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.

INTERVENTIONAL CARDIOLOGY

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

FORMATION

INTERVENTIONAL CARDIOLOGY

• UNITED STATES 1.2 MILLION DIAGNOSTIC CATHETERIZATIONS PER YEAR

• 480,000 CORONARY ANGIOPLASTIES PER YEAR

• 1 MILLION WORLDWIDE

INTERVENTIONAL CARDIOLOGY

• HISTORY– FORSSMAN 1929

• 1st RIGHT HEART CATH

– ZIMMERMAN 1950• 1st LEFT HEART CATH

– SELDINGER 1953– SONES 1958– GRUENTZIG 1977

INTERVENTIONAL CARDIOLOGY

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

INTERVENTIONAL CARDIOLOGY

• 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

INTERVENTIONAL CARDIOLOGY

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

• POST MYOCARDIAL INFARCTION– FAILED THROMBOLYTIC THERAPY– SUSPECTED COMPLICATIONS

INTERVENTIONAL CARDIOLOGY

• 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

INTERVENTIONAL CARDIOLOGY

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

INTERVENTIONAL CARDIOLOGY

LIMITATIONS OF ANGIOGRAPHY

INTERVENTIONAL CARDIOLOGY

INTERVENTIONAL CARDIOLOGY

INTERVENTIONAL CARDIOLOGY

INTERVENTIONAL CARDIOLOGY

ULCERATED PLAQUE

INTERVENTIONAL CARDIOLOGY

INDICATIONS FOR PTCA

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

INTERVENTIONAL CARDIOLOGY

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

INTERVENTIONAL CARDIOLOGY

INTERVENTIONAL CARDIOLOGY PTCA PROCEDURE

• FEMORAL ARTERIAL/ VENOUS ACCESS

• PLACE GUIDE CATHETER

• WIRE LESION

• BALLOON ANGIOPLASTY

• STENT

• “SEAL ARTERIOTOMY”

INTERVENTIONAL CARDIOLOGY

PHARMACOLOGIC THERAPY• ASPIRIN

• HEPARIN

• GLYCOPROTEIN 2B-3A INHIBITORS

• TICLID

• PLAVIX

• TREATMENT OF RISK FACTORS

INTERVENTIONAL CARDIOLOGY

INTERVENTIONAL CARDIOLOGY

CONTRAINDICATIONS• ABSOLUTE

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

• RELATIVE– DIFFUSELY DISEASED SVG– DIFFUSELY DISEASED NATIVE VESSELS

WITH GOOD DISTAL TARGETS

INTERVENTIONAL CARDIOLOGY

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

INTERVENTIONAL CARDIOLOGY

MAJOR COMPLICATIONS

• DEATH (0.5%-1%)

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

• EMERGENT SURGERY (1%)

INTERVENTIONAL CARDIOLOGY

PROCEDURAL COMPLICATIONS

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

• PERFORATION

INTERVENTIONAL CARDIOLOGY

INTERVENTIONAL CARDIOLOGY

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

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

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

INTERVENTIONAL CARDIOLOGY

INTERVENTIONAL CARDIOLOGY

INTERVENTIONAL CARDIOLOGY

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%)

INTERVENTIONAL CARDIOLOGY

NEW DEVICES• STENTS

• DIRECTIONAL ATHERECTOMY

• ROTATIONAL ATHERECTOMY

• TRANSLUMINAL ATHERECTOMY

• ANGIOJET

• RADIATION

• PMR

INTERVENTIONAL CARDIOLOGY

INTERVENTIONAL CARDIOLOGY

NIR STENT

• C:\WINDOWS\All Users\Application Data\Microsoft\Works\Portfolio\Sample.dir\70\Portfolio file 1.emf

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

INTERVENTIONAL CARDIOLOGY

INTERVENTIONAL CARDIOLOGY

Failed Retavase Prior to AngiojetFailed Retavase Prior to Angiojet

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

INTERVENTIONAL CARDIOLOGY

MITRAL VALVULOPLASTY

INTERVENTIONAL CARDIOLOGY

CAROTID STENOSIS

INTERVENTIONAL CARDIOLOGY

CAROTID STENOSIS AFTER STENTING

INTERVENTIONAL CARDIOLOGY

SUBCLAVIAN STENOSIS

INTERVENTIONAL CARDIOLOGY

SUBCLAVIAN STENOSIS POST PTA

INTERVENTIONAL CARDIOLOGY

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