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  • Review Article
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Optical coherence tomography in coronary atherosclerosis assessment and intervention

Nature Reviews Cardiology volume 19, pages 684–703 (2022)Cite this article

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An Author Correction to this article was published on 18 December 2023

This article has been updated

Abstract

Since optical coherence tomography (OCT) was first performed in humans two decades ago, this imaging modality has been widely adopted in research on coronary atherosclerosis and adopted clinically for the optimization of percutaneous coronary intervention. In the past 10 years, substantial advances have been made in the understanding of in vivo vascular biology using OCT. Identification by OCT of culprit plaque pathology could potentially lead to a major shift in the management of patients with acute coronary syndromes. Detection by OCT of healed coronary plaque has been important in our understanding of the mechanisms involved in plaque destabilization and healing with the rapid progression of atherosclerosis. Accurate detection by OCT of sequelae from percutaneous coronary interventions that might be missed by angiography could improve clinical outcomes. In addition, OCT has become an essential diagnostic modality for myocardial infarction with non-obstructive coronary arteries. Insight into neoatherosclerosis from OCT could improve our understanding of the mechanisms of very late stent thrombosis. The appropriate use of OCT depends on accurate interpretation and understanding of the clinical significance of OCT findings. In this Review, we summarize the state of the art in cardiac OCT and facilitate the uniform use of this modality in coronary atherosclerosis. Contributions have been made by clinicians and investigators worldwide with extensive experience in OCT, with the aim that this document will serve as a standard reference for future research and clinical application.

Key points

  • The appropriate use of optical coherence tomography (OCT) depends on the accurate interpretation and understanding of the clinical importance of OCT findings.

  • In vivo diagnosis of plaque erosion with OCT could lead to a major shift in the management of patients with acute coronary syndromes.

  • Detection by OCT of healed coronary plaque is important for understanding the mechanism of plaque destabilization and healing with rapid progression of atherosclerosis.

  • Accurate detection by OCT of findings after percutaneous coronary intervention that could be missed by angiography has the potential to improve clinical outcomes.

  • OCT has become an essential diagnostic modality for patients with myocardial infarction and non-obstructive coronary arteries.

  • Insights from OCT into neoatherosclerosis could improve our understanding of the mechanisms of very late stent thrombosis.

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Fig. 1: Artefacts on optical coherence tomography.
Fig. 2: Optical coherence tomography images of normal vessel and atherosclerotic plaques.
Fig. 3: Qualitative findings from optical coherence tomography.
Fig. 4: Possible treatment algorithm for patients with ACS based on the assessment of microstructures by OCT.
Fig. 5: Optical coherence tomography images of culprit lesions in patients with acute coronary syndromes.
Fig. 6: Optical coherence tomography findings after percutaneous coronary intervention.
Fig. 7: Optical coherence tomography images of vascular response to stenting.

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Acknowledgements

I.-K.J.’s research is supported by Mrs Gillian Gray through the Allan Gray Fellowship Fund in Cardiology.

Author information

Authors and Affiliations

  1. Massachusetts General Hospital, Boston, MA, USA

    Makoto Araki, Guillermo J. Tearney, Brett Bouma, Aaron D. Aguirre, Vikas Thondapu, Akihiro Nakajima, Lena M. Seegers, Iris McNulty, Hang Lee & Ik-Kyung Jang

  2. Asan Medical Center, Seoul, South Korea

    Seung-Jung Park

  3. University of Vermont, Burlington, VT, USA

    Harold L. Dauerman

  4. Kawasaki Medical School, Okayama, Japan

    Shiro Uemura & Teruyoshi Kume

  5. Yonsei University College of Medicine, Seoul, South Korea

    Jung-Sun Kim, Myeong-Ki Hong & Yangsoo Jang

  6. Careggi University Hospital, Florence, Italy

    Carlo Di Mario

  7. University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK

    Thomas W. Johnson

  8. Ospedale Papa Giovanni XXIII, Bergamo, Italy

    Giulio Guagliumi

  9. Technische Universität München and Munich Heart Alliance, Munich, Germany

    Adnan Kastrati

  10. German Heart Center, Munich, Germany

    Michael Joner

  11. Aarhus University Hospital, Skejby, Denmark

    Niels Ramsing Holm

  12. Hospital Universitario La Princesa, Madrid, Spain

    Fernando Alfonso

  13. National University of Ireland Galway and Saolta University Healthcare Group, Galway, Ireland

    William Wijns

  14. University Hospitals Leuven, Leuven, Belgium

    Tom Adriaenssens

  15. University of Giessen, Giessen, Germany

    Holger Nef

  16. Hospices Civils de Lyon and Claude Bernard University, Lyon, France

    Gilles Rioufol

  17. Institut Mutualiste Montsouris, Paris, France

    Nicolas Amabile

  18. University Hospital of Clermont Ferrand, Clermont-Ferrand, France

    Geraud Souteyrand

  19. University Hospital Jean Minjoz, Besançon, France

    Nicolas Meneveau

  20. University Hospital of Bordeaux, Pessac, France

    Edouard Gerbaud

  21. National Institute of Cardiology, Warsaw, Poland

    Maksymilian P. Opolski

  22. Hospital Clinico San Carlos, IdISSC, Universidad Complutense, Madrid, Spain

    Nieves Gonzalo

  23. Cardiovascular Research Foundation, New York, NY, USA

    Gary S. Mintz, Akiko Maehara, Ziad Ali & Juan F. Granada

  24. Icahn School of Medicine at Mount Sinai, New York, NY, USA

    Gregg W. Stone, Jagat Narula & Valentin Fuster

  25. Barts Health NHS Trust, University College London and Queen Mary University London, London, UK

    Christos V. Bourantas

  26. Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland

    Lorenz Räber

  27. Centro Cardiologico Monzino, IRCCS, Milan, Italy

    Sebastiano Gili

  28. Mitsukoshi Health and Welfare Foundation, Tokyo, Japan

    Kyoichi Mizuno

  29. Yokohama Minami Kyosai Hospital, Kanagawa, Japan

    Shigeki Kimura

  30. Showa University Hospital, Tokyo, Japan

    Toshiro Shinke

  31. Kyung Hee University, Seoul, South Korea

    Jin Man Cho, Hyung Oh Kim & Ik-Kyung Jang

  32. Chinese University of Hong Kong, Hong Kong, Hong Kong

    Bryan P. Yan

  33. University of Genoa, Genoa, Italy, San Martino Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy

    Italo Porto

  34. University of Parma, Parma University Hospital, Parma, Italy

    Giampaolo Niccoli

  35. Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy

    Rocco A. Montone

  36. University Hospital of Ioannina, Ioannina, Greece

    Michail I. Papafaklis & Lampros K. Michalis

  37. New York University Grossman School of Medicine, New York, NY, USA

    Harmony Reynolds

  38. Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada

    Jacqueline Saw

  39. Brigham and Women’s Hospital, Boston, MA, USA

    Peter Libby & Kevin Croce

  40. New York Presbyterian Hospital, Columbia University Medical Center and Cardiovascular Research Foundation, New York, NY, USA

    Giora Weisz

  41. Ospedale San Giovanni Bosco, Turin, Italy

    Mario Iannaccone

  42. Universitäts medizin Mainz and DZHK Rhein-Main, Mainz, Germany

    Tommaso Gori

  43. National and Kapodistrian University of Athens, Athens, Greece

    Konstantinos Toutouzas

  44. Tokyo Medical and Dental University, Tokyo, Japan

    Taishi Yonetsu

  45. Kitasato University School of Medicine, Kanagawa, Japan

    Yoshiyasu Minami

  46. Nippon Medical School Chiba Hokusoh Hospital, Chiba, Japan

    Masamichi Takano & Osamu Kurihara

  47. The Prince Charles Hospital, Chermside, Queensland, Australia

    O. Christopher Raffel

  48. Nara Medical University, Nara, Japan

    Tsunenari Soeda

  49. Tsuchiura Kyodo General Hospital, Ibaraki, Japan

    Tomoyo Sugiyama & Tsunekazu Kakuta

  50. Japanese Red Cross Musashino Hospital, Tokyo, Japan

    Tetsumin Lee

  51. Kawasaki Municipal Tama Hospital, St. Marianna University School of Medicine, Kanagawa, Japan

    Takumi Higuma

  52. Kyoto University Graduate School of Medicine, Kyoto, Japan

    Erika Yamamoto

  53. Jagiellonian University Medical College, Institute of Cardiology, Department of Interventional Cardiology, John Paul II Hospital, Krakow, Poland

    Krzysztof L. Bryniarski

  54. Mazzoni Hospital, Ascoli Piceno, Italy

    Luca Di Vito

  55. Catholic University of the Sacred Heart, Rome, Italy

    Rocco Vergallo, Francesco Fracassi, Michele Russo & Filippo Crea

  56. Korea Advanced Institute of Science and Technology, Daejeon, South Korea

    Sangjoon Park & Jong Chul Ye

  57. University of Texas Health, San Antonio, TX, USA

    Marc Feldman

  58. Hospital Clínico San Carlos, Madrid, Spain

    Javier Escaned

  59. UniCamillus – Saint Camillus International University of Health Sciences, Rome, Italy

    Francesco Prati

  60. IRCCS Foundation University Hospital Policlinico San Matteo, Pavia, Italy

    Eloisa Arbustini

  61. Santa Maria University Hospital, CHULN Center of Cardiology of the University of Lisbon, Lisbon School of Medicine, Lisbon Academic Medical Center, Lisbon, Portugal

    Fausto J. Pinto

  62. MedStar Washington Hospital Center, Washington, DC, USA

    Ron Waksman & Hector M. Garcia-Garcia

  63. CV Path Institute, Gaithersburg, MD, USA

    Aloke V. Finn & Renu Virmani

  64. Mount Sinai Hospital, New York, NY, USA

    Annapoorna S. Kini

  65. Erasmus University Medical Centre, Rotterdam, Netherlands

    Joost Daemen

  66. Yokohama City University Medical Center, Kanagawa, Japan

    Kiyoshi Hibi

  67. Wakayama Medical University, Wakayama, Japan

    Atsushi Tanaka, Takashi Akasaka & Takashi Kubo

  68. Tohoku University Graduate School of Medicine, Sendai, Japan

    Satoshi Yasuda

  69. Mayo Clinic, Rochester, MN, USA

    Amir Lerman & Abhiram Prasad

  70. University Hospital Zürich, Zürich, Switzerland

    Evelyn Regar

  71. Gifu University Graduate School of Medicine, Gifu, Japan

    Yoshihiko Saito

  72. Madras Medical Mission, Chennai, India

    Mullasari Ajit Sankardas & Vijayakumar Subban

  73. MedStar Health Research Institute, Washington, DC, USA

    Neil J. Weissman

  74. Sixth Medical Center, Chinese PLA General Hospital, Beijing, China

    Yundai Chen

  75. The Second Affiliated Hospital of Harbin Medical University, Harbin, China

    Bo Yu

  76. Monash University, Melbourne, Victoria, Australia

    Stephen J. Nicholls

  77. University of Melbourne, Melbourne, Victoria, Australia

    Peter Barlis

  78. Royal Papworth Hospital, Cambridge, UK

    Nick E. J. West

  79. Johns Hopkins University, Baltimore, MD, USA

    Armin Arbab-Zadeh

  80. Leiden University Medical Centre, Leiden, Netherlands

    Jouke Dijkstra

  81. New Tokyo Hospital, Chiba, Japan

    Sunao Nakamura

  82. Massachusetts Institute of Technology, Cambridge, MA, USA

    James Fujimoto

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M.A. and I.-K.J. discussed the content of the article and wrote the manuscript. All the authors reviewed and/or edited the manuscript before submission.

Corresponding author

Correspondence to Ik-Kyung Jang.

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Competing interests

H.L.D. is a consultant to Baim Clinical Research Institute, Boston Scientific, Cardiovascular Research Foundation and Medtronic, and has research grants from Boston Scientific and Medtronic. S.U. received educational grants from Abbott Vascular Japan. J.-S.K. received proctoring fees from Abbott Vascular. C.D.M. received research grants (to the institution) from AMGEN, Behring, Boston Scientific, Chiesi, Daiichi-Sankyo, Edwards, Medtronic, and Shockwave Volcano-Philips and speaker fees from Abbott and Shockwave. T.W.J. received consultancy and speaker fees from Abbott Vascular & Terumo. G.G. received consultant fees from Abbott Vascular and Infraredx and research grants from Abbott Vascular, Amgen and Infraredx. M.J. received personal fees from Abbott, AstraZeneca, Biotronik, Boston Scientific, Edwards, OrbusNeich, Recor, and Shockwave and grants from Amgen, Boston Scientific, Cardiac Dimensions, Edwards and Infraredx. N.R.H. received speaker fees from Terumo, research grants and speaker fees from Abbott and Reva Medical, and research grants from B. Braun, Biosensors, Boston Scientific and Medis Medical Imaging. W.W. received institutional research grants and honoraria from MicroPort (steering Committee TARGET AC trial); is co-founder of Argonauts, an innovation facilitator; and is medical adviser to Rede Optimus Research and Corrib Core Laboratory, NUI Galway. T.Adriaenssens received educational grants from Abbott Vascular. H.N. received speaker honoraria and research grants from Abbott Vascular. N.A. received proctoring and consulting fees from Abbott Vascular and Boston Scientific, consulting fees from Shockwave Medical, and institutional research grants from Abbott Vascular. G.S. received consulting fees from Abbott Medical, Boston Scientific, Medtronic, Shockwave and Terumo. E.G. is a consultant for Abbott Vascular and Terumo. N.G. received speaker and consultant fees from Abbott and speaker fees from Boston Scientific. G.J.T. receives sponsored research funding from AstraZeneca, Canon, CN USA Biotech Holdings, and VivoLight and catheter materials from Terumo. G.J.T. has a financial/fiduciary interest in SpectraWave, a company developing an OCT–NIRS intracoronary imaging system and catheter; this financial/fiduciary interest was reviewed and is managed by the Massachusetts General Hospital and Mass General Brigham HealthCare in accordance with their conflict-of-interest policies. G.J.T. (Canon, Spectrawave and Terumo) has the right to receive royalties from licensing arrangements. B.B. has OCT patents assigned to Massachusetts General Hospital and licensed to Terumo. A.D.A. received research grants from Amgen and Philips Healthcare. G.S.M. received honoraria from Abiomed, Boston Scientific, Medtronic and Philips/Volcano, and has equity in SpectraWave. G.W.S. received speaker honoraria from Cook, Infraredx and Terumo; is a consultant to Ablative Solutions, Abiomed, Ancora, Cardiomech, CorFlow, Elucid Bio, Gore, HeartFlow, MAIA Pharmaceuticals, Miracor, Neovasc, Occlutech, Reva, Robocath, Shockwave, TherOx, Valfix, Vascular Dynamics, Vectorious and V-Wave; and has equity/options from Ancora, Applied Therapeutics, Aria, Biostar family of funds, Cagent, Cardiac Success, MedFocus family of funds, Orchestra Biomed, SpectraWave and Valfix. L.R. received grants to the institution from Abbott, Biotronik, Boston Scientific, Heartflow, Sanofi, and Regeneron and speaker/consultation fees from Abbott, Amgen, AstraZeneca, Canon, Occlutec, Sanofi and Vifor. T.S. received research grants from Abbott Medical Japan. B.P.Y. received research grants and speaker honorarium from Abbott Vascular. L.K.M. received departmental grants from Abbott. H.R. received donations for research from Abbott Vascular, BioTelemetry and Siemens. P.L. is an unpaid consultant to, or involved in clinical trials for Amgen, AstraZeneca, Baim Institute, Beren Therapeutics, Esperion Therapeutics, Genentech, Kancera, Kowa Pharmaceuticals, Medimmune, Merck, Norvo Nordisk, Novartis, Pfizer, Sanofi-Regeneron. P.L. is a member of scientific advisory board for Amgen, Caristo, Cartesian, Corvidia Therapeutics, CSL Behring, DalCor Pharmaceuticals, Dewpoint, Kowa Pharmaceuticals, Medimmune, Novartis, Olatec Therapeutics, PlaqueTec and XBiotech. P.L.’s laboratory has received research funding in the past 2 years from Novartis. P.L. is on the Board of Directors of XBiotech. P.L. has a financial interest in Xbiotech, a company developing therapeutic human antibodies. P.L.’s interests were reviewed and are managed by Brigham and Women’s Hospital and Partners HealthCare in accordance with their conflict-of-interest policies. G.W. is a member of the medical advisory board for Filterlex, Intratech, Microbot and Trisol, and received equity from Filterlex, Intratech and Microbot and consulting fees from Cuspa, Filterlex, Intratech, Magenta and Microbot. T.G. received speaker’s honoraria and research support from Abbot Vascular. K.T. received research grants from Medtronic, and is proctor for Abbott and Medtronic. T.Y. received an endowment from Abbott Vascular Japan, Boston Scientific Japan, Japan Lifeline, Takeyama KK and WIN International. Y.M. received an honorarium and consulting fee from Abbott. R.Vergallo received speaker fees from Abbott. E.A. received grants from the Ministry of Health to the National IRCCS Cardiology Network (RCR-2019-23669116-001 and RCR-2020-23670065) and from FRRB grant CP_14/2018, INTESTRAT-CAD, Lombardia Region, Italy. H.M.G.-G. received institutional grant support from Abbott, Biotronik, Boston Scientific, CorFlow, Medtronic, Neovasc, Philips and Shockwave. Z.A. received institutional grants from Abbott Vascular and Cardiovascular Systems to Columbia University and Cardiovascular Research Foundation; honoraria from Amgen, AstraZeneca and Boston Scientific; and equity from Shockwave. A.V.F. and R.Virmani received institutional research support from NIH (HL141425), Leducq Foundation Grant; 480 Biomedical, 4C Medical, 4Tech, Abbott, Accumedical, Amgen, Biosensors, Boston Scientific, Cardiac Implants, Celonova, Claret Medical, Concept Medical, Cook, CSI, DuNing, Edwards Lifesciences, Emboline, Endotronix, Envision Scientific, Lutonix/Bard, Gateway, Lifetech, Limflo, MedAlliance, Medtronic, Mercator, Merill, Microport Medical, Microvention, MitraAlign, Mitra Assist, NAMSA, Nanova, Neovasc, NIPRO, Novogate, Occulotech, OrbusNeich Medical, Phenox, Profusa, Protembis, Qool, Recor, Senseonics, Shockwave, Sinomed, Spectranetics, Surmodics, Symic, Vesper, W.L. Gore and Xeltis. A.V.F. received honoraria from Abbott Vascular, Biosensors, Boston Scientific, Celonova, Cook Medical, CSI, Lutonix Bard, Sinomed and Terumo; and is a consultant to Amgen, Abbott Vascular, Boston Scientific, Celonova, Cook Medical, Lutonix Bard and Sinomed. R.Virmani received honoraria from Abbott Vascular, Biosensors, Boston Scientific, Celonova, Cook Medical, Cordis, CSI, Lutonix Bard, Medtronic, OrbusNeich Medical, CeloNova, SINO Medical Technology, ReCore, Spectranetics, Terumo, and W. L. Gore and is a consultant for Abbott Vascular, Boston Scientific, Celonova, Cook Medical, Cordis, CSI, Edwards Lifesciences, Lutonix Bard, Medtronic, OrbusNeich Medical, ReCore, Sinomededical Technology, Spectranetics, Surmodics, Terumo, W. L. Gore and Xeltis. T.K. received personal fees from Abbott Japan. K.H. received remuneration for lectures from Terumo, Abbott Vascular and Boston Scientific Japan. T.Akasaka received research grants from Abbott Vascular Japan, Nipro, and Terumo and is a medical adviser for Terumo. A.L. received consultant fees from Volcano and Philips. E.R. is a member of the medical advisory board for Zed Medical and a clinical adviser for Kaminari Medical. B.Y. received research grants from the National Key R&D Program of China (2016YFC1301103) and the National Natural Science Foundation of China (81827806). F.C. received personal fees from Amgen, AstraZeneca, BMS and Servier, and other fees from GlyCardial Diagnostics. J.F. has financial interests in Optovue, receives royalties from intellectual property owned by MIT and licensed to Optovue and receives research support from the NIH and Topcon. I.-K.J. received educational grants from Abbott Vascular and consulting fees from Mitobridge and Svelte. The other authors declare no competing interests.

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Supplementary information

Glossary

Axial resolution

The minimum distance between two objects that can be resolved along the axial dimension.

Near-infrared

Light with wavelengths extending from 0.78 µm to 2.50 µm.

Cross-sectional images

The traditional mode for optical coherence tomography (OCT) images that displays a cross-section of the vessel with a circular shape.

Penetration depth

The depth within a tissue or object at which an OCT image signal has been attenuated (via scattering or absorption) to a level indistinguishable from the background noise.

L-mode

The longitudinal mode represents an OCT image along the longitudinal dimension at a particular rotational angle.

Co-registration

The process of registering two or more images so that they can be viewed and analysed together.

Backscattered light

The reflection of light back in the direction from which it came; usually a diffuse reflection due to scattering as opposed to specular reflection as from a mirror.

Leading edge

The first edge in an object that is encountered along a vector that is pointing away from the catheter; by contrast, the trailing edge is the last edge that is encountered.

Z-offset

Slight variations in optical path length within the catheter, which can be adjusted using the catheter diameter within an image as a reference.

Refractive index

A property of a material that governs the speed of light through that material.

Centroid

The arithmetic mean position of all the points in the figure; also known as the centre of mass.

Adluminal

Near or towards the lumen.

Pullback rate

The speed at which an OCT catheter is pulled back during imaging.

Frame rate

The number of images captured per second.

Attenuation

Loss of light due to scattering and/or absorption by flushing media, blood or tissue that results in a weaker OCT signal.

Speckle

The grainy pattern that appears in OCT images because of the interference of waves with random phase.

Abluminal

Away from the lumen.

Computational fluid dynamics

A branch of fluid mechanics that uses numerical analysis and data structures to analyse and solve problems that involve fluid flows.

Contour

The boundary of a certain object, such as the lumen, stent or plaque component.

Deep learning

A class of machine learning algorithm that uses multiple layers to progressively extract higher-level features from the raw input.

Fluorescence

The emission of light by a substance that has absorbed light or other electromagnetic radiation.

Polarization

A property of light described by the magnitude, orientation and precession of its electric field.

Birefringence

A phenomenon exhibited by a material in which light travelling through the material is divided into two beams of different polarizations.

Depolarization

When the incident beam is fully linearly or circularly polarized, the scattered light can become partially polarized or even totally unpolarized.

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Araki, M., Park, SJ., Dauerman, H.L. et al. Optical coherence tomography in coronary atherosclerosis assessment and intervention. Nat Rev Cardiol 19, 684–703 (2022). https://doi.org/10.1038/s41569-022-00687-9

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