Intravascular optical coherence tomography (OCT) is a new imaging modality in interventional cardiology providing highresolution intracoronary images. The modality is already established as an efficient and precise research tool and is increasingly used for guiding coronary intervention. The quantitative capabilities of marketed OCT systems have been validated and measurements are found accurate and precise in bench testing [1]. When using OCT it is important to carefully calibrate the system for accuratemeasurements [2,3]. Present standard in marketed systems is automated calibration. Still the calibration can be incorrect due to failed automated calibration, wrong manual adjustment, or changes to the length of the optic fiber due to altered bending of the imaging wire. Correct calibration and the identification of incorrect calibration can be challenging due to mirror artifacts, blood in the imaging wire and proximity to the vessel wall. Looking for guidance on calibration of intravascular OCT in published peer reviewed papers led to the identification of some inconsistencies similar to our own experience. Still we do not have a database of wrong calibrations owing to immediate corrections. Therefore we aimed at identifying patterns of failed calibration as presented in images in peerreviewed papers. Using the PubMed internet database, we built a search containing following MESH-terms: “Tomography, Optical Coherence” AND (“Percutaneous Coronary Intervention”OR “Coronary Occlusion”OR “Coronary Stenosis” OR “Coronary Restenosis” OR “Coronary Vessels” OR “Coronary Disease”OR “Coronary Circulation”OR “Coronary Thrombosis” OR “Coronary Artery Disease” OR “Myocardial Reperfusion”). With this search more than 300 articles published since 1 January 2011 were identified. Of these, 222 were included in the analysis giving a total of 1164 OCT images with the information needed for evaluating the calibration. Articles which were excluded from the analysis are due to lack of images (N = 57), lack of fiduciaries (N = 38) or no full-text subscription by the local university library (N = 27). Calibration errors were divided into 8 groups, ranging from slightly incorrect through errors with potentially clinical relevant impact on quantitative measurements. Errors in classes that may likely affect stent sizing if applied in clinical practice were termed serious calibration errors (Classes 3, 4 and 6). Frames which we were unable to classify were not counted and if a frame appearedmore than once or in more articles (e.g. editorials), it was only counted once. Our findings (shown in Table 1) were 1) 640 images produced by time domain OCT systems. Of these 15% were in-assessable. Worse than slightly incorrect calibration, was found in 35% of assessable cases. Serious calibration incorrectness was seen in 16% of images. 2) A total of 524 images had been obtained bymarketed frequency domain systems (482 by C7 system and 42 images by Illumien—both St. Jude Medical, USA). In images acquired by the C7 system serious calibration incorrectness was detected in 16% of cases. In images acquired by the Illumien system (42) only a single acquisition with 3 images was severely incorrect calibrated due to inverted calibration. Inverted calibration may cause the depicted catheter to resemble a correct calibrated OCT catheter. This is an occasional finding termed “inverted calibration” (Class 4 error). A related finding due to inverted calibration is the distortion of the image and appearance of vessel wall or wires inside the apparent imaging wire (Fig. 1 error Class 4). We propose the term “inverted calibration artifacts” for such findings. The “slightly incorrect”-group was expanded to contain also the Class 1 categorized images, as the error in these groups only result in minimal error of the measurements. For the C7 system 43% of images in articles presenting quantitative measurements showed any degree of incorrect calibration. For the M2 system, this was 40%. We are aware, that images shown in articles are chosen for illustrative purpose. This is a process different from the systematic core lab evaluation, andwe assume that all results derivedweremade from correctly calibrated images. Still, systematic errors inmany or all images in a paper might induce a slight uncertainty about derived quantitative results. Incorrect calibration in images presented for tissue characterization or similar could be seen as unimportant. Still, when presented in high impact journals, in expert reviews or consensus reports some users might potentially adopt this as the gold standard of calibration. In conclusion, a high incidence of incorrect calibrated images was found in systematic review of peer reviewed publications. Improved calibration facilities by newer generation OCT systems seems to reduce errors though not alleviating the risk associated with not identifying inverted calibration.
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