1. Prof Dr Rasim ENAR İÜ. CTF. Department of Cardiology
INVASİVE CARDIOLOGY: Percutaneous Intervention. PART- I: Diagnostic Techniques Left and Right Heart Catheterisatıon. Coronary angıography.
Prof Dr Rasim ENAR
İÜ. CTF. Department of Cardiology

2. Types of percutaneous intervention:
A. Diagnostic:
Diagnostic Cath:
Right and left heart cath.
Coronary angiography.
EPS, IVUS…
B.Therapetic:
1- Standart PCI: PTCA, Stents.
2- New İntracoronary devices: Atherectomy, Rotablator, Laser, Brachytherapy (radiotherapy), Thrombectomy, distal- protection.
3- Non-coronary intervention:
Valvuloplasty, Septal ablation, septal defect closure, valve replacement , PM, ICD, CRT….

3. CATHETERISATION Definition:
Invasive procedures for the diagnosis and assesment severity of cardiovascular disease.
Essentially,Catheterisation of right and left heart and coronary angiography. This procedure is done by using various methods and various catheters.
Catheter: Are small plastic tubes which has empty tunel inside.

4. Main condition for PCI:…”Have to be”… Appropriate Cath Lab and Staf.
Semi-sterile Catheterisation Laboratory: A movable table for the patient lying supine, - film camera, a scope with rotating head, - angiyography and monitors for intra cardiac pressure and ECG monitoring. –Emergent CPR conditions and PCI materials.

5. Catheterisation access methods.
A- Arterial access:
Direct access. Brachial artery dissection.
Percutaneous access. Punction of radial, brachial, femoral arteries.
B- Other ways of access:
1– Transeptal. For entrance to left atrium: For mitral valvuloplasty in MS.
Contraindications: Huge left atrium, atriyal mixoma, thrombus ve haemorhagic diatesis.
2– Direct LV puncture. Conditions in which LV cannot be entered throgh mitral and aortic valves: “Tilting-prostesis valves”.

6. Percutaneous catheteter sheath introductıon :

7. Normal Heart and Coronary arteries Anatomy.

8. Anatomy of femoral artery ande vein
Anatomy of femoral artery ande vein. Catheterizatıon from the femoral vein; right- heart cath. Retrograde crossing of aortic valve(pigtail cath and with guide vire combination).

9. Major type of Heart Catheterisation:
RIGHT HEART CATHETERISATION:
Vena Cava, Right- atrium, Right- ventricle, Pulmonary- artery, Pulmonary- capillary wedge pressure and measurement of oxygene saturation, calculation of Cardiac output.
Importance:
1- Measurement of right side pressures; establish prescence of Tricuspid or Pulmonary valves dysfunctıon and estimating sevirity.
2- Pulmonary hypertension can be evaluated and pulmonary vascular resistance can be calculated.
3- Pulmonary capillary wedge pressure; reflect the diastolic filling pressure of the left heart indirectly: Shows indirectly the left atrial and LV end- diastolic pressures. Is an important parameter in LV failure and MS.

10. 1- Most reliable diagnoses of AS and MS by pressure calculations.
LEFT HEART CATHETERISATION:
Mitral and Aort valve functions, systemic vascular resistance and LV function, and coronary artery anatomy.
Importance:
1- Most reliable diagnoses of AS and MS by pressure calculations.
MS: Gradient between LV diastolic – Pulmonary capillary wedge pressure measurements.
AS: Gradient is present between LV and systolic Aortic peak pressure when the catheter is pulled back from LV to the Aorta.
2- Ventriculography,Aortography: During catheterisation, prescence of AR and/or MR is shown: Contrast material is given by pump to the LV and regurgitation of the contrast from LV to LA shows MR. When contrast is given from the Aorta at supravalvular level and contrast regurgitates to the LV, AR is present.
3- Evaluation of LV function: Beating LV is filled with contrast. (a) LV segmentar wall motion is evaluated. (b) LV EF (% fractional shortening) can be calculated.
4- Coronary angiography.

11. HEMODYNAMİC MESURMENTS:
1. Cardiac output.
2. Pressure measurements of cardiac cavities and large arteries (aorta, pulmonary arteries).
3. Evaluation of pressure waves.
4. Evaluation of valvular heart disease.
(a) Assesment of Valvular stenosis and measurement of valve area.
(b) Evaluation of valvular regurgitation.
5. Diagnosis of left and right shunts (with oxygen saturatıon).
6. Angiography.
(a) Left ventriculography.
(b) Right ventriculography.
(c) Aortography.

12. Normal Values of Hemodynamıc Parameters:
Left Ventricle ( mmHg):
Systolic:
End- diastolic: 3- 12
Right Ventricle (mmHg):
Systolic:
End- diastolic: 2- 8
Aortic (mmHg):
Diastolic:
Mean:
Right atrıum (mmHg):
Mean: 2 -8
A wave: 2- 10
V wave: 2- 10
Cardiac ındex: L/min/m2
Stroke index: mL/meat/m2
Systemic vascular resistance (Dynes-sec-cm-5 ):
PVR:
Pulmonary artery (mmHg):
Diastolic: 4- 12
Mean:
Arterial oxygen saturatıon(%):93- 98
Arteriovenous oxygen difference (mL/L):
PCWP (mmHg) = (Left atrıum):
Mean: 2- 12
A wave: 3- 15
V wave: 3- 15

13. Left Ventriculography

14. Aort and Mitral stenosis: Pressure gradients:MS AS

15. AS ve MS; pressure gradients.

16. Right and left Judkins catheters:

17. Cannulatıon of left and right coronary arteries using the judkins catheters:

18. Left and Right Coronary Angiography:

19. DIAGNOSTIC HEART CATHETERISATION Basic indications:
1- Documentation or to rule out heart disease if there is strong suspection by physical examination or non-invasive diagnostic tests.
2- If there is discrepancy between clinical findigs and non-invasive diagnostic modalities, to explain the clinic situation.
3- To evaluate other cardiac comorbid pathologic conditions in patient who has been given to open heart surgery for any cause.

20. Indications for Coronary Angiography.
CLINICAL CONDITIONS:
Essential İndicatıon: Known or suspected CAD. High- risk Asymptomatic patient: History of Previous MI, PTCA, CABG, with Ischemic findings on resting or exercise ECG.
1. stable angina.
2. Unstable coronary syndrome.
3. Post-revascularisation ischemia.
4. Primary treatment of AMİ (with STE or LBBB in ECG); before PCI.
5. Pre and post cardiac surgery.
6. Patient with valvular disease.
7. Congenital heart disease.
8. Congestive heart failure.

21. Unstable coronary syndromes.
USAP:
Prior Urgent and early, delayed PCI.
1- Urgent PCI: AP with hemodynamic or electrical instability (high cTn).
2- Early PCI:
Refractory to initial treatment.
Recurrence of symptoms after becoming stable by initial medical therapy.
3- Delayed PCI (selected patients):
High risk and complicated USAP. + hemodynamic and electrical instability: ”Urgent catheterisation” is recommended.
Low risk patient at presentation; but high risk on non-invasive tests ( Ischemia at low- level exercise, EF <0.40).
Suspected Prinzmetal Variant angina.

22. Treatment of STE- AMI
Prior PCI or surgery (Primer, rescue, inhospital).
1- Primer PCI: Alternative to Thrombolytic therapy: STE,LBBB, admitted with in <12 or >12 hrs of AMİ.
Cardiogenic Shock: In the first 36 hrs of MI, (<75 yrs and in 18 hrs of shock).
2- Rescue PTCA: Failed Thrombolysis.
3. Early coronary angiography (İnhospital or before discharge):
a- Spontaneously or stimulated (E-ECG) ischemic episodes (with dynamic ECG changes: ±).
b- depressed LV systolic functıon (LVEF<0.40).
c- Mechanical complicatıon, prior repair surgery.

23. CA: Relative Contraindications.
1- Decompensated HF (Pulmonary Edema).
2- Uncontrolled ventricular irritability (arrythmia with hemodynamic compromise).
3- Uncontrolled systemic hypertension.
4- Acute and severe renal failure.
5- Inability of vascular access.
6- Electrolyte imbalance: Hypokalemia, Hyperkalemia.
7- Digital intoxication.
8- Active infection and septic conditions.
9- Uncontrolled Haemorrhagic diastesis.
10- Severe anemia.
11- Active haemmorhage.
12- Contrast allergy.
13- Loss of consciousness.
* **!!!- ABSOLUTE CONTRAINDICATION: Disclaim of conscious patient.

24. COMPLICATIONS:
Complication prevalance was reduced as the number of procedures was increased in any center (!).
MAJOR Complications (% ): Death, AMI, SVA.
*** DEATH (% ).
Cause: Perforation, arrythmia, AMI, or contrast anaphylaxis.
Patients with Hıgh- Rısk of Death (risk %2.8):
1- Patients >70, <1 years.
2- NYHA-4 HF or angina.
3- Severe LV dysfunction (EF<%25).
4- Severe and extensive CAD (LMCA or ostial, 3- vessel disease).
5- Severe valvular disease (with LV dysfunction).
6- Severe comorbid conditions (renal, hepatic, lung disease).
7- Known contrast allergy.

25. Contrast nephropathy:
Is generally secondary to high doses of contrast material, and especially develops in diabetic patients.
Prevention:
a- Dose of the contrast material must be calculated according to the patients body surface area, weight and serum creatinin levels.
b- Non-ionic contrast material is the prefere.
c- Before vatheterization, oral homosistein can be given and bicarbonate infusion can be made.
d- In patients using diuretics, the diuretic dose befor catheterization must be passed, and especially in diabetics, iv hydration must be increased. IV hydration must be continued during the procedure if needed.
e- During the 6-12 hour period after catheterization, oral and iv hydration must be sufficient (1.5 – 2 Lt).

27. Prof Dr Rasim ENAR İÜ. CTF. Department of Cardiology
INVASİVE CARDIOLOGY: Percutaneous Intervention. PART- II: İnvasive Therapies PCI, Stenting PMV, ASD- Closure. PM- ICD, CRT.
Prof Dr Rasim ENAR
İÜ. CTF. Department of Cardiology

28. PERCUTANEOUS CORONARY INTERVENTION (PCI):
Definition: Is the treatment intended percutaneous coronary procedure.
Was known as “PTCA” in the past.
For optimal procedure: Standart catheterization laboratory, dilatation material and experienced staff able to use these material must be present.
Ideal patient:
(a) One vessel disease.
(b) Older patients, performed CABG at past; who has fragile lesion (“discrete; length <10 mm. Diameter of the vessel >2.5 mm), and 3- vessel disease with high success rate (high- risk for reoperatıon).
(c) In the case of ACS and especially STEMI, primary treatment choice is percutaneous coronary intervention.
Power of PCI: To be successfull in >%90 of cases.

29. Limitations of PCI:
1- Success rate is low in chronic total occlusions.
2- Early and long term efficacy is low in saphenous vein greft lesions.
High- Risk Stenotic Lesions:
a- Diffuse (>20 mm). Vessel Diameter: < mm.
b- Dense tortuous- proximal segment.
c- Severely angulated segment (≥90 degee).
d- Total occlusion (>3 months). Degenerated vein greft (fragyl lesion).
e- Ostial lesions, side branch originating from the lesion.
Advers effects of the intervention:
a- Fatal event (%1).
b- Acute and late ischemic complications (%2).
c- Signifficant Restenosis in the first months. (%10).

30. Complications of PCI: 1. Mortality. (a) In stable patients: <%2.
(b) AMI + CS : >%50.
2. Myocardial Infarction.
Elevation of cardiac markers: %5- 10.
3. No- ReFlow: Proksimal vessel is open, but myocardial tissue is not perfused. Also called “Malperfusıon, and inadequate tissue-level perfusıon”.Incidence; % at reperfused vessel.
Vasoactive materials emanating by the disintegration or breaking up of the thrombus of the proximal lesion and microembolisation.
Diagnosis: Elevation of cardiac markers, ST- T wave changes on ECG and regional wall motion abnormalities.
4. Coronary perforation and rupture.

31. STENTS.
Are the supplementary and complementary components of balloons.
Rutine stenting has become the routine procedure of PCI. (“Direct Stenting”).
Types:
Drug eluting Active - Stents (“Drug Eluting Stent”).
Metal, Passive- Stents (Bare- Stent”).
Difficulties of PCI:
a- Passing chronic total occlusion.
b- Optimization of anti-thrombotic and anti-thrombin therapies for acute total occlusions.
c- Retsenosis is a problem, decreasing with Active- stents. Although acute, subacute restenosis decreases more compared with passive stents, but late restenosis in 2 years is more frequent in DES.

32. INDICATIONS OF PCI: CLINICAL INDICATIONS:
1- Acute Cornary Syndromes: STEMI, NSTEMI, USAP).
2- Stable AP: Positive exercise testing (at low-level), LV dysfunction, electrical instability.
3- Angina equivalents (with known, documented CAD): Arrythmia (symptomatic tachy-, brady-), lightheadness, dyspnea.
4- MS - CT’de; Sign of proximal stenosis (must be confırmed by coronary angıography).
5- Objective signs of reversible ischemia.
ANGIOGRAPHIC INDICATIONS:
Lesions are apopriate for PCI.
2- There is no life threatening effects of occluding these lesions for ≥1 minute( ie. LMCA, ostial lesions).
3- Prescence of functional myocardium or collateralls.

33. CONTRAINDICATIONS FOR PCI:
CLINICAL CONTRAINDICATIONS:
1- Terminal heart disease or other disease (except uncontrolled AP).
2- Post-MI CS (with multiorgan failure).
ANGIOGRAPHIC CONTRAINDICATIONS:
1- LMCA disease.
2- LMCA equivalent: Proximal LAD + CX disease.
3- Last vessel: Other 2 coronary artery occluded.
4- Three vessel disease (except inop patient).
5- Characteristics of hard lesions:
(a)- Chronic total occlusion.
(b)- No collateral to the distal artery.
(c)- Diffuse old lesion (>20 mm).
(d)- No cut off..
(e)- No critical CAD in the prescence of thrombotic lesion.
(f)- Diffuse atherosclerotic or small diameter vessel (<2 mm). Saphenous vein greft.

34. Materials for PCI:

35. Mechanism of PTCA and Stenting.
Dissection of intima and media in the nneighbor sections of the vessel near the plaque. Circumferential dilatation of the vessel is the key mechanism for luminal increase (increasing diameter).
STENT: Is the key material for preventing “elastic recoil of the widening vessel. Keeps the plaque particles and intima away from the luminal surface.

36. Schematized STENTING.
Beginning of the procedure: Angaging the guiding catheter successfully to the coronary ostiyum and passing the guide wire hrough the lesion.
A- Passing the stented ballon from the stenotic lesion. Before this, standart predilatation of the lesion mey be needed.
B- Inflating the ballon and widening of the stent.
C-, D- Deflating the balloon and pulling back from the widened stent.

37. Baloon and + Stent. ADDITIONAL THERAPİES: Efficacy of PCI:
1. Oral- Antiplatelet : ASA, Clopidogrel.
2. İV- Antiplatelet : GP-2b/3a İnh.
3. Antithrombins: Heparin(UFH, LMWH Bivaluridin, Fondaparinux).
4. Planned Secondary prevention strategy at discharge (ASA,CLP,Statin, BBl, ACEİ).
Efficacy of PCI:
a- High Success rate of the intervention.
b-Symptomatic relief after intervention: %90.
c- Complications: ≤ %2.

38. Coronary Angiography: Successfull Stenting.

39. Percutaneous Mitral Baloon Valvotomy (PMV)
Percutaneous ASD Closure
İndicatıons:
Symptoms of dyspne,fatigue or RHF.
Reccurrent pulmonary infectıon.
Paradoxical embolism.
Atrial arrhytmia even ın the presence of a small defect.
Moderate Pulmonary hypertensıon without pulmonary vascular disease.
Asymptomatic large ASD (Qp/Qs>1.5:1.0),RH volum overload and no pulmonary hypertensıon.
İnd: MV: Echo score <8.
MVA<1.0 cm2.
No subvalvular fibrosis,
mobile valve and noncalcified.

40. ICD: Implantable Cardioverter Defibrillator:
(Chest Radiograph and figure of PM locatıon)
ICD İndications:
Reduced EF who had history of cardiac arrest,VT,VF.
Ischemic CMP; at least 40 days post-MI with EF <%30, NYHA II or III on chronic OMT.

41. CRT: Cardiac Resynchronısatıon Therapy
İndicatıons:
LVEF<%35.
Sinus rhym.
NYHA class –III-IV, despite optimal therapy (OMT).
Have cardiac dyssynchrony,
QRS duratıon >120 ms.