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#1006 New Approaches to Cardio Re-vascularization
October 26 to October 29
Robert E. Michler, MDProfessor of SurgeryChief, Division of Thoracic and Cardiovascular SurgeryThe Ohio State University Medical Center
Gregory M. Eaton, MDAssistant Professor of Clinical Internal MedicineDivision of CardiologyThe Ohio State University Medical Center
Gregory M. Eaton, MDAssistant Professor of Clinical Internal Medicine
Division of CardiologyThe Ohio State University Medical Center 1
PTCA PTCA
• 1997 - 20th anniversary
• Tremendous growth
• Relieves angina
• Comparable to CABG in select patient population
• Effective in acute myocardial infarction
• 1997 - 20th anniversary
• Tremendous growth
• Relieves angina
• Comparable to CABG in select patient population
• Effective in acute myocardial infarction
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BARI, CABRI, EAST, GABI And RITA:Coronary Angioplasty On Trial
BARI, CABRI, EAST, GABI And RITA:Coronary Angioplasty On Trial
• Balloon angioplasty initially developed: - To support a technique of myocardial revascularization which is minimally invasive
- Performed via a percutaneous approach with little patient discomfort
- Shorter hospital stays
• Balloon angioplasty initially developed: - To support a technique of myocardial revascularization which is minimally invasive
- Performed via a percutaneous approach with little patient discomfort
- Shorter hospital stays
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Advances In coronaryStenting
Advances In coronaryStenting
• Less intense anticoagulation
• More flexibility in deployment
• Better patency
• Safer deployment
• Less intense anticoagulation
• More flexibility in deployment
• Better patency
• Safer deployment
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IntracoronaryBrachytherapy
IntracoronaryBrachytherapy
• Prevention of restenosis after intervention remains greatest therapeutic challenge in interventional cardiology
• Pre-clinical trials using ionizing radiation shows significant reduction in neointimal proliferation
• Prevention of restenosis after intervention remains greatest therapeutic challenge in interventional cardiology
• Pre-clinical trials using ionizing radiation shows significant reduction in neointimal proliferation 9
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IntracoronaryBrachytherapy
IntracoronaryBrachytherapy
• High risk for restenosis: - Restenotic lesions - Diffuse or multifocal disease - Smaller arteries - Recanalized chronic total occlusion - ? Diabetes
• High risk for restenosis: - Restenotic lesions - Diffuse or multifocal disease - Smaller arteries - Recanalized chronic total occlusion - ? Diabetes
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NOGAEndomyocardial Mapping
NOGAEndomyocardial Mapping
• Evaluating patients with ischemic heart disease needs to accurately define presence and nature of dysfunctional myocardial tissue
• Nature of dysfunctional but viable tissue important component of the clinical assessment of patients with chronic CAD
• Evaluating patients with ischemic heart disease needs to accurately define presence and nature of dysfunctional myocardial tissue
• Nature of dysfunctional but viable tissue important component of the clinical assessment of patients with chronic CAD
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NOGAEndomyocardial Mapping
NOGAEndomyocardial Mapping
• Designed to acquire, analyze and display real time electromechanical maps of the human heart
• Accurate 3D mapping
• Non-flouroscopic location
• System uses magnetic technology to accurately determine location and orientation of catheter
• Designed to acquire, analyze and display real time electromechanical maps of the human heart
• Accurate 3D mapping
• Non-flouroscopic location
• System uses magnetic technology to accurately determine location and orientation of catheter 14
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NOGA NOGA
• 3D geometry constructed real time
• Electrophysiologic information superimposed on electroanatomical map
• Non-fluoroscopic guidance - Transmyocardial revascularization - Gene therapy
• 3D geometry constructed real time
• Electrophysiologic information superimposed on electroanatomical map
• Non-fluoroscopic guidance - Transmyocardial revascularization - Gene therapy 17
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Transmyocardial LaserRevascularization
Transmyocardial LaserRevascularization
• Surgical or percutaneous approach
• Investigational therapeutic strategy to enhance myocardial perfusion by applying laser source into ischemic myocardium
• Preliminary surgical trials significant reduction in angina, improved quality of life, some improved perfusion
• Surgical or percutaneous approach
• Investigational therapeutic strategy to enhance myocardial perfusion by applying laser source into ischemic myocardium
• Preliminary surgical trials significant reduction in angina, improved quality of life, some improved perfusion
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Transmyocardial LaserRevascularization
Transmyocardial LaserRevascularization
• Mechanism of benefit unknown: - Long-term patency of channels conflicting
- “Anesthetic effect” from vaporization of myocardial nerve fibers
- Angiogenesis with enhanced collateral development and increased myocardial perfusion
• Mechanism of benefit unknown: - Long-term patency of channels conflicting
- “Anesthetic effect” from vaporization of myocardial nerve fibers
- Angiogenesis with enhanced collateral development and increased myocardial perfusion
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Robert E. Michler, MDProfessor of Surgery
Chief, Division of Thoracic and Cardiovascular SurgeryThe Ohio State University Medical Center 30
Profile Profile
Mike• 47 year old male• Father, grandfather• Symptoms - Chronic history of fatigue
- Bee sting - Self-injected epinephrine
- Seen at ER - acute EKG changes
Mike• 47 year old male• Father, grandfather• Symptoms - Chronic history of fatigue
- Bee sting - Self-injected epinephrine
- Seen at ER - acute EKG changes 31
Profile Profile
Mike
Diagnosis: High-grade lesion; left anterior descending artery
Recommended: FDA approved minimally invasive surgical procedure
Mike
Diagnosis: High-grade lesion; left anterior descending artery
Recommended: FDA approved minimally invasive surgical procedure
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ConventionalCABG Surgery
ConventionalCABG Surgery
• Proven safety and efficacy• Recovery time• Pain / discomfort• Neurologic disorders• CPB sequelae
• Proven safety and efficacy• Recovery time• Pain / discomfort• Neurologic disorders• CPB sequelae
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Principle Causes Of MorbidityAnd Mortality In CABG
Principle Causes Of MorbidityAnd Mortality In CABG
• Cardiopulmonary bypass• Sternotomy
• Cardiopulmonary bypass• Sternotomy
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Minimally Invasive DirectCoronary Artery Bypass
Minimally Invasive DirectCoronary Artery Bypass
Definition: Limited coronary artery bypass grafting without sternotomy, cardiopulmonary bypass or manipulation of the ascending aorta, usually using arterial conduits.
Definition: Limited coronary artery bypass grafting without sternotomy, cardiopulmonary bypass or manipulation of the ascending aorta, usually using arterial conduits.
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Advantages OfMIDCAB
Advantages OfMIDCAB
• Avoidance of sternotomy• Avoidance of cardiopulmonary bypass• Shorter or no stay in ICU• Shorter hospitalization• Quicker convalescence• Lower cost
• Avoidance of sternotomy• Avoidance of cardiopulmonary bypass• Shorter or no stay in ICU• Shorter hospitalization• Quicker convalescence• Lower cost 39
Expanded IndicationsFor MIDCAB
Expanded IndicationsFor MIDCAB
• “Culprit vessel” revascularzation• Previously complicated sternotomy• Substernal patent IMA graft• Inordinate risk of cardiopulmonary bypass• High risk for aortic manipulation
• “Culprit vessel” revascularzation• Previously complicated sternotomy• Substernal patent IMA graft• Inordinate risk of cardiopulmonary bypass• High risk for aortic manipulation
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VADCAB VADCAB
• Decreases the amount of post-operative pain
• Anterior Thoracotomy Site can be centered over target vessel
• No rib resection is required
• Sequential anterior wall grafting can be performed with longer ITA mobilization
• Decreases the amount of post-operative pain
• Anterior Thoracotomy Site can be centered over target vessel
• No rib resection is required
• Sequential anterior wall grafting can be performed with longer ITA mobilization 41
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Advantages OfMIDCAB / VADCAB
Advantages OfMIDCAB / VADCAB
• No risk of stroke• No neurocognitive changes• No coagulopathy• Reduced hospitalization and disability• More cosmetic incision
• No risk of stroke• No neurocognitive changes• No coagulopathy• Reduced hospitalization and disability• More cosmetic incision
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MIDCABDisadvantages
MIDCABDisadvantages
• Incomplete revascularization (analogous to PTCA)• Unproven survival benefit in multivessel disease• Acceptable short term follow-up• Difficult management of intraop ischemia and hemodynamic instability
• Incomplete revascularization (analogous to PTCA)• Unproven survival benefit in multivessel disease• Acceptable short term follow-up• Difficult management of intraop ischemia and hemodynamic instability 44
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Trans Myocardial LaserRevascularization
Trans Myocardial LaserRevascularization
• For diffuse small vessel disease• Higher cardiac event-free survival• Fewer cardiac-related rehospitalizations• Improved exercise tolerance• Similar one-year survival (84% vs 89%)• HCFA approved reimbursement
• For diffuse small vessel disease• Higher cardiac event-free survival• Fewer cardiac-related rehospitalizations• Improved exercise tolerance• Similar one-year survival (84% vs 89%)• HCFA approved reimbursement
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Profile Profile
Mike
Treatment - Minimally invasive heart surgery
- FDA approved robotic procedure
Mike
Treatment - Minimally invasive heart surgery
- FDA approved robotic procedure
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Profile Profile
Mike
Evaluation - Operation went smoothly - Post Op coronary angiogram - 3rd day post op - symptom free, went home - 2 weeks post op - back to work part time
Prognosis: Good
Mike
Evaluation - Operation went smoothly - Post Op coronary angiogram - 3rd day post op - symptom free, went home - 2 weeks post op - back to work part time
Prognosis: Good
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#1007 3rd Annual G.I. Quiz
November 2 to 5
Sheryl A. Pfeil, MDAssistant Professor of Clinical Internal MedicineDivision of Digestive DiseasesThe Ohio State University Medical Center
Robert Murray, MDAssociate Professor of PediatricsSection of GastroenterologyChildren’s Hospital & The Ohio State University Medical Center
NEXT WEEK
