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Posts Tagged ‘cath lab hardware’

The concept of TAVR(Trancutaneous aortic valve replacement ) is trying hard  to prevail over surgical aortic valve replacement .Two companies Medtronic and Edwards life have their products (Core and Sapiens)  tested and used with varying success.Meanwhile, Boston scientific has come out with a new one , Lotus valve made with stainless steel and bovine pericardium.

 

lotus valve tavr

Lotus valve  seems to have a distinct  advantage* (over the Core and Sapiens ) in terms of easy delivery and adjustment (or retrieval ) of valve till  final position and efficient adoptive steel technology in preventing para-valvular leak.

* Outcome awaited.

Human  trials has started with lotus valve in USA 2014.The REPRISE III trial would compare  one to one Lotus vs core valve . Results will be out by 2017.Unlike many interventions the utility value and long-term outcome of  TAVR  seem to be genuine and patients  waiting for aortic valve surgery can look forward to this as a genuine non surgical alternative.

Responding to this , Medtronic and Edwards are  improving upon core valve with Evolute R /Engager and SAPIEN3 , expected  to give a tough time for LOTUS.

Reference

1.RESPOND registry , REPRISE 1, 2 and 3 trials

2.A review article on TAVR 

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Interventional cardiologists in one way be labelled as intra-cardiac and intra-vascular civil engineers.Their primary  job is to create ,or close vascular tunnels and holes in various locations within the heart.How to deliver the  working hardware  to the  site of action ?. Temporary bridges ? .The vascular access is through long sheaths though which , wires, catheters, and devices , valves  are transported. It’s the key supply line to the ultimate battle field of life , right inside the beating heart.  .

So far,the sheaths  and catheters were rigid tubes with a fixed diameter.Innovative sparks come from  strange thoughts.As we struggled to take the per-cutaneous valve for  TAVR  through small caliber sheaths , some one thought why should the sheath be fixed and static .Why can’t it accommodate  liberal sized devices just by expanding its shaft like a python ,come back to its original state once the device passes by ?

Expandable sheath 164 solo path tavi tavr cathlab hardware

Thus came the expandable sheaths. Soon this concept is going to come in a big way and most complex and large device interventions will be benefited by this.

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Complex coronary lesions require  not only  expertise it needs better hardware .A key  factor is the support from  guide catheter.Innovations are hall mark  Interventional cardiology community.Every few years a hard ware breakthrough is expected.

Boston scientific has an answer for improving frequent guide catheter destabilisation in complex anatomy and lesions .A dramatic new concept for guide catheter support .They have named it  in a hollywood fashion “Guidezilla”

Major advantage : Extending the tip of the guide with an anchor to  facilitate smooth balloon approach to the  lesion which  i avoids repeated disengagement of guide catheter.

Watch this animation . It comes with a music stunning too !

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Dear Cardiologist , can you spare a minute  extra  in cath  lab   . . . and give many happy years for your patients !

clock

PCI  (Fondly  called PTCA)  made  a  humble  beginning from  a Zürich hospital in 1977 . In 4 decades  it has become the staple diet  of most cardiologists ,   of course bulk of our patients benefit from that . When Gruentzig introduced the concept stent was never in the picture .Now stents have become mandatory in all most all PCI (We have gone one stop ahead (probably in  the  wrong direction !)  and given a cult status  to  drug electing stent .

Now we enjoy our work  with countless tools and techniques in our coronary automobile shop .

Suddenly  . . .   0ne primitive ,  common sense based question  is  asked !

How many seconds are required to optimally dilate and deploy the coronary stent ?

This  debate is   thrown out  live into  cath lab  . . .  by this simple and elegant study from the prestigious CCI journal.

cci journal ptca pci balooln inflation time

Highlights

  • 105 patients, 150 lesions , Three different stents were used
  • Cypher Select (55%)  , Xience V (30.%), Taxus Liberté (15.%)
  • Three  balloon inflation timing
  • 5, 15, 25 seconds
  • Complex lesion (B2) formed 26 %

balloon inflation time pci ptca

 

This paper concludes ,  duration of stent balloon inflation has a significant impact on stent expansion. Stent deployment for >25 sec is recommended.

It again keeps the vital answer  to our guess !  Can we inflate it for 60 seconds  ?  After all 60 /120 seconds both  are greater than 25 sec is isn’t ?

Final message

This seemingly simple paper  conveys a  strong  message  .

Time is every thing , . . . we have to be fast . . . where we need to  (Time is muscle)  and we have to be slow where we  need to*  .  It has rekindled  the  basic senses  of  our  supposedly advanced brains !

I agree  . . . every minute of cardiologist’s life is precious  as  “Time is  also  Wealth”  , still few minutes of caution and   patience  in cath lab can make world of good for our patients !

* The most important determinant of cath lab complications ,   is lack of patience on the part of cardiologist .Next only comes , expertise , adequacy of hardware  etc . Surprisingly , patient factors  come in the bottom of the list in most non emergency interventions.

Reference

http://onlinelibrary.wiley.com/doi/10.1002/ccd.23343/abstract

Further questions ?

  1. Can post dilatation be as  efficacious   as that of  stent- balloon  dilatation ?
  2. In difficult lesions  , the sum of  “Pre  / Per / Post”  balloon dilatation  gives  us net inflation  time(NIT)  Does it  add any sense to our understanding of optimal stent deployment  ?

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