OCT product materials-ST.JUDE MEDICAL.pptx

RFR (Resting Full-cycle Ratio):

Measurement: Takes the lowest Pd/Pa ratio over the entire cardiac cycle.
Application: This method does not isolate a specific phase of the cardiac cycle, using the entire cycle instead.
iFR (Instantaneous Wave-free Ratio):

Measurement: Calculates the average Pd/Pa ratio during the wave-free period (WFP) in diastole.
Application: Focuses on a specific phase in diastole when coronary blood flow is most stable, minimizing the influence of myocardial contraction.
DFR (Diastolic Flow Ratio):

Measurement: Similar to iFR, but it averages the Pd/Pa when Pa is less than the mean Pa during diastole.
Application: Another diastolic-specific measurement, potentially offering slightly different physiological insights compared to iFR.
dPR (Diastolic Pressure Ratio):

Measurement: Averages the Pd/Pa ratio over the entire diastolic phase.
Application: Provides a broader assessment during diastole, which is crucial since coronary perfusion predominantly occurs during diastole.
cRR (Continuous Resting Ratio):

Measurement: Involves the derivative of Pd/Pa (d(Pd/Pa)/dt) over the cardiac cycle, focusing on how this ratio changes continuously.
Application: This method looks at the rate of change of the Pd/Pa ratio, which might provide additional information about dynamic changes in coronary flow or resistance.
Pd/Pa (Whole Cycle Average Pd/Pa):

Measurement: Computes the average Pd/Pa over the entire cardiac cycle.
Application: This is a basic measure, providing an overall assessment without focusing on any specific phase of the cardiac cycle.
Key Differences:

Focus on Cardiac Phase: Some methods like iFR, DFR, and dPR specifically focus on the diastolic phase, while others like RFR and cRR consider the entire cardiac cycle.
Physiological Consideration: iFR and DFR are more specific to the wave-free period in diastole, where the influence of myocardial contraction is minimal.
Data Utilization: RFR uses the lowest point in the entire cycle, whereas cRR uses the rate of change (derivative), offering dynamic insights into how Pd/Pa varies.
d(Pd/Pa)/dt Calculation:

To calculate d(Pd/Pa)/dt, you would need to take the derivative of the Pd/Pa ratio with respect to time over the cardiac cycle. This would give you the rate of change of this ratio, which is particularly useful in methods like cRR.
Each method has its advantages and may be chosen based on specific clinical needs or the particular characteristics of the patient being assessed.

1. Optical Coherence Tomography

2. 2 Optical Coherence Tomography (OCT) is an optical imaging modality that uses near-infrared light to create high-resolution images of tissue microstructure. Blood is displaced from the target segment for imaging, using low-volumes of 100% contrast Key Features:  Micrometer-level resolution (15 microns)  Sub-surface imaging  Safe, non-ionizing radiation What is OCT?

3. Flexible fiber-optic with distal lens used for light delivery Fiber-optic rotates inside 2.7F catheter to create image frames Pure contrast (15ml) flushed along lumen to create “imaging window” Syringe or injector pump “4ml/s for 4sec = 16ml” Intravascular OCT – key parameters OPTIS ( pulbacks ) 75mm at 36mm/s in 2.1sec – 5 frames per mm OR 54mm at 18mm/s in 3.0sec – 10 frames per mm

4. OCT Procedure ILUMIEN ™ PCI Optimization System 4

5. Prior to Starting a Case Required Materials Dragonfly Optis ™ 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) 5

6. New OCT Recording 6

7. Catheter Preparation Insert the DOC into the sterile bag and place it on the table. 7

8. Catheter Preparation Remove the hoop carefully from the catheter, and wipe the catheter with heparinized saline. 8

9. Catheter Preparation Purge with contrast until 3-5 drops exit distal tip. 9

10. Connecting Catheter to DOC 10

11. Connect Catheter 11

12. Preparations 12

13. Preparations Watch the five yellow LEDs light up on the DOC 13

14. Preparations 14

15. Loading the Guidewire 15

16. Pullback Preparation – Purge the Catheter If blood enters the catheter lumen, purge with the attached 3 cc contrast syringe. 16 Blood in catheter lumen Purged catheter lumen

17. Image Acquisition Engage GC and remember PLACES P – Purge Catheter L – Live View A – Auto C – Calibrate E – Enable S – Start Flush OCT taking you PLACES

18. OCT vs IVUS

19. ILUMIEN / C7-XR IVUS Axial Resolution 15 – 20 µm 100 – 200 µm Beam Width 20 – 40 mm 200 – 300 mm Frame Rate 100 frames/s 30 frames/s Pullback Speed 20 mm/s 0.5 - 1 mm/s Max. Scan Dia. 10 mm 15 mm Tissue Penetration 1.0 - 2.0 mm 10 mm Lines per Frame 500 256 Lateral Sampling (3 mm Artery) 19 µm 225 µm Blood Clearing Required Not Required OCT vs. IVUS 20 Gonzalo N. Optical Coherence Tomography for the Assessment of Coronary Atherosclerosis and Vessel Response After Stent Implantation (Thesis) 2010

20. OCT vs. IVUS OCT imaging provides superior imaging of: Tri-laminar vessel structure Stent apposition/malapposition/underexpansion Strut distribution at side-branch, overlap segment etc Restenosis/Neo-intimal hyperplasia Thin-capped fibro-atheroma (TCFA) Plaque rupture Tissue protrusion after stenting Edge dissection Thrombus 21

21. OCT vs IVUS 22 Edge dissection during stent implantation Neointimal growth on previously implanted stent at follow-up

22. Measurement of Lumen Area in Phantom Model by FD-OCT and IVUS. In this representative cross-sectional image, the mean lumen diameter of IVUS was 3.27 mm, whereas that of FD-OCT was 3.06 mm, closer to true value (3.08 mm). OCT Measurements Are More Accurate than IVUS 23 Kubo T, Akasaka T, Shite J, et al. OCT Compared With IVUS in a Coronary Lesion Assessment: The OPUS-CLASS Study. JACC Cardiovasc Imaging. 2013 Aug 31. [Epub ahead of print]

23. A1 – Lipid core B1 – Dissection/thrombus formation C1 – Rupture cavity with flaps

24. Calcified Plaque

25. OCT Image Interpretation

26. Systematic approach to OCT image analysis Step 1 - IDENTIFICATION OF RELEVANT STRUCTURES catheter/vessel /contour /lumen / guidewire Step 2 - QUALITY CONTROL Is calibration ok? Is flush ok? Is catheter purged ok? Is the quality of the catheter ok? Step 3 - ORIENTATION Use L-view to get an overview and locate side branches, features/region of interest Evaluation of consecutive images is crucial for all analyses!!!

27. Systematic approach to OCT image analysis Step 4 - IDENTIFICATION OF REFERENCE STRUCTURES Intima, media and adventitia – is the media visible? Step 5 - IDENTIFICATION OF THE THREE MAIN TISSUE TYPES Fibrous plaque / Fibro-calcific plaque / Fibro-atheroma

28. IDENTIFICATION OF RELEVANT STRUCTURES Data on file at LLI Imaging catheter Guidewire shadow Adventitia Media Intima Lumen

29. IDENTIFICATION OF REFERENT STRUCTURES Normal coronary artery Uniform silhouette 3 layers visible in vessel wall Data on file at LLI Adventitia Media Intima

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

31. Systematic approach for OCT Image interpretation / Major Plaque Characteristics Lesion Bright (Signal Rich) Dark (Signal Poor) Attenuation (Absorption) High Low Sharp edge C alcific 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)

32. Plaque Types - Recognition Signal Penetration Edge Nature of the Plaque Fibrous Bright Deep penetration depth Homogeneous Lipid Dark Low penetration depth Diffuse edge Homogeneous Calcium Dark Deep penetration depth Sharp edge Heterogeneous Fibrous Fibroatheromas Fibrocalcific Gonzalo N. 2010 ”Optical Coherence Tomographty for the Assessment of Coronary Atherosclerosis and Vessel Response after Stent implantation”. (Thesis)

33. 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

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

35. Image Quiz

36. Drs Grube, Buellesfeld, Guerkens, Mueller, Helios Heart Center, Siegburg, Germany. Guide flush, 12 mL contrast; 100 f/s; 15 mm/s pullback Normal, Mild Intimal Thickening Data on file at LLI

37. Calcium 38

38. Thrombus over ruptured calcified plaque

39. Stent Edge-dissection Data on file at LLI

40. White thrombus in Stent 41

41. Calcium and dissection 42

42. Drs Grube, Buellesfeld, Guerkens, Mueller, Helios Heart Center, Siegburg, Germany. Guide flush, 12 mL contrast; 100 f/s; 15 mm/s pullback Lipid Pool Data on file at LLI

43. Protrusive calcified plaque 44

44. Stent overlap 45

45. Ring of calcium 46

46. Malapposition 47

47. Lipid Pool (TCFA)

48. Coronary dissection 49

49. Dissection flap/ex-false lumen 50

50. Unexpanded stent in left-main 51

51. Clearly visible tri-laminate structure Excellent reference segment

52. Calcium and side branch

53. Eccentric vulnerable calcified plaque protruding into lumen – Media visible opposite

54. Side branch not visible from L-Mode

55. Eccentric Calcium – Media clearly visible in rest of vessel

56. Blood and Optical Artifacts & Image troubleshooting

57. Blood Swirls Turbulent flow between flush and blood Flush not filling lumen, perhaps going into other arteries OR End of flush bolus Not injecting hard enough Poor GC engagement Data on file at LLI

58. Broken Dragonfly 59

59. Rotational distortion 60

60. Stitch/Sew up artefact