INTERVENTIONAL CARDIOLOGY AN OVERVIEW Timothy P. Morris, D.O., F.A.C.C

INTERVENTIONAL CARDIOLOGY

AN OVERVIEW

Timothy P. Morris, D.O., F.A.C.C.


• DIAGNOSTIC CATHETERIZATION• CORONARY ANGIOPLASTY• AORTIC AND PERIPHERAL ANGIOPLASTY• PERCUTANEOUS CLOSURE OF SHUNTS• FOREIGN BODY REMOVAL• STIMULATION OF COLLATERAL

FORMATION


• UNITED STATES 1.2 MILLION DIAGNOSTIC CATHETERIZATIONS PER YEAR

• 480,000 CORONARY ANGIOPLASTIES PER YEAR

• 1 MILLION WORLDWIDE


• HISTORY– FORSSMAN 1929

• 1st RIGHT HEART CATH

– ZIMMERMAN 1950• 1st LEFT HEART CATH

– SELDINGER 1953– SONES 1958– GRUENTZIG 1977


INDICATIONS

• ASYMPTOMATIC– POSITIVE STRESS TEST

– SUDDEN CARDIAC DEATH

– INDIVIDUALS IN HIGH RISK PROFFESIONS

– PRIOR TO SURGERY WITH BORDERLINE POSITIVE NONINVASIVE STRESS TESTS AND RISK FACTORS


• SYMPTOMATIC– FAILED MEDICAL THERAPY– UNSTABLE ANGINA PECTORIS– PRINZMETAL’S ANGINA– ANGINA PECTORIS

• INTOLERANCE TO MEDS

• HIGH RISK OCCUPATION

• MARKEDLY ABNORMAL STRESS TEST

– PRIOR TO VASCULAR SURGERY


• ATYPICAL CHEST PAIN– HIGH RISK NON-INVASIVE STUDIES– SUSPECTED CORONARY VASOSPASM– CONGESTIVE HEART FAILURE

• POST MYOCARDIAL INFARCTION– FAILED THROMBOLYTIC THERAPY– SUSPECTED COMPLICATIONS


• VALVULAR HEART DISEASE– POSITIVE NON-INVASIVE STRESS TEST– PRIOR TO VALVE REPLACEMENT

• MALES > 35 y.o.• FEMALES > 40 y.o.

• CONGENITAL HEART DISEASE– SUSPECTED CORONARY ANOMALIES– MALES > 40 y.o., POST MENOPAUSAL

FEMALES


• PROCEDURE– ARTERIAL ACCESS– VENOUS ACCESS– LEFT HEART CATH– RIGHT HEART CATH– SELECTIVE CORONARY ANGIOGRAPHY


LIMITATIONS OF ANGIOGRAPHY





ULCERATED PLAQUE


INDICATIONS FOR PTCA

• ASYMPTOMATIC , MILD SYMPTOMS– SUDDEN CARDIAC DEATH– SEVERE MYOCARDIAL ISCHEMIA– FAILURE MEDICAL THERAPY– INTOLERANT OF MEDICAL THERAPY– PRIOR TO HIGH RISK SURGERY


INDICATIONS FOR PTCA

• SYMPTOMATIC– UNSTABLE ANGINA PECTORIS– FAILED MEDICAL THERAPY– LARGE AREA VIABLE MYOCARDIUM– RESCUE PTCA– PRIMARY PTCA IN ACUTE MI– CARDIOGENIC SHOCK



INTERVENTIONAL CARDIOLOGY PTCA PROCEDURE

• FEMORAL ARTERIAL/ VENOUS ACCESS

• PLACE GUIDE CATHETER

• WIRE LESION

• BALLOON ANGIOPLASTY

• STENT

• “SEAL ARTERIOTOMY”


PHARMACOLOGIC THERAPY• ASPIRIN

• HEPARIN

• GLYCOPROTEIN 2B-3A INHIBITORS

• TICLID

• PLAVIX

• TREATMENT OF RISK FACTORS



CONTRAINDICATIONS• ABSOLUTE

– UNPROTECTED LEFT MAIN– LESION LESS THEN 50% – NO SURGICAL BACKUP

• RELATIVE– DIFFUSELY DISEASED SVG– DIFFUSELY DISEASED NATIVE VESSELS

WITH GOOD DISTAL TARGETS


CONTRAINDICATIONS• RELATIVE (continued)

– BLEEDING DIASTHESIS– PTCA OF NON-INFARCT VESSEL DURING

PRIMARY PTCA – HIGH RISK ANATOMY FOR ABRUPT

CLOSURE– SOLE VESSEL SUPPLYING HEART– DIABETICS WITH MULTIVESSEL Dx


MAJOR COMPLICATIONS

• DEATH (0.5%-1%)

• Q-WAVE MYOCARDIAL INFARCTION ( 1%-3%)

• EMERGENT SURGERY (1%)


PROCEDURAL COMPLICATIONS

• ACUTE CLOSURE (4%-8%)– SPASM– THROMBUS – DISECTION– EMBOLISM– TREATABLE WITH STENTS

• PERFORATION



SHORT TERM RESULTS• SUCCESS RATES (90%-95%)

• RESTENOSIS – OCCURS IN 2-4 MONTHS ,RARE AFTER 6

MONTHS– RATE (32%-57%)– STENTS ( 20%-30%)




LONG TERM RESULTS

• SURVIVAL– 1 YEAR ( 97%)– 5 YEARS (88%-97%)– 10 YEARS (78%-90%)

• EVENT-FREE SURVIVAL– 1 YEAR (81%-90%)– 5 YEARS ( 79%)– 10 YEARS ( 65%)


NEW DEVICES• STENTS

• DIRECTIONAL ATHERECTOMY

• ROTATIONAL ATHERECTOMY

• TRANSLUMINAL ATHERECTOMY

• ANGIOJET

• RADIATION

• PMR



NIR STENT

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Non Non ––Q Wave MIQ Wave MI

NonNon--Q MI s/p stentQ MI s/p stentNonNon--Q MI s/p stentQ MI s/p stent

PostPost--infarct Anginainfarct Angina

PostPost--infarct Angina s/p stentinginfarct Angina s/p stenting



Failed Retavase Prior to AngiojetFailed Retavase Prior to Angiojet

Failed Retavase s/p Angiojet and Failed Retavase s/p Angiojet and stentingstenting


MITRAL VALVULOPLASTY


CAROTID STENOSIS


CAROTID STENOSIS AFTER STENTING


SUBCLAVIAN STENOSIS


SUBCLAVIAN STENOSIS POST PTA


PTMR

INTERVENTIONAL CARDIOLGY

SUMMARY• RAPIDLY GROWING FIELD

• PTCA IDEAL FOR SINGLE VESSEL AND 2-VESSEL DISEASE WITHOUT PROXIMAL LAD INVOLVEMENT

• STENTS USED IN 80% PTCA CASES

• RESTENOSIS A LIMITING FACTOR

• NON-CORONARY PTA EXPANDING

Documents

INTERVENTIONAL CARDIOLOGY AN OVERVIEW Timothy P. Morris, D.O., F.A.C.C