Current Non-Surgical Cardiac Interventions. By Pam Bayles, RN, BSN

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1 Current Non-Surgical Cardiac Interventions By Pam Bayles, RN, BSN

2 Balloon Angioplasty & DES A balloon-tipped catheter was first used in 1964 to treat a cause of atherosclerotic disease in a patient s leg After this pt., Andreas Gruentzig performed the first Percutaneous Transluminal Coronary Angioplasty (PTCA) on a human on Sept. 16, 1977 in Zurich The results were presented at the AHA two months later By the mid 1980 s over 300,000 PTCAs were being performed for CAD Now approximately 12 million percutaneous catherizations performed worldwide with about 70% being diagnostic angiography

3 Early there were serious complications Abrupt vessel closure occurred in 1% of cases requiring emergency bypass surgery Vessel dissection secondary to improper sizing of the balloon Late restenosis occurred in 30% of pts. Often requiring repeat procedures To help counteract this, it was theorized that a scaffoldtype structure could be placed into the artery The first intracoronary stent was first successfully deployed in 1986 Lowered rate of restenosis

4 Early complications were subacute thrombosis and post-procedure bleeding By late 1990s incidence of in-stent restenosis was 15-30% Manufacturers began experimenting with adding chemical agents to the stents to prevent the neointimal hyperplasia that is the cause of instent restenosis Some of the early stents were coated with heparin and showed a lower incidence of subacute thrombosis that with bare metal stents but didn t stand up to decreased rates of restenosis as with later stents

5 In 2003 the Cypher stent was approved in USA Released sirolimus ( a chemotherapeutic agent) Low restenosis rate except for pts. With high risk features DM Long areas of restenosis In 2004 the Taxus stent was approved Has a copolyner coating of paclitaxel Inhibits cell replication No re-stenosis after six months By 2004, DES were used in nearly 80% of all PCIs

6 Femoral Artery Closure Devices Debuted in early 1990s Safe alternative to manual compression Improve pt. comfort and decrease time to ambulation and discharge >90% success rate Complications from femoral arteriotomy include: Bleeding from hematoma to retroperitoneal hemorrhage Increased risk due to use of thrombolytics, anticoagulation and antiplatelet therapy Bleeding rates reported as high as 11% Infection Arterio-venous fistulas Pseudoaneurysms Occlusive or thromboembolic events requiring vascular surgery

7 Retroperitoneal hemorrhage most serious complication Assoc. with 10% mortality Independent predictor include: Female, low BSA, GIIb/IIIa inhibitor use, and a high arteriotomy

8 Closure Devices Angio-Seal Evolution Vascular Closure Device Allows a quick and effective seal of the femoral artery during minimally invasive catheterbased procedures Hemostasis achieved through deployment of a bioabsorable anchor, suture, and collagen seal An automated collagen compaction system ensures consistent compaction of the collagen against the exterior wall of the vessel, reducing procedural variables. Fully absorbed by body within days

9 Cardiva Caralyst ( formerly Boomerang) Quickly facilitates closure of arteriotomy site Allows gently removal of device and preserves the artery which helps the body heal itself Helps eliminate devicfe-related implant complications, allows for re-access and provides faster ambulation First closure device to achieve final hemostasis for diagnostic pts. Leaving nothing in pt.

10

11 StarClose Vascular Closure System Closure with deployment of a shape-memory clip onto the surface of an artery Grasps the tissue on top of the artery around the access site in a purse-string fashion and closes the opening in the femoral artery rapidly with minimal affect to the lumen diameter or the blood flow inside the vessel Safe for pts. With moderate PAD and calcified femoral arteries

12 Carotid Stenting 100,000 recurrent strokes occur each year Within 1 yr. of a stroke 22% of men and 25% of women will die 14% of stroke survivors will experience a recurrent stroke within 1 year

13 Estimated 10-Year Rate (%) Men Women A B C D E F A B C D E F Systolic BP* Diabetes No No Yes Yes Yes Yes Cigarettes No No No Yes Yes Yes Prior Atrial Fib. No No No No Yes Yes Prior CVDNo No No No No Yes *Closest ranges for women are: and Estimated 10-year stroke risk in 55-year-old adults according to levels of various risk factors (Framingham Heart Study). Source: Wolf et al., Stroke.1991;22:

14 Carotid Stents Symptomatic carotid artery stenosis that reduces the diameter of the vessel by 70% or more carries a higher incidence of stroke if treated medically compared to surgically Percutaneous transluminal angioplasty (PTA) is an alternative to vascular surgery Benefits are shortened hospital stay, reduced procedure time and avoidance of general anesthesia First stent approved in US in 2005

15 Carotid endarterectomy preferred treatment except for high risk pts. Carotid stenosis usually > 60% and had symptoms of stroke or TIA Being investigated for the following pts.: Symptomatic pts. With > 50% stenosis or asymptomatic with > 80% stenosis in pts. Who are at least one anatomic or co-morbid risk factor placing them at high-risk for adverse events from CEA Anatomic contralateral carotid occlusion, contralateral laryngeal palsy, post-radiation treatment, previous CEA, recurrent stenosis, High cervical ICA, lesions CCA, lesions below the clavicle, severe tandem lesions

16 Co-morbid CHF (Class III/IV), and/or known severe left ventricular dysfunction <30%, Open-heart surgery within 6 weeks, recent MI ( >24 hrs. and < 4 weeks), UA (Class III/IV), synchronous severe cardiac and carotid disease requiring open heart surgery and carotid revascularization, severe pulmonary disease to include any of the following: chronic O2 therapy, resting PO2 of < 60 mm Hg, baseline Hct > 50%, FEV1 < 50% or normal, abnormal stress test, age greater than 80 years.

17 Radiofrequency Ablation Therapy

18 Indications for RF Ablation

19 The Ablation Procedure

20

21

22 Cardiac Resynchronization Therapy

23 Indications for CRT

24 Achieving Cardiac Resynchronization Goal: Atrial synchronous biventricular pacing Transvenous approach for left ventricular lead via coronary sinus Back-up epicardial approach Right Atrial Lead Left Ventricular Lead Right Ventricular Lead Doug Smith:

25

26 Vascular procedures Chronic Total Occlusions Peripheral artery disease (PAD) affects 8-12 million Americans according to the AHA If untreated, pts. Can experience ulcerations & gangrene that can increase the risk of loss of limb or even death Balloon Angioplasty with laser and stents Atherectomy Thrombolysis Inject clot-busting drugs via a catheter Can use mechanical thrombolysis where a blender sucks out the clot Stereotaxis RF

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