Linee guida e timing chirurgico insufficienza aortica
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Linee guida e timing chirurgico dell’insufficienza valvolare aortica: che cosa attende migliore definizione. Dr. Antonio Federico - Villa Maria Cecilia Hospital - Maggio 2009
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The document discusses strategies for percutaneous coronary intervention (PCI) of chronic total occlusions (CTOs). It describes:
1. The antegrade approach is the most commonly used, with success rates of 60-80%. Tapered guidewires are first-choice to probe microchannels.
2. A four-wire strategy is recommended, starting with a polymer-coated wire and progressing to stiffer wires if needed.
3. Advanced techniques like parallel wiring or antegrade dissection and reentry may be used if initial wiring fails.
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Approach to coronary bifurcation lesions
This document discusses approaches to treating bifurcation lesions in coronary arteries. It defines a bifurcation lesion as occurring at the point where a main blood vessel splits into two branches. There are several challenges to treating these lesions, including difficult access to the side branch, plaque shifting, and high rates of restenosis. The document discusses techniques for classifying bifurcation lesions and outlines strategies such as provisional stenting of the main branch or elective double stenting of both branches. It provides guidance on factors to consider such as vessel size, angle of bifurcation, and extent of disease in determining the best approach.
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1) Left main coronary artery disease has traditionally been treated with coronary artery bypass grafting (CABG), which is considered the gold standard.
2) Recent studies comparing percutaneous coronary intervention (PCI) using drug-eluting stents to CABG have shown no significant differences in mortality or major adverse cardiac events between the two treatments.
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2. A four-wire strategy is recommended, starting with a polymer-coated wire and progressing to stiffer wires if needed.
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This document discusses approaches to treating bifurcation lesions in coronary arteries. It defines a bifurcation lesion as occurring at the point where a main blood vessel splits into two branches. There are several challenges to treating these lesions, including difficult access to the side branch, plaque shifting, and high rates of restenosis. The document discusses techniques for classifying bifurcation lesions and outlines strategies such as provisional stenting of the main branch or elective double stenting of both branches. It provides guidance on factors to consider such as vessel size, angle of bifurcation, and extent of disease in determining the best approach.
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Left main disease final
- Left main coronary artery disease occurs in 5-7% of patients undergoing coronary angiography and is associated with high mortality if left untreated. The left main artery supplies a large portion of the heart.
- Left main disease can be caused by atherosclerosis, infections, inflammation, anomalies, or compression. Atherosclerosis particularly affects areas of low shear stress like the bifurcation.
- Percutaneous coronary intervention or coronary artery bypass grafting may be considered for treatment depending on the patient's characteristics and complexity of the disease. Outcomes are generally better when intravascular ultrasound is used to guide stenting of left main lesions. Patient selection is important to achieve good long-term results.
Left Main Coronary Artery Disease- Management Strategy
1) Left main coronary artery disease has traditionally been treated with coronary artery bypass grafting (CABG), which is considered the gold standard.
2) Recent studies comparing percutaneous coronary intervention (PCI) using drug-eluting stents to CABG have shown no significant differences in mortality or major adverse cardiac events between the two treatments.
3) PCI may be preferable to CABG for patients with isolated left main or left main plus single vessel disease, while CABG remains the standard treatment for more complex multi-vessel disease.
Descending aortic aneurysm
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This document discusses techniques and tools for percutaneous coronary intervention (PCI) in calcified lesions. It summarizes that calcified lesions are challenging to treat with PCI due to increased risk of incomplete lesion preparation and stent failure. Imaging modalities like intravascular ultrasound (IVUS) and optical coherence tomography (OCT) can help identify calcification. Treatment options discussed include rotational atherectomy, orbital atherectomy, cutting/scoring balloons, and lithoplasty balloons. Clinical trials found that while these techniques can treat calcified lesions, they also carry higher risks of complications compared to conventional angioplasty. Careful lesion assessment and technique selection are important for optimizing outcomes in patients with calcified coronary lesions.
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Echocardiography plays an important role in the care of patients undergoing transcatheter aortic valve implantation (TAVI). Pre-procedurally, echocardiography is used to confirm the severity of aortic stenosis, assess the aortic annulus size, exclude contraindications like left ventricular thrombus, and help determine the optimal access route. During TAVI, echocardiography guides valve selection and positioning, identifies complications, and can help address issues like paravalvular regurgitation. Post-procedure, echocardiography is crucial for long-term monitoring of valve function and the detection of any late complications.
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IVUS and OCT are intracoronary imaging modalities that provide information about coronary artery walls and atherosclerotic plaque beyond what can be seen through angiography alone. IVUS uses ultrasound to image plaque and vessel wall characteristics in 3D, while OCT has higher resolution but more limited depth, using near-infrared light. Both techniques can identify plaque morphology and composition, detect disease not seen on angiograms, and help assess stent results. IVUS is useful for pre-PCI decision making and vessel sizing while OCT can image plaque features at a higher resolution.
Which mechanical circulatory support should we use as first line option
1) Temporary mechanical circulatory support options like intra-aortic balloon pumps, Impella pumps, TandemHeart pumps, and extracorporeal membrane oxygenation (ECMO) can be used as first-line support for acute cardiogenic shock.
2) These temporary options are placed percutaneously in the catheterization lab and can provide partial to full cardiac output support.
3) Larger ventricular assist devices require open heart surgery and are better suited for longer term chronic support if the patient does not recover with temporary support. The optimal support strategy depends on the individual patient's clinical status and prognosis.
Approach to left main bifurcation stenting
Despite the recent developments that have been made in the field of percutaneous left main (LM) intervention, the
treatment of distal LM bifurcation remains challenging. The provisional one-stent approach for LM bifurcation has
shown more favorable outcomes than the two-stent technique, making the former the preferred strategy in most
types of LM bifurcation stenosis. However, elective two-stent techniques, none of which has been proven superior
to the others, are still used in patients with severely diseased large side branches to avoid acute hemodynamic
compromise. Selecting the proper bifurcation treatment strategy using meticulous intravascular ultrasound evaluation
for side branch ostium is crucial for reducing the risk of side branch occlusion and for improving patient outcomes. In
addition, unnecessary complex intervention can be avoided by measuring fractional flow reserve in angiographically
isolated side branches. Most importantly, good long-term clinical outcomes are more related to the successful
procedure itself than to the type of stenting technique, emphasizing the greater importance of optimizing
the chosen technique than the choice of metho
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Left main stenting
1. Significant unprotected left main coronary artery (ULMCA) disease occurs in 5–7% of patients undergoing CAG and is treated medically has a 3-year mortality rate of 50%.
2. Studies have shown PCI with drug-eluting stents for ULMCA disease can achieve low rates of death, MI, and TLR at 12 months compared to bare-metal stents which had high rates of restenosis and mortality.
3. While CABG remains the standard of care for many patients, randomized trials found PCI with DES to have non-inferior outcomes to CABG at 1-2 years for death, MI, and stroke in selected patients with low complexity lesions. Rates
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Coronary intravascular lithotripsy and lasers/ IVL
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2. Early studies found IVL to be safe and effective for facilitating stent delivery and expansion in calcified lesions, with low rates of complications.
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Echocardiography plays an important role in the care of patients undergoing transcatheter aortic valve implantation (TAVI). Pre-procedurally, echocardiography is used to confirm the severity of aortic stenosis, assess the aortic annulus size, exclude contraindications like left ventricular thrombus, and help determine the optimal access route. During TAVI, echocardiography guides valve selection and positioning, identifies complications, and can help address issues like paravalvular regurgitation. Post-procedure, echocardiography is crucial for long-term monitoring of valve function and the detection of any late complications.
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IVUS and OCT are intracoronary imaging modalities that provide information about coronary artery walls and atherosclerotic plaque beyond what can be seen through angiography alone. IVUS uses ultrasound to image plaque and vessel wall characteristics in 3D, while OCT has higher resolution but more limited depth, using near-infrared light. Both techniques can identify plaque morphology and composition, detect disease not seen on angiograms, and help assess stent results. IVUS is useful for pre-PCI decision making and vessel sizing while OCT can image plaque features at a higher resolution.
Which mechanical circulatory support should we use as first line option
1) Temporary mechanical circulatory support options like intra-aortic balloon pumps, Impella pumps, TandemHeart pumps, and extracorporeal membrane oxygenation (ECMO) can be used as first-line support for acute cardiogenic shock.
2) These temporary options are placed percutaneously in the catheterization lab and can provide partial to full cardiac output support.
3) Larger ventricular assist devices require open heart surgery and are better suited for longer term chronic support if the patient does not recover with temporary support. The optimal support strategy depends on the individual patient's clinical status and prognosis.
Approach to left main bifurcation stenting
Despite the recent developments that have been made in the field of percutaneous left main (LM) intervention, the
treatment of distal LM bifurcation remains challenging. The provisional one-stent approach for LM bifurcation has
shown more favorable outcomes than the two-stent technique, making the former the preferred strategy in most
types of LM bifurcation stenosis. However, elective two-stent techniques, none of which has been proven superior
to the others, are still used in patients with severely diseased large side branches to avoid acute hemodynamic
compromise. Selecting the proper bifurcation treatment strategy using meticulous intravascular ultrasound evaluation
for side branch ostium is crucial for reducing the risk of side branch occlusion and for improving patient outcomes. In
addition, unnecessary complex intervention can be avoided by measuring fractional flow reserve in angiographically
isolated side branches. Most importantly, good long-term clinical outcomes are more related to the successful
procedure itself than to the type of stenting technique, emphasizing the greater importance of optimizing
the chosen technique than the choice of metho
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Microcatheter selection and manipulation- How to make the right choice
Kambis Mashayekhi, Lahr, Germany
Room:
Guteberg Hall (Auditorium) - Saturday 13:30
Speaker:
Gerald Werner, Darmstadt, Germany;
Kambis Mashayekhi, Lahr, Germany;
Jo Dens, Genk, Belgium;
Gregor Leibundgut, Bâle, Suisse
Bifurcation stenting
A 47-year-old male presented with angina and a history of hypertension and smoking. Tests showed T-wave inversion and normal left ventricular function. He underwent bifurcation stenting of a true bifurcation lesion where both the main branch and side branch were significantly narrowed. The current preferred approach for treating non-true bifurcations is provisional stenting of the main vessel with optional stenting of the side branch. A two-stent strategy may be used for large side branches supplying a significant area of myocardium, especially when the side branch arises at a shallow angle.
Left main stenting
1. Significant unprotected left main coronary artery (ULMCA) disease occurs in 5–7% of patients undergoing CAG and is treated medically has a 3-year mortality rate of 50%.
2. Studies have shown PCI with drug-eluting stents for ULMCA disease can achieve low rates of death, MI, and TLR at 12 months compared to bare-metal stents which had high rates of restenosis and mortality.
3. While CABG remains the standard of care for many patients, randomized trials found PCI with DES to have non-inferior outcomes to CABG at 1-2 years for death, MI, and stroke in selected patients with low complexity lesions. Rates
Technique of peripheral angiogram and complication
The document discusses techniques for peripheral angiograms and potential complications. It covers operating room preparation including equipment such as needles, guide wires, sheaths, and catheters. Access site selection is discussed including the common femoral, popliteal, tibial, brachial, subclavian, and radial arteries. The angiogram procedure is outlined including artery puncture, sheath placement, guidewire insertion, catheter selection, contrast injection, and closure techniques such as manual compression or closure devices. Complications from the procedure are also mentioned.
Vte 2014
This document discusses the diagnostic and treatment approaches to venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE). It provides details on evaluating patients using Wells criteria and D-dimer testing to determine pre-test probability and decide between imaging with CT pulmonary angiogram or VQ scan. For confirmed VTE, treatment options include warfarin, novel oral anticoagulants (NOACs), inferior vena cava filters or thrombolytics. The document reviews best practices for treating isolated distal DVT, catheter-related thrombosis, and selecting appropriate long-term anticoagulation therapy.
Coronary intravascular lithotripsy and lasers/ IVL
1. The document discusses coronary intravascular lithotripsy (IVL), a new technique for treating severely calcified coronary lesions by using low-pressure shockwaves to fracture calcium deposits.
2. Early studies found IVL to be safe and effective for facilitating stent delivery and expansion in calcified lesions, with low rates of complications.
3. Larger trials confirmed IVL's safety and ability to modify calcium, with most lesions experiencing calcium fracture and acute gains in lumen size post-IVL.
Bifurcation stenting seminar
Bifurcation stenting is challenge for intervention cardiologist, understanding of lesion, strategy for stenting, imaging has very important for success.
Vascular access
This document discusses vascular access for hemodialysis and a programmatic approach. It covers the multidisciplinary care team involved, background on chronic kidney disease and end stage renal disease in the US, and options for vascular access at initiation of dialysis. The document reviews guidelines promoting arteriovenous fistulas over catheters, quality standards, and complications associated with different access types. It also discusses strategies for a systems approach to access management, including timing of access creation and cannulation, monitoring access, and interventions for access issues.
Hemodynamic support in pci
This document discusses hemodynamic support devices used in the cath lab, including the Impella system. It outlines the types of indications for cath lab hemodynamic support, such as elective high-risk PCI, PCI for cardiogenic shock, and recent high-risk acute coronary syndrome. The document reviews evidence from the PROTECT II trial that demonstrates improved left ventricular function and NYHA class with the Impella system, as well as superior outcomes compared to intra-aortic balloon pumps. It concludes that the Impella system provides better hemodynamic support than intra-aortic balloon pumps, especially when placed pre-PCI, for high-risk PCI and cardiogenic shock patients.
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Clinical management of crt non responders
1. While CRT is effective for many patients, approximately one-third do not experience full benefits. Non-response can be due to factors like suboptimal device settings, medical therapy, or lead placement.
2. Managing CRT patients involves optimizing medical treatment, monitoring the device, educating patients, and regular follow-ups. Device settings like AV/VV timing and using multi-site pacing can improve outcomes.
3. For non-responders, following a protocol to re-evaluate device settings, medical compliance, and consider lead repositioning or additional optimization may increase the likelihood of a positive response.
Cardiac resynctmh
This document summarizes information on device therapy for congestive heart failure, including cardiac resynchronization therapy (CRT). It discusses:
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This document provides an overview of cardiac resynchronization therapy (CRT), including indications, assessment of dyssynchrony, rationale/mechanism, trials, procedures, and programming. It discusses the types and assessment of cardiac dyssynchrony using ECG, echocardiography, MRI, and nuclear imaging. Key trials on CRT are summarized, showing benefits for heart failure patients with reduced ejection fraction and wide QRS duration or echocardiographic evidence of dyssynchrony even in narrow QRS.
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Multimodality imaging.
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This document discusses evidence for performing PCI on chronic total occlusions (CTOs). It summarizes several studies that found:
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Linee guida e timing chirurgico insufficienza aortica
- 1. Linee guida e timing chirurgico dell’Insufficienza Aortica : che cosa attende migliore definizione Dr. Antonio Federico “ L’Insufficienza Valvolare Aortica” Villa Maria Cecilia Hospital 15 – 16 Maggio 2009
- 4. Indici di performance ventricolare sinistra + + + + + + + + + + + S.F. (v.n. 25%-45%) + + + + + + + + + 0 + Dimens. sistoliche + + + + + + + + 0 + + + VCF (SF/ET) (v.n.>1,1circ./sc) + + + + + + + + + + + + dP/dt + + + + + + + + + + + + F.E. fattibilità Dipendenza Massa/vol. Dipendenza da postcarico Dipendenza da precarico Sensibilità a inotropismo
- 8. BNP e timing CCH nella SVA severa JACC 2006 (47), 11:2141 - 2151
- 11. EF 54 % EF 51 % Rest Exercise Sv 5.4 cm/s Sv 6.1 cm/s Delay 60 ms F UP:Acute HF EF 34% Sv 2.4 cm/s “ Stress testing could be useful for the early detection of latent systolic failure”
- 12. Proposta flow chart per timing chirurgico in I. Ao DTD 55-70 mm + DTS 45/55 mm DTD > 70 mm + DTS > 55 mm F.E. > 55% F.E. < 55% dP/dt + BNP = < > + stress ECO = < Follow up CCH
- 13. Quale ruolo per la terapia medica ?
- 14. Quale ruolo per la terapia medica ? JACC 2005;45:1205-30