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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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Figure 10-23 A, Positioning of Edwards SAPIEN delivery catheter in the
ascending aortic before crossing the aor tic valve. Note the deliver y catheter
with the enclosed valve position in the aor tic root across the previously
dilated aortic valve. B, Frames from cineangiogram of Edwards SAPIEN valve
being deployed. Note expansion of the stent valve to its full diameter in
bottom frame. (26 mm). (A, From Webb JG, et al: A new transcatheter aortic
valve and percutaneous valve delivery system; J Am Coll Cardiol 53(20):1855 –
1858, 2009; with permission from Edwards Lifesciences Corporation. All
rights reserved. B, Reprinted with permission from the Cath Lab Digest.
Copyright, HMP Communications.)
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Interventional Cardiology Procedures 453
Preprocedure
Anachrotic shoulder, dichrotic notch
Delayed upslope
Figure 10-24
(TAVR). Left, Preprocedure with 80 mm Hg (black areas), slow upstroke, and
moderated left ventricular end-diastolic volume (LVEDP). Right, Post-TAVR
shows elimination of left ventricular (LV)-aor tic (Ao) gradient and restoration of anachrotic shoulder and dichrotic notch. There is some increase in
LVEDP. (Reprinted with permission from Cath Lab Digest. Copyright, HMP
Communications.)
Hemodynamics of transcatheter aortic valve replacement
LA
RA
Postprocedure 26 mm
Edwards SAPIEN
Diastolic dysfunction?
A
C
Figure 10-25 Method of atrial septal defect (ASD)/patent foramen ovale
(PFO) closure. A, Delivery catheter is placed across PFO. B, The left atrial
(LA) disk is deployed. C, The PFO device is pulled back into the defect, and
the right atrial (RA) disk is deployed. D, After confirmation of atrial defect
tissue capture, the device is released.
B
D
atrial septum. The procedure is monitored continuously by either
TEE or intracardiac echocardiography. Postprocedure care involves
removal of the large venous sheath and treatment with aspirin and
clopidogrel for 6 to 12 months.
The indication for PFO closure for cryptogenic stroke is controversial. The RESPECT trial reported a trend toward a lower stroke
recurrence rate with PFO closure using the AMPLATZER device compared with medical therapy. However, patients who were treated per
protocol, and as treated, significantly favored PFO closure. The percutaneous closure trial showed no statistically significant benefit with
PFO closure using the AMPLATZER device (Fig. 10-27).
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Interventional Cardiology Procedures
A B
C D
E F
G H
Figure 10-26
A, AMPLATZER PFO Occluder (St. Jude Medical, St. Paul, MN). B, NMT Septal
Occluder (NMT Medical, Inc., Boston, MA). C, GORE HELEX Septal Occluder
(W.L. Gore & Associates, Inc., Flagstaff, AZ). D, Premere (St. Jude Medical,
St. Paul, MN). E, Occlutech PFO Occluder (Occlutech, Jena, Thuringia,
Germany). F, Solysafe (Swissimplant AG, Solothurn, Switzerland). G, SeptRx
(Secant Medical, Perkasie, PA). H, PFx (Cierra, Redwood City, CA). (From
Steinberg DH, et al: Eur Hear t J Suppl 12:E2–E9, 2010.)
Various patent foramen ovale (PFO) closure devices.
ASD OCCLUDER
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Figure 10-27 Left, AMPL ATZER atrial septal defect (ASD) and (right) patent
foramen ovale (PFO) occluders. Note the difference in left atrium (LA) disk
size and diameter of the connecting waist. RA, Right atrium.
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Interventional Cardiology Procedures 455
PFO OCCLUDER
LA disc
Waist
RA disc
A B
Figure 10-28 Left atrial appendage (LAA) occluders. A, WATCHMAN
(Boston Scientific, Marlborough, MA). B, AMPL ATZER Cardiac Plug (St. Jude
Medical, St. Paul, MN). (From Steinberg DH, et al: Eur Heart J Suppl 12:E2–
E9, 2010.)
Left Atrial Appendage Closure
Patients with atrial fibrillation are at risk for stroke, presumably due to
thrombus formation in the LAA. Patients are commonly treated with
chronic oral anticoagulants but are at risk for life-threatening bleeding
complications, including intracranial hemorrhage. An alternative to
chronic oral anticoagulation is occlusion of the LAA to prevent thrombus formation.
The LAA closure device placement procedure may be done under
local or general anesthesia using a standard transseptal catheterization technique. The procedure usually lasts approximately 1 hour, and
the patient is typically discharged the day following the procedure.
Before placement, a transesophageal echocardiogram is used to
measure the LAA to determine the device size suitable for implantation. After the interatrial septum is crossed using a standard transseptal access system, the LAA access sheath system is advanced over a
guidewire into the left atrium. The access sheath is then advanced into
the distal portion of the LAA over a pigtail catheter. The LAA device
delivery system is prepped, inserted into the access sheath, and slowly
advanced under fluoroscopic guidance followed by deployment into
the LAA. Device release criteria are confirmed via fluoroscopy and
before releasing the device. After release, the catheters are removed,
and venous access hemostasis is obtained.
The WATCHMAN device (Fig. 10-28; Boston Scientific, Marlborough, MA) was superior to warfarin for reducing the risk of the
composite endpoint of cardiovascular mortality, all stroke and systemic embolization, and all causes of mortality and cardiovascular
mortality.
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Interventional Cardiology Procedures
Alcohol Septal Ablation for
Hypertrophic Obstructive
Cardiomyopathy
In some patients, symptoms of dyspnea, presyncope, chest pain, or
syncope are due to HOCM. In this entity, there is obstruction of flow
across the left ventricular outflow tract (LVOT) by septal hypertrophy
and systolic anterior motion of the mitral valve. For patients with
symptoms refractory to medical therapy or are either high risk or not
candidates for surgical myectomy, a controlled septal MI can be produced by injecting alcohol into the septal artery with angioplasty
techniques. This nonsurgical septal mass reduction method is called
alcohol septal ablation for HOCM.
In brief, a small balloon catheter is inserted into the septal artery
with standard angioplasty techniques and alcohol is instilled. This
causes the septal muscle to infarct, become noncontractile, and scar,
which eliminates the LVOT gradient.
Criteria for alcohol septal ablation for HOCM include (1) refractory symptoms on maximal medical therapy, (2) septal thickness
of ≥1.8, (3) outflow tract gradient >
with provocation (e.g., premature ventricular contraction [PVC] or
Valsalva maneuver, amyl nitrate challenge), and (4) LVOT gradient
localized to the proximal region of the ventricular septum with obstruction demonstrated by echocardiogram. Other considerations should
be the absence of moderate MR with no organic abnormalities of the
mitral valve and no indication for cardiac surgery that is either in need
of treatment or might explain the symptoms.
30 mm Hg at rest or >50 mm Hg
Technique of Alcohol Septal Ablation
Complete hemodynamic and angiographic study should precede
alcohol-induced septal ablation. The right and left femoral arteries and
veins are cannulated. A 5-F pigtail (carefully positioned for accurate
hemodynamic data) or Halo ventriculography catheter is positioned
in the LV. A 6-F Judkins left 4-cm guide catheter is inserted into the left
coronary ostium from the contralateral artery. A 5-F balloon-tip pacemaker is positioned in the right ventricle for pacing if complete heart
block is induced. In some patients, an internal jugular vein is selected
for pacer insertion if more than 48 hours of temporary pacing is necessary. A pulmonary artery catheter may provide more hemodynamic
data and cardiac output. After the catheters are positioned, coronary
arteriography identifies the large septal artery originating in the proximal left anterior descending (LAD) artery. The echocardiography
technician performs imaging of the LV septum and LVOT gradient.
Heparin, 40 U/kg as a bolus, is administered because manipulations
of angioplasty guidewires and catheters may induce thrombus.
Heparin is discontinued after the procedure. Analgesia with fentanyl
or a similar agent is given intravenously before septal cannulation and
occlusion.
A 0.014-inch angioplasty guidewire is used to enter the largest,
most proximal septal artery. A large double 45-degree bend on the
angioplasty guidewire facilitates entry into the 90 -degree origin of the
septal branch. A 2- × 10-mm OTW balloon catheter is advanced into
the septal artery and inflated. Angiography is performed to show that
the balloon is located properly within the septum and it occludes
antegrade septal flow. The guidewire is removed with the balloon,
occluding the septal artery. A small amount of contrast material is
injected into the septal balloon to (1) ensure no reflux of contrast
material or, later, alcohol and (2) opacify the septal artery and subbranch distribution. Subselective septal artery branch ablation may
render hemodynamic results equivalent to those with complete septal
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Interventional Cardiology Procedures 457
artery ablation with a lower rate of heart block. After x-ray contrast
imaging of the septum, echocardiographic microbubble contrast
material is diluted, and 0.5 to 1 mL is injected into the septal artery.
Echo contrast imaging allows visualization of the distribution of blood
to the septum, hopefully corresponding to the site of LVOT obstruction.
This is best seen on four-chamber, long-axis, and two-chamber
echocardiographic views. In addition, this technique identifies those
patients in whom the septal artery empties into the RV or perfuses the
inferior wall and apex, which might be infarcted by alcohol runoff.
After echocardiographic confirmation of correct septal branch
occlusion, 1 to 2 mL of 98% denatured alcohol is delivered slowly
during 3 minutes into the septal arter y, followed by a 5-minute observation period. Complete heart block may occur, with the need for
temporary pacing. Chest pain with alcohol instillation is a common
occurrence. LVOT pressures are obtained continuously before, during,
and after alcohol septal ablation. The LVOT gradient is often abolished
immediately with the septal infarction. After a 5-minute observation
period, the balloon catheter is aspirated and then the balloon deflated.
Suction is kept on the catheter lumen as the catheter is withdrawn
from the LAD. Coronary angiography is repeated. Final hemodynamics are again measured. In most cases, the LV outflow gradient is
abolished; 10% to 20% of patients may need permanent ventricular
pacing. A modest MI occurs with creatinine phosphokinase elevation
of 500 to 2000 units. Patients are monitored in the hospital for 4 to 5
days after the procedure to ensure absence of late heart block. Examples are shown in Figures 10-29 through 10-31.
A B
C D
Figure 10-29
first and second septal arteries (arrow). B, A small angioplasty balloon is
placed (arrow) and its position verified by echocardiographic and radiographic contrast imaging. C, Selective x-ray contrast injection into septal
artery through occlusion balloon (arrow). D, After alcohol (1 to 2 mL) is
instilled, the balloon is deflated and removed. The angiogram shows cutoff
of a thrombosed first septal artery (arrows).
A, Coronar y angiogram of left anterior descending (LAD) and
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Interventional Cardiology Procedures
200 mm Hg
A
Pre-ETOH
200 mm Hg
After TASH
200 mm Hg
B
Figure 10 -30
A, Before transcoronar y ablation of septal hypertrophy (TASH) (pre- ETOH)
for hypertrophic cardiomyopathy. B, After TASH during Valsalva maneuver.
ETOH, Ethyl alcohol.
Hemodynamics of left ventricular (LV) and aor tic pressures.
Figure 10 -31 Hemodynamics of hypertrophic cardiomyopathy before (left)
and after (right) transcoronary ablation of septal hypertrophy ( TASH). Ao,
Aortic; LV, left ventricle; PA, pulmonar y ar tery.
III III
200
180
95
64
Ao
76
160
140
95
120
LV LV
100
80
60
0
0
PA PA
0
40
20
AO
Ao
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Interventional Cardiology Procedures 459
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Optimization of Clinical
Outcomes and Quality
in the Cardiac
Catheterization
Laboratory
MORTON J. KERN • CHARLES CHAMBERS
“Every PCI program must have a quality improvement program that
routinely: (a) reviews quality and outcomes for the entire program; (b)
reviews results of individual operators; (c) includes risk adjustment;
(d) provides peer review of difficult or complicated cases; and (e)
performs random case reviews.”
The above is a class I recommendation from the 2011 American
College of Cardiology Foundation/American Heart Association/
Society for Cardiovascular Angiography and Interventions (ACCF/
AHA/SCAI) Guideline for percutaneous coronary intervention (PCI)
update. This chapter reviews the necessary steps to putting this into
practice. In concert with prior editions, the assurance of quality as it
relates to documentation and patient safety with potential risk management is also reviewed in this chapter.
Quality Assurrance and Peer Review
Quality care in the cardiac catheterization laboratory requires each
program to evaluate its performance through a meaningful continuous
quality improvement (CQI) process providing program evaluation,
deficiency identification, methods for remediation, and final reassessment. The SCAI has previously published nearly 20 years of guidelines,
culminating in the 2011 SCAI Quality Improvement Toolkit (QIT) to
assist individual laboratories in this effort. The only catheterization
laboratory accreditation program, Accreditation for Cardiovascular
Excellence (ACE), not only requires a CQI program for every health care
facility but also provides guidance in this area when issues arise.
CQI is an iterative method to evaluate operational approaches
and remedy deficiencies beyond the isolated assessment of adverse
outcomes. The primar y emphasis in CQI is on evaluating the overall
structure, processes, and outcomes of care. The peer review (PR)
assessment of operator performance, assessed for both specific index
case PR as well as randomly selected case PR, is an essential component of this process. CQI requires a dedicated quality physician champion, partnered with a dedicated staff champion, in corporation with
an assembled quality improvement committee specific to the catheterization laboratory. The invasive cardiologist must assume the primary role with full support from hospital administration. Increasingly
recognized, the interconnectivity of quality of care, cost effectiveness,
and reimbursement ramifications requires this integral partnership.
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