3D3D--OCT an indispensable guide for OCT an indispensable guide for ggpercutaneous intervention ? percutaneous intervention ? 3D3D R i f h PR i f h P dil d dil d -- 3D3D--Reconstruction of the PostReconstruction of the Post--dilated dilated

ABSORB BVS in a bifurcation for flow ABSORB BVS in a bifurcation for flow restorationrestoration

Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands Kosin University Hospital, Busan, Korea

Jung Ho Heo, Bill D Gogas,

Robert J van Geuns Patrick W SerruysRobert J. van Geuns, Patrick W. Serruys

BackgroundsBackgrounds

With d t f thWith d t f th ti OCT t (C7 Li htL b OFDIti OCT t (C7 Li htL b OFDI With advent of the newWith advent of the new--generation OCT system (C7 LightLab, OFDI generation OCT system (C7 LightLab, OFDI

Terumo) with a high frame rate (100Terumo) with a high frame rate (100--160fps) and fast pull160fps) and fast pull--back back ) g () g ( p ) pp ) p

speed (20speed (20--40mm/s), 340mm/s), 3--dimensional reconstruction of OCT became dimensional reconstruction of OCT became

feasible due to elimination of motion artefacts.feasible due to elimination of motion artefacts.

33--dimensional OCT reconstruction might give us better dimensional OCT reconstruction might give us better

understanding of coronary anatomy compared to the conventional understanding of coronary anatomy compared to the conventional

22 D OCTD OCT22--D OCT.D OCT.

MethodologyMethodology All pullback speeds 20 mm/sec with OFDI All pullback speeds 20 mm/sec with OFDI

Bitmap (704 x 704 pixels)Bitmap (704 x 704 pixels) sequences generatedsequences generatedBitmap (704 x 704 pixels)Bitmap (704 x 704 pixels) sequences generatedsequences generated

Every singleEvery single strut manually or strut manually or automaticallyautomatically detected in detected in each OCT cross section ( Ip and software developed byeach OCT cross section ( Ip and software developed byeach OCT cross section ( Ip and software developed by each OCT cross section ( Ip and software developed by Yamaguchi University)Yamaguchi University)

ii d ffd ff li i lli i l d id i 3D images3D images reconstructed offreconstructed off--line using volumeline using volume--rendering rendering software (INTAGE Realia,software (INTAGE Realia, KGT, Tokyo, Japan or OSIRIX)KGT, Tokyo, Japan or OSIRIX)

Image calibration Image calibration transversetransverse resolution (scan diameter divided by pixel resolution (scan diameter divided by pixel

size) size) longitudinallongitudinal resolution (pullback speed divided by frame resolution (pullback speed divided by frame

rate: 0 2 mm for C7 and 0rate: 0 2 mm for C7 and 0 125125 mm for TERUMO)mm for TERUMO)rate: 0.2 mm for C7 and 0.rate: 0.2 mm for C7 and 0. 125125 mm for TERUMO). mm for TERUMO). OKAMURA ET AL. 2010 JACC INTERVENTIONS

OKAMURA ET AL. 2011 EUROINTERVENTION

Anatomy of the LMS,Anatomy of the LMS, circumflex, LAD, diagonal Anatomy of the LMS, circumflex, LAD, diagonal

and septal branchesand septal branchesLCx LCx

PROXAnatomy of the LMS,

circumflex, LAD, diagonal and septal branches

and septal branchesand septal branchesLAD D1LAD LAD LAD D1

D1LADLAD

septal branches

View from the LMS

LCx

D1CARINA D1

LAD

SEPTAL

LAD

1b

Non-jailed

V type40%

1 2

yp

Classification of Jailed sidebranch

T t

ostium according to number of

t t25%

12

3

T typecompartment created by the overhanging struts 2

H type

overhanging struts with different configuration (e.g.

25%

13

4

V, T and H type)

12

4

10%

Jailed sidebranches are no longer an issue

CASE Summary CASE Summary CASE Summary CASE Summary

Brief Hx : M/68Brief Hx : M/68 Sudden onset chest pain for 3 hoursSudden onset chest pain for 3 hours Sudde o set c est pa o 3 ou sSudde o set c est pa o 3 ou s

NonNon--STEMI at LADSTEMI at LAD Direct Stenting was done Direct Stenting was done Direct Stenting was done Direct Stenting was done

Initail CAGInitail CAG significant true bifurcation lesion LAD to involve the second significant true bifurcation lesion LAD to involve the second

diagonal side branch (SideB) (Medina classification: 1, 1, 1) diagonal side branch (SideB) (Medina classification: 1, 1, 1)

B li CAGB li CAGBaseline CAGBaseline CAG

Preparation of the lesion with Preparation of the lesion with ballooningballooning

BVS deploymentBVS deploymentBVS deploymentBVS deployment

SB Jailing SB Jailing SB Jailing SB Jailing

PrePre--dilatation dilatation with balloonwith balloonwith balloonwith balloon

BVS deploymentBVS deployment

SB jailingSB jailing

A 1.5 * 12 mm TrekA 1.5 * 12 mm Trek--compliant balloon was compliant balloon was ppsubsequently used to subsequently used to cross the cells of the cross the cells of the ABSORB BVS t d ABSORB BVS t d ABSORB BVS toward ABSORB BVS toward the SB. the SB.

Nominal pressure Nominal pressure ballooning.ballooning.

Restoration of TIMI flow Restoration of TIMI flow grade 3 without significant grade 3 without significant g gg gmyocardial damage.myocardial damage.

After stenting OCT findings6

After stenting OCT findings

2, 3

4, 5 6

1

2, 3

4 5

23

1

3D reconstruction view3D reconstruction view3D reconstruction view3D reconstruction view

Virtual FlyVirtual Fly--through view through view

( distal to proximal )( distal to proximal )

Virtual FlyVirtual Fly--through view through view ( ( Proximal to distal.)Proximal to distal.)

( distal to proximal .)( distal to proximal .)

Reconstruction of flow dividerReconstruction of flow divider( Diagonal Branch ) ( Diagonal Branch )

EA D

**1

HF G

2

4, 5

6

B3

12, 34, 5

B

M

GWS

4

A

M

I J4

** 5

C 6

Could we dilate these jailed slide branchs : feasibility  In In‐vitro experimentIn In vitro experiment

From Inside

From Outside

Offline 3Offline 3--dimensional reconstructions of the MB and the SB dimensional reconstructions of the MB and the SB constructed using 2constructed using 2--dimensional (2D) frequency domain dimensional (2D) frequency domain gg ( ) q y( ) q y(FD) optical coherence to(FD) optical coherence to-- mography (OCT) images are a mography (OCT) images are a novel approach to visualizing these lesions. novel approach to visualizing these lesions.

The possibility of onThe possibility of on-- line use of such imaging modalities for line use of such imaging modalities for bifurcation lesions or other lesion types may help improve bifurcation lesions or other lesion types may help improve

t t t t t i t t t t t i our treatment strategies. our treatment strategies.

ConclusionConclusion3D OCT3D OCT

t ti l li ti f thi t h l dditi l f PCIt ti l li ti f thi t h l dditi l f PCIpotential application of this technology as an additive role for PCI potential application of this technology as an additive role for PCI if 2D OCT analysis is performedif 2D OCT analysis is performedpotential application to the bifurcation?potential application to the bifurcation?p ppp pp

Improvements in current 3D Improvements in current 3D ““realtimerealtime”” OCT technology OCT technology required to match off line imagesrequired to match off line imagesrequired to match off line imagesrequired to match off line images

automatic strut detectionautomatic strut detectionImage qualityImage qualityg q yg q y

Potential of this technology will be demonstrated with offPotential of this technology will be demonstrated with off--line line 3D3D--OCTOCT3D3D OCTOCT