Interventional Cardiology


The first percutaneous transluminal coronary angioplasty was performed in 1977, by Dr. Andreas Gruentzig. This marked the birth of interventional cardiology, although catheter-based alternatives to valvuloplasties had been explored (unsuccessfully) since the 1960s. The first successful percutaneous mitral (1982) and aortic valvuloplasties were performed in the 1980’s, although these procedures did not achieve widespread acceptance at that time. The 1990’s were a major growth period for the field of interventional cardiology, with introduction of atherectomies, as well as the use of stents in combination with antithrombotic agents (Abciximab was approved in 1995). The first successful percutaneous pulmonic valve replacement was performed in 2000. Distal protection devices were introduced in 2001, and drug eluting stents emerged in 2003 [Kaplan JA, ed. Essentials of Cardiac Anesthesia. Saunders, 2008 p 33-47].

Percutaneous Coronary Intervention

Indications for Percutaneous Coronary Intervention

An abbreviated list of indications for percutaneous coronary intervention can be found below. For a more complete list, see [Kaplan JA, ed. Essentials of Cardiac Anesthesia. Saunders, 2008 p 34]

Common Indications for Percutaneous Coronary Intervention [Kaplan JA, ed. Essentials of Cardiac Anesthesia. Saunders, 2008 p 34] Unstable Angina (UA) / Non-ST Elevation MI (NSTEMI) Cardiogenic shock in setting of MI Unsuccessful thrombolysis in patient with MI


Generally occurs within the first 6 months [Kaplan JA, ed. Essentials of Cardiac Anesthesia. Saunders, 2008 p 34] and has been significantly reduced by the use of drug eluting stents (DES) [Sousa JE et al. Circulation 107: 2274, 2003; FREE Full-text at Circulation]. Of note, the reduction in restenosis that accompanies the use of DES has been accompanied by an increased risk of in-stent thrombosis, as the same agents which prevent restenosis also inhibit endothelialization.

Mayo Stent Data

Retrospective study of 899 patients at Mayo Clinic showed that major adverse cardiac events (MACE) after non-cardiac surgery (NCS) decreased with increased time post-BMS placement – 10.5% (< 30d), 3.8% (31-90d), 2.8% (> 90d) and that bleeding complications were not associated with antiplatelet therapy within a week of surgery [Nuttal et. al. Anesthesiology 109: 588, 2008]

Retrospective study of 520 patients at Mayo Clinic suggested that MACE after NCS was independent of time post-DES-placement – 6.4% (0-90d), 5.7% (91-180d), 5.9% (181-365d), and 3.3% (>356d, p = 0.727) and that bleeding complications were not associated with antiplatelet therapy within a week of surgery [Rabbitts et. al. Anesthesiology 109: 596, 2008]. Note, that the study was “underpowered” to detect observed differences (6% vs 3.3% mortality), which are presumably clinically significant


There are a variety of antithrombotic (heparin, enoxaparin, coumadin, bivalirudin, argatroban) and antiplatelet (aspirin, clopidogrel, abciximab) agents available to the cardiologist and his/her patients. Importantly, when patients present to the operating room following failed percutaneous intervention, they will likely have been anticoagulated with both antithrombotic and antiplatelet agents – this has major implications for the anesthesiologist both in terms of establishing adequate intravascular access and the potential for intraoperative blood loss

Failed Percutaneous Coronary Intervention

In centers performing 400 or more PCIs annually, the rate of emergency surgery following failed stent placement is less than 1% [Williams DO. Circulation 102: 2945, 2000; FREE Full-text at Circulation]. In the TRULY emergent case (ex. profound shock or complete arrest), Kaplan recommends ensuring adequate vascular access and airway control and then proceeding immediately to cardiopulmonary bypass, emphasizing that in this unique situation any additional measures (ex. additional monitoring) might prolong the time to CPB, which is the only realistic therapeutic option [Kaplan JA, ed. Essentials of Cardiac Anesthesia. Saunders, 2008 p 38]

PCI versus CABG

Early studies (Angioplasty and BMS vs. CABG)

Early studies comparing CABG to angioplasty were underpowered for the detection of mortality differences (save for the BARI trial, which showed a lower 5-year mortality in diabetic patients who underwent CABG) [Casey and Faxon. Heart 90: 341, 2004; FREE Full-text at Heart]. A metaanalysis of 13 trial comparing CABG to angioplasty and including 7964 patients revealed mixed results [Hoffman SN et al. J Am Coll Cardiol 41: 1293, 2003]. The ARTS-I study randomized patients to BMS vs. CABG and found that while overall freedom from death, stroke, or myocardial infarction was not significantly different between groups, the composite event-free survival rate (which included re-vascularization) significantly lower in the CABG group as compared to BMS (78.2% versus was 58.3% at five years) [Serruys PW et al. J Am Coll Cardiol 46: 575, 2005]

Recent studies (DES vs. CABG)

The ARTS-II study was designed to compare DES (sirolimus) to BMS and CABG data from ARTS-I. Importantly, patients in ARTS-II were not randomized to DES vs. CABG (but rather were compared to previous patients randomized to BMS vs. CABG). 3-year ARTS-II data, when compared to ARTS-I, suggest that patients who undergo DES placement will have better composite outcomes than patients who under BMS placement, and equivalent composite outcomes to those who undergo CABG [Daemen J et al. J Am Coll Cardiol 52: 1957, 2008]. 5-year ARTS-II data suggest that while event free survival was no different between DES and CABG, the 5-year major adverse cardiac and cerebrovascular event rate may be lower in those undergoing CABG (as compared to DES) [Serruys PW et al. J Am Coll Cardiol 55: 1093, 2010]

Percutaneous Valvular Intervention

Percutaneous Mitral Valvuloplasty / Valve Replacement

First performed in 1982. Anterograde procedure requiring venous access and transseptal puncture. Thus, there is a possibility of residual ASD, although this is clinically insignificant in most (> 90%) of patients. Preoperative echocardiography is used to classify the anatomy of the mitral valve (usually using the Wilkins score) – mobility, thickening, and calcification are important, as is operator experience, in determining outcomes. Intraoperative echocardiography is critical as existing LA thrombus is an absolute contraindication to this procedure. Relative contraindications include significant aortic valve disease, CAD, pregnancy. Severe post-procedure MR occurs in up to 10% of procedures and may require emergent surgery to correct [Kaplan JA, ed. Essentials of Cardiac Anesthesia. Saunders, 2008 p 46]

Repair and replacement of the mitral valve have also been attempted recently, although these approaches are best described as experimental. Approaches include percutaneous stitching of the MV, placement of an anchor in the coronary sinus (which, when tightened, cinches the mitral annulus), as well as actual valve implantation

Percutaneous Aortic Valvuloplasty / Valve Replacement

Can be done via a retrograde transfemoral approach (usually performed with sedation, also requires placement of a transvenous right ventricular pacing lead) or using an antegrade transapical approach (under general anesthesia) [Heinze H et al. J Clin Anesth 22: 373, 2010]. Should only be considered when short-term relief is required (i.e. advanced age or as bridge to surgery), as virtually all patients will restenose by 2 years and PAV is always accompanied by some degree of AI. An early comparison to aortic valve surgery in elderly patients did not support the use of this procedure [Bernard Y et al. J Am Coll Cardiol 20: 796, 1992]

Because of the poor outcomes associated with aortic valvuloplasty, attempts have been made at accomplishing percutaneous aortic valve replacement, which was first performed in 2002. A recent, non-randomized study of percutaneous aortic valve replacement in elderly patients have suggested that the risks may be more reasonable than in the valvuloplasties of the past [Bekeredjian R et al. Am J Cardiol. 2010 Nov 3 Epub ahead of print]

Percutaneous Pulmonic Valve Replacement

Because of improvements in the management of complex congenital heart disease, the number of patients with complex congenital heart disease surviving to adulthood is increasing. As a result of their early corrective operations, many of these patients will have abnormal right ventricular outflow tracts / pulmonic valves. Combined with tricuspid insufficiency, pulmonic insufficiency is difficult to tolerate. As this is a relatively new field of study (because in the past, patients with complex congenital heart disease did not survive long enough for pulmonic valve dysfunction to manifest), the criteria for pulmonic valve replacement have not been firmly established. Lurz et al. replace the pulmonic valve in any patient with pulmonic pressures 65% of systemic and symptoms, or 75% of systemic without symptoms. First performed successfully in 2000. Antegrade procedure which may require balloon dilation after deployment of the valve [Lurz P et al. Circulation 117: 1964, 2008; Lurz P et al. Expert Rev Cardiovasc Ther 7: 823, 2009; Lurz P et al. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu: 112, 2009]