Dr. Giuseppe Sangiorgi, FESC, FSCAI Laboratorio di Emodinamica Università di Modena Ruolo della...
-
Upload
bailey-egan -
Category
Documents
-
view
217 -
download
2
Transcript of Dr. Giuseppe Sangiorgi, FESC, FSCAI Laboratorio di Emodinamica Università di Modena Ruolo della...
Dr. Giuseppe Sangiorgi, FESC, FSCAIDr. Giuseppe Sangiorgi, FESC, FSCAI
Laboratorio di EmodinamicaLaboratorio di EmodinamicaUniversità di ModenaUniversità di Modena
Ruolo della cardiologia interventistica nel paziente con patologia extracoronarica complessa
Ruolo della cardiologia interventistica nel paziente con patologia extracoronarica complessa
Giuseppe Sangiorgi, MD
Cardiac Cath LabModena Policlinic
Giuseppe Sangiorgi, MD
Cardiac Cath LabModena Policlinic
L’idraulico dell’ExtracoronaricoL’idraulico dell’Extracoronarico
• Quanti di voi hanno mai chiamato l’idraulico?
• Avete chiamato l’idraulico per il gabinetto ed è arrivato uno specialista solo in docce?
• Noi emodinamisti dovremmo saper riparare tutto?
33
Chi vede il Paziente Affetto da Patologia Extracoronarica ?
MEDICINA DI BASEMEDICINA D’URGENZAInternistaCardiologo clinicoCardiologo interventistaAngiologoNefrologoNeurologo
Medicina Interna
Chirurgo GeneraleCardiochirurgoChirurgo VascolareNeurochirurgoRadiologia
Non-interventistaInterventistaNeuroradiologo
Chirurgia
My personal experience My personal experience
in developing an in developing an ““open cath-lab platformopen cath-lab platform””
In 15 MinutesIn 15 Minutes• How all this developed in the places How all this developed in the places
where I have been working up to now where I have been working up to now - and how this could develop in your place (I and how this could develop in your place (I
really hope your dreams comes true)really hope your dreams comes true)
• What you really need to make that happenWhat you really need to make that happen- and what could be helpful in these daysand what could be helpful in these days
• How this will develop in the futureHow this will develop in the future- and where we should work onand where we should work on
21 Years in 15 min21 Years in 15 min
19891989• University of Tor Vergata - RomeUniversity of Tor Vergata - Rome
- Coronary angiogramsCoronary angiograms- PTCAPTCA- Coronary angiogramsCoronary angiograms- PTCAPTCA- Coronary angiogramsCoronary angiograms- PTCAPTCA
• Max Sangiorgi: Max Sangiorgi: "Is there anything else I could "Is there anything else I could do?"do?"
• Senior Physician (Prof. Gioffrè): Senior Physician (Prof. Gioffrè): "Well, I have "Well, I have just got this balloon from Meditech. Some crazy just got this balloon from Meditech. Some crazy people have started to dilate pulmonary valves"people have started to dilate pulmonary valves"
Starting a pulmonary valvuloplasty Starting a pulmonary valvuloplasty program was pretty easy at that timeprogram was pretty easy at that time
• Doctor: Doctor: "Listen, you have a blocked heart valve! "Listen, you have a blocked heart valve! We are going to balloon it"We are going to balloon it"
• Patient: Patient: "Great, please go ahead""Great, please go ahead"
• No ethical committeeNo ethical committee• No regulatory issuesNo regulatory issues• No reimbursement issuesNo reimbursement issues• No paperwork at allNo paperwork at all
That's how we started to do That's how we started to do something else beside coronariessomething else beside coronaries
1989
If you are doing If you are doing coronaries only …coronaries only …
… … could you start a could you start a pulmonary valvuloplasty pulmonary valvuloplasty
program in your institution program in your institution today?today?
Of course!! No problemOf course!! No problem• You may just need …You may just need …
- some discussion with the general director of the hospitalsome discussion with the general director of the hospital- some discussion with CADMsome discussion with CADM- some discussion with administrationsome discussion with administration- some discussion with pharmacysome discussion with pharmacy- some discussion with clinical engineersome discussion with clinical engineer- a little bit more of discussion with the surgeons than we had a little bit more of discussion with the surgeons than we had
in the 80iesin the 80ies- a dedicated 3 day training organized by the medical device a dedicated 3 day training organized by the medical device
companycompany- a certificate from the scientific society of somethinga certificate from the scientific society of something- May be you will need IRB approval May be you will need IRB approval - and may be some other paper workand may be some other paper work
Needless to mention …Needless to mention …
… … that it is an absolute requirement that it is an absolute requirement that you already have done 100 that you already have done 100
cases (for the general director and cases (for the general director and CADM) with excellent outcome CADM) with excellent outcome beforebefore you start your program you start your program
19901990• PTCA in a 68 y/o patientPTCA in a 68 y/o patient• I punctured the right femoral I punctured the right femoral
- and failedand failed• I punctured the left femoralI punctured the left femoral
- and failedand failed• I punctured the right brachialI punctured the right brachial
- and failedand failed• I did not know about the radial approach I did not know about the radial approach
- and punctured the left brachialand punctured the left brachial- crossed a proximal stenosis of the left subclaviancrossed a proximal stenosis of the left subclavian- … … finally performed the PTCAfinally performed the PTCA
• "Would be nice to have that subclavian artery open""Would be nice to have that subclavian artery open"- The cath lab nurse run into the radiology department for a 5 mm The cath lab nurse run into the radiology department for a 5 mm
balloonballoon- I did my first peripheral angioplastyI did my first peripheral angioplasty- … … and finally learned what turf battle meansand finally learned what turf battle means
Next morning in the office Next morning in the office of the head of radiologyof the head of radiology
• Head of radiology (Prof. Giovanni Head of radiology (Prof. Giovanni Simonetti): Simonetti): "How could you as a cardiologist "How could you as a cardiologist do a peripheral angioplasty without do a peripheral angioplasty without permission?!?!permission?!?!What would you say if I as a radiologist would What would you say if I as a radiologist would start coronary angiography?"start coronary angiography?"
• My answer: My answer: "I would be more than happy to "I would be more than happy to train you"train you"
• Head of radiology: very angry with Head of radiology: very angry with cardiologists after 20 years cardiologists after 20 years
We moved on We moved on with other procedures with other procedures
which required big which required big balloonsballoons
… … like aortic valvuloplastylike aortic valvuloplasty
Angioplasty of coarctationAngioplasty of coarctation
1992
Thereafter, we pushed the balloon forward ....Thereafter, we pushed the balloon forward ....
Retrograde Mitral Valvuloplasty
1993
and transeptal mitral and transeptal mitral valvuloplasty with ugly balloonsvalvuloplasty with ugly balloons
1993
Later on Later on we did this with umbrellaswe did this with umbrellas
Rashkind-OkkluderRashkind-Okkluder
If you are familiar with...If you are familiar with...
• transseptal puncturetransseptal puncture
• the left atriumthe left atrium
• umbrellasumbrellas
So now you have some So now you have some contacts to the pediatric contacts to the pediatric
world, world,
so it is only a small step to so it is only a small step to become involved in VSD become involved in VSD
closureclosure
Congenital Muscular VSDCongenital Muscular VSD
San Donato 1998
Of course, you are still Of course, you are still involved in the sometimes involved in the sometimes
boring coronary workboring coronary work
So you will become So you will become involved in post-Myocardial involved in post-Myocardial
infarction VSD closureinfarction VSD closure
Post Myocardial Infarction VSDPost Myocardial Infarction VSD
Device released Final angio
By the way: By the way: Do not forget the coronary fistulasDo not forget the coronary fistulas
Only a small step to peripheral fistulasOnly a small step to peripheral fistulas
Pulmonary AV-FistulaPulmonary AV-Fistula
San Donato 2001
When you alreayd have When you alreayd have experience with really large experience with really large
sheaths...sheaths...
SPIRAL ANGIO CT
D3
D5
D4
IMALumbar aa.
Accessory renal a.
ANGIO DSA
Anatomical landmarks to be considered prior to EVG intervention
Renal a.
D5
D1
D : diameter L : length A : angulation
L2
D3
D5
D4
Giorgio S.Rx. 3242118\10\2000
Giorgio S.Rx. 3242118\10\2000
Selective injection of SMAfills back IMA up to the coilSelective injection of SMAfills back IMA up to the coil
Selective 3rd left lumbar a. arteriography
Selective 3rd left lumbar a. arteriography
Super-selective 3rd left lumbar a. arteriographythrough Fast Traker 325
Super-selective 3rd left lumbar a. arteriographythrough Fast Traker 325
Catheter treatment of Catheter treatment of congenital heart diseasecongenital heart disease
Non-congenital Non-congenital heart defectsheart defects
Other Other cardiovascular cardiovascular
diseasesdiseases
If you have learned transseptalsIf you have learned transseptalsand if you know where the left and if you know where the left
atrium is....atrium is....
Alain Cribier's Valve (PVT)Alain Cribier's Valve (PVT)
• Equine pericardiumEquine pericardium
• Balloon expandable Balloon expandable
stentstent
• One size: 23mm One size: 23mm
CoreValve PAVR CoreValve PAVR ReValvingReValving System System
• Nitinol frameNitinol frame- Self expandingSelf expanding
• Porcine pericardial valvePorcine pericardial valve
• Low radial force- Orients the system
• Constrained area- Avoids coronaries
• High radial force- Secure anchoring
• 26 and 29mm diameter
If you are dealing with stroke If you are dealing with stroke prevention like PFO and LAA prevention like PFO and LAA
closure you have some contacts closure you have some contacts to the world of neurologyto the world of neurology
And And Carotid Carotid Stenting?Stenting?
Siti più comuni di PTA
su vasi epiaortici
Siti più comuni di PTA
su vasi epiaortici
ACC corpoACC corpo
ACIACI
Tronco anonimoTronco anonimo
ACC ostialeACC ostiale
SucclaviaSucclavia
Critical left subclavian a. stenosis in a pt with CABG: LIMA to LAD
Critical left subclavian a. stenosis in a pt with CABG: LIMA to LAD
Post PTA + stentingPost PTA + stenting
Remo S.Rx 1132321\02\1995
Remo S.Rx 1132321\02\1995
PTA Carotide ComunePTA Carotide Comune
Post PTAPost PTA
Remo S.Rx 11323 22\02\1995
Remo S.Rx 11323 22\02\1995
Post stent J&J 204Post stent J&J 204
PTA Carotide ComunePTA Carotide Comune
Bartolomeo G.Rx. 1768524\01\2007
Bartolomeo G.Rx. 1768524\01\2007
Association of critical left CCA ostial and distal calcified stenosis at bifurcation.Strategy : exposure of CCA, direct stenting of ostial and CEA at bifurcation. Post direct JOMED P 38 stenting
Bartolomeo G.Rx. 1768524\01\2007
Bartolomeo G.Rx. 1768524\01\2007
Post CEAPost CEA
PTA + stent
retrogrado
della ACC
ostiale
via puntura
diretta dopo
esposizione
chirurgica
del vaso
PTA + stent
retrogrado
della ACC
ostiale
via puntura
diretta dopo
esposizione
chirurgica
del vaso
b
• The diameter of The diameter of the LAD is equal the LAD is equal to the diameter of to the diameter of the tibial arteriesthe tibial arteries
3 mesi dopo il trattamento
6 mesi dopo il trattamento
Basale 3 mesi dopo
PADunderdiagnosed and
undertreateddisease
• High prevalence and high morbidity (non-healing wounds, gangrene, and amputation) lead to the publication of a “call to action” to physicians to increase detection of and treatment for PAD
Arch Intern Med 2003;63:884–92.
Sensitivity and specificity
• Resting ABI value <0.9 approaches 95% sensitivity in detecting angiogram positive disease, and it is associated with the presence of 50% or greater stenosis in 1 or more major vessels.
• It is almost 100% specific in excluding healthy individuals.
ABI and Survival
We have been involved We have been involved in all of thisin all of this
Can you become Can you become involved as well?involved as well?
Of course!! No problemOf course!! No problem• You may just need …You may just need …
- some discussion with the director of the hospitalsome discussion with the director of the hospital- some discussion with the administrationsome discussion with the administration- some discussion with the health care insurancessome discussion with the health care insurances- a little bit more of discussion with the surgeons than a little bit more of discussion with the surgeons than
we had in the 80ieswe had in the 80ies- a dedicated 3 day training organized by the medical a dedicated 3 day training organized by the medical
device companydevice company- a certificate from the scientific society of somethinga certificate from the scientific society of something- May be you will need IRB approval May be you will need IRB approval - and may be some other paper workand may be some other paper work
What do you What do you really need ?really need ?
You really needYou really need• Cath labCath lab• Echo and TEE and someone who helps Echo and TEE and someone who helps
you with thatyou with that
• … … and for some more complex and for some more complex procedures… anestesiologist, Vascular procedures… anestesiologist, Vascular surgeons, neurologists, cardiothoracic surgeons, neurologists, cardiothoracic surgeonssurgeons
You don't really needYou don't really need• Hybrid roomHybrid room
• CT CT
• MRIMRI
• 3 D Angio3 D Angio
• Although all this may be helpfulAlthough all this may be helpful
And of course all of the following is And of course all of the following is helpful in these dayshelpful in these days
• some discussion with the director of the hospitalsome discussion with the director of the hospital• some discussion with the administrationsome discussion with the administration• some discussion with the health care insurancessome discussion with the health care insurances• a little bit more of discussion with the surgeons than a little bit more of discussion with the surgeons than
we had in the 80ieswe had in the 80ies• a dedicated 3 day training organized by the medical a dedicated 3 day training organized by the medical
device companydevice company• a certificate from the scientific society of somethinga certificate from the scientific society of something• IRB approval IRB approval • and may be some other paper workand may be some other paper work
In 15 MinutesIn 15 Minutes• How all this I have been wish that could How all this I have been wish that could
developed in my place that now is Modenadeveloped in my place that now is Modena- and how this could develop in your placeand how this could develop in your place
• What you really need to make that happenWhat you really need to make that happen- and what could be helpful in these daysand what could be helpful in these days
• How this will develop in the futureHow this will develop in the future- and where we should work onand where we should work on
There will be much more catheter There will be much more catheter techniques available to treat all kind techniques available to treat all kind
of cardiovascular diseases of cardiovascular diseases
We should always tryWe should always try• to keep the doors opento keep the doors open• to stop over-regulationto stop over-regulation• to avoid turf battlesto avoid turf battles• and to train the radiologists and to train the radiologists
and vascular surgeons in and vascular surgeons in coronary angiographycoronary angiography
Conclusioni Il trattamento percutaneo delle diverse patologie
periferiche si è rapidamente sviluppato ed è in rapida evoluzione
Molte applicazioni interventistiche periferiche hanno tratto enorme vantaggio dalla traslazione della tecnologia coronarica
L’intero campo ha avuto ed avrà enormi benefici dalla partecipazione di un maggior numero di colleghi cardiologi
Come cardiologi, la partecipazione in questo programma di sviluppo è imperativa
Il trattamento percutaneo delle diverse patologie periferiche si è rapidamente sviluppato ed è in rapida evoluzione
Molte applicazioni interventistiche periferiche hanno tratto enorme vantaggio dalla traslazione della tecnologia coronarica
L’intero campo ha avuto ed avrà enormi benefici dalla partecipazione di un maggior numero di colleghi cardiologi
Come cardiologi, la partecipazione in questo programma di sviluppo è imperativa
STROKE