(BQ) Part 1 book Diagnostic methods in the cardiac catheterization laboratory presents the following contents: Coronary anomalies and fistulae - An overview of important entities, practical uses of online quantitative coronary angiography, preintervention evaluation of chronic total occlusions,...
Diagnostic Methods in the Cardiac Catheterization Laboratory Diagnostic Methods in the Cardiac Catheterization Laboratory Edited by Pedro A Lemos Heart Institute (InCor) University of São Paulo Medical School and Sirio-Libanes Hospital São Paulo, Brazil Paul Schoenhagen Cleveland Clinic Foundation Cleveland, Ohio, USA Alexandra J Lansky Cardiovascular Research Foundation New York, New York, USA Informa Healthcare USA, Inc 52 Vanderbilt Avenue New York, NY 10017 C 2010 by Informa Healthcare USA, Inc Informa Healthcare is an Informa business No claim to original U.S Government works Printed in the United States of America on acid-free paper 10 International Standard Book Number-10: 1-8418-4658-9 (Hardcover) International Standard Book Number-13: 978-0-8418-4658-3 (Hardcover) This book contains information obtained from authentic and highly regarded sources Reprinted material is quoted with permission, and sources are indicated A wide variety of references are listed Reasonable efforts have been made to publish reliable data and information, but the author and the publisher cannot assume responsibility for the validity of all materials or for the consequence of their use No part of this book may be reprinted, reproduced, transmitted, or utilized in any form by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying, microfilming, and recording, or in any information storage or retrieval system, without written permission from the publishers For permission to photocopy or use material electronically from this work, please access www.copyright.com (http://www.copyright.com/) or contact the Copyright Clearance Center, Inc (CCC) 222 Rosewood Drive, Danvers, MA 01923, 978-750-8400 CCC is a not-for-profit organization that provides licenses and registration for a variety of users For organizations that have been granted a photocopy license by the CCC, a separate system of payment has been arranged Trademark Notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe Library of Congress Cataloging-in-Publication Data Diagnostic methods in the cardiac catheterization laboratory / edited by Pedro A Lemos, Paul Schoenhagen, Alexandra J Lansky p ; cm Includes bibliographical references and index ISBN-13: 978-1-84184-658-3 (hardcover : alk paper) ISBN-10: 1-84184-658-9 (hardcover : alk paper) Cardiac catheterization I Lemos, Pedro A II Schoenhagen, Paul III Lansky, Alexandra [DNLM: Coronary Angiography–methods Heart Catheterization–methods Coronary Artery Disease–diagnosis Diagnostic Imaging–methods Radiography, Interventional–methods WG 141.5.C2 D5365 2009] RC683.5.C25D535 2009 616.1 20754–dc22 2009035198 For Corporate Sales and Reprint Permission call 212-520-2700 or write to: Sales Department, 52 Vanderbilt Avenue, 7th floor, New York, NY 10017 Visit the Informa Web site at www.informa.com and the Informa Healthcare Web site at www.informahealthcare.com Foreword It is remarkable that it has now been 80 years since the German surgical resident Werner Forssmann inserted a small catheter into his antecubital vein, walked to the radiology suite, and took an X-ray of the catheter’s position in his right atrium (1) Now a designated landmark in medical history, this revolutionary event demonstrated that the heart could be safely accessed from the forearm, but resulted in the immediate termination of Dr Forssman from his training program Unfortunately for Dr Forssman, who ended his career as a rural practitioner, it was not until 25 years later in 1956 that Forssman’s discovery was appropriately recognized when he shared the Nobel Prize with pioneers Andre Cournand, MD, and Dickinson Richards, MD, for their combined work in developing cardiac catheterization (2,3) Over the next 30 years, the methodology for diagnostic cardiac catheterization advanced markedly, but was primary focused on ventricular hemodynamics, shunts, and cardiac physiology I recently pulled out the dusty hemodynamic textbooks that I used during my Cardiology Fellowship Training program at the University of Texas Southwestern Medical Center in Dallas under the mentorship of Dr L David Hillis (4,5) Paging through them now, these textbooks were quiet dense, even for an energetic cardiology fellow, with plenty of mathematic derivations for cardiac output, intracardiac shunts, and indices of ventricular performance and coronary physiology In the clinical laboratory during my fellowship training, we used oximetry, thermodilution and green dye curves to detect cardiac output and shunts, Douglas bags to determine true oxygen consumption, and Millar catheters and contrast ventriculography to assess left ventricular performance and pressure volume relationships Because these calculations were manually derived, a right and left heart catheterization took several hours and a full morning to complete As fellows, we were masters of ventricular performance and coronary physiology Little did we know that our world as interventionalists had already changed, as a result of the events that occurred in September 1977 by a humble interventionalist in Zurich, Switzerland (6) The use of balloon angioplasty dramatically expanded over the 1980s, even after the tragic death of Andreas Gruentzig in 1985 The focus of the catheterization laboratory then changed substantially – detailed hemodynamic evaluations were replaced by therapeutic interventions coupled with diagnostic imaging As we began to understand the limitations of balloon angioplasty, including abrupt closure and restenosis in the early 1990s, the diagnostic components of the catheterization laboratory evolved to advanced imaging and plaque characterization, most often using intravascular ultrasound(IVUS) We developed a parade of new devices to address the specific morphologic components of the plaque (e.g, rotational atherectomy for calcified lesions; directional coronary atherectomy for bulky lesions, excimer laser ablation for in-stent restenosis) Seminal work using IVUS also identified that restenosis after balloon angioplasty and directional atherectomy was primarily due to arterial remodeling rather than intimal hyperplasia, a transformation finding at that time (7,8) We also learned that atherosclerosis was ubiquitous in the “normal” appearing coronary vessels in patients undergoing coronary intervention (9), and that we needed to treat the patient, and not simply the lesion These findings obtained from diagnostic imaging completely changed our understanding of coronary atherosclerosis and restenosis At the same time, we learned the importance of providing more quantitative methods of coronary stenosis severity, and this expansion to vascular intervention has allowed the extension of these techniques to the peripheral vascular bed Diagnostic Methods in the Cardiac Catheterization Laboratory, edited by Pedro A Lemos, MD, Paul Schoenhagen, MD, and Alexandra J Lansky, MD, is a contemporary textbook that reviews the more timely topics in diagnostic imaging required for the evaluation and treatment vi Foreword of patients with complex coronary artery and myocardial disease Both students of cardiac catheterization and seasoned interventional cardiologists will benefit from a thorough read of this insightful textbook Diagnostic Methods hits the mark on so many different levels I still find occasional coronary anatomy that I have not seen, or if I have, it was so long that my memory is a little fuzzy These rare anatomic conditions are concisely reviewed in Diagnostic Methods in “Coronary Anomalies and Fistulae An Overview of Important Entities” Furthermore, having spent my academic career studying quantitative angiography, I keenly appreciate both the value and the limitations of these methods Diagnostic Methods focuses on a number of outstanding challenges of quantitative angiography, including the “Practical uses of online QCA”, “Pre-intervention evaluation of CTO, “Myocardial perfusion blush evaluation”, “Challenges in the assessment of bifurcation lesions” and “The Vulnerable Plaque and Angiography “ Each of these chapters provide keen insights into the state-of-the-art of quantitative angiography in several practical and clinically relevant sections Diagnostic Methods also provides superb reviews of the expansion of quantitative angiography to the peripheral vasculature These include, “Peripheral Qualitative and quantitative angiography of the great vessels and peripheral vessels”, “Tips and tricks of the angiographic anatomy of the carotid arteries and vertebrobasilar system”, “Invasive Evaluation of Renal Artery Stenosis”, and “Angiographic Assessment of Lower Extremity Arterial Insufficiency” Intravascular ultrasound (IVUS) holds a special place in my heart, having worked side by side with Gary Mintz, MD, at the Washington Hospital Center for years I must admit that after comparative studies in thousands of patients during the 1990s, Gary finally convinced me that IVUS provides much more extensive and accurate diagnostic information than angiographic alone Diagnostic Methods provides a contemporary overview of IVUS in several chapters, including “Merits and limitations of IVUS for the evaluation of the ambiguous lesion”, “An in-depth insight of intravascular ultrasound for coronary stenting”, “Intravascular ultrasound to guide stent deployment,” “A practical approach for IVUS in stent restenosis and thrombosis”, “Pharmacological intervention trials, and “IVUS and IVUS-derived methods for vulnerable plaque assessment” These chapters are essential for the complete understanding of IVUS in contemporary practice A final chapter “Optical coherence tomography” addresses very important clinical role of high-end imaging for assessment of lesion composition and healing response to stenting I remember first hearing Nico Pijls talk about Fractional Flow Reserves while I was an interventional cardiology fellow at the University of Michigan over 15 years ago At that time, we were testing angiographic measures of coronary flow reserve using digital subtraction methods, but the techniques were cumbersome and poorly reproducible Doppler flow catheters were just being developed, but, as I sat in the audience listening to Dr Pijls, I was struck with the simplicity and relevance of measuring fractional flow reserve Although we were primarily focused on intermediate lesions, coupling both FFR and Doppler flow may provide a more complete assessment of coronary flow and microvascular disease The FAME study has substantially altered our approach in patients with multivessel coronary artery disease, and a precise understanding of both fractional flow reserve and intracoronary Doppler measurements is critical (10) Diagnostic Methods includes important updates on the state of the art for physiologic assessment of lesion severity in several chapters, including “Evaluation of acute and chronic microvascular coronary disease”, “Collateral function assessment,” and “Merits and limitations of FFR for the evaluation of ambiguous lesions” I would highly recommend that all interventionalists are fully familiar with the physiologic assessment of coronary lesion severity Our world is changing rapidly, and I am certain that the interventionalist for the next decade will also have a keen understanding of non invasive cardiac imaging This is not only due to the rapid transition toward structural heart disease, for which a multimaging assessment is essential, but also for assessing coronary anatomy using less invasive methods Diagnostic Methods also provides an extensive review of noninvasive imaging, including “Cardiac magnetic resonance imaging: viability assessment and cardiac function”, “Cardiovascular interventional MR Imaging”, “Role of MDCT for the diagnosis of coronary anomalies and fistulae”, “A practical overview of coronary CT angiography”, and “Multidetector computed tomography imaging for myocardial perfusion, viability and cardiac function” This comprehensive overview will Foreword vii provide the interventionalist with an integrated knowledge of noninvasive and invasive images Diagnostic Methods also provides a very focused review of several challenging clinical conditions These include, “Evaluation of LV function in cases of global and segmental disease”, “Obstructive hypertrophic cardiomyopathy”, “The role of the cath lab in patients with advanced heart failure and cardiac transplantation”, and “Evaluation of common congenital heart defects in the adult” Diagnostic Methods is highly recommended for all clinicians who wish to provide “State of the Art” care to their highly complex patients in the catheterization laboratory With our rapidly evolving knowledge base and continued quest for evidence based practices, Diagnostic Methods will be an important addition to the interventionalist’s core library Jeffrey J Popma, MD Director, Innovations in Interventional Cardiology Beth Israel Deaconess Medical Center Associate Professor of Medicine Harvard Medical School Boston, Massachusetts, U.S.A REFERENCES Forssman W Die sondierung des rechten Herzens Klin Wochenschr 1929; 8:2085 Cournand AF and Ranges HS Catheterization of the right auricle in man Proc Soc Exp Biol Med 1941; 46:462 Richards DWJ Cardiac output by catheterization technique, in various clinical conditions Fed Proc 1945; 4:215 Grossman W Cardiac Catheterization and Angiography First ed 1974, Philadelphia: Lippincott Williams and Wilkins Yang S, Bentivoglio L, Maranhao V, et al From Cardiac Catheterization Data to Hemodynamic Parameters Third ed 1988, Philadelphia: Davis, F.A Gruntzig A Transluminal dilation of coronary artery stenosis Lancet 1978; 1:263 Kimura T, Nobuyoshi M Remodelling and restenosis: intravascular ultrasound studies Semin Interv Cardiol 1997; 2(3):159–166 Hoffmann R, Mintz GS, Popma JJ, et al Chronic arterial responses to stent implantation: a serial intravascular ultrasound analysis of Palmaz-Schatz stents in native coronary arteries J Am Coll Cardiol 1996; 28(5):1134–1139 Mintz GS, Painter JA, Pichard AD, et al Atherosclerosis in angiographically “normal" coronary artery reference segments: an intravascular ultrasound study with clinical correlations J Am Coll Cardiol 1995; 25(7):1479–1485 10 Tonino PA, De Bruyne B, Pijls NH, et al Fractional flow reserve versus angiography for guiding percutaneous coronary intervention N Engl J Med 2009; 360(3):213–224 Preface Coronary angiography has revolutionized the diagnostic approach to patients with coronary artery disease and plays a central role in modern, pharmacological, transcatheter, and surgical treatment approaches It has transformed the field of cardiology and defined the subspecialty of interventional cardiology However, despite the increasing understanding of the atherosclerotic disease process and advanced diagnostic and therapeutic options, coronary artery disease remains a major cause of morbidity and mortality worldwide These facts demonstrate the need for additional anatomic and physiologic assessment of coronary disease beyond angiographic luminal stenosis, which has led to the development of several secondary transcatheter diagnostic modalities In modern catheterization laboratories worldwide, diagnostic evaluation of coronary artery disease has evolved far beyond angiography alone, allowing not only anatomic assessment of the artery lumen/stenosis but also of the wall/plaque, and physiologic assessment of hemodynamic lesion significance In addition, more recent developments of noninvasive modalities, and in particular cardiac computed tomography and magnetic resonance imaging, allow complementary assessment with the future prospect of hybrid laboratories Such comprehensive diagnostic evaluation of coronary lesions is the basis for advances in transcatheter interventions This expanding focus of coronary multimodality imaging in modern catheterization laboratories requires knowledge of several diagnostic modalities In this title an international group of authors and editors including cardiologists and radiologists have collected comprehensive state-of-the-art information about the evolving diagnostic approach in the catheterization laboratory The use of qualitative and quantitative angiography of the coronary arteries, great vessels, and peripheral arteries is discussed in the context of routine and challenging clinical scenarios (chronic total occlusion, bifurcation lesions, plaque vulnerability) Additional chapters discuss further catheter-based anatomic evaluation with intravascular ultrasound and optical coherence tomography, and assessment of lesions significance with fractional flow reserve and intracoronary Doppler The emerging role of complementary noninvasive imaging with cardiac computed tomography and magnetic resonance imaging is the topic of dedicated chapters The chapters describe diagnostic assessment and therapeutic consequences This title provides a comprehensive guide to the diagnostic approach in modern catheterization laboratories and its impact on interventional transcatheter treatment strategies Directed toward cardiologists and radiologists performing diagnostic and interventional procedures in the catheterization laboratory, this title gives an up-to-date perspective but also a look into the future Pedro A Lemos Paul Schoenhagen Alexandra J Lansky DIAGNOSTIC METHODS IN THE CATHETERIZATION LABORATORY 122 Table 13.1 Intracoronary Doppler measurements Parameter Average peak velocity (APV)39 – 42 Basal (cm/s) Hyperemic (cm/s) Diastolic/systolic mean velocity ratio (DSVR)39 – 43 Left anterior descending artery Left circumflex artery Proximal right coronary artery (RCA) Distal RCA and posterior descending artery Translesional velocity gradient (or proximal/distal velocity ratio)39 – 45 Distal coronary flow reserve42,45,46 Relative coronary flow reserve42 Normal value ≥20 ≥30 >1.7 >1.5 >1.2 >1.4