SERVICIO DE HEMODINAMIA
I have no conflict of interest to declare
OCT: Definición La Tomografía de Coherencia Óptica es una técnica similar a la ecografía (IVUS), utiliza fuente de LUZ de banda ancha. Realiza imágenes Tomográficas de alta resolución (10-15 mm) Para estudio de micro-estructuras y materiales biológicos mediante la medición del tiempo de retardo y la magnitud de la luz reflejada por tejido investigado. Espectro cercano a la luz infrarroja
Light Scattering Espalhamento DISPERSION REFECTOMETRIA REFLEXION RETRODISPERSA -La dispersión es un proceso físico en el que algunas formas de radiación (por ejemplo Luz) se desvían de su trayectoria recta original, y dispersados en todas las direcciones por una o más superficies irregulares ubicados en el medio a través del cual pasan. - La dispersión que generan los tejidos tienen diferentes formas según el tejido.
OCT: Formación de la Imagen El método mide el tiempo de retraso de la luz emitida sobre el tejido utilizando un proceso de interferometría de baja coherencia. La luz reflejada (BACKCATTERED) por el tejido es correlacionada con parte de la luz que viaja a una distancia conocida por el BRAZO DE REFERENCIA (interferómetro)
Time-Domain OCT Tomografía de dominio de tiempo Frequency-Domain OCT Tomografía de dominio de frecuencia Espejo móvil Espejo fijo Low-coherence light source or short optical pulses Scanning reference delay It measures the time delays of optical echoes sequentially, by scanning a reference path, so that echo delays are measured at different times Interferometer with a narrow bandwidth Frequency-swept light source Stationary reference delay It measures all of the optical echoes at the same time, rather than sequentially, as done in time-domain detection. This improves detection sensitivity.
Time-Domain vs. Frequency-Domain OCT Improved Image Quality M3 System (TD-OCT) 3 mm/ seg C7 XR System (FD-OCT) 20 mm/ seg
Atenuación de la Luz La mayoria de los equipos de OCT operan con una logitud de onda de 700 nm
La señal captada por el OCT está influenciada por las propiedades ópticas del tejido (absorción y dispersión), así como los componentes ópticos del sistema de formación de imágenes Fibrotic Calcified Lipid Attenuation 3.2/mm Backscattering 6.7/mm Attenuation 1.7/mm Backscattering 5.4/mm Attenuation 7.5/mm Backscattering 6.6/mm
SERVICIO DE HEMODINAMIA
Catéter Dragonfly A Catheter shaft B Guidewire exit port Proximal marker Distal tip marker Catheter tip 20 mm span 4 mm Connector Hub DOC Connection Side-arm port Optical Lens in forward position ready for an imaging pullback
Preparado del Catéter Flush con contraste (100%) hasta que 3-5 gotas salgan por la punta distal del Catéter Manipulación delicada del Catéter
Posicionamiento del Catéter 4 mm Target Lesion Optical Lens Target Lesion 20 mm 5 mm OCT catheter Radiopaque Marker
Inyección del Contraste para Blood Clearance Confirmar si el catéter-guia -coaxializado con el vaso cateteres-guia 6F NO USAR SIDE HOLE Bomba inyectora con contraste 100%. Programación de bomba: ovolumen total: 10 20 ml otasa de flujo: 3-6 ml/s opresión límite: 300 psi tasa de flujo mejora el clearance distal volumen total mejora la longitud del clearance (segmento proximal) Hacer click en enable y accionar la bomba inyectora.
Kume, et al. Circ J 2005;69: 903-907
Lumen Accuracy: OCT vs. IVUS Accuracy of OCT and IVUS was evaluated in a totally controlled fashion, using a dedicated cylindrical phantom with 4 different dimensions OCT IVUS Mean Lumen Diameter Max / Min Lumen Diameter Lumen Area Tahara S, et al. EuroIntervention 2011;6:875-882
SERVICIO DE HEMODINAMIA y con F.F.R. Reserva Fraccional de Flujo Coronario
Combined OCT and FFR UH-CMC First Experience FFR and OCT were performed in 17 intermediate lesions FFR < 0.80 ( 23.5%) FFR > 0.80 ( 76.5%) MLA 2.43 [1.03-3.35] 3.78 [1.95-9.04] MLD 1.48 [1.03-1.79] 1.84 [1.36-2.6] MLA: r=0.167 CI 95%: -0.378-0.626 p=0.56 MLD: r=0.203 CI 95%: -0.258-0.700 p=0.297 %Stenosis: r= - 0.424 CI 95%: -0.779-0.137 p=0.133
Relación entre FFR e OCT 61 estenosis intermedias validadas con FFR, OCT e IVUS Mejor Cut-off para FFR 0.80: MLA < 1.95 mm 2 Sensibilidad: 82% Especificidad: 63% VPP: 66% VPN: 80% Gonzalo N, et al. J Am Coll Cardiol. 2012;59:1080-1089
ACS and FFR 57-yo, male, HTN, Hypercholesterolemia, positive family Hx for CAD Presentation: NSTEMI 1 day before angiography EKG: anterior wall T-wave inversion Positive Troponin T FFR = 0.85
E Diagonal Branch * * F Prox Reference * * F E D C A C MLA = 1.9 mm 2 D Culprit Site Xience V 3.0x23mm Lipid Lipid Lipid Plaque rupture A Distal Reference B Fibro-Fatty Plaque
SERVICIO DE HEMODINAMIA Aplicaciones Clínicas Caracterización de la arteriosclerosis Cuantificación de Estenosis Seguimiento ATC Utilización en el IAM
Anatomía Arterial Normal
Caracterización de Ateriosclerosis Componentes de las placas Fibrotic Fibrocalcific Lipid-Rich Signal-rich region High backscattering Homogeneous Signal-poor region w/ sharp borders Low backscattering Heterogeneous Signal-poor region w/ diffuse (not well defined) borders Low backscattering
Caracterización de Placas Validación En Vivo Lipid Fibrous Calcific Comments Sens Spec Sens Spec Sens Spec Yabushita H, et al Circulation 2002 OCT 90% 92% 96% 97% 79% 97% 357 segments of 90 cadavers Kume T, et al Am J Cardiol 2006 Kawasaki M, et al JACC 2006 Rieber J, et al Coron Artery Dis 2006 OCT 85% 94% 96% 88% 79% 99% IVUS 59% 97% 88% 86% 98% 96% OCT 95% 98% 98% 94% 100% 100% IVUS 67% 95% 93% 61% 100% 99% IB IVUS 84% 97% 94% 84% 100% 99% OCT 77% 94% 67% 97% 64% 88% IVUS 10% 96% 63% 59% 76% 98% 166 coronary segments 128 segments from 17 cadavers 17 segments from 8 in situ arteries Manfrini O, et al Am J Cardiol 2006 OCT 45% 83% 83% 82% 68% 76% 79 coronary seg/15 cadavers
Quantification of Macrophage Content in Atherosclerotic Plaques by Optical Coherence Tomography Figure 2. Raw (A) and logarithm base 10 (B) OCT images of a fibroatheroma with a low density of macrophages within the fibrous cap. C, Corresponding histology for A and B (CD68 immunoperoxidase; original magnification 100). Raw (D) and logarithm base 10 (E) OCT images of a fibroatheroma with a high density of macrophages within the fibrous cap. F, Corresponding histology for D and E (CD68 immunoperoxidase; original magnification 100). Figure 1. OCT and histology images of a fibroatheroma with superimposed ROIs. Raw (A) and base 10 logarithm (B) OCT images. C and D, Corresponding histology (C, Masson s trichrome; D, CD68 immunoperoxidase; original magnification 40). The high contrast and resolution of OCT enables the quantification of macrophages within fibrous caps. The unique capabilities of OCT for fibrous cap characterization suggest that this technology may be well suited for identifying vulnerable plaques in patients.
Caracterización de la Ateriosclerosis
Caracterización de Aterosclerosis Definición de la Lesión Culpable en SCA Plaque Rupture Plaque Erosion
Caracterización de la Aterosclerosis Hallazgos adicionales Cholesterol Clefts Intimal Vasculature cristales
Caracterización de los Trombos Trombo ROJO Trombo BLANCO
SERVICIO DE HEMODINAMIA Aplicaciones Clínicas Cuantificación de Estenosis
Lumen Segmentation Distal Reference LA: 6.08 mm 2 Min : 2.52 mm Max : 3.05 mm Mean : 2.77 mm Lesion LA: 1.88 mm 2 Min : 1.44 mm Max : 1.82 mm Mean : 1.54 mm Lesion LA: 1.97 mm 2 Min : 1.45 mm Max : 1.80 mm Mean : 1.58 mm Prox Reference LA: 8.32 mm 2 Min : 3.12 mm Max : 3.40 mm Mean : 3.25 mm 23.0 mm 18.0 mm 9.2 mm 0
Segmentación Anatómica del Lumen
SERVICIO DE HEMODINAMIA Aplicaciones Clínicas Seguimiento ATC
ICP Guiada por OCT 335 pts sometidos a ICP guiada por angiografia + OCT fueron comparados con un grupo de 335 pts sometidos à ICP guiada solo por angiografia en un mismo período (dentro de 30 dias) Menor riego de muerte e infarto ICP guiada por OCT se asocio independentemente con menor riesgo de muerte e infarto Análisis multivariado por regresion logística: OR: 0.49 [0.25-0.960, p=0.037 Ajuste por score de propension: OR: 0.37 [0.10-0.90], p=0.050 Análisis de riesgo proporcional de Prati F, Cox: et al. EuroIntervention.2012;8:823-829 HR: 0.51 [0.28-0.93], p=0.028
Stent Malapposition Acute Effects of PCI Plaque Prolapse In-Stent Dissection Edge Dissection Intramural Hematoma In-Stent Thrombus
FD-OCT.. aclara el mecanismo de la trombosis del stent (MALA APOSICIÓN.) Primera intervención con balón (4,0 mm) persistente mala aposición Una mayor dilatación con un balón grande (4,5 mm)
CONDUCTA POSTERIOR A OCT
Malapposition Resolved
OCT and Acute CoronarySyndrome OCT performed before stenting-morphological ambiguities Atheromatous plaque? Thrombus component? Coronary spasm? Spontaneous intramural haematoma? -Did the lesion involve LM bifurcation? -Optimal sizingof stent
OTOCLAV study Optimal Timing to performoctto assessculpritlesionafteracsrevascularization (observational, non randomizedstudy) Results: 101 pts were included OCT feasibility = 100%, @D5onaverage No events befored eferred control orduring OCT procedure Residual thrombus in 68% by OCT (21% by angio alone) Plaque rupture : 65%, median length lesion = 12 mm MotreffP, ESC Munich 2012
OTOCLAV study Optimal Timing to performoctto assessculpritlesionafteracsrevascularization (observational, non randomizedstudy) Results: 2 MACEs @ 1year (1Stroke+1TLR;noACS) Conclusion: Our pilot study included non consecutive patients, selected because of a large thrombus component in the angiography performed at the acute phase of myocardial infarction. However, in this context, OCT is feasible, safe and could help to guide PCI for ACS treatment, confirming that thrombus is underestimated by angiography alone. MotreffP, ESC Munich 2012
STENTS CUBIERTOS PLACA VULNERABLE NEOATEROESCLEROSIS RUPTURA CAPA FIBRÓTICA
SERVICIO DE HEMODINAMIA QUÉ HACEMOS CON ESTA INFORMACION?
Cobertura de Struts Strut Level Covered Uncovered Malapposed
Accurateness of OCT to Detect Strut Coverage 20 stents implanted in 10 pigs OCT and Pathology (SEM and LM) @ 1, 3, 10, 14 and 28 days Neointimal thickness detected by OCT correlated closely with the neointimal thickness measured by LM (r=0.90, p<0.01) Comparison of strut coverage by OCT and SEM revealed an excellent agreement (r=0.96, p<0.01) Templin C, et al. Eur Heart Journal 2010;31:1792-1801
Neointimal Thickness/mm Cobertura Endotelial: Predictor Histológico más robusto para eventos de trombosis de SF 0,3 0,2 0,1 0 PLC-1 PLC-2 PLC-3 PLC-4 PLC-5 PLC-6 PLC-7 9 8 7 6 5 4 3 2 1 0 No. of uncovered Struts/Section
Trombosis Tardía Definitiva de SF: hallazgos OCT Guagliumi G, et al. JACC Interv 2012;5:12-20 * Median 615 days after the index procedure
Neoatherosclerosis!! OCT Links Very Late Stent Thrombosis to Neoatherosclerosis, Plaque Rupture Neovascula rization Intimal Rupture MLA Site Proximal to the MLA Distal to the MLA TCFA- Containing Neointima MLA Site Proximal to the MLA Distal to the MLA Proportion of Lesions with at Least 1 Frame with Uncovered Strut Proportion of Lesions with at Least 1 Frame with Malapposed Strut DES (n = 27) BMS (n = 6) P Value 41% 50% 0.687 63% 44% 30% 4% 56% 41% 30% 11% 100% 50% 83% 0 100% 50% 83% 33% 0.074 0.805 0.015 0.632 0.041 0.678 0.015 0.170 56% 17% 0.085 52% 0 0.020 Neointimal rupture was present in 70% of all lesions, and thin-cap fibroatheroma (TCFA)-containing neointima in 64%, with more vulnerable plaque seen with BMS than DES In patients with very late stent thrombosis, optical coherence tomography (OCT) often reveals advanced atherosclerosis with thrombosis at the site of neointimal rupture, according to a small observational study published Que salió MAL Renu Virmani, MD, of CVPath Institute (Gaithersburg, MD), called OCT the way to go to examine the morphology behind stent thrombosis. Now when a patient presents, we have a tool that we can use to look at the plaque and say, What went wrong? That is very exciting. Dr. Virmani concluded that for DES patients who are 5 years out from implantation, OCT monitoring may help prevent a catastrophic event. LUEGO DE 5 ANOS DE STENT DES June 2013 issue of JACC: Cardiovascular Imaging
Neoatherosclerosis may cause late failure in DES Ali ZA. Circ Cardiovasc Interv. 2013;doi:10.1161/circinterventions.112.000248. October 3, 2013 Thin-cap neoatheroma and in-stent restenosis occur more frequently in drug-eluting stents compared with bare-metal stents, according to findings published in Circulation: Cardiovascular Interventions.
Relato de Caso Neoaterosclerose Precoce como Causa de Reestenose de Stent Farmacológico de Segunda Geração Daniel Chamié1, J. Ribamar Costa Jr.2, Alexandre Abizaid3 Rev Bras Cardiol Invasiva. 2012;20(3):333-6
Increased Thin-Cap Neoatheroma and Periprocedural Myocardial Infarction in Drug-Eluting Stent Restenosis Multimodality Intravascular Imaging of Drug-Eluting and Bare-Metal Stents Ziad A. Ali, MD, DPhil; Tomasz Roleder, MD; Jagat Narula, MD, PhD; Bibhu D. Mohanty, MD; Usman Baber, MD; Jason C. Kovacic, MD, PhD; Gary S. Mintz, MD; Fumiyuki Otsuka, MD, PhD; Stephen Pan, MD; Renu Virmani, MD; Samin K. Sharma, MD; Pedro Moreno, MD; Annapoorna S. Kini, MD (Circ Cardiovasc Interv. 2013;6:00-00.) Conclusions In-stent NA is common and diffuse. It occurs earlier in DES, with more TCNA, and is associated with more periprocedural MI compared with BMS. These findings support NA to be a mechanism for late DES failure.
Different Stent Healing Patterns Homogeneous High Backscattering Low-Intensity NIH Peri-Strut Infiltrate NIH Neovascularization Lipid-Laden Neointima Strut Coverage Lipid Lipid Stent Struts Lipid Lipid
Scaffold Strut Morphologic Changes Preserved Box Open Box Elongation - Hydration Incorporation A B C D A B C D Box-shaped appearance [preserved integrity] Bright Borders [preserved integrity] Clustering of Neighbor Struts [preserved integrity] Loss of box-shaped appearance, diffuse boundaries [Altered integrity]
SERVICIO DE HEMODINAMIA 3D - OCT * *
A C 2.5x13 mm 1 2 3 2.25x23 mm B 1 2 3
F G *
CONCLUSIÓN La OCT es una técnica de imagen intravascular novedosa. Proporciona un estudio detallado de la enfermedad ATEROSCLERÓTICA identificando placas de alto riesgo. ( PLACA VULNERABLE) Aporta información cuantitativa de las características de las estenosis. Evalúa la implantación del stent, de forma inmediata y a largo plazo. COBERTURA DEL STENT Esclarece las complicaciones más importantes en la colocación del stent - REESTENOSIS Y TROMBOSIS. Nuevo concepto de Faltan estudios para determinar el valor clínico. NEOATEROESCLEROSIS Es prometedor para la toma de decisiones, revascularización y resultados
SERVICIO DE HEMODINAMIA Muchas gracias!