#1006 New Approaches to Cardio
Re-vascularization
October 26 to October 29
Robert E. Michler, MD
Professor of Surgery
Chief, Division of Thoracic and Cardiovascular Surgery
The Ohio State University Medical Center
Gregory M. Eaton, MD
Assistant Professor of Clinical Internal Medicine
Division of Cardiology
The Ohio State University Medical Center
Gregory M. Eaton, MD
Assistant Professor of Clinical Internal Medicine
Division of Cardiology
The Ohio State University Medical Center
1
PTCA
• 1997 - 20th anniversary
• Tremendous growth
• Relieves angina
• Comparable to CABG in select
patient population
• Effective in acute
myocardial infarction
2
BARI, CABRI, EAST, GABI And RITA:
Coronary Angioplasty On Trial
• Balloon angioplasty initially
developed:
- To support a technique of myocardial
revascularization which is minimally
invasive
- Performed via a percutaneous
approach with little patient discomfort
- Shorter hospital stays
3
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6
Advances In coronary
Stenting
• Less intense anticoagulation
• More flexibility in deployment
• Better patency
• Safer deployment
7
8
Intracoronary
Brachytherapy
• Prevention of restenosis after
intervention remains greatest
therapeutic challenge in
interventional cardiology
• Pre-clinical trials using ionizing
radiation shows significant
reduction in neointimal
proliferation
9
10
Intracoronary
Brachytherapy
• High risk for restenosis:
- Restenotic lesions
- Diffuse or multifocal disease
- Smaller arteries
- Recanalized chronic total
occlusion
- ? Diabetes
11
12
NOGA
Endomyocardial Mapping
• Evaluating patients with ischemic
heart disease needs to accurately
define presence and nature of
dysfunctional myocardial tissue
• Nature of dysfunctional but viable
tissue important component of the
clinical assessment of patients
with chronic CAD
13
NOGA
Endomyocardial Mapping
• Designed to acquire, analyze and display
real time electromechanical maps of the
human heart
• Accurate 3D mapping
• Non-flouroscopic location
• System uses magnetic technology to
accurately determine location and
orientation of catheter
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NOGA
• 3D geometry constructed real
time
• Electrophysiologic information
superimposed on
electroanatomical map
• Non-fluoroscopic guidance
- Transmyocardial revascularization
- Gene therapy
17
18
Transmyocardial Laser
Revascularization
• Surgical or percutaneous approach
• Investigational therapeutic strategy to
enhance myocardial perfusion by
applying laser source into ischemic
myocardium
• Preliminary surgical trials significant
reduction in angina, improved quality of
life, some improved perfusion
19
Transmyocardial Laser
Revascularization
• Mechanism of benefit unknown:
- Long-term patency of channels
conflicting
- “Anesthetic effect” from vaporization
of myocardial nerve fibers
- Angiogenesis with enhanced collateral
development and increased
myocardial perfusion
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21
Robert E. Michler, MD
Professor of Surgery
Chief, Division of Thoracic and Cardiovascular Surgery
The Ohio State University Medical Center
30
Profile
Mike
• 47 year old male
• Father, grandfather
• Symptoms
- Chronic history of fatigue
- Bee sting
- Self-injected epinephrine
- Seen at ER - acute EKG changes
31
Profile
Mike
Diagnosis: High-grade lesion; left
anterior descending artery
Recommended: FDA approved minimally
invasive surgical procedure
31 A
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33
Conventional
CABG Surgery
• Proven safety and efficacy
• Recovery time
• Pain / discomfort
• Neurologic disorders
• CPB sequelae
34
Principle Causes Of Morbidity
And Mortality In CABG
• Cardiopulmonary bypass
• Sternotomy
35
36
Minimally Invasive Direct
Coronary Artery Bypass
Definition:
Limited coronary artery bypass
grafting without sternotomy,
cardiopulmonary bypass or
manipulation of the ascending
aorta, usually using arterial
conduits.
37
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Advantages Of
MIDCAB
• Avoidance of sternotomy
• Avoidance of cardiopulmonary
bypass
• Shorter or no stay in ICU
• Shorter hospitalization
• Quicker convalescence
• Lower cost
39
Expanded Indications
For MIDCAB
• “Culprit vessel” revascularzation
• Previously complicated
sternotomy
• Substernal patent IMA graft
• Inordinate risk of
cardiopulmonary bypass
• High risk for aortic manipulation
40
VADCAB
• Decreases the amount of
post-operative pain
• Anterior Thoracotomy Site can
be centered over target vessel
• No rib resection is required
• Sequential anterior wall grafting
can be performed with longer
ITA mobilization
41
42
Advantages Of
MIDCAB / VADCAB
• No risk of stroke
• No neurocognitive changes
• No coagulopathy
• Reduced hospitalization and
disability
• More cosmetic incision
43
MIDCAB
Disadvantages
• Incomplete revascularization
(analogous to PTCA)
• Unproven survival benefit in
multivessel disease
• Acceptable short term follow-up
• Difficult management of intraop
ischemia and hemodynamic
instability
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Trans Myocardial Laser
Revascularization
• For diffuse small vessel disease
• Higher cardiac event-free survival
• Fewer cardiac-related
rehospitalizations
• Improved exercise tolerance
• Similar one-year survival
(84% vs 89%)
• HCFA approved reimbursement
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51
Profile
Mike
Treatment
- Minimally invasive heart surgery
- FDA approved robotic procedure
52
Profile
Mike
Evaluation
- Operation went smoothly
- Post Op coronary angiogram
- 3rd day post op - symptom free,
went home
- 2 weeks post op - back to work
part time
Prognosis: Good
52 A
NEXT WEEK
#1007
3rd Annual G.I. Quiz
November 2 to 5
Sheryl A. Pfeil, MD
Assistant Professor of Clinical Internal Medicine
Division of Digestive Diseases
The Ohio State University Medical Center
Robert Murray, MD
Associate Professor of Pediatrics
Section of Gastroenterology
Children’s Hospital &
The Ohio State University Medical Center