Dr.S.Venkatesan MD

Cath lab tips : Post dilatation is an unique “Art” . . . can’t learn it from textbooks or workshops !

December 24, 2017 by dr s venkatesan

In the modern era of cardiology,  PCI has become the single therapeutic modality  that determines the survival of both cardiologists and possibly their patients! The procedure is all about launching  a metal coil inside the coronary artery of a live beating heart.

Millions of diseased and (not much) diseased coronary arteries are serviced (either re/deconstructed ) world-wide on a day-to-day basis.The benefits of the modality is  directly related to the wisdom of treating cardiologist and patient’s luck than the original severity of the disease. However, with greatly improved coronary  metallurgy , well assisted by drug coating technology and antiplatelet Industry , cardiac physicians believe they have reached the zenith of this procedure.

But the truth is , PCI still has many lingering issues regarding safety , efficacy and cost effectiveness.Early hazard in the form of acute stent thrombosis and sudden death is  a  reality. Blaming it on patients and their lesions ( condition of blood , gene included) , metal behavior is easy , but, wrong selection (Ignoring the option of CABG) and technical inadequacy of the procedure in the setting of complex  vessel wall disease (Hard calcium , deep tunnels , fissures , dead spaces ) is a major cause for concern.

Some personal thoughts about Post dilatation 

Lesion preparation , pre/per-dilatation /POTS , etc by itself  a big topic (which is not discussed here) Post dilatation after direct stenting is much more vital concept that determines not only the immediate but also the , Intermediate and long-term outcome.

Is routine post dilatation harmful ? or beneficial ?

This is the most tough question to answer . The answer is both Yes and No !  While it was thought useful and mandatory by some , the oppositeis also being adviced few  (CCL 2003 POSTIT trial)

What balloon pressure one should post dilate ? At what compliance ?  What is the Inflation time ? 

It’s akin to asking a musician  how to play a piano with fingers or guitar with various strings !

The effect of balloon pressures in the long term outcome. note both low and high pressure dilatation ( blue and orange worms ) hike the risk of restenosis. Too gentle is as dangerous as too harsh making post dilatation a secret and unique art.

 

Physics of post-dilatation  . . . again more questions !

• Is there a role for compliant balloons ?
• Does the compliance of balloon gets altered with hard lesions?
• Is regional compliance matters ?
• Can balloon exert same radial pressure all 360 degrees ?

It’s very likely, the moment balloon encounters an area of resistance it tends to avoid that area and would love to drag on to the area of least resistance and this is often diagonally opposite  zone of hard lesions ( if that segment  is free from hardness).Then , it  will face more stress and likely to bear the brunt of the force risking endothelial disruption . In other words , concentric hard lesions are more amenable for dilatation than patchy hard segments. While the physical forces vary in a stented vs non stented segment , the principle of dynamic forces on static tissue masses  with Intervening metal is too complex. (Mind you , we are not discussing  entirely different  issue , ie  thrombus laded ACS lesion , where displacement and pinching of of inter-strut thrombus into distal circualtion would cause no reflow!)

Impact of newer hardware

*Ablation catheters either rotational or Orbital can help , but must be done prior to stenting .Unfortunately , the hardness of a lesion is often realised  only after stenting

Is selective high pressure inflations over a particular struts possible ?

As of now , it would be challenging ,( if not outright impossible) .

Let us realise with all our intellect, complex PCI as a whole is taking an uncalculated risk  and leave the rest to GOD and DAPT !

Reference article 

In an elegant study of more than 90000 PCIs from Sweden and  Holland (Ref : Fröbert O, PLoS ONE. 2013 ) found routine post-dilatation pushes the harm curve little more than benefit.  The was more with both low and very high pressures .

The outcome of post-dilatation  in 900,00 PCIs 

 

Estimated cumulative event rates of stent thrombosis (Panel A) Restenosis (Panel B ) Cumulative death (Panel C) in relation to post-dilatation .Note the height of coronary Irony, Post dilatation Increase stent thrombosis and restenosis but saves life too !

 

The stunning truth revealed in this study was , early deaths were more common if  post dilatation was not done ! (Panel C in above figure) 

Role of Imaging in the decision-making prior to  Post dilatation

IVUS, OCT has been extensively used in recent times to diagnose suboptimal deployment and to asses lesion morphology.Though they are expected to improve the quality of angioplasty and hence the  outcome , the real world scenario is not really confirming our expectations.

This is because , eagle-eyed HD  imaging throws  more questions than answers in many and it converts coronary artery into a confused Pandora’s box . In fact these Imaging modalities has created fresh confusions , definitions and guidelines for malapposition under and over expansion , strut fracture, plaque prolapse, internal elastic laminar stress.( Still , I am not able eo understand  whats malapposition  vs  under deployed stent from a practical , pateint point of view !)

Is the Self expanding  stent is the answer ?

The conundrum of post dilatation might be cracked if the built-in radial force of self expanding stents is optimally utilised .This could be useful in some  tricky lesions when the vessel goes for progressive Glagovian  remodeling post PCI. The self expanding stent because of the stored potential energy keep hugging the vessel wall as it expands centrifugally.

Final Message

Post dilatation is neither a mandatory nor a sacred  protocol in cath lab. However , it would seem bulk of PCI’s still will require it . Its done judiciously with reference to   clinical setting, (ACS vs CCS) , type and location of lesion , stent characteristics etc .Most Importantly , the experience of the cardiologists counts ,and he or she will decide when, where, how much of post dilatation is required (or not required) .

Please remember , PCI as a whole (more so the Pre/ Post dilatation !)  is an art by itself. It’s never learnt in text books or even  watching  live work shops. Every young Cardiologists are enouraged to master the art of PCI ,  with a huge caveat . Always ensure  patient’s  Interest are placed first in every step forward. If you are not clear in comphrehending  “What is meant by true  patient’s Interest ? never Indulge in the procedure or call your mentor , if you have one !

Reference

1.Brodie BR1, Cooper C, Jones MCatheter Cardiovasc Interv. 2003 Jun;59(2):184-92. Is adjunctive balloon postdilatation necessary after coronary stent deployment? Final results from the POSTIT trial. Postdilatation Clinical Compartative Study (POSTIT) Investigators.

2.Fröbert O, Sarno G, James SK, Saleh N, Lagerqvist B. Effect of Stent Inflation Pressure and Post-Dilatation on the Outcome of Coronary Artery Intervention. A Report of More than 90 000 Stent Implantations. Agostoni P, ed. PLoS ONE. 2013;8(2):e56348. doi:10.1371/journal.pone.005634

3.Zhang Z-J, Marroquin OC, Stone RA, et al. Differential effects of post-dilation after stent deployment in patients presenting with and without acute myocardial infarction. American heart journal. 2010;160(5):979-986.e1. doi:10.1016/j.ahj.2010.07.007.

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Posted in Uncategorized | Tagged post dilatation, pre vs postdilatation, ptca post dilatation | 1 Comment »

Pressure recovery phenomenon : A brief attempt to understand it !

December 20, 2017 by dr s venkatesan

Bernoulli principle states that , when a high pressure jet (Air, Water, blood etc ) moves over a conduit, the pressure exerted by the jet on its sides (Lateral wall) reduces . The velocity gain is equal to pressure drop .This is why we take velocity as a rough guide to pressure gradient and the sacred formula in doppler echocardiography 4V2 came in to vogue . (Incidentally, Bernoulli principle shares the same principle when aircrafts lifts from runway at its peak speed as the pressure above the wings drops to zero or negative and the plane lifts up.)

Please note , the pressure should drop both above and below the aircraft by Bernoulli principle .But, the engine and wings are arranged in such a way , the air speed below the aircraft is slower and hence the pressure is high below and low above and the lift occurs promptly at take of velocity. Imagine , how the valve leaflets in heart is subjected to lift and drag forces every time the blood gushes with high velocity flows.This is also the reason for the Pulsus bisferiens, SAM in HOCM, Coanda effect in supra valvular stenosis, and any post stenotic dilatation.

In Echocardiography the Bernoulli equation is modified.

In clinical doppler echocardiography, we have liberally simplified the original Bernoulli equation by ignoring the the proximal sub valvular velocity V1 . Further , two more components in the equation is also amputated for our convenience ! (Flow acceleration and the viscous friction) .This is the reason we tend to err many times especially in outflow tract gradients and prosthetic valve gradients .

Pressure recovery phenomenon.

This is another hemodynamic lacunae in clinical echocardiography. We know, thepeak velocity of blood is attained just distal to site of obstruction. As the distal velocity beyond the obstruction begins to fall, the pressure tends to recover corresponding to the loss of velocity. This happens to certain distance beyond the obstruction. Since continuous wave doppler measures the pressure in its entire axis of alignment , it is likely to pick more pressure samples from the recovered areas and net result is, it measures more than the true difference in gradient across the valve.The phenomenon is most relevant in assessment of Aortic stenosis and results in over estimation of severity of stenosis.

Importance of Aortic root dimension

Pressure recovery is more likely to occur with small Aortic root. A stiff  so be careful when interpreting echo gradients in small aorta. Relationship between size of aorta and pressure recovery is complex .(Niederberger of pressure recovery for the assessment of aortic stenosis by Doppler ultrasound. Role of aortic size, aortic valve area and direction of the stenotic jet in vitro. Circulation 1996; 94:1934–40)

How much can be the overestimation ?

It can be up to 30 % or even more.Especially in prosthetic Aortic valves.

How to recognise it and overcome it ?

1. First of all, recognise such a hemodynamic phenomenon exists and the sacred 4v square can be a myth !
2. Never go with gradient alone in diagnosing valve stenosis. Look for 2D features also.This is more vital when you suspect acute valve obstruction.
3. Always add the proximal sub valvular velocity (V1 ) in your Bernoulli equation .It need to be subtracted.
4. The effect of heart rate on pressure recovery has not been properly studied.(The impact of which could be vital and hence too many false prosthetic emergencies could be avoided, as cardiologists tend to rely mostly on gradient than anatomical diagnosis of valve obstruction like visualising thrombus or struck leaflet by TEE or fluro.

Does this phenomenon happen with cath gradient ?(Generally it’s more pronounced in doppler echo )

Yes, It does happen in cath lab also , as its related to physics of flow. It can be minimised if we can use two simultaneous catheters ,one in LV and the other Aortic catheter placed very close to the leaflets.

Click below for an Animated version

Note the pressure recovers from P 2 to P3

Reference

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Posted in Cardiology -unresolved questions, Cardiology-Echocardiography, Infrequently asked questions in cardiology (iFAQs) | Tagged bernoulli equation, doppler echocardiography, doppler principles, overestimation of doppler gradient by pressure recovery, pressure recovery phenomenon | 3 Comments »

“Non academic” Tips and tricks in CTO – PCI : Open sesame ! , Show me your treasures !

November 27, 2017 by dr s venkatesan

We know, The Mysterious Alibaba cave opens  with a voice password . . . legend  tell us it had unlimited hidden treasures. It would appear , CTOs mimic the cave in several ways. What is inside ? Should we open it ?  Can we come out safely ? Do we have any magical password in cath lab to get across the complex tissue boulders ?,   every cardiologist would love to have one !

Dear CTO,Open Sesame . . . I have come with all the wires you love !  Please let me in !

Indication

“CTOs are never an emergency  . . .but please realise  we can very easily create one  while resuscitating a dead snake  ! 

Don’t think hard on evidence , then , you may not do a single case of CTO in your life .Forget all those pessimistic trials like OAT,COAT, etc and the recent ones DECISION-CTO. Ignore all guidelines. Ask your patient, and his insurance company , if they are willing , reserve the cath lab and get ready.

Pre-procedure  planning

Spend at least a hour to analyse the CTO Imagery one day prior and create n action plan.

Keep knowledgeable staff for assisting , but never ask for fellow colleagues help because it hurts our ego !  Cardiac surgeon’s back up is a welcome addition even if it’s on paper.

If possible , try to ask the patient genuinely ,what is his symptom at least once !  before starting the procedure. 

Timing of the procedure.

Don’t post a CTO patient  either on a busy Monday morning  or lazy Friday afternoon.

Hardware Inventory

The wires ,catheters, the balloons form the essential tool box .There is more than a  handful of coronary automobile companies manufacture this .It is all about metallurgy , knowledge of wires, catheters , and tip thickness, (Bullet shaped as in Asahi ) , slipping , hydrophophic or philic,  polymer coating , trackability, pushability , memory etc etc.

Guide wire tip morphology is as Important as the  Lesion characteristics !

Analysis of the lesion (Probably most important)

Unlike conventional PCI we have no initial target.We need to poke first and find the target next ! Distal vessel status  is most important ( Careful review of retrograde filling  through collaterals could give more information than CT angiograms .Calcification, diffuse disease can be a real hurdle)

Lesion morphology

Softness of lesion has to be felt (Requires good wire which has sensor (Paccinian corpuscles and Merckle disc ideal ?) I guess the cortical tactile feel is as vital as the  intervention expertise .I know at least one diabetic colleague of mine who finds it difficult  to cross a CTO  and admits he never found it easy to feel  the lesion through the wires . Autonomic dysfunction ?)

Operator  expertise

(Note: These are like reading  swimming guidelines , you can’t learn in the shores reading books ! you have to plunge !)

Many techniques are proposed .Sequential approach (Ironically experts are licensed to use  specialized wired wires directly .Beginners  are advised to go with non specialized hardware and escalate step by step) Some centers are blessed with new age weapons like cross Boss and sting ray that confront the lesions in multiple frontiers. (Carpet bombing?)

CTO playground. : Its essentially a coronary contact sport with expert septal surfing , tunnelling, knuckling , kneeling , bending . Of course , It  can end up in a gratifying win in few , still most of us tend to play this game without a goal (post !) Source of the Image : Unknown Due credits to the creator.

They are basically about poking the head of the lesion and trying to cross an occluded vessel  millimeter  by mm towards the presumed distal vessel in an Imaginary trajectory. Proximal cap, central core ,the blind tunnel , distal capsule and exit points each must be successfully conquered.

CTO crossing is  the ultimate capacity of the operator to realise and feel the position of the wires in true lumen and their confidence levels in their conviction!

Multiple wires up to three are used some times to poke the lesion two of them are used to shut the false tracks and the other one is expected to enter the true lumen (Looks too good on theory !) . These are referred to in as many terms like parallel wire see-saw , CART ,Reverse CART etc .Retrograde techniques do help us but has no magic solutions.The lumen contrast , guide wire tip movement and its  side branch entry  would help.

Tacking complication :Always anticipate , it’s not negative mind set to look for it  !

Keep pericardiocentesis kit , covered stents , micro  snares and other retrieval devices ready in cart. Your support staff should be well versed with what is happening around them. Some of  the dye leaks and stains are safe .They imply minor perforations that form  sealed hematomas  (The plane of perforations also matters. myocardial (ab-pericardial ) leaks are well tolerated .Distal perforations are also safe as long as CTO is not opened ) Online echocardiography should be readily available to monitor  pericardial space leak.

When bleed into pericardial space is life threatening , A comical, but life saving option is to close the artery and restore the CTO  its original state and come out of the lab quietly ! 

Newer Imaging guidance : Can be useful , still may not matter much  when considering the interventional acumen .

CTO PCI : Time as therapeutic end point.

CTO is not an endless game with out time frame .In my opinion it shouldn’t cross 45 minutes each as in a  soccer  game with a brief  strategic time out and of course with liberal use of ,yellow and red cards

Future directions

Japanese are the ones who pioneered  CTO Interventions . We expect more Innovations ! Is it the forward looking IVUS ? It is akin to tunneling for underground metro train with GPS guiding .If you can mark the proximal and distal  points , rest will be be taken care by mortised self tunneling catheters from Robotic arms steered by sophisticated algorithms.

Final  message

CTO PCI remains a real Interventional challenge. We are often double blinded  in both directions (antegrade as well as retrograde ). Needs much effort ,time, hardware and most importantly a non fatigued mind and body. The benefits we get may vary  between  gratifying to outright mediocre .Of course , it surely satisfies operator ego and express pride and courage !

Is crossing and stenting  a CTO  synonymous with true success ?

Yes it is , for the cardiologist and  the hospital  . . . I’m not sure about it for the patient !

In this  sense , CTOs  mimic the mysterious Alibaba cave that tempts us with Imaginary treasures but can trap us with a wrong password !

Post-Ample

* Who should CTO PCI  ?

I have seen  young , enthusiastic cardiologists with Immature support staff attempting CTO in remote sub- urban settings ! Though patience and expertise are essential ingredients, some amount of organised training and hardwares make CTO PCI safe and effective. Enthusiasm and affordability alone can’t be an Indication for this complex set of coronary lesions.

Reference 

 

I still wonder why  this vital paper was never published , it was just presented in the Annual ACC conference March 2017

http://www.eurocto.eu/

 http://www.cct.gr.jp/

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Posted in cardiology -Therapeutics, Cath lab Hardware, cath lab tips and tricks, cto chronic total occlusion | Tagged absolute refractory period, Best guideline on cto pci, cart reverse cart, chronic total occlsuion, cross boss sting ray, cto club, CTO club euro, cto euro club, cto japan club, cto mmc chennai madras medical college, decision cto trial drsvenkatesan, dr s venkatesan, ethical guidelines in cardiology, ethical issues in cto, management strategies in chronic total occlusion, see saw technique, tips and tricks for cto opening | Leave a Comment »

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