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INVASİVE CARDIOLOGY:
Percutaneous Intervention.
PART- I: Diagnostic Techniques.
Left and Right Heart Catheterisatıon.
Coronary angıography.
Prof Dr Rasim ENAR
İÜ. CTF. Department of Cardiology
Types of percutaneous intervention:
A. Diagnostic:
•
•
•
•
Diagnostic Cath:
Right and left heart cath.
Coronary angiography.
EPS, IVUS…
B.Therapetic:
1- Standart PCI: PTCA, Stents.
2- New İntracoronary devices: Atherectomy, Rotablator, Laser,
Brachytherapy (radiotherapy), Thrombectomy, distalprotection.
3- Non-coronary intervention:
Valvuloplasty, Septal ablation, septal defect closure, valve
replacement , PM, ICD, CRT….
CATHETERISATION
Definition:
• Invasive procedures for the diagnosis and assesment severity
of cardiovascular disease.
• Essentially,Catheterisation of right and left heart and coronary
angiography. This procedure is done by using various methods
and various catheters.
Catheter: Are small plastic tubes which has empty tunel inside.
Main condition for PCI:…”Have to be”…
Appropriate Cath Lab and Staf.
• Semi-sterile Catheterisation Laboratory: A movable table for the
patient lying supine, - film camera, a scope with rotating head, angiyography and monitors for intra cardiac pressure and ECG
monitoring. –Emergent CPR conditions and PCI materials.
Catheterisation access methods.
A- Arterial access:
• Direct access. Brachial artery dissection.
• Percutaneous access. Punction of radial, brachial, femoral
arteries.
B- Other ways of access:
1– Transeptal. For entrance to left atrium: For mitral valvuloplasty
in MS.
Contraindications: Huge left atrium, atriyal mixoma, thrombus ve
haemorhagic diatesis.
2– Direct LV puncture. Conditions in which LV cannot be entered
throgh mitral and aortic valves: “Tilting-prostesis valves”.
Percutaneous catheteter sheath
introductıon :
Normal Heart and Coronary arteries Anatomy.
Typical catheters used for pressure measurements and angiography
Lange, R. A. et al. Circulation 2003;107:e111-e113
Copyright ©2003 American Heart Association
Anatomy of femoral artery ande vein.
Catheterizatıon from the femoral vein; right- heart cath.
Retrograde crossing of aortic valve(pigtail cath and with guide vire
combination).
Major type of Heart Catheterisation:
RIGHT HEART CATHETERISATION:
Vena Cava, Right- atrium, Right- ventricle, Pulmonary- artery,
Pulmonary- capillary wedge pressure and measurement of oxygene
saturation, calculation of Cardiac output.
Importance:
1- Measurement of right side pressures; establish prescence of
Tricuspid or Pulmonary valves dysfunctıon and estimating sevirity.
2- Pulmonary hypertension can be evaluated and pulmonary vascular
resistance can be calculated.
3- Pulmonary capillary wedge pressure; reflect the diastolic filling
pressure of the left heart indirectly: Shows indirectly the left atrial
and LV end- diastolic pressures. Is an important parameter in LV
failure and MS.
LEFT HEART CATHETERISATION:
• Mitral and Aort valve functions, systemic vascular resistance and
LV function, and coronary artery anatomy.
Importance:
1- Most reliable diagnoses of AS and MS by pressure calculations.
MS: Gradient between LV diastolic – Pulmonary capillary wedge
pressure measurements.
AS: Gradient is present between LV and systolic Aortic peak
pressure when the catheter is pulled back from LV to the Aorta.
2- Ventriculography,Aortography: During catheterisation, prescence
of AR and/or MR is shown: Contrast material is given by pump to
the LV and regurgitation of the contrast from LV to LA shows MR.
When contrast is given from the Aorta at supravalvular level and
contrast regurgitates to the LV, AR is present.
3- Evaluation of LV function: Beating LV is filled with contrast. (a) LV
segmentar wall motion is evaluated. (b) LV EF (% fractional
shortening) can be calculated.
4- Coronary angiography.
HEMODYNAMİC MESURMENTS:
1. Cardiac output.
2. Pressure measurements of cardiac cavities and large arteries
(aorta, pulmonary arteries).
3. Evaluation of pressure waves.
4. Evaluation of valvular heart disease.
(a) Assesment of Valvular stenosis and measurement of valve
area.
(b) Evaluation of valvular regurgitation.
5. Diagnosis of left and right shunts (with oxygen saturatıon).
6. Angiography.
(a) Left ventriculography.
(b) Right ventriculography.
(c) Aortography.
Normal Values of Hemodynamıc Parameters:
Left Ventricle ( mmHg):
Right Ventricle (mmHg):
Systolic: 100- 140
Systolic: 15- 30
End- diastolic: 3- 12
End- diastolic: 2- 8
Aortic (mmHg):
Right atrıum (mmHg):
Systolic: 100- 140
Mean: 2 -8
Diastolic: 60- 90
A wave: 2- 10
Mean:70- 105
V wave: 2- 10
Cardiac ındex: 2.6- 4.2 L/min/m2
Pulmonary artery (mmHg):
Stroke index: 30- 65 mL/meat/m2
Systolic: 15- 30
Systemic vascular resistance (Dynes-sec-cm-5
): 700- 1600
Diastolic: 4- 12
Mean: 9- 18
PVR: 20- 130
Arterial oxygen saturatıon(%):93- 98
PCWP (mmHg) = (Left atrıum):
Arteriovenous oxygen difference (mL/L): 3050
Mean: 2- 12
A wave: 3- 15
V wave: 3- 15
Left Ventriculography
Aort and Mitral stenosis: Pressure gradients:
AS
MS
AS ve MS; pressure gradients.
Right and left Judkins catheters:
Cannulatıon of left and right coronary arteries
using the judkins catheters:
Left and Right Coronary Angiography:
DIAGNOSTIC HEART CATHETERISATION
Basic indications:
1- Documentation or to rule out heart disease if there is strong
suspection by physical examination or non-invasive diagnostic
tests.
2- If there is discrepancy between clinical findigs and non-invasive
diagnostic modalities, to explain the clinic situation.
3- To evaluate other cardiac comorbid pathologic conditions in
patient who has been given to open heart surgery for any
cause.
Indications for Coronary Angiography.
CLINICAL CONDITIONS:
Essential İndicatıon: Known or suspected CAD. High- risk
Asymptomatic patient: History of Previous MI, PTCA, CABG, with
Ischemic findings on resting or exercise ECG.
1. stable angina.
2. Unstable coronary syndrome.
3. Post-revascularisation ischemia.
4. Primary treatment of AMİ (with STE or LBBB in ECG);
before PCI.
5. Pre and post cardiac surgery.
6. Patient with valvular disease.
7. Congenital heart disease.
8. Congestive heart failure.
Unstable coronary syndromes.
USAP:
Prior Urgent and early, delayed PCI.
1- Urgent PCI: AP with hemodynamic or electrical instability (high cTn).
2- Early PCI:
• Refractory to initial treatment.
• Recurrence of symptoms after becoming stable by initial medical
therapy.
3- Delayed PCI (selected patients):
• High risk and complicated USAP. + hemodynamic and electrical
instability: ”Urgent catheterisation” is recommended.
• Low risk patient at presentation; but high risk on non-invasive tests
( Ischemia at low- level exercise, EF <0.40).
• Suspected Prinzmetal Variant angina.
Treatment of STE- AMI
Prior PCI or surgery (Primer, rescue, inhospital).
1- Primer PCI: Alternative to Thrombolytic therapy: STE,LBBB, admitted
with in <12 or >12 hrs of AMİ.
• Cardiogenic Shock: In the first 36 hrs of MI, (<75 yrs and in 18 hrs of
shock).
2- Rescue PTCA: Failed Thrombolysis.
3. Early coronary angiography (İnhospital or before discharge):
a- Spontaneously or stimulated (E-ECG) ischemic episodes (with
dynamic ECG changes: ±).
b- depressed LV systolic functıon (LVEF<0.40).
c- Mechanical complicatıon, prior repair surgery.
CA: Relative Contraindications.
1- Decompensated HF (Pulmonary Edema).
2- Uncontrolled ventricular irritability (arrythmia with hemodynamic
compromise).
3- Uncontrolled systemic hypertension.
4- Acute and severe renal failure.
5- Inability of vascular access.
6- Electrolyte imbalance: Hypokalemia, Hyperkalemia.
7- Digital intoxication.
8- Active infection and septic conditions.
9- Uncontrolled Haemorrhagic diastesis.
10- Severe anemia.
11- Active haemmorhage.
12- Contrast allergy.
13- Loss of consciousness.
* **!!!- ABSOLUTE CONTRAINDICATION: Disclaim of conscious patient.
COMPLICATIONS:
Complication prevalance was reduced as the number of procedures
was increased in any center (!).
MAJOR Complications (%0.2- 0.3): Death, AMI, SVA.
*** DEATH (%0.1- 0.2 ).
Cause: Perforation, arrythmia, AMI, or contrast anaphylaxis.
Patients with Hıgh- Rısk of Death (risk %2.8):
1- Patients >70, <1 years.
2- NYHA-4 HF or angina.
3- Severe LV dysfunction (EF<%25).
4- Severe and extensive CAD (LMCA or ostial, 3- vessel disease).
5- Severe valvular disease (with LV dysfunction).
6- Severe comorbid conditions (renal, hepatic, lung disease).
7- Known contrast allergy.
Contrast nephropathy:
Is generally secondary to high doses of contrast material, and
especially develops in diabetic patients.
Prevention:
a- Dose of the contrast material must be calculated according to the
patients body surface area, weight and serum creatinin levels.
b- Non-ionic contrast material is the prefere.
c- Before vatheterization, oral homosistein can be given and
bicarbonate infusion can be made.
d- In patients using diuretics, the diuretic dose befor catheterization
must be passed, and especially in diabetics, iv hydration must be
increased. IV hydration must be continued during the procedure if
needed.
e- During the 6-12 hour period after catheterization, oral and iv
hydration must be sufficient (1.5 – 2 Lt).
INVASİVE CARDIOLOGY:
Percutaneous Intervention.
PART- II: İnvasive Therapies
PCI, Stenting.
PMV, ASD- Closure.
PM- ICD, CRT.
Prof Dr Rasim ENAR
İÜ. CTF. Department of Cardiology
PERCUTANEOUS CORONARY INTERVENTION (PCI):
Definition: Is the treatment intended percutaneous coronary
procedure.
• Was known as “PTCA” in the past.
For optimal procedure: Standart catheterization laboratory,
dilatation material and experienced staff able to use these
material must be present.
Ideal patient:
(a) One vessel disease.
(b) Older patients, performed CABG at past; who has fragile
lesion (“discrete; length <10 mm. Diameter of the vessel >2.5
mm), and 3- vessel disease with high success rate (high- risk
for reoperatıon).
(c) In the case of ACS and especially STEMI, primary treatment
choice is percutaneous coronary intervention.
• Power of PCI: To be successfull in >%90 of cases.
Limitations of PCI:
1- Success rate is low in chronic total occlusions.
2- Early and long term efficacy is low in saphenous vein greft
lesions.
High- Risk Stenotic Lesions:
a- Diffuse (>20 mm). Vessel Diameter: <1.5- 2.0 mm.
b- Dense tortuous- proximal segment.
c- Severely angulated segment (≥90 degee).
d- Total occlusion (>3 months). Degenerated vein greft (fragyl
lesion).
e- Ostial lesions, side branch originating from the lesion.
Advers effects of the intervention:
a- Fatal event (%1).
b- Acute and late ischemic complications (%2).
c- Signifficant Restenosis in the first months. (%10).
Complications of PCI:
1. Mortality.
(a) In stable patients: <%2.
(b) AMI + CS : >%50.
2. Myocardial Infarction.
Elevation of cardiac markers: %5- 10.
3. No- ReFlow: Proksimal vessel is open, but myocardial tissue is not
perfused. Also called “Malperfusıon, and inadequate tissue-level
perfusıon”.Incidence; %10- 30 at reperfused vessel.
Vasoactive materials emanating by the disintegration or breaking up of
the thrombus of the proximal lesion and microembolisation.
Diagnosis: Elevation of cardiac markers, ST- T wave changes on ECG and
regional wall motion abnormalities.
4. Coronary perforation and rupture.
STENTS.
Are the supplementary and complementary components of balloons.
Rutine stenting has become the routine procedure of PCI. (“Direct
Stenting”).
Types:
• Drug eluting Active - Stents (“Drug Eluting Stent”).
• Metal, Passive- Stents (Bare- Stent”).
Difficulties of PCI:
a- Passing chronic total occlusion.
b- Optimization of anti-thrombotic and anti-thrombin therapies for
acute total occlusions.
c- Retsenosis is a problem, decreasing with Active- stents. Although
acute, subacute restenosis decreases more compared with
passive stents, but late restenosis in 2 years is more frequent in
DES.
INDICATIONS OF PCI:
CLINICAL INDICATIONS:
1- Acute Cornary Syndromes: STEMI, NSTEMI, USAP).
2- Stable AP: Positive exercise testing (at low-level), LV
dysfunction, electrical instability.
3- Angina equivalents (with known, documented CAD):
Arrythmia (symptomatic tachy-, brady-), lightheadness,
dyspnea.
4- MS - CT’de; Sign of proximal stenosis (must be confırmed by
coronary angıography).
5- Objective signs of reversible ischemia.
ANGIOGRAPHIC INDICATIONS:
1- 1-4 Lesions are apopriate for PCI.
2- There is no life threatening effects of occluding these lesions
for ≥1 minute( ie. LMCA, ostial lesions).
3- Prescence of functional myocardium or collateralls.
CONTRAINDICATIONS FOR PCI:
CLINICAL CONTRAINDICATIONS:
1- Terminal heart disease or other disease (except uncontrolled AP).
2- Post-MI CS (with multiorgan failure).
ANGIOGRAPHIC CONTRAINDICATIONS:
1- LMCA disease.
2- LMCA equivalent: Proximal LAD + CX disease.
3- Last vessel: Other 2 coronary artery occluded.
4- Three vessel disease (except inop patient).
5- Characteristics of hard lesions:
(a)- Chronic total occlusion.
(b)- No collateral to the distal artery.
(c)- Diffuse old lesion (>20 mm).
(d)- No cut off..
(e)- No critical CAD in the prescence of thrombotic lesion.
• (f)- Diffuse atherosclerotic or small diameter vessel (<2 mm).
Saphenous vein greft.
Materials for PCI:
Mechanism of PTCA and Stenting.
• Dissection of intima and media in the nneighbor sections of the
vessel near the plaque. Circumferential dilatation of the vessel is
the key mechanism for luminal increase (increasing diameter).
• STENT: Is the key material for preventing “elastic recoil of the
widening vessel. Keeps the plaque particles and intima away
from the luminal surface.
Schematized STENTING.
• Beginning of the procedure:
Angaging the guiding
catheter successfully to the
coronary ostiyum and
passing the guide wire
hrough the lesion.
• A- Passing the stented
ballon from the stenotic
lesion. Before this, standart
predilatation of the lesion
mey be needed.
• B- Inflating the ballon and
widening of the stent.
• C-, D- Deflating the balloon
and pulling back from the
widened stent.
Baloon and + Stent.
ADDITIONAL THERAPİES:
1. Oral- Antiplatelet : ASA,
Clopidogrel.
2. İV- Antiplatelet : GP-2b/3a İnh.
3. Antithrombins: Heparin(UFH,
LMWH Bivaluridin,
Fondaparinux).
4. Planned Secondary prevention
strategy at discharge
(ASA,CLP,Statin, BBl, ACEİ).
Efficacy of PCI:
a- High Success rate of the
intervention.
b-Symptomatic relief after
intervention: %90.
c- Complications: ≤ %2.
Coronary Angiography: Successfull Stenting.
Percutaneous Mitral Baloon
Valvotomy (PMV)
İnd: MV: Echo score <8.
• MVA<1.0 cm2.
• No subvalvular fibrosis,
• mobile valve and
noncalcified.
Percutaneous ASD Closure
İndicatıons:
• Symptoms of dyspne,fatigue or RHF.
• Reccurrent pulmonary infectıon.
• Paradoxical embolism.
• Atrial arrhytmia even ın the presence of a
small defect.
• Moderate Pulmonary hypertensıon without
pulmonary vascular disease.
• Asymptomatic large ASD (Qp/Qs>1.5:1.0),RH
volum overload and no pulmonary
hypertensıon.
ICD: Implantable Cardioverter
Defibrillator:
(Chest Radiograph and figure of PM locatıon)
ICD İndications:
• Reduced EF who had history of cardiac arrest,VT,VF.
• Ischemic CMP; at least 40 days post-MI with EF <%30, NYHA II or III on
chronic OMT.
CRT: Cardiac Resynchronısatıon Therapy
İndicatıons:
• LVEF<%35.
• Sinus rhym.
• NYHA class –III-IV, despite optimal
therapy (OMT).
• Have cardiac dyssynchrony,
QRS duratıon >120 ms.