por John R. Fischer
, Senior Reporter | March 09, 2020
From the March 2020 issue of HealthCare Business News magazine
By circumventing anatomic barriers, today’s cardiologists are getting to the heart of the issue less invasively than ever before.
It wasn’t so long ago when patients with ventricular septal defects had no choice but to undergo sternotomies. The invasive procedure was carried out with a vertical incision made down the sternum so it could be “cracked” open for the physician to find and close the defect, recalls Dr. J. Jeffrey Marshall. Treatments for this condition, as well as other structural heart diseases, have come a long way since then.
“They can all be done by arteriotomy, usually from femoral access but they can be done from the axillary artery too,” Marshall, chief of the Northside Hospital Cardiovascular Institute and a board member of the Accreditation for Cardiovascular Excellence (ACE), told HCB News. “They can be done transcavally. You start in the vein and end up in the aorta. People have done things transcarotid. There are all kinds of different access points for those structural heart disease procedures.”
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Due to the reduced invasiveness of these procedures, many of them are no longer performed in the OR but can be done in smaller cardiac catheterization labs. This shift has prompted clinicians to re-evaluate the role of the lab, and implement new guidelines and equipment to accommodate its operational needs and ensure the safety of patients and staff inside it.
A new role
Cardiac cath labs were primarily diagnostic 30-40 years ago and not designed to treat patients. Today’s labs are still the site of diagnostic exams, but also are where procedures for valvular and structural heart diseases take place, says Dr. Khaldoon “Kal” Alaswad, director of the cardiac catheterization laboratory at Henry Ford Hospital.
“Valvular heart disease management became possible in the cath lab with TAVR (transcatheter aortic valve replacement) for severe aortic valvular stenosis, even in patients with surgical risk,” he said. “Innovation in the management of mitral valvular disease is also moving from the OR to the cath lab. For instance, the treatment of mitral valve regurgitation with the mitral valve clip was recently approved, and complex mitral valvular stenosis can be treated with a transcatheter valve.”
Other cardiac-related diseases that can be addressed in the cath lab include complex peripheral artery and venous diseases; pulmonary embolism; hemodynamic support; and coronary artery disease. Chronic total occlusion is another one, with the success rate for CTO percutaneous coronary intervention (PCI) rising from 60 percent to about 90 percent, and complication rates less than seven percent.