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: André 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 Grüntzig - 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 cost-effectiveness
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
disease.
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 (pressure-dome,
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
justify the risks.
Based on an 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
Contraindications to Cardiac Catheterization

Absolute contraindications
Inadequate equipment or catheterization facility
Relative contraindications
Acute gastrointestinal bleeding or anemia
Anticoagulation (or known uncontrolled bleeding diathesis)
Electrolyte imbalance
Infection/fever
Medication intoxication (e.g., digitalis, phenothiazine)
Pregnancy
Recent cerebral vascular accident (>1 mo)
Renal failure
Uncontrolled congestive heart failure, high blood pressure,
arrhythmias
Uncooperative patient
ACC/AHA guidelines for coronary
angiography
The Complications During Angiography
Conditions of Patients at Higher Risk for
Complications of Catheterization
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
Estimated The Risk(Mayo Score)

2% patients
with total score
over 14
expected
procedural
mortality 25%!
Conditions Requiring Special Preparations for Cardiac Catheterization
Condition Management
Allergy Treat potential hypersensitivity
Prior contrast studies Contrast premedication
Iodine, fish Contrast reaction algorithm
Premedication allergy Hold premedication
Lidocaine Use Marcaine (1 mg/mL)
Patients receiving anticoagulation Defer procedure
(INR >1.5) Vitamin K
Fresh frozen plasma
Hold heparin
Protamine for heparin
Diabetes Hydration, urine output >50 mL/h
NPH insulin (protamine reaction) Glucophage held 48 h
Renal function If renal insufficiency postpone catheterization
Glucophage usage (prone to CIN) Consider urgency and risks of lactic acidosis
Electrolyte imbalance (K or Mg) Defer procedure, replenish/correct electrolytes
Arrhythmias Defer procedure, administer antiarrhythmics
Anemia Defer procedure
Control bleeding
Transfuse
Dehydration Hydration
Renal failure Limit contrast
Maintain high urine output
Hydrate
Right Coronary Artery Left Coronary Artery
SA = Sino-Atrial Node branch LAD = Left Anterior Descending
RV = Right Ventricular branch Dx = Diagonal
AM = Acute Marginal branch SP = Septal Perforator
AV = Atrio-Ventricular branch; Cx = Circumflex
OM = Obtuse Marginal
RPLA = Right Postero-Lateral branch
RPDA = Right Posterior Descending Artery PLA = Postero-Lateral branch
PDA = Posterior Descending Artery
Coronary Artery
LCA RCA
The Catheters
Overview

• Coronary catheters are available in 5F, 6F, 7F, or 8F

• Constructed of polyethylene, polyurethane and
reinforcing materials excellent torque control
needed for coronary cannulation.
• Current catheters may have a soft distal tip to
minimize the risk of arterial dissection.
• Usually 6 F catheters for routine procedures
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
N
O
R
M
A
L

H
E
M
O
D
Y
N
A
M
I
C
S
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 • Sites

with significant obstructive – Single and multivessel
lesions – Left main (protected or
– Acute myocardial infarction unprotected†)
– Unstable angina – Saphenous vein†
– Stable angina – Arterial grafts
– Depressed left ventricular
function • Lesions
– Elderly – Discrete, concentric*
– Post coronary artery bypass – Tandem, long, eccentric, diffuse
surgery – Angulated
– Bifurcation (for side branch†)
– Total and subtotal occlusions
– Ostial, proximal†
* Good indications for POBA. – Mid and distal
† Relative contraindications for – Calcified
POBA. – 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 non-

compliant balloons. (a) A compliant
balloon tends to be oversized at the
edges, with less dilatation at the obstruc-
tive segment of the lesion (‘dog-boning’).
(b) A noncompliant balloon gives a pre-
dictable amount of pressure at the lesion
without uncontrolled radial and longi-
tudinal 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 POST PCI / STENTING

- STENOSIS 60% DI LAD MID
- STENOSIS 60% DI LAD DISTAL
- OKLUSI TOTAL(BUNTU) DI LCx DISTAL
 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 Percutaneous Transluminal Mitral Commissurotomy (PTMC)

STENOSIS

MS Pressure Gradient
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, ruptura
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.
 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 heart’s conduction

system, examined by placing electrode catheters inside the heart’s
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 patient’s 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-Parkinson-
White 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 echo-
cardiography 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.