Alternative Approaches Flashcards
Prevalence of Heart Disease
in the U.S. (2006) ?%
81,100,000 (>30% of the population) has some form of heart disease
Most common types of Heart Disease??
Hypertension (74,500,000) (systolic >140; diastolic >90) Age 60 or older (38,100,000) Coronary heart disease (17,600,000) angina pectoris (10,200,000) myocardial infarction (8,500,000) Stroke (6,400,000) Congestive heart failure (5,800,000) Congenital cardiovascular defects (650,000 –1,300,000)
What age has the most prevelance of CVD?
80+ (83/87%)
60-79 (70% ish)
First two most prevalent mortality causes in the US? (2006 -2010)
- Cardiovascular disease
- Cancer
- Accidents (M) Chronic lower Resp Disease (F)
Elimination of all forms of cardiovascular disease would increase average life span by what??
Average: 77.7 years - 2002
by 7 years
Elimination of all forms of cancer would increase the average life span by what?
Average: 77.7 years - 2002
by 3 years
Top 3 CV procedures in 2002?
Cath lab
angioplasty
total surgical
1929: Dr. Werner Forssmann
–First documented human cardiac catheterization
1941: Cournand and Richards
Employ cardiac catheter as diagnostic tool for the first time
1956: Forssmann, Cournand and Richards
Share the Nobel Prize
1958: Dr. Mason Sones
Developed the concept of the diagnostic coronary angiogram
1964: Dr. Charles Dotter
Introduced the concept of transluminal angioplasty
1967: Dr. Rene Favalo
Performs first saphenous vein graft surgery in Cleveland
1974: Andreas Gruentzigro
Performs first peripheral human balloon angioplasty
1976: Andreas Gruentzig
Presents results of animal studies of coronary angioplasty at the American Heart Association meeting
1977: Gruentzig, Myler and Hanna
First intraoperative human coronary balloon angioplasty (San Francisco)
1977: Andreas Gruentzig
First cath lab PTCA on awake patient (Zurich)
1978: Myler and Stertzer
First PTCA cases performed in America (San Francisco/New York)
1982
Over-the-wire coaxial balloon systems introduced –steerable guide wires developed
1986:
Coronary atherectomy devices introduced
1986: Puel and Sigwart
-First use of stents in humans reported
1987-1994:
number of interventional devices invented, perfected and approved (lasers, rotational atherectomy devices, intravascular ultrasound, stents)
1997:
Over one million angioplasties performed world-wide –most common medical intervention in world
2001
Almost two million angioplasties
performed world-wide
Percutaneous Transluminal Coronary Angioplasty (PTCA)
balloon advanced to level of blockage
–balloon inflated –plaque pushed back against vessel wall / small cracks created with the plaque (plaque fissures) / artery stretched
Stenting
balloon advanced to level of blockage –balloon inflated to deploy the stent
bare-metal versus drug-eluting stents
Criteria for Angioplasty? (5)
- Balloon can be passed through the blockage
- Blockage can be reached by the catheter
- Blocked vessel is not the left main original use for one or two vessel disease –now being applied to multi-vessel cases
- Patient is not in heart failure
- Patient is having a heart attack (if treatment can begin within two to six hours of onset)
Advantages of Angioplasty ?
- Less invasive than bypass surgery
- Relatively low risk
- Relatively low cost
- Local anesthesia versus general
- Percutaneous incision
- Patient able to return to normal activity shortly after procedure (most go home after 24hrs –return to normal activity within one week)
How may stents be prevented from causing clot formation?
most patients placed on antiplatelet
therapy including aspirin and clopidogrel ticlopidine (Plavix /Ticlid)
must continue therapy for at least one year
–additional benefit has been shown if therapy started one to three days before procedure
Risks/Complications of Angioplasty ? (LOTS)
Bleeding from the insertion artery
Damage to the insertion artery by the catheter
Damage to the coronary artery by the catheter
Restenosis (long term)
Sudden vessel closure
5% of patients with PTCA only
Stents may cause clot formation
Infection
Allergic reaction to dye
Myocardial infarction
Need for emergency bypass surgery
2 to 5 percent for PTCA / 0.5% w/ stenting
Stroke
DeathRestenosis Rates – PTCA ?
PTCA –10% to 40% during the first six months
Restenosis Rates of Bare Metal Stent?
Bare-metal stent –30% to 50% during first six months
Restenosis Rate of Drug Eluting Stent?
Drug eluting stent –7% to 15% during first six months
Pt Restrictions Following Angioplasty (3)
-Refrain from lifting heavy objects, engaging in
strenuous exercise or sexual activity for at least 24 hrs
-Increased fluid intake first 24 hrs –help remove dye
-Most pts will receive some sort of anti-platelet therapy
75% of the stent insertions follow plaque treatment with what?
PTCA or atherectomy
Stent Sizing???
- -stent must cover the complete length of the blockage
- -stent must be fully expanded so there are no gaps btwn the surface of the plaque and the stent
Where is it difficult to stent?
bifurcations of two vessels
When is stent covered with layer of endothelial cells?
Within four to six weeks the stent is covered with a thin layer
Drug Eluting Stent is what?
Bare-metal stent coated with slow-to-moderate-release drug formulation that is embedded in a polymer
What is restenosis ?
restenosis not a recurrence of CAD –actually bodies response to the “controlled injury” of angioplasty
restenosis characterized by growth of smooth muscle cells (i.e. scar formation)
Boston Scientific–
Taxus paclitaxel- eluting stent chemotherapeutic drug
Johnson and Johnson / Cordis =
Cypher sirolimus-eluting stent
immunosuppressive agent
Medtronic & Guidant have what kind of stents??
drug-eluting stents in the early stages of clinical trials (2006 at the earliest)
Drug Eluting stents have the biggest action on what type of patients?
Biggest impact may be on patients with diabetes
Atherectomy
Currently used as adjunct to PTCA and
stent placement
Actually removed plaque material
Atherectomy may work best in what??
COMPLEX LESIONS heavily calcified / fibrotic / undilatable lesions ostial & branch-ostial lesions chronic total occlusions in-stent restenosis
Types of Atherectomy Devices?
Directional
Rotational
Transluminal extraction
Directional Atherectomy
(RPM?)
Percutaneous over-the-wire cutting and retrieval system
Cutting window placed toward the plaque –balloon inflated pushing plaque into cutting cup–cutter rotates at 2,000 RPM –advanced by physician
Rotational Atherectomy?
Elliptical-shapes brass burr coated with 5-10 micron diamond chips
Saline flush solution infused into the plastic sheath around the drive shaft to minimize frictional heat
Burr ablates and pulverizes inelastic plaque tissue –5 micron particles eventually removed by reticuloendothelial system
Rotational Atherectomy speed?
Rotates at 140-190,000 RPM
Rotational Atherectomy burr ablates what size particles and what happens to them?
Burr ablates and pulverizes inelastic plaque tissue –5 micron particles eventually removed by reticuloendothelial system
Transluminal Extraction Atherectomy
what? RPM?
Percutaneous over-the-wire cutting and aspiration system
Head with two stainless steel blades –turn at 750 RPM
Lactated Ringers solution flushed into area creates particulate slurry that is suctioned back through the catheter
Transluminal Extraction Atherectomy – flushing solution?
Lactated Ringers solution flushed into area creates particulate slurry that is suctioned back through the catheter
Plaque Laser Problems?
precise control of laser
right laser for the type of plaque
Transluminal Angiogenesis Aka:
Transmyocardial revascularization
Transluminal Angiogenesis does what?
Improve blood flow to an area of the heart where surgery or angioplasty may not reach
Use a CO2 laser to make 20-40 mm channels in myocardium
Outer channel closes and inner channel open to inside
the heart
May promote the growth of small new blood vessels
Transluminal Angiogenesis option for who?
May be option for patients who are not candidates for
angioplasty or surgery
Transluminal Angiogenesis done how? (incision? with?)
Done through L. Chest incision or midline inscision
Could be done in conjunction with angioplasty or surgery
CABG without bypass? (2)
MIDCAB
OPCAB
CABG with assisted perfusion?
PADCAB (perfusion assisted direct coronary artery
bypass)
Minimal CABG with cardiopulmonary bypass access?
Portal-access
OPCAB devices to hold heart/ chest open?
Genzyme
Guident (Ultima II)
Octopus
Robotic type?
DaVinci
Percutaneous Valves
Mitral valves?
Aortic Valves?
MV – E Clip
AV – Edwards, Sorin
Aortic Valve Types? (3)
Edwards SAPIEN
Medtronic CoreValve
Sorin Perceval (investigational)
Aortic Valve Insertion ways ? (4)
Tranfemoral
Transapical
Subclavian
Direct Aortic
