Interventional cardiology

Percutaneous transluminal coronary angioplasty remains the standard interventional catheterization approach for the treatment of coronary artery disease. Three broad groups of new therapeutic devices, including atherectomy or devices for mechanical debridement, lasers, and endoprostheses, and diagnostic devices such as ultrasonography and angioscopy are discussed in this article.     

Interventional cardiology

This listing acknowledges with appreciation the receipt of books sent to Clinical Cardiology. Boots will be listed upon receipt in order to provide timely publishing information. Books of particular interest will be reviewed in Clinical Cardiology as space permits.     

Interventional cardiology

Percutaneous intervention, both coronary and noncoronary, is one area of medicine that has experienced significant progress in recent years. This article does not attempt to present an exhaustive review of all the publications that have appeared in the field in the last year, but is rather intended to summarize those which have had the greatest impact on daily practice. The controversy about drug-eluting stents (DESs) revived in the last year with the emergence of copious data that has, finally, demonstrated that DESs can reduce the need for revascularization at the expense of a slight increase in the rate of late stent thrombosis, though without a significant increase in mortality. Nonetheless, the patients who will benefit most must be carefully selected and double antiplatelet therapy must be continued for at least a year. The debate about the use of percutaneous coronary intervention (PCI) for unprotected left main coronary artery stenosis remains open while the results of randomized clinical trials comparing it with surgery are awaited. For the treatment of bifurcation lesions, it appears that implantation of a single stent, when possible, provides the optimum approach. The treatment of chronic total occlusions continues to provide a real challenge for PCI, though both the number treated and the success rate are increasing. The use of DESs and new antiplatelet drugs, which are safer but no less effective, is revolutionizing the treatment of non-ST-elevation acute coronary syndrome. Moreover, the role of primary PCI is increasingly being recognized in the treatment of acute myocardial infarction, as is the importance of reducing the door-to-balloon-angioplasty time. However, there are well-founded doubts about the safety of DESs in this setting. There has been a significant increase in the use of closure devices for closing patent foramen ovale in the past year, and there have been reports of possible benefits in patients with migraine.     

Interventional cardiology in Chile

In Chile the first experiences with cardiac catheterization began very shortly after Forssmann's first studies. Percutaneous coronary balloon angioplasty (PTCA) was first performed in 1982. Despite a progressively great interest and training of physicians in invasive cardiology there are still restrictions in its development. Most private institutions have modern facilities but their caseloads, ever increasing, are still limited because they take care of only 35% of the population. Public institutions are limited because of funding, and some are just developing PTCA. The situation has improved recently because of deals between the private and public systems. Experience with newer devices is even more limited.     

The clinical academic pathway in New Zealand cardiology

Cardiologists Martin Stiles and Nigel Lever speak of the challenges facing clinicians in academia to Iona MacDonald.     

Interventional cardiology in 2005

Drug-eluting stents have been shown to reduce the rate of restenosis significantly in all types of lesion, patient and clinical context without increasing thrombotic complications. Although their high cost limits the extent to which they can replace bare-metal stents, their use will increase inexorably in coming years. In addition to stents containing sirolimus and paclitaxel, which have already been approved, two additional drug-eluting stents have appeared on the market this year: one elutes tacrolimus and the other, ABT578 (a rapamycin analogue). Now that the restenosis rate has been dramatically reduced, the main limitations on percutaneous coronary intervention (PCI) stem from problematic lesions such as those at bifurcations and chronic total occlusions. Although these lesions can be tackled more often and more successfully than in the past, the results obtained are very different from those achieved with other types of lesion. With improvements in safety and long-term efficacy, the number of indications for PCI has expanded to include patients with multivessel disease, left main coronary artery disease, left ventricular dysfunction, and diabetes, conditions in which surgical revascularization was thought necessary only a few years ago. Acute coronary syndromes now make up an increasing proportion of indications for PCI, both in absolute and relative terms. One future challenge is the early identification and treatment of vulnerable plaques before they manifest clinically in the form of irreversible complications such as sudden death or acute myocardial infarction. The use of multislice computed tomography, such as 64-slice detector systems, has considerably increased the sensitivity, specificity, and positive and negative predictive values of diagnosis to around 90%, though diagnostic accuracy may be considerably less in patients with severe coronary calcification, stents, or cardiac arrhythmias. Although the technique is straightforward for patients, the image reconstruction process is time-consuming, few centers currently offer the technique, and radiation exposure is several times that with conventional invasive coronary angiography. It appears that the main application of the technique is in ruling out coronary disease in low-risk patients rather than being part of the diagnostic work-up in those with a high probability of coronary artery disease.     

Interventional cardiology 2006

The range of applications of percutaneous coronary intervention (PCI) continues to expand and a growing number of patients are being treated, including those with extensive cardiovascular disease, more serious comorbid conditions, and more complex lesions. Even so, the success rate is high, serious complications are rare in stable patients, and the restenosis rate has been dramatically reduced by drug-eluting stents. Nevertheless, percutaneous techniques still have major limitations restricting their use in some type of lesions, such as bifurcations and total occlusions, and their role in relation to surgical revascularization has not yet been well defined in the treatment of the left main coronary artery or multivessel disease. The development of novel types of coated stent with better mechanical characteristics and a lower risk of occlusion will further expand the ambit of PCI. The role of PCI in the management of acute coronary syndromes is already well defined, and has increased the preference for an invasive rather than a conservative approach in high-risk patients without ST elevation and the preference for primary angioplasty rather than thrombolysis in those with ST elevation. The development and implementation of integrated coronary syndrome treatment networks will enable human and material resources to be used efficiently, and will guarantee rapid access to high-quality PCI for those who need it. The potential usefulness of combining cellular therapy with interventional procedures in the treatment of acute myocardial infarction has still to be determined. At present, there is extensive research into noncoronary interventions, which, in the not too distant future, could provide percutaneous treatment for the many elderly patients with severe aortic stenosis who are not currently eligible for surgery.     

Interventional cardiology in South Africa

South Africa is a country in political and cultural flux. Because of the iniquitous system of apartheid, inequalities have been perpetuated at all levels including health care. Due to the high prevalence of ischemic heart disease and rheumatic heart disease, coronary angiography, PTCA, intracoronary stenting, and balloon valvuloplasty have become established cardiological procedures in South Africa. However, a new political dispensation promises changes to health care, which will impact on interventional cardiology. With a proposed emphasis on primary health care, resources for tertiary health care will probably be curtailed. Thus consideration will have to be given to reducing expenditure by careful review of indications for expensive interventional procedures and developing new ideas to contain costs. This will be the challenge facing cardiologists in a "New South Africa".     

Interventional cardiology in Europe 1994

The working group Coronary Circulation of the European Societyof Cardiology conducts an annual survey of cardiac interventionsin Europe with the support of the national societies of cardiology.A detailed questionnaire about cardiac interventions performedduring 1994 was mailed to all members of the European Societyof Cardiology. Incomplete or absent data from eight nationalmembers precluded their inclusion in the final analysis. Thus,this report summarizes the cardiac interventions performed during1994 in 29 of 37 members of the European Society of Cardiology,representing a total population of approximately 490 millioninhabitants. Coronary angiography A total of 922687 coronary angiograms werereported during 1994, representing an increase of 22% comparedwith 1993 and of 35% compared with 1992. The mean incidenceof coronary angiograms was 1881/10⁶inhabitants, ranging from4417/10⁶inhabitants in Germany to 35/10⁶inhabitants in Romania.Germany, France, Great Britain, and Italy with 50% of the Europeanpopulation performed 73% of all cardiac interventions. Coronary angioplasty During 1994, a total of 224722 coronaryangioplasty (PTCA) procedures were reported in Europe, an increaseof 22% compared with 1993 and of 52% compared with 1992. Adjustedper capita, the mean incidence of coronary angioplasty was 458/10⁶inhabitants,ranging from 1091/10⁶inhabitants in Germany to 6/10⁶inhabitantsin Romania. On average, the ratio PTCA per coronary angiogramwas 0·24, ranging from 0·37 in the Netherlandsto 0·06 in Cyprus. Ad hoc PTCA accounted for 22% of allPTCA cases. The majority (81%) of PTCAs were restricted to asingle vessel. Major com-plications were reported in 2% of patientsundergoing PTCA, including death (0·3%), myocardial infarction(1·0%) and need for emergency coronary artery bypassgrafting (0·7%). Coronary stenting Coronary stents were utilized in 21599 coronaryinterventions during 1994, an increase of 235% compared with1993 and thus representing the fastest growth in interventionalcardiology. The number of European countries employing stentsduring coronary angioplasty grew from 14 during 1993 to 24 during1994. Elective use (38%) became the most frequent indicationfor coronary stenting during 1994, replacing bail-out stentingas the primary indication during 1993. Other new devices Other new interventional therapeutic deviceswere employed in 8827 cases. Only the Rotablator was used morefrequently during 1994 as compared with 1993. All other newtherapeutic devices showed a decline. Coronary ultrasound wasutilized in 3032 interventions and coronary angioscopy in 304cases during 1994. Non-coronary interventions Valvuloplasty remained the most frequentnon-coronary intervention in Europe during 1994 with a totalof 2622 mitral, 609 pulmonary and 506 aortic valvuloplasties. Catheterization facilities The number of facilities per 10⁶inhabitantsperforming invasive cardiac procedures in Europe during 1994ranged from 7·7 in Iceland to 0·2 in Romania (Europeanmean 2·9). The number of trained operators per 10⁶inhabitantsranged from 24 in Germany to 0·4 in Romania (Europeanmean 10). During 1994, a mean of 701 coronary angiograms and170PTCAs were performed per catheterization facility in Europe(range: 1052 coronary angiograms and 293PTCAs per facility inNorway to 218 coronary angiograms and 37PTCAs per facility inRomania). Conclusions The number of both coronary angiograms and coronaryangioplasties continues to grow at an annual rate of approximately20% in Europe. There is a wide range in the amount of revascularizationprocedures performed between western and eastern European countries.However,countries with the lowest numbers of coronary angiogramsandcoronary angioplasties, e.g. Romania, also show the fastestannual growth. About one quarter of all patients undergoingcoronary angiography are subsequently revascularized by coronaryangioplasty. Coronary angioplasty is employed for the treatmentof a single vessel in the majorityof cases. Coronary stentingis the fastest growing procedure in interventional cardiologyand its primary indication has changed from bail-out stentingin previous years to its elective use during 1994.     

Interventional cardiology in Europe 1999.

AIMS: The purpose of this registry is to collect data on trends in interventional cardiology within Europe. Special interest focuses on relative increases and ratios in newer revascularization approaches and its distribution in different regions in Europe. METHODS AND RESULTS: Questionnaires distributed to delegates of the national societies of cardiology represented in the European Society of Cardiology to be completed by local institutions and operators yielded that 1,452,751 angiograms and 452,019 PTCAs were performed in 1999. This is an increase of 28% and 16%, respectively, compared with 1998. Most of these increases are due to high relative increases in eastern European countries. The number of PTCAs per 106 inhabitants rose to 714 in 1999. Coronary stenting increased by 31% to about 313,000 stents implanted in 1999. Complication rates remained stable, the need for emergency coronary artery bypass grafting showing a further slight decrease to currently 0.3%. CONCLUSION: Interventional cardiology in Europe is still growing, mainly due to rapid growth in countries with lower socio-economical levels. In some central European countries a saturation seemed to be reached with only minor increases in procedures performed. Coronary stenting remains the only noteworthy and growing complement or alternative to balloon angioplasty.