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University of Medicine and Pharmacy Tirgu-Mures

Course of Interventional Cardiology



Authors:
Benedek Theodora and Benedek Imre


2013




This book is for educational purposes only, to be used by the medical students


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Table of contents

1. Introduction..3
2. Historic perspectives3
3. The structure of a laboratory of interventional cardiology .6
4. Cardiac catheterization**.8
5. Coronary angiography**23
6. Percutaneous coronary interventions..35
7. Imaging in interventional cardiology..46
8. Structural interventions....59
9. Interventional treatment in peripheral arterial diseases...72
10. Interventional treatment in aortic aneurysms.81
11. Interventional treatment in carotid artery diseases...83
12. Interventional treatment in renal artery stenosis.85
13. Renal denervation in severe hypertension..87
14. Interventional electrophysiology88
15. Interventional therapy in heart failure96
References.98




*This book includes a selection of the most relevant and recent publications and
guidelines in the field of interventional cardiology, together with original texts of the
authors.
**by permission of Oxford University Press

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1. Introduction

The goal of this book is to provide the necessary knowledge to
become familiar with invasive techniques used in cardiology for
interventional diagnosis and treatment of different heart diseases.
Therapeutic decisions in cardiology are crucially determined by
invasive imaging of coronary arteries and haemodynamics, which are
essential for understanding the pathophysiological and diagnostic aspects of
cardiovascular disease.

2. Historic perspectives

The first catheterization in animals was performed by Charles Bernard
in 1846, and the first measurement of intracardiac pressures in animals by
Chauveau and Marey in 1861.
The first right heart catheterization as self-experiment was performed
by Forssmann in 1929 followed by the first clinically used cardiac
catheterization performed in 1930 by Klein.
Cournard and Marurice initiated the routine clinical use of cardiac
catheterization therapy in 1939 and since than, cardiac catheterization it
rapidly became one of the most commonly performed medical techniques in
cardiology.
After first clinical application of cardiac catheterization procedures in
the period of 1938-1948, left heart access was first tempted in the ages of
`50. The period of 1960-1977 was characterized by large scale spread of
coronary angiography procedures, and since 1977 a rapid development of
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different therapeutic procedures is encountered, with applications in
different fields of cardiology (ischaemic heart diseases, valvular heart
diseases, congenital heart diseases, electrophysiology, structural
interventions, etc) so that in present almost the full spectrum of heart
diseases is covered by applications of interventional cardiology.

Different cornerstones have been recorded during the years, like:
-1942 - catheterization of right venbtrile by Cournard and Maurice
-1944 - catheterization of pulmonary artery by Cournard and Maurice
-1949 - regtrograde catheterization by Zimmerman
-1956 - first apical left ventricular puncture by Brock
-1959 - first transseptal left atrial access by Ross
-1970 - Bedside catheterization and monitoring of right heart pressures by
Ganz and Swan

The pioneer of therapeutic interventional cardiology was Andreas
Grunzig, who performed the first Percutaneous Transluminal Coronary
Angioplasty (PTCA) in 1977. From 1977 to 1981, coronary angioplasty was
recommended for only selected cases, in symptomatic patients with good
ventricular function. However, since the `80s an impressive spread of the
indications of coronary angioplasty has been recorded, after new
technological advances such as steerable guidewires and monorail catheters
had made PTCA easier and more successful.
The concept of directional atherectomy was introduced by Simpson in
1985 and the first atherectomy was performed in 1987 in femoral superficial
artery.
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As the restenosis remained the main limitation of coronary
angioplasty, new devices have been developed to overcome the potential risk
of neointimal proliferation, such as brachyterapy in 1996. However, the
main and revolutionary development in interventional cardiology is
represented by introduction of coronary stenting, which brought a solution to
the main problem of restenosis. The first coronary stenting was performed in
1986 by Puel, and initially it was recommended only for treatment of
coronary occlusions during PCI. In 1991, Serruys reported a re-stenosis rate
of 14%, much below the one recorded by PTCA alone. The risk of stent
thrombosis was overcomed after initiation of dual antiplatelet therapy as
adjuvant.
As the restenosis of implanted stents remained a critical issue, during
the last years of the 21th century a large number of drug-eluting stent (DES)
types have been proposed to prevent restenosis (Cypher, Taxus, etc). Over
the following years, many new generations DES have been introduced in the
interventional cardiology market leading to achievement of very low
resetenosis rates nowadays. Since 2005, new generations of biodegradable
stents have also bee introduced on the market
The latest years are dominated by an impressive expansion of new
imaging techniques in interventional cardiology: Intravascular Ultrasound
associated with Virtual Histology, allowing complex assessment of the
morphology of coronary plaques based on the echo-attenuations of plaques,
Optical Coherence Tomography, allowing intracoronary visualization of
coronary plaques, accurate assessment of intima and superb visualization of
intracoronary thrombus, or Near-infrared spectroscopy (NIR), characterizing
the plaque composition according to its cholesterol content.

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3. The structure of a laboratory of interventional cardiology

A laboratory of interventional cardiology contains a special X-ray
equipment called angiograph, consisting in an X-ray tube and a generator of
X-ray source. The tub of the angiograph has a mobile component, allowing
rotation and tilting in order to provide visualization of coronary tree from
different angles, which is crucial for accurate assessment of coronary artery
stenoses. Also, the angiograph is equipped with monitors on which coronary
arteries are visualized after injection of contrast material in the coronary
ostium.
Usually images and cineloops are saved on dedicated workstations of
on storage devices.
The injection of high volumes of contrast material (necessary in case
of ventriculography, aortography or arteriography) is usually performed
using contrast injectors with adjustable presetings of speed and volume.
All the interventional laboratories should be equipped with the
necessary devices for cardio-pulmonary resuscitation or other types of
emergencies (defibrillators, temporary pacemaker, monitors, ECG, etc),
while in a complex laboratory of interventional cardiology more complex
equipments should be present, such as contrapulsation pump, intravascular
ultrasound, etc.
In case of a laboratory dedicated to electrophysiology procedures, it
contains also special equipments (EP lab systems, stimulators and devices
for ablation of cardiac arrhythmia)
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Fig. 1 - structure of a cardiac catheterization laboratory











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4. Cardiac catheterization
Cardiac catheterization represents introduction of special catheters in
the heart chambers, allowing hemodynamic measurements in the heart
cavities (pressure, gradients, shunts). Invasive assessment of cardiac
haemodynamics and coronary physiology and imaging needs temporary
vascular access, which is realized using arterial puncture (usually femoral or
radial). The femoral approach is the most used currently, however the radial
approach is gaining in popularity and acceptance. Similarly, venous
puncture (femoral, brachial, internal jugular vein, subclavian) is currently
used to access the right heart (or the left heart through trans-septal puncture).
The term right heart catheterization refers to catheterization of right
cardiac chambers, performed using venous femoral approach, by puncturing
either left or right femoral vein, while left heart catheterization means
catheterization of left cardiac chambers performed using arterial approach,
puncturing right or left femoral artery (fig.2).
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Fig. 2 - Right and left cardiac approach
Indications:
The main indications for cardiac catheterization are the following,
when these data cannot be ontained non-invasively.
-assesment of valvulopathy severity
-determination of cardiac output
-determination of intracardiac shunts
-determination of pulmonary artery pressure and pulmonary capilary
wedge pressure
-determination of Left ventricular end-diastolic pressure indicator of
LV dysfunction severity
-determination of pulmonary and systemic vascular resistences
-asesment of reversibility degree of pulmonary hypertension.
Right heart catheterisation
Following local anaesthesia, the femoral vein is punctured before the
common femoral artery is catheterized, and the sheath introduced by the
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Seldinger technique. Using a 6F SwanGanz catheter allows a mostly easy
passage to the pulmonary artery with low risk of injury to the right-heart
chambers (fig.3).
To advance the catheter from the femoral vein to the pulmonary artery,
the tip of the catheter is advanced from the lower right atrium by clockwise
rotation over the tricuspid orifice, and then advanced into the right ventricle.
To reach the pulmonary artery, the catheter must be slightly withdrawn so
that its tip lies horizontally and just to the left of the spine. Clockwise
rotation then causes the tip of the catheter to point upwards towards the right
ventricular outflow tract. The catheter should only be advanced when it is in
this position in order to minimize the risk of arrhythmia and injury to the
right ventricular wall. If these manoeuvres fail to gain access to the
pulmonary artery due to enlarged right-heart chambers, the catheter may be
withdrawn to the right atrium and formed into a large reverse loop by
catching the tip in a hepatic vein and advancing the catheter quickly into the
right atrium. This allows the tip of the catheter to advance through the
tricuspid valve in an upward position. The catheter should then cross the
pulmonary valve and advance to a pulmonary wedge position without
difficulty. If the pulmonary valve cannot be passed, a guidewire can be
employed to facilitate positioning in the pulmonary artery. Once in the
pulmonary wedge position, measurements of pressure and blood oxygen
saturation are recorded. Following measurement of the wedge pressure, the
catheter is withdrawn into the proximal pulmonary artery, into the right
ventricle and then into the right atrium, with corresponding recordings of
pressure and oxygen saturation.

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Fig. 3 - Right cardiac catheterization
To advance the catheter from the femoral vein to the pulmonary artery,
the tip of the catheter is advanced from the lower right atrium by clockwise
rotation over the tricuspid orifice, and then advanced into the right ventricle.
To reach the pulmonary artery, the catheter must be slightly withdrawn so
that its tip lies horizontally and just to the left of the spine. Clockwise
rotation then causes the tip of the catheter to point upwards towards the right
ventricular outflow tract. The catheter should only be advanced when it is in
this position in order to minimize the risk of arrhythmia and injury to the
right ventricular wall. If these manoeuvres fail to gain access to the
pulmonary artery due to enlarged right-heart chambers, the catheter may be
withdrawn to the right atrium and formed into a large reverse loop by
catching the tip in a hepatic vein and advancing the catheter quickly into the
right atrium. This allows the tip of the catheter to advance through the
tricuspid valve in an upward position. The catheter should then cross the
pulmonary valve and advance to a pulmonary wedge position without
difficulty. If the pulmonary valve cannot be passed, a guidewire can be
employed to facilitate positioning in the pulmonary artery. Once in the
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pulmonary wedge position, measurements of pressure and blood oxygen
saturation are recorded. Following measurement of the wedge pressure, the
catheter is withdrawn into the proximal pulmonary artery, into the right
ventricle and then into the right atrium, with corresponding recordings of
pressure and oxygen saturation.
Access to the right heart through the internal jugular vein is often used
when only right heart catheterization is performed. The key point for a
successful puncture is correct identification of anatomical landmarks. To
puncture the right internal jugular vein, the high anterior approach is
recommended whereby the puncture site is at the top of the triangle formed
by the two heads of the sternocleidomastoid muscle and the clavicle.
Alternatively, ultrasound guidance puncture has been proposed when this
triangle is difficult to localize as is the case in obese or short-necked patients.
Left heart catheterisation
The common femoral artery is punctured as follows: the three middle
fingers of the left hand palpate the pulse and the skin is pierced with the
needle three finger-breadths below the inguinal ligament. The radiological
identification of the femoral head with the puncture performed at the
junction of the upper third and lower two-thirds results in higher puncture
sites than the standard technique but avoids puncture below the femoral
bifurcation and possibly reduces vascular complications. After puncture of
the artery, a 0.89-mm (0.035-inch) J -guidewire should be advanced carefully
into the needle. It should move freely up the aorta and be placed at the level
of the diaphragm. When it is difficult to advance the guidewire close to the
tip of the needle, the wire should be withdrawn to ascertain that forceful
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arterial flow is still present; if not, the needle should be removed and the
groin compressed for 5min. Problems that can be encountered in advancing
the guidewire include severe arterial tortuosity, stenosis, occlusion or
dissection. Left heart catheterization via the femoral approach is performed
using an appropriately sized vascular sheath (we use 45F for diagnostic
coronary angiography, 58F for percutaneous coronary interventions). The
sheath is introduced via the guidewire and flushed with heparinized saline.
For routine diagnostic coronary angiography, intravenous bolus
administration of unfractionated heparin is not required but for long
diagnostic procedures or when a radial approach is used, 30005000 units of
heparin are normally administered.
All left-heart catheters are exchanged via the guidewire, which is
positioned with its tip at the level of the diaphragm. The pigtail catheter for
left ventricular (LV) pressure measurements and angiography can be easily
advanced across the aortic valve in the absence of aortic stenosis. If the latter
is present, a 0.89-mm (0.035-inch) straight guidewire is employed to cross
the valve, with its soft tip leading and pointing towards the stenotic valve
and with the pigtail catheter pulled back into the ascending aorta by about 4
5cm. In this position, the wire tip usually quivers in the systolic jet. The
pigtail catheter remains fixed and the guidewire is moved towards the valve
in attempts to cross it. If this is not possible, the process can be repeated
using a J udkins right coronary catheter or a left Amplatz or Feldman catheter,
which allow better targeting of the valve opening than the pigtail catheter.
When the guidewire has crossed the valve, it should be placed in the left
ventricle, with a loop to minimize the risk of injury to the left ventricle.
Accurate measurement of the true pressure gradient across the stenotic valve
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requires simultaneous pressure measurements in the left ventricle and in the
ascending aorta just above the valves (fig. 4).

Fig. 4 - Left heart catheterization
Another way to approach the left cardiac chambers is via the
transeptal catheterization, which involves right atrium approach followed by
puncture of the intraatrial septul with special needles (fig.5). After puncture
of the intraatrial septum, an introducer sheath is advanced in the left atrium
and than passed through the mitral valve into the left ventricle.

Fig. 5 - Transseptal catheterization - needles for transseptal puncture


Haemodynamic measurements during cardiac catheterization
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Pressure measurements
An important goal of cardiac catheterization is precise assessment of
pressure waves generated by the different cardiac chambers.
Measurement of intracardiac pressure is possible after placing an open
lumen catheter in the respective cardiac chamber, catheter which is
connected to a pressure tranducer which is in turn connected to a monitor.
After calibration of the transducer, the pressure value and waveforms are
displayed on a monitor (fig. 6)

Fig. 6 - Intracardiac pressure measurements

Intracardiac pressure measurements are useful especially for
assessment of valvular heart disease severity.
In case of mitral stenosis, cardiac catheterisation is useful for:
1) Assesment of mitral stenosis severity, using the pressure gradient
between LA and LV, based on the difference between the pressures in the:
-pulmonary capillary wedge pressure (equal with the one in
LA) right catheterisation
-end-diastolic pressure in the LV left catheterisation
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2) Determination of the severity of pulmonary hypertension


Fig. 7 - Assessment of diastolic gradient across the mitral valve in case of mitral stenosis
In case of aortic stenosis, cardiac catheterisation is useful for the
assessment of aortic stenosis severity, based on the pressure gradient
between LV and aorta (fig.8)
1) using retraction of the catheter from the LV in the aorta, or
2) positioning 2 catheters one in the LV and one in the aorta
-peak-to-peak gradient maxim instantaneously
-average gradient tracing the area between the two curves

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Fig. 8 - Assessment of systolic gradient across the aortic valve in case of aortic stenosis

However, positioning of a Pigtail catheter in the LV could be difficult
in aortic stenosis, due to difficulties in crossing a calcified aortic valve.
Therefore alternative techniques for crossing the aortic valve should be used
in these cases (fig. 9)

Fig. 9 - alternative techniques for crossing aortic valve

Cardiac catheterization could also serve for determination of valvular
area using Gorlin formula in case of mitral or aortic stenosis:
AVA =(cardiac output/systolic ejection periodheart rate)/44.3P

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MVA =(cardiac output/diastolic filling periodheart rate)/37.7P

Determination of cardiac output using cardiac catheterization uses
the thermodilution method or the Fick method.
Thermodilution method involves injection of a saline solution in the
proximal end of a special catheter and determination of the modification in
the temperature at the distal part of the catheter, where a termistor is placed.
The result is displayed on a screen (fig. 10).
Fick method requires determination of O2 consumption via
determination of O2 concentration in expired air. According to the Fick
principle, the total uptake or consumption of a substance by an organ is the
product of the blood flow to that organ and the arteriovenous concentration
difference of the substance.

Fig. 10 - determination of cardiac output

Blood oxygen measurement
Oximetry at different levels of cardiac cavities is useful for assesment
of cardiac shunts. Detection and localization of an intracardiac shunt can be
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easily performed using blood oxygen saturation as the indicator, which is
obtained at many different sites within and close to the heart. Quantification
of the shunt is based on measurements of pulmonary (Q
p
, l/min) and
systemic (Q
s
) CO.
For shunt determination, blood samples are taken fom different levels
of the cardiac chambers:
-superior RA
-medium RA
-inferior RA
-PA
-RV outflow tract
-VD - inflow
-VCI
-VCS
-Ao
-LV
-pulmonary capillar

Catheterization protocol
The following steps are necessary for a complete cardiac
catheterisation procedure:
1. Record phasic and mean pressure in right atrium and aorta
2. Withdraw simultaneously blood samples from right atrium and
aorta for oxygen saturation measurements
3. Advance the SwanGanz catheter sequentially into the right
ventricle and pulmonary artery for pressure measurements and blood
samples for oxygen saturation measurements

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4. Measure cardiac output using the triple lumen thermodilution
catheter (SwanGanz)
5. Advance the SwanGanz catheter to pulmonary wedge pressure and
cross the aortic valve with the pigtail catheter for simultaneous recordings of
left ventricular end-diastolic pressure and pulmonary wedge pressure (same
scale)
6. Deflate the balloon and pull the Swan-Ganz catheter back towards
the pulmonary artery
7. Record simultaneous left ventricle pressure and femoral artery
pressure (through the arterial sheath) or aortic pressure (via double lumen
catheter)
8. After left ventriculography (if needed) pull back from the left
ventricle into the aorta.

Normal pressure ranges (mmHg), oxygen saturations (%), and oxygen
volume percentages in resting conditions are indicated below:
S D Mean O
2
sat O
2
volume %
RA 5 75 15
RV 24 4 75 15
PA 24 10 15 75 15
PCW 12
LV 120 12 95 19
LA 12 95 19
Ao 120 80 95 19
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Ao: aorta; LV, left ventricle; LA: left atrium; PA, pulmonary artery; PCW, pulmonary
wedge pressure; RA, right atrium; RV, right ventricle.
Determination of vascular resistance is useful for estimation of
reversibility degree of pulmonary hypertension, based on determination of
pulmonary vascular resistance before and after oxigen or nitric oxide
inhalation, effort or administration of sodium nitropruside
Ventriculography is a technique based on injection of contrast
material into the LV, serving for assesment of LV motion and mitral
regurgitation degree (fig. 11).

Fig. 11 - Left ventriculography
Ventriculograms are usually recorded at 3060 frames/s, and
radiographic contrast agent is injected in adults at rates of 1015mL/s for a
total volume of 3050mL.
Based on information provided by ventriculography, mitral
regurgitation severity is estimated on the following scale:

Trivial (grade 1 or 1+/4+): contrast material enters the left atrium during
systole without filling the entire atrial cavity and is cleared in the subsequent
beat
Mild (grade 2 or 2+/4+): contrast opacification of the left atrium is less
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dense than the opacification of the left ventricle but contrast is not cleared
with each beat
Moderate/severe (grade 3 or 3+/4+): opacification of the left atrium is as
dense as the opacification of the left venticle
Severe (grade 4 or 4+/4+): opacification of the left atrium greater than that
of the left ventricle and/or complete atrial filling in one systole and/or
contrast opacifies the pulmonary veins

Ventricular volumes are possible to be determined using
ventriculography. For the calculation of LV volume, the outermost margin
of visible radiographic contrast is traced. Volume (V) is computed using
long-axis (L) and short-axis (S) measurements (V = [frac16] LS
2
) or area
length measurements (V =8A
2
/3L) using an ellipsoid approximation for
ventricular shape.
Ventriculography also serves for assessment of wall motion of
different ventricular segments according to their projection (fig. 12).


Aortography is represented by injection of contrast material in aorta
(fig. 12) and serves for assesment of severity degree of aortic regurgitation,
on the following scale:
Trivial (grade 1 or 1+/4+): contrast visible in the left ventricle, without
Fig. 12 - Regional wall motion during left
ventriculography as assessed in the right and left
oblique views
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reaching the apex, clears during each heart beat
Mild (grade 2 or 2+/4+): contrast opacification less dense than that of the
ascending which does not clear during a single heart beat
Moderate/severe (grade 3 or 3+/4+): opacification of the left ventricle as
intense as that of the ascending aorta
Severe (grade 4 or 4+/4+): opacification of the left ventricle more intense
than that of the ascending aorta and/or full left ventricular cavity opacified in
one beat
Fig. 12 - Aortography

5. Coronary angiography

Coronary angiography, represented by injection of contrast material
into the ostium of the coronary arteries, has become nowadays the golden
standard for for identification of coronary artery stenoses or occlusions
caused by ischaemic heart diseases.
Indications of coronary angiography
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Main indications of coronary angiography are represented by:
-Unstable angina or acute myocardial infarction for urgent
revascularisation
-Stable angina class III and IV after medical treatment
-Survivals of cardiac arrtes
-Postrevascularization ischaemia (suspicion of stent thrombosis)
-Before open heart surgery for valvular heart diseases, in those >50
years.
-High risk for coronary artery disease in non-invasive testing
-For safety reasons (pilots, drivers)
-After AMI especially if EF is <40%




Contraindications.
Relative contraindications for coronary angiography include:
-Fever
-Infections
-Severe anemie with Hbg <8g/dl
-Diselectrolitemia
-Active bleeding
-Uncontrolled hypertension
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-Stroke in evolution
-Acute renal failure
-Active endocarditis

Approach
The most used approaches for coronary angiography are the femoral
approach and radial approach (fig. 13). Both use the Seldinger technique for
puncture of the femoral/radial artery (fig. 14)

Fig. 13 a) Femoral approach b) Radial approach


Fig. 15 - Seldinger technique

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The main complications of femoral access are: retroperitoneal
bleeding (more frequent if body surface >1.72 m2, in case of suprainguinal
acces, in case of puncture of posterior arterial wall or excessive tortuosity),
pseudoaneurism, arterio-venous fistula and hematoma. To overcome the risk
of bleeding associated with femoral puncture, different types of closure
devices have been introduced in the market (Vasoseal, AngioSeal, Duett,
QuickSeal, etc - fig.16). Closure devices present multiple advantages against
the manual compression: help to reduce bleeding at the site of the puncture,
lower mortality, and are preffered by the patients
Fig. 16 - closure devices
Technique
Catheter selection
Pre-shaped catheters (e.g. J udkins, Amplatz) can be used for injection
of both coronary vessels, not only via the femoral and left radial or brachial
approach but also the right radial/brachial approach. A large spectrum of
different catheter configuration is available nowadays (fig. 17), adapted for
each particular case (large or small aortic root, different angulation of
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coronary origin, etc), the most used being the J udkins and Amplatz types
(fig. 18).



Improvements in catheter technology have allowed the flow rate
obtained with old 8F (1F =0.33mm) diagnostic catheters to be achieved
with 6F thin-walled catheters and satisfactory coronary opacification with 4F
and 5F diagnostic catheters. Newly developed automatic injectors with
adjustable increases in injection pressure have the potential to allow more
consistent homogeneous opacification of large left coronary arteries through
45F catheters.
When retrograde bleeding ensures the catheter has been purged of air,
a pressure line is connected and a test injection performed, often showing
that the catheter is already engaged or is located immediately below or in
front of the ostium. In the latter case, gentle withdrawal of the catheter tip
(helped by asking the patient to take a deep breath) will allow engagement of
the catheter tip in most cases. If the tip of the catheter immediately closes in
the ascending aorta, prolonged attempts with the same catheter should be
avoided and rapid switching to a larger catheter is probably advantageous in
terms of time lost and contrast used. When it is known that the coronary
Fig. 17 - Different types of catheters
for coronary angiography
Fig. 18 - a) Judkins L and R curve .
b) Amplatz L and R curve
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ostia are in an unusual position (aortic valve disease, Marfan syndrome,
congenital heart disease), it is probably worthwhile performing an aortic
angiogram in the left anterior oblique view in order to guide catheter
selection, since this may require unusual shapes.

Cannulation of left coronary artery
Selection of coronary catheters should aim at an optimal coaxial
atraumatic intubation of the coronary artery and should be based on the size
of the aortic root. In the majority of cases standard 4.0 J udkins catheters can
be used. If it is known from previous invasive or non-invasive examination
that there is an enlarged ascending aorta, a 4.5 or 5.0 left J udkins catheter
should be preferred. Smaller sizes, 3.5 or 3.0 J udkins, can be a first choice in
small females or for right radial approaches.
The optimal view for engaging both the right and left coronary
arteries is the left anterior oblique view where the ostium is not covered by
the aorta. The left coronary artery requires only minimal catheter
manipulation; the J -tipped 0.89-mm (0.035-inch) wire is atraumatically
advanced to the level of the aortic valve and the tip of the previously flushed
J udkins catheter is opened as low as possible pointing to the left coronary
ostium (fig. 20).
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Cannulation of Right coronary artery
Catheter selection for cannulation of the right coronary artery (RCA)
should be based on the same policy as for the left coronary artery, taking
into account the size of the aortic root. In the left anterior oblique or lateral
view, the catheter must be rotated to point to the left of the screen and this is
better achieved when the rotation is performed during a slow pull-back
motion of the catheter from the right coronary sinus. Breath-holding after a
deep inspiration may facilitate this manoeuvre. In 1015% of cases a high
origin of the RCA complicates the search for the right coronary ostium.
Even in the presence of a hypoplastic non-dominant RCA, selective injection
is still required because small proximal branches can be an important source
of collaterals for occluded vessels. It is often possible to obtain a semi-
selective injection with the J udkins catheter that will further guide catheter
selection. A multipurpose catheter should be used for downward-looking
RCAs, and Amplatz right 2 or Amplatz left 1 or 2 are required in patients
with high take-off and/or with dilatation of the coronary sinus and ascending
aorta. Careful review of the images should be performed before finishing the
examination in order to avoid missing a separate origin from the aorta or an
abnormal origin from the proximal RCA of the LCX, the most frequent
Fig. 19 - catheter manipulation for cannmulation of
left coronary artery

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coronary anomaly, or the separate origin of a conus branch that provides
important collaterals to occluded arteries.

Contrast injection should be sufficiently rapid and large to fully
replace the epicardial vascular volume and avoid the phenomenon of
streaming or incomplete visualization. On the other hand, angiographic
acquisition should be prolonged to allow visualization of the distal vessels,
identification of thrombolysis in myocardial infarction (TIMI) flow, and
characterization of type of dissection (with/without persistence of contrast at
the end of the injection). An important determinant of injection duration is
the need to visualize collaterals for occluded vessels, which also means
adjustment of the view to include the recipient vessel in the image.
Visualisation of coronary circulation
There are 3 types of coronary circulation, according to the distribution
of coronary arteries:
1. Right dominance - 80% of cases, when the diafragmatic wall is
irrigated by the right coronary artery
Fig. 20 - catheter manipulation for cannmulation of
right coronary artery

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2. Left dominance - 10-15% of cases, when the diafragmatic wall is
irrigated by the left coronary artery
3. Codominant- 10% of cases, when the diafragmatic wall is irrigated
by both coronary arteries
Left coronary artery
Left coronary artery (Left main) divides immediately after originating
from aorta into 2 major vessels: the Left Anterior Descendent (LAD)
coronary artery and the Circumflex artery (Cx).
The branches of left coronary artery are presented in fig. 21

1 Left main, 2 Proximal LAD (SI), 3 - Medial LAD (SII), 4 - Distal LAD (SIII), 5 -
Proximal Cx, 6 - Distal Cx, 7 - Marginal artery, 8 - 1st diagonal, 0 - 2nd diagonal, 10 -
septal arteries, 11 - 2nd marginal.

Fig. 22 - examples of left coronary angiography
To delineate the branching of the left main coronary artery from the
aorta and its bifurcation into the left anterior descending (LAD) and left
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circumflex (LCX) arteries (or trifurcation if an intermediate branch is
present), the most used incidence is the so-called spider view (left 4055,
caudal 2540).
In the left cranial view (3045 left, 2540 cranial) the LAD is
further elongated by asking the patient to take a deep breath and maintain
breath-holding during injection. The cranial view also offers optimal views
of the mid and distal segments of the LCX, and is especially useful in the
presence of a dominant LCX. The lateral view provides excellent
visualization of the mid/distal LAD around the apex, information which is at
most complementary to right caudal views.

Right coronary artery
Right coronary artery has few branches in the first, second, and third
segments (from the ostium to the crux cordis) and often two views (left
anterior and right anterior oblique views) are sufficient to identify all
stenoses, including eccentric stenoses. The lateral view might be ideal for
assessment of the mid segment of the artery and may occasionally be used as
a working projection for occlusions in this segment or stent positioning.
The branches of left coronary artery are presented in fig. 23

33
Fig. 23 - 1 - first (orizontal) segment, 2 - 2nd (vertical) segment, 3 - 3rd (orizontal)
segment, 4 - posterior interventricular branch, 5 - retroventricular artery, 6 - conus
artery, 7 - sinus node artery, 8 - right ventricular artery, 9 - right marginal artery, 10 -
artery of the AV node, 11- inferior septal branches

Fig. 24 - examples of right coronary angiography

Complications of coronary angiography
The most frequent complications of angiography occur at the catheter
entry site. Closure devices have reduced the time to ambulation, increased
patient comfort, and shortened the hospital stay, but do not appear to have
modified the bleeding risk and have added some rare specific new
complications (infection, embolization, or arterial stenoses due to
components of the closure device or procoagulant factors injected into the
bloodstream).
Large haematomas requiring drainage, blood transfusions, prolonged
bed rest, and hospitalization are rare and often the consequence of the
inability to comply with bed rest, or the clinical need for prolonged
anticoagulation.
Other more serious vascular complications include pseudoaneurysm,
fortunately often closed with ultrasound-guided compression and/or
34
selective thrombin injection, arteriovenous fistulae, arterial thrombosis, and
distal embolization.
The most dreadful but fortunately rare vascular complication is
retroperitoneal bleeding, mostly managed conservatively, while iliac or
aortic dissections tend to seal spontaneously if antegrade flow is preserved.
The frequency of serious complications, such as death, myocardial
infarction, or cerebrovascular accident with permanent damage, is very low
(0.10.2%).
Myocardial infarction is often due to catheter-induced ostial damage
due to pre-existing severe pathology or the presence of unstable plaques at
risk of embolization and can potentially be treated with angioplasty and
stenting.
Stroke is the consequence of thromboembolism due to thrombi in the
access sheath or the catheter, dislodgement of plaques from the iliac vessels
or aorta, calcium from the aortic valve, or thrombi in the left ventricle.
Meticulous attention to catheter flushing and atraumatic wire-lead insertion
can reduce but not eliminate the risk, whilst there is no evidence that
systemic heparinization is required for diagnostic catheterization.
Reactions to the contrast medium (nausea, vomiting, rash) are very
rare and the amount of contrast used for a diagnostic angiogram cannot
induce permanent renal damage unless a severe previous dysfunction was
present.
Bradycardia and hypotension develop because of periprocedural
vasovagal reactions, prevented by generous sedation, liberal local
35
anaesthesia, reassurance, and appropriate filling with intravenous fluids.
Other major arrhythmias (ventricular fibrillation and tachycardias,
supraventricular arrhythmias) can be induced by catheter damping,
excessively prolonged injection, or mechanical stimulation.














6. Percutaneous coronary interventions
Percutaneous Transluminal Coronary Angioplasty (PTCA), known
also as Percutaneous Coronary Intervention (PCI), represents dilatation of a
coronary stenosis using a dedicated catheter with a deflated balloon at its tip,
36
which is advanced at the site of the coronary plaque under X-ray control (fig.
25). At this site, the balloon is inflated using an external syringe and
compresses the coronary plaque against the vessel wall.


Fig. 25 - PTCA technique.

Coronary stenting represents introduction, using femoral or radial
access, of a coronary stent which is expanded against the vessel wall at the
site of the coronary plaque using an external syringe and remains in place at
the site of the coronary stenosis, isolating the atheromatous plaque and thus
preventing the restenosis(fig. 26).


A B C
37
Fig. 26 A -coronay artery stenting. B- angiographic aspect before stenting. C -
angiographic aspect after stenting

Traditionally, 3 types of coronary stenoses have been described:
Type A - >85% succes rates, low risk
-length <10 mm
-concentric
-easy accessible
-segment angulation <45 degrees
-smooth contour
-low grade or absent calcification
-no ostial involvement
-no collateral branch involved
-no thrombus
-no total occlusion
Type B - 60-80% success rates, moderate risk
-tubular lesions, with length of 10-20 mm
-excentric
-moderate tortuosity of the proximal segment
-moderate angulation (45-90 degrees)
-moderate or severe calcification
-ostial localization
-bifurcation lesions necessitating double guidewires
-thrombus
Type C - <60% success rates, high risk
-diffuse lesions, >20 mm
38
-excessive tortuosity of the proximal segment
-extremely angulated segment, >90 degrees
-total occlusion, >3 months
-major collateral branch involved
-degenerated saphenous graft with friable content.

Materials for PTCA
1. Guiding catheters
The guiding catheters are manipulated in order to be positioned in the
ostium of the coronary artery (fig. 27). They have a standard diameter of 350
m, and a length between 150 and 350 cm.

Fig. 27 - positioning of the guiding catheter in the ostium of the coronary
artery
Similar with coronary diagnostic catheters, there are many different
types of shapes of guiding catheters (J udkins, Amplatz, etc) - fig. 28.
39

Fig. 28 - canulation of left and right coronary ostium with different types of
catheters.

2. Guidewires
A guidewire is a device used to cross the coronary lesion. After
crossing the coronary lesion, a PTCA balloon catheter is advanced along the
guidewire until it reaches the coronary lesion. Usually, the guidewires have a
diameter of 0.010 - 0.018, a tip diameter of 0.014 0.009, a standard
length of 175-190 cm, and 3 components: a core, a tip and a coating (fig. 29).





3. PTCA balloons
40
PTCA balloons are catheters having attached at their distal tip a
deflated balloon (fig. 30), which can easily be inflated in order to compress
the plaque.


4. Coronary stents
Coronary stents are metallic devices which are surmounted on a
deflated PTCA balloon and are placed at the site of coronary plaque in order
to treat it and prevent restenosis (fig.31).

Fig. 31 - coronary stent at the site of the plaque

The major two types of stents are available nowadays:
-Bare metal stents are classical stents, that are not covered with
antiproliferative substances, and
-Drug-eluting stents are stents covered with anti-restenotic
medication.
41
Bioabsorbable stents have also been introduced in the recent years,
with similar results as for DES.
Advances in techniques, equipment, stents and adjuvant therapy have
established PCI as a routine and safe procedure in patients with SCAD and
suitable coronary anatomy. The mortality risk associated with the procedure
in SCAD is 0.5%.
Bare metal stents (BMS) are associated with a 2030% rate of
recurrence of angiographic stenosis within 69 months after implantation.
Drug-eluting stents (DES) reduce the incidence of angiographic restenosis
and ischaemia-driven repeat revascularization. For the first generation of
DES, this benefit has been extensively demonstrated in spite of a slightly
higher incidence of late and very late stent thrombosis, related to delayed
endothelialization, which requires longer dual antiplatelet therapy (DAPT) to
prevent stent thrombosis. First- generation sirolimus-eluting stents (SES)
and paclitaxel-eluting stents (PES) have been extensively compared in head-
to-head randomized controlled trials. Angiographic results were better with
SES and translated into significant differences in terms of repeat
revascularization.
The most recent or second- generation DES (with thinner struts and
biodegradable or more biocompatible polymers) showed superior clinical
outcomes for both efficacy and safety when compared with first-generation
DES.
New-generation DES have been associated with lower rates of stent
thrombosis, and recent data from registries and randomized controlled trials
suggested that a shorter duration of dual antiplatelet therapy might be
sufficient in stable coronary patients.
42
Special devices are used in coronary interventions, in special complex
cases. Among them are:
- Thrombectomy devices, used in cases of large thrombotic material, for
removal of the thrombus especially in cases of acute coronary syndromes


- Aterectomy devices, rotational or directional, which fragments the coronary
plaque and eliminate the debris


- Laser catheters, used especially for dissipation of coronary plaque and
thrombus





43
- Maneuvrable guidewires, used especially in cases with difficult abord



Microdissection, useful expecially for penetratic the fibrous cap of a chronic
total occlusion.


Safe cross, especially in complex cases when it generates an audio signal
each time the catheter is closer than 1 mm to the vessel wall, eliminating the
risk of perforation.





44
Antiembolic filters which could be proximal or distal to the lesion


Proximal antiembolic protection devices Distal antiembolic protection devices

Primary PCI in STEMI
There is general agreement that reperfusion therapy should be
considered if there is clinical and/or Electrocardiographic evidence of
ongoing ischaemia, even if, according to the patient, symptoms started 12 h
before as the exact onset of symptoms is often unclear, or when the pain and
ECG changes have been stuttering.
There is, however, no consensus as to whether PCI is also beneficial
in patients presenting 12 h from symptom onset in the absence of clinical
and/or electrocardiographic evidence of ongoing ischaemia. In such
asymptomatic late-comers, a small (n 347) randomized study has shown
myocardial salvage and improved 4-year survival resulting from primary
PCI, compared with conservative treatment alone, in patients without
persistent symptoms 12 48 h after symptom onset. Primary PCIdefined
as an emergent percutaneous catheter intervention in the setting of STEMI,
without previous fibrinolytic treatmentis the preferred reperfusion
strategy in patients with STEMI, provided it can be performed expeditiously
(i.e. within guideline-mandated times), by an experienced team, and
45
regardless of whether the patient presents to a PCI-capable hospital. If FMC
is via an EMS or at a non-PCI-capable centre, transfer via the EMS to the
catheterization laboratory for PCI should be implemented Immediately. An
experienced team includes not only interventional cardiologists, but also
skilled support staff. This means that only hospitals with an established
interventional cardiology programme (available 24/7) should use primary
PCI as a routine treatment. Lower mortality rates among patients undergoing
primary PCI are observed in centres with a high volume of PCI procedures.
Primary PCI is effective in securing and maintaining coronary artery patency
and avoids some of the bleeding risks of fibrinolysis. Randomized clinical
trials comparing timely primary PCI with in-hospital fibrinolytic therapy in
high-volume, experienced centres have repeatedly shown that primary PCI is
superior to hospital fibrinolysis.
According to all these data, the European Society of Cardiology
elaborated the guidelines for STEMI treatment presented below:

European guidelines on STEMI treatment


46
According to the recommendation of the European Society of
Cardiology, the prehospital management of STEMI patients must be based
on regional networks designed to deliver reperfusion therapy, with efforts
made to make primary PCI available to as many patients as possible.


















47
7. Imaging in interventional cardiology

Intracoronary ultrasound imaging
Intravascular ultrasound represents intracoronary visualization of
atherosclerotic plaques using a dedicated catheter which is advanced into the
coronary lumen, having a miniaturized flexible intracoronary ultrasound
probe mounted on the tip, which generates high-resolution cross-sectional
images by spinning a single piezoelectric crystal at 360 degrees or by
activating in sequence multiple (64) transducer elements. The technique is
useful for measurements of vessel dimensions (diameter, area). When
associated with Virtual Histology, it allows quantification of coronary
plaque components. Virtual Histology is an IVUS-derived technique which
provides a colour codification of the atheromatous plaque based on echo
density of the plaque component. According to ultrasound density, the
plaque components are classified as fibrous, calcific, soft atheroma and
necrotic core. This technique allows not only visualization of these
components but also their quantification and is currently used as a golden
standard for characterizing vulnerable plaques, which are prone to plaque
rupture and consecutive development of an acute coronary syndrome.
Unstable plaque are characterized by VH-IVUS specific markers, such as a
large necrotic core especially when situated in the proximity of the intimal
layer, a large content in soft atheroma and positive remodeling. All these
features are currently used in the cardiac catheterization laboratories to asses
the risk associated with coronary stenoses.
48
Calcification, detected with greater sensitivity than with angiography,
can be located within the plaque, from superficial subendothelial calcium
speckles to deep deposits at the base of the plaque, and can be quantified
based on their circumferential extension, measured in degrees or quadrants,
and length.

Fig. 32 - Intravascular ultrasound with virtual histology
Multislice 64 computed tomography coronary angiography is a
new technology which allows noninvasively quantification of atherosclerotic
burden of coronary lesions and can therefore predict risk of cardiac events. It
can not only evaluate the presence of obstructive coronary artery disease, but
also can provide a plaque characterization classified as calcified,
noncalcified or mixed.


49
Optical coherence tomography
OCT is a novel imaging modality that is capable of visualizing vessel
anatomy at a resolution around ten times greater than IVUS due to the much
shorter wavelength of the imaging light.
Current OCT images are obtained via 0.019 in imaging wires
containing optical fibres, at a peak wavelength in the 12801350nm band,
that enables a 1015 tissue axial resolution. Images are then displayed
using a log false colour scale, at 20 frames/s and 200 lines/frame. These
parameters have been further improved with the use of frequency domain
OCT which allows acquisition of 100 frames/s and 500 lines/frame, allowing
a more rapid pull-back and a wider field of view with maintained or
improved image quality. The superb resolution of OCT is obtained at the
expense of a limited tissue penetration, which is the main limitation of OCT.
Penetration is dependent on tissue characteristics and is between 0.51.5mm
of imaging depth; it is minimal in presence of thrombus, poor for superficial
necrotic lipid pools, higher for calcific components, and maximal for fibrous
tissues.
Calcifications within plaques are identified by the presence of well-
delineated, low back-scattering heterogeneous regions. Fibrous plaques
consist of homogeneous high back-scattering areas. Necrotic lipid pools are
less well-delineated than calcifications and exhibit lower signal density and
more heterogeneous back-scattering than fibrous plaques. There is a strong
contrast between lipid-rich cores and fibrous regions within OCT images.
Therefore, lipid pools most often appear as diffusely-bordered, signal-poor
regions (lipid pools) with overlying signal-rich bands, corresponding to
50
fibrous caps Pathological studies of plaques leading to fatal events have
established 65m as the threshold of fibrous cap thickness that best
identifies vulnerable lesions so that this value is often adopted as the cut-off
threshold for identifying thin capped atheromas prone to rupture in vivo.
Thrombi are identified as masses protruding into the vessel lumen
discontinuous from the surface of the vessel wall. Red thrombi are
characterized by high-backscattering protrusions with signal-free shadowing.
White thrombi appear as signal-rich, low-backscattering billowing
projections protruding into the lumen.

Fig. 34 - Left panel: normal three layer appearance in a 31-year-old female
patient can be appreciated, with the muscular media being shown as a low
signal layer comprised between internal and external lamina. Right panel:
eccentric coronary plaque with fibrous (arrow) and calcific (arrow-head)
components.
OCT has the potential to identify inflammatory cells such as clusters
of macrophages, seen as bands of high reflectivity in OCT images. When
macrophages are located in a plaque with a lipid pool, macrophage streaks
appear within the fibrous cap covering the lipid pool. Acute plaque
ulceration or rupture can be detected by OCT as a ruptured fibrous cap that
connects the lumen with the lipid pool. These ulcerated or ruptured plaques
may occur with a superimposed thrombus and this can impair the
visualization of the underlying rupture.
51
Optical coherence tomography for assessment of coronary interventions
Poor penetration limits the practical value of OCT for preintervention
imaging, making this technique less suitable than IVUS for sizing balloons
and stents. Still lumen area, with the exception of the largest vessels, can be
easily detected with OCT. Potentially, all the considerations made before to
determine when treatment is warranted and when the lumen inside the stent
matches the proximal and distal
A great value of OCT is the superior ability to study apposition and
intimal coverage after stent implantation. Struts are seen as dense strips
because metal, unlike calcium, cannot be penetrated by OCT. Although the
intima immediately below the strut cannot be seen, the artefacts around
struts are much less prominent than with ultrasound and the relationship
between strut and surrounding intima can be studied. Struts often appear as
protruding from the intima but the physical thickness of the strut must be
considered to judge apposition. Thinner stent struts have been shown to have
fewer protruding or unapposed struts than thicker stent struts but no
longitudinal observations correlating these findings with late coverage or
clinical events are available at this stage.





52
Imaging the vulnerable plaque
Intracoronary vulnerable plaques are associated with a high risk for
plaque rupture and development of an acute coronary syndrome. Therefore
detection of vulnerable plaques and quantification of plaque vulnerability
and its risk for further rupture and complications represents one of the main
goals of the new imaging techniques in cardiology.
Detection of vulnerable plaues is one of the most challenging issues
raised by the recent developments in imaging techniques in cardiology.
Ability to detect features which characterise the unstable plaque continues to
be in the focus of several new imaging techniques. Detection of vulnerable
plaque is of extreme importance due to the well-known risk associated with
these plaques. Rupture of an unstable plaque rapidly evolves towards
development of an acute coronary syndrome, either ST or nonST elevation
myocardial infarction or unstable angina.
Intravascular ultrasound represents nowadays a golden standard for
detection and assessment of vulnerable plaques, due to its ability, when
associated with virtual histology, to distinguish between soft atheroma with
a lipid reach core and eventually a necrotic core, characteristic for unstable
plaques, and fibrous atheroma or calcified plaques typically associated with
stable plaques. Another important information provided by IVUS for
assessment of unstable plaques is the evaluation of the fibrous cap of the
coronary plaque, being known nowadays that a thin fibrous cap is
significantly associated with a high risk for development of an acute
coronary syndrome as a marker of plaque instability. Assessment of vascular
remodeling, which has been shown to be correlated with a significant risk
for development of an acute coronary syndrome, is another important
53
application of IVUS with significant potential impact in detecting the risk
associated with a vulnerable plaque. Another method useful for evaluation of
coronary plaques is represented by Multislice Computed Tomography
Coronarography (MSCT), which presents the advantage of obtaining
complex information related to coronary plaques via a noninvasive method.
The gold standard for assessing vulnerable plaque is nowadays
represented by Intravascular Ultrasound associated with Virtual Histology
(IVUS-VH) because of excellent visualization of intracoronary plaques
associated with exact quantification of low-density atheroma within the
plaque. Indeed, virtual histology techniques is a recently developed
application of intravascular ultrasound technology, in which coronary
plaques are color coded according to their content in low density, vulnerable
atheroma, fibrous atheroma, calcifications or necrotic core. After tracing the
external and internal borders of the coronary plaque, the plaque is displayed
in different colors according to its content in lipid-reach atheroma or stable
atheroma, and in the same time a graphical display of the percentage of
plaque burden with low or high density atheroma is displayed on the screen.
Considering the concomitant possibility of measuring the thickness of
the fibrous cap with IVUS and to evaluate the vascular remodeling in the
immediate proximity and distality of the plaque, it is clear that the IVUS
examination associated with virtual histology provides all the necessary
information to estimate the vulnerability of the plaque, as it provides
important information regarding several parameters known as being
associated with plaque instability and evolution towards development of an
acute coronary syndrome (presence of necrotic core, lipid-reach burden, thin
fibrous cap, vascular remodeling).
54
One disadvantage of IVUS technique is represented by difficulty in
visualization of intracoronary thrombus, which is a major finding associated
with an acute coronary syndrome especially in acute cases such information
could be essential to establish the proper treatment strategy. In these cases an
alternative interventional imaging method could be represented by optical
coherence tomography (OCT), which offers superb visualization of
intracoronary thrombus and coronary plaque in the same time, but without
the possibility of virtual histology analysis.
However, the discomfort associated with an interventional technique
and the high cost of the IVUS or OCT technologies and catheters precludes
IVUS or OCT technology from being used on a large scale for detection of
vulnerable plaques.
Noninvasive techniques have emerged to replace interventional
imaging techniques in complex assessment of intracoronary plaques. The
recent progress in non-invasive imaging techniques represented by
Multislice 64 Computed Tomography Coronaroangiography (MSCT) has
made possible noninvasive visualization of coronary plaques along a
complex assessment of coronary lesions. MSCT analysis of intracoronary
plaque is mainly used on a large scale in present in order to classify the
coronary plaques as obstructive or non-obstructive according to the degree
of luminal narrowing realized by the stenosis. Another important application
of MSCT is represented by calcium scoring which is used in many times as a
screening tool to assess the cardiovascular risk, based on calculation of
calcium burden within the coronary arteries, which has been shown to be
directly correlated with the evolution of the patients towards development of
a cardiovascular event. However, in cases with very high calcium score
invasive coronarography is indicated as the severe calcification of the
55
coronary arteries makes it very difficult to provide an accurate assessment of
the coronary arteries due to intense reverberations.
One of the most important applications of MSCT technique is
represented by possibility to determine intraplaque densities and therefore to
estimate the content in low-density atheroma versus high-density atheroma,
providing a differentiation between low-density fibroadipous atheroma and
high-density calcified atheroma. Similar with virtual histology analysis, a
color coded representation of the coronary plaque is displayed, in which the
atheroma is represented in different colors according to its content in low-
density or high-density atheroma. One of the main issues raised by this
approach is the difficulty to differentiate between low-density fibrous
atheroma which is a stable atheroma, and low-density adipous, cholesterol
reach atheroma, which is a very unstable one. Therefore definition of a
cutting point of plaque density, according to which we would be able to
differentiate the unstable atheroma with a density below the cutting point,
from the stable atheroma with a density above the cutting point, would be of
extreme importance for a proper assessment of plaque-related risk. Such a
cutting point has not been identified yet in the literature, however there are
several ongoing studies to asses the role of MSCT in assessing markers
related to plaque vulnerability.
The detection of vulnerable plaques is one of the most challenging
tasks made possible by the recent developments in cardiovascular imaging
technologies. Taking into consideration the significant risk associated with
vulnerable plaques, which are prone to rupture and rapid evolution towards
the development of Acute Coronary Syndromes, the ability to detect features
that characterize unstable plaques is of extreme importance. If rupture-prone
56
plaques could be identified in time, the appropriate initiation of adequate
therapeutic measures could prevent the evolution to an acute coronary event.
A vulnerable plaque is characterized by a large necrotic core, a thin
fibrous cap demonstrating macrophage infiltration, a large lipid pool, and
several specific features such as positive remodeling (PR) or spotty
calcifications (SC). When these characteristics are present, the fibrous cap
can rupture and the lipid core, which is thrombogenic, is then exposed to the
blood flow, inducing thrombus formation and the development of ACS.

The morphological characteristics associated with unstable plaques
are generally evaluated using three main imaging methods: Intravascular
ultrasound with virtual histology (VH-IVUS), Coronary Computed
Tomography Angiography (CCTA), and Optical Coherence Tomography
(OCT).
Intravascular ultrasound is currently the gold standard for the
detection and assessment of vulnerable plaques due to its ability, when
associated with virtual histology, to differentiate the soft atheroma with a
lipid reach or necrotic core, which is typically associated with vulnerable
plaques, from a fibrous or calcified atheroma, which is generally associated
with stable plaques. VH-IVUS is able to combine intracoronary imaging
data with a color-coded representation of plaque components, which are
classified as fibrotic, fibro-fatty, calcified or necrotic core, while at the same
time offering the possibility for precise quantification of these components.
Cardiac Computed Tomography Angiograph is another imaging
technique that can identify specific parameters associated with plaque
vulnerability, such as PR, SC and burden with low attenuation plaque (LAP).
It has been shown that a PR on CCTA is associated with higher percentages
of necrotic cores within the plaque on IVUS and that the percentage of the
57
necrotic core by IVUS is significantly higher in plaques with SC identifiable
by CCTA compared to non-calcific plaques. However, although these
studies have demonstrated the association between the presence of different
CT and IVUS features of coronary plaques in different clinical settings, the
precise correspondence between plaque components classified on the basis
of CT attenuations and VH-IVUS derived components, has not been clearly
established yet.
Available softwares have enabled CCTA to be used for quantitative
analysis of plaque components based on different CT attenuations within the
plaque. In most ACS cases, CCTA plaque quantification demonstrates a
mixed composition of the coronary plaques, containing variable proportions
of a lipid-reach core with a low CT density (with mean attenuation values
reported in a range between 11 and 99 HU), a fibrous component with
higher CT densities (with mean attenuation values reported in a range
between 77 and 121 HU), and calcium.
Several studies that compared CCTA with intravascular ultrasound
have validated the role of CCTA for the detection of coronary plaques,
reporting sensitivities and specificities that vary between 80 and 90%.
However, CT imaging is not restricted only to plaque visualization, as it
provides additional information regarding plaque burden, composition and
remodeling, which are directly correlated with plaque vulnerability.
In a prospective study including 1059 patients who were followed for
a mean period of 2.3 years after having undergone CCTA, Motoyama et al
demonstrated that specific plaque parameters such as PR and low CT
attenuation may be associated with a particularly high risk for plaque rupture
and the development of an acute coronary event. Another retrospective study
demonstrated that culprit lesions present a more positive remodeling (815 vs.
58
12%), more low-density (<30 HU) plaque components (79% vs. 9%) and a
higher prevalence of spotty calcifications (63% vs 21%), and all of these
features were shown to represent significant predictors for ACS.
It has been speculated that the identification of very low CT densities
(below 30 HU) within a plaque may be associated with a higher
predisposition towards rupture and could therefore represent a marker of
vulnerability.
Given the current necessity for a cost-effective approach and
justification of expensive imaging tests, together with the high degree of
accuracy of information provided by CCTA using a non-invasive plaque
quantification, CCTA could replace in the future invasive techniques such as
IVUS or optical coherence tomography for the complex evaluation of
intracoronary plaque vulnerability.
a) Cardiac CT b) VH-IVUS c) OCT
Fig. 36 - Multimodality imaging of the vulnerable plaque




Fig. 37 - color coded quantification of plaque
component by Cardiac CT

59

Fig. 38 - Vulnerable plaque by Cardio CT - dark spots representing necrotic core of the
plaque
Intracardiac echography
Intracardiac echography represents visualization of heart structures
using special miniaturizd transducers placed at the tip of intracardiac
steerable catheters, which are advancd using standard interventionl
techniques in the heart chambers.
Information provided by intracardiac echocardiography are in a
certain extent superposable with those offered by transesophageal
echocardiography, still carrying the advantage of a significantly higher
comfort for the patient, therefore intracardiac ech is the procedure of choice
in many structural interventions, interventions that take usually a longer time
and require echocardiographic monitorization due to their complexity.



Fig. 39 - Intracardiac echocardiography - technique and catheter

60
8. Structural interventions

1) Interventional closure of Atrial Septal Deffects and Patent
Foamen Ovale
Atrial Septal Deffects are the most common congenital heart diseases
that could be encountered de novo in an adult. In patients with significant
ASD, ASD closure leads to a symptomatic improvement and regression of
right ventricular size and pulmonary hypertension. The best outcomes of this
procedure are encountered in young patients. The main indications for ASD
closure are the clinical symptoms in presence of a significant shunt and
dilated RV, while main contraindications are represented by Eisenmenger
physiology, pulmonary hypertension and sinous venosus or ostium primum
type. Also, all ASDs regardless of size in patients with suspicion of
paradoxical embolism should be considered for intervention.
The success rates for ASD closure are quite high, approaching 98%,
the most important key for success being the correct assessment of ASD
type before the procedure. In order to be amenable for closure, a defect
should have a rim of at least 5 mm to assure the correct apposition and
stabilisationof the disks. The procedure of interventional closure of ASD
involves placement of an occluder at the site of the defect, wihch is
advanced using right heart catheterization, passes through the defect and is
than opened to close the deffect and released (fig. 40-42).

61

a b c d e
Fig. 40: Interventional closure of ASD. The Device catheter placed into the
LA (a), than the device fed into the catheter until the proximal part emerges
into the LA (b), and the device catheter retracted against the septum until
resistance is felt (c). Catheter is withdrawn until the proximal part emerges
from the catheter (d), followed by release of the proximal disk and the device
is disengaged from the insertion catheter (e)

Fig. 41 - schematic representation of ASD closure.

Fig. 2 - Implantation of Amplatzer occluder device and intracardac echo control.

62
Different types of occluders have been manufactured by different
companies, with similar succe rates in providing a complete closure of the
defect (fig. 43). The most commonly used occluders for ASD are Amplazer,
Premiere, Cadioseal, Starflex, Helex and Intrasept.

Amplatzer Cardioseal Starflex Helex Premiere Intrasept
Fig. 43 - different types of closure devices
While ASD is a communication between two atria, usually
complicated by pulmonary hypertension, the PFO represents a lack of fusion
of the flap-like opening between the atrial septum primum and secundum.
The closing procedure is similar in case of Patent Foramen Ovale, in
which the indication is mainly based on the suspicion of the associated
paradoxical thromboemblism,multiple neurologic events and eventually
migrena.
However, different types of septal morphology exists in these cass (fig.
44), some of them being quite challenging and involving a higher degree of
difficulty for the operator. Assessment of anatomical variations that may
affect the procedure and device choice is based on the presence of atrial
septal aneurysm, the degree of separation from septum secundum, the length
of septal overlap and the evaluation of the septum secundum

63

Fig. 44 - Different types of difficult septum morphology
2) Interventional closure of Ventricular Septal Deffects
Ventricular Septal Deffects is associated in almost 30% of all
congenital heart diseases and the interventional treatment of VSD is much
more complicated that of ASD, due to the presence of valve aparatus in the
cavity, of the moderator band in the RV and of the chordae tendinee and
papilary muscles in the left ventricle.
Similarly with the devices for ASD, many types of devices have ben
developed for treatment of VSD, adapted according to the specific location
of the defect (fig. 46): Amplatzer muscular, postmyocardial,
perimembranous, etc.

Rashkind Clamshell Amplzer muscular Amplatzer concentric Amplazer excentric
Fig. 45 - Closure devices for closure of ventricular septal deffects
64
All procedures for VSD closure are performed under general
anesthesia and with fluoroscopic and transesophageal or intracardiac
guidance. The VSD is crossed from the left side, and the left disk is
deployed in the left ventricular cavity, followed by retraction of the system,
control angiogram and final release of the device (fig. 46).

Fig. 46 - Closure of a VSD - Technique and echocardiogaphic control

3) Interventional closure of Patent Ductus Arteriosus
Patent ductus arteriosus has an incidence of approximatey 1 in 2.000
infants, representing 5-10% of all congenital heart diseases in children. The
clinical significance of a PDA are determined by size, length and age at
presentation.
The closure of a PDA is performed usually in general anesthesia in
children and in local anesthesia in adults.
Different devices are available for closing PDA, most commonly used
being modified Amplatzer (fig. 47), Rashkind or coil occluders (Gianturco
65
coils). Ducts smaller than 5 mm could be occluded with coil, but ducts
greater than 5 m in diameter are unsuitable for coil occlusion.
Technical challenges associated with coil occlusions are related to
crossing the duct, coil position and embolisation.
The accepted standard treatment of patients with Patent Ductus
Arteriosus is currently the transcatheter occlusion with one of the available
devices. However, in very small infants and preterm newborns, surgical
treatment is still the procedure of choice.
Fig. 47 - Closure device for closing Patent Ductus Arteriosus

4) Interventional closure of Left Atrial Appendage
Closure of LAA is required as atrial fibrillation is one of the most
frequent cardiac diseases and it frequently complicates with thrombus
formation in LAA. In turn, the LAA is the most common site of thrombus
development, which results in systemic thromboembolism.
Percutaneous closure of LAA presents an overall improved safety
profile compared to surgical closure or medical therapy. A number of
devices have been developed for this indication, including the Watchmann
and the Plaato devices (fig. 48), which have recently become available.
66
Prior to the procedure, the LAA should be evaluated by
transesophageal echocardiography in order to exclude the presence of
thrombus. If thrombus is present, the procedure should be postponed and
appropriate anticoagulation treatment should be initiated. Left atrial access is
gained using transseptal puncture and angiographic control from different
views is necessary for a complex evaluation of left atrial appendage
morphology. After the appropriate size is determined, the device is placed
into the LAA and deployed.


Watchman (nitinol) Plaato (nitinol covered with PTFE)
Fig. 48 - Devices for percutaneous closure of left atrial appendage

5) Percutaneous interventions in valvular heart diseases
Percutaneous intervention in mitral stenosis
Percutaneous treatment in mitral stenosis is recommended in selected
cases of mitral stenosis, in cases with anatomy suitable for balloon dilatation
(no valve fibrosis, no severe subvalvular stenosis, no sever associated mitral
67
regurgication and no intraatrial thrombus. A transesophageal examin ation
should be performed before the procedure in order to assess all these
characteristic.
The technique for mitral valvuloplasty involves transeptal puncture
and placement of a special ballon (Inoue balloon) accros the mitral valve.
The Inoue balloon composed as nylon and rubber micromesh, is
selfpositioning and pressure expandable and is inflated once it reaches the
desired position (fig. 49). An alternative technique is represented by double
balloon technique, which uses a treoil balloon and a single balloon
positioned across the mitral valve (fig. 50). All the procedure is performed
under careful ECG and hemodynamic monitoring and at the end it may
require placement of an occluder disk at the site of atrial septum puncture.

a b
Fig. 49 - Mitral valvuloplasty - a) Inoue balloon b) double balloon technique
The most frequent complication is acute mitral insufficiency, followed
by embolism and haemopericardium related to transseptal catheterization.

68
Transacatheter Aortic Valve Replacement
Transcatheter aortic valve replacement is gaining an increased role in
interventional cardiology. TAVI is currently indicated for high surgical risk
patients with symptomatic aortic valve stenosis requiring aortic valve
replacement.
The interventional aortic valve replacement is currently performed
using two main approaches:
-the apical antegrade approach, which involves puncture of the left
ventricle, being a hybrid procedure (surgical-percutaneous)
-the femoral approach (retrograde) involving introduction of the valve
system via the femoral puncture (fig. 51).
Regardless of the device used, the procedure requires general
anesthesia, temporary pacemaker implantation and careful monitorization.
Different valves have been tested and are being used for replacement
of aortic native valves: Edwards Sapient, Medtronic CoreValve, Lotus valve,
etc (fig. 52).


69

Fig. 50 - transcatheter aortic valve replacement

Fig. 51 - different types of percutaneous aortic valves
Crossing the native calcified valve could be very challenging and
several special catheters and guidewires have been proposed as solutions,
offering different shapes and curve lengths adapted to the size of the annulus
and aortic root.
A pre-implant aortic balloon valvuloplasty is followed by prosthesis
positioning and development, using techniques that may vary according to
prosthesis type.
The procedure-related complications are: paravalvlar leak (fig. 52)
which can be recorded in as many as 70% of patients, depending largely on
the amount of valve calcification and the size of the aortic annulus,
conduction disturbances, cardiac arrhythmia, perforations and coronary
occlusions.
70

Fig. 52 - Paravalvular leak
Interventional treatment for mitral regurgitation
Percutaneous treatment in mitral regurgitation consists mainly in two
techniques:
a) Mitral annulus reshape (indiect anuloplasty), technique which takes
advantage on the proximity of the mitral annulus to the coronary sinus. A
catheter is advanced into the coronary sinus and anchors in the distal and
proximal part, pushing the mitral annulus and reducing the size of the mitral
regurgitation (fig. 53a).
b) Mitral leaflet repair (mitral clips) uses a transseptal approach, after which
a guide catheter is positioned in relation to mitral regurgitation orifice and a
mitral clip is deployed (fig. 53b)

Fig. 53 - a) Mitral annulus reshape, b) mitral clip
71
6). Percutaneous Left Ventricular reconstruction
Percutaneous left ventricular reconstruction is indicated in cases of
large ventricular aneurysms, usually following anterior myocardial
infarctions, and realizes exclusion of the aneurismal part of the left ventricle,
leading to a superior contractility and better outcome (fig. 54)

Fig. 54 - implantation of left ventricular parachute valve
7. Interventional treatement in Hypertrophic cardiomyopathy
Percutaneous treatment in hypertrophic cardiomyopathy is
recommended in cases of severe septal hypertrophy which realizes a
significant gradient in the left ventricular outflow tract (>30 mm Hg at rest
or >60 mm Hg after Valsalva maneuver, physiologic strass or post
extrasystole).
The technique, known as septl ablation, consists in injection of
alcohol into a septal artery (usually the first septal artery) and has been
proved to significantly reduce the hypertrophy and the gradient in the
outflow tract (fig. 55)

72
The morphologic indications for septal ablation consist in:
-subaortic, SAM (systolic anterior movement) associated gradient
-mid-cavitary gradient
-exclusion of intrinsic mitral valve apparatus disease
-suitable septal branch at coronarography.


Fig. 55 - Alcohol septal ablation in hypertrophic cardiomyopathy.







73
9. Interventional treatment in peripheral arterial
diseases

The prevalence of Peripheral Arterial Disease increases with age,
reaching 3% at 40-59 years, 8% at 60-69 years and 9% over 70 years of
age.
The main techniques used in interventional treatment of peripheral
arterial diseases are:
-Balloon angioplasty
-Subintimal angioplasty
-Stenting (direct or provisional)
-Laser angioplasty
-Cutting balloon
-Atherectomy
-Crioaterectomy

1. Balloon angioplasty (Percutaneous Transluminal Angioplasty - PTA) is a
technique similar to the one described in coronary interventions, involving
passage of a balloon catheter across the lesion and inflation of the balloon
(fig. 56), thus realizing a complete compression of atheromatous plaque
against the vessel wall.
74

Fig. 56 - Percutaneous Transluminal Angioplasty

The term subintimal angioplasty refers to passage of a wire within
the intima and inflation of the balloon in the space between the intima and
the rest of the vessel wall, creating a new healthy lumen (fig. 57)

Fig. 57 - subintimal angioplasty
Stenting in peripheral arteries is called direct stenting, when stentin g
is performed as first choice option, or provisional stenting, whent it is
performed only in case of suboptimal result on angioplasty (fig.58).
Conventional
angioplasty
Subintimal
angioplasty
75

Fig. 58 - iliac stenting.
Opposite to coronary interventions, where almost in all the cases the
stents used are ballon-expandable stents, autoexpandable stents are much
more frequent used in peripheral interventions.
Results of the clinical trials proved that peripheral stenting is safe,
efficient and durable and has superior long-term results, compared with PTA,
being the elected treatment in majority of aortoiliac occlusive disease
Stent-grafts are a special type of peripheral stents used in case of
perforations of vessel wall during angioplasty. They consist in a classic stent
covered with PTFE membrane (fig. 59), and are placed using endovascular
route at the site of the rupture to prevent bleeding. It has been proved that
neointimal formation is more reduced in case of stent-grafts than with
classical stenting.
Fig. 59 - Peripheral stent grafts
76
The concept of laser angioplasty has been introduced in the 80`s,
based on the concept of plaque ablation and atherosclerotic material
vaporization. Laser energy realizes a complete absorption of thrombus and
plaque, which is much higher compared with the effect on the arterial wall
and offers the possibility of selective elimination of plaque and thrombus
without injury on the vessel wall (fig. 60a). Using laser angioplasty, a
channel is created within the atherosclerotic material and the catheter is
advanced over the frontrunner guidewire step by step (fig. 60b)

a b
Fig. 60 -a) laser angioplasty b) step-by-step technique
Cutting ballons are conventional balloon catheter with vertical micro
blades, at the balloons surface, realizing 3-4 endovascular incisions during
dilatation (fig. 61).

Fig. 61 - Cutting balloon
77
There are two types of atherectomy devices used in peripheral
interventions:
1. Extirpative atherectomy, or directional atherectomy, which
provides removal plaque and delivering it outside, using the Simpson
device/SilverHawk device (fig. 62).
2. Ablative, or Rotational Atherectomy, which fragments the plaque
into small particles that enter the reticuloendothelial system, using a
rotablator device.

Fig. 62 - excisional atherectomy
Crioballoons (PolarCath) are catheters with 2 balloons which use the
Nitrous oxide injection -10 Celsius degrees, leding to minimal neointimal
proliferation and cellular apoptosis induction.
Fig. 63 - Criocatheter
78
Access route in peripheral interventions
The main access routes in peripheral interventions are (fig. 64):
1. Ipsilateral acces in majority of not technically-challenging cases
2. Cross-over, used mainly for:
-External Iliac Artery
-Distal Common Iliac Artery oclusions
Used in the majority of CTOs
3. Bilateral access, used mainly for:
-Proximal oclusion of Common Iliac Artery
-Contralateral access, antegrade passage, retrograde recanalization
4. Axillar acces, recommended mainly in case for bilateral occlusion of
Common Iliac Artery or External Iliac Artery

a b c
Fig. 64: a - controlateral acces; b - bilateral access c) axillar acces

79
In order to provide a clear stratification of lesion severity, TASC
classification has been introduced, classifying lesions into TASC A, B, C
and D class, D being the most severe class. Usually, interventional treatment
is recommended in TASC A and B cases, while surgery is an option for
difficult TASC C and D cases, however the recent developments in
interventional technology opened new frontiers for extending interventional
indications to more severe cases belonging to TASC C and D class.
Different TASC classifications have been proposed for different
locations of lesions (iliac, femoral or infrapopliteal), and they are
represented below (fig. 65-68):

Fig. 65 - TASC A and B iliac lesions

80
Fig. 66 - TASC C and D iliac lesions


Fig. 67 - TASC A and B femoro-popliteal lesions


Fig. 68 - TASC C and D femoro-popliteal lesions
81
Several exemplifications of interventional procedures in aortoiliac
arteries are presented below (fig.69-70):

Fig. 69 - Aortic angioplasty - a) placement of the catheter at the site of the
lesion; b) inflation of balloon-expandable stent; c) result after stenting

Fig. 70 - Aortoiliac laser angioplasty - a) before - occlusion of iliac artery at
the origin. b) result after laser angioplasty and stenting.
82
10. Interventional treatment in aortic aneurysms

Aortic anurysms could be located in different sites and endovascular
repair techniques depend largely on their location (fig. 71-72) and consists
mainly in mplantation of special sent-grafts using endovascular routes
during extremely complex and time-consumning procedures.

Fig. 71 - endovascular repair of abdominal aortic aneurysm

Fig. 72 - endovascular repair of thoracic aortic aneurysm.
83
Established Indications for Endovascular repair of aortic aneurysms
include:
1. AAA >5.5 cm in diameter in patients over 70 years of age
3. Symptomatic aneurysms
4. Saccular aneurysms

Endovascular Repair of Thoracic Aorta Lesions has the following
theoretical advantages against the surgical approach:
-Avoids thoracotomy
-No aortic cross clamping
-One-lung-ventilation unnecessary
-Post operative ventilation not required
-Decreased incidence of paraplegia
-Avoids coagulopathy
-Renal and pulmonary complications
-No ICU, shorter hospitalization
-Decreased cost
-Lower morbidity and mortality
The mortality rate of open repair in population based studies is
reported to be between 5 to 10 %, while mortality and morbidity rates in
patients with severe compromise of the heart, lungs or kidneys are extremely
high.( 22 to 66 %).



84
11. Interventional treatment in carotid artery diseases

Interventional treatment is replacing nowadays the classical
endartherectomy in patients with carotid artery senosis.
However, the following conditions are associated with high risk
during the carotid artery stenting:
-age>80 years
-symptomatic ICA lesions
-severe renal insufficiency
-severely diseased aortic arch
-severely diseased or tortuous CCA
-severely diseased or tortuous distal ICA
-long subtotal ICA occlusion
-major stroke within 4-6 weeks
Endovascular treatment of carotid artery stenosis is contraindicated in
case of intolerance to aspirin and/or clopidogrel, circumferential ICA
calcification, intraluminal thrombus, chronic ICA occlusion, and intracranial
aneurysm.
In order to overcome the risk of plaque dislodgement and
embolisation during the procedure, carotid filters have been developed
which are used in all procedures of carotid interventions (fig. 73-75),
collecting the embolic debris which result from plaque fragmentation.
85

Fig. 73 - carotid stenting and use of embolic protection device
Fig. 74 - MOMa protection device for carotid procedures


Fig. 75 - Carotid stenting procedure

86
12. Interventional treatment in renal artery stenosis

Atherosclerosis is the most frequent aetiology of renal artery stenosis,
having preferential ostial location. While renal stenting is the procedure of
choice in atherosclerotic stenosis of renal arteries, fibromuscular displazia,
the second most frequent cause of renal artery stenosis, is primarily treated
with balloon angioplasty only.
The main indications for renal revascularization are:
-Progressive renal failure of short duration
-Pulmonary oedema and refractory congestive cardiac failure (volume
overload)
-Severe renal failure precipitated by ACE- inhibitors
-Refractory hypertension
-Severe stenosis (>90%)
-Renal length <8cm
A schematic representation of renal artery stenting is provided in fig. 76.

Fig. 76 - Renal angioplasty and stenting
87
13. Renal denervation in hypertension

Renal denervation has been proved to represent an effective treatment
addressed to severe, resistant hypertension, that do not respond to optimum
medical therapy.
The renal denervation procedure involves femoral artery
catheterization, with the tip of the catheter being placed in the distal renal
artery. Radiofrequency (RF) energy is then applied to the endothelial lining,
the catheter is drawn back 12 cm, circumferentially rotated, and a further
RF energy is applied. This procedure is repeated 45 times in the individual
renal artery and then the same RF energy is applied to the contralateral renal
artery.
In a major clinical trial, half of the patients were treated for
hypertension with lifestyle changes and medications, and the other half was
treated with RDN therapy using the Symplicity renal denervation system.
The patient group treated with lifestyle changes and medications saw a 1-
mmHg rise in blood pressure, while the group treated with RDN therapy had
an average systolic blood pressure reduction of 32 mmHg.5 Neither group
experienced serious complications or unusual side effects.
Fig. 77 - Renal denervation
88
14. Interventional electrophysiology

Diagnostic and treatment of cardiac arrhythmia
Interventional diagnostic and treatment of cardiac arrhythmia is based
on interventional electrophysiology procedures, which represent introduction
of several catheters with different configurations in different locations of the
heart chambers (according to the pathology studied) (fig. 78). These
catheters are available in a large variety of shapes, many of them being
steerable in order to achieve an easier positioning of the catheter, and have a
variable number of electric poles which record the electrical activity inside
the heart (fig. 79). Catheters are connected via special cables to a signal
amplifier which processes the information and display the electrical activity
recorded and depolarization waves. Current systems are able to display up to
several hundreds of intracavitary ECG traces simultaneously (fig. 80).


Fig. 78 - EP catheters
89


Fig. 79 - Position of intracardiac catheters during an EP study



Fig. 80 -Simultanous display of intracadiac electrograms

AD superior (HRA)
Sinus coronar (CS)

Fascicol His
Apex VD
(RVA)
90
Of critical importance during a basic Electrophysiology study is the
correct identification of His location, according to the intracardiac specific
waveform. (fig. 81)

Fig. 81 - His electrogram

After identification of the origin and substrate of cardiac arrhythmia,
the therapeutic intervention consists in ablation of the identified circuits
responsible for arrhythmia.
Ablation represents application of a radiofrequency energy at the site
of the electrical circuit, interrupting the aberant circuit and thus treating the
arrhythmia. The ablation procedure is realized using special ablation
catheters, usually steerable and available in different sizes, connected via a
cable to the ablation generator. After the intracardiac ECG tracing indicates
that the tip of the ablation catheter is placed in the desired position,
radiofrequency energy is applied several times and with a pre-specified
energy power.
91
-In case of atrioventricular reentrant nodal tachycardia (AVNRT),
ablation is performed at the site of the slow pathway, in order to interrupt the
reentrant circuit.
-In case of atrial flutter, the ablation should be performed at the site
of the cavo-tricuspid isthmus (fig. 82), the site where the macro-reentrant
circuit is located, and with catheters having a larger (8 mm) tip to assure
delivery of a higher amount of energy, needed in these cases.

Fig. 82 - Location of catheter tip for ablation of atrial flutter

-Modern treatment of atrial fibrillation is addressed to ablation of
pulmonary veins, the site from where the arrhythmia originates. This
requires very complex procedures for pulmonary vein isolation and ablation,
usually performed under CARTO electroanatomical mapping (fig. 83-84),
which are extremely expensive, technically challenging and time consumig.
92

Fig. 83 - Placement of pulmonary vein catheters using transseptal approach


Fig. 84 - Isolation of pulmonary veins using 3D CARTO technology


Diagnostic and treatment of Atrio-Ventricular blocks
Diagnostic of AV blocks is easily performed using surface ECG or EP
studies in more complex cases.
Interventional treatment of AV blocks consists in implantation of
cardiac pacemakers, according to specific indications.
Cardiac stimulators could be unicameral (fig. 85) (one single electrode
positioned in the right ventricle) or bicameral (fig. 86) two electrodes
93
positioned in the right ventricle and right atrium). Bicameral stimulation
assures a more physiologic stimulation, as it provides the possibility to
synchronize atrial and ventricular contraction.




Fig. 85 - Unicameral stimulation



Fig. 86 - Bicameral stimulation

After the implanting procedure, control X-ray should be performed in
order to make sure that the electrodes are in the right position and that no
complications occurred (fig. 86). Possible procedure-related complications
include infections, hematoma, electrode dislodgement, and haemothorax.

94

Fig. 87 - X-ray control after pacemaker implantation

Intracardiac defibrillators
Intracardiac defibrillators have been introduced in 1966 (fig. 88) and
proved to represent an effective therapeutic option in patients with high risk
for malignant cardiac arrhythmia.
Intracardiac defibrillators are special devices implanted under the skin
and connected to an electrode introduced in the apex of the right ventricle
(fig. 89). The battery delivers anti-arrhythmia or schock therapy according to
programmable protocols immediately after a malignant arrhythmia is
detected (fig. 90-91).
The AVID trial, which randomized patients who have survived VF,
experienced VT with syncope or experienced VT with EF<40%, randomized
to antiarrhythmic therapy or ICD implantation, showed that the ICD group
experienced a 39% reduction in mortality in the first year, with a 27% and
31% reduction in years 2 and 3.
95

Fig. 88 - History of ICD





Fig. 89 - ICD implantation


a b
Fig. 90 - ICD - Electrical therapy in malign arrhythmia a) burst in VT b)
electrical schock in VF
96
15. Interventional therapy in heart failure
In approximately 30% of patients with heart failure, an abnormality in
the heart's electrical conducting system, called an "intraventricular
conduction delay" or bundle branch block causes the two ventricles to beat
in an asynchronous fashion. This asynchrony greatly reduces the efficiency
of the ventricles in patients with heart failure.
Cardiac Resynchronization Therapy re-coordinates the beating of the
two ventricles by pacing both ventricles simultaneously. This differs from
typical pacemakers, which pace only the right ventricle. When the work of
the two ventricles is coordinated, the heart's efficiency increases, and the
amount of work it takes for the heart to pump blood is reduced.
Studies with CRT have demonstrated its ability to improve the
symptoms, the exercise capacity, and the feeling of well-being of many
patients with moderate to severe heart failure. Studies have also shown that
CRT can improve both the anatomy and function of the heart - tending to
reduce the size of the dilated left ventricle, and therefore improving the left
ventricular ejection fraction. Most importantly, CRT has been demonstrated
to improve the survival of patients with heart failure (fig. 92).
There are two types of implantable heart failure heart devices: a CRT
pacemaker and a combination CRT pacemaker with defibrillation therapy.
Both of these devices help to coordinate the heart's pumping action and
improve blood flow.

97

Fig. 91 - Electrode placement in cardiac resynchronization therapy


Fig. 92 - Improved survival after CRT - results of the Miracle trial





98
Further reading

1. Eeckhout E., Serruys P., Wijns W., Vahanian A., van Sambeek M, de Palma R -
Percutaneous Interventional Cardiovascular Medicine - the PCR-EAPCI textbook.
2. Camm J., Luscher T., Serruys P. - The ESC Textbook of Cardiovascular Medicine. Ed.
Oxford University Press, New York, 2009.
3. Benedek Teodora, Gyngysi Mariann, Benedek Imre. Multislice computed
tomographic coronary angiography for quantitative assessment of culprit lesions in acute
coronary syndromes. Canadian Journal of Cardiology. 2013 Mar;29(3):364-71.
4. 1. Benedek Theodora, Jako Beata, Benedek Imre. Plaque Quantification by Coronary
CT and Intravascular Ultrasound Identifies a Low CT Density Core as a Marker of
Plaque Instability in Acute Coronary Syndromes. International Heart Journal
5. Baim D (ed). Grossmans Cardiac Catheterization, Angiography and Intervention, 7
th

edn, 2006. Philadelphia, PA: Lippincott William & Wilkins.
6. Di Mario C, Gorge G, Peters R, et al. Clinical application and image interpretation in
intracoronary ultrasound. Study Group on Intracoronary Imaging of the Working Group
of Coronary Circulation and of the Subgroup on Intravascular Ultrasound of the Working
Group of Echocardiography of the European Society of Cardiology. Eur Heart J 1998;
19: 20729.
7. Di Mario C, Barlis P, Dangas G (eds.). Textbook of Interventional Cardiology, in press.
Wiley.
8. Mintz GS, Nissen SE, Anderson WD, et al. American College of Cardiology Clinical
Expert Consensus Document on Standards for Acquisition, Measurement and Reporting
of Intravascular Ultrasound Studies (IVUS). A report of the American College of
Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol
2001; 37: 147892.
9. Pijls NHJ, Bruyne B, Peels K, et al. Measurement of fractional flow reserve to assess
the functional severity of coronary artery stenoses. N Engl J Med 1996; 334: 17038.

10. Prati F, Regar E, Mintz G, et al. Expert review. Methodology, terminology and
clinical application of OCT. Physical principles, methodology of image acquisition and
clinical application for assessment of coronary arteries and atherosclerosis. Eur Heart J
2009;

99
11. Silber SP, Albertsson P, Fernandez-Avils F, et al. Guidelines for percutaneous
coronary interventions. Eur Heart J 2005; 26: 80447.
12. Vahanian A, Baumgartner H, Bax J, et al. Management of valvular heart disease. Eur
Heart J 2007; 28: 23068.
13. Seldinger SI. Catheter placement of the needle in percutaneous arteriography, a new
technique. Acta Radiol 1953; 39: 36880.
14. Kim D, Orron DE, Skillman JJ. Role of superficial femoral artery puncture in the
development of pseudoaneurysm and arteriovenous fistula complicating percutaneous
transfemoral cardiac catheterization. Cathet Cardiovasc Diagn 1992; 25: 91100.
15. Fick A. Ueber die Messung des Blutquantums in den Herzventrikeln. Sitz der
Physikalisch-Medzinischen Gesellschaft Wuertzburg 1870; pp.1620.
16. Kendrick AH, West J, Papouchado M, et al. Direct Fick cardiac output: are assumed
values of oxygen consumption acceptable? Eur Heart J 1988; 9: 33745.
17.Antman EM, Marsh JD, Green LH, et al. Blood oxygen measurements in the
assessment of intracardiac left to right shunts: a critical appraisal of methodology. Am J
Cardiol 1980; 46: 26572.
18. Baan J, Van Der Velde ET, De Bruin H, et al. Continuous measurements of left
ventricular volume in animals and humans by conductance catheter. Circulation 1984;
70: 81223.
19. Gorlin R, Gorlin G. Hydraulic formula for calculation of area of stenotic mitral valve,
other cardiac valves and central circulatory shunts. Am Heart J 1951; 41: 195160.
20. Bashore TM, Bates ER, Berger PB, et al. American College of Cardiology/Society
for Cardiac Angiography and Interventions Clinical Expert Consensus Document on
cardiac catheterization laboratory standards. A report of the American College of
Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol
2001; 37: 2170214.
21. Ryan TJ, Faxon DP, Gunnar RP, et al. ACC/AHA Task Force Guidelines for
percutaneous transluminal coronary angioplasty. J Am Coll Cardiol 1988; 12: 52945.
22. Hausmann D, Erbel R, Alibelli-Chemarin MJ, et al. The safety of intracoronary
ultrasound. A multicenter survey of 2207 examinations. Circulation 1995; 91: 62330.

23. Son R, Tobis JM, Yeatman LA, et al. Does use of intravascular ultrasound accelerate
arteriopathy in heart transplant recipients? Am Heart J 1999; 138: 35863.
100
24. Di Mario C, Gorge G, Peters R, et al. Clinical application and image interpretation in
25. Hong MK, Mintz GS, Lee CW, et al. Comparison of coronary plaque rupture
between stable angina and acute myocardial infarction: a three-vessel intravascular
ultrasound study in 235 patients. Circulation 2004; 110: 92833.
26. Erbel R, Ge J, Bockisch A, et al. Value of intracoronary ultrasound and Doppler in
the differentiation of angiographically normal coronary arteries: a prospective study in
patients with angina pectoris. Eur Heart J 1996; 17: 8809.
27. Prati F, Arbustini E, Labellarte A, et al. Correlation between high frequency
intravascular ultrasound and histomorphology in human coronary arteries. Heart 2001;
85: 56770.
28. von Biergelen C, Klinkhart W, Mintz GS, et al. Mechanical and structural
characteristics of vulnerable plaques: analysis by coronary angioscopy and intravascular
ultrasound. J Am Coll Cardiol 2001; 38: 93440.
29. Rodriguez-Granillo GA, Garca HM, Valgimigli M. Global characterization of
coronary plaque rupture phenotype using three-vessel intravascular ultrasound
radiofrequency data analysis. Eur Heart J 2006; 27: 192127.
30. Van Mieghem CAG, Mc Fadden EP, De Feyter PJ, et al. Non invasive detection of
sub-clinical coronary atherosclerosis coupled with assessment of changes in plaque
characteristics using novel invasive imaging modalities. the integrated biomarker and
imaging study (IBIS). J Am Coll Cardiol 2006; 47: 113442.
31. Abizaid, AS, Mintz, GS, Mehran, R et al. Long-term follow-up after percutaneous
transluminal coronary angioplasty was not performed based on intravascular ultrasound
findings: importance of lumen dimensions. Circulation 1999; 100: 25661.
32. Jasti, V, Ivan, E, Yalamanchili, V, et al. Correlations between fractional flow reserve
and intravascular ultrasound in patients with an ambiguous left main coronary artery
stenosis. Circulation 2004; 110: 28316.
33. Peters, RJ, Kok, WE, Mario, C et al. Prediction of restenosis after coronary balloon
angioplasty. Results of PICTURE (Post-IntraCoronary Treatment Ultrasound Result
Evaluation), a prospective multicenter intracoronary ultrasound imaging study.
Circulation 1997; 95: 225461.
34. Stone, GW, Hodgson, JM, St Goar, FG et al. Improved procedural results of coronary
angioplasty with intravascular ultrasound-guided balloon sizing: the CLOUT Pilot Trial.
Circulation 1997; 95: 204452.
101
35. Colombo, A, Hall, P, Nakamura, S et al. Intracoronary stenting without
anticoagulation accomplished with intravascular ultrasound guidance. Circulation 1995;
91: 167688.
36. Mudra, H, Mario, C, Jaegere, P et al. Randomized comparison of coronary stent
implantation under ultrasound or angiographic guidance to reduce stent restenosis
(OPTICUS Study). Circulation 2001; 104: 13439.
37. Mintz GS, Weissman NJ. Intravascular ultrasound in the drug-eluting stent era. J Am
Coll Cardiol 2006; 48: 4219.
38. Serruys, PW, Degertekin, M, Tanabe, K et al. Intravascular ultrasound findings in the
multicenter, randomized, double-blind RAVEL (RAndomized study with the sirolimus-
eluting VElocity balloon-expandable stent in the treatment of patients with de novo
native coronary artery Lesions) trial. Circulation 2002; 106: 798803.
39. Colombo, A, Orlic, D, Stankovic, G et al. Preliminary observations regarding
angiographic pattern of restenosis after rapamycin-eluting stent implantation. Circulation
2003; 107: 217880.
30. Takebayashi H, Kobayashi Y, Mintz GS, et al. Intravascular ultrasound assessment of
lesions with target vessel failure after sirolimus eluting stent implantation. Am J Cardiol
2005; 95: 498 502.
41. Kim S-W, Mintz GS, Escolar E, et al. An intravascular ultrasound analysis of the
mechanisms of restenosis comparing drug-eluting stents with brachytherapy. Am J
Cardiol 2006; 97: 12928.
42. Hong MK, Mintz GS, Lee CW, et al. Intravascular ultrasound predictors of
angiographic restenosis after sirolimus-eluting stent implantation. Eur Heart J 2006; 27:
130510.
43. Hong MK, Mintz GS, Lee CW et al. Impact of late drug-eluting stent malapposition
on 3-year clinical events. J Am Coll Cardiol 2007; 50: 151516.
44. Siqueira DA, Abizaid, AA, de Ribamar J et al. Late incomplete apposition after drug-
eluting stent implantation: incidence and potential for adverse clinical outcomes. Eur
Heart J 2008; 28: 13049.
45. Fujii, K, Carlier, SG, Mintz GS, et al. Stent underexpansion and residual reference
segment stenosis are related to stent thrombosis after sirolimus-eluting stent implantation:
an intravascular ultrasound study. J Am Coll Cardiol 2005; 45: 9958.
46. Okabe T, MD, Mintz GS, Buch AN, et al. Intravascular ultrasound parameters
associated with stent thrombosis after drug-eluting stent deployment. Am J Cardiol 2007;
100: 61520.
102

47. Takebayashi, H, Mintz, GS, Carlier, SG, et al. Nonuniform strut distribution
correlates with more neointimal hyperplasia after sirolimus-eluting stent implantation.
Circulation 2004; 110: 34304.
48. Yabushita H, Bouma BE, Houser SL, et al. Characterization of human atherosclerosis
by optical coherence tomography. Circulation 2002; 106: 16405.
49. Jang I, Bouma B, Kang D, et al. Visualization of coronary atherosclerotic plaques in
patients using optical coherence tomography: comparison with intravascular ultrasound. J
Am Coll Cardiol 2002; 39: 60449.
50. Regar E, Prati F, Serruys PW. Intracoronary OCT application: methodological
considerations. In van Leeuwen TG, Serruys P (eds.) Handbook of Optical Coherence
Tomography, 2006. London: Taylor Francis, pp. 5364.
51. Prati F, Cera M, Ramazzotti V, et al. From bench to bed side: A novel technique to
acquire OCT images. Circ J 2008; 72: 83943.
52. Prati F, Cera M, Ramazzotti V, et al. Safety and feasibility of a new non-occlusive
technique for facilitated intracoronary optical coherence tomography (OCT) acquisition
in various clinical and anatomical scenarios. EuroInterv 2007; 3: 36570.
53. Kume T, Akasaka T, Kawamoto T, et al. Measurements of the thickness of the
fibrous cap by optical coherence tomography. Am Heart J 2006; 152: 755.e1755.e4.
54. Kume T, Akasaka T, Kawamoto T, et al. Assessment of coronary arterial plaque by
optical coherence tomography. Am J Cardiol 2006; 97: 11725.
55. Boden WE, ORourke RA, Teo KK, et al. Optimal medical therapy with or without
PCI for stable coronary disease. N Engl J Med 2007; 49: 210511.