INVASİVE CARDIOLOGY: Percutaneous Intervention. PART- I: Diagnostic Techniques. Left and Right Heart Catheterisatıon. Coronary angıography. Prof Dr Rasim.

INVASİVE CARDIOLOGYINVASİVE CARDIOLOGY::PerPerccutanutaneouseous InterventionIntervention..

PART- I:PART- I: Diagnostic Techniques.Diagnostic Techniques. Left and Right Heart Left and Right Heart

Catheterisatıon.Catheterisatıon.Coronary angıography.Coronary angıography.

Prof Dr Rasim ENARProf Dr Rasim ENAR

İÜ. CTF. İÜ. CTF. Department of Department of CardiologyCardiology

Types of percutaneous interventionTypes of percutaneous intervention::

AA. . DiagnosticDiagnostic::

• Diagnostic CathDiagnostic Cath: :

• Right and left heart cath.Right and left heart cath.

• Coronary angiographyCoronary angiography..

• EEPSPS, , IIVUS…VUS…

B.TB.Therapeticherapetic::

1- 1- SStandart Ptandart PCICI:: PTCA, Stent PTCA, Stentss..

2- 2- NNeeww İntra İntraccoronoronaryary devicesdevices:: At Athhereerecctomtomyy, Rotablat, Rotablatoor, Laser,r, Laser, BraBrachychytthheraperapyy (rad (radiiotothheraperapyy), T), Thhromberombecctomtomyy, distal-, distal-protectionprotection..

3- Non3- Non-c-coronoronaarryy interventionintervention::

ValvuloplastValvuloplastyy, Septal abla, Septal ablatition, septal defeon, septal defecct t closureclosure, , valvevalve replareplacecemmeenntt , PM, ICD, CRT, PM, ICD, CRT….….

CATHETERISATIONCATHETERISATION

DefinitionDefinition::

• Invasive procedures for the diagnosis and assesment severity Invasive procedures for the diagnosis and assesment severity of cardiovascular disease.of cardiovascular disease.

• Essentially,Catheterisation of right and left heart and coronary Essentially,Catheterisation of right and left heart and coronary angiography. This procedure is done by using various methods angiography. This procedure is done by using various methods and various catheters. and various catheters.

Catheter:Catheter: Are small plastic tubes which has empty tunel inside. Are small plastic tubes which has empty tunel inside.

Main condition for Main condition for PPCI:CI:…”…”Have to beHave to be”…”… Appropriate Cath Lab and Staf.Appropriate Cath Lab and Staf.

• Semi-sterilSemi-sterilee CatheterisationCatheterisation Laborat Laboratoorryy:: A movable table for the A movable table for the patient lying supinepatient lying supine, - film , - film ccamera, amera, a scope with rotating heada scope with rotating head, -, -ananggiyograiyographyphy andand monitors for monitors for intra intra ccardiaardiacc pressurepressure andand E ECCG G monitoring.monitoring. – –Emergent CPR conditions and PCI materials.Emergent CPR conditions and PCI materials.

Catheterisation access methodsCatheterisation access methods..

A- Arterial accessA- Arterial access::

• DireDirectct accessaccess.. Bra Brachchial arterial arteryy disse dissectction.ion.

• PerPerccutanutaneouseous accessaccess.. Punction of rPunction of radial, braadial, brachchial, femoral ial, femoral arterarteriesies..

B-B- Other ways of accessOther ways of access::

1–1– Transeptal.Transeptal. For entrance to left atriumFor entrance to left atrium: : For For mitral mitral vvalvuloplastalvuloplastyy in MS.in MS.

Contraindications:Contraindications: Huge left atriumHuge left atrium, atriyal mi, atriyal mixxoma, toma, thhrombus ve rombus ve haemorhagichaemorhagic diatesisdiatesis..

2– 2– DireDirectct LVLV p puunncturecture.. Conditions in which LV cannot be entered Conditions in which LV cannot be entered throgh throgh mitral mitral andand aort aorticic valvesvalves: “Tilting-pro: “Tilting-prostesisstesis valvesvalves”. ”.

Percutaneous catheteter sheath introductıon :

Normal Normal Heart and Coronary arteries AnatomyHeart and Coronary arteries Anatomy..

Copyright ©2003 American Heart Association

Lange, R. A. et al. Circulation 2003;107:e111-e113

Typical catheters used for pressure measurements and angiography

Anatomy of femoral artery ande vein.Anatomy of femoral artery ande vein. Catheterizatıon from the femoral vein; right- heart cath. Catheterizatıon from the femoral vein; right- heart cath.Retrograde crossing of aortic valve(pigtail cath and with guide vire Retrograde crossing of aortic valve(pigtail cath and with guide vire combination).combination).

MajorMajor type of type of Heart CatheterisationHeart Catheterisation:: RIGHT HEART CATHETERISATIONRIGHT HEART CATHETERISATION::

Vena Vena CCava, ava, Right-Right- atrium, atrium, Right-Right- ventri ventriccllee, , PPulmonulmonaarry-y- arter arteryy, , Pulmonary- capillary wedge pressurePulmonary- capillary wedge pressure andand measurement of oxygene measurement of oxygene saturationsaturation, , calculation of Cardiac output.calculation of Cardiac output.

ImportanceImportance: :

1- 1- Measurement of right side pressures; Measurement of right side pressures; establish prescence of establish prescence of Tricuspid or Pulmonary valves dysfunctıonTricuspid or Pulmonary valves dysfunctıon and estimating sevirity. and estimating sevirity.

2-2- Pulmonary hypertension can be evaluated and pulmonary vascular Pulmonary hypertension can be evaluated and pulmonary vascular resistance can be calculated.resistance can be calculated.

3-3- PulmonPulmonaarryy capillary wedge pressurecapillary wedge pressure;; reflect the diastolic filling reflect the diastolic filling pressure of the left heart indirectly: Shows indirectly the left atrial pressure of the left heart indirectly: Shows indirectly the left atrial and LV end- diastolic pressures.and LV end- diastolic pressures. Is an important parameter in LV Is an important parameter in LV failure and MS.failure and MS.

LEFT HEART CATHETERISATIONLEFT HEART CATHETERISATION::

• Mitral Mitral andand Aort Aort valvevalve f functionsunctions, s, syystemistemicc vascular resistancevascular resistance andand LLV V function, and coronary artery anatomyfunction, and coronary artery anatomy..

ImportanceImportance::1-1- Most reliable diagnoses of AS and MS by pressure calculations.Most reliable diagnoses of AS and MS by pressure calculations. MMSS:: Gradient between LGradient between LV diastoliV diastolic c – – Pulmonary capillary wedge Pulmonary capillary wedge

pressure pressure measurementsmeasurements.. AASS:: Gradient is present between LV and systolic Aortic peak Gradient is present between LV and systolic Aortic peak

pressure when the catheter is pulled back from LV to the Aorta.pressure when the catheter is pulled back from LV to the Aorta.

2-2- Ventriculography,Aortography:Ventriculography,Aortography: During catheterisation, prescence During catheterisation, prescence of AR and/or MR is shown: Contrast material is given by pump to of AR and/or MR is shown: Contrast material is given by pump to the LV and regurgitation of the contrast from LV to LA shows MR. the LV and regurgitation of the contrast from LV to LA shows MR. When contrast is given from the Aorta at supravalvular level and When contrast is given from the Aorta at supravalvular level and contrast regurgitates to the LV, AR is present.contrast regurgitates to the LV, AR is present.

3-3- Evaluation of LV functionEvaluation of LV function: : Beating LV is filled with contrast. Beating LV is filled with contrast. (a) (a) LV LV segmentar wall motion is evaluatedsegmentar wall motion is evaluated.. (b) (b) LLV EF (% fraV EF (% fractctionionaal l shorteningshortening) ) can be calculatedcan be calculated. .

4- 4- Coronary angiographyCoronary angiography..

HEMODYNAMİC MESURMENTS:HEMODYNAMİC MESURMENTS:

1.1. Cardiac outputCardiac output..2.2. Pressure measurements of cardiac cavities and large arteries Pressure measurements of cardiac cavities and large arteries

(aorta, pulmonary arteries)(aorta, pulmonary arteries)..3.3. Evaluation of pressure waves.Evaluation of pressure waves.

4.4. Evaluation of valvular heart diseaseEvaluation of valvular heart disease..(a)(a) Assesment of Valvular stenosis and measurement of valve Assesment of Valvular stenosis and measurement of valve

area. area. (b)(b) Evaluation of valvular regurgitation.Evaluation of valvular regurgitation.

5.5. Diagnosis of left and right shunts (with oxygen saturatıon).Diagnosis of left and right shunts (with oxygen saturatıon). 6.6. An Anggiograiographyphy..(a)(a) LeftLeft ventri ventricuculogralographyphy..(b)(b) RightRight ventri ventricuculogralographyphy..(c)(c) Aortogra Aortographyphy..

Normal Values of Hemodynamıc Parameters:Normal Values of Hemodynamıc Parameters:

Left Ventricle ( mmHg):

Systolic: 100- 140

End- diastolic: 3- 12

Right Ventricle (mmHg):

Systolic: 15- 30

End- diastolic: 2- 8

Aortic (mmHg):

Systolic: 100- 140

Diastolic: 60- 90

Mean:70- 105

Right atrıum (mmHg):

Mean: 2 -8

A wave: 2- 10

V wave: 2- 10

Cardiac ındex: 2.6- 4.2 L/min/m2

Stroke index: 30- 65 mL/meat/m2

Systemic vascular resistance (Dynes-sec-cm-

5 ): 700- 1600

PVR: 20- 130

Pulmonary artery (mmHg):

Systolic: 15- 30

Diastolic: 4- 12

Mean: 9- 18

Arterial oxygen saturatıon(%):93- 98

Arteriovenous oxygen difference (mL/L): 30- 50

PCWP (mmHg) = (Left atrıum):

Mean: 2- 12

A wave: 3- 15

V wave: 3- 15

Left VLeft Ventrientricuculogralographyphy

Aort Aort andand Mitral Mitral stenosisstenosis: : Pressure Pressure gradients:gradients:

AS MS

AS ve MS; pressure gradients.AS ve MS; pressure gradients.

Right and left Judkins catheters:Right and left Judkins catheters:

Cannulatıon of left and right coronary arteries using the judkins catheters:

Left and Right Coronary Angiography:Left and Right Coronary Angiography:

DIAGNOSTIC HEART CATHETERISATIONDIAGNOSTIC HEART CATHETERISATION Basic indicationsBasic indications::

1- 1- Documentation or to rule out heart disease if there is strong Documentation or to rule out heart disease if there is strong suspection by physical examination or non-invasive diagnostic suspection by physical examination or non-invasive diagnostic tests.tests.

2- 2- If there is discrepancy between clinical findigs and non-If there is discrepancy between clinical findigs and non-invasive diagnostic modalities, to explain the clinic situation.invasive diagnostic modalities, to explain the clinic situation.

3- 3- To evaluate other cardiac comorbid pathologic conditions in To evaluate other cardiac comorbid pathologic conditions in patient who has been given to open heart surgery for any patient who has been given to open heart surgery for any cause.cause.

Indications for Coronary AngiographyIndications for Coronary Angiography..

CLINICAL CONDITIONSCLINICAL CONDITIONS::

Essential İndicatıon:Essential İndicatıon: Known or suspected CAD. Known or suspected CAD. High- risk High- risk Asymptomatic patientAsymptomatic patient: : History of Previous MIHistory of Previous MI, PTCA, , PTCA, CABG, withCABG, with Ischemic findings on resting or exercise ECGIschemic findings on resting or exercise ECG..

1.1. stable angina stable angina.. 2.2. Unstable coronary syndromeUnstable coronary syndrome.. 3.3. Post-revascularisation ischemiaPost-revascularisation ischemia.. 4.4. Primary treatment of AMİ (with Primary treatment of AMİ (with STSTEE oror LBBBLBBB in ECG); in ECG);

before PCI.before PCI. 5.5. Pre and post cardiac surgeryPre and post cardiac surgery.. 6.6. Patient with valvular disease.Patient with valvular disease.

7.7. CCononggenital enital heart diseaseheart disease.. 8.8. Congestive heart failureCongestive heart failure..

Unstable coronary syndromesUnstable coronary syndromes..

UUSAPSAP::

Prior Urgent and early, delayed PCI. Prior Urgent and early, delayed PCI.

1- Urgent PCI: 1- Urgent PCI: AP with hemodynamic or electrical instability (high cTn).AP with hemodynamic or electrical instability (high cTn).

2- Early PCI:2- Early PCI:

• Refractory to initial treatment.Refractory to initial treatment.

• Recurrence of symptoms after becoming stable by initial medical Recurrence of symptoms after becoming stable by initial medical therapytherapy..

3- Delayed PCI (selected patients):3- Delayed PCI (selected patients):

• High risk and complicated USAP. High risk and complicated USAP. + hemod+ hemodyynaminamicc andand ele elecctritricalcal instabilitinstabilityy: : ””Urgent catheterisationUrgent catheterisation”” is recommended is recommended..

• Low risk patient at presentation; but high risk on non-invasive tests ( Low risk patient at presentation; but high risk on non-invasive tests ( Ischemia at low- level exercise, EF <0.40). Ischemia at low- level exercise, EF <0.40).

• Suspected Suspected Prinzmetal VarPrinzmetal Variiant angina.ant angina.

Treatment of STE- AMITreatment of STE- AMI

PriorPrior P PCI or surgery (Primer, rescue, inhospital). CI or surgery (Primer, rescue, inhospital).

1- Primer PCI:1- Primer PCI: Alternative to Alternative to TThhrombolrombolyytiticc therapytherapy:: STE,LBBB, admitted STE,LBBB, admitted with in with in <12 <12 oror >12 >12 hrs of AMİhrs of AMİ..

• Cardiogenic Shock:Cardiogenic Shock: In the first 36 hrs of MI, In the first 36 hrs of MI, (<75 (<75 yrsyrs andand in in 18 18 hrs of hrs of shockshock).).

2- Rescue PTCA:2- Rescue PTCA: Failed Thrombolysis. Failed Thrombolysis.

33.. Early coronary angiography (İnhospital or before discharge)Early coronary angiography (İnhospital or before discharge)::

a- a- Spontaneously or stimulated (E-ECG) ischemic episodesSpontaneously or stimulated (E-ECG) ischemic episodes ( (with with dynamic ECG changesdynamic ECG changes:: ±±).).

b- b- depressed LV systolic functıon (LVEF<0.40).depressed LV systolic functıon (LVEF<0.40).

c-c- Mechanical complicatıon, prior repair surgery. Mechanical complicatıon, prior repair surgery.

CA: Relative Contraindications.CA: Relative Contraindications.

1- 1- Decompensated HFDecompensated HF ( (Pulmonary EdemaPulmonary Edema).).2- 2- Uncontrolled ventricular irritabilityUncontrolled ventricular irritability ( (arrythmia with hemodynamic arrythmia with hemodynamic

compromisecompromise).).3- 3- Uncontrolled systemic hypertensionUncontrolled systemic hypertension..4-4- Acute and severe renal failure Acute and severe renal failure..5- 5- Inability of vascular accessInability of vascular access..6-6- Electrolyte imbalanceElectrolyte imbalance: H: Hyypopokalemiakalemia, H, Hyyperperkalemiakalemia..7- Di7- Diggital intoital intoxxiiccaationtion..8- A8- Acctivtivee infe infectionction andand septic conditionsseptic conditions..9- 9- Uncontrolled Haemorrhagic diastesisUncontrolled Haemorrhagic diastesis..10- 10- Severe anemiaSevere anemia..11- A11- Acctivtivee haemmorhagehaemmorhage..12- 12- Contrast allergyContrast allergy..13- 13- Loss of consciousnessLoss of consciousness..

* * **!!!- **!!!- ABSOLUTE CONTRAINDICATIONABSOLUTE CONTRAINDICATION:: Disclaim of conscious Disclaim of conscious patient.patient.

COMPLICATIONS:COMPLICATIONS:Complication prevalance was reduced as the number of procedures Complication prevalance was reduced as the number of procedures

was increased in any centerwas increased in any center (!). (!).

MAJOR MAJOR ComplicationsComplications (%0.2- 0.3): (%0.2- 0.3): DeathDeath, AM, AMII, SV, SVAA..

*** *** DEATHDEATH (%0.1- 0.2 ). (%0.1- 0.2 ).

CauseCause:: PerforationPerforation, ar, arrythmiarythmia, AM, AMII, , oror ccontrast anaontrast anaphyphylalaxxis.is.

Patients with Hıgh- Rısk of DeathPatients with Hıgh- Rısk of Death (risk %2.8): (risk %2.8):

1- 1- PatientsPatients >70, >70, <1 y<1 yearsears. .

2- 2- NYHA-4 NYHA-4 HFHF oror angina. angina.

3-3- SevereSevere LLV dV dyysfsfuunnctionction (EF<%25). (EF<%25).

4-4- Severe and extensive CADSevere and extensive CAD (LMCA (LMCA or ostial or ostial, 3- , 3- vesselvessel diseasedisease). ).

5- 5- Severe valvular diseaseSevere valvular disease ( (withwith LLV dV dyysfsfuunnctionction). ).

6- 6- SevereSevere ccomorbid omorbid conditionsconditions ( (renalrenal,, hepatic hepatic,, lung lung diseasedisease). ).

7- 7- KnownKnown ccontrast allerontrast allergygy..

Contrast nephropathyContrast nephropathy: : Is generally secondary to high doses of contrast material, and Is generally secondary to high doses of contrast material, and

especially develops in diabetic patients.especially develops in diabetic patients.

PreventionPrevention::

a-a- Dose of the contrast material must be calculated according to the Dose of the contrast material must be calculated according to the patients body surface area, weight and serum creatinin levels. patients body surface area, weight and serum creatinin levels.

b-b- Non-ionic contrast material is the prefereNon-ionic contrast material is the prefere..

c- c- Before vatheterization, oral homosistein can be given and Before vatheterization, oral homosistein can be given and bicarbonate infusion can be made. bicarbonate infusion can be made.

d- d- In patients using diuretics, the diuretic dose befor catheterization In patients using diuretics, the diuretic dose befor catheterization must be passed, and especially in diabetics, iv hydration must be must be passed, and especially in diabetics, iv hydration must be increased. IV hydration must be continued during the procedure if increased. IV hydration must be continued during the procedure if needed. needed.

e- e- During the 6-12 hour period after catheterization, oral and iv During the 6-12 hour period after catheterization, oral and iv hydration must be sufficient (1.5 – 2 Lt).hydration must be sufficient (1.5 – 2 Lt).

INVASİVE CARDIOLOGYINVASİVE CARDIOLOGY::PerPerccutanutaneouseous InterventionIntervention..

PART- II:PART- II: İnvasive İnvasive TherapiesTherapiesPCI, Stenting. PCI, Stenting.

PMV, ASD- Closure. PMV, ASD- Closure.PM- ICD, CRT.PM- ICD, CRT.

Prof Dr Rasim ENARProf Dr Rasim ENAR

İÜ. CTF. İÜ. CTF. Department of Department of CardiologyCardiology

PERCUTANEOUS CORONARY INTERVENTIONPERCUTANEOUS CORONARY INTERVENTION (PCI): (PCI):

DefinitionDefinition:: Is the treatment intended percutaneous Is the treatment intended percutaneous coronary procedure.coronary procedure.

• Was known as “PTCA” in the past. Was known as “PTCA” in the past.

For optimal procedureFor optimal procedure:: Standart Standart catheterization catheterization laboratlaboratory, dilatation material and experienced staff ory, dilatation material and experienced staff able to use these material must be present. able to use these material must be present.

Ideal patientIdeal patient:: (a)(a) One vessel diseaseOne vessel disease..(b)(b) Older patients, performed CABG at past; who has Older patients, performed CABG at past; who has

fragile lesion fragile lesion (“(“disdisccretrete;e; length length <10 mm. <10 mm. Diameter of Diameter of the vessel the vessel >2.5 mm)>2.5 mm), and , and 33-- vessel disease withvessel disease with high high success rate (high- risk for reoperatıon)success rate (high- risk for reoperatıon)..

(c)(c) In the case of ACS and especially STEMI, primary In the case of ACS and especially STEMI, primary treatment choice is percutaneous coronary treatment choice is percutaneous coronary intervention.intervention.

• Power of Power of PPCICI:: To be successfull in To be successfull in >%90>%90 of cases of cases..

Limitations of PCI:Limitations of PCI:

1-1- Success rate is low in chronic total occlusions.Success rate is low in chronic total occlusions. 2-2- Early and long term efficacy is low in Early and long term efficacy is low in saphenoussaphenous vein vein

greft legreft lesions.sions.HighHigh- R- Riskisk Stenoti Stenoticc Le Lesisiononss::a-a- Di Diffuseffuse (>20 mm). (>20 mm). Vessel DiameterVessel Diameter: <1.5- 2.0 mm.: <1.5- 2.0 mm.b- b- DenseDense tort tortuous-uous- pro proxximal segment.imal segment.c- c- SeverelySeverely angulatedangulated segm segmeent (≥90 dent (≥90 degegee).e).d-d- Total o Total occcclulusision (>3 on (>3 monthsmonths). De). Degeneratedgenerated ve veiin greftn greft

(fra(fragygyl lel lesionsion).).e- e- Ostial leOstial lesisiononss, , side branch originating from the side branch originating from the lelesision.on.

Advers effects of the interventionAdvers effects of the intervention::a- a- Fatal Fatal eventevent (%1). (%1).b-b- A Accututee andand latelate is ischchemiemicc complicationscomplications (%2). (%2).c-c- Signifficant Restenosis in the first months.Signifficant Restenosis in the first months. (%10). (%10).

Complications of PCIComplications of PCI::

1. 1. MortalityMortality. .

(a)(a) In stable patientsIn stable patients: <%2. : <%2.

(b)(b) AM AMII + + CS CS : >%50.: >%50.

2. M2. Myyooccardardialial IInfarnfarccttionion. .

Elevation of cardiac markersElevation of cardiac markers: %5- 10.: %5- 10.

3.3. No- ReFlow:No- ReFlow: Proksimal Proksimal vessel is openvessel is open, , but myocardial tissue but myocardial tissue is not perfusedis not perfused.. Also called Also called “Malperfusıon, and inadequate “Malperfusıon, and inadequate tissue-level perfusıon”.tissue-level perfusıon”.Incidence; %10- 30 at reperfused Incidence; %10- 30 at reperfused vessel.vessel.

Vasoactive materials emanating by the disintegration or Vasoactive materials emanating by the disintegration or breaking up of the thrombus of the pbreaking up of the thrombus of the proroxximal leimal lesisionon and and microembolisationmicroembolisation..

DiagnosisDiagnosis: : Elevation of cardiac markersElevation of cardiac markers, ST- T , ST- T wave changes on wave changes on ECGECG andand regional wall motion abnormalitiesregional wall motion abnormalities..

4. 4. Coronary perforation and rupture.Coronary perforation and rupture.

STENTSTENTSS..

Are the supplementary and complementary components of Are the supplementary and complementary components of balloons.balloons.

Rutine stenting has become the routine procedure of PCI.Rutine stenting has become the routine procedure of PCI. (“(“DireDirectct Stent Stentinging”).”).

TTypesypes:: • Drug elutingDrug eluting AAcctitive ve - Stent- Stentss (“Drug Eluting Stent (“Drug Eluting Stent””)).. • Metal,Metal, PassiPassive- ve- Stent Stents (Bare- Stent”)s (Bare- Stent”)..

Difficulties of PCI:Difficulties of PCI:a-a- Passing chronic total occlusion.Passing chronic total occlusion.b-b- Optimization of anti-thrombotic and anti-thrombin Optimization of anti-thrombotic and anti-thrombin

therapies for acute total occlusions.therapies for acute total occlusions.c-c- Retsenosis is a problem, decreasing with Active- stents.Retsenosis is a problem, decreasing with Active- stents.

Although acute, subacute restenosis decreases more Although acute, subacute restenosis decreases more compared with passive stents, but late restenosis in 2 compared with passive stents, but late restenosis in 2 years is more frequent in DES. years is more frequent in DES.

INDICATIONS OF PCIINDICATIONS OF PCI::

CLINICAL INDICATIONSCLINICAL INDICATIONS::

1-1- Acute Cornary SyndromesAcute Cornary Syndromes:: STEM STEMII,, NSTEMNSTEMII, , USAPUSAP).).

2- 2- StabStablele AP: AP: Po Possitiitiveve exercise testing (at low-level)exercise testing (at low-level), , LLV V ddyysfsfuunnctction, ion, electrical instabilityelectrical instability..

3-3- Angina eAngina equivalentsquivalents (with known, documented CAD) (with known, documented CAD): : Arrythmia (symptomatic tachy-, brady-)Arrythmia (symptomatic tachy-, brady-), , lliightheadnessghtheadness, d, dyyspnespneaa..

4-4- MSMS - CT’de;- CT’de; Sign of proximal stenosis (must be Sign of proximal stenosis (must be confırmed by coronary angıography).confırmed by coronary angıography).

5-5- Objective signs of reversible ischemia.Objective signs of reversible ischemia.

ANGIOGRAPHIC INDICATIONSANGIOGRAPHIC INDICATIONS::

1-1- 1-4 Lesions are apopriate for 1-4 Lesions are apopriate for PPCI.CI.

2- 2- There is no life threatening effects of occluding these There is no life threatening effects of occluding these lesions for ≥1 minute( ie. LMCA, ostial lesions).lesions for ≥1 minute( ie. LMCA, ostial lesions).

3-3- Prescence of functional myocardium or collateralls.Prescence of functional myocardium or collateralls.

CONTRAINDICATIONS FOR PCICONTRAINDICATIONS FOR PCI::

CLINICAL CONTRAINDICATIONSCLINICAL CONTRAINDICATIONS::1-1- Terminal heart disease or other disease (except uncontrolled Terminal heart disease or other disease (except uncontrolled

AP).AP).2- 2- PostPost--MMII CSCS ( (with multiorgan failurewith multiorgan failure).).

ANGIOGRAPHIC CONTRAINDICATIONSANGIOGRAPHIC CONTRAINDICATIONS::1- 1- LMCALMCA disease disease. . 2- 2- LMCA LMCA equivalentequivalent: Pro: Proxximal LAD + CX imal LAD + CX diseasedisease..3-3- Last vesselLast vessel: : OtherOther 2 2 coronary artery occludedcoronary artery occluded..4- 4- Three vessel diseaseThree vessel disease ( (except inop patientexcept inop patient).).

5- 5- Characteristics of hard lesionsCharacteristics of hard lesions::(a)-(a)- Chronic total occlusionChronic total occlusion..(b)-(b)- No collateral to the distal artery.No collateral to the distal artery. (c)-(c)- Diffuse old lesionDiffuse old lesion (>20 mm). (>20 mm).(d)-(d)- No cut off.No cut off...(e)(e)- - No critical CAD in the prescence of thrombotic lesion.No critical CAD in the prescence of thrombotic lesion. • (f)-(f)- Diffu Diffusese atherosclerotic or small diameter vessel atherosclerotic or small diameter vessel (<2 mm). (<2 mm).

SaSaphenousphenous ve veiin greft. n greft.

Materials for PCIMaterials for PCI::

Mechanism of PTCA and StentingMechanism of PTCA and Stenting..

• Dissection of intima and media in the nneighbor sections Dissection of intima and media in the nneighbor sections of the vessel near the plaque.of the vessel near the plaque. Circumferential dilatation Circumferential dilatation of the vessel is the key mechanism for luminal increase of the vessel is the key mechanism for luminal increase (increasing diameter). (increasing diameter).

• STENT:STENT: Is the key material for preventing “elastic recoil Is the key material for preventing “elastic recoil of the widening vessel.of the widening vessel. Keeps the plaque particles and Keeps the plaque particles and intima away from the luminal surface.intima away from the luminal surface.

Schematized STENTINGSchematized STENTING..• Beginning of the Beginning of the

procedureprocedure: : Angaging the Angaging the guiding catheter guiding catheter successfully to the successfully to the coronary ostiyum and coronary ostiyum and passing the guide wire passing the guide wire hrough the lesion.hrough the lesion.

• A-A- Passing the stented Passing the stented ballon from the stenotic ballon from the stenotic lesion.lesion. Before this,Before this, standart predilatation of standart predilatation of the lesion mey be needed.the lesion mey be needed.

• B- B- Inflating the ballon and Inflating the ballon and widening of the stent. widening of the stent.

• CC--,, D- D- Deflating the Deflating the balloon and pulling back balloon and pulling back from the widened stent. from the widened stent.

BaloBalooon n andand + Stent. + Stent.

ADDITIONAL THERAPİESADDITIONAL THERAPİES::1.1. OralOral-- Anti Antiplateletplatelet : : ASA, ASA,

CClopidogrel.lopidogrel.2.2. İVİV-- AAntintiplateletplatelet : : GP-GP-2b/3a 2b/3a

İnh.İnh.3.3. AntitAntithhrombinrombinss:: Heparin Heparin(UFH, (UFH,

LMWH Bivaluridin, LMWH Bivaluridin, Fondaparinux)Fondaparinux)..

4. 4. Planned Secondary Planned Secondary

prevention strategy at prevention strategy at dischargedischarge (ASA,CLP,Statin, (ASA,CLP,Statin, BBl, ACEİ).BBl, ACEİ).

Efficacy of PCIEfficacy of PCI::a- a- HighHigh Success rate of the Success rate of the

intervention.intervention. b-b-Symptomatic reliefSymptomatic relief after after

intervention:intervention: %90. %90.c-c- ComplicationsComplications:: ≤ %2. ≤ %2.

Coronary AngiographyCoronary Angiography: : SuccessfullSuccessfull S Stenting.tenting.

Percutaneous Mitral Baloon Valvotomy (PMV)

Percutaneous ASD Closure

İndicatıons: • Symptoms of dyspne,fatigue or RHF.• Reccurrent pulmonary infectıon.• Paradoxical embolism.• Atrial arrhytmia even ın the presence of a small defect.• Moderate Pulmonary hypertensıon without pulmonary vascular disease.• Asymptomatic large ASD (Qp/Qs>1.5:1.0),RH volum overload and no pulmonary hypertensıon.

İnd: MV: Echo score <8. • MVA<1.0 cm2.• No subvalvular fibrosis,• mobile valve and noncalcified.

ICD: Implantable Cardioverter Defibrillator:(Chest Radiograph and figure of PM locatıon)

ICD İndications:• Reduced EF who had history of cardiac arrest,VT,VF.• Ischemic CMP; at least 40 days post-MI with EF <%30, NYHA II or III on chronic OMT.

CRT: Cardiac Resynchronısatıon Therapy

İndicatıons:

• LVEF<%35.• Sinus rhym. • NYHA class –III-IV, despite optimal therapy (OMT).• Have cardiac dyssynchrony, QRS duratıon >120 ms.