter presentation title via "insert>header and footer>footer" | 74

75. OCT Image Interpretation Terminology Backscatter The reflection of light waves off the tissue and back to the Dragonfly catheter High backscatter means a brighter pixel Also described as a “signal rich” region Low backscatter means a darker pixel Also described as a “signal poor” region Attenuation The reduction in intensity of the light waves as they pass through tissue due to absorption or scattering High attenuation means the light cannot penetrate very deep Low attenuation means the light can pass through to allow visualization of deeper tissue

76. OCT Image Interpretation Terminology Composition Homogeneous Uniform in structure ( Uniform or similar pixels) Heterogeneous Structure consists of dissimilar elements ( Non-uniform or dissimilar pixels) Texture Coarse Fine 76

77. OCT Image Interpretation Terminology Edge/Border The creation of a border is due to the interface between different tissue types One of the parameters used to differentiate plaque types Calcium Lipid

78. Image Orientation Normal coronary artery Uniform silhouette 3 layers visible in vessel wall Data on file at LLI Imaging catheter Guidewire shadow Adventitia Media Intima 78

79. Fibrous Plaque 79 Homogeneous High backscatter signal rich brighter pixel Finely textured Low attenuation deeper tissue can be visualized

80. Fibrous Rich Plaque, Homogeneous EEM 80 Not to be distributed or reproduced

81. Calcified Plaque Sharp edges Heterogeneous Low backscatter signal poor Low attenuation deeper tissue can be visualized 81 Data on file at LLI

82. Calcium Fibrous 82 Not to be distributed or reproduced Calcium and Fibrous Plaque

83. Lipid Plaque High attenuation low tissue penetration Diffuse shadowy edges High backscatter on surface Low backscatter deeper 83 Data on file at LLI

84. Systematic Approach for OCT image interpretation / Major Plaque Characteristics (Signal Rich /poor) (Backscatter high or low ) Bright / Dark Edge Sharp v s diffuse Attenuation (Absorption) low vs high Homogeneous / Heterogeneous Yes or no

85. Systematic approach for OCT Image interpretation Lesion Signal /Backscatter Brighter Signal Backscatter Darker Attenuation (Absorption) High (signal poor) Low Sharp edge Calcium Diffuse edge Heterogeneous Homogeneous Lipid Attenuation (Absorption) Low Homogeneous Fibrous Gonzalo N. 2010 ”Optical Coherence Tomographty for the Assessment of Coronary Atherosclerosis and Vessel Response after Stent implantation”. (Thesis)

86. Plaque Types - Recognition Fibrous Bright pixels Finely textured Deep penetration Homogeneous Lipid Dark pixels Diffuse edge Low penetration Homogeneous Calcium Dark pixels Sharp edge Deep penetration Heterogeneous Fibrous Lipid Calcium 86 Gonzalo N. 2010 ”Optical Coherence Tomographty for the Assessment of Coronary Atherosclerosis and Vessel Response after Stent implantation”. (Thesis)

87. PCI Follow up Bioabsorbable vascular scaffold Strut appearance is translucent Metal stents Struts are opaque Bright reflection on the surface of the stent strut Struts cast a shadow into the vessel wall Data on file at LLI Images: European Heart Journal (2011):32;294–304

88. PCI Follow up

89. PCI Follow up

90. PCI follow up Vessel Wall Damage Tissue prolapse Convex shaped protrusion of tissue between adjacent stent struts towards the lumen without disruption of the continuity of the luminal vessel surface Data on file at LLI Image: Image: Gonzalo N. Optical Coherence Tomography for the Assessment of Coronary Atherosclerosis and Vessel Response After Stent Implantation (Thesis) 2010

91. Stent Strut Apposition Strut malapposition Undersized Stent

92. PCI Follow up Stent Strut Coverage 2 months 7 months Data on file at LLI Images: Dr. Suzuki, Toyohashi Heart Center Data on file at LLI

93. PCI Follow up Neointimal Hyperplasia In-stent restenosis Thick layer between stent struts and lumen Data on file at LLI Stent struts

94. In-Stent Restenosis 94 Not to be distributed or reproduced

95. PCI follow up Thrombosis Data on file at LLI Thrombus Stent struts Data on file at LLI

96. PCI Follow up Thrombus – Red (Acute) Thrombus – red Absorbs near-infrared light High backscatter on surface due to signal attenuation Appears as a bright mass Shadow (cannot see behind it) Data on file at LLI Red thrombus Data on file at LLI

97. White thrombus PCI Follow up Thrombus – White (Chronic) Thrombus – white High backscatter Low attenuation Can see behind it Data on file at LLI

98. PCI Follow up Vessel Wall Damage Edge dissection A disruption of the vessel luminal surface in the edge region Easy to interpret using cross-sectional and longitudinal views Data on file at LLI Image: Columbia Presbyterian Hospital

99. PCI follow up Vessel Wall Damage Intimal tear Clear visualization of even small irregularities Data on file at LLI

100. WHAT’s NEW in OCT

101. Automated Measurements Stent Roadmap Apposition Indicator 3D Bifurcation Mode Side-branch detection Carina view Expanded 3D Navigation 3D flythrough view Object segmentation OPTIS™ Stent Optimization Software broadens the clinical utility for OCT to guide daily decision making for complex PCI both pre and post stenting though: What’s New?

102. New Default with Lumen Profile Automated measurements Close out X added for both Lumen Profile and L-mode TSC also easy to toggle Menu/Settings to change this default

103. Stent roadmap with optional bookmarks Displays lumen profile markers: distal, proximal landing and MLA on the co-registration angiogram image Optional bookmarks Icon to toggle this view on and off 2.8 mm tolerance ( ±1.4mm on each end) Note: OCT Frame Indicator changes Thinner for less angio -obstruction Length reduced from 3mm to 2mm (±1.0mm on each end)

104. Stent display for Apposition indicator Displays sent apposition information in four locations Apposition indicator bar L-mode Stent roadmap Cross-sectional view (dots)

105. Apposition Thresholds: Optional adjustment Measurement is taken from the leading edge of the stent or what is closest to the lenses of the OCT catheter Software identifies struts that are >25% malapposed across a 1mm length Default Settings : >300 microns red >200 microns yellow <200 microns silver Could also take the red down to 200 if user would rather see only two colors Note: this functionality is not available for BVS

106. 3d Bifurcation mODE Side branches are displayed as pink dots on the lumen profile and dotted lines trailing into the L-mode 3D Bifurcation mode will open with the view that matches the closes side branch view of where the OCT frame marker is currently positioned Bifurcation mode is hidden if no side branches are detected that are approximately 1.5mm diameter or greater The software default zoom level for bifurcation mode is optimized for the OCT system not the demo laptop .  You may want to zoom out when you first open the bifurcation mode. If you don't have a TSC, you can hold down the right mouse button and use the zoom bar at the far left of the 3D screen to adjust the zoom

107. 3d nAVIGATION with NEW 3D OPTIONs Menu

108. 3D Object Display View Options: Lumen Mode Tissue + Lumen Mode Stent Only Mode Additional Options: Individually turn up to two guidewire (s) on/off Turn side-branch (es) on or off Note: Guidewire rendering may vary due to shadow, artifact or out of the cut-plane Flythrough *any of the above modes can be viewed in the flythrough view

109. AptiVue™ Software for OPTIS™ (version E.5.1) Features: Automated Stent Expansion Calculations Under expansion Indicator for BMS/DES 2 Methods – Dual and Tapered Resting Index, Resting Full Cycle Ratio (RFR) 1 Identifies ischemia-causing lesions like FFR without hyperemia Allows pullbacks to assess serial lesions and diffuse disease Personally Identifiable Information (PII) Security Full Encryption of patient data User authentication (login) Current Algorithm Improvements 2 nd Guide wire detection Stent rendering in 3D 1. Svanerud et al. VALI.DATE RFR. EuroIntervention 2018.

110. Summary: OCT for PCI Optimization Pre- and post-stent assessment Stent size selection and landing zone planning Position, expansion, apposition Intimal tear, dissection, false lumen Tissue prolapse Calcification PCI follow-up Strut coverage Neo-intimal growth Restenosis/thrombosis Data on file at LLI

111. Optimize your pci with OCT OCT has clear advantages for stent optimization – PCI OPTIMIZATION It’s all about the lumen Fast, easy to use, easy to read 10 times Superior Image Resolution than IVUS SEE BETTER… TREAT BETTER….

112. 112 THANK YOU FOR ATTENDING

113. OCT IN CATH LAB Pre - PCI OCT Pull Back Check Clearance and then only do Pull Back – PUFF Calibration If ACR –CO Register Morphology – Calcified, Lipid & Fibrotic lesions zones, healthy 3 layered zones (180D) Landing Zone – Distal & Proximal Luminal & EEL Dimensions (Mean Diameter), Length of the lesion Dissection Thrombus presence 113

114. OCT IN CATH LAB Post - PCI OCT Pull Back Calibration Lumen Profile, Rendered Stent, If ACR – Co Register Lumen Profile - Place the Distal & Proximal Markers in the edge of the stent Check for Edge dissections Check for MLA – Ilumien 3 Crieteria Apposition 114