1、冠心病介入治疗冠心病介入治疗的现状的现状与展望与展望Charles T.Dotter M.D.(1920-1985)Interventional Radiologist Pioneer in the Field of Minimally Invasive Procedures(Catheterization)Developed Continuous X-Ray Angio-Cardiography Performed First Angioplasty(PTCA)Procedure in 1964.Maurice Buchbinder,MD Foundation for Cardiovascu
2、lar MedicineHistory of Interventional Cardiology19771984198819891997199920002002200320042005200616Maurice Buchbinder,MD Foundation for Cardiovascular MedicineHistory of Interventional Cardiology1977七十年代 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 Medicine
3、History of Interventional Cardiology19771984Maurice Buchbinder,MD Foundation for Cardiovascular MedicineDirectional 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 occlusion lesion）3 个月
4、，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 MedicineHistory of Interventional Cardiology197719841988Maurice Buchbinder,MD Foundation for Cardiovascular MedicineRotational Atherectomy(PTCRA)David AuthMaurice Buchbinder,MD Foundation for Cardiovascular
5、 MedicineHistory of Interventional Cardiology1977198419881989The X-Sizer Thrombectomy Catheter System远端保护装置AngioguardBare 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急性下壁心肌梗死直接支架植入直接支架植入冯某，男，32岁病例演示一Maurice Buchbinder,MD Foundation for Cardiovascular Medici
6、neHistory of Interventional Cardiology1977198419881997-AngiosculptFlextome0.0155inch(0.39mm)ElementScoring Balloon PCI for Severe Calcified Lesions120CrackingCrack Formation(Intentional Dissection)InflationCompared to Rotablatorless invasiveeasier to use Semi-compliant balloon,dual wires exert focus
7、ed inflation force Facilitate controlled plaque fractures-creation of focused force in a localized region of the plaque197719831985198820001997再狭窄再狭窄:新内膜过度增生所致新内膜过度增生所致治疗方案治疗方案放射治疗药物治疗Maurice Buchbinder,MD Foundation for Cardiovascular MedicineHistory of Interventional Cardiology19771984198819891997
8、199920002000冠脉介入治疗最新亮点冠脉介入治疗最新亮点药 物 支 架Drug Eluting StentMaurice Buchbinder,MD Foundation for Cardiovascular Medicine Drug Eluting StentsStentBasecoat 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控制释放雷帕霉素的聚合物Topcoat(TC)TAXUSCypherFirst Generation DESPolyolefin derivativePolymerPEVA+PBMA blendPaclitaxe
9、lDrugSirolimusExpress2StentBX VelocityIntervention 2006Just DEStent It!DES in FIM术前术后FU1年年FU4年年DESDES支架内预防再狭窄率支架内预防再狭窄率3.235.401020304050In-stent%P0.00191%CYPHER组组对照组对照组再狭窄率(%)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,the bad,and the ugly!48 months40 mosB
10、MSDESIncompleteappositionLate stentthrombosis-10-15-200-5105252015Distal Ref.Abn VasomotionSirolimusControl*P200 TAVR cases have been done in 11 CVcenters in 7 cities in mainland China including:Beijing:Fu-Wai Hosp.,301 Hosp.Shanghai:Zhongshan Hosp.,Ruijin Hosp.,Changhai Hosp.Chengdu:West China Univ
11、.Hosp.Hangzhou:Zhejiang Univ.2nd Hosp.Nanjing:Nanjing Med Univ.Hosp.,South middleChina Univ.Hosp.Xiamen:Xiamen Heart Center Guizhou:Guizhou Provincial Hosp.Valves InternationalCorValve(n=118)(self-expanding,Medtronic)Sapien XT(n=16)(balloon-expandable,Edwards)Domestic(self-expanding)Venus-A:(Venus M
12、ed-Tech,Hangzhou)The registry(n=81)finished&in follow-upJena.ValveTM:(Transapical,Suzhou)The registry(n=114)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=10JiangsuN=6ShanghaiN=2TotalN=81En
13、rolling Study Sites2012-9-7 Start2014-6-3 finishFuwai Hospital41Case 1.TCT2014 Live Demonstration CaseFemale,77yrs,Risk Scores:STS 8.24%Maurice Buchbinder,MD Foundation for Cardiovascular MedicineHistory of Interventional Cardiology1977198419881989199719992000200220032004Maurice Buchbinder,MD Founda
14、tion for Cardiovascular MedicineAtrial fibrillation is a major source of cardiogenic embolism-related stroke（三）Source:Neurology,1978;Stroke,1985;European Heart Journal,1987;Lancet,1987 500,000 strokes per year AHA estimates that 15 20%of strokes/year are related to AFMaurice Buchbinder,MD Foundation
15、 for Cardiovascular MedicineWATCHMAN Device Frame:Nitinol(shape memory)Contour shape accommodates most LAA anatomy Barbs engage the LAA tissue Fabric Cap:Polyethyl terephthalate(PET)Fabric Prevents harmful emboli from exiting during the healing processBarbs160 PET fabric Device available in various
16、sizes:21,24,27,30 and 33 mm(diameter)Device diameter is measured across face of device Device Length=Device DiameterLAA Closurefor 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(
17、falls,poly-pharmacy)Autopsy&TEE data implicate LAA LAA Closure DevicesBarbs EngageLAA Wall160 PETfabricPercutaneous Ventricular Restoration（四）（四）Treatment GoalImprove hemodynamics by:Partition ScarLV Volumes ReductionLVED Pressure ReductionRestoring LV Conical ShapeNot preventing TorsionalContractio
18、nNot causing arrhythmiasProcedural aspects similar to a standard PCI(Duration 80 min/Flouroscopy time 20 min)A PATIENT WITH RESISTANT HYPERTENSION（五）（五）Hyperactivity of the renal sympathetic nerves plays a key role in hypertensionSymplicity HTN-2 Investigators,Lancet Published online November 17,201
19、0 DOI:10.1016/S0140-6736(10)62039-9Concept Description Catheter-based procedure using standard interventional techniques RF energy delivered through the renal artery wall to denervate the renal nerves RESISTANT HYPERTENSION CATHETER BASED TECHNOLOGIESRESULTS SYMPLICITY HTN 2*Trial performed with SYM
20、PLICITY CATHETER SYSTEM A device developed by Ardian The trasaction is subject to customary closing conditions,including U.S.and foreign regulatory clearancesEUCE mark in 2008No RCT evidenceSymplicity Registry in 5000 ptsRenal Denervation forResistant HypertensionSymplicity HTN-3:(NEJM 2014)No evide
21、nce of efficacyUSANo FDA approvalANATOMICAL LOCATION OF RENAL SYMPATHETIC NERVES Arise from T10-L1 Follow the renal artery to the kidney Primarily lie within the adventitiaThe Journal of Clinical Hypertension.14,pages 799801,2012Circulation.2002;106:19741979IABPAbrupt inflation after AV closure-incr
22、eases Aortic Root diastolic pressureAbrupt deflation upon AV opening decreases impedance to ejection(ie-afterload)Intra-Aortic Balloon Pump（六）（六）diastolic pressure systolic pressure afterload cardiac output filling pressures coronary artery perfusionECMO-extracorporeal membrane oxygenationvenous-=RA
23、 arterial=FACombines membrane oxygenator with pump Post cardiac arrestRV failurehours to daysmembrane actives harmful cytokinesExtraCorporeal Membrane Oxygenation(ECMO)（七）TandemHeart Centrifugal flow,lubricated mechanical bearing Disposable pump head short-term use(up to 7-10 days)Can be implanted p
24、ercutaneously as an LVAD,RVAD,BiVAD(in cath lab)lLVAD Cannulation:Inflow is placed in left atrium through septal puncture.Outflow is placed in femoral arterylPump generates flow of 1 to 5 LPM,with RPMs from 1,000 to 7,500,depending on cannula sizesComponents and Properties Minimal invasive Compact s
25、ize and lightweight Continuous flow and very quiet Up to 4-5LPM Priming volume of only 60ml Novel lubrication and anticoagulation systemControllerPumpImpella （八）Directly unload the left ventricleReduce myocardial workload and oxygen consumptionIncrease cardiac output and coronary and end-organ perfusionImpellaTM Device
