CARDIAC INTERVENTIONAL THERAPY

Dr. TONY E. PARENGKUAN,

Sp.JP (Bag. Jantung FK UHT
Surabaya)

History of cardiac catheterization

1929: Werner Forssmann - chest X-ray and document the first right heart
catheterization study
1941: Andr Cournand - more detailed right heart studies
1947: Zimmerman - the first simultaneous left and right heart
catheterization study.
1953: Sven-Ivar Seldinger - the eponymous technique for percutaneous
vascular access.
1956: Forssmann, Cournand, and co-worker Dickinson Richards were
awarded the Nobel Prize
1959: Mason Sones - new technique for selective coronary angiography
1977: Andreas Grntzig - the first coronary angioplasty
The first coronary artery stents were implanted in 1986. Since the early 1990s
there has been a rapid and successful development of PCI procedures and
devices.

KATETERISASI JANTUNG
Cardiac catheterization is the passage of a catheter
into the left and/or right heart to provide diagnostic
information about the heart and/or blood vessels.

ANGIOGRAFI KORONER
Coronary angiography is a procedure where contrast
material is injected into the coronary arteries under
X-ray guidance in order to define the coronary anatomy
and determine the degree of luminal obstruction.
It remains the standard investigation for patients
with known or suspected coronary artery disease.

CATHETERIZATION LABORATORY FACILITIES

Cardiac catheterization (cath lab) facilities have

several venues, including:
Traditional hospital-based laboratories with in-house

cardiothoracic surgical programs

Hospital-based laboratories without on-site surgical programs
Free-standing laboratories
Mobile laboratories
The goals of free-standing and mobile cardiac catheterization facilities
are to reduce cost while offering services in a convenient location for
low-risk patients. The safety of mobile catheterization in properly
selected low-risk patients has been well established and appears
comparable with that of other settings.

 As a result of the documented safety and costeffectiveness of diagnostic cardiac catheterization in the
outpatient setting, there has been increasing use of this
approach.
Currently, about 50 percent of most hospital-based
procedures are done on an outpatient basis. In general,
patients who require preprocedural hospitalization for
diagnostic catheterization are uncommon, such as those
with severe congestive heart failure or renal insufficiency
requiring prehydration.
Noninvasive testing can identify patients who would be
more appropriately evaluated in a setting in which cardiac
surgery is available, such as patients with severe ischemia
discovered during stress testing, ischemia at rest, known or
highly suspected severe left main or proximal three-vessel
disease, critical aortic stenosis, and severe comorbid

Tim Kateterisasi Kardiovaskuler

Dokter
Adalah seorang kardiolog yang telah mendapat
pendidikan khusus bidang intervensi. Dalam
pelaksanaannya dapat dibantu dokter/residen
kardiologi.
Perawat

Perawat yang terlibat adalah

yang sudah mendapat latihan khusus bidang
kateterisasi diagnostik maupun intervensi.

Radiografer

Tenaga yang mampu

mengoperasikan mesin kateterisasi dan telah
mengikuti latihan khusus

CATH LAB PERSONNEL

Medical director
Physicians
Nurses
Cardiology trainees (fellows)
Physician extenders, including nurse practitioners
and physician assistants
Radiological technologists

All members should be trained in cardiopulmonary resuscitation

and preferably in advanced cardiac life support.

EQUIPMENT
radiographic system
physiological / hemodynamic data monitoring,
including recording and acquisition instrumentation
sterile supplies
emergency cart
support equipment, consisting of a power injector,
image
processing (preferably with digital archiving
capabilities),
adequate viewing equipment, and a uniform method of
report generation.

A. Persiapan penderita
1. Informed Concent :
Sebelum ditandatangani, dokter operator/asisten harus:
a. menjelaskan tindakan dan prosedur yang akan dilakukan.
b. menjelaskan risiko tindakan kateterisasi, yaitu:
* risiko mayor: kematian, stroke, infark miokard
* risiko minor: perlukaan vaskuler, reaksi alergi, perdarahan, hematoma.
c. memberikan gambaran data risiko tindakan, misalnya; risiko emboli
< 1:500, risiko perforasi < 1:500
2. Meningkatkan rasa percaya diri penderita
a. Dengarkan keluhan penderita
b. Menjelaskan secara gamblang tujuan tindakan
c. Tim tidak boleh ragu-ragu (meyakinkan), bersikap sopan dan profesional
d. Menjelaskan kepada keluarga tentang tujuan kateterisasi sebelum
tindakan
3. Evaluasi EKG ulang
4. Evaluasi Vital sign: nadi, tekanan darah, suara nafas, suara jantung
5. Catheterization's orders: sehari sebelum kateterisasi (malam harinya)
perintah persiapan ditulis pada status penderita misalnya; obat yang
diteruskan, obat yang dihentikan, pemberian premedikasi bila diperlukan,
cukur rambut pubis, tidak perlu puasa, pasang infus tangan kanan.

B. Persiapan di Lab. Kateterisasi

1. Melakukan evaluasi kembali sesuai "checklist"
a. Identitas penderita
b. Tekanan darah, nadi dan EKG
c. Riwayat allergi
d. Terapi antikoagulan? jika ya , PTT ..?
e. Informed consent
f. Pemberian obat sesuai catheterization's order
g. Premedikasi apakah sudah diberikan ?
h. Apakah pasien sudah mengerti akan tindakan yang akan dilakukan
2. Check Defibrilator (lakukan test)
3. Pasang EKG monitor
4. Check IV line
5. Sterilisasi :
a. Desinfeksi daerah inguinal kiri dan kanan dengan larutan betadin 3 %
b. Pasang duk steril
c. Persiapkan : anastesi lokal, peralatan monitor tekanan (pressuredome, manifold), seldinger, spuit 10 cc, guide-wire pendek, sheath
kateter, kateter diagnostik, kateter multi purpose MPA dan kontras,
persiapkan power-injector"

INDIKASI KATETERISASI JANTUNG KANAN

Diagnostik Penyakit Jantung Kongenital (ASD, VSD,
PDA, PS, PDA, TF, dll)
Diagnostik Penyakit Jantung Rematik (MS / pre PTMC,
MR, MSI, Kelainan katup multipel)
Monitor pada Infark miokard akut dengan komplikasi
syok kardiogenik, komplikasi ruptur dinding ventrikel/
septum, infark ventrikel kanan
Evaluasi syok dengan kausa tidak jelas

INDIKASI KATETERISASI JANTUNG KIRI

Diagnostik Penyakit Jantung Kongenital (VSD,
PDA,PDA, TF, dll)
Diagnostik Penyakit Jantung Katup (MS / pre PTMC,
MR, AS, AR, Kelainan katup multipel)
Diagnostik Kelainan Aorta ( Aneurisma Aorta, Coartasio
Aorta, dll)
Diagnostik Kelainan Arteri Perifer

INDIKASI ANGIOGRAFI KORONER

1. Angina Pektoris yang refrakter terhadap obat-obatan
2. Angina pektoris tidak stabil (ST depresi, chest pain at
rest, heart failure)
3. Kecurigaan variant angina
4. Paska infark miokard akut -rekuren spontan angina,
exercise-induced angina, residual iskemia, failed
trombolitik, mechanical complication
5. Rekuren angina paska intervensi koroner/paska
CABG
6. Paska Ventrikel Takhikardi/fibrilasi yang kausanya
tidak jelas
7. Riwayat resusitasi oleh karena henti jantung
8. Pre PTMC, pada umur > 40 tahun

The Purpose
Define coronary anatomy
Degree of luminal obstruction.
Identification of the location, length, diameter, and contour of the
coronary arteries
The presence and severity of coronary luminal obstruction
Characterization of the nature of the obstruction (including the
presence of atheroma, thrombus, dissection, spasm, or myocardial
bridging), and an assessment of blood flow.
Addition : the presence and extent of coronary collateral vessels.

The Purpose
Incidences of significant morbidity and mortality
are low, but coronary angiography may cause
serious complications and, thus, the benefits must
justifyon
theanrisks.
Based
appropriate risk-benefit ratio.
In general, is recommended whenever it is clinically
important to define the presence or severity of a
suspected cardiac lesion that cannot be adequately
evaluated by noninvasive techniques.

Indication for Non Specific Chest Pain

Indication for Heart Failure

Indication for Noncardiac Surgery

ontraindications to Cardiac Catheterizati

Absolute contraindications
Inadequate equipment or catheterization facility

Relative contraindications
Acute gastrointestinal bleeding or anemia
Anticoagulation (or known uncontrolled bleeding diathesis)
Electrolyte imbalance
Medication intoxication (e.g., digitalis, phenothiazine)
Infection/fever
Pregnancy
Recent cerebral vascular accident (>1 mo)
Renal
failure congestive heart failure, high blood pressure,
Uncontrolled
arrhythmias
Uncooperative patient

ACC/AHA guidelines for coronary

angiography

The Complications During Angiography

Conditions of Patients at Higher

Risk for
Acute myocardial infarction
Advanced age (> 75 y)
Aortic aneurysm
Aortic stenosis
Congestive heart failure
Diabetes
Extensive three-vessel coronary artery disease
Left ventricular dysfunction (left ventricular ejection fraction
<35%)
Obesity
Prior cerebral vascular accident
Renal insufficiency
Suspected or known left main coronary stenosis
Uncontrolled hypertension
Unstable angina

Complications of
Catheterization

Estimated The Risk(Mayo Score)

2% patients
with total score
over 14
expected
procedural
mortality 25%!

ons Requiring Special Preparations for Cardiac Cathete

Condition
Allergy
Prior contrast studies
Iodine, fish
Premedication allergy
Lidocaine
Patients receiving anticoagulation
(INR >1.5)

Diabetes
NPH insulin (protamine reaction)
Renal function
Glucophage usage (prone to CIN)
Electrolyte imbalance (K or Mg)
Arrhythmias
Anemia
Dehydration
Renal failure

Management
Treat potential hypersensitivity
Contrast premedication
Contrast reaction algorithm
Hold premedication
Use Marcaine (1 mg/mL)
Defer procedure
Vitamin K
Fresh frozen plasma
Hold heparin
Protamine for heparin
Hydration, urine output >50 mL/h
Glucophage held 48 h
If renal insufficiency postpone catheterization
Consider urgency and risks of lactic acidosis
Defer procedure, replenish/correct electrolytes
Defer procedure, administer antiarrhythmics
Defer procedure
Control bleeding
Transfuse
Hydration
Limit contrast
Maintain high urine output

Right Coronary Artery

Left Coronary Artery

SA = Sino-Atrial Node branch

RV = Right Ventricular branch
AM = Acute Marginal branch
AV = Atrio-Ventricular branch;
RPLA = Right Postero-Lateral branch
RPDA = Right Posterior Descending Artery

LAD = Left Anterior Descending

Dx = Diagonal
SP = Septal Perforator
Cx = Circumflex
OM = Obtuse Marginal
PLA = Postero-Lateral branch
PDA = Posterior Descending Artery

Coronary Artery

LCA

RCA

The Catheters

Overview

reinforcing materials excellent torque control

needed for coronary cannulation.
Current catheters may have a soft distal tip to
minimize the risk of arterial dissection.
Coronary
catheters
areforavailable
in 5F, 6F, 7F, or 8F
Usually
6F
catheters
routine procedures
Constructed of polyethylene, polyurethane and

Berbagai jenis dan ukuran kateter untuk pemeriksaan dan intervensi jantung / a. koroner

The Coronary Catheters

- Amplatz

Right
- Judkins Right
- Sones
- Judkins Left
- Amplatz Left

Judkins Left (JL) Catheter

3.5

4.0
5.0

Judkins Left (JL) Catheter

The arm of the catheter traversing the ascending aorta at an

angle of approximately 45
If adequate : the catheter tip is aligned with long axis of main
coronary trunk

NORMAL
MODYNAMICS

Normal morphology and timing of left ventricular (LV), right ventricular

(RV), left atrial (LA), and aortic pressure waveforms in relationship to
each other, ECG intervals, and heart sounds.

INTRACARDIAC PRESSURES

Indications for POBA

Clinical indications

Morphologic indications

Patients with evident ischemia

with significant obstructive
lesions
Acute myocardial infarction
Unstable angina
Stable angina
Depressed left ventricular
function
Elderly
Post coronary artery bypass
surgery

Sites
Single and multivessel
Left main (protected or
unprotected)
Saphenous vein
Arterial grafts

* Good indications for POBA.

Relative contraindications for
POBA.

Lesions
Discrete, concentric*
Tandem, long, eccentric, diffuse
Angulated
Bifurcation (for side branch)
Total and subtotal occlusions
Ostial, proximal
Mid and distal
Calcified
In-stent restenosis*
Small and large vessels*

Mechanisms of balloon dilatation. The components of the dilating

force are the vector force, the tension, and the pressure of the
balloon.
Difference between compliant and noncompliant balloons. (a) A compliant
balloon tends to be oversized at the
edges, with less dilatation at the obstructive segment of the lesion (dog-boning).
(b) A noncompliant balloon gives a predictable amount of pressure at the lesion
without uncontrolled radial and longitudinal growth.

Intracoronary Stents
Intracoronary stents were initially developed as bail-out devices to
avoid CABG when abrupt closure followed angioplasty-induced
dissection of the target vessel.
Stent design is complex, with ever-evolving technology aimed at
improving physical properties, including handling, delivery,
immediate recoil, flexibility, radial strength, visibility etc. No one
design is optimal in all regards, and final properties depend on both
material and design.
Stent materials
Stents are generally manufactured from 316L stainless steel, with
increasing use of cobalt/chromium, cobalt/nickel alloys, and other
metals.
Work is currently being undertaken evaluating prototype metallic
and polymer-based bioabsorbable stent designs.

STENTS

Open-cell Stent Design

Closed-cell Stent Design

Palmaz Stent

Percutaneous Transluminal Coronary Angioplasty ( PTCA )

Drug-eluting stents
With virtual elimination of immediate elastic recoil and late negative
remodelling by routine use of intracoronary stents, intimal proliferation's
role in restenosis became the focus of much research work. Similarities
between the rapid proliferation of smooth muscle cells in the nascent
neointima and the proliferation of malignant neoplastic cells in tumours
sparked interest in anti-cancer and immunomodulatory agents.
Stent delivery of drug
Stents are ideal vectors to carry drug agents, targeting geographically the
site of intimal proliferation and potentially limiting systemic toxicity.
Drug delivery is usually achieved by combining the drug with a
biocompatible polymer which can then be used to coat the stent. Such
polymers will also allow a gradual elution of the drug (dependent on
polymer characteristics) to ensure that the agent is released during peak
neointimal proliferation.
Antiproliferative agents
Currently available DES deliver either cytotoxic (paclitaxel) or cytostatic
(sirolimus and analogues) agents to either kill proliferating cells or arrest

PCI Bifurcation stenosis

CHRONIC TOTAL OCCLUTION

Stenting

LEFT MAIN SEGMEN (LMS)

DISSECTING

POST-STENTING

PCI Saphenous Vein Graft

PRIMARY PCI

PEMASANGAN STENT PADA Px LAKI-LAKI, 64 THN, PURN TNI-AL

- STENOSIS >95% DI LAD PROX

- STENOSIS 60% DI LAD MID
- STENOSIS 60% DI LAD DISTAL
- OKLUSI TOTAL(BUNTU) DI LCx DISTAL

POST PCI / STENTING

STENTING ( PADA MID-LAD )

Penyempitan pada arteri koroner kiri yang dilakukan pemasangan stent.

A.Stenosis pada arteri koroner, mid-LAD; B.Stent terpasang, belum
dikembangkan; C.Stent berhasil dikembangkan; Hasil evaluasi 4 bulan (D),
1 tahun (E), dan 2 tahun (F) setelah tindakan

Rotational Ablation
The Rotablator uses an over-the-wire, high-speed, rotating burr to ablate
plaque.

Ablation of plaque results in fragmentation of the plaque components into

particulate emboli, 90% of which are smaller than red blood cells. There is
little impact of particulate emboli on the distal vascular bed when
appropriate techniques are used. The debris is eventually cleared by
the reticuloendothelial system in the spleen, liver, and bone marrow.

ROTABLATION ATHERECTOMY

PROSEDUR DIAGNOSTIK / INTERVENSI

PENYAKIT JANTUNG KATUP
I.

PERCUTANEOUS TRANSLUMINAL MITRAL COMMISSUROTOMY

II.

BALLOON AORTIC VALVULOPLASTY (BAV)

III. BALLOON PULMONIC VALVULOPLASTY (BPV)

IV. BALLOON TRICUSPID VALVULOPLASTY
V.

BALLOON VALVULOPLASTY PADA AORTA STENOSIS DAN MITRAL

STENOSIS

VI. BALLON VALVULOPLASTY PADA MITRAL DAN TRIKUSPID

STENOSIS

PROSEDUR DIAGNOSTIK / INTERVENSI PENYAKIT JANTUNG KATUP

I.

PERCUTANEOUS TRANSLUMINAL MITRAL COMMISSUROTOMY

PENGUKURAN TEKANAN LA-LV PRE & POST PTMC

MITRAL
STENOSIS

MS Pressure Gradient

Percutaneous Transluminal Mitral Commissurotomy (PTMC)

AORTA VALVULOPLASTY

STENTING pada COARCTATIO AORTA

MITRAL REGURGITATION

Pacu jantung temporer

Indikasi
1. Bradikardia simtomatik.
a. Blok a-v komplit
b. Blok a-v derajat 11 (Mobitz tipe 1 atau tipe 11)
c. Sick Sinus Syndrome
2. Pemasangan pacu jantung untuk profilaksis .
a. Kateterisasi jantung kanan pada penderita dengan LBBB
b. Kardioversi pada penderita dengan Sick Sinus Syndrome
c. Penderita Infark Miokard Akut yang disertai :
1) Bifascicular Bundle Branch Block yang baru
2) BBB yang baru disertai Blok A-V komplit transien
3) Blok A-V derajad II Mobitz tipe II.
4) Blok A-V komplit
3. Penanganan takikardia.
a. Torsade de pointes yang disebabkan "long QT syndrome
b. Overdrive Pacing pada takikardi re-entrant yang resisten
pengobatan medikamentosa (SVT,VT,Atrial flutter)

Indikasi Pacu Jantung Permanen

1.Blok A-V yang di dapat
a.Blok A-V komplit permanen atau intermiten disertai salah satu
keadaan di bawah ini :
1)bradikardi simtomatik, simtom harus dianggap disebabkan oleh
blok a-v kecuali jika terbukti sebaliknya.
2)Payah jantung kongestif
3)Ritme ektopik atau kondisi lain dimana pengobatan dengan obat
anti aritmia menyebabkan terjadinya bradikardi simtomatik.
4)Periode asistol 3,0 detik atau irama lolos < 40 kali permenit
walaupun tanpa keluhan.
5)Delirium yang membaik dengan pemasangan pacu jantung
temporer.
6)Setelah ablasi a-v junction, myotonic dystrophy.
b.Blok a-v derajat II, permanen atau intermiten disertai bradikardi yang
simtomatik.
c.Atrial fibrilasi, atrial flutter, atau supraventrikuler takikardi disertai total
AV blok atau AV blok derajat tinggi , bradikardi dan salah satu kondisi
seperti yang disebutkan di atas pada Blok AV yang didapat. Bradikardi
tidak disebabkan oleh digitalis atau obat-obat yang mempengaruhi
konduksi AV.

2.Pasca Infark miokard

a.Blok a-v derajat II atau blok a-v total yang persisten pasca infark
disertai blok pada tingkat His Purkinye (bilateral bundle branch block)
b.Penderita dengan blok a-v derajat tinggi yang transien disertai
dengan Bundle Branch Block.
3.Bifascicular dan Trifascicular Block
1.Bifascicular block disertai blok a-v total intermitten yang disertai
bradikardi simtomatik.
2.Bifascicular atau trifascicular block disertai blok a-v derajad II (Mobitz
type II) walaupun tanpa keluhan yang berkaitan dengan blok a-v nya.
4.Disfungsi sinus node disertai dengan bradikardi yang simtomatik.
Pemacuan jantung pada penderita dengan sinus karotis yang hipersensitif
dan sidroma neurovaskular; termasuk di sini adalah penderita sinkop yang
berulang yang disebabkan oleh stimulasi sinus karotis atau asistol >3 detik
sebagai aki bat dari penekanan minimal pada sinus karotis , dimana pada
penderita tersebut tidak menggunakan obat-obatan yang menekan SA
node atau AV conduction.

PERICARDIOCENTESIS

Indikasi
1. Tamponade jantung
2. Pericardial effusion
post cardiotomy
3. Hemopericardium
post
transeptal
puncture

PEMASANGAN POMPA BALON AORTA (IAB)

Indikasi
Refractory ventricular failure.
Syok kardiogenik.
Unstable refractory angina
Impending infarction
Komplikasi mekanik karena IMA, misalnya : VSD, Mitral regurgitasi,
musculus papilaris
Ischemia related intractable ventricular arrhythmia.
Cardiac support pada operasi non cardiac dengan risiko tinggi.
Septik syok.
Weaning dari Cardiopulmonary bypass.
Support dan stabilisasi selama angiografi koroner atau PTCA.
Intra-operative pulsative flow generation.
Kontra infikasi
1. Aorta Insufisiensi berat.
2. Aneurisma aorta abdominalis.
3. Penyakit aorta-iliaka yang berat/kalsifikasi atau penyakit arteri perifer.
4. Irreversible brain damage.
5. End stage heart disease.

ruptura

PEMASANGAN KATETER SWAN-GANZ

Pengertian
Memasukan kateter intra vena yang ujung kateternya berada di
dalam arteri pulmonalis untuk mengukur tekanan pengisian ventrikel
kiri, tekanan arteri pulmonalis, tekanan ventrikel kanan, tekanan
pengisian ventrikel kanan, curah jantung dan saturasi oksigen.
Kateter dapat dimasukkan melalui vena basilika, subclavia, mediana
cubiti atau jugularis

Indikasi
1. Payah jantung berat atau progresif.
2. Shock kardiogenik atau hipotensi progresif.
3. Komplikasi mekanik : defek septum ventrikel atau ruptur otot
papilaris

Kontraindikasi
Gangguan faal hemostasis / pembekuan darah.

KATETER SWAN-GANZ

Komplikasi Pemasangan Kateter Swan-Ganz

1. Hematoma.
2. Arteri tertusuk.
3. Emboli udara.
4. Kateter menekuk atau melilit.
5. Tidak mencapai wedge.
6. Pneumothoraks
7. Aritmia.
8. Perforasi atrium kanan / ventrikel kanan.
9. Infeksi.
10. Infark paru.

Electrophysiology Study (EPS)

Intracardiac electrophysiology is the study of the hearts conduction
system, examined by placing electrode catheters inside the hearts
chambers.
An invasive cardiac electrophysiology study (EP or EPS) is undertaken to
evaluate the cardiac conduction system in order to relate associated
findings with the patients clinical symptomatology.
It is performed using a systematic approach and can be diagnostic or
therapeutic.
Diagnostic purposes include locating and defining patterns of
arrhythmogenic substrates, assessing antiarrhythmic drug efficacy or
proarrhythmia, and evaluating current rhythm control therapy.
The most common therapeutic purpose of an EP study is to identify the
location of arrhythmogenic substrates in order to alleviate them with
radiofrequency catheter ablation.

Electrophysiology study and catheter ablation therapy

have led to a widespread increase in its use in
management of cardiac arrhythmias.
Catheter ablation can be defined as the use of an electrode
catheter to destroy small areas of myocardial tissue or
conduction system, or both, that are critical to the initiation
and/or maintenance of cardiac arrhythmias.
During radiofrequency (RF) ablation, current flows into the
tissue in contact with the electrode in alternating direction
at high frequency.
Thermal injury is the principal mechanism of tissue
destruction during RF catheter ablation procedures

Application of radiofrequency (RF)

current at proximal His recording
site causes accelerated junctional
activity followed by complete
atrioventricular block and paced
rhythm (A). (B) Atrial fibrillation with
complete atrioventricular block and
a junctional escape rhythm with
narrow QRS. (C) Following ablation
of the atrioventricular junction, a
single chamber pacemaker was
implanted (arrow).

Catheter Ablation Therapy in Arrhythmia

For most types of Supraventricular arrhythmias, medical treatment with
antiarrhythmic drugs is not completely effective. In addition,
antiarrhythmic drugs can be associated with a number of side-effects.
The high success rates and low complication rates of catheter ablation
have revolutionized treatment of such conditions as Wolff-ParkinsonWhite syndrome and atrioventricular (AV) nodal re-entrant tachycardia
More recently, the first-line therapy for treatment of patients with atrial
flutter and focal or re-entry atrial tachycardia / incisional atrial tachycardia
is mediated by macro-re-entry around the scar of a prior surgical
atriotomy
The most recent developments interventional treatment of atrial
fibrillation (paroxysmal atrial fibrillation in selected patients), and
selected patients with ventricular tachycardia (recurrent, symptomatic
idiopathic ventricular tachycardia; bundle branch re-entry ventricular
tachycardia ; sustained monomorphic VT, post-infarct VT, incessant VT)

AMPLATZER
DEVICE
OCCLUDER
(ADO)

(A) Starflex device with only

the left disk deployed. (B)
Amplatzer PFO Occluder with
larger right atrial than left
atrial disk, consisting of a
nitinol wire mesh. The disks
are filled with thin polyester
fabric. (C) PFO-Star device.
Transoesophageal echocardiography of a device (25
mm Amplatzer PFO occluder
shown in the insert) 6 months
after implantation. LA: left
atrium; RA: right atrium; SVC:
superior vena cava.

PERCUTANEOUS MITRAL ANNULOPLASTY

CATH LAB - INSTALASI DIAGNOSTIK & INTERVENSI KARDIOVASKULAR (IDIK) RSUD DR.SOETOMO

Indications for PCI

Gruentzig's original selection criteria for angioplasty demanded that the patient
have:
Stable angina
Documented ischaemia on functional testing
Single vessel disease (preferably proximal, non-occluded, and non-calcified
lesion)
No features precluding CABG (if required as bailout) for example malignancy,
severe LV dysfunction, pulmonary disease etc.
Advances in interventional technology have resulted in lesion and patient
subsets of increasing complexity being tackled, including:
Unstable patients
Primary PCI for acute myocardial infarction (MI)
PCI in acute coronary syndromes
PCI in cardiogenic shock
Multi-vessel disease
Bifurcation lesions
Ostial left mainstem disease
Vein graft disease
Patients deemed unsuitable/unfit for CABG.

PCI versus CABG

Initial studies of balloon angioplasty versus
CABG (BARI, EAST) demonstrated similar
outcomes in terms of death and MI, but increased
event rates driven by repeat interventions in the
angioplasty group.
Stent-era studies show some reduction in need
for further PCI (SoS, ARTS), and when compared
with historical controls, DES compare favourably
with CABG (ARTS-II).
Ongoing randomized studies (SYNTAX,
FREEDOM) will address the question of the utility
of multi-vessel (including LMS) stenting with DES
versus CABG.