Matheen Khuddus (director of Cardiovascular Research, The Cardiac & Vascular Institute, Gainesville, USA) discusses the LightLab initiative, and how it is changing the perception of optical coherence tomography (OCT) imaging technology in the cath lab.
There have been tremendous advancements in the field of interventional cardiology since the first coronary intervention was performed over 40 years ago. From balloon catheters to guidewires to the blood thinners we use, these advances are nothing short of extraordinary. But despite these improvements, the fundamental technique used to perform percutaneous coronary intervention (PCI) has not changed and too often is guided only by a shadowy angiogram.
In recent years, the development and improvement in intracoronary imaging technology represent a significant advancement in PCI technique. Optical coherence tomography (OCT), in particular, with its powerful platform, provides operators with a tremendous amount of information very rapidly in a user-friendly format. Nevertheless, the utilisation of intracoronary imaging in the USA remains very low despite clearly demonstrated benefits in multiple clinical trials.
So why the resistance to adoption and what are the barriers? The perception that imaging takes too long and lengthens the procedure is one of the most often mentioned reasons. Some cardiologists feel that their experience with angiography is sufficient and do not believe that intracoronary imaging would change their decision-making or provide additional benefit to the patient. And of course, for many (myself included), the lack of formal training during fellowship can be an obstacle to adoption. Any interventional cardiologist can attest to the fact that learning to use a new guidewire or balloon is relatively easy but that the effective utilisation of intracoronary imaging requires more extensive education and training.
LightLab paves the way
While these barriers are frequently referenced, it is unknown whether these are real or just perceived. Is it possible that when utilised with a prescribed workflow algorithm, the routine use of OCT can overcome these reported barriers to intracoronary imaging?
That’s where the LightLab clinical initiative comes in. The LightLab initiative is a multi-phase program designed to evaluate the impact of routine OCT utilisation on physician decision-making, procedural efficiency, and safety when compared with angiography alone to guide percutaneous coronary intervention (PCI). Abbott field clinical engineers collaborated with interventional cardiologists in 16 medical centres across the USA and collected real-world procedural data over a 24-month period to determine the impact of utilising OCT with a prescribed workflow algorithm. The MLD MAX algorithm focuses first on strategising pre-PCI with a stepwise evaluation of Morphololgy, lesion Length and vessel Diameter and then optimizing the result post stent placement with the assessment for Medial dissection, stent Apposition and stent eXpansion.
The LightLab goal is to not only better understand the barriers to routine adoption of OCT, but also if the routine use of OCT coupled with the MLD MAX algorithm can overcome these barriers or even provide previously unrecognised procedural benefits. For example, if time is the issue, how much more time is it (if any) that physicians are spending daily in the cath lab when using OCT and the prescripted workflow? Is it ten minutes or two hours? If it is ten minutes and it means improved procedural or clinical outcomes, less radiation or a reduction in equipment use, then I think we would all agree that is time well spent.
The utilisation of OCT along with the workflow algorithm represents the first systematic implementation of artificial intelligence in the cath lab and incorporating this into my own practice has resulted in a remarkable transformation. I no longer rely solely on intuition or my previous experience to interpret angiograms; instead, I have access to rich data with detail and precise measurements. The technology does not take the decision-making away from me, but rather facilitates the process allowing me to make better and more informed decisions. The synergy between the OCT platform and the workflow algorithm means there is no more “guesstimating” related to selecting a stent size, stent length, strategy for plaque modification, or stent optimization post PCI.
The LightLab findings will certainly serve to drive future platform improvements. Similar to software releases and new generations of mobile phones, laptops and tablets, I can say with confidence that future iterations will only get better and further compliment the workflow algorithm with more rapid determination of vessel sizing and improved assessment of plaque morphology.
We already know that intracoronary imaging improves patient care; this has been validated in numerous clinical trials and is being further examined in the recently enrolled ILUMIEN IV trial comparing OCT guided PCI to angiographic guided PCI. I believe that the LightLab data will demonstrate additional benefits of using OCT with a prescribed algorithm. But don’t just take the word of early adopters like me—the proof will be in the results. I look forward to seeing what the subsequent phases of the LightLab Initiative reveal with the continued focus on the effect the prescribed workflow will have on efficiency, cost, and safety gains during PCI procedures—something I certainly value greatly as an interventional cardiologist.
Matheen Khuddus reports that he serves as a consultant for Abbott, and on an advisory panel for Boston Scientific.