The evolution of embolic protection devices

Manipulation of atherosclerotic lesions with wires, catheters, balloons, stents and other intravascular devices during invasive procedures releases are associated with small, but clinically important and discrepant, rates of procedural complications, including cerebral and myocardial ischaemic events, cranial nerve injury and access site haematoma. Embolic protection devices (EPDs) may lower the rate of ipsilateral ischaemic events during CAS and are considered by the majority of interventionists to be mandatory during CAS. Embolic protectiondevices can be divided into three distinct types based on their mechanism of operation: distal occlusion aspiration devices, distal filters and proximal occlusion aspiration devices.

The importance of these devices are discussed in articles on Radcliffe Cardiology’s website, home to a number of cardiology review journals including Interventional Cardiology Review, European Cardiology Review and Arrythmia & Electrophysiology Review. Current evidence suggests improved stroke and death outcomes in contemporary series evaluation proximal EPDs compared with earlier series employing filter-type protection. The use of EPDs has been shown to substantially reduce the risk of major adverse cardiovascular events in patients undergoing saphenous vein graft (SVG) and percutaneous coronary intervention (PCI) although the actual use of these devices in the real-world is surprisingly low. EPDs are used routinely for carotid stenting and being tested for peripheral and renal artery interventions.

Heart electrophysiology procedures which require catheters threaded to the heart also place patients at risk of embolisms. Invasive management of heart rhythm disorders by heart electrophysiology procedures including catheter ablation and device implantation has been established as the therapy of choice for most cardiac arrhythmias, and the number of patients and complex procedures has increased dramatically. An important way to promote quality in these procedures is by increasing public awareness about the importance of heart rhythm disorders. This in turn often results in increasing public resources to reduce the impact of heart rhythm disease on society.

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The importance of Fractional Flow Reserve (FFR) in Coronary Artery Disease Management

Patients with insufficient oxygen supply to the heart, or myocardial ischemia, may benefit from coronary intervention (PCI), such as stenting of partially occluded vessels. The course of treatment for patients with CAD depends on disease severity. While coronary angiography is always performed prior to PCI, it may underestimate or overestimate the severity of specific cardiac lesions. In contrast, Fractional Flow Reserve (FFR) provides a quantitative ratio of the actual blood flow in a narrowed artery, compared with the normal achievable blood flow and is more accurate in diagnosing ischemic lesions than angiography alone. Using this functional or morphological measurement, Fractional Flow Reserve (FFR) can quantify the severity of specific stenoses.

A 2012 report prepared by multiple cardiology medical societies addressed the use of FFR in appropriate use criteria for diagnostic cardiac catheterization. These appropriate use criteria recommend FFR for diagnostic evaluation of most CAD cases determined by angiography to be of intermediate, obstructive/significant or indeterminate severity. Further targeted appropriate use criteria update for coronary revascularization were launched in the same year by various societies including the ACCF, SCAI, STS, AATS, AHA, ASNC, HFSA and SCCT. Within the criteria, the use of diagnostic cardiac catheterization is recommended as an additional invasive measurement to determine the need for PCI for patients with coronary narrowing of uncertain severity.

The critical role of physiological fractional flow reserve (FFR), in guiding interventions is discussed at a number of cardiology conferences. One such cardiology conference is the European Society of Cardiology (ESC) 2014 which takes place in Barcelona this year. The ESC hosts the world’s largest and most influential cardiovascular event every year in August. Record numbers of hot line sessions and abstracts were submitted this year and the congress is on track to host the largest number of delegates in its history.

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Advances in mitral valve disease treatment

Treatment of mitral valve disease is a very common condition, affecting about 3% of the population. Recent years have seen major advances in minimally invasive mitral valve surgery and several new catheter-based techniques are being clinically evaluated. Indeed, percutaneous therapy has emerged as an option for treatment of mitral valve disease including regurgitation and prolapse for selected, predominantly high-risk patients.

Many patients with symptomatic, severe mitral regurgitation never undergo surgery due to a deemed excessive surgical risk and complete endovascular surgery is therefore an exciting alternative for these patients. Several technologies are being investigated, most of them based on long-standing surgical techniques. Over 1,000 patients have been treated worldwide with the Mitraclip system for leaflet plication, for example. This device has gained the CE mark and there has been a shift in the spectrum of candidates suitable for this technique, as recent experiences have shown that adverse mitral anatomies and functional MR patients may also benefit from this form of complete endovascular surgery and device.

An overview of recent technology for mitral heart disease can be found on Radcliffe Cardiology’s website which has a strong focus on cardiologist education. Anatomic evaluation seems crucial in order to select the most suitable patient for the procedure and cardiac computed tomography angiography is probably the best tool for patient selection. Indeed, mitral regurgitation is a complex disease with many aetiologies and pathophysiologies and therefore it seems unlikely that a single device can fix the problem. The first challenge is in fact to really understand MV disease which is why focus on education for cardiologists is so important, then a combination of techniques will be necessary for a satisfactory MR repair. Close collaboration between interventional cardiologists, cardiac surgeons, imaging cardiologists, basic scientists and the industry is essential for these technologies to progress and become a real alternative for this group of patients.

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