2019 - volume 74 (S1)
|Editorial The odyssey of interventional cardiology|
|The heart team : definition and organization. Point of view of the cardiologist|
Lancellotti P , Ancion A , Davin L , Dulgheru R , Gach O , Lempereur M , Marchetta S , Marechal P , Martinez C
Rev Med Liege 2019, 74(S1),5-9
Summary : The management of complex cardiovascular disease has changed considerably with the development of new care strategies. In cardiology, the «Heart Team» or literally «Equipe du cœur» occupies a prominent place in the latest European and American recommendations, particularly in the management of complex coronary or valvular diseases and in heart failure patients. The concept of «Heart Team» is based on the need for a multidisciplinary holistic approach based on evidence (respect of the recommendations of the scientific societies), the patient as a whole (comorbidities, preferences), risks and long-term benefits of the treatment selected and performed, as well as on the level of local expertise. It aims to determine the best management strategy for the patient, and perhaps to guarantee a better result (prognosis).
|Non-invasive imaging and interventional cardiology|
Davin L , Dulgheru R , Marchetta S , Lancellotti P
Rev Med Liege 2019, 74(S1),10-16
Summary : In the last decades, interventional cardiology has received fast and wide implementation as an effective alternative treatment to surgery for several congenital and acquired diseases. Imaging provides solutions for most clinical needs, from diagnosis to prognosis and risk stratification, as well as anatomical and functional assessment. In this article, we present recent innovations in medical imaging for structural heart disease and coronary artery disease, emphasizing the progress achieved in the field of multimodality imaging. Intra-procedural guidance can be facilitated by established multimodality cardiac imaging such as transesophageal 2D and 3D echocardiography and by novel techniques as echo-fluoroscopy overlay and 3D imaging fusion. Computed tomography and magnetic resonance imaging are particularly helpful for preprocedural morphology assessment and device sizing. Successful planning, guidance, and monitoring of interventions depend heavily on accurate imaging for both structural heart disease and complex coronary artery disease.
Gach O , Davin L , Lempereur M , Marechal P , Martinez C , Lancellotti P
Rev Med Liege 2019, 74(S1),17-21
Summary : Coronarography consists in selective angiography of the coronary arteries obtained invasively. It represents the gold standard for the anatomical exploration of the coronary arteries and establishes the first step for the indication of possible percutaneous or surgical revascularisation. According to substantial progress, it represents an essential diagnostic tool frequently used with, despite its invasive characteristic, a very low complication’s rate. The present article describes the patient’s preparation for this procedure, technical modalities, major indications, contraindications and possible complications.
|Invasive physiological evaluation of coronary artery disease|
Marechal P , Lempereur M , Gach O , Lancellotti P
Rev Med Liege 2019, 74(S1),22-28
Summary : Percutaneous or surgical coronary revascularization must only be realized if myocardial ischemia is clearly demonstrated. In practice, this ischemia is most often seeked by non-invasive tests. These ones are unfortunately not systematically realized or may bring equivocal results compared to angiographic images. Coronary angiography remains the test of choice for the evaluation of coronary disease, but visual analysis of coronary stenosis does not confirm their hemodynamic significance. The measurement of coronary flow reserve by FFR (“fractional flow reserve”) or iFR («instantaneous wave-free ratio») is a simple method to invasively assess the hemodynamic impact of a coronary lesion. Spastic angina, when suspected by clinical history, can also be confirmed during coronary angiography by the provocative methylergonovine test.
|Intracoronary imaging modalities in interventional cardiology|
Gach O , Davin L , Lancellotti P
Rev Med Liege 2019, 74(S1),29-33
Summary : According to technical and pharmacological innovations and to a better comprehension in pathophysiology, interventional cardiology has continuously progressed to push forward the frontiers of its indications. Despite these evolutions, it still uses an imaging modality based on X-ray, which presents numerous limitations in interpreting three-dimensional structures. The present chapter describes two available additive technologies used to optimize the resolution and the information obtained by intravascular imaging, adding key complementary information to angiography imaging : intravascular ultrasound (IVUS) and intravascular optical coherence tomography.
|Percutaneous transluminal coronary angioplasty: from revolution to evolution|
Gach O , Davin L , Lempereur M , Marechal P , Martinez C , Lancellotti P
Rev Med Liege 2019, 74(S1),34-38
Summary : In interventional cardiology, percutaneous transluminal coronary angioplasty (PTCA) definitely represents a revolution in the history of medicine, illustrating the medical community intention to replace aggressive revascularization intervention by less invasive procedure. Rapidly adopted by physicians and patients, its utilization has grown exponentially and in parallel, numerous technical progresses have pushed forward the frontiers of its indications. This article summarizes the principal evolution of this revascularization technique from its beginning until its last innovations, describing some technical characteristics and emphasizing on some changes and extension of its indications.
|Rotational atherectomy (Rotablator®) : complementary technique in management of undilatable coronary lesions|
Gach O , Lempereur M , Marechal P , Lancellotti P
Rev Med Liege 2019, 74(S1),39-43
Summary : In 40 years of existence, interventional cardiology has witnessed the introduction of numerous tools and techniques that have contributed to the important application’s broadening of percutaneous techniques, particulary in anatomical situations previously unfavourable, and which were, at that time, subject to surgical revascularization. Among these hostiles situations, one of the principal consists in failure to adequately dilate the lesions and/or to the inability to deliver and implant a stent appropriately, situations frequently associated with a high rate of procedural complications and poor long-term clinical outcomes. Thanks to the development of complementary dedicated techniques such atherectomy device, the treatment of most fibrotic and heavily calcified lesions has become feasible and safe. The present article describes the rotational atherectomy procedure, its indications and its clinical results.
|Percutaneous treatment of chronic total coronary occlusion|
Maréchal P , Davin L , Lhoest N , Lancellotti P
Rev Med Liege 2019, 74(S1),44-50
Summary : Although frequent, chronic total occlusion (CTO) has long been neglected by interventional cardiologists, considering that the risk of complications was too high compared to the expected benefits. The presence of a CTO has therefore been an essential decision-making factor for referral of patients with multivessel disease to surgical coronary revascularization, or for the choice of the optimization of medical treatment in patients with an isolated CTO. The recent years technical progress of and the development of specific tools for percutaneous treatment of CTO have allowed to gradually change the vision within the cardiology community as the benefits in terms of quality of life and of complete revascularization have been clearly demonstrated. In contrast, the benefit on survival and improvement of left ventricular systolic function, although highlighted in meta-analyses and in some registries, has yet to be demonstrated by prospective randomized studies. The different reasons for considering percutaneous revascularization of CTO are discussed in this article. We will also review how to select patients based on clinical and angiographic data
|Alcohol septal ablation for obstructive hypertrophic cardiomopathy|
Lancellotti P , Gach O , Davin L , Marchetta S , Dulgheru R
Rev Med Liege 2019, 74(S1),51-56
Summary : Alcohol septal ablation has become an attractive alternative to surgical myomectomy in symptomatic patients with obstructive hypertrophic cardiomyopathy. Its purpose is to achieve a therapeutic infarction in the sub-aortic territory responsible of the obstruction. It is indicated in symptomatic patients resistant to optimal medical treatment and having a left intraventricular gradient equal or higher than 50 mmHg, spontaneous or with exercise. The selection of candidates must be rigorous and the procedure must be performed in an experienced center, associating interventionalists and echocardiographists. Alcohol septal ablation is preferred in cases of favourable coronary anatomy, sub-aortic obstruction and absence of associated mitral valve defect. The septal alcohol technique is fast, effective and safe. The per-procedural contrast echocardiography helps identifying whether the myocardial segment is vascularized by the septal branch to be occluded. The benefits of alcohol septal ablation are comparable to those seen with surgical myectomy in terms of functional class, exercise capacity, and gradient regression. The morbidity and mortality observed in the short and mid terms are globally equivalent to that of the surgical intervention. The major complication is dominated by the occurrence of complete atrioventricular block requiring the implantation of a definitive pacemaker, a complication in sharp decline since the contrast ultrasound-guided technique has become widespread.
|Lower extremity artery disease. Angioplasty and stenting in 2019.|
Sprynger M , Maréchal P , Moonen M , Martinez C , Lancellotti P
Rev Med Liege 2019, 74(S1),57-63
Summary : Lower extremity artery disease (LEAD) is frequent and too often neglected. The ongoing evolution of endovascular techniques has revolutionised its management. Vascular surgery is still recommended in specific clinical situations. It can be performed alone or combined with angioplasty-stenting in a hybrid procedure. Various parameters related to the patient, his pathology and to the medical team must be considered especially as randomized trials comparing devices and techniques are lacking. Technical progress should not mask the high cardiovascular morbi-mortality risk of these patients. Therefore LEAD must be detected as soon as possible and optimally managed by a multidisciplinary team. According to clinical stage and comorbidities, the team can include a general practitioner, an angiologist, a cardiologist, a nephrologist, a diabetologist, an oncologist, a radiologist, a vascular surgeon, a dermatologist, etc. Medical treatment of atherosclerosis and prevention are mandatory, as well as walking exercise. Due to its high cardiovascular and amputation risk, chronic limb-threatening ischemia must be quickly and optimally managed by a multidisciplinary team.
|Transcatheter aortic valve replacement : from a concept to a medical revolution|
Martinez C , Gach O , Radermecker MA , Lancellotti P
Rev Med Liege 2019, 74(S1),64-72
Summary : Since the first transcatheter aortic valve implantation (TAVI) in 2002, the paradigm for the treatment of severe aortic stenosis has changed. In the recent past, medical therapy with or without balloon aortic valvuloplasty was the only option for inoperable patients but now, TAVI has become the treatment of choice for these patients and the preferred alternative for high-risk operable patients. Surgical aortic valve replacement (SAVR) currently remains the gold standard for patients at low operative risk. As randomized trials have demonstrated comparable (or better results with TAVI) between TAVI and SAVR in the high-risk population, there is now a clear trend towards performing TAVI even in intermediate-risk. Nevertheless, there are still questions regarding TAVI involving paravalvular leak, stroke, pacemaker requirements, and durability, which remain to be more definitively answered before TAVI can routinely be performed in lower risk and younger population. Improvements in patient selection, multimodal imaging, and third generation devices have significantly decreased the incidence of TAVI complications. A role for post-procedure antithrombotic or anticoagulant management remains unanswered. Waiting for current studies to provide us with clear answers to these questions, it is the Heart Team’s task to determine the optimal treatment for each patient based on risk scores, frailty metrics, comorbidities, patient’s preference, and potential for improvement in quality of life.
|Percutaneous mitral interventions|
Lempereur M , Dulgheru R , Marchetta S , Davin L , Lancellotti P
Rev Med Liege 2019, 74(S1),73-81
Summary : After aortic valve diseases, mitral valve diseases represent the most numerous indications of surgical or percutaneous valvular intervention. Surgical management is favoured in severe symptomatic mitral regurgitation. In case of high or prohibitive surgical risk, new techniques are developed to allow percutaneous, less invasive management. In these circumstances, MitraClip® allows the treatment of mitral regurgitation in case of adequate valve morphology. Percutaneous balloon valvuloplasty is currently the first-line treatment of mitral stenosis related to rheumatic disease when anatomical features are favourable. Alongside the Inoue technique, which remains the classical procedure, other approaches are available with encouraging results.
|Percutaneous closure of paravalvular leak|
Lancellotti P , Lempereur M , Marchetta S , Dulgheru R
Rev Med Liege 2019, 74(S1),82-86
Summary : Paravalvular leaks (PVL) are a serious complication after surgical or transcatheter aortic valve replacement. They are mostly small and unimportant. When they manifest clinically (1 to 5 % of PVL), they can become responsible for severe hemolytic anaemia or cause congestive heart failure. For years, surgical re-intervention has been considered the treatment of choice for symptomatic patients with PVL. However, surgical re-intervention is associated with a high risk of morbidity and mortality. Percutaneous PVL closure is a less invasive alternative to surgical re-intervention. The safety and feasibility of percutaneous PVL closure has been confirmed in several studies. In this article, we discuss the issue of PVL and their percutaneous management.
|Percutaneous treatment of atrial septal defect and patent foramen ovale|
Lempereur M , Lancellotti P
Rev Med Liege 2019, 74(S1),87-96
Summary : Atria septal defect (ASD) is one of the most common congenital heart disease. ASD can be responsible for a volume overload of the right chambers associated with an increased morbi-mortality. In these circumstances, percutaneous closure of ASD secundum-type is recommended as a first line therapy. The persistence of a patent foramen ovale (PFO) is found in approximately 25 % of adults. This anomaly can be responsible for paradoxical embolism, especially cryptogenic stroke. Recent studies have shown a clinical benefit to the percutaneous closure of FOP in cryptogenic stroke, with a modest, but significant, decrease in the risk of recurrence. In this article, we discuss the indications and procedure for percutaneous closure of ASD and PFO.
|Percutaneous left atrial appendage occlusion for thromboembolism protection in patients with atrial fibrillation|
Lempereur M , Davin L , Dulgheru R , Lancellotti P
Rev Med Liege 2019, 74(S1),97-103
Summary : Atrial fibrillation (AF) is the most common clinical arrythmia and can be associated with severe thromboembolic complications. For different reasons, a large number of AF patients who would benefit from oral anticoagulation (OAC) are not treated. In case of contra-indications to long-term OAC, left atrial appendage (LAA) closure allows the exclusion of the LAA from the systemic circulation and significantly reduces the thromboembolism risk. Results from large randomized trials show that this technique is non-inferior in terms of efficacy compared to OAC and that it can significantly reduce the rate of haemorrhagic complications. Large-scale registries show promising results in patients with contra-indications to long-term OAC. Clinical trials are under way to define the role and spectrum of LAA occlusion and to optimize post-procedural treatment.
|Micra® leadless pacemaker|
Lancellotti P , Gach O , Marechal P , Robinet S
Rev Med Liege 2019, 74(S1),104-108
Summary : The Micra® leadless pacemaker has demonstrated both safety and efficacy in the short and mid-term as an alternative to conventional transvenous pacemakers. This technology provides a new solution, especially for patients without conventional venous approach and for older patients with atrial fibrillation presenting with symptomatic bradycardia. The advantages of this approach are multiple : a miniature technology therefore less invasive, short procedure, no stimulation leads, or need to create a surgical pocket with a reduced risk of infection. The pacemaker’s battery has a life expectancy similar to that of a conventional transvenous pacemaker. In this article, we discuss the characteristics of Micra® versus the traditional transvenous pacemaker.
|Arterial hypertension and renal denervation : fantasy or reality ?|
Martinez C , Lancellotti P
Rev Med Liege 2019, 74(S1),109-114
Summary : Sympathetic hyperactivity is involved in the early stages of hypertension (HTN) and the mechanism persists during the course of HTN until organ damage and significant increase in cardiovascular risk. Radiofrequency renal denervation (RDN) using a percutaneous catheter inserted into the renal artery helps to destroy adventitial sympathetic nerve fibers, interrupting the connections between the renal sympathetic system and the central nervous system. After the first very encouraging clinical results in a small number of patients, the SIMPLICITY HTN-3 study halted the expansion of the technique because of negative results. From there, the technique has been redesigned conceptually as well as technically with the development of a new quadripolar spiral catheter. The first results of the SPYRAL program show this time a proven efficacy in hypertension and a larger study is underway. The results of this trial will help us to decide definitively on the future of this technique. Other pathologies such as heart failure, atrial fibrillation, obstructive sleep apnea and insulin resistance could also be improved by the RDN and studies to demonstrate this are ongoing.