Avoid Unnecessary Stenting

Optical Coherence Tomography (OCT) 1

The cutting-edge technology, known as Optical Coherence Tomography (OCT), enables physicians to be extremely precise when performing such heart procedures as placing a stent to unblock an artery. The high-resolution images can be especially important in assessing stent placement by clearly showing how the stent is holding the artery open and whether it is positioned correctly against the artery wall, optimizing treatment and follow-up strategies.
The enhanced precision should result in better outcomes for patients .OCT is a diagnostic tool that allows a physician to understand the composition of a heart blockage." According to Dr Amit Bhushan Sharma senior consultant and director heart attack Program at Artemis Health sciences Gurgaon.
Dr Sharma was among the first cardiologists to treat patients with OCT at Mount Sinai Newyork , beginning May 2011. He also was a co investigator in Yellow trial which researched the technology prior to its being approved by the FDA in May 2010 for use in the United States.
"We have developed a good understanding of how OCT works and know it really well," Dr Sharma said, noting that other interventional cardiologists in India are rapidly adopting the new technology.
OCT- already used in Europe and Japan-is employed in conjunction with heart catheterization procedures, including angioplasty, in which a cardiologist uses a tiny balloon on the tip of a catheter to unblock an artery in the heart. Most patients who undergo balloon angioplasty also receive a stent-a small mesh-like device placed inside the artery to keep the vessel open.
Before performing angioplasty, a cardiologist may use intravascular ultrasound, which utilizes sound waves to send back images showing where blockages are located in heart arteries and where to place the stent. Rather than using sound waves, OCT forms images by reflecting light inside blood vessels, allowing the cardiologist to see 10 times more detail than with intravascular ultrasound technology.
Dr Sharma added, "We are now able to clearly see the plaque, determine how much fat or clot there may be in an artery and take precise measurements before and after placing stents. The technology is also fast and easy to use."
Optical Coherence Tomography (OCT) C7-XR System

Optical Coherence Tomography (OCT) 2

Optical coherence tomography (OCT) is a diagnostic procedure that is used in combination with a procedure called cardiac catheterization. The technique uses near-infrared light to create images of the inside of your blood vessels. Unlike ultrasound, which uses sound waves to produce an image of the blood vessels, OCT uses light. With OCT, doctors can obtain images of the blood vessels that are about the same as if they were looking under a microscope.
How does it work?
OCT uses near-infrared light to create images of the inside of the coronary arteries. The technique delivers such high-resolution images because it uses light instead of sound waves. A beam of light is directed at the artery, and some of the light reflects from inside the artery tissue and some of it scatters. This scattered light causes something called "glare." Using OCT, the glare can be filtered out. Even the smallest amount of reflected light that is not scattered can be detected and used to form the image of the coronary artery. In fact, OCT allows cardiologists to see in 10 times more detail the inside an artery than if they were using intravascular ultrasound.
OCT is used along with heart catheterization procedures, including angioplasty, in which cardiologists use a tiny balloon on the tip of a catheter to unblock a coronary artery. Most patients who undergo balloon angioplasty also receive a stent—a small mesh-like device placed inside the artery to keep it open. OCT images can help cardiologists see if a stent is holding an artery open and whether the stent is positioned correctly against the artery wall. OCT also lets cardiologists clearly see the plaque inside an artery, find out how much fat or clot is inside an artery, and take precise measurements before and after placing stents.
What should I expect?
Do not eat or drink anything after midnight the night before your procedure. Talk to your doctor about any medicines that you are taking, because he or she may want you to stop taking them before the procedure. Also, it may be helpful if you make a list of the medicines and take it with you to the procedure, so that the doctors and technicians know exactly what you are taking and how much. You will most likely have blood tests, an electrocardiogram, and a chest x-ray taken before the procedure.
Once you are in the catheterization laboratory (also called the cath lab), you will see television monitors, heart monitors, and blood pressure machines. You will lie on an examination table, which is usually near an x-ray camera.
Electrodes will be placed on your chest. These electrodes have wires called leads, which hook up to an electrocardiogram machine. This machine will monitor your heart rhythm.
To prevent infection, you will be shaved and cleansed around the area of your groin or arm where the catheter will be inserted.
A needle with a tube connected to it will be put in your arm. This is called an intravenous line or IV. You will get a mild sedative through the IV to relax you.
You will be given an anesthetic medicine with a needle to numb the area around where the catheter will be inserted. You may feel mild discomfort when the local anesthetic is given.
You should not feel any further pain from this point forward in the procedure. Doctors then insert a sheath into the artery or vein. Different catheters can be inserted and removed through the sheath to perform the catheterization
Before performing angioplasty or placing a stent, cardiologists may use OCT to create images that show where the blockages are in the coronary arteries and where to place the stent.
After the procedure, the catheter and IV line will be removed. You will also be disconnected from the electrocardiogram machine. Firm pressure will be applied to the site where the catheter was inserted to stop any bleeding. You will also be bandaged.
You will be moved to another room where you will need to rest for 5 or 6 hours. You may feel a little sleepy until the sedative has worn off. You will be told to lie still. If the catheter was inserted in your groin, try not to bend your knee. If the catheter was inserted in your arm, try not to bend your elbow. Nurses will watch you to see that your heart rate and blood pressure are normal. After this time of rest, you can go home.

Intravascular ultrasound ( IVUS ) / Fractional flow reserve ( FFR )

The First Question to be answered during conventional angiography
“Is the patient’s blockage responsible for the clinical syndrome?” If the answer is no, then stenting is of no value to the patient and introduces unneeded risk and cost.
To measure the effect of the stenosis on blood flow, FFR is calculated by measuring the pressure across the blockage with a 0.014-inch pressure sensor guide wire. FFR values of <0.80 are strongly associated with positive ischemia testing and appropriateness of stenting. FFR values >0.80 are associated with low event rates in patients who have intermediate lesions managed medically without stenting. The FAME study3 has convincingly demonstrated the superiority of FFR-guided multi-vessel percutaneous coronary intervention (PCI) over the conventional, angiographically-guided PCI.
IVUS – Dimensions for decisions Intravascular ultrasound (IVUS) imaging provides a picture from within a coronary artery showing the vessel wall, plaque and lumen in precise detail with resolution to 150 microns. IVUS use is based on one critical principle, which is angiography cannot accurately show the sizes (dimensions) or composition of coronary arteries and luminal narrowings. This information is critical to stent size selection and implantation, as well as selection of devices to treat calcified stenoses. The IVUS advantage over angiography for determining when a stent is correctly sized, fully expanded and struts apposed to the vessel wall is indisputable

To be issued for public use

Heart disease accounts for almost 40% of all the deaths in India. There are about 200,000 cases of coronary stenting yearly in India. Unnecessary or inappropriate coronary stenting has been estimated to occur in up to 10-20% of cases.
With advances in technology, now not every block will need an open heart surgery or a stent. New techniques and better imaging tools like Fractional flow reserve (FFR) and Intravascular Imaging ( IVUS and OCT ) make it possible to get closer view of the heart and decide whether a surgery or a stent is required to correct the defect.
Dr Sharma who was one of the co investigators for Yellow trial which is a multicentre trial involving 8 countries and 5500 patients integrated angiography with OCT and FFR which helps reduce death and heart attack by 35% at 1 year follow-up compared with angiography alone.
In FFR technology a wire is inserted into the artery of the patient to reach the block of the heart. The wire which has a device attached to it measures the pressure levels above and below the block and feeds the data to a monitor. The doctor has to calculate the ratio of the two flows and if the result is below .8 then the block has to be treated through a stent or surgery, otherwise it can be left alone.
Optical Coherence Tomography (OCT). Through this a 3D image of the blood vessel is taken it can detect which blockages will lead to heart attacks & makes it possible to assess the situation inside the blood vessel after a stent is placed.
All these can be done along with angiography and it takes an additional 5 to 7 minutes
Dr Amit B. Sharma is a senior consultant cardiologist at Artemis Health institute Gurgaon.He underwent fellowship in complex angioplasty in the busiest centre of united states Mount Sinai Hospital New York He is a visting a faculty in prestigious Michigan state university USA and Asan Medical centre South Korea.
He has more than 7500 angioplasties to his credit with a vast experience in OCT, IVUS and FFR. He is a founder member of SAUS ( society to avoid unnecessary stenting ). His website avoid unnecessarystenting.com and amitsharmacardiologist.com deals with all the information one needs to know before going for stenting. He can be reached at amit@amitsharmacardiologist.com.

For apptments please contact:
Artemis health institute is headed by world renowned Cardiologist Dr MS sandhu, both these consultants among them have an national and international experience of over 20000 cases and have over 100 publications to their credit.