Dr. Andreas Gruentzig
“I don’t know how anyone can do these procedures without measuring pressures!”
That’s what Andreas Gruentzig, the father of coronary angioplasty, said to me back in 1985. He knew that looking at the angiogram alone was not sufficient for judging the blockage in an artery. Integral to the design of his technological breakthrough, the double-lumen angioplasty balloon, was a feature which allowed him to measure the blood pressure at either end of the arterial blockage. At the start of the procedure, he could quantify how significant the blockage was; when he was done inflating the balloon, he could see the benefit of the dilatation. The post-angiogram might look good, but the pressures sometimes signaled that blood flow through the area was not. So, inflate again. And maybe again. OK, pressure now looks good, we’re done! Pretty simple. Not brain surgery. Continue reading
This week started off with me watching a demonstration of fractional flow reserve (FFR) during multivessel PCI. This very instructive case was transmitted live from Hammersmith Hospital in London and featured Dr. Justin E. Davies showing how to perform FFR and, more importantly, how the use of FFR changed the treatment plan for this patient.
The angiogram had shown three intermediate blockages (LAD, OM, RCA) and, as such, this patient might have been a candidate for CABG instead of PCI. However, when FFR was used to measure whether or not these blockages were ischemic, two were found to be hemodynamically insignificant: it would be safe to defer stenting and treat them medically. The third lesion in the LAD clearly was the cause of the symptoms and stenting would have benefit for the patient. Continue reading
The coronary angiogram is often referred to as a road map of the heart. As such, it serves the cardiologist and cardiac surgeon well. It shows where the coronary arteries are, how they intersect, the angles of the branches, etc. There are diagrams of these anatomical features in many textbooks, but the reality is that these characteristics can vary from individual to individual, so it’s necessary to get a road map for each individual in whom an intervention is being contemplated. Then, of course, there’s the issue of narrowings in the coronary arteries. Should these receive stents? Should they be bypassed? Should they be left alone and treated with medical therapy? Continue reading
Dr. Charles Dotter’s “logo”: angioplasty is plumbing
How does a physician treat a heart attack where the blood flow to the heart muscle is suddenly cut off by a blocked artery? In the most severe cases, the ST segments on the ECG are elevated, signalling that a major part of the heart muscle is at risk. It’s called a STEMI (ST-Elevated Myocardial Infarction). And, if you subscribe to the concept that the heart and circulation are like the plumbing in your house, like Dr. Charles Dotter did (he invented the concept of angioplasty and, in his offbeat humorous way, he used the graphic to the left as his logo), then you would assume there are two major ways to treat the problem: use Drano to dissolve the blockage or use a mechanical roto-rooter to clear it out. Continue reading
Nortin M. Hadler, MD, MACP, MACR, FACOEM
I’m in shock. Dr. Nortin Hadler of the University of North Carolina has proclaimed that the era of coronary angioplasty is over.
Poor, poor angioplasty…you were barely 36 years old, but you’re no longer needed. Guess we’re going to have to find a new name for our web site!
Of course, my first thought upon seeing this Op-Ed piece posted today on The Health Care Blog was that it was yet another article railing against the overuse of stents in patients with stable angina. Continue reading
Former President George W. Bush received an angioplasty and stent this morning at Texas Health Presbyterian Hospital Dallas. The stent was recommended by Bush’s doctors to open a blockage in one of his coronary arteries, found yesterday during what was described by Bush spokesman Freddy Ford as his annual physical exam at the Cooper Clinic in Dallas. Continue reading
Filed under Angiograms, Appropriate Use Criteria (AUC), Cardiac CT, Celebrity Patients, COURAGE, Drug-Eluting Stents, FFR, Imaging, Media Coverage, Non-Invasive Testing, Optimal Medical Therapy, Stent
Yesterday’s edition of USA Today carried an article by Peter Eisler titled, “Six common surgeries often done unnecessarily” — and, you guessed it, angioplasty and stents were at the top of the list of “six common surgeries that carry significant risks of being done without medical necessity, according to federal data and independent studies.”
I was a bit taken aback because I was not aware of any new study, federal or independent, that concluded stents were being vastly over-used. And it turns out that there wasn’t one. Continue reading