Heparin Pharmacology

Unfractionated heparin is a heterogeneous group of glycosaminoglycans of various lengths (5000 to 30,000 daltons mean, 15,000 daltons) that exhibits a high-affinity for antithrombin. This binding augments antithrombin's enzymatic inactivation of thrombin, factor Xa, and factor IXa, with its effects on thrombin being the most pronounced.11 Given heparin's reliance on antithrombin for a therapeutic effect, it is considered as an indirect antithrombin. The antithrombin effect of heparin requires...

The Future Of Percutaneous Intervention

The thorny issues in patients with prior bypass surgery remain vein graft atheroembolism and restenosis and progressive vein graft disease. Major expansion of indications in this subgroup of patients awaits solutions to these problems. To avoid embolization, vein graft atheroma must be removed, excluded from the circulation, fragmented and removed, or ablated. Even with the permissively large lumen of many Figure 25-16. A, An 80-year-old man with unstable angina was found to have a long...

Procedural Technique

Coronary Ethanol Injection

Given the fact that most patients with HOCM are diagnosed noninvasively with echocardiography and many have not had invasive hemodynamic studies performed before presenting for ablation, many operators reconfirm the presence of significant LVOT obstruction by positioning an end-hole catheter in the ventricular apex and recording a slow pullback under fluoroscopy. Alternatively, simultaneous measurement of the ascending aortic and intracavity pressures may be obtained via placement of an...

Drug Eluting Stents

Although BMSs improve initial and long-term outcomes of SVG PCI, the impact is modest because of restenosis and disease progression. DESs have been Survival time in years Survival time 1-year 2-year 3-year 4-year 5-year Diabetic group 0.88 0.80 0.73 0.68 0.63 A Nondiabetic group 0.95 0.91 0.87 0.83 0.79 Survival time in years Survival time 1-year 2-year 3-year 4-year 5-year Diabetic group 0.88 0.80 0.73 0.68 0.63 A Nondiabetic group 0.95 0.91 0.87 0.83 0.79 Survival time 1-year 2-year 3-year...

Electrocardiographic Stress Testing

From the beginning, the application of exercise stress testing for the diagnosis of obstructive CAD has been focused on the presence and extent of ST-segment deviations during and immediately after exercise. This is obtained by serial recordings of the 12-lead electrocardiograph (ECG), which is often aided by computer analysis. Exercise ECG testing has modest diagnostic utility, mostly in patients with an intermediate pretest likelihood for having disease. It is now recognized that the early...

Tomographic Imaging Techniques

Tomographic imaging techniques such as CTA and MRA are excellent noninvasive, high-resolution imaging techniques that are useful tools for establishing the diagnosis of proximal arch and upper extremity vascular disease. They are capable of defining complex anatomy (as in the case of a congenital abnormality or prior intervention), allow visualization of the vasculature in multiple planes without the problem of overlap, and also show extravascular structures. MRA has the advantage over CTA (and...

Transmyocardial Delivery Of Biologic Compounds

Endocardial Injection With Catheter

The delivery of biologic compounds (e.g., genetic sequences or progenitor cells) has been considered as an alternative and more natural approach for restoration of myocardial perfusion and or mechanical function in the diseased heart. One of the fundamental biologic processes being explored is myocardial HIF-1, HIF-2, VEGF, Ang-2, A MMP, PA Smooth muscle cell migration, matrix remodeling Figure 57-5. Schematic diagram of the various stages of angiogenesis attached to the formation of branching...

Symptomatic Indication For Revascularization Pci Versus Medical Therapy Alone

Several studies from the pre-stent era compared PCI with lone medical therapy in patients with single- or double-vessel disease without a prognostic indication for CABG. The Veterans Affairs ACME trial was the first randomized trial to compare plain balloon angioplasty with medical therapy.91 In this study, 212 patients with single-vessel disease, stable angina pectoris, and positive results on stress testing or MI within the preceding 3 months were randomized to an initial strategy of plain...

Plaato

Nitinol Laa

The PLAATO device (ev3, Inc., Plymouth, MN) was the first percutaneously implanted occluder to find human use (see Fig. 49-8). Its framework is a nitinol basket with a tissue anchoring system on the struts designed to maintain position. A minimally throm-bogenic expanded polytetrafluoroethylene (ePTFE) membrane covers the basket and is designed to seal the LAA orifice and allow endothelialization. Figure 49-7. A, Postmortem human heart reveals the three-dimensional internal anatomy of the left...

Chronic Venous Disease

Chronic venous insufficiency is a significant problem in the United States, affecting as much as a quarter of the population. Venous valve incompetence is central to the venous hypertension that appears to underlie most or all signs of chronic venous disease. Chronic venous disease afflicts a younger segment of the population, and the morbidity of edema, leg pain, and ulceration may result in lifestyle alterations, loss of work, and frequent hospitalizations. The prevalence of venous...

Mid Stent

Stent strut discontinuity (fracture) observed 8 months after deployment of three overlapping drug-eluting stents. On the cross-sectional intravascular ultrasound (IVUS) image (bottom, middle), an abnormal paucity of stent struts, not seen at implantation, is detected at a portion of the mid stent. The longitudinal IVUS image (top) shows an acute-angled bend at the corresponding segment. In this particular case, the strut discontinuity is not associated with increased intimal...

Revascularization and Outcomes in the Symptomatic Patient

The two main reasons to consider revascularization in any patient with CAD are improvement of prognosis and alleviation of symptoms to improve the QOL. The risk of major adverse events in patients with CCS is low, but the costs are significant. Methods by which the clinician can identify patient subsets at higher risk are numerous. Despite the high prevalence of chronic stable angina, relatively little is known about the impact on outcomes of modern coronary revascularization in contemporary...

Laser Tissue Effects

Laser energy has specific tissue interactions that are fundamental for achieving controlled channel formation and tissue response, thereby avoiding unwarranted excessive myocardial damage.28 In general, thermal injury leads to intense collagen deposition and scarring.29,30 The myocardial tissue response to a laser energy source has been characterized acutely by sharply demarcated tracks appearing as open channels surrounded by a rim of necrotic tissue secondary to excessive heat (Fig. 57-1).31...

Accesssite Complications

Vasoseal Datascope

Local vascular complications at the site of catheter insertion constitute the most common adverse events after cardiovascular interventions. Vascular complications can extend the patient's length of hospitalization and increase the associated procedural costs. Vascular access complications include external bleeding, hematoma, pseudoaneurysm, arteriovenous fistula, vessel dissection, acute vessel closure, retro-peritoneal hemorrhage, neural damage, infection, and venous thrombosis. One way to...

Perioperative Myocardial Infarction Pathophysiology

Similar to myocardial infarction (MI) outside the context of surgery, perioperative MI can result either from atherosclerotic plaque rupture, with subsequent thrombotic occlusion of the involved coronary artery, or from a transient stress-induced mismatch of myo-cardial oxygen supply and demand, often in the setting of a fixed coronary artery stenosis. Among patients with fatal perioperative MI, autopsy series have demonstrated histologic characteristics of recent plaque rupture in...

Etiology and Prevalence

TOS is commonly classified as either neurogenic or vascular (Table 40-5). Neurogenic TOS, which refers to the symptomatic compression of the brachial plexus, is thought to account for 95 of cases. The site of compression is usually in the scalene triangle. Seventy percent of neurogenic TOS cases occur in female patients. Vascular TOS accounts for the remaining 5 of cases, with the majority of those affecting the subclavian artery and the minority affecting the subclavian vein. The site of...

Choice and Use of Contrast Agent

The choice of contrast agent is an important intra-procedural consideration and has evolved considerably over the last several years with the development of low- and iso-osmolar contrast agents. Traditional iodine-based contrast agents were hypertonic and included ionic compounds such as diatrizoate (Hypaque, Renografin) that frequently caused mild hemodynamic changes in addition to contrast-related nephropathy. Given substantially lower costs in recent years, most laboratories have switched to...

The Very Different Advantages And Disadvantages Of Pci And Cabg

*Babapulle MN, Joseph L, Belisle P, et al A hierarchical Bayesian meta-analysis of randomized clinical trials of drug-eluting stents. Lancet 2004 364 583-591. 'Antonucci D, Valenti R, Migliorini A, et al Abciximab therapy improves survival in patients with acute myocardial infarction compliated by early cardiogenic shock undergoing coronory artery stent implantation. Am J Cardiol 2002 90 353-357. 'Valgimigli M, Malagutti P, Aoki J, et al Sirolimus-eluting versus paclitaxel-eluting stent...

Systemic Therapy

The treatment of high-risk, vulnerable plaques relies on aggressive medical therapy, which has been shown to reduce coronary events and improve survival. As a result, systemic therapy is the cornerstone of plaque stabilization, with documented reductions in lipid content, inflammation, and vasa vasorum neovascularization.142 Intensive statin therapy has produced a significant decrease in coronary events in patients with stable disease (Treating New Targets study TNT and Incremental Decrease in...

Cost Study Structures CostEffectiveness Analysis

Cost studies generally fall into one of three categories randomized, controlled trials observational studies and cost-effectiveness models. Cost-effectiveness models are discussed in the next section. A cost study in a randomized clinical trial is usually ancillary to the primary objective of the trial. Typically, cost or resource consumption patterns are a secondary end point in a trial that has either a composite clinical or (preferably) a mortality primary end point. Some have argued that...

Continuous Quality Improvement in the Cardiac Catheterization Laboratory

Continuous quality improvement (CQI) is a methodology to improve the processes associated with providing a product or service to meet or exceed consumer expectations.1 Based on the work of pioneers in industrial management, specifically Deming and Juran, the CQI process is a collection of techniques borrowed from the fields of systems theory, statistics, engineering, and psychology.36 CQI is an organized, scientific process for evaluating, planning, improving, and controlling quality. The goal...

Planning Access

The selection of an appropriate access site is frequently a key issue for the successful completion of coronary or peripheral vascular procedures. Proficiency with all available vascular puncture techniques is therefore a basic requirement for the interventionalist. It is important to review clinical reports and perform preprocedural vascular assessment of the quality of all peripheral pulses, presence of bruits, blood pressure difference between arms, and other pertinent findings, such as skin...

Cardiac Neuropathy

Cardiac neuropathy is characterized by an attenuation of heart rate variability in response to breathing, Valsalva and posture maneuvers, and an impairment of heart rate recovery following exercise. A recent population-based study including more than 2000 individuals demonstrated that diabetes was the primary contributor to reduced heart rate variabil-ity.35 Growing evidence suggests that cardiac neuropathy in diabetes mediates alterations in the regulation of coronary vasodilator function in...

Thrombolytic Therapy

In the United States, more than 200,000 patients each year get acute reperfusion therapy for ST-eleva-tion acute myocardial infarction (STEMI). The use of thrombolytic therapy has diminished in recent years in favor of primary PCI, and the use of streptokinase is particularly uncommon. In contrast, in the remainder of the world, streptokinase continues to be the most commonly used thrombolytic. With regard to the cost of thrombolytic therapy relative to conventional therapy, the major variable...

Fibromuscular Dysplasia

The gold standard for evaluating renal artery FMD, as for atherosclerotic RAS, is DSA. Different pathologic lesions have different angiographic patterns. Medial fibroplasia has the classic string of beads appearance, with the diameter of the beading larger than the diameter of the artery (aneurysmal). In perimedial fibroplasia, the beads are smaller than the diameter of the artery and less numerous than in medial fibroplasia. Medial hyperplasia and intimal fibroplasia manifest as concentric...

Contributors

Fellow, Interventional Cardiology, Mayo Clinic College Balloon Angioplasty Is It Still a Viable Intervention Research Associate, Harvard Medical School Assistant Director, Angiographic Core Laboratory, Brigham and Women's Hospital, Boston, Massachusetts Qualitative and Quantitative Coronary Angiography Associate Professor of Medicine and Director of Interventional Cardiology, Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida Elective...

Monarc Percutaneous Transvenous Mitral Annuloplasty System

Originally developed as the VIKING system (Edwards Lifesciences Inc., Irvine, CA), the first iteration of this device consisted of a distal self-expanding anchor, a spring-like bridge segment, and a proximal self-expanding anchor. The distal anchor is deployed in the great cardiac vein, and the proximal anchor deployed in the proximal coronary sinus. The bridge segment was designed with shape-memory properties that lead to shortening of the device at body temperature. A new iteration of the...

Patent Foramen Ovale

Fluoroscopy Ablation

The details of this procedure are covered in Chapter 48. Briefly, under normal embryologic processes, the septum primum and secundum (two independent, crescent-shaped membranes) make up the IAS. During fetal life, the mobile septum primum allows right-to-left shunting to maintain life. However, after birth, left atrial pressure increases and helps to fuse these two membranes. In about 15 to 20 of individuals, this fusion does not occur and allows occasional right-to-left shunting, which is...

Low Risk Patients

Concordant with the findings of the surgical revascularization versus medical therapy trials, very-low-risk patients with coronary artery disease without ACS or demonstrable ischemia need to be triaged carefully to an invasive strategy. Results from the early stent era 341-patient Atorvastatin versus Revas-cularization Treatments (AVERT) trial suggested that aggressive lipid lowering with 80 mg of atorvastatin might be as effective as PCI and usual care in reducing ischemic events during...

Central Venous Stenosis

Risk factors for chronic venous disease Genetic factors Female sex (progesterone) Pregnancy Age Greater height Prolonged standing Obesity Figure 45-1. Venous hypertension as the hypothetical cause of the clinical manifestations of chronic venous disease, emphasizing the importance of inflammation. SVC syndrome is a serious disorder resulting from impeded venous return from the upper body caused by obstruction of the SVC. The symptoms include severe congestion and edema of the face, arms, and...

Diabetic Nephropathy

Renal failure is a major independent predictor of cardiovascular events. Diabetes is the leading cause of renal failure in Western countries. In 2002 in the United States, diabetic nephropathy accounted for more than 40 of the new cases of renal failure, and 44,000 diabetic patients began treatment for endstage renal disease.2 The condition underlying diabetic nephropathy is microvascular disease. Even in the absence of renal failure, albuminuria is a frequent finding in diabetes. Any degree of...

Conclusion

Defining inflammatory status in patients with ACS and in those with coronary atherosclerosis is becoming paramount to the efficient risk assessment and appropriate treatment of patients. As our grasp of molecular and genetic tools improves, the ability to break down the complex pathways and modulate them as potential therapeutic targets in susceptible individuals will take hold. The implications are far reaching and hold the potential to significantly alter the way clinical medicine is...

Percutaneous Mechanical Thrombectomy

Deep Venous Katheter

Issues surrounding CDT for lower extremity DVT include the time to lysis, need for intensive care monitoring, hemorrhagic risks, cost, and lack of prospective, randomized clinical trials. With these issues in mind, PMT is conceptually attractive because such a technique may result in a shorter time to vein patency, shorter length of stay, reduction in hemor-rhagic risk, and overall cost savings because of reduced hospitalization and elimination or reduction in thrombolytic drugs. From a...

Chronic Kidney Disease

Mehran Score

The population of patients with CKD worldwide is growing at a tremendous rate. Consequently, these high-risk patents are now encountered much more frequently in the cardiac catheterization laboratory. In one recent registry, for example, 25 of patients undergoing PCI had at least mild CKD.14 For the interventional cardiologist, identifying these patients is important for two reasons. First, this group Figure 5-2. Risk score for determining risk of contrast-induced nephropathy and dialysis after...

Future Directions

There is room for improvement in the current DES delivery systems. Better flexibility and conformabil-ity are likely high on the wish list of most modern interventional cardiologists, who no longer fear Figure 32-7. Cumulative frequency distribution of in-segment minimal luminal diameter on quantitative coronary angiography. Data are shown for the uncoated-balloon group and the coated-balloon group before the procedure, after the procedure, and at 6 months. (From Scheller B, Hehrlein C, Bocksch...

Manual Compression

Clamp Stop Bleeding

Digital compression should be considered the gold standard for compressive methods. Performed properly, it can prevent bleeding and maintain distal perfusion. This procedure may be performed by a physician, nurse, or technician who has received formal training. Before sheath removal, the distal pulses and the access site are assessed for signs of an existing hematoma. The duration of manual compression and the time of immobilization are proportional to the size of the introducer sheath and the...

Interventional Treatment and Surgery

The decision regarding management of CLI depends on the risk profile of the patient (e.g., expected operative mortality, underlying renal function and the risk of contrast nephropathy) and the anatomic profile of the patient (e.g., multisegment and or multivessel disease, number of runoffs, suitability of the disease to PTA versus surgery). Figure 39-8 outlines a general approach to the management of CLI. Figure 39-8. Treatment algorithm for patients with critical limb ischemia. (Redrawn from...

Complications and Followup

The equipment used to perform percutaneous renal artery revascularization has changed dramatically in the last decade, and the procedure has become safer and more reliably successful. However, deterioration in renal function is still the most important complication of the procedure and can be multifactorial (e.g., contrast toxicity, embolization, incorrect patient selection). Every effort should be made to avoid using an excessive volume of contrast material, and great care should be exercised...

Studies on Plain Balloon Angioplasty

Four of the studies comparing CABG with plain balloon angioplasty for multivessel disease reported subgroup analyses for diabetics. The largest of these subgroup analyses was derived from BARI, which included 353 patients with diabetes. During the 5-year follow-up, the mortality rate of diabetics randomized to plain balloon angioplasty was 34.5 , and after seven years it was 44.3 , whereas after CABG the respective mortality rates were 19.4 (P .03) and 23.6 (P .01).57 The difference in...

National Percutaneous Coronary Intervention Registries

The role of national registries focusing on PCI and cardiac catheterization has grown substantially, particularly since the launching of the ACC-NCDR CathPCI registry in 1998 (Fig. 66-6). This registry, created under the auspices of the ACCF, was developed to respond to clinicians' and hospitals' needs for standardized elements to accurately describe clinical outcomes it offers risk-adjusted quarterly data reports with comparisons against national and like hospital benchmarks.44 Table 66-2...