Interventional Cardiology / PVD

Question 1

General Interventional Cardiology Principles

• Non-invasive testing
• Coronary angiogram
• Cath lab
• Mainstays of treatment for CADConditions improved w/ interventional cardiology (angoiplasy, stenting)

Answer 1

• Non-invasive testing
  
  • Most diagnostic tests
  • Assess ventricular function, valvular disease, & coronary anatomy
• Coronary angiogram
  
  • Invasive gold standard for identifying stenosis due to CAD
  • Provides the most reliable anatomical info for determining treatment
  • Performed by directly injecting radio-opaque contrast material into coronary arteries & imginag them w/ fluoroscopy
• Cath lab
  
  • Measures hemodynamic & anatomical details
  • Diagnoses valvular, pericardial, & myocardial disease states
  • Delivers targeted therapeutic interventions
• Mainstays of treatment for CAD
  
  • Medical therapy
  • Percutaneous coronary intervention (angioplasy / stent replacement)
  • Coronary artery bypass graft surgery
• Conditions improved w/ interventional cardiology (angoiplasy, stenting)
  
  • Angina pectoris (symptomatic CAD)
  • Valvular heart disease
  • Congenital heart disease
  • Extra-cardiac vascular disease

Question 2

Access Sites for Cardiac Procedures

• Most commonly used site for arterial access
• Other access sites
• How access is gained

Answer 2

• Most commonly used site for arterial access
  
  • Common femoral artery in the inguinal region
• Other access sites
  
  • Used to improve comfort, safety, &/or efficacy
  • Brachial & radial arteries: when needed based on aorto-iliac anatomy
  • Internal jugular or common femoral veins: when need venous access
• How access is gained
  
  • Seldinger technique: percutaneous approach
  • Needle is placed through the skin & subcutaneous tissue until it enters the vessel lumen

Question 3

Intracoronary Devices & Equipment: CAD

Answer 3

• Access gained into a vascular structure
• Intravascular sheath placed to allow equipment to be delivered w/o bleeding
• Catheters
  
  • Long hollow tubes inserted into the body through the sheath
  • Placed in various vascular structures
• Contrast dye is injected to obtain digital images
• Wires may be threaded into the vessel & placed in distal portions
  
  • Balloon catheters can be inserted to dilate blood vessels (angioplasty)
  • Followed by stent placement to…
    
    • Open narrowed blood vessels
    • Treat aneurysmal segments

Question 4

Structural Heart Disease

• Structural heart disease
• Structural heart diseases that can be treated by interventional procedures

Answer 4

• Structural heart disease
  
  • Non-coronary CV disease processes & related interventions
• Structural heart diseases that can be treated by interventional procedures
  
  • Hypertrophic cardiomyopathy
  • Valvular heart disease
  • Patent foramen ovale
  • Atrial septal defect
  • Ventricular septal defect
  • Left atrial appendage
  • Left ventricular aneurysm
  • Patent ductus arteriosus
  • Paravalvular leak

Question 5

Treatment of Symptomatic Severe Aortic Stenosis

Answer 5

• Surgical valve replacement
  
  • In ideal candidates
• Transcatheter aortic valve implantation (TAVI) or replacement (TAVR)
  
  • In patients who aren’t ideal candidates due to advanced age or co-morbidities
  • Less invasive treatment for aortic valve replacement
  • Two major bioprosthetic valves available

Question 6

Treatment of Symptomatic Severe Mitral Regurgitation

Answer 6

• Poor prognosis
• Surgical therapy
  
  • Primary means
• Endovascular intervention
  
  • Edge-to-edge repair techniuqe of leaflets w/ a MitraClip device
  • Also treats ASDs, VSDs, & patent foramen ovales
    
    • Occlusion devices interrupt the communication b/n chambers of the heart which eliminates blood shunting

Question 7

Treatment of Atrial Fibrillation

Answer 7

• AFib
  
  • Can be associated w/ thrombus formation in the LA appendage –> stroke risk
• Medications: warfarin or aspirin
  
  • Standard treatment for stroke prevention
• Non-FDA-approved devices
  
  • In patients who rae at high risk for stoke & can’t tolerage anticoagulation or medical therapy

Question 8

Structural Heart Disease

• Congenital anomlaies
• Acquired heart disease

Answer 8

• Congenital anomalies
  
  • Atrial septum
  • Ventricular septum
  • Pulmonic valve
• Acquired heart disease
  
  • LAA (Watchman)
  • Mitral vavle (Mitraclip)
  • Aortic valve (TAVR)
  • Paravalvular leaks
  • Ventricular support

Question 9

Calcific Aortic Stenosis

• General
• Dianosis
  
  • Murmur
  • Disease progression
  • Echo
  • Cardiac cath
• Treatment

Answer 9

• General
  
  • Mainly solid Ca2+ deposits within valve cusps
  • Similar risk factors for CAD
  • High coincidence of CAD & AS
  • 6th, 7th, & 8th decades of life
• Diagnosis
  
  • Murmur
    
    • Crescendo-decrescendo SEM radiating to the neck
    • Mild: murmur peaks early
    • Progressive: murmur becomes louder & peaks progressively later in systole (+/- thrill)
  • Disease progression
    
    • Murmur intensity lessens as SV decreases
    • Carotid upstrokes are diminished in volume & rate or rise is delayed
  • Echo
    
    • Establishes the diagnosis
    • LV function / hypertrophy
    • Extent of Ca2+
    • Transvalvular pressure gradient
    • Aortic valve area (dimension / velocity)
  • Cardiac cath
    
    • Gold standard
    • Gradient & CO needed to calculate valve area
    • Simultaneous pressure measurement in LV & aorta
• Treatment
  
  • Surgical aortic valve replacement
    
    • Large mortality benefit in patients w/ symptomatic, severe AS