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1、冠心病介入治疗的现状与展望,Charles T.Dotter M.D.(1920-1985),Interventional RadiologistPioneer in the Field of Minimally Invasive Procedures(Catheterization)Developed Continuous X-Ray Angio-CardiographyPerformed First Angioplasty(PTCA)Procedure in 1964.,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine
2、,History of Interventional Cardiology,1977,1984,1988,1989,1997,1999,2000,2002,2003,2004,2005,2006,16,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,History of Interventional Cardiology,1977,七十年代 PCI 适应证和禁忌证,PCI 初期 单纯球囊扩张（PTCA）年代适应证局限,Maurice Buchbinder,MD Foundation for Cardiovascular
3、Medicine,History of Interventional Cardiology,1977,1984,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,Directional Coronary Atherectomy(DCA)John Simpson,八十年代 PCI 适应证,病变适应证：简单病变 各类型复杂病变 远端、长节段（10mm）、偏心、钙化、分叉病变（bifurcation）一支多处病变（tandem）位于血管转弯处 成角病变（angular lesion 45）完全闭塞病变（total occlusi
4、on lesion）3 个月，新近阻塞；3个月，慢性阻塞 冠脉口病变（ostial lesion）溃疡或血栓病变,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,History of Interventional Cardiology,1977,1984,1988,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,Rotational Atherectomy(PTCRA)David Auth,Maurice Buchbinder,MD Foundat
5、ion for Cardiovascular Medicine,History of Interventional Cardiology,1977,1984,1988,1989,The X-Sizer Thrombectomy Catheter System,远端保护装置,Angioguard,Bare Metal Stents.,the good,the bad,and the ugly!,九十年代 PCI 适应证和禁忌证,PCI 成熟期 以支架术为主要技术的年代,急性下壁心肌梗死直接支架植入,冯某，男，32岁,病例演示一,Maurice Buchbinder,MD Foundation f
6、or Cardiovascular Medicine,History of Interventional Cardiology,1977,1984,1988,1997,-Angiosculpt,Cutting balloon,Flextome,0.0155inch(0.39mm),Element,Scoring Balloon PCI for Severe Calcified Lesions120Cracking,Crack Formation(Intentional Dissection),InflationCompared to Rotablatorless invasiveeasier
7、to use,Semi-compliant balloon,dual wires exert focused inflation force Facilitate controlled plaque fractures-creation of focused force in a localized region of the plaque,Scoreflex,RS,再狭窄:新内膜过度增生所致,治疗方案,放射治疗,药物治疗,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,History of Interventional
8、 Cardiology,1977,1984,1988,1989,1997,1999,2000,2000,冠脉介入治疗最新亮点,药 物 支 架Drug Eluting Stent,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,Drug Eluting Stents,Stent,Basecoat,Basecoat=聚合物+雷帕霉素+Topcoat=弥散屏障,控制释放雷帕霉素的聚合物,Topcoat(TC),TAXUS,Cypher,First Generation DES,Polyolefin derivativePoly
9、merPEVA+PBMA blend,PaclitaxelDrugSirolimus,Express2StentBX Velocity,Intervention 2006,Just DEStent It!,DES in FIM,术前,术后,FU1年FU4年,DES支架内预防再狭窄率,3.2,35.4,0,10,20,30,40,50,In-stent,%,P0.001,91%,CYPHER组,对照组,再狭窄率(%),高危情况的多支血管病,高龄患者 Stent左心功能受损 Stent肾功能不全 Stent糖尿病 DES,病例演示 二,男，47岁急性非ST段抬高性心肌梗死,DES.the good
10、,the bad,and the ugly!,48 months,40 mos,BMS,DES,Incompleteapposition,Late stent,thrombosis,-10-15-20,0-5,105,252015,Distal Ref.,Abn Vasomotion,SirolimusControl,*P0.001*vs.controlProx.Ref.Prox.Stent,*Distal,Delayed Healing!,AngioscopyBMS,DES,Late loss=0,Giant cells,IVUS,EosInflammation,The ESC Firest
11、orm(August 06),Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,History of Interventional Cardiology,1977,1984,1988,1989,1997,1999,2000,2002,2003,2004,2005,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,Treating Bifurcation LesionsLimitations of Current DES,Stents are tubul
12、ar structures not intended for Y-shaped anatomySide branch jailingLimited ostial coverage(“Gaps”)Technically demandingMultiple layers of metalIncreasing risk of thrombosisMyriad of Techniques,Gap,MultipleLayers,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,History of Interventional Ca
13、rdiology,1977,1984,1988,1989,1997,1999,2000,2002,2003,2004,2005,2006,IN.PACT DRUG ELUTING BALLOON,Freepac Separates Paclitaxel moleculesBalances hydrophilic and lipophilic propertiesFacilitates Paclitaxel elution into the vessel wall,DEB:short term elution for long term effect,Drug-Eluting Balloons(
14、and beyond),In.PactInvatecElutax-Aachen Resonance,SeQuent PleasePaccocath Technology B.BraunDIOR-EuroCor,ClearWayAtrium,GenieAcrostak,CricketMercator,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,Why Degradable Stents?,No late adverse eventsLate thrombosisHypersensitivity reactions(ch
15、ronic inflammation)Stent fracturesDoes not restrict arterial remodelingPermits non-invasive imaging of arteryPermits bypass surgery in future,Degradable Stents,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,Bioabsorbable Stent Design,.,Fully Bioresorbable Stents(Scaffolds),Igaki-TamaiB
16、VSREVAELIXIRBiotronik,PLAPLLA(with everolimus)Iodinated tyrosine-polycarbonate(withsirolimus)PLLA(with novolimus)Magnesium(withsirolimus),1,Initial Clinical Experience,Performing Robotic PercutaneousCoronary Intervention from theRadial Approach,J.D.Sheets,MS-IV,Michigan State UniversityCollege of Hu
17、man Medicine,Frederik Meijer Heart&Vascular Institute,Frederik Meijer Heart&Vascular Institute,BMW wire into,diagonal branch,3.0 x 26 mm,Resolute DESdeployed inLAD,Frederik Meijer Heart&Vascular Institute,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,介入心脏病学新进展,Percutaneous“Mitral”Valv
18、e Repair,Catheter-Based Mitral Valve Repair（一）,MitraClip System,PARTNER THV Evolution,PII-2010Edwards SAPIENXT THV23 mm,26 mm,and 29mm,PI-2007Edwards SAPIENTHV23 mm and 26 mm,PII S3-2013Edwards SAPIEN3 THV20 mm,23 mm,26 mm,and 29mm,PARTNER enrolled 8,494 patients in FDA studies(including 4 RCTs)with
19、 3 generations ofTAVR systems in 7 years!,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,Self-expandingNitinol multi-level frame,Porcine pericardium Tissue Valve,Disposable Loading System,Delivery Catheter 18 French 12 Fr body,The CoreValve Revalving SystemSelf-Expanding Support Frame,
20、No.at Risk,TranscatheterSurgical,391 378359 343,354304,334282,219191,14.1%,=4.8,All-Cause Mortality,Months Post-Procedure,40,18.9%22.2%,ACC 2015=6.528.6%,Log-rank P=0.04,TAVR Development in China,In 2010,with the technical help of proctors from,Europe,We in China cooperate with Medtronic Co.In start
21、ing the first TAVR case in Zhong-Shang,Hospital Shanghai on Oct.3 with CorValve,And the 2nd and 3rd TAVR cases in Fu-Wai,Hospital Beijing on Dec.9 also with,CorValve,Thereafter,more sites such as west China Univ.,Hospital etc.started the TAVR Progame,The Site List of TAVR Program in China,200 TAVR c
22、ases have been done in 11 CV,centers in 7 cities in mainland China including:,Beijing:Fu-Wai Hosp.,301 Hosp.,Shanghai:Zhongshan Hosp.,Ruijin Hosp.,Changhai Hosp.,Chengdu:West China Univ.Hosp.Hangzhou:Zhejiang Univ.2nd Hosp.,Nanjing:Nanjing Med Univ.Hosp.,South middle,China Univ.Hosp.,Xiamen:Xiamen H
23、eart Center,Guizhou:Guizhou Provincial Hosp.,Valves International,CorValve(n=118)(self-expanding,Medtronic)Sapien XT(n=16)(balloon-expandable,Edwards),Domestic(self-expanding),Venus-A:(Venus Med-Tech,Hangzhou)The registry(n=81)finished&in follow-upJena.ValveTM:(Transapical,Suzhou)The registry(n=114)
24、finished and in follow-upMicroPort:(MicroPort Co.,Shanghai)FIM(n=10)finished&in follow-upTaurus(Peijia Co.,Suzhou)FIM(n=10)in preparation,.,HuaxiN=22,苏ZhejiangN=10,JiangsuN=6ShanghaiN=2,TotalN=81,Enrolling Study Sites2012-9-7 Start2014-6-3 finishFuwai Hospital41,Case 1.TCT2014 Live Demonstration Cas
25、eFemale,77yrs,Risk Scores:STS 8.24%,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,History of Interventional Cardiology,1977,1984,1988,1989,1997,1999,2000,2002,2003,2004,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,Atrial fibrillation is a major source of cardiogenic em
26、bolism-related stroke（三）,Source:Neurology,1978;Stroke,1985;European Heart Journal,1987;Lancet,1987,500,000 strokes per yearAHA estimates that 15 20%of strokes/year are related to AF,Maurice Buchbinder,MD Foundation for Cardiovascular Medicine,WATCHMAN Device,Frame:Nitinol(shape memory)Contour shape
27、accommodates most LAA anatomyBarbs engage the LAA tissueFabric Cap:Polyethyl terephthalate(PET)FabricPrevents harmful emboli from exiting during the healing process,Barbs,160 PET fabric,Device available in various sizes:21,24,27,30 and 33 mm(diameter)Device diameter is measured across face of device
28、Device Length=Device Diameter,LAA Closure,for Stroke Prevention in AF,Difficulties with Warfarin use,Frequent Monitoring,Difficulty in Compliance(TTR 48-63%)Drug/Diet Interactions Bleeding Risk(ICH),Risks in Elderly(falls,poly-pharmacy),Autopsy&TEE data implicate LAA LAA Closure Devices,Barbs Engage
29、,LAA Wall,160 PET,fabric,Percutaneous Ventricular Restoration（四）Treatment GoalImprove hemodynamics by:,Partition ScarLV Volumes ReductionLVED Pressure ReductionRestoring LV Conical ShapeNot preventing TorsionalContractionNot causing arrhythmias,Procedural aspects similar to a standard PCI(Duration 8
30、0 min/Flouroscopy time 20 min),A PATIENT WITH RESISTANT HYPERTENSION（五）,Hyperactivity of the renal sympathetic nerves plays a key role in hypertension,Symplicity HTN-2 Investigators,Lancet Published online November 17,2010 DOI:10.1016/S0140-6736(10)62039-9,Concept DescriptionCatheter-based procedure
31、 using standard interventional techniquesRF energy delivered through the renal artery wall to denervate the renal nerves,RESISTANT HYPERTENSION CATHETER BASED TECHNOLOGIES,*Trial performed with SYMPLICITY CATHETER SYSTEM A device developed by Ardian,The trasaction is subject to customary closing con
32、ditions,including U.S.and foreign regulatory clearances,EUCE mark in 2008No RCT evidenceSymplicity Registry in 5000 pts,Renal Denervation forResistant HypertensionSymplicity HTN-3:(NEJM 2014)No evidence of efficacy,USANo FDA approval,ANATOMICAL LOCATION OF RENAL SYMPATHETIC NERVES,Arise from T10-L1F
33、ollow the renal artery to the kidneyPrimarily lie within the adventitia,The Journal of Clinical Hypertension.14,pages 799801,2012Circulation.2002;106:19741979,IABP,Abrupt inflation after AV closure-increases Aortic Root diastolic pressureAbrupt deflation upon AV opening decreases impedance to ejecti
34、on(ie-afterload),Intra-Aortic Balloon Pump（六）,diastolic pressure systolic pressure afterload cardiac output filling pressures coronary artery perfusion,ECMO-extracorporeal membrane oxygenation,venous-=RA arterial=FACombines membrane oxygenator with pump Post cardiac arrestRV failurehours to daysmemb
35、rane actives harmful cytokines,ExtraCorporeal Membrane Oxygenation(ECMO)（七）,TandemHeart,Centrifugal flow,lubricated mechanical bearingDisposable pump head short-term use(up to 7-10 days)Can be implanted percutaneously as an LVAD,RVAD,BiVAD(in cath lab),LVAD Cannulation:Inflow is placed in left atriu
36、m through septal puncture.Outflow is placed in femoral arteryPump generates flow of 1 to 5 LPM,with RPMs from 1,000 to 7,500,depending on cannula sizes,Components and Properties,Minimal invasiveCompact size and lightweightContinuous flow and very quietUp to 4-5LPMPriming volume of only 60mlNovel lubrication and anticoagulation system,Controller,Pump,Impella（八）,Directly unload the left ventricleReduce myocardial workload and oxygen consumptionIncrease cardiac output and coronary and end-organ perfusion,ImpellaTM Device,
