Stenting For Multivessel Coronary Artery Disease

Hardening of arteries (atherosclerosis) not only causes lesions in the blood vessels but also results in the obstruction of blood supply to the heart muscles. During strenuousactivities, narrowed coronary arteries won’t be able to supply enough blood to the myocardium leading to angina (chest pain). Coronary artery disease (CAD) can be fatal as it is a major cause of heart attacks (myocardial infarction). CAD  can also lead to disability and decreased quality of life. Managing coronary heart disease has always been a challenge to cardiologists due to the increasing complexity of lesions and location of stenosis. Symptomatic Multivessel coronary artery disease that affects two or more epicardial vessels is a case in point. Optical therapeutic approach for treating multivessel disease (MVD) is still a point of fervent discussion within the medical community.

There are mainly three treatment modalities available for patients with MVD which includes medical therapy, non-invasive percutaneous coronary intervention (PCI)and coronary artery bypass graft (CABG) surgery. Though bypass surgery was a preferred approach over stenting in MVD treatment, the recent advancements in catheterization procedures and technologies have reignited an interest in percutaneous intervention. Drug eluting stenting (DES) has proven successful in overcoming the adverse clinical outcomes of bare metal stenting (BMS) by a greater extent.  Moreover, widespread application of fractional flow reserve measurement technique has made it easier for physicians to choose between the non-invasive percutaneous coronary intervention and pharmaceutical treatment for a CAD patient. As per the famous FAME study, it has been proved that FFR guided percutaneous approach can ensure better outcomes in managing the symptomatic multivessel coronary disease. Followed by that, the FAME 2 study results demonstrated PCI along with medical therapy can ensure better outcomes when compared to medical therapy alone.

Innovative advancements in the cath lab set up and interventional environments have been helping physicians to perform both interventional and surgical procedures with great accuracy and precision. For example, Philip’sXper Flex Cardio equipped with multiple functionalities aids physicians in treatment decisions. This hemodynamic cardiac monitoring system supports FFR measurements and provides 16-lead ECG analysis, culprit Artery detection and patented ST maps. Philip’s Xper Flex Cardio system and similar physiomonitoring systems can surely enhance the efficiency on multiple levels.

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FFR-Guided Percutaneous Coronary Intervention Gain Advantage Over Medical Therapy

Coronary heart disease also known as ischemic heart disease can be described as a condition where the coronary arteries are severely narrowed because of atherosclerosis. When the heart muscle is starved of oxygen and nutrients, it induces chest pain (angina). However, in some cases there is a complete blockage in blood supply leading to heart muscle damage and myocardial infarctions (heart attacks). Some of the common symptoms of coronary artery disease (CAD) to watch out for include chest pain, nausea, dizziness and shortness of breath. It is advisable to seek medical treatment immediately before the symptoms turn severe and frequent. Remarkable advances in the diagnostic procedures, standard blood flow measurement techniques and medical imaging devices have been helping cardiologists to evaluate CAD in a better way.

Angiography is the first-line diagnostic investigation recommended by cardiologists. Having a detailed physiological analysis of stenosis in the arteries is essential to choose between the varied treatment options – pharmaceutical therapy, FFR-guided percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) surgery.  However, several studies and clinical trials have pointed out the limitations of coronary angiography in estimating the degree of luminal narrowing. Standard blood flow measurement techniques and imaging tools can provide a detailed visualization of the blood flow and performance of the heart.  Fractional Flow Reserve (FFR), as a case in point, assists the physicians in identifying the ischemic and non-ischemic lesions. Results published by the FAME (Fractional Flow Reserve Versus Angiography in Multivessel Evaluation) study demonstrated the superiority of FFR over angiography in deciding whether or not to stent the lesions. Moreover, it has been proved that FFR-guided percutaneous coronary intervention assure better outcomes and significantly lower complication rates.

Medical therapy was considered to be the best approach for patients with stable CAD and significant stenosis. Results from the latest FAME 2 trials conclude that FFR-guided drug-eluting stenting (PCI) is superior to medical therapy for managing stable coronary disease. Two year data from FAME 2 trials shows a great reduction in the major adverse cardiac events and decrease in the risk of urgent revascularization. As per the latest FAME 2 study results, FFR-guided PCI plus optimal medical therapy shows sustained clinical and economic benefits when compared with medical therapy alone.

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Treatment of Coronary Bifurcation Lesions

Interventional cardiology has been witnessing technological advances and improved success over the last decade. Increasing success and safety levels of interventional cardiac procedures has improved the outcomes for patients with coronary artery disease (CAD). An underlying pathologic process called atherosclerosis can make the coronary arteries lose their flexibility and elasticity over time. Plaque build-up causes the artery to narrow thereby impairing the blood flow to the heart tissues. One of the common coronary heart disease symptoms is chest pain or discomfort accompanied by shortness of breath. In most cases, the pain may occur during physical or emotional stress. Early diagnosis and treatment is the best way to tackle heart disease and live a quality life. That is why it is often advised to seek immediate medical attention when faced with common coronary heart disease symptoms.

Advanced diagnostic techniques and therapeutic approaches are available for detecting and treating CAD conditions. Percutaneous coronary intervention (PCI) with its minimally invasive procedure and reduced complication rate has superseded Coronary Artery bypass Grafting (CABG) in the treatment of single vessel CAD. Despite the advancements in stent technology and catheterization tools, interventional cardiologists find it a challenge to treat some complex coronary lesions that are often associated with higher restenosis, worse outcomes and greater complication rates. Complex bifurcation lesions are a case in point. When defined in medical terms, coronary bifurcation lesions can be defined as – “a lesion ≥50% diameter stenosis involving a main branch and/or contiguous side branch with a diameter of ≥2.5 mm”. Around 15% to 20% of the CAD lesions are bifurcation lesions, which present a challenge to interventional cardiologists.  Even though coronary angiography is considered as the gold standard for diagnosing heart ailments, angiographic evaluation alone can’t provide substantial information about the stenosis.

Innatelimitations of coronary angiography were a major concern in devising a right risk stratification approach for the complex lesions. Moreover, plain balloon angioplasty and bare metal stenting results were suboptimal because of the high rates of restenosis. But with the introduction of fractional flow measurement, advanced medical imaging methods and bioabsorbable drug eluting stent technology, percutaneous treatment of complex bifurcation lesions seems possible. Several studies and clinical trials are going on with the objective to address concerns related to stenting, and will hopefully hold the key to the successful treatment of bifurcations.

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Fractional Flow Reserve Measurement For Assessing Coronary Stenosis

Coronary Heart Disease which occurs as a result of atherosclerotic plaque-build up in the inner walls of coronary arteries is a common heart ailment that has been affecting millions of people worldwide. The field of cardiac science and interventional cardiology has been striving hard to devise an optimal approach to manage coronary artery disease (CAD).  Evaluating the physiological significance and severity of lesions is a challenging factor in most cases which is why pressure-based Fractional Flow Reserve measurement method was introduced. FFR provides a well-validated index in deciding between coronary stenting and medical therapy. Thses days, it is considered an indispensable clinical tool in the catheterization laboratory.

Pressure-based Fractional Flow reserve measurement provides the ratio of normal blood flow to the maximum achievable blood flow in the same coronary artery, given the maximal vasodilated condition. Lesions that measure a FFR value of less than 0.75 need percutaneous coronary intervention (PCI) with stenting, while lesions of a value higher than 0.75 should be managed with pharmacological treatment. Minimally invasive FFR technique possesses several special features that make it a gold standard for diagnosis in the catheterization laboratory. A well-defined cut-off value, unequivocally normal value for every patient and narrow gray zone are some of the major characteristics. Fluoroscopy guided pullback pressure recording performed during the catheterization proves to be a great tool in obtaining detailed spatial information and evaluating the hemodynamic effect of stenoses. The sensor placed in the distal coronary artery during FFR procedure is simply pulled back under fluoroscopic guidance to measure the pressure levels across the blood vessel. Helping the interventional cardiologist to assess the extent of lesions and exact location of the pressure drop, fluoroscopy guided pullback pressure recording proves to be a great diagnostic tool for different patient subsets.

Bifurcation lesions that involve the proximal main vessel, the distal main vessel and the side branch are one of the most challenging lesion subsets. Associated with restenosis, greater complications and lower success rates, severe coronary artery bifurcation lesions pose a major challenge for the interventional cardiologists. PCI is not considered as a favourable approach to treat the symptomatic coronary artery bifurcation lesions. However, with the advent of fractional flow reserve method and pullback pressure measurements, FFR guided PCI assures excellent results and safer outcomes.

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Left Main Coronary Artery Stenting – Is it a Safe Approach?

Common coronary heart disease (CHD) also to referred as ischemic heart disease is the leading cause of heart attacks and angina. Atherosclerotic plaque build-up in the inner walls of coronary arteries hardens the blood vessels and restricts the blood supply to heart. Lack of oxygen leads to the damage or death of heart tissues which results in ischemia. Clots in the arteries can be life-threatening, as it eventually restricts or completely cuts off the oxygen-rich blood supply resulting in angina or myocardial infarctions (heart attacks). Some of the common coronary heart disease symptoms include sharp pain or pressure in the chest that travels to the arms and jaw, shortness of breath, light-headedness and fatigue. Even if the symptoms are mild, seeking immediate medical attention is necessary.

The left main coronary artery (LMCA) is responsible for supplying blood to a large segment of the myocardium and stenosis of LMCA will lead to acute cardiac events. Coronary Artery Bypass Graft (CABG) has been considered the standard therapeutic option for treating left main coronary artery disease (LMD), because it provides better survival rates when compared to drug therapy. Percutaneous coronary intervention (PCI) with bare metal stents tended to result in in-stent restenosis and a need for revascularization, making it a risky choice. But with the advent of state-of-the-art catheterization technologies, drug-eluting stents and antithrombotic agents, newer left main coronary artery stenting has made it a viable option for patients with high surgical risks or co-morbidities.

Ongoing clinical trials and research studies have been evaluating the effectiveness of using drug-eluting stents (DES) for Unprotected LMCA compared with CABG. Targeted lesion revascularization advantages of minimally invasive newer left main coronary artery stenting can be considered as a safe and effective alternative to CABG, especially for patients in a high-risk group. Even though DES is considered as a great step in interventional cardiology, concerns over the polymer-associated complications and risk of thrombosis have raised questions about its safety. Drug-eluting stent thrombosis is closely associated with acute myocardial infarction resulting in mortality and morbidity. Biocompatible and bioabsorbable stents that are developed in order to overcome issues such as drug-eluting stent thrombosis is a recent development in the interventional community that offers a promising approach for PCI in treating left main coronary artery disease. But in the meantime, cardiologists have to choose either PCI or CABG to manage the left main disease based on the SYNTAX score and medical-surgical consultation. 

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