Advanced Image Interpretation pdf.pptx

Peter Barlis MBBS MPH PhD FESC FCSANZ FACC FRACP

Northern & St Vincent’s Hospitals, Melbourne Associate Professor of Medicine The University of Melbourne

Outline   •  OCT:  Brief  Overview   •  OCT:  beau3ful  images  but  what  do  they  all   mean??   •  Case  illustra3ons  and  reference  to  the   Consensus  Document  from  the  Interna3onal   Working  Group  on  intravascular  OCT  imaging   •  Quiz  

•  In  March  2014  we  celebrated  5  years  of  OCT  in  Australia  

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In  2009   Ques+ons  that  I  was  being  asked   What  is  OCT?   Is  OCT  safe?   How  do  you  perform  OCT?   Which  is  be:er,  IVUS  or  OCT?   Comments  I  was  hearing   “We  don’t  need  TCO,  we  use  IVUS”   “I  don’t  see  a  need  for  OCT  as  our  lab  doesn’t  do   CTO’s”  

2014  –  OCT  Landscape   •  •  •  •  • 

30+  Systems  across  Australia  and  New  Zealand   1500+  Systems  globally   Key questions being asked in 2014: How  do  you  interpret  the  OCT  images?   What  clinical  role  does  OCT  have  over  and   above  its  research  u3lity?  

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2013   2012   2011   2010   2009   2008   2007   2006   2005   2004   2003   2002   2001   2000   1999   1998   1997   1996  

Key  Areas  for  intracoronary  imaging   •  Plaque/lesion  assessment   •  Pre  and  Post-­‐interven3on  op3misa3on   •  Complica3on  evalua3on   •  Restenosis  /  thrombosis  evalua3on      

Coronary  flush  –  3ps  for  op3mal   clearance  and  imaging   •  Ensure  guiding  catheter  is   intubated  into  the  LM  or   RCA   •  Close/lock  the  Y  –   connector   •  If  manual  injec3ng    -­‐   minimise  the  length  of   tubing   •  Adjust  flush  rates  of   contrast  depending  on  the   calibre  of  the  vessel  

Importance of getting image interpretation right § The  detec3on  of  TCFA,  par3cularly  in  stable   pa3ents  is  desirable  and  may  principally  allow  for   early  interven3on  and  preven3on  of  adverse   events.   § More  and  more  studies  are  incorpora3ng  3  vessel   OCT  to  examine  non-­‐culprit  plaques   § Mastering  OCT  images  does  take  3me  and  pa3ence   and  preferably  the  support  of  a  mentor  

Consensus  Document   JACC,  2012   •  Interna3onal  Working  Group  (IWG)  on  OCT   standardisa3on   –  60  %  academic   –  40  %  industry  

•  (Academic  )Wri3ng  commigee  produced  this   document  aher  nine  mee3ngs    of  IWG.    

Types  of  plaques   •  •  •  • 

Fibrous  plaque   Fibrocalcific  plaque   Fibroatheroma     Unstable  lesions     –  Thin  cap  fibroatheroma   –  Ruptured  plaques   –  Plaque  erosion   –  Thrombus   –  High  cap  macrophage  content  

Normal  artery  

Normal  artery  –  three  layer  appearance   Hematoxylin-­‐Eosin  stain  

OCT  

ElasAca-­‐van  Gieson  stain   external   media   elasAc  lamina   adven33a  

adven33a  

Masson-­‐trichrome  stain  

in3ma   In3ma-­‐media   complex  

IVUS  

T.  Akasaka,  “New  horizon  of  coronary  intervenAon:  histological  plaque  diagnosis  and  treatment.”  

A  spectrum  of  OCT  findings  can  be  iden3fied  in  a  single   pullback  ,  therefore  analysis  is  3me  consuming  

Normal  vessel   appearance  

Atherosclerotic  plaque  

Coronary  stents  

67  yr  old  female,  single  OCT  pullback  in  the  LCx  artery  

40 MHz - IVUS

Fibrous  Plaques  

OCT

Smooth,  bright,  homogeneous  plaques,  shown  lower  propensity   to  be  unstable  but  as  they  develop,  do  cause  luminal  constric3on   and  typically  stable  coronary  syndromes  

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A  

B  

a-­‐2  

a-­‐1   40 MHz - IVUS

OCT Image

Fibrous  and  fibrocalcific  plaques   (A)  Fibrous  plaque  with  IEM  (green   arrow)  and  EEM  (yellow  arrow).  (B)   Plaque  without  IEM  or  EEM  (white   arrow).  The  EEM  (yellow  arrow)  and   IEM  (green  arrow)  can   be  visualized  opposite  to  the  main   lesion.  (C)  Fibrocalcific  plaque   showing  circumferen3al  signal-­‐poor   heterogeneous  region  with  well-­‐ delineated  borders.  (D)  Mixed   plaque  with  focal  calcific  deposit   comprising  regions  with  sharply   delineated  borders,  consistent  with   calcium  (red  arrow),  and  adjacent   signal-­‐poor  areas  with  poorly   delineated  borders,  sugges3ve  of   lipid  (yellow  arrows).  Scale  bars   represent  500  m.  IVOCT  technology,   image  contributor  and  ins3tu3on,   and  commercial  IVOCT  vendor   for  each  figure  is  provided  in  the   Online  Supplementary  Material.   *Guide-­‐wire  ar3fact.  Abbrevia3ons   as  in  Figure  1.  

Unstable/vulnerable  plaque  

•   A  fibrous  cap  is  a  3ssue   layer,  which  is  ohen   signal-­‐rich,  overlying  a   signal-­‐poor  region   •   Fibroatheroma  is  a   lesion  with  an  IVOCT-­‐ delineated  fibrous  cap   and  a  necro3c  core  

71  year  old  man   Admiged  with  chest  pain  over  4  hours   ECG  T  wave  inversion  leads  II,  aVF   Troponin-­‐I  0.50   PHx  –  Diabetes,  hypertension,  ex/smoker   No  further  chest  pain  in  CCU  however  3  brief   runs  of  ventricular  tachycardia   •   coronary  angiography   •  •  •  •  • 

Distal   RCA  OCT   Ruptured   Plaque  

•  Lipid-­‐rich  plaques   •  Low  agenua3on,  dark,   diffuse  borders  as  dis3nct  to   calcified  plaques   •  Plaque  rupture  common  at   shoulder   •  Pathological  studies  have   shown  that  macrophages   collect  more  at  plaque   shoulder   •  Poten3al  mechanisms   include  stress  /  shear  force