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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3597_Библиотеки_им_академика_М_И_Перельмана
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femoral artery (SFA)-profunda bifurcations are below this point and
permit access to ipsilateral SFA, profunda, popliteal, and below-theknee vessels.
2. Retrograde, common femoral: Access of the ipsilateral iliac artery
permits a contralateral approach to iliac SFA and below-the-knee
lesions.
3. Brachial-axillary (radial with extra long catheters) access requires
extra-long catheters and balloons (120 to 145 cm). Access is used
when bilateral iliofemoral vessels are occluded.
4. Popliteal: Retrograde access for SFA occlusions avoids the proximal
cap and minimizes the likelihood of entering side branches in total
occlusions. There is risk of joint space (knee) injury.
5. Tibial: Retrograde access for tibial occlusions avoids the proximal
cap.
Interventional Cardiology Procedures
Angiography
1. Cardiac catheterization laboratory equipment (Digital subtraction
angiography should be considered for noncoronary imaging.)
•
Image intensifier, 9-inch mode
• Digital imaging subtraction to reduce radiation exposure
• Cineframe rates show flow dynamics (helpful in assessing
collaterals)
•
Speed of 15 frames/sec is adequate
2. Abdominal aortogram
• Catheter positioned above or at the level of renal arteries (L1
or L2 disk space)
•
Contrast medium injection, 15 mL/sec × 3 sec or 20 mL/sec ×
2 sec
• Pan to iliofemoral vessels
• Lateral plane for celiac, superior mesenteric, or inferior mesen-
teric artery origins
•
LAO 20 degrees for renal artery origins
3. Selective iliofemoral angiography with runoff to feet
• Catheter positioned in proximal common iliac artery
• Simmons, SOS Omni Selective Catheter (AngioDynamics,
Latham, NY), VCF, Cobra (Terumo Medical, Somerset, NJ),
internal mammary, or pigtail catheters used
•
Contrast medium injection, 6 to 8 mL/sec × 4 to 6 sec
• Lateral angulation of image intensifier at 30 degrees (SFA-
profunda bifurcation)
•
Pan from common iliac artery to foot vessels
• Chapter 5 provides illustrations of common peripheral vascular
interventions and complications
Figure 10-16 shows an example of renal artery stenting.
Structural Heart Disease:
Valvuloplasty and Percutaneous
Valve Replacement
Percutaneous techniques as alternatives to surgery for the treatment
of valvular and congenital heart disease were introduced in the early
1980s and have undergone dramatic advances. Today, we have a large
spectrum of therapeutic interventions to address problems once confined to the cardiothoracic surgeon (Fig. 10-17).
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Interventional Cardiology Procedures 443
A
B
Figure 10-16 Cineframe of left renal arter y before (A) and after (B) renal
artery stenting.
This section addresses balloon valvuloplasty for aortic and mitral
valves in adults, transcatheter aortic valve replacement (TAVR) for
adult aortic stenosis, MitraClip (Abbott Vascular, Redwood City, CA)
for mitral regurgitation (MR), patent foramen ovale (PFO)/ASD closure
devices, left atrial appendage (LAA) closure devices, and alcohol
septal ablation for hypertrophic obstructive cardiomyopathy (HOCM).
This review is not intended to be comprehensive but merely a source
of introductory information regarding some of the available devices
and techniques that may be encountered in catheterization laboratories across the country.
Percutaneous Balloon Mitral Valvuloplasty
For mitral stenosis, balloon mitral valvuloplasty is as an excellent
alternative to surgical commissurotomy or valve replacement and, in
selected patients, considered to be the initial mechanical treatment of
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Interventional Cardiology Procedures
Valvular
heart
disease
Hypertrophic
cardiomyopathy
Other
Paravalvular
leak
Patent
ductus
artieriosus
Figure 10-17 Spectrum of structural heart disease. (From Steinberg DH,
Staubach S, Franke J, et al: Defining structural heart disease in the adult
patient: current scope, inherent challenges and future directions. European
Heart Journal Supplements 12(Supplement E), E2–E9, 2010.)
Patent
foramen
ovale
Atrial septal
defect
Ventricular septal
defect
Left atrial
appendage
Left
ventricular
aneurysm
choice. Percutaneous balloon mitral valvuloplasty (PBMV) for the
treatment of mitral stenosis has been studied extensively, and when
successful, yields marked immediate hemodynamic improvement and
sustained clinical benefit. Prospective comparisons of PBMV with surgical commissurotomy in selected patients have shown similar hemodynamic and clinical results in follow-up. Clinical success is high, and
complication rates are low. However, not all patients are optimal candidates for PBMV. Echocardiography is essential to evaluate mitral
valve structure and to exclude LA thrombus before making decisions
to proceed with PMBV.
Indications
Symptomatic Mitral Stenosis
Patients with isolated symptomatic mitral stenosis or stenosis combined with mixed valvular disease, less than moderate MR, and
suitable valvular characteristics can be offered PBMV because of comparable risk and relative ease of the procedure.
Immobile, severely thickened, and fused or calcified valve leaflets
may not respond well to PBMV. However, patients with symptoms of
mitral stenosis with these unfavorable characteristics who are not
candidates for surgery may still benefit from the procedure. PBMV is
contraindicated in the presence of atrial thrombus, which is best
detected by transesophageal echocardiography (TEE).
Procedure
Antegrade transseptal access to the mitral valve with use of a single,
specially designed balloon catheter (Inoue balloon) (Fig. 10-18) is the
easiest and most reliable method for LA access. Because of its
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Interventional Cardiology Procedures 445
A
B
Figure 10-18
mitral valve during mitral valvuloplast y. B, Cineangiogram frame of Inoue
balloon catheter in position across the mitral valve during mitral valvuloplasty. Front and back portions of balloon are inflated, creating a “dogbone”
shape that self- positions the balloon in the mitral orifice. The balloon con tinues to be inflated until the waist is eliminated. Transmitral pressure gradient must be checked before increasing inflation volume on the next balloon
expansion.
A, Diagram of Inoue balloon catheter in position across the
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single-balloon design and relative ease in crossing the mitral valve,
use of the Inoue balloon generally requires less fluoroscopic and
procedural time than previously used double-balloon techniques.
After baseline hemodynamic measurements are obtained, transseptal catheterization is performed (see Chapter 7). Experienced
operators perform the puncture mid to low on the septal wall to avoid
a high puncture, because this location presents great difficulty in
crossing the mitral valve and positioning the balloon catheter.
Dilating the Interatrial Septum. After crossing the atrial septum
with the catheter and placement of the exchange guidewire, a 6- to
8-mm balloon is used to dilate the septum and allow easy passage of
the larger dilation catheters. The residual small ASD is not generally
clinically important.
Inoue Balloon Technique. The Inoue balloon catheter has a unique
design that allows inflation of the distal part of the balloon to facilitate
crossing the mitral valve. Once across the mitral valve, a step-wise
incremental valve dilation can be performed using a calibrated inflation syringe. Selection of balloon size is based on patient height. After
LA access is obtained, the interatrial septum is dilated, and the Inoue
balloon is tracked over the special guidewire into the left atrium. The
distal balloon tip is floated across the mitral valve, steered with a
stylet. The partially inflated balloon is withdrawn to engage the mitral
valve leaflets and then fully inflated to achieve commissural splitting.
The transmitral pressure gradient and an echocardiographic assessment of commissural splitting and any regurgitation have been recommended after each dilating step to assess the need for continued larger
balloon dilations to safely obtain the maximum mitral orifice possible
without producing MR.
After the last inflation, LA-LV pressure and right-sided oxygen
saturation (to detect left-to-right shunting at the atrial septal level) are
measured. The average decrease in mitral valve gradient is approximately 50% to 75% of the baseline gradient, and the increase in valve
area is usually around 100% (average 2 cm2), leading to a doubling of
the cardiac output. Figure 10-19 shows a hemodynamic case example
of PBMV.
Interventional Cardiology Procedures
Complications
Procedural and hospital mortality are rare (0% to 2%) and usually the
result of ventricular perforation. Complications of transseptal puncture, such as hemopericardium or tamponade, are also rare (<2%).
Systemic emboli may occur in 1% to 2% of patients. MR increases in
20% to 50% of patients but significantly (by more than one angiographic grade) in only 8% to 10% of patients. Significant MR may
appear late after PBMV. MR severe enough to require valve replacement occurs in 0.9% to 3% of patients after PBMV and is usually the
result of noncommissural tearing of the mitral leaflets or chordal
rupture. An ASD with left-to-right shunting is detectable in 8% to 87%
of patients (depending on the sensitivity of the method used for detection); most of these defects have shunt fractions of <1.4 to 1, are clinically unimportant, and decrease or disappear during follow-up.
Follow-Up
The symptomatic status of the patient generally improves immediately
and during follow-up. Short-term symptomatic improvement is present
in most patients. Long-term results (≥5 years) remain positive in wellselected patients. In such patients, event-free 5-year survival is >80%.
Patients with more deformed valves and higher echocardiographic
scores have a higher rate of restenosis. The incidence of restenosis and
long-term outcome after PBMV is comparable to closed mitral commissurotomy in selected patients.
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Interventional Cardiology Procedures 447
A
B
Figure 10-19 A, Directly measured left atrial (LA)-left ventricular (LV) gradi-
ent and transmitral Doppler flow velocity before a percutaneous balloon
mitral valvuloplasty (PBMV) shows a gradient of 32 mm Hg. B, After PBMV,
the LA-LV gradient is 8, with corresponding reduction in Doppler flow velocity
and no mitral regurgitation (MR).
MitraClip for Mitral Regurgitation
The standard of care for treatment of severe degenerative MR is surgical mitral valve repair or replacement. The MitraClip (Fig. 10-20) is the
most widely used percutaneous repair system, duplicating a stitched
“edge-to-edge” technique to create a smaller double-orifice valve. The
MitraClip system has been evaluated in EVEREST I and II studies.
Indications
Patients with a class-I indication for mitral valve surger y (according to
the American Heart Association/American College of Cardiology
[AHA/ACC] 2014 guidelines for valvular heart disease) are suitable
candidates if they are believed to be at high or prohibitive risk for open
surgical repair. Symptomatic patients with severe MR in the absence
of severe LV dysfunction and/or an LV end systolic dimension >
(class-I recommendation, level of evidence [LE] B) are the target
population. In asymptomatic patients with severe MR, mitral valve
surgery is indicated if LV dysfunction is present (class-I recommendation, LE B). Additionally, patients with severe MR and new-onset atrial
fibrillation or pulmonary hypertension are also candidates.
55 mm
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A
Interventional Cardiology Procedures
B
C
Figure 10-20
Vascular). B, Approximation of anterior and posterior mitral valve leaflets as
effected by the MitraClip. C, Ventriculogram in systole with MitraClip in
place, showing minimal mitral regurgitation (MR). (From Steinberg DH, et al:
Eur Heart J Suppl 12:E2–E9, 2010.)
A, MitraClip (Abbott Laboratories, Abbott Park, IL, Abbott
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Interventional Cardiology Procedures 449
MitraClip Procedure
The MitraClip procedure is performed with the patient under general anesthesia and with the use of fluoroscopy and TEE for device
guidance. The right femoral vein is accessed and an 8 -F sheath
inserted. Right-heart catheterization is then performed.
Transseptal puncture follows using standard technique via the
right femoral vein at a height of 3.5 to 4.0 cm above the mitral valve
in a posterior superior orientation. Heparin is then given with a goal
ACT of >
and 22 F at the atrial septum. The transseptal sheath is exchanged for
the guide catheter and tapered dilator. The clip delivery system is
advanced through the guide catheter and into the left atrium. Controls
on the guiding catheter allow deflection of the distal tip. The clip
delivery system has two dials that permit medial-lateral and anteroposterior steering. Using fluoroscopic and echocardiographic guidance,
the MitraClip is steered until axially aligned and centered over the
origin of the regurgitant jet. The clip is opened to extend the two arms
and then advanced into the LV below the mitral leaflets. The clip is
retracted so that each leaflet is grasped by an extended arm and then
closed to coapt the mitral leaflets. The inner portion of the clip has
two “grippers” adjacent to each arm to secure the leaflets as the clip
is closed. Leaflet insertion into the clip and MR reduction are assessed
by two-dimensional and Doppler echocardiography. If reduction in
MR is not adequate, the clip can be reopened to release the leaflets
and the clip repositioned. After adequate reduction of MR has been
achieved, the clip is deployed and the delivery system and guide
catheter are removed.
cutaneous mitral valve repair system is a safe and effective treatment option that reduces MR, has a favorable impact on LV remodeling,
improves symptoms, and reduces hospitalizations for heart failure.
tions, and outcomes is provided in the Interventional Cardiac Catheter-
ization Handbook.
300 seconds. The steerable guide catheter is 24 F proximally
In patients who are at high risk for surgery, the MitraClip per-
A full discussion of the indications, contraindications, complica-
Transcatheter Aortic Valve Replacement
The advent of TAVR provided an option for those previously unable to
undergo surgical AVR. Indications are limited to those patients with
symptomatic critical aortic stenosis if they are deemed by a surgeon
to be inoperable or high risk.
Evaluation for TAVR is very detailed and includes determination
of any coronar y artery disease, LV dysfunction, presence of concomitant medical comorbidities (chronic obstructive pulmonary disease
[COPD], renal insufficiency, carotid disease), assessment of the patient’s frailty, and determination of the degree of peripheral vascular
disease. The workup requires transthoracic echocardiography (TTE)
and/or, cardiac catheterization with coronary angiography and pulmonary function testing, carotid duplex imaging, and body computed tomography (CT) angiography. CT is the imaging modality of choice for
the preprocedural workup of the TAVR patient and assists in device
size selection and route of placement. Preprocedural evaluation of vascular access with CT angiography is an important step to determine suitability for a transfemoral (TF) or transapical (TA) approach for TAVR.
Standard for TAVR is a hybrid operating room/catheterization
laboratory for simultaneous fluoroscopy guided catheter manipulation and conversion to open surgery, if needed. The room should
be large enough to accommodate a team consisting of cardiac anesthesiologists, echocardiographers, cardiac surgeons, and interventional cardiologists.
Two valves for TAVR are currently available: the balloonexpandable Edwards SAPIEN system and the self-expanding Medtronic
CoreValve system (Fig. 10-21).
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Interventional Cardiology Procedures
A
CoreValve PHV
Edwards SAPIEN PHV
1
2
3
Valve loaded
1 2
3 4
B
Figure 10-21
Edwards SAPIEN (Edwards Lifesciences Corp., Irvine, CA) percutaneous
heart valve (PHV). Bovine pericardium leaflets 1, (blue arrowhead) sutured
(expanded polytetrafluoroethylene) 3, (black arrow) onto a stainless-steel
stent frame 2, (blue arrow). Bottom right, Delivery catheter (RetroFlex II,
Edwards Lifesciences Corp., Irvine, CA) with valve loaded (red arrow). B,
Percutaneous aortic valves: 1, Edwards SAPIEN. 2, Fluoroscopic image of
Edwards SAPIEN device in place. 3, CoreValve. 4, Aortogram with CoreValve
in place. (A, From Chiam PTL, et al: J Am Coll Cardiol Intv 1:341–350, 2008.
B, From Steinberg DH, et al: Eur Heart J Suppl 12:E2–E9, 2010.)
A, Left, CoreValve (Medtronic, Inc., Minneapolis, MN). Right,
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Interventional Cardiology Procedures 451
Procedural Details
Large-bore vascular access (or TA access) is obtained followed by
guidewire crossing of the aortic valve with balloon valvuloplasty (Fig.
10-22). Delivery of the valve catheter is performed under fluoroscopic
guidance and positioned across the aortic valve. An aortogram identifies calcific aortic and valvular landmarks and overall valve position
before deployment (Fig. 10-23). Once position is confirmed, usually
using fluoroscopy and TEE guidance, rapid pacing is initiated to halt
ventricular ejection. Once achieved, the valve can be deployed using
fluoroscopic and echocardiographic guidance. TEE before and during
the procedure is important for defining valvular anatomy, annular
sizing, valvular regurgitation, and ventricular function. Postdeployment, TEE is necessary to accurately assess for either valvular or
paravalvular (PVL) aortic regurgitation, ventricular function, mitral
valve function, coronary ostial blood flow, and complications, such as
annular rupture, pericardial effusion, or tamponade. An immediate
assessment can be helpful in identifying a potential complication of
the valve deployment (Fig. 10-24). Procedural risks of TAVR are summarized in Box 10-3.
Structural Heart Disease: Atrial Septal
Defects and Patent Foramen Ovale Closure
Most full service catheterization laboratories treat ASDs and PFO with
specific closure devices used by experienced operators. In brief, the
technique involves placing an 8-F or 9-F sheath across the defect (Fig.
10-25). An appropriately sized closure device (Fig. 10-26) is delivered
to the left atrium. The device is partially deployed, pulled back into
the septal defect, and the right-sided disk is deployed, capturing the
Figure 10-22 Diagram of two techniques of aortic balloon valvuloplast y.
A, Retrograde approach; B, antegrade, transseptal approach.
Box 10 -3 Transcatheter Aortic Valve Replacement
Procedural Risks
Stroke
Vascular complications
Conduction system abnormalities
Valvular insuf ficiency
Coronary ostial compromise
BA
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