curs cardiologie intervent 3 martie 2011-final

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IN1LRVLN1IONALIN1LRVLN1IONAL CARDIOLOGY CARDIOLOGYPro Uni Dr Ion (. 1intoiuPro Uni Dr Ion (. 1intoiu 1

| |IN1LRVLN1IONAL (ARDIOLOG\SubcIinicaITARGET ORGANS DAMAGESPresence ofMuItipIeCoronary PIaquesVascuIarInfIammationCIinicaIA1HLRO1IC LLSIONS IcebergACS = acute coronary syndromes; UA = unstable angina; NSTEM = nonST-segment elevation myocardial infarction; STEM = ST-segment elevation myocardial infarction. Adapted from Bhatt DL. J Invasive Cardiol.;15(suppl B):B-9B.50(.3a(raWo(|sWHERE IS INTERVENTIONAL CARDIOLOGY?HEAR$URGLON(ARDIOLOGI$1CON1LINS Procedures or Inter.(ardiol. (oronarographv.IVU$ .O(1, (oronarv heart disease (arotid arterv Renal arterv (ongenital heart disease Valular pathologv Peripherical arterv disease Aorta pathologv (ardiac pacingCONTEINSCoronarography IVUS.OCT What`s behind ???99What is InterventionalWhat is Interventional Cardiology CardiologyInterentionalInterentionalcardiologv cardiologv is the non is the non--surgical treatment usingsurgical treatment using radiologic imaging. with contrast. to guide instrumentsradiologic imaging. with contrast. to guide instruments catheters. balloons. etc, through the bodv`s blood esselscatheters. balloons. etc, through the bodv`s blood essels and other organs.1his tvpe o procedure is done or bothand other organs.1his tvpe o procedure is done or both diagnostic and therapeutic procedures and is usuallv donediagnostic and therapeutic procedures and is usuallv done on an outpatient basis. on an outpatient basis.$ome common tvpes o procedures done in interentional$ome common tvpes o procedures done in interentional cardiologvcardiologvinclude: include:1. 1. Angiographv Angiographv2. 2. Angioplastv Angioplastv. . Atherectomv Atherectomv4. 4. $tent insertion $tent insertion5. 5. lemodinamic ealuationcatetherism, lemodinamic ealuationcatetherism,6. 6. Biopsies Biopsies. . Occlusionand and opening procedures Occlusionand and opening procedures8. 8. treatment treatmentIN1LRVLN1IONAL(ARDIOLOG\!1Slide 3!1 !on, 2/22/2011110Objectives and Goals Objectives and Goals Basic understanding o interentionalBasic understanding o interentional cardiologv cardiologv Gain knowledge o kev terms and phrases Gain knowledge o kev terms and phrases PracticePractice -- participate in case examples andparticipate in case examples and exercises exercises11INTERVENTIONAL CARDIOLOGYCORONARYREGIONALCAROTID,RENALVALVULAR,Pace makerCONGENITAL HEART DISEASEA0RTAPUL. ARTINCENTIVES & REWARDSCLINICIANSINDI(A1IONDIAGNO$1I(1RLA1MLN111he Cardiovascular System: 1he1he Cardiovascular System: 1he Heart Heartleart pumps oerleart pumps oer 1 million gallons1 million gallons per vear per vearOer 60.000 milesOer 60.000 miles o blood essels o blood essels1uguIar veinssuperior vena cavapuImonary veinshepatic portaI veinrenaI veininferior vena cavaiIiac veinsfemoraI veincarotid arteriesascending aortapuImonary arteriescoronary arteriesrenaI arterybrachiaI arteryabdominaI aortaiIiac arteriesfemoraI arteryajor Vessels ajor Vessels14The result is a heart that functions more like aThe result is a heart that functions more like a reptilian heart, in which approximately half of thereptilian heart, in which approximately half of the myocardial blood supply comes from sinusoidalmyocardial blood supply comes from sinusoidal perfusion by the left ventricular cavity. perfusion by the left ventricular cavity.(ORONAR\ lLAR1 DI$LA$LANA1OM\ AND PA1lOGLNL$I$Time for Coronarography Time for Coronarography16Coronary Circulation Coronary Circulation (oronarv circulation is blood supplv to the heart (oronarv circulation is blood supplv to the heart leart as a erv actie muscle needs lots o O leart as a erv actie muscle needs lots o O22 \hen the heart relaxes high pressure o blood in\hen the heart relaxes high pressure o blood in aorta pushes blood into coronarv esselsaorta pushes blood into coronarv essels Manv anastomoses Manv anastomoses connections between arteries supplving blood to the sameconnections between arteries supplving blood to the same region. proide alternate routes i one arterv becomesregion. proide alternate routes i one arterv becomes occluded occludedIN1LRVLN1IONAL CARDIOLOGY IN ISCHLIC HLAR1 DISLASL (ORONAROGRAPl\ IN1RAVA$(ULAR UL1RA$OUND IVU$, OP1I(AL (OlLRLN(L 1OMOG1RAPl\ O(1, (ORONAR\ ANGIO$(OP\CORONAROGRAPHY PRO(LDURL$ LL$ION DIAGNO$1I( 1RLA1MLN1 Percutaneous coronarv interention-P(I, (OMPLI(A1ION -In $tent Restenosis19Coronary Arteries Coronary Arteries

!osterior ViewPosterior View Posterior View1Semilunar Valves and CoronarySemilunar Valves and Coronary

Coronary artery circulation Coronary artery circulation

Coronary Veins Coronary Veins(ollects wastes rom cardiac muscle (ollects wastes rom cardiac muscleDrains into a large sinus on posterior surace o heart calledDrains into a large sinus on posterior surace o heart called the coronarv sinus the coronarv sinus(oronarv sinus empties into right atrium (oronarv sinus empties into right atrium5Coronary Artery Disease Coronary Artery DiseasePathoIogicaIPathoIogicaI anatomy anatomyCORONAROGRAPHY1L(lNI(AL PRO(LDURL

CORONAROGRAPHYUnic lesion$ecential lesion(OMPLLX LL$ION$bi-coronariantri-coronarianostial lesionbiurcation lesionstriurcation lesionstotal oclusionlet main protected or unprotected,9SLLDINGLRSSLLDINGLRS 1LKNIKK 1LKNIKKSVLN SVLN- -IVAR IVAR SLLDINGLR SLLDINGLR 1921 1921--1999 1999,. ,. radiologist. radiologist. was was born born in in Mora Mora..$weden $weden.. Graduating Graduating in in medicine medicine rom rom the the Karolinska Karolinska Institute Institute in in 1948 1948.. he he began beganhis his training training in in radiologv radiologv in in 1950 1950.. In In 195 195.. Dr Dr.. $eldinger $eldinger published published the the description descriptiono o a a percutaneous percutaneous entrv entrv technique technique in in the the journal. journal. .cta .cta Raaiotogica Raaiotogica.. 1he 1he equipment equipmentrequired requiredto toperorm perormthe thebasic basictechnique techniqueincludes includesonlv onlv11,, a athinwall thinwall introducer introducerneedle. needle. 22,,a awire wireguide guideand and,,a aplastic plasticpreormed preormedcatheter catheter.. 1hrough 1hrougha asimple simplepuncture. puncture. access access is is gained gained to to anv anv part part o o the the bodv bodv ia ia the the cardioascular cardioascular svstem. svstem.using using a a series series o o x x--rav rav ilms ilms as as a a guide guide..Dr Dr.. $eldinger $eldinger pioneered pioneered in in applving applving his his technique technique to to the the localization localization o otumors tumors bv bvarteriographv. arteriographv. selectie selectierenal renal angiographv. angiographv. percutaneous percutaneous transhepatic transhepaticcholangiographv. cholangiographv. and and portal portal enographv enographv..1he 1he simplicitv simplicitv o o the the $eldinger $eldinger technique technique which which continues continues to toreolutionize reolutionizecardiologv cardiologvand andradiologv radiologvhas has proided proidedthe thecatalvst catalvst or or innoatie innoatieapplication applicationin inthe theareas areaso ointerentional interentional radiologv. radiologv. urologv. urologv. anesthesiologv anesthesiologvand andcritical critical care care medicine medicine..

Seldingers teknikk Seldingers teknikkCopyright by the American RoentgenRay SocietySun, J. et aI. Am. J. RoentgenoI. 2008;190:748-754--Let coronarv arterv

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"UAN1I1A1IVL (ORONAROGRAPl\4R(A UNI(ORONARIAN LL$ION-5Ostium6

CORONAROGRAPHY (ON(LU$ION:-comon used in coronarv heart disease-parameters: -tvpe o lesions-quantitatie ealuation o stenosis-treatment solutions-P(I proceduresTime for IVUS Time for IVUSIN1RAVASCULAR UL1RASOUND (IVUS)-1L(lNI( PRO(LDURL -INDI(A1ION$-ADVAN1A(L -(LINI(AL IMPLI(A1ION-1RLA1MLN1 (ORONAR\ LL$ION$444445464449PrincipIe of IVUS transducer puIIback.Schoenhagen P , Nissen S Heart 2002;88:91-96 by BMJ Publishing Group Ltd and British Cardiovascular Society5155Vulnerable Plaque andVulnerable Plaque and IVUS Greyscale Imaging IVUS Greyscale ImagingSTEM THE VOLCANO ofACS ofACS culprit lesions culprit lesions3 ofACS culprit3 ofACS culprit lesions lesionsagbari et at. Circvtatiovagbari et at. Circvtatiov 200 200::]0 ]0::]1 ]1 2 2))Vulnerable Plaque = thrombosis Vulnerable Plaque = thrombosis- -prone prone plaqueplaque and plaque with a high probability ofundergoingand plaque with a high probability ofundergoing rapid rapidprogression progression= 5 = 5Davies MJ. Circulation. 1996;94:2013-2020.Fissures inthe fibrous cap1he atrix Skeleton of UnstableCoronary Artery PlaqueContinuing Medical mplementation....bridging the care gap S1 Llevation I (S1LI) S1 Llevation I (S1LI)9 ofacute Is are caused by thrombus formation from rupture ofunstable plaquesRuptured PlaquePathogenesisPlaque rupture or erosion1hrombosis withwithout occlusionNecrosis contingent on$eeritv o plaque ruptureDuration o ischaemiaLabilitv o occlusie thrombusAdequacv o collateralsVasoconstrictionDownstream plateletibrin embolimm mm 4mm 4mm 0 0 1.5 1.5 . .0 0rr rrIn paneI A, the Ieft anterior descending (LAD) artery appears normaI on the angiogram, yet on IVUS there is a cIear crescent of soft atheromatous pIaque.Schoenhagen P , Nissen S Heart 2002;88:91-96 by BMJ Publishing Group Ltd and British Cardiovascular Society.1 rr .1 rr.1 rr .1 rrAngiography FaiIs to Depict Coronary ArteriaI RemodeIingIVUS versus Angiography IVUS versus Angiography65IVUS(ON(LU$ION$-local lesions-aterosclerotic plaque structure and composition-irtual hvstologv-thrombus ormation-precise ealuation in lesion-stent malposition.racture-reascularisation P(I,6Time for OCT Time for OCTCommercially available intracoronary Fourier domain OCT system (Lightlab Imaging Inc, Westford, MA) A) OCT system consistingin a) console containing the light source, a computer and imaging display screen and b) the automated pullback device allowing for pullback speedsup to 20mm/sec B) OCT