atrogenic coronary artery stenosis following surgical valve repair is a rare but potentially lethal complication. However, it can be successfully treated using percutaneous coronary intervention (PCI). A 49-year-old female patient was referred for urgent coronary angiography due to cardiogenic shock developed within three hours after surgical mitral and tricuspid valve repair. Bedside echo-cardio-graphy revealed severe right ventricular failure and moderately reduced left ventricular function, with normal valve function. The patient’s coronary angiography before surgery was unremarkable. Urgent coronary angiography showed a subocclusive stenosis of the posterolateral (PL) branch with Thrombolysis In Myocardial Infarction (TIMI) 1 flow (Figure 1A, Moving ...

Background: In peripheral artery disease, two different types of calcification are frequently observed, i.e., medial and intimal calcification. Aims: The aim of this study was to determine the ability of intravascular ultrasound (IVUS) imaging and optical frequency domain imaging (OFDI) to detect medial and intimal calcification in human peripheral arteries. Methods: We performed ex vivo intravascular imaging of cadaveric human peripheral arteries with calcifications. IVUS and OFDI images were co-registered with histology. A total of 12 legs from nine patients were examined, and 438 cross-sectional images were co-registered with histology. Results: OFDI could detect 183 of 231 intimal calcifications ...

Over the last three decades, developments in intravascular ultrasound (IVUS) and optical coherence tomography (OCT) have advanced our understanding of coronary disease pathophysiology and improved outcomes of percutaneous coronary intervention (PCI) procedures. Although in daily clinical practice most imaging utilisation relies on a simple, two-dimensional display of cross-sectional coronary images, real-time three-dimensional (3D) visualisation of coronary arteries with OCT offers advantages over and above simple vessel sizing and plaque characterisation. Fourier domain OCT, with superior axial (10-15 µm) and lateral (20-40 µm) resolutions and a faster image acquisition rate (180 scans/second), as well as quicker pullback speeds (18 .

Optical coherence tomography (OCT) has been increasingly utilised to guide percutaneous coronary intervention (PCI). Despite the diagnostic utility of OCT, facilitated by its high resolution, the impact of intracoronary OCT on clinical practice has thus far been limited. Difficulty in transitioning from intravascular ultrasound (IVUS), complex image interpretation, lack of a standardised algorithm for PCI guidance, and paucity of data from prospective clinical trials have contributed to the modest adoption. Herein, we provide a comprehensive up-do-date overview on the utility of OCT in coronary artery disease, including technical details, device set-up, simplified OCT image interpretation, recognition of the imaging artefacts ...

Background: Optical flow ratio (OFR) is a novel method for fast computation of fractional flow reserve (FFR) from optical coherence tomography (OCT) images. Aims: We aimed to evaluate the accuracy of OFR in predicting post-percutaneous coronary intervention (PCI) FFR and to evaluate the impact of stent expansion on within-stent OFR pressure drop (In-stent OFR). Methods: Post-PCI OFR was computed in patients with both OCT and FFR interrogation immediately after PCI. Calculation of post-PCI OFR (called simulated residual OFR) from pre-PCI OCT pullbacks after elimination of the stenotic segment by virtual stenting was performed in a subgroup of patients who had ...

Background Intravascular optical coherence tomography (IVOCT) enables detailed plaque characterisation in-vivo, but visual assessment is time-consuming and subjective. Aims This study aims to develop and validate an automatic framework for IVOCT plaque characterisation using artificial intelligence (AI). Methods IVOCT pullbacks from 5 international centres were analysed in a corelab, annotating basic plaque components, inflammatory markers and other structures. A deep convolutional network with encoding-decoding architecture and pseudo-3D input was developed and trained using hybrid loss. The proposed network was integrated into commercial software to be externally validated on additional IVOCT pullbacks from three international corelabs, taking the consensus among corelabs ...

Background: Early spontaneous reperfusion (ESR) is not an uncommon phenomenon in clinical settings. Aims: To detect potential mechanisms of early spontaneous reperfusion in patients with STEMI. Methods: This prospective study enrolled a total of 241 consecutive patients with STEMI undergoing optical coherence tomography (OCT) from July 2016 to August 2019. Forty-five (18.7%) met angiographic ESR criteria (TIMI-3 flow on the initial angiogram). Among those without ESR (TIMI-0 flow on initial angiogram), 45 patients were assigned into the control group according to propensity score matching with the ESR group. Results: Although the group’s baseline characteristics were comparable, non-ruptured plaque ...

In the current issue of EuroIntervention, the one-year follow-up of the ILUMIEN III trial1 and the design and rationale of the ILUMIEN IV trial2 are presented. Both trials are part of a series of clinical studies designed to provide hypothesis-generating knowledge and hypothesis-confirming answers in a systematic way. The prospective, observational ILUMIEN I trial demonstrated that the anatomical vessel information, as provided by optical coherence tomography (OCT), impacts on the clinician’s decision making during percutaneous conronary intervention (PCI) concerning stent size, length and post-dilatation3. The retrospective, post hoc, matched pair ILUMIEN II trial revealed that clinicians

Aims: The comparative efficacy of balloon-based techniques to prepare severely calcified coronary lesions before stenting remains poorly studied. We sought to compare stent expansion following preparation of severely calcified coronary lesions with either super high-pressure balloon or scoring balloon. Methods and results: In this randomized, open-label trial 74 patients with severely calcified coronary lesions were enrolled at 5 centers in Germany and Switzerland. After unsuccessful lesion preparation with standard non-compliant balloon (<30% reduction of baseline diameter stenosis), participants were randomized to pre-dilation with either super high-pressure balloon or scoring balloon before drug-eluting stent (DES) implantation. The primary endpoint of the ...

Despite the established usefulness of optical coherence tomography (OCT) guidance in percutaneous coronary intervention (PCI), the quality of the obtained OCT images is sometimes low due to inadequate clearance of blood flow in cases involving extremely tight stenotic lesions. Increasing the volume of contrast media, generally used for blood flow clearance, is also a problem. A novel OCT procedure, “low molecular weight dextran (LMWD) infusion followed by catheter push (D-PUSH)” procedure, in which an OCT catheter is advanced from the proximal to distal target lesion segment after initiating LMWD infusion from a guiding catheter, may improve image quality compared with ...

Aims: IVUS is currently recommended by international guidelines to guide left main stem (LMS) PCI. Although OCT resolution outmatches IVUS, this tool is not yet recommended in LMS angioplasty due to the absence of data. This pilot study aimed to analyze the feasibility, safety and impact of OCT-guided LMS PCI. Methods and results: This prospective, multicenter trial investigated whether patients might benefit from OCT-guided PCI for mid/distal LMS according to a pre-specified protocol. The primary endpoint was procedural success defined as follows: residual angiographic stenosis &lt;50% + TIMI 3 flow in all branches + adequate OCT stent expansion (LEMON criteria ...

A 56-year-old male with current smoking and dyslipidemia was admitted to our hospital because of anterior ST-segment elevation myocardial infarction (STEMI). Echocardiogram showed akinesis in the apex of the left ventricle, and the ejection fraction was 55%. There was no evidence of atrial fibrillation, cardiac shunts or any cardiac thrombus. He had no history of the emotional stress, cocaine intake or thrombophilia. And, also there was no episode that suspected coronary spasm. After administration of aspirin 200mg and prasugrel 20mg, the emergent coronary angiogram (CAG) was performed. CAG showed the total occlusion at the distal portion of left anterior descending ...

Background: The ability of optical coherence tomography (OCT) to identify specific types of stent has never been systematically studied. Methods and results: A series of 212 consecutive patients with OCT from six international centres were retrospectively screened, finding 294 metallic stents or scaffolds in 146 patients. The sample was analysed by two blinded operators, applying a dedicated protocol in 4 steps to identify the type of stent: 1) 3D and automatic strut detection (ASD), 2) 3D tissue view, 3) Longitudinal view with ASD, 4) Mode “stent only” and ASD. The protocol correctly identified 285 stents (96.9%, kappa 0.965 ...

Aims- We assessed the safety and efficacy of the DynamX™ Novolimus-Eluting Coronary Bioadaptor System, a novel device that initially acts as a second-generation drug-eluting stent, but after six months frees the vessel through uncaging elements. Methods and results- This multi-center study enrolled 50 patients with single de novo lesions. In-device acute lumen gain was 1.61±0.34 mm, and device and procedure success was 100%. Through 12 months, two target lesion failures occurred, both were cardiac deaths (day 255 and 267 post-procedure). No definite or probable device thrombosis was observed. Mean late lumen loss was 0.12±0.18 ...

AIMS: Randomized trials have demonstrated improvement in clinical outcomes with intravascular ultrasound (IVUS)-guided percutaneous coronary intervention (PCI) compared with angiography-guided PCI. The ILUMIEN III trial demonstrated non-inferiority of an optical coherence tomography (OCT)- versus IVUS-guided PCI strategy in achieving similar post-PCI lumen dimensions. ILUMIEN IV is a large-scale, multicenter, randomized trial designed to demonstrate the superiority of OCT- versus angiography-guided stent implantation in patients with high-risk clinical characteristics (diabetes) and/or complex angiographic lesions in achieving larger post-PCI lumen dimensions and improving clinical outcomes. METHODS AND RESULTS: ILUMIEN IV is a prospective, single-blind clinical investigation that will randomize between ...

Aims: The goal of the present post hoc analysis of the CLIMA registry was to establish the relationship between calcified nodules (CNs) with (CND) or without (CNWD) disruption of the superficial intimal fibrous layer and one-year occurrence of target lesion myocardial infarction (MI) and/or cardiac death. Methods and results: CND and CNWD were identified based on the presence or absence of superficial irregularities indicative of disruption of the intimal fibrous layer, with possible overlying local thrombus. In total, 222 CNs were found in the 1,776 non-culprit LAD plaques. CND had larger maximum calcific arc and smaller lumen area ...

Pre-procedural optical coherence tomography (OCT) of the left anterior descending artery (LAD) in a 58-year-old man with unstable angina due to a stenosis involving LAD and first diagonal branch detected underlying mixed plaque, partially containing lipid in a circumferential distribution distal to the first diagonal branch (Figures A1-3). Bifurcational percutaneous coronary intervention with side-branch-stenting (double-kissing mini-crush: 2.0x18mm zotarolimus-eluting-stent (ZES) in diagonal branch, 2.25x38mm-ZES in LAD with post-dilation using 3.0x20mm and 3.5x8mm non-compliant balloons) was performed after loading with ticagrelor (180mg) and cumulative administration of 15’000 IU of heparin to achieve an activated clotting time >250 ...

A 68-year-old man was admitted to our hospital with unstable angina. His medical history was remarkable for an acute myocardial infarction one year ago, treated with a zotarolimus-eluting stent (3.5×30 mm) in the mid right coronary artery. Coronary angiography showed a diffused in-stent restenosis (ISR) with haziness and filling defects (Figure 1A, Video 1). In order to identify the underlying mechanisms of ISR, optical coherence tomography (OCT) was performed due to its high resolution. OCT showed a large, recanalized thrombus with multiple channels divided by thin septa (longitudinal view and Figure 1C-1E) in the setting of an undersized ...

Aims: In the ILUMIEN III trial, among 450 randomised patients with non-complex lesions undergoing percutaneous coronary intervention (PCI), optical coherence tomography (OCT) guidance led to greater stent expansion than angiography guidance, similar minimal stent area compared to both intravascular ultrasound (IVUS) guidance and angiography guidance, and lower rates of uncorrected dissection and malapposition than both IVUS guidance and angiography guidance. Whether these differences impact clinical outcomes is unknown. Methods and results : OCT-guided PCI, using an external elastic lamina-based protocol, was compared to operator-directed IVUS-guided or angiography-guided PCI. Target lesion failure (TLF) and major adverse cardiovascular events (MACE) at 12 months ...

Aims: This study evaluated the optical frequency domain imaging (OFDI) artifact of tangential signal dropout (TSD), which mimics the appearance of lipid-rich plaque and macrophage (Mø) infiltration. Methods and results: A total of 1,019 histological cross-sections from 23 autopsy hearts were matched with the corresponding OFDI images. Of those, 232 OFDI cross-sections that contained signal-poor regions with diffuse borders were classified as lipid-rich plaques. The angle θ was calculated between the OFDI beam that strikes the edge of the luminal surface of the low-intensity region and that which strikes the surface line of the low-intensity region. On histological evaluation, 182 ...

Aim: To determine the ability of optical frequency domain imaging (OFDI)/optical coherence tomography (OCT) imaging systems to visualize presence of cholesterol crystals (CCR) in human atherosclerotic coronary arteries. Methods and Results: We performed ex vivo imaging by OFDI/OCT of human coronary arteries. A total of 559 cross-sectional images from 45 autopsy cases were co-registered with histology and 117 histologic sections showed presence of necrotic core with cholesterol clefts (CC). We modified a previously used OFDI/OCT definition for identification of CCRs which we now define as a linear and discreet high intensity signal (bright area) within the plaque ...

Aims: We sought to evaluate procedural complications and one-year clinical outcomes for patients who underwent percutaneous coronary intervention (PCI) with orbital (OA) and rotational atherectomy (RA). Methods and results: From a total of 13,467 patients who underwent PCI in our hospital between January 2013 and June 2016, 1,149 consecutive patients were treated with atherectomy for moderately-severely calcified lesions (184 with OA, 965 with RA). Procedural complications were similarly observed in the two groups except for higher dissection and perforation rates with OA. Major adverse cardiovascular events (MACE) were defined as the composite of death, myocardial infarction or target ...

Aims: To evaluate the diagnostic performance of OCT-based optical flow ratio (OFR) in unselected patients and compare it with angiography-based quantitative flow ratio (QFR), using wire-based FFR as reference standard. Methods and results: All patients with OCT and FFR assessment prior to revascularization were analyzed. OFR and QFR were computed in blinded fashion and compared with FFR, all applying same cut-off value of ≤0.80 to define ischemia. Paired comparison between OFR and QFR was performed in 212 vessels from 181 patients. Average FFR was 0.82±0.10 and 40.1% vessels had FFR≤0.80. OFR showed significant ...

Aims: We aimed to evaluate whether optical coherence tomography (OCT)-guided rotational atherectomy (RA) improves stent expansion and clinical outcomes compared to intravascular ultrasound (IVUS)-guided RA. Methods and results: We identified 247 de-novo calcified coronary lesions that underwent RA from our database between September 2013 and December 2017. Of these, lesions with no intravascular imaging data (n=11), poor image quality (n=7), balloon angioplasty alone (n=16), and complications (2 burr entrapment, 2 perforation) were excluded. Finally, 88 and 121 lesions that underwent OCT-guided and IVUS-guided RA, respectively, were enrolled. The primary endpoint of the present study was ...