Interventional Cardiology and Surgery

Introduction
Interventional cardiology is a branch of cardiology using specialized
catheter -based techniques to analyse and treat coronary artery
disease, vascular disease, Structural Heart disease and congenital
heart defects. Interventional cardiologist use numerous diagnostic
tools and imaging techniques to measure cardiovascular functions
such as blood pressure and blood flow in major arteries throughout
the body and within the different chambers of the heart.
Interventional cardiologists do not perform traditional ‘open’ heart
surgeries. Andreas Gruentzig is considered the father of
interventional cardiology after the development of angioplasty by
interventional radiologist Charles Dotter. The main advantages of
using the interventional cardiology or radiology approach are the
avoidance of the scars and pain, and long post-operative recovery.
Moreover, interventional cardiology procedure of primary
angioplasty is now the gold standard of care for an acute myocardial
infarction.

It is only 26 years since the first Percutaneous Trans-luminal

Coronary Angioplasty (PTCA) was carried out by the pioneering Swiss
radiologist, Andreas Greuntzig, heralding the dawn of interventional
cardiology. In this short time, interventional cardiology has overcome
many limitations and undergone major evolutionary changes.
Worldwide, many thousands of patients now safely undergo
percutaneous coronary intervention every day, and the numbers
continue to grow. In many countries, the numbers are similar to, or
exceed, bypass surgical procedures.
CORONARY ARTERY DISEASE
Coronary artery disease (CAD) represents a global leading
cause of death especially for middle- and high-income
countries. It is also called ischemic disease. Coronary artery
disease is a narrowing or blockage of your coronary arteries
usually caused by the build-up of fatty material called plaque.
Coronary arteries are the blood vessels that supply oxygen-
rich blood to your heart muscle to keep it pumping. The
coronary arteries are directly on top of your heart muscle.
You have four main coronary arteries: The right coronary
artery, the left coronary artery, the left anterior descending
artery, the left circumflex artery.

Coronary artery disease is caused by atherosclerosis.

Atherosclerosis is the build-up of plaque inside your arteries.
Plaque consists of cholesterol, fatty substances, waste
products, calcium and the clot-making substance fibrin. As
plaque continues to collect on your artery walls, your arteries
narrow and stiffen. Plaque can clog or damage your arteries,
which limits or stops blood flow to your heart muscle. If your
heart does not get enough blood, it can't get the oxygen and
nutrients it needs to work properly. This condition is called
ischemia. Not getting enough blood supply to your heart
muscle can lead to chest discomfort or chest pain
(called angina). It also puts you at risk for a heart attack.
Coronary artery disease happens in everyone. The speed at
which it develops differs from person to person. The process
usually starts when you are very young. Before your teen
years, the blood vessel walls start to show streaks of fat. As
plaque deposits in your artery’s inner walls, your body fights
back against this on-going process by sending white blood
cells to attack the cholesterol, but the attack causes more
inflammation. This triggers yet other cells in the artery wall to
form a soft cap over the plaque.
This thin cap over the plaque can break open (due to blood
pressure or other causes). Blood cell fragments called
platelets stick to the site of “the injury,” causing a clot to
form. The clot further narrows arteries. Sometimes a blood
clot breaks apart on its own. During Other times the clot
blocks blood flow through the artery, depriving the heart of
oxygen and causing a heart attack.
What are the symptoms of coronary artery disease?
You may not know you have coronary artery disease since
you may not have symptoms at first. The build-up of plaque
in your arteries takes years to decades. But as your arteries
narrow, you may notice mild symptoms that indicate your
heart is pumping harder to deliver oxygen-rich blood to your
body. The most common symptoms are chest pain or
shortness of breath, especially after light physical activity like
walking up stairs, but even at rest.
Sometimes you won’t know you have coronary artery disease
until you have a heart attack.
Can coronary artery disease be prevented?
You can certainly make changes that will lower your chance
of developing coronary artery disease, but this condition is
not 100% preventable. This is because there are two kinds of
risk factors: Those that can’t be changed (non- modifiable)
and those that can be (modifiable).
Non modifiable risk factors include older age, male gender, a
family history of heart disease and genetic factors. However,
there are many risk factors that you can modify. These are
mostly lifestyle changes like losing weight if you’re
overweight, stopping smoking if you smoke, keeping your
blood pressure and cholesterol level at their goal numbers
and managing diabetes.
Non-Invasive treatment for Coronary artery disease
Balloon Angioplasty: Balloon angioplasty is done in the
catheterization laboratory (“cath lab”). The doctor injects a
special dye through a small, thin tube called a catheter into
your bloodstream. The dye allows the doctor to view your
arteries on an X-ray monitor. A device with a small balloon on
its tip is then inserted through an artery in your leg or arm
and threaded through the arteries until it reaches the
narrowed area. The balloon is inflated to flatten the plaque
against the wall of the artery, opening the artery and
restoring blood flow. Then the balloon is deflated and
removed from your body.

Cardiac catheterization: Cardiac catheterization (also called

cardiac cath or coronary angiogram) is an invasive imaging
procedure that allows your doctor to evaluate your heart
function. During a cardiac catheterization, a long, narrow tube
called a catheter is inserted through a plastic introducer
sheath The catheter is guided through the blood vessel to the
coronary arteries with the aid of a special x-ray machine.
Contrast material is injected through the catheter and x-ray
movies are created as the contrast material moves through
the heart’s chambers, valves and major vessels. This part of
the procedure is called a coronary angiogram (or coronary
angiography). The digital photographs of the contrast
material are used to identify the site of the narrowing or
blockage in the coronary artery. Additional imaging
procedures, called intra-vascular ultrasound (IVUS) and
fractional flow reserve (FFR) may be performed along with
cardiac catheterization in some cases to obtain detailed
images of the walls of the blood vessels. Both of these
imaging procedures are currently only available in specialized
hospitals and research centres.
With IVUS, a miniature sound-probe (transducer) is
positioned on the tip of a coronary catheter. The catheter is
threaded through the coronary arteries and, using high-
frequency sound waves, produces detailed images of the
inside walls of the arteries. IVUS produces an accurate
picture of the location and extent of plaque.
With FFR, a special wire is threaded through the artery and a
vasodilator medication is given. This test is functionally
performing a very high quality stress test for a short segment
of the artery.

Balloon angioplasty with stenting: In most cases, balloon angioplasty

is performed in combination with the stenting procedure. A
stent is a small, metal mesh tube that acts as a scaffold to
provide support inside the coronary artery. A balloon
catheter, placed over a guide wire, is used to insert the stent
into the narrowed artery. Once in place, the balloon is
inflated and the stent expands to the size of the artery and
holds it open. The balloon is deflated and removed, and the
stent stays in place permanently. During a period of several
weeks, the artery heals around the stent. In this way,
restenosis is somewhat diminished. Angioplasty with stenting
is most commonly recommended for patients who have a
blockage in one or two coronary arteries. If there are
blockages in more than two coronary arteries, coronary
artery bypass graft surgery may be recommended.

Cutting balloon: The cutting balloon catheter has a balloon tip

with small blades. When the balloon is inflated, the blades
are activated. The small blades score the plaque, then, the
balloon compresses the fatty matter into the arterial wall.
This type of balloon may be used to treat the build-up of
plaque within a previously placed stent (restenosis) or other
types of blockages.
VALVULAR HEART DISEASE
Valvular heart disease is when any valve in the heart has
damage or is diseased. There are several causes of valve
disease.
The normal heart has four chambers (right and left atria, and
right and left ventricles) and four valves (Figure 1).
The mitral valve, also called the bicuspid valve, allows blood
to flow from the left atrium to the left ventricle.
The tricuspid valve allows blood to flow from the right atrium
to the right ventricle.
The aortic valve allows blood to flow from the left ventricle to
the aorta.
The pulmonary valve allows blood to flow from the right
ventricle to the pulmonary artery.
The valves open and close to control or regulate the blood
flowing into the heart and then away from the heart. Three
of the heart valves are composed of three leaflets or flaps
that work together to open and close to allow blood to flow
across the opening. The mitral valve only has two leaflets.
Healthy heart valve leaflets are able to fully open and close
the valve during the heartbeat, but diseased valves might not
fully open and close. Any valve in the heart can become
diseased, but the aortic valve is most commonly affected.
Diseased valves can become “leaky” where they don’t
completely close; this is called regurgitation. If this happens,
blood leaks back into the chamber that it came from and not
enough blood can be pushed forward through the heart.
The other common type of heart valve condition happens
when the opening of the valve is narrowed and stiff and the
valve is not able to open fully when blood is trying to pass
through; this is called stenosis. Sometimes the valve may be
missing a leaflet—this more commonly involves the aortic
valve. If the heart valves are diseased, the heart can’t
effectively pump blood throughout the body and has to work
harder to pump, either while the blood is leaking back into
the chamber or against a narrowed opening. This can lead to
heart failure, sudden cardiac arrest (when the heart stops
beating), and death.
Heart valve disease Symptoms and causes
Bicuspid aortic valve With this birth defect, the aortic
valve has only 2 leaflets instead of
3. If the valve becomes narrowed, it
is harder for the blood to flow
through, and often the blood leaks
backward. Symptoms usually don't
until the adult years.
Mitral valve prolapse (also With this defect, the mitral valve
known as click-murmur leaflets bulge and don't close
syndrome, Barlow's properly during the contraction of
syndrome, balloon mitral the heart. This lets blood to leak
valve, or floppy valve backward. This may result in a
syndrome)
Mitral valve stenosis
Aortic valve stenosis
Pulmonary stenosis
mitral regurgitation murmur.
With this valve disease, the mitral
valve opening is narrowed. It is
often caused by a past history of
rheumatic fever. It increases
resistance to blood flow from the
left atrium to the left ventricle.
This valve disease occurs mainly in
the elderly. It causes the aortic
valve opening to narrow. This
increases resistance to blood flow
from the left ventricle to the aorta.
With this valve disease, the
pulmonary valve does not open
sufficiently. This forces the right
ventricle to pump harder and
enlarge. This is usually a congenital
condition.

How is heart valve disease diagnosed?

Your doctor may think you have heart valve disease if your
heart sounds heard through a stethoscope are abnormal.
This is usually the first step in diagnosing a heart valve
disease. A characteristic heart murmur (abnormal sounds in
the heart due to turbulent blood flow across the valve) can
often mean valve regurgitation or stenosis. To further define
the type of valve disease and extent of the valve damage,
doctors may use any of the following tests:
Electrocardiogram (ECG): An electrocardiogram (ECG) is a
simple test that can be used to check your heart's rhythm
and electrical activity. Sensors attached to the skin are used
to detect the electrical signals produced by your heart each
time it beats. These signals are recorded by a machine and
are looked at by a doctor to see if they're unusual. There are
several different ways an ECG can be carried out. Generally,
the test involves attaching a number of small, sticky sensors
called electrodes to your arms, legs and chest. These are
connected by wires to an ECG recording machine. You don't
need to do anything special to prepare for the test. You can
eat and drink as normal beforehand. Before the
electrodes are attached, you'll usually need to remove your
upper clothing, and your chest may need to be shaved or
cleaned. Once the electrodes are in place, you may be
offered a hospital gown to cover yourself. The test itself
usually only lasts a few minutes, and you should be able to go
home soon afterwards or return to the ward if you're already
staying in hospital

Echocardiogram (echo). This non-invasive test uses sound waves to

evaluate the heart's chambers and valves. The echo sound
waves create an image on a monitor as an ultrasound
transducer is passed over the heart. This is the best test to
evaluate heart valve function.

Transesophageal echocardiogram (TEE).This test involves passing a

small ultrasound transducer down into the oesophagus. The
sound waves create an image of the valves and chambers of
the heart on a computer monitor without the ribs or lungs
getting in the way.

Chest X-ray. This test that uses invisible electromagnetic energy

beams to produce images of internal tissues, bones, and
organs onto film. An X-ray can show enlargement in any area
of the heart.

Magnetic resonance imaging (MRI). This test uses a combination of

large magnets, radiofrequencies, and a computer to produce
detailed images of organs and structures within the body.
Atrial Fibrillation
In a patient with a normal heart rhythm (sinus rhythm), an
electrical signal spreads through the top chambers of the
heart (the atria), causing them to squeeze and fill the lower
chambers (the ventricles), which then pump the blood all
over the body. When a patient is diagnosed with atrial
fibrillation (AFib), the electrical signals become disorganized
and the atria no longer contract effectively. Rather, they
quiver at rapid rates, so blood is not pushed to the ventricles
as efficiently. With blood sitting stagnantly in the atrium,
blood clots are more likely to form. These clots can travel
from the heart to the brain, causing a stroke. The most
common spot for clots to form is a small wind-sock shaped
sac off the left atrium, called the left atrial appendage (LAA).
The LAA is thought to be the site of over 90 per cent of blood
clots associated with AFib. Similar to the appendix in the
abdomen, the LAA has no critical function in the heart
Treatment Options for Atrial Fibrillation
Minimally Invasive Procedures
Radiofrequency Ablation
The goal of radiofrequency ablation is to restore normal
heart rhythm, reducing the stroke risk. The ablation is
performed by an electro physiologist, a type of cardiologist
that specializes in abnormal heart rhythms. An ablation
catheter uses high-frequency electrical energy to scar the
specific tissue responsible for the abnormal rhythm. As a
result, the tissue can no longer send the electrical signal
causing the AFib. This procedure is not effective in all cases
and tends to be more successful in younger patients.
Left Atrial Appendage Closure (or Exclusion)
In this procedure, a small plug called a Watchman device is
placed into the LAA to seal it off from the rest of the heart.
This keeps blood clots from forming in the LAA, reducing the
risk of stroke significantly. The procedure is performed with
general anaesthesia and takes about one hour. Patients can
return home the next day and to full activities within 2–3
days. The Watchman procedure is an excellent alternative to
blood thinners in many patients. Medical trials comparing the
Watchman device to on-going blood-thinner therapy have
shown that patients who receive the Watchman have fewer
strokes, fewer bleeding complications, and live longer.
Electrical cardio version: The doctor gives your heart a shock to
regulate your heartbeat. They’ll use paddles or stick patches
called electrodes onto your chest. First, you'll get medicine to
make you fall asleep. Then, your doctor will put the paddles on
your chest, and sometimes your back. These will give you a
mild electrical shock to get your heart's rhythm back to normal.
Most people only need one. Because you’re sedated, you
probably won’t remember being shocked. You can usually go
home the same day. Your skin may be irritated where the
paddles touched it. Your doctor can point you toward a lotion
to ease pain or itching.
Adult Congenital Heart Disease
Congenital is a word meaning a “birth defect”. Babies born
with birth defects of the heart are reaching adulthood in
record numbers. While some patients are first diagnosed
with simple birth defects as adults, many others, with more
complex cardiac abnormalities, have undergone surgical and
catheter-based interventions as children but continue to
require specialized care as adults. Cardiac catheterization is
an important tool not only in the evaluation of these
patients, but it also presents numerous options for
treatment, previously the exclusive domain of the cardiac
surgeons.
The most common types of congenital heart disease
diagnosed for the first time in adults include holes in the
walls separating the right and left sides of the heart, heart
valves which are abnormal and not working properly, and
narrowing of blood vessels which may interfere with the
normal flow of blood. Patients who have undergone previous
surgery will often require revisions of previous repairs,
including repair/replacement of valves, or artificial tubes
placed by the surgeons to bypass congenital obstructions in
the normal pathways exiting the heart.
Symptoms of Adult Congenital Heart Disease
Many patients with simple congenital heart disease will be
completely free of symptoms as children and young adults.
As they age, issues can develop. The signs of congenital heart
disease are varied, but most often involve shortness of
breath during exertion/exercise and heart palpitations or
other rhythm changes. Neurologic symptoms, such as stroke
or migraine headache, can also be related to an undiagnosed
congenital heart defect. Low oxygen levels in the blood, from
abnormal flows through holes in the heart can also be seen.
Selected Treatments for Adult Congenital Heart Disease
Atrial Septal Defect (ASD) / Patent Foramen Ovale (PFO)
Both ASD and PFO are holes in the wall (the septum) which
separates the top two chambers of the heart. Through a tube
introduced in the vein of the leg, a self-expanding patch,
resembling two small umbrellas connected to one another
may be used to close the defect in a 30-minute ambulatory
procedure. This procedure has replaced open heart surgery
for many patients.
Pulmonary Valve Replacement
In many patients with prior surgery, the pulmonary valve
placed at the time of surgery can wear out over time,
becoming either obstructed (not opening well) or insufficient
(leaking). Rather than doing open-heart surgery to replace
the valve again, a new valve can be implanted through a
catheter, with minimal discomfort and a 1 day hospital stay.
Medical device –You might need a pacemaker to keep your
heart beating in a normal rhythm. Or you might need a
device called an "implantable cardioverter defibrillator" to
get your heart back to normal quickly if it beats irregularly.
CONCLUSION
Interventional cardiology explains different diagnostic
procedures and techniques concerning coronary artery
diseases, Valvular diseases, and different structural diseases.
Interventional cardiology has expanded in scope since its inception.
Interventional procedures now account for two-thirds
of catheterisation cases in children and increasingly offer a viable
alternative to surgery. Interventional techniques may be used
to close septal defects and patent arterial ducts, to balloon and
stent stenosed vessels, to implant artificial valves into
conduits or to ablate aberrant conduction
pathways. Interventional cardiology has undergone numerous
changes in recent decades, and advances allowed a
significant reduction in the incidence of unfavourable clinical
outcomes to patients. Interventional cardiologists use
specialized tools such as catheters and advanced imaging
techniques to measure and access cardiovascular functions
and provide treatment that is minimally invasive, requires
less time to perform, does not require general anaesthesia,
and offers a faster recovery time.
This is not “open” heart surgery! On the contrary,
interventional cardiology typically requires only a small
incision or just a needle puncture and does not require large
cuts or an opening of your body. Instead, a catheter – a long,
flexible instrument – is inserted through a patient’s blood
vessels and then navigated to the area of concern. At this
point, a patient’s condition can be then assessed and
repaired.
Interventional cardiologists often use the latest techniques
and cutting-edge technology. Continuing advances in
interventional cardiology provides state-of-the-art diagnostic
and therapeutic care. Among these advancements is the field
of medical imaging. Many of us have heard of CT (computed
tomography) scans, ultrasounds, and certainly MRIs
(magnetic resonance imaging). These are all forms of medical
imaging but are more often used in the assessment of a
patient’s condition before the therapy – before the
treatment.