Percutaneouse coronary intervention
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Balloon angioplasty was first performed in 1977 and involved passing a guide wire and deflated balloon catheter across a stenosis, inflating the balloon to enlarge the vessel lumen, and removing the balloon. Major advances in technology led to an increase in PCI procedures surpassing CABG. Stents were a major development as they reduced complications like abrupt closure and restenosis compared to balloon angioplasty alone.
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The cumulative rates of DES failure have created a major clinical problem so that > 10% of all PCIs done in the United States are to treat ISR, and the number of ISR interventions appears to be increasing year over year
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BMS were developed to mitigate elastic recoil and negative remodeling, but they remain prone to NIH. DES were developed to prevent NIH, and these devices (especially first-generation DES) can be accompanied by delayed reendothelialization, which has been associated with stent thrombosis.
Even in the contemporary era of percutaneous coronary intervention using drug-eluting stents, ISR remains a common problem, occurring in 5% to 20% of cases, depending on several patient and lesion characteristics.
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The document discusses multiple coronary stent implantations and outcomes. A sirolimus-eluting stent was implanted in the left anterior descending coronary artery (LAD) 16 months prior. Another sirolimus-eluting stent was implanted in the LAD 6 months prior. A multilink stent was implanted in the right coronary artery (RCA) 24 months prior.
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Schmitz et al studied the use of ultrasmall superparamagnetic iron oxide (USPIO) particles to enhance MRI imaging of atherosclerosis in rabbits. They administered different doses of USPIO to rabbits and imaged them at various time points up to 48 hours later. Their results demonstrated contrast enhancement of atherosclerotic plaques on MRI scans after USPIO injection.
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This document proposes 5 scientific research projects and 6 core projects for a Program Project Grant from the NIH to study detection of vulnerable plaque and vulnerable patients. The 5 research projects are: 1) MRI imaging of inflammation and vulnerable plaque in humans and animals; 2) Intravascular thermography to detect inflammation in plaque; 3) Development of new MRI and CT nanoparticle contrast agents; 4) Development of enhanced intravascular and surface MRI coils; 5) Imaging of vulnerable patients using CT and a new calcium scoring system in humans. The 6 core projects provide support in pathology, MRI, microCT, image processing, data analysis, and administration.
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This document summarizes research on matrix metalloproteinases (MMPs) and their role in weakening atherosclerotic plaques. It finds that MMPs are expressed in human atherosclerotic plaques, especially in macrophage foam cells located in the vulnerable shoulders of plaques. Several MMPs have been shown to degrade components of the fibrous cap, including collagen. Reactive oxygen species produced by macrophage foam cells can activate latent MMPs. Treatments that reduce oxidative stress, such as N-acetyl cysteine, decrease MMP expression and activity in experimental atherosclerosis. Overall, the document provides evidence that MMPs expressed by macrophage foam cells may weaken plaques through degradation of the fibrous cap, making plaques more
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This document provides an overview of MRI system components and basic MRI physics concepts. It includes:
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This document discusses developing an artificial intelligence system to predict short-term cardiovascular disease (CVD) events. The goal is to eradicate unexpected heart attacks by predicting risk similar to hurricane forecasts. Existing studies are cited that show over 50% of heart attacks are first symptoms of underlying disease. The document outlines previous work by SHAPE to define vulnerable patients and release guidelines. It proposes using machine learning on existing cohort data to develop algorithms predicting heart attacks within 12 months, and validate the system. The hope is this can trigger preventative actions and add over 10 years to life expectancy. Funding is needed to implement the proposed "Machine Learning Vulnerable Patient Project".AHA SHAPE Symposium 2017 Dr. Kloner Presentation
Triggers of cardiovascular events can include physical and emotional stress. Stress from events like earthquakes, blizzards, intense sporting games, and overexertion from activities like snow shoveling have been shown to increase the risk of acute cardiovascular outcomes like myocardial infarction. While modern therapies have improved cardiovascular health, research continues to show temporary increases in cardiovascular mortality associated with highly emotional sporting events even in recent years. Managing risk factors, reducing stress, and utilizing preventative therapies may help reduce the impact of triggers on cardiovascular health.
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A machine learning model outperformed the ACC/AHA Pooled Cohort Equations Risk Calculator in detecting high-risk asymptomatic individuals and recommending statin treatment for cardiovascular disease prevention in the Multi-Ethnic Study of Atherosclerosis. The machine learning model used support vector machines and data augmentation to derive a CVD risk predictor from nine variables in the MESA study population. It demonstrated higher sensitivity, specificity, and AUC compared to the ACC/AHA risk calculator, recommending statin treatment for fewer individuals while missing fewer cardiovascular events.
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Vulnerable plaque refers to dangerous forms of atherosclerotic plaques that can rupture or induce thrombosis, disrupting blood flow. The document discusses the history and research around vulnerable plaque, including pioneers in the field and emerging techniques to detect vulnerable plaque such as intravascular ultrasound, optical coherence tomography, and magnetic resonance imaging. It summarizes that vulnerable plaques are typically characterized by a thin fibrous cap, large lipid core, and presence of macrophages.
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The document summarizes research on vulnerable plaques and markers of vulnerability. It finds that ruptured plaques are the most common type of culprit lesion, accounting for around 70% of cases. Major criteria for defining vulnerable plaque include outward remodeling, endothelial dysfunction, and a thin fibrous cap with a large lipid core. Both plaque morphology and activity need to be assessed to identify vulnerability.
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This document contains a summary of a presentation on vulnerable patient syndrome. It includes PowerPoint slides and videos on defining and identifying vulnerable plaques and patients. It thanks sponsors for their support of the educational event. The slides define vulnerable plaques as those likely to rupture in the future, causing heart attacks, and provide criteria for identifying them based on morphology and activity. Biomarkers and conditions that increase plaque and myocardial vulnerability are also summarized. The presentation outlines a pyramid approach for screening, diagnosing, and treating vulnerable patients annually to help reduce heart attacks and their high costs.
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This document discusses triggers for sudden cardiac arrest (SCA) and death (SCD). It notes that over 2/3 of SCD cases are unable to be predicted due to a lack of well-established risk factors. While population risk factors can identify at-risk groups, they cannot predict risk for individuals. The document explores various biological, anatomical, and environmental factors that can precipitate fatal arrhythmias and discusses how the timing of transient initiating events is critical for the development of ventricular tachyarrhythmias. It emphasizes that myocardial electrophysiological processes likely determine the onset or lack of VT/VF/SCD and that immediate access to automated external defibrillators is needed to save lives.
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The document discusses vulnerable plaque and challenges in detecting and treating it. It describes various imaging techniques for detecting vulnerable plaque such as thermography, MRI, CT angiography, and optical coherence tomography. However, it notes that while these can identify high-risk features, it remains unclear what exactly defines vulnerable plaque and whether imaging findings truly correlate with risk. The document also notes that while statins reduce events, the relationship between plaque burden and events is unclear, and better defining and detecting the disease is still needed before new therapies can be developed.
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1) The study examined 92 hearts from patients with severe coronary artery disease who died suddenly. The hearts were sectioned and plaque types were classified.
2) The number of "vulnerable" plaques, particularly thin cap atheromas, was highest in hearts of patients who died from acute plaque rupture and lowest in those with incidental disease.
3) Thin cap atheromas and other unstable plaque types were concentrated in the proximal coronary segments, similar to the distribution of plaque ruptures. The study suggests vulnerable plaques contribute to acute coronary syndromes and are non-uniformly distributed within the coronary arteries.
Vp watch editorial_slide 25short-
1) Drug-coated stents, particularly those coated with sirolimus, have shown promise in reducing restenosis compared to bare metal stents. Sirolimus inhibits cell proliferation and has been shown in studies to reduce intimal hyperplasia and restenosis in animal models by 50% or more.
2) A study by Suzuki et al. found that a sirolimus-coated stent reduced restenosis by 50% through inhibiting cellular proliferation in a dose-dependent manner compared to a bare metal stent. Adding dexamethasone to the coating did not provide additional benefit.
3) If results of the RAVEL clinical trial showing "zero" restenosis out to 5 years
Vp watch editorial_slide25
This document discusses drug-coated stents for preventing restenosis. It summarizes a study showing that stents coated with sirolimus via a polymer matrix reduced restenosis by 50% by inhibiting cell proliferation. Adding dexamethasone provided no additional benefit. Other studies also showed sirolimus inhibits smooth muscle cell proliferation. If results of the RAVEL trial showing "zero" restenosis at 210 days hold true long-term, sirolimus-coated stents may become the standard therapy for coronary revascularization. Questions are raised about whether coating vulnerable plaques could be a primary treatment and if multiple vulnerable plaques would all be stented.
Vp watch editorial_slide25short-
1) Drug-coated stents, particularly those coated with sirolimus, have shown promise in reducing restenosis compared to bare metal stents. Sirolimus inhibits cell proliferation and has been shown in studies to reduce intimal hyperplasia and restenosis in animal models by 50% or more.
2) A study by Suzuki et al. found that a sirolimus-coated stent reduced restenosis by 50% through inhibiting cellular proliferation in a dose-dependent manner compared to a bare metal stent. Adding dexamethasone to the coating did not provide additional benefit.
3) If results of the RAVEL clinical trial showing "zero" restenosis out to 5 years
Vp watch2002
I. This document discusses various animal models that have been used to study atherosclerosis and plaque rupture, including quail, pigeons, chickens, dogs, monkeys, pigs, rats, rabbits, and mice. It provides details on the types of lesions developed and similarities to human disease for each model.
II. The double knockout LDL/apoE mice are highlighted as offering improvements in studying clinical complications of atherosclerosis like human heart disease. However, it is unclear how closely they model vulnerable plaques.
III. Questions are raised about how closely the coagulation systems of these animal models resemble humans and whether any model fully captures repeated plaque ruptures and the role of aging in natural history as seen in humans.
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Trans-Blood Vision is a patented infrared technique that uses short-wave infrared wavelengths to see directly through blood. It has the potential to find vulnerable plaque lesions without first entering them, determine their size and surface characteristics in high resolution, and look at their material constituents both on and below the surface. While it cannot provide direct visual guidance for therapy or penetrate as deeply as ultrasound, combining it with augmentative technologies could allow for real-time multi-mode detection, analysis, and therapy guidance of vulnerable plaque lesions. The document concludes that Trans-Blood Vision warrants significant investigation, possibly in combination with other emerging technologies.
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- 2. HISTORICAL PERSPECTIVE Balloon angioplasty was first performed by Andreas Gruentzig in 1977 with a fixed-wire balloon catheter.
- 3. design border spectrum of patients with more complex lesion are undergoing PCI.
- 4. Major advances The major advances in interventional cardiology continue as new technology is developed,tested,and brought to the clinical arena.These advances have led to the significant increase in procedural volume so that currently,the number of PCI exceeds the number of CABGs.
- 5. THE TECHNIQUE OF BALLOON DILATATION A guide wire is passed across the stenosis This is followed by deflated balloon The balloon catheter is inflated within the lesion The lumen is enlarged after balloon removal
- 7. BALLOON ANGIOPLASTY The improvement in luminal diameter of vessel is mainly due to cracking of the vessel wall that frequently extends through the plaque and the underlying media,allowing expansion of both the inner and outer diameter of the treated segment.
- 8. TWO MAJOR LIMITATIONS OF BALLOON ANGIOPLASTY : *Abrupt vessel closure 2-8% *Restenosis 30%-50%
- 9. THE NEW CORONARY DEVICES TO IMPROVE UPON PROCEDURAL OUTCOMES ACHIEVED WITH BALLOON ANGIOPLASTY:
- 10. Removing devices: Directional atherectomy Extraction atherectomy Debulking devices: Excimer laser angioplasty Scaffolding device: Stents Rotational atherectomy
- 12. STENTS(scaffolding devices) Coronary stents have fundamentally changed the practice of interventional cardiology by reducing early complication(abrupt vessel closure) and improving late clinical outcome(restenosis) and it is estimated that 50-80 percent of PCI procedures now involved the use of stent.