benedek theodora - curs cardiologie interventionala final

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    University of Medicine and Pharmacy Tirgu-Mures

    Course of Interventional Cardiology


    Benedek Theodora and Benedek Imre

    2013 This book is for educational purposes only, to be used by the medical students

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    Table of contents

    1. Introduction..3

    2. Historic perspectives3

    3. The structure of a laboratory of interventional cardiology .6

    4. Cardiac catheterization**.8

    5. Coronary angiography**23

    6. Percutaneous coronary interventions..35

    7. Imaging in interventional cardiology..46

    8. Structural interventions....59

    9. Interventional treatment in peripheral arterial diseases...72

    10. Interventional treatment in aortic aneurysms.81

    11. Interventional treatment in carotid artery diseases...83

    12. Interventional treatment in renal artery stenosis.85

    13. Renal denervation in severe hypertension..87

    14. Interventional electrophysiology88

    15. Interventional therapy in heart failure96


    *This book includes a selection of the most relevant and recent publications and guidelines in the field of interventional cardiology, together with original texts of the authors. **by permission of Oxford University Press

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    1. Introduction

    The goal of this book is to provide the necessary knowledge to

    become familiar with invasive techniques used in cardiology for

    interventional diagnosis and treatment of different heart diseases.

    Therapeutic decisions in cardiology are crucially determined by

    invasive imaging of coronary arteries and haemodynamics, which are

    essential for understanding the pathophysiological and diagnostic aspects of

    cardiovascular disease.

    2. Historic perspectives

    The first catheterization in animals was performed by Charles Bernard

    in 1846, and the first measurement of intracardiac pressures in animals by

    Chauveau and Marey in 1861.

    The first right heart catheterization as self-experiment was performed

    by Forssmann in 1929 followed by the first clinically used cardiac

    catheterization performed in 1930 by Klein.

    Cournard and Marurice initiated the routine clinical use of cardiac

    catheterization therapy in 1939 and since than, cardiac catheterization it

    rapidly became one of the most commonly performed medical techniques in


    After first clinical application of cardiac catheterization procedures in

    the period of 1938-1948, left heart access was first tempted in the ages of

    `50. The period of 1960-1977 was characterized by large scale spread of

    coronary angiography procedures, and since 1977 a rapid development of

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    different therapeutic procedures is encountered, with applications in

    different fields of cardiology (ischaemic heart diseases, valvular heart

    diseases, congenital heart diseases, electrophysiology, structural

    interventions, etc) so that in present almost the full spectrum of heart

    diseases is covered by applications of interventional cardiology.

    Different cornerstones have been recorded during the years, like:

    -1942 - catheterization of right venbtrile by Cournard and Maurice

    -1944 - catheterization of pulmonary artery by Cournard and Maurice

    -1949 - regtrograde catheterization by Zimmerman

    -1956 - first apical left ventricular puncture by Brock

    -1959 - first transseptal left atrial access by Ross

    -1970 - Bedside catheterization and monitoring of right heart pressures by

    Ganz and Swan

    The pioneer of therapeutic interventional cardiology was Andreas

    Grunzig, who performed the first Percutaneous Transluminal Coronary

    Angioplasty (PTCA) in 1977. From 1977 to 1981, coronary angioplasty was

    recommended for only selected cases, in symptomatic patients with good

    ventricular function. However, since the `80s an impressive spread of the

    indications of coronary angioplasty has been recorded, after new

    technological advances such as steerable guidewires and monorail catheters

    had made PTCA easier and more successful.

    The concept of directional atherectomy was introduced by Simpson in

    1985 and the first atherectomy was performed in 1987 in femoral superficial


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    As the restenosis remained the main limitation of coronary

    angioplasty, new devices have been developed to overcome the potential risk

    of neointimal proliferation, such as brachyterapy in 1996. However, the

    main and revolutionary development in interventional cardiology is

    represented by introduction of coronary stenting, which brought a solution to

    the main problem of restenosis. The first coronary stenting was performed in

    1986 by Puel, and initially it was recommended only for treatment of

    coronary occlusions during PCI. In 1991, Serruys reported a re-stenosis rate

    of 14%, much below the one recorded by PTCA alone. The risk of stent

    thrombosis was overcomed after initiation of dual antiplatelet therapy as


    As the restenosis of implanted stents remained a critical issue, during

    the last years of the 21th century a large number of drug-eluting stent (DES)

    types have been proposed to prevent restenosis (Cypher, Taxus, etc). Over

    the following years, many new generations DES have been introduced in the

    interventional cardiology market leading to achievement of very low

    resetenosis rates nowadays. Since 2005, new generations of biodegradable

    stents have also bee introduced on the market

    The latest years are dominated by an impressive expansion of new

    imaging techniques in interventional cardiology: Intravascular Ultrasound

    associated with Virtual Histology, allowing complex assessment of the

    morphology of coronary plaques based on the echo-attenuations of plaques,

    Optical Coherence Tomography, allowing intracoronary visualization of

    coronary plaques, accurate assessment of intima and superb visualization of

    intracoronary thrombus, or Near-infrared spectroscopy (NIR), characterizing

    the plaque composition according to its cholesterol content.

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    3. The structure of a laboratory of interventional cardiology

    A laboratory of interventional cardiology contains a special X-ray

    equipment called angiograph, consisting in an X-ray tube and a generator of

    X-ray source. The tub of the angiograph has a mobile component, allowing

    rotation and tilting in order to provide visualization of coronary tree from

    different angles, which is crucial for accurate assessment of coronary artery

    stenoses. Also, the angiograph is equipped with monitors on which coronary

    arteries are visualized after injection of contrast material in the coronary


    Usually images and cineloops are saved on dedicated workstations of

    on storage devices.

    The injection of high volumes of contrast material (necessary in case

    of ventriculography, aortography or arteriography) is usually performed

    using contrast injectors with adjustable presetings of speed and volume.

    All the interventional laboratories should be equipped with the

    necessary devices for cardio-pulmonary resuscitation or other types of

    emergencies (defibrillators, temporary pacemaker, monitors, ECG, etc),

    while in a complex laboratory of interventional cardiology more complex

    equipments should be present, such as contrapulsation pump, intravascular

    ultrasound, etc.

    In case of a laboratory dedicated to electrophysiology procedures, it

    contains also special equipments (EP lab systems, stimulators and devices

    for ablation of cardiac arrhythmia)

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    Fig. 1 - structure of a cardiac catheterization laboratory

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    4. Cardiac catheterization

    Cardiac catheterization represents introduction of special catheters in

    the heart chambers, allowing hemodynamic measurements in the heart

    cavities (pressure, gradients, shunts). Invasive assessment of cardiac

    haemodynamics and coronary physiology and imaging needs temporary

    vascular access, which is realized using arterial puncture (usually femoral or

    radial). The femoral approach is the most used currently, however the radial

    approach is gaining in popularity and acceptance. Similarly, venous

    puncture (femoral, brachial, internal jugular vein, subclavian) is currently

    used to access the right heart (or the left heart through trans-septal puncture).

    The term right heart catheterization refers to catheterization of right

    cardiac chambers, performed using venous femoral approach, by puncturing

    either left or right femoral vein, while left heart catheterization means

    catheterization of left cardiac chambers performed using arterial approach,

    puncturing right or left femoral artery (fig.2).

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    Fig. 2 - Right and left cardiac approach


    The main indications for cardiac catheterization are the following,

    when these data cannot be ontained non-invasively.

    -assesment of valvulopathy severity

    -determination of cardiac output

    -determination of intracardiac shunts

    -determination of pulmonary artery pressure and pulmonary capilary

    wedge pressure

    -determination of Left ventricular end-diastolic pressure indicator of

    LV dysfunction severity

    -determination of pulm