SOG | Interventional Cardiology

Interventional Cardiology

Interventional cardiology is a branch of cardiology that deals specifically with various non-surgical procedures for treating cardiovascular disease. Interventional cardiologists use catheters – thin, flexible tubes – to get inside blood vessels for diagnostic tests or to repair damaged vessels or other heart structures, often avoiding the need for surgery.

A large number of procedures can be performed on the heart by catheterization. This most commonly involves the insertion of a sheath into the femoral artery (but, in practice, any large peripheral artery or vein) and cannulating the heart under X-ray visualization (most commonly fluoroscopy). The radial artery may also be used for cannulation; this approach offers several advantages, including the accessibility of the artery in most patients, the easy control of bleeding even in anticoagulated patients, the enhancement of comfort because patients are capable of sitting up and walking immediately following the procedure, and the near absence of clinically significant sequelae in patients with a normal Allen test.

The main advantages of using the interventional cardiology or radiology approach are the avoidance of the scars and pain, and long post-operative recovery. Additionally, interventional cardiology procedure of primary angioplasty is now the gold standard of care for an acute myocardial infarction. It involves the extraction of clots from occluded coronary arteries and deployment of stents and balloons through a small hole made in a major artery, which has given it the name "pin-hole surgery".

Cardiovascular Interventional Procedures

The growth and success of minimally invasive procedures such as Percutaneous Coronary Interventions (PCI) or Percutaneous Transluminal Coronary Angioplasty (PCTA) has now lead to it being one of the most common medical interventions performed today. These procedures have transformed the practice for revascularization for coronary artery disease. Coronary angioplasty has several indications today, including multivessel coronary artery disease, unstable angina and acute myocardial infarction (MI).

Percutaneous Coronary Interventions (PCI)
Percutaneous coronary interventions (PCI) were previously referred to as Angioplasty, Percutaneous Coronary or Balloon Angioplasty. These are procedures used to open the narrowing in an artery without the use of surgery.

What types of heart disease are treated with interventional cardiology?

Interventional cardiologists treat narrowed arteries and weakened heart valves – often caused by coronary artery disease, heart valve disease, or peripheral vascular disease.

Coronary artery disease is the narrowing of the coronary arteries, the tubes which supply the heart muscle with blood and oxygen. This narrowing of the arteries is caused by atherosclerosis – the buildup of fatty deposits, cholesterol, calcium, and plaque on the inner surface of the arteries. Atherosclerosis restricts blood flow to the heart, which can lead to heart attack or other heart problems. Symptoms may include angina (intermittent chest pain), shortness of breath, sweating, nausea, and/or weakness.
Heart Valve Disease involves heart valves that are not working correctly to regulate the flow of blood through the heart chambers. This can arise from birth defects or through damage by rheumatic fever, bacterial infection, or heart attacks. Valves also can degenerate with the normal aging process. To compensate, your heart must pump harder, and may be unable to supply adequate blood circulation to the rest of your body. Two common forms of heart valve disease are aortic valve stenosis and mitral valve regurgitation. Symptoms may include shortness of breath, chest pain, swelling of the ankles and legs, fatigue, dizziness, and/or fainting.
Peripheral Vascular Disease involves the other arteries that run throughout your body. Like the coronary arteries in your heart, these vessels can become clogged and hardened through atherosclerosis, and can increase your risk for high blood pressure, heart attack, and stroke, or limb loss. Symptoms may also include pain in the leg muscles (particularly calves and thighs) and/or severe aching pain in your toes or feet at night.

How is cardiac catheterization used to diagnose cardiovascular disease?

Cardiac catheterization is a test used to evaluate your coronary arteries and heart valve function, It will identify the size and location of plaques that may have built up in your arteries from atherosclerosis, the strength of your heart muscle, and the adequacy of valve function. To start the cardiac catheterization, the interventional cardiologist threads a catheter (thin flexible tube) through a blood vessel in your arm or groin and into your heart. With the catheter in place, the cardiologist can measure blood pressure, take blood samples, and inject dyes into your coronary arteries or arteries elsewhere in your body to trace the movement of blood through the arteries and chambers of the heart. By watching the dye move through your heart's chambers and blood vessels, your cardiologist can see whether the arteries are narrowed or blocked, and whether the valves are working properly. This helps determine whether you may need bypass or valve surgery (by a cardiac surgeon) or angioplasty or catheter-based valve repair (by an interventional cardiologist).

What types of procedures do interventional cardiologists perform?

Interventional cardiologists at BWH's Shapiro Cardiovascular Center select one or a combination of procedures best-suited to each patient. Procedures include:

Angioplasty and stenting – A long, slender tube is inserted through a blood vessel in your leg or wrist, and guided to the heart or elsewhere in your body. A dye is injected through the arteries to guide the cardiologist during the stenting procedure. A balloon at the tip of the catheter is inflated to stretch open the artery and restore increased blood flow to the heart. In most cases, a small metal mesh cylinder called a stent is then placed in the vessel to help keep it open.
Atherectomy – Devices with tiny blades are sometimes used to cut away plaque deposits caused by atherosclerosis inside the blood vessel.
Carotid Stenting – Similarly, balloons and stents can be used to open the carotid arteries, the main blood vessels to the brain, and thereby lessen the risk of stroke. This procedure was just recently approved by the FDA.
Embolic protection – In some cases, particularly when the narrowing being treated is in a bypass graft or in the carotid arteries, filters and other specialized devices are used to help ensure that pieces of the plaque don’t break off and travel in the blood to cause damage.
Percutaneous mitral valve repair – A catheter is introduced through a blood vessel in your leg and guided through a vein to the heart. Smaller catheters holding a special clip is guided into place and positioned near to, or actually attached to, the mitral valve to make it function properly. This is a very new procedure and BWH is one of just a few centers in the world participating in the clinical trials for this procedure.

What is a drug-coated stent?

A stent is a mesh metal tube inserted after angioplasty to keep the artery propped open. Drug-coated stents (also called drug-eluting stents) provide an additional benefit: They release a medication that prevents scarring during the first few weeks after insertion, when scarring is most likely to occur. With traditional stents, about 20% of patients who undergo angioplasty experience restenosis – scarring of tissue around the stent – which can narrow or block the artery again. Use of a drug-coated stent dramatically lowers the patient’s risk of needing another procedure due to restenosis. Although drug-coated stents were just approved by the FDA in April 2003, cardiac patients at BWH have had access to these devices for years, through clinical trials. BWH physicians have been pioneers in all phases of the development of drug-coated stents, and continue to participate in and direct clinical trials offering new generations of these devices to patients.

What is Radial Artery Catheterization?

Cardiac catheterization is most commonly performed by entering the circulatory system through a blood vessel in the groin (the femoral artery). However, at Brigham and Women’s Hospital, over half of patients will have their procedure performed through the radial artery which courses through the wrist.
Catheterizations through the radial artery have several advantages:

Patient comfort is significantly improved. Because the entry site is at the wrist, patients are able to sit up and walk immediately after their procedure whereas patients having their procedures via the femoral artery approach will often require up to six hours of bed rest. As result, there are fewer issues with back discomfort and patients are able to eat comfortably after their procedure.
Patients who are scheduled for same day discharge can be discharged at an earlier time period than if their procedure was performed through the femoral approach since the post-procedure recovery is shorter than with the femoral approach.
The radial approach is safer than the femoral approach for the majority of patients undergoing cardiac catheterization. Because the artery is smaller and very close to the skin, important bleeding is significantly reduced compared to the femoral approach.

Prior to your procedure, your physician will examine your wrists and ensure you are a good candidate for the radial artery approach and determine which wrist will be utilized for the procedure. During your procedure, your physician will administer a local anesthetic at your wrist and this is generally the only discomfort during the procedure. Once the arterial catheter is placed in the artery, your arm will be brought by your side. A medication will be administered that helps prevent spasm or narrowing of the radial artery. This medication can give a warm, burning sensation in the hand and arm and this generally resolves within seconds. At the conclusion of the procedure, a transparent inflatable wrist band will be placed around the catheter entry site and will be left in place for at least two hours. A nurse or physician assistant will assess your wrist prior to removing the band and your wrist will be further watched for an hour. Your physician may ask that you avoid activities that are strenuous on your wrist for at least 48 hours. The activities include lifting heavy objects and paddle sports. The majority of patients will be back to simple activities such as writing immediately after their procedure.

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