Multimodal Imaging of a Culotte Bifurcation Procedure in the Left Main Coronary Artery of a Perfusion-Fixed Human Heart: Step-by-Step with Serial Micro-CT Analyses

Fig. 1. Visible Heart® apparatus. a After each key step of the procedure, the tubes were clamped and the descending aorta, guide catheters, and guidewires were tied alongside the acrylic case before being transported to b a micro-CT scanner for imaging. The heart was then returned to the laboratory to continue intervention

Fig. 2. (Top) Direct visualization of the left main ostia was used to guide the operator and capture anatomical changes during percutaneous coronary intervention (PCI). At the eight steps that were micro-CT scanned, endoscopic cameras were used to capture the stent and bifurcation in real time (see also Online Resource 1). (Bottom) Micro-CT scans were taken (a) before PCI, (b) post initial stent deployment, (c) following proximal optimization technique (POT) of the initially placed stent, (d) showing patenting of the side branch using a kissing balloon technique (KBT), (e) after the secondary stent deployment, (f) following POT of the secondary stent, (g) after patenting the main branch using second KBT, and (h) after final POT

Fig. 3. a Optical coherence tomography (OCT) scans were taken before percutaneous coronary intervention (PCI). b Proximal optimization technique (POT) of the initially placed stent. c Patenting the side branch using kissing balloon technique (KBT). d After secondary stent deployment. e Patenting main branch using a second KBT. f And after final POT. Scans were not obtained to capture initial stent deployment and POT of second stent due to the risk associated with advancing OCT catheter

Fig. 4. Micro-CT imaging of anatomy before percutaneous coronary intervention (PCI) (a) allowed for visualization of diseased anatomy. Stepwise procedure of provisional technique (b–d) enhanced understanding of how the anatomy, the stent, and its apposition were altered during PCI. After completion of provisional technique, the same stepwise approach was used to perform a Culotte technique (e–h) from the preexisting provisional. The change in image orientation after the second stent deployment helps to view both stents and appreciate changes in anatomy, stent, and apposition during PCI

Fig. 5. Stent apposition. Distribution of elements according to their apposition from Table 1 was converted into stacked percentage graph, enabling easy representation and comparison of apposition in each procedural step

Fig. 6. Blood volume and stent 3D models from scans of each procedural step were further analyzed to create consistent polygon of confluence (POC) for each model. The resulting models before and after percutaneous coronary intervention are placed side by side and displayed from a posterior and b side views. Each model illustrates the centerline, planes along the centerline, bifurcation angle, segments of left main, left anterior descending, and left circumflex artery blood volume (shown in opaque portions), and POC (transparent center region)