Structural Heart Disease Interventions Research Articles

Optimal imaging for planning and guiding interventions in structural heart disease: a multi-modality imaging approach

Recent advances in catheter-based interventions have provided effective alternative treatments to surgery for several structural heart diseases such as atrial or ventricular septal defects. Particularly, the advent of transcatheter valve implantation/repair techniques constitutes one of the main breakthroughs of the last decades offering an effective alternative to patients with symptomatic valvular heart disease and high mortality operative risk. In addition, the role of novel catheter-based interventions has been explored in several clinical conditions that convey an increased risk of cerebrovascular stroke such as patent foramen ovale or atrial fibrillation. Specific devices have been developed to treat all these clinical conditions. To improve the procedural success rate and minimize the frequency of complications, multimodality cardiac imaging plays a central role providing an accurate selection of patients and invaluable assistance during the procedure. Technological advances in the equipments and image post-processing softwares have provided improved accuracy of the image quality and analysis leading to an increasing implementation of these imaging techniques in the clinical practice. The present state-of-the-art article reviews the role of multimodality imaging for planning and guiding interventions in structural heart disease.

Core curriculum and training pathways to become a structural cardiac interventionalist

The field of interventional cardiology continues to evolve. This evolution is based on continued improvements in equipment, increasing operator experience and, perhaps most importantly, the creative application of percutaneous techniques to treat a variety of conditions and diseases. The treatment of structural heart disease represents expanding opportunities but carries with it expanding complexities. Training programmes are being developed to address the issues of knowledge of pathophysiology and natural history of the specific lesions to be treated, the application and understanding of haemodynamics and cardiac imaging, knowledge about the specific technical aspects of the procedure, and potential complications and pre- and post-procedural care and follow-up. Multiple disciples will be involved as the specific competencies for both programmes and individuals become more formalized.

New actors, new theater

Since the first catheterization of a human ves­ sel by Werner Forssmann in 1929 [1], the actors playing in the field of vessel catheterization have continued to change over time, passing from the radiologist to the radiologist with angio­ logy expertise to the cardiologist with radiologi­ cal expertise, and with the advent of coronary angio plasty by Gruentzing [2], to the cardiolo­ gist with surgical skills, that is, the interven­ tional cardiolo gist. Similarly, the old, dirty and dark radiological suites, which resembled a photo graphy dark room rather than an operat­ ing room, have becoming larger, brighter and contain plenty of new and exciting equipment including the brilliance intensificator, the recent flat panel, intravascular ultrasound, intracardiac echocardiogram, functional flow and pressure wire consoles, optical coherence tomography, angioplasty catheters and a number of differ­ ent small and large stents and occluder devices. This technological escalation changed the role of the invasive professional from a simple observer and recorder of physiological and pathological pheno mena to a real endovascular intervention­ alist, the expert in translating body images into therapeutic actions. Now, with the advent of hybrid procedures such as congenital heart and structural heart disease interventions, in particular percutaneous heart valve implantation, the interventionalist’s next leap is to gain real surgical skills, becoming a new figure – a true endocardiovascular sur­ geon. In the 1940s’ poor Italy, which lacked a true working public health system, the family physician was not only the physician, but also the surgeon and medicine doctor. They were able to not only make a diagnosis, but also to carry out surgical procedures such as cesarean partum, skin incision and abscess drainage. Now, we have to simply go back and re­educate ourselves about a little bit of surgery. By changing the actor, the theater cannot remain the same; it is necessary that health sys­ tem governers throughout the world are aware of the dramatic changes and must be prepared to provide hybrid rooms that incorporate all the necessities of this new age: space, sterility and powerful image equipment including flat panel and computed tomography, together with all the usual instrumentation of the interventional cardiologist. The cost would probably be high to begin with, but this new combination of actor and theater will probably be the only cardiovascular surgery required for the next 30 years.

The SCAI Structural Heart Disease Council: Toward addressing training, credentialing, and guidelines for structural heart disease intervention

The field of structural heart disease (SHD) intervention has grown rapidly over the past several years. While training program content, standards, credentialing, and board examinations for percutaneous coronary intervention have matured and become well developed, no such structure exists in the field of SHD. Recognition of the need for training program standards and SHD curriculum stimulated the SCAI to form a SHD council, described in this report. In the accompanying two articles, we report the results of a survey of the status of SHD training in programs in the United States and define a core curriculum for structural intervention training.

Interventional fellowship in structural and congenital heart disease for adults

Training for structural and adult congenital heart disease interventions remains undeveloped. With the advent of recent percutaneous interventions for the treatment of structural and valvular heart disease, such as transcatheter aortic and pulmonary valve implantation, mitral valve repair, and the expansion of shunt closure procedures, there is a clear need to define the training requirements for this category of procedures. The training needs to be aligned with the goals and priorities of a basic or advanced level and be categorized into acquired and congenital. This document will define the training needs and knowledge base for the developing field of structural heart disease intervention.

Optimizing technique and outcomes in structural heart disease interventions: Rapid pacing during aortic valvuloplasty?

Optimizing technique and outcomes in structural heart disease interventions: Rapid pacing during aortic valvuloplasty?

Actualización en cardiología intervencionista

This article contains a review of the most important developments in the field of interventional cardiology reported during the past year. With regard to coronary interventions, the review covers: progress in drug-eluting stents; interventions for acute coronary syndrome, with or without ST-segment elevation; percutaneous treatment of the left main coronary artery, bifurcation lesions and chronic occlusions; and recent developments in the treatment of diabetic patients. Developments in invasive (i.e. intracoronary ultrasound, optical coherence tomography and pressure wires) and non-invasive (i.e. multislice CT) diagnostic techniques are also described. In addition, this article contains a review of recent developments in regenerative therapy and in the percutaneous treatment of structural heart diseases, such as patent foramen ovale and valvular heart disease.

Interventional cardiovascular MR—The next stage in pediatric cardiology

Real-time magnetic resonance imaging is attractive to guide minimally invasive treatment of structural heart disease not only because it can spare radiation but also because soft tissue imaging may add value. Interventional cardiovascular magnetic resonance imaging will allow simple as well as novel non-surgical treatments of structural heart disease in children. Real-time MRI tools already are available. Catheter tools are emerging. A handful of pediatrics hospitals are installing investigational systems now to explore this promising technology.

Implementation of Real Time Three‐Dimensional Transesophageal Echocardiography in Percutaneous Mitral Balloon Valvuloplasty and Structural Heart Disease Interventions

Percutaneous interventions for structural heart disease are performed in a dynamic and complex environment that necessitates multiple imaging modalities to achieve procedural success. Structural interventions are routinely guided by two-dimensional (2D) modalities such as x-ray fluoroscopy, transesophageal echocardiography (TEE), and intracardiac echocardiography. Real time imaging with three-dimensional (3D) echocardiography is a novel method of guidance to facilitate complex structural interventions with the promise of greater safety and efficacy. Real time 3D TEE (RT3D-TEE) affords the capability of imaging catheters and devices, the interventional objective, and adjacent structures simultaneously. We present an overview of RT3D-TEE and explore its functionality in structural heart interventions by using percutaneous mitral balloon valvuloplasty as a model.

Rapid pacing rotational angiography with three-dimensional reconstruction: use and benefits in structural heart disease interventions

High quality three-dimensional imaging is one of the cornerstones in structural heart disease interventions. Current mainstream technology to acquire three-dimensional imaging utilises computed tomography or magnetic resonance imaging. Incorporation of these data with conventional angiographic images may not be sufficient. We describe a new imaging technique consisting of rotational angiography combined with rapid pacing to obtain real-time, high-quality, three-dimensional images in the catheterisation laboratory. Rotational angiography is performed with breath holding and rapid pacing on a large format digital flat-panel angiographic system. During a 200 degrees rotation, 150 angiographic images are acquired in five seconds and automatically reconstructed in less than 30 seconds. This imaging technique was used in six patients (mean age 32 +/- 10 years) to guide structural heart disease interventions. No complications were associated with rapid pacing. This imaging technique allowed acquisition of high-quality, three-dimensional images with a low volume of contrast media. Volume renderings helped appreciation of the lesions and optimisation of the working views. Multiplanar visualisation allowed true orthogonal measurements of vascular diameter during the procedures. The advantages of this imaging technique include rapid image acquisition and precise imaging of complex structures using low volume of contrast media.

A Comparison of Echocardiographic Modalities to Guide Structural Heart Disease Interventions

Percutaneous techniques to treat structural heart disease are rapidly evolving based on innovative interventions and the considerable advancement in image guidance technology. While two-dimensional transthoracic and transesophageal echocardiography have been integral to procedural planning and execution, intracardiac and three-dimensional echocardiography supply unique visualization of target structures with a potential improvement in patient safety and procedural efficacy. The choice of image guidance modality is based on specific differences between imaging systems, as well as other variables including cost, patient safety, operator expertise, and complexity of procedure. We will compare the adjunctive imaging tools for structural heart disease interventions, with a focus on intracardiac echocardiography and real-time three-dimensional transesophageal echocardiography.

The off‐versus on‐label use of medical devices in interventional cardiovascular medicine?: Clarifying the ambiguity between regulatory labeling and clinical decision making, Part III: Structural heart disease interventions

The majority of devices used to treat congenital cardiac lesions in the cardiac catheterization laboratory are used on an off-label basis. This article discusses the predicaments faced by the interventional cardiologist when implanting devices on an off-label basis, using procedural examples of PFO closure and endovascular stent placement. Strategies that may benefit patient and provider, as well as satisfying regulatory agencies are suggested.

A conversation with Dr. Ted Feldman: Interventional treatment of structural heart disease

A conversation with Dr. Ted Feldman: Interventional treatment of structural heart disease

BioSTAR® bioabsorbable septal repair implant

Thousands of patients have had congenital defects of their intra-atrial septa successfully closed via percutaneous techniques in the cardiac catheterization laboratory for hemodynamic correction, stroke, migraine and decompression illness. However, currently available closure technologies leave a permanent cardiac implant in a relatively young patient population. As the first device incorporating a bioabsorbable material for the treatment of structural heart disease, BioSTAR® is uniquely designed to remodel into native tissue following closure, providing a more natural method of defect repair. This paper reviews atrial morphology, with a focus on patent foramen ovale, indications both present and emerging, and the development of technologies that promote a healthy natural healing response, with a focus on the design, testing and clinical experience with BioSTAR.

2007 James B. Herrick Award and Lecture—The Road Ahead

The road ahead always starts from where it began. For the field of interventional cardiology, the road began 30 years ago this past September, when a 38-year-old physician treated a 38-year-old man for symptomatic coronary artery disease. After this “disruptive” experience, using “disruptive” technology, by a “disruptive” young physician, the landscape has never been the same. Andreas Gruentzig, that physician, revolutionized the practice of modern cardiovascular care, not just with the introduction of percutaneous transluminal coronary angioplasty, but even more with the concept that a person could work safely in an awake patient within a vascular tree to achieve a specific goal. This sentinel event spurred the development of an extensive family tree of discipline, including intravascular ultrasound; angioscopy; percutaneous treatment of structural heart disease, including among others valvular heart disease, hypertrophic obstructive cardiomyopathy, and atrial fibrillation; ablation; and treatment of carotid and peripheral arterial disease and, more recently, stroke. In addition, Dr Gruentzig can be said to have encouraged the development of less invasive surgical revascularization approaches, such as “mid-cab” coronary bypass graft surgery. Now that we have broken the barrier of working therapeutically within the vascular tree, the road ahead will include continual assignments and miniaturization of techniques for identification, prevention, and treatment of disease. That road ahead will only be limited by our ability to imagine and create and then our ability to document improved outcome for society, in both individuals and as a whole.

Transcatheter Valve Repair

Ziyad M. Hijazi, Philipp Bonhoeffer, Ted Feldman, Carlos E. Ruiz, eds 382 pages. London, UK: Taylor & Francis; 2006. $95.00. ISBN 1-84184-472-1 Modern interventional cardiology is grounded in the performance of percutaneous coronary interventions. However, beginning with the introduction of atrial septostomy and then followed by percutaneous balloon valvuloplasty, noncoronary interventions have provided a growing contribution to general procedures in the cardiac catheterization laboratory. Today, up to 30% of all interventions reflect a growing list of both peripheral procedures and cardiac noncoronary interventions for structural and valvular heart disease. The first successful valvular interventions, namely balloon valvuloplasty for pulmonic, mitral, and aortic stenosis, were performed more than 20 years ago, but only recently have successful interventions for aortic stenosis and regurgitant valvular disease been developed and attempted. The combination of these valvular interventions, other interventions for patients with structural heart disease, and the growing population of adults with congenital heart disease provide the basis for a whole new subspecialty within interventional cardiology. This book is one of the first to specifically address this new subspecialty. It was compiled by a who’s who of …