同舟共济守望生命 Optical Coherence Tomography (OCT) for the Coronary Artery Disease Patients with Moderate Stenosis 上海市同济医院蒋金法

同舟共济守望生命

Optical Coherence Tomography (OCT) for the Coronary Artery Disease Patients with Moderate

Stenosis

上海市同济医院蒋金法


INTRODUCTION

Cardiovascular disease (CVD) causes almost half of all deaths in the developed world and 25% of deaths in the developing world. Coronary artery disease (CAD) is the leading cause of cardiovascular mortality worldwide, with more than 4.5 million deaths occurring in the developing world each year.

By the year 2030, cardiovascular disease will cause an estimated 23.6 million deaths worldwide, becoming the predominant cause of death in the world, surpassing infectious diseases and death caused by cancer.


INTRODUCTION

Cardiologists now know that the “vulnerable plaque” is the atherosclerotic lesion defined as the precursor to coronary plaque rupture, hence the proximate cause of acute coronary syndromes (ACS).

Acute coronary syndromes often result from rupture of a modestly stenotic vulnerable plaque,not visible by x-ray angiography.


INTRODUCTION

The most common mechanism, occurring in approximately 60-75% of cases is the rupture of a mild to moderately sized plaque in a coronary artery with a necrotic core and thin, structurally weak intimal wall, referred to as a thin-capped fibroatheroma (TCFA).

The presence of a plaque with an echolucent central core and a thin fibrous capsule, the so-called “vulnerable plaque,”can also be identified by IVUS. Whether these lesions should be treated by percutaneous coronary intervention (PCI)versus medical therapy has not been elucidated by clinical trials


INTRODUCTION

(OCT) has emerged as one of the most promising investigation modality thanks to its ability to provide unique information about the plaque composition, the thickness of the fibrous cap, the presence of macrophages and tissue collagen composition.

coronary angiography may no longer be the true gold standard for detecting coronary stenosis.Coronary angiography only displays the opacified “silhouette”.


INTRODUCTION

An intermediate coronary lesion on angiography is defined as a luminal narrowing with a diameter stenosis 40% but 70%.

All measures of noninvasive assessment of myocardial ischemia are compared with the presence on angiography of a focal stenosis 50% diameter. This cutoff is based on animal

studies and human clinical correlations that demonstrate functional significance (the induction of ischemia) with the anatomic presence of a 50% diameter stenosis .


Libby P. Lancet. 1996;348:S4-S7.

中层

– T 淋巴细胞

– 巨噬细胞泡沫细胞（组织因子）

– “激活的” 内膜平滑肌细胞 (HLA-DR+)

– 正常平滑肌细胞

纤维帽内膜脂核

管腔

易损斑块


Non-vulnerable plaque ( 非易损斑块 )

纤维组织部分阻塞血流，但不易引起血凝块及心脏事件。

Vulnerable Plaque （易损斑块）富含脂质核、纤维帽薄、边缘炎症反应明

显，易于破裂。

易损斑块


Coronary Artery Disease: Coronary Artery Disease: Stable vs. Unstable plaqueStable vs. Unstable plaque

Stable (obstructive)Vulnerable (non-obstructive)

• Progressively flow-limiting• Often causes chest pain• Detected by angiography• Main target of interventional therapies (angioplasty, stents)

• Minimal effect on blood flow • First symptom is often sudden death • No established detection method• Preventative drug therapies; directed therapies still unproven

Precision ImagingPrecision Imaging – Plaque differentiationPrecision ImagingPrecision Imaging – Plaque differentiation



Microscopic resolution (15 m)

Real time Imaging (to 30fps)

Portable Design

Digital System Architecture

Automated pullback – up to 55mm

LightLab ImagingLightLab Imaging

M2 – The next generation of micron resolution M2 – The next generation of micron resolution imagingimaging


The resolving power of the microscope brought into the human body to enable earlier detection, better characterization, and precisely guided and targeted interventions.

Precision ImagingPrecision Imaging

Optical Coherence TomographyOptical Coherence Tomography


Visualize• Understand fluoroscopically

ambiguous lesions

Characterize• Evaluate detailed plaque characteristics

utilizing a versatile complement ofOCT Imaging modes

The LightLab Imaging Platform gives you enhanced diagnostic power to:

Precision ImagingPrecision ImagingPrecision ImagingPrecision Imaging


阻断球囊导管

低压力、大直径阻断球囊

不透 X 线标记


影像学技术影像学技术

IVUS

Angioscopy

OCT

Thermography

Spectroscopy

Intravascular MRI

分辨率分辨率

100μm

不知

10μm

0.5mm

不适用

160μm

纤维帽纤维帽

+

+

+++

－

+

+

脂核脂核

++

++

+++

－

++

++

钙化钙化

+++

－

+++

－

++

++

血栓血栓

+

+++

+

－

－

+

+++= 灵敏度 >90%; ++= 灵敏度 80~90%; += 灵敏度 50~80%; － = 灵敏度 <50%

Arterioscler Thromb Vasc Boil. 2003;23:1333-1342


OCT 、 IVUS 与病理解剖的对比


Kawasaki Medical School Hospital

Akasaka M.D. Kume M.D.

钙化斑块钙化斑块

纤维斑块纤维斑块

脂质斑块脂质斑块

各种斑块形态

钙化钙化

纤维斑块纤维斑块脂池脂池


Histology OCTMixed plaque, previous rupturesMixed plaque, previous ruptures

High lipidcontent

Fibro-fattyplaque

Thin Cap

Renu Virmani, MD, Erik Mont, MD AFIP

Precision ImagingPrecision Imaging – Vulnerable PlaquePrecision ImagingPrecision Imaging – Vulnerable Plaque


Thick Fibrous PlaqueThin Capped Fibroatheroma

(Renu Virmani, MD, AFIP)

Two lesions: Similar under fluoroscopy - Same course of therapy?

Precision ImagingPrecision Imaging – Plaque differentiationPrecision ImagingPrecision Imaging – Plaque differentiation

< 60 micron CapLesion


Thin-cap fibroatheroma (TCFA)

Possibility to identify TCFA has been demonstrated

by several pilot studies.


OCT 能精确测量纤维帽厚度OCT 能精确测量纤维帽厚度

同舟共济守望生命OCTOCT 能帮助进行支架术后随访能帮助进行支架术后随访OCTOCT 能帮助进行支架术后随访能帮助进行支架术后随访

~0.07mm

((Dr. U.Gerckens, Prof. E. Grube, Herzzentrum Siegburg, Germany)Dr. U.Gerckens, Prof. E. Grube, Herzzentrum Siegburg, Germany)

晚期支架内血栓晚期支架内血栓

支架内内膜增生支架内内膜增生

雷帕霉素药物支架雷帕霉素药物支架 66 个月随访个月随访


High-Risk PlaquesMatched images of IVUS (A), virtual histology (B), and OCT (C) for the 4 types of plaques considered at high risk of rupture.1: fibroatheroma, 2: calcified fibroatheroma, 3: thin-cap fibroatheroma, 4: calcified thin-cap fibroatheroma.

Precision ImagingPrecision ImagingPrecision ImagingPrecision Imaging


Titration – insufficient stent expansionTitration – insufficient stent expansion Precision Therapy – Precision Therapy – StentingStenting

Stent malapposition – 10atm

OCTOCT IVUSIVUS

Images courtesy of Dr. Takahiko Suzuki, Toyohashi Heart Center



Morphology of Exertion-Triggered Plaque Rupture in Pts With ACS

Atsushi Tanaka, Toshio Imanishi, et al.

Circulation 2008;118;2368-2373


Assessment of High-Risk Coronary Plaques at Bifurcations With Combined IVUS and OCT

Nieves Gonzalo, Hector M. J. Am. Coll. Cardiol. Img. 2009;2;473-482


Assessment of High-Risk Coronary Plaques at Bifurcations With Combined IVUS and OCT

Nieves Gonzalo, Hector M. J. Am. Coll. Cardiol. Img. 2009;2;473-482

同舟共济守望生命Feasibility of combined use of IVUS and OCT for detecting TCFA

T. Sawada et al European Heart Journal (2008) 29, 1136–1146


OCT Assessment of Thin-Cap FibroatheromaDistribution in Native Coronary Arteries

OCT in Culprit and Nonculprit Lesions

J. Am. Coll. Cardiol. Img. 2010;3;168-175



Case One

患者，男， 56 岁，前壁心肌梗死再梗

LAD 再次 PCI 术后 3 个月后复查 CAG 及 OCT检查



Case Two

患者，男， 63 岁， UAP 入院


LAD of Patient Yang



LCX of Zhu miaozhen


LAD of Jin guijun


CONCLUSION

a powerful new tool to assist in diagnosis and treatment of coronary artery disease

Visualization of Neointimal Growth in Drug Eluting Stents

Visualization of Thin-Capped Lesions and Ruptured Plaques

In-Vivo 15μm Imaging allows for development of new areas of invesigation


Documents

同舟共济 守望生命 Optical Coherence Tomography (OCT) for the Coronary Artery Disease Patients with Moderate Stenosis 上海市同济医院 蒋金法

同舟共济守望生命 Optical Coherence Tomography (OCT) for the Coronary Artery Disease Patients with Moderate Stenosis 上海市同济医院蒋金法