Download - Minimally Invasive Image Guided Therapy
Minimally InvasiveImage-Guided Therapy:
Cardiovascular ApplicationsKendall R. Waters, PhD
Presented on Mar. 4, 2010Triple Ring Technologies, Newark, CA
MedTech Frontiers Serieswww.tripleringtech.com
Original Image from iStockPhoto.com
Minimally Invasive Surgery without Image Guidance is Surgery Blindfolded
Animation from iStockPhoto.com
72 BPM, 100,000 Day, 2.5 Billion LifetimeCVD: Affect over 86 Million Americans, Estimated direct and indirect costs for 2010 are $500 Billion
A silhouette misses part of the picture
Pilobolus Video from YouTube.com
Pilobulus @ 2007 Oscars
Angiograms are Silhouettes
Is the standard good enough?
Contrast Angiography: Shadows hide some details
Poor Soft Tissue Contrast
Is the standard good enough?
X-Ray: Poor Tissue Contrast
Unable to predict which plaques will
lead to clinical events
Coronary heart disease is the largest major killer
Image from Northwest Houston Heart Center (www.houstonheartcenter.com)
CHD: Largest killer, >17M pts$177B direct/indirect costs 2006Unable to predict which plaques lead to events
Imaging inside the coronary arteries
Image from ShutterStock.com
Catheter-Based Imaging: Retrograde approach
Courtesy of Sean Madden, PhD, InfraReDx
Catheter-Based Imaging: Retrograde approach
Mechanically Rotating Catheter
Synthetic Aperture Array Catheter
Array Catheter: Ease of Use (No flushing required)Mechanically Rotating Catheters (US, OCT, NIRS): Image Quality
Watch an artery get cloggedThe Poster Child of Vulnerable Plaques
Thin Fibrous Cap<65 µm
Lipid-Richor
NecroticCore~25%
Courtesy of Geoff Vince, PhD, Volcano Corp
Normal > Constrictive Remodeling > Core Development > Rupture > Occlusion > MIThin Cap Fibroatheroma: Thin Cap + Necrotic Core Content
IVUS image ... or Hurricane MapIVUS image ...Is this a vulnerable plaque?
Zoomed View of a Diseased Vessel with Array CatheterModest Spatial Resolution > Poor Tissue DifferentiationSegmentation > Plaque Burden + Lumen Area > Advanced Analysis
Do advanced algorithms help?
Necrotic Fibrotic
Lipidic Calcified
BSC iMAPVolcano VH-IVUSTM
Fibro-Fatty Calcification
Necrotic CoreFibrosis
VH-IVUS > Spectral Parameters > Statistical Classification > 4 Categories > ColorizediMAP > Spectral Signatures > Statistics Classification > 4 Categories > ColorizedPROSPECT Trial > Plaque Burden & Necrotic Core & Minimum Lumen Area
Will emerging technologies find plaques that
lead to clinical events?
!"#$%"&'(')*+(,-'*,./
0')(.1'2+-
3*+/*-
".4+('2+5/+.,/*,6'5&+'7,/2
OCT provides striking detail
Vulnerable ?
but has limited penetration
OCT > 15/30 um resolution > 1-2 mm penetration > Minimum Lumen AreaPlaque Characterization > Fibrous (Signal Rich Homogeneous) & Lipid (Signal Poor with Diffuse Borders)
IVUS OCT
Fine Structural Detail
IVUS + OCT Combination
Courtesy of Dr. Brian Courtney MD and Brian Liang, Sunnybrook Health Sciences Centre, Toronto, CA
Penetration
Sunnybrook + Colibri > IVUS + OCT > Penetration + Lumen Detail
Spectroscopy = Chemical Composition
Limited Spatial ResolutionCourtesy of Sean Madden, PhD, InfraReDx
Pullback Distance
Ang
le
NIRS > Spectroscopy = Chemical Composition > Lipid ContentLimited Penetration and Resolution“This is the first device that can help assess the chemical makeup of coronary artery plaques and help doctors identify those of particular concern.” -- FDA
Chemical Composition + Structural Detail
NIRS + IVUS Chemogram
IVUS Long View
NIRS + IVUS Combination
Courtesy of Sean Madden, PhD, InfraReDx
InfraReDx > NIRS + IVUS > Composition + Structure
Very Good Structural Detail
A Much Better (HD) IVUS
Better image quality. IVUS with near-optical resolution. Device simplicity.
Some valves become leaky
1% to 5 % mortality rateImage from Consultants in Cardiology (www.cicmd.com)
Can imaging help?
Soft Tissue Imaging
Image from the GE Healthcare Vivid Image Library
Soft Tissue StructureColor Flow > MVR Jets
Can imaging help?
Precision Guidance
Image from Siemens Ultrasound
PFO Closuremm Length Scale
Alignment of Delivery Catheter in LACan imaging help?
Real-Time 3D
Image from presentation by J. D. Carroll, MD at TCT 2009
Matrix Array Technology > RT3DCatheter > Transseptal > MV
Can imaging help?
Reduced X-Ray Dose
Procedure Length > X-Rays (Pt & Operator)US > Non-Ionizing > Reduce X-Ray Need
Image from ShutterStock.com
Imaging from inside the heart
Access > Right Side > IVC & SVC
Image from Hao and Hongo, EPLab Digest 5(4) (2005). (www.eplabdigest.com)
AcuNav > Steerable > 8-10F > 5-10MHz
Imaging from the esophagus
Access > Eso > Proximity
Imaging from the esophagus
Images from Toronto General Hospital Department of Anesthesia and Pain Management
HUDSON, ET AL.
Figure 1. Comparison of echocardiographic transducers. (A) ICEtransducer (AcuNav,TM Siemens, Mountain View, CA, USA). (B)Conventional two-dimensional multiplane TEE transducer. (C) 3Dmatrix array TEE (X7-2t, Philips, Andover, MA, USA) transducer.
Figure 6. 2D- and 3D-TEE guidance of percutaneous mitral valveballoon valvuloplasty. (A) 2D-TEE demonstrating a “hockey-stick”configuration of the anterior mitral valve leaflet (arrowhead) proto-typical of rheumatic mitral stenosis. (B) 3D volumetric reconstruc-tion of an en face view of the restricted mitral valve as viewed fromthe left atrium demonstrating a narrowed mitral orifice (arrow) andcommissural fusion (arrowheads). (C) 2D X-Plane view of the inter-atrial septum illustrating “septal tenting” (arrows) during transseptalpuncture. (D) Live 3D-TEE guidance of the Inoue balloon catheteracross the rheumatic mitral valve. (E) 3D-TEE view of Inoue ballooninflation across the rheumatic mitral valve. (F) 3D-TEE volumetricreconstruction demonstrating an enlarged mitral valve orifice (ar-row) and split commissure (arrowhead). LA = left atrium; LV = leftventricle; RA = right atrium; RV = right ventricle.
!"""""""""""""""""""""""""""""""""""""
Figure 4. Percutaneous ASD closure with an Amplatzer Septal Oc-cluder using 2D- and 3D-TEE guidance. (A) 2D-TEE suggesting asmall ASD (arrows). (B) Live 3D-TEE displaying an en face viewof the ASD (arrow) from the left atrium, revealing its oval shapewith a long-axis twice the short-axis dimension. (C) 3D volumetricreconstruction with color Doppler demonstrating left to right shunt-ing across the ASD (arrow). (D) Live 3D-TEE of an en face viewfollowing deployment of the left atrial disk of a 12 mm AmplatzerSeptal Occluder (arrowheads) with excellent visualization of thedelivery cable (arrow) through the ASD. (E) Live 3D-TEE demon-strating good positioning of ASD occluder following right atrialdisk (arrowheads) deployment. (F) 2D X-plane with color Dopplerdemonstrating final device positioning without evidence of residualshunting from two simultaneous planes of view. LA = left atrium;RA = right atrium; # = septum primum; ## = septum secundum.
540 Journal of Interventional Cardiology Vol. 21, No. 6, 2008
Image From Philips Healthcare (www.medical.philips.com) Image from Hudson et al., J Interv Cardiol 21(6) (2008).
Steerable > Matrix Array > Multi-plane
A Leaky Mitral Valve
Image from Weill Cornell Medical College, Cardiothoracic Surgery (www.cornellheartsurgery.org)
Normal
Prolapse
Normal Leaflets > One-way FlowProlapse Leaflets > Leaky
We can visualize soft tissue and blood flow
Image from Philips Healthcare iE33 Echocardiography System Image Library
Philips xPlane > Biplane TEEMVR > Mixing of Reds and Blues = Regurgitation
3D Imaging Provides Stunning Detail ...
3D TEE Photograph during Surgery
Images from Ma et al., Chinese Med J 121(20) (2008).
RT3D > Inferior View > Ruptured ChordPhotograph > Ruptured Chord
... and Roadmaps the Repair
Images from Ma et al., Chinese Med J 121(20) (2008).
Quantitative Analysis > 3D Visualization > Specific AreaRoadmap the Intervention
Image Guidance Devices are Expensive
Philips X7-2t Probe > Engineering Marvel > many $10Ks > outside CV systemAcuNav > ~10 yrs old > $2500 disposable > Certified Resterilization
A Cardiologist ... and a Cast of Thousands
Images from iStockPhoto.com and ShutterStock.com
Complexity > Echo > Anasthesia > Surgeons
“Structural Heart Disease Interventions are to Cardiac Ultrasound
what
Percutaneous Coronary Interventions were to X-Ray Coronary Angiography.”
John D. Carroll, MDTranscatheter Cardiovascular Therapeutics 2009
Acknowledgements
All my colleagues at SVMI
Sean Madden, PhD! InfraReDx, Boston, MA
Geoff Vince, PhD! Volcano Corporation, San Diego, CA
Brian Courtney, MD ! Sunnybrook Health Science Center, Toronto, Canada
Chris Daft, PhD! Siemens Ultrasound, Mountain View, CA
Thank YouKendall R. Waters, PhD