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  • HARVARD MEDICAL SCHOOL

    Case Based Interventional Cardiology

    Teaching for the PCP

    Update in Internal Medicine

    Duane Pinto, MD, MPH, FACCCO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    Agenda

    • Introduction to the Cath Lab

    • What types of procedures are done in a cath lab

    • Considerations for PCP before and after interventional

    procedures

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    What Procedures Done in the Cardiac Cath Lab

    • Coronary angiography and revascularization

    • Hemodynamic studies

    – Valve interrogation

    – Heart failure/Pericardial Constriction

    – Pulmonary hypertension evaluation

    • Structural heart procedures

    – ASD/PFO/PDA/Paravalvular leak

    – Ethanol ablation for HOCM

    – Transcatheter AVR

    – Transcatheter Mitral and Tricuspid Valve repair/replacement

    – Appendage closure

    • Mechanical assist devices for shock

    • Peripheral revascularization studies/IVC Filter

    insertion/removal

    • Pericardial tap/balloon ostomy

    • Endomyocardial Biopsies

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    RHC

    • Pressure measurements

    –Valvular heart disease

    –Filling Pressures

    –Pulmonary hypertension

    –Pericardial processes/Restriction

    • Oximetric Measurements

    –Shunts

    –Cardiac output- Fick Equation

    –Resistances- Ohm’s Law

    4

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    RHC

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    Detecting Shunts by Oxymetry

    ∆mean ∆highest QP/QS Site Sat% Sat% threshold

    ANY (PA from SVC) ≥7 ≥8 1.5

    RA (from SVC/IVC) ≥7 ≥11 1.5-1.9

    RV (from RA) ≥5 ≥10 1.3-1.5

    PA (from RV) ≥5 ≥5 1.3

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    Atrial Tracings

    Chest 2000; 118:1788-91.

    JVP x

    x+x’ y

    v

    ca

    x’

    S1 S1 S2S2

    RA

    a c

    x’

    v x

    y

    a v

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    Case: ET

    Severe mitral regurgitation

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    The World Changed for Functional MR on 9/23/18

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    Exercise Hemodynamics

    • For evaluation of valvular disease and other situations

    • Simultaneous catherization is done and pressure measurements of RT & LT heart is taken –At rest

    –With exertion

    • Catheter is placed in: –An artery (femoral or brachial)

    –Vein (femoral or basilic)

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    Advanced Diagnostic Studies of the Vascular System

    • Biopsy catheter with bioptome tip is inserted into jugular or femoral vein into RT ventricle

    • Jaws are opened and many biopsies are taken

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    Bioptome Biopsies

    • Used to monitor cardiac

    transplants for tissue rejection

    • And to differentiate between

    various types of cardiomyopathies

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    Radial Sheath

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    Rate Ratio 0.83; 95% CI, 0.73 to 0.96; p=0.0092

    11.7%

    9.8%

    NNTB: 53 Femoral Radial

    Primary EP: NACE

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    Coronary Angiography

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    67 Year old woman with chest pain

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    I didn t tell you the whole story…..

    That was 23 years ago. Now she is 90 and in

    shock with STEMI

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    • My left arm was cold all of the time!

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    • Recovered from MI, Shock and ATN

    • Discharged to 12 days later

    CO PY RIG HT

  • Duration of DAPT

    • Dual antiplatelet therapy (ASA and P2Y12) is used for secondary

    prevention of vascular disease and to prevent device

    thrombosis

    • DAPT is mandatory for a period of time without interruption to

    prevent stent thrombosis.

    –Peripheral vascular stents 1 month

    –Percutaneous valves 3 months unless bleeding or need anticoagulation

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    In patients with ACS (STEMI or NSTEACS) who receive PCI:

    Values and Preferences: These recommendations place greater emphasis on reduction of major cardiovascular events and stent thrombosis versus an increase in bleeding complications.

    Recommendations

    • We recommend dual antiplatelet therapy (DAPT) with ASA 81 mg daily plus either ticagrelor 90 mg twice daily or prasugrel 10 mg once daily over clopidogrel 75 mg once daily for 1 year (Strong

    Recommendation, High Quality Evidence).

    • We recommend that in patients who tolerate 1 year of DAPT without a major bleeding event and who are

    not at high risk of bleeding, DAPT should be extended beyond 1 year (Strong Recommendation, High Quality Evidence for up to 3 years of treatment). After 1 year, we recommend a DAPT regimen of ASA 81 mg daily plus either ticagrelor 60 mg twice daily or clopidogrel 75 mg once daily (Strong

    Recommendation, High Quality Evidence) or prasugrel 10 mg once daily (Weak Recommendation, Moderate Quality Evidence).

    2018 CCS/CAIC Focused Update of the Guidelines for the Use of Antiplatelet Therapy

    https://www.ccs.ca/images/Guidelines/Educational.../APT_Gui_2018_SD_EN.pptx

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    Duration of DAPT for patients treated with PCI in ACS

    settings

    Practical tips:

    • Recommendations on duration of DAPT apply specifically to duration of P2Y12 inhibitor

    therapy. ASA should be continued indefinitely in most patients with CAD who are not on oral

    anticoagulant therapy.

    • Patients who have clinical or angiographic features for an increased risk of a thrombotic

    cardiovascular event may derive greater absolute benefit from extended DAPT beyond 1 year.

    • Quantitative risk scores have been developed. These scores may help identify higher risk

    patients with greater absolute benefit of extended DAPT .

    • An ongoing assessment of bleeding and ischemic risk should be performed at least annually to

    determine whether DAPT should be continued.

    • Prasugrel should be avoided in patients with previous TIA or stroke.

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    PCI for STEMI or NSTEACS

    DAPT for 1 year

    ASA 81 mg once daily +

    Ticagrelor 90 mg BID or Prasugrel 10 mg once daily preferred over

    Clopidogrel 75 mg once daily

    At 1 year, determine bleeding risk

    Not at high risk of bleeding1

    1 Factors associated with increased bleeding risk include: need for OAC in addition to DAPT,

    advanced age (> 75 years), frailty, anemia with hemoglobin < 110 g/dL, chronic renal failure

    (creatinine clearance < 40 mL/min), low body weight (< 60 kg), hospitalization for bleeding within

    last year, prior stroke/intracranical bleed, regular need for NSAIDS or prednisone 2 Instead of ticagrelor or clopidogrel, prasugrel 5-10 mg daily is also an option (weak

    recommendation)

    DAPT=dual antiplatelet therapy SAPT=single antiplatelet therapy STEMI=ST segment elevation

    myocardial infarction NSTEMI=non-ST segment elevation myocardial infarction BID=twice daily

    Strong recommendation

    Weak recommendation

    High risk of bleeding1

    Continue DAPT for up to 3 years

    ASA 81 mg once daily +

    Ticagrelor 60 mg BID or

    Clopidogrel 75 mg once daily2

    SAPT ASA 81 mg once daily

    or Clopidogrel 75 mg once daily

    2018 CCS/CAIC Focused Update of the Guidelines for the Use of Antiplatelet Therapy

    https://www.ccs.ca/images/Guidelines/Educational.../APT_Gui_2018_SD_EN.pptx

    CO PY RIG HT

  • HARVARD MEDICAL SCHOOL

    Clinical Angiographic Prior myocardial infarction or troponin

    positive acute coronary syndrome

    Multiple stents (≥ 3 stents implanted, ≥

    3 lesions stented)

    Diabetes Mellitus treated with oral

    hypoglycemics or insulin

    Long lesion length (> 60 mm total stent

    length)

    Chronic kidney disease (creatinine

    clearance ≤ 60 ml/min)

    Complex lesions (bifurcation treated

    with 2 stents, stenting of chronic

    occlusion)

    Prior stent thrombosis Left main or proximal LAD stenting

    Multivessel PCI

    Net b