Christopher M. Wright, MD, MBA Pioneer Cardiovascular Consultants Tempe, Arizona

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1 Christopher M. Wright, MD, MBA Pioneer Cardiovascular Consultants Tempe, Arizona

2 Areas to be covered Historical, current, and future treatments for various cardiovascular disease: Atherosclerosis (Coronary Artery Disease) Valvular Heart Disease Arrhythmias (Abnormal Heart Rhythms)

3 Coronary Artery Disease Atherosclerosis is the leading cause of death in the United States accounting for ~25% of all deaths annually Plaque build- up in the heart arteries Common Symptoms or problems related to Coronary disease: Chest pain Heart Attack or Myocardial Infarction

4 Coronary Artery Disease Multiple Tools to Detect EKG Laboratory Assays Stress Testing Echocardiography Cardiac CT MRI Cardiac Catheterization Multiple Tools to Treat Medical Therapy Cardiac Angioplasty and Stenting Bypass Surgery

5 Coronary Artery Disease Cardiac Catheterization use of catheters (hollow tubes ) and X- rays to view the heart arteries First performed in the 1930 s in humans - Werner Forssmann won the Noble Prize for this work. Made into a diagnostic tool in humans in the 1950 s

6 Coronary Artery Disease How do you turn a Catheterization into a treatment option?

7 Coronary Artery Disease Cardiac Catheterization is turned into a treatment with the addition of Balloon Angioplasty in 1977 A balloon on the end of a catheter is used to dilate areas of blockage

8 Coronary Artery Disease Angioplasty was associated with several problems ~85% success rate Acute rupture or disruption of the artery leading to emergency surgery Restenosis 30% (up to 60%) of plaques would renarrow

9 Coronary Artery Disease Cardiac Stenting similar to Angioplasty but a metal framework is left inside the artery to hold the plaque open First approved for use in 1994 in the US Procedural success >95% Up to 30% eventually developed restenosis

10 Coronary Artery Disease Drug Eluting Stents stents embedded with various drugs designed to prevent restenosis First used in the US in 2003 Restenosis rates drop to less than 1% New problem develops: stent thrombosis blood clot forms inside the stent leading to complete blockage and a large heart attack and death Problem partially addressed with newer medical regimens

11 Coronary Artery Disease Bioabsorbable stents THE FUTURE Hold the artery open to avoid the early problems that were associated with plain angioplasty and dissolve over time to avoid the later complications of stents.

12 Valvular Heart Disease

13 Valvular Heart Disease Narrowing and leakage of the valves of the heart can lead to severe physical debility and death. Valve surgery was first successfully completed in the 1950 s

14 Valvular Heart Disease Bioprosthetic and Mechanical Valves are both used Both have advantages and disadvantages

15 Valvular Heart Disease Surgical technique and the quality of the valves have improved the recovery and success of valve surgery However recovery is still quite lengthy Some patients are too sick to survive the surgery Surgical Complications Infection Bleeding Valve malfunction Stroke or mental decline Kidney failure Death

16 Valvular Heart Disease The Future Henning Rud Andersen, MD first patents a percutaneous or catheter delivered valve in 1988 (after attending a conference in Phoenix) Clinical Trials underway to test this device since 2005

17 Valvular Heart Disease

18 Cardiac Arrhythmias

19 Cardiac Arrhythmias Abnormal Heart Rhythms either fast or slow. Various treatment options Pacemakers - for slow rhythms Defibrillators - for fast rhythms

20 Cardiac Pacemaker Electrical stimulation of the heart dates back to the 1700 s Attempts at designing an external pacemaker for humans date back to the 1930 s First used successfully in the 1950 s external transvenous

21 Cardiac Pacemaker First battery powered pacemaker 1957 External device with implanted electrodes 1959 First fully implanted pacemaker system is developed First transvenous implanted system is used

22 Cardiac Pacemaker 1970 s 1980 s Devices become smaller with better longevity Better power supply developed Lithium batteries Nuclear energy fueled pacemakers Programmability Physiologic adaptability 1983 Dual Chamber pacing 1985

23 Cardiac Pacemaker 1990 s Cardiologists become the principle implanters of devices

24 Cardiac Pacemaker 2000 s Cardiac Resynchronization addition of a third lead to augment heart function in patients with congestive heart failure

25 Cardiac Pacemaker

26 Cardiac Pacemaker Problem

27 Cardiac Pacemaker Present Problem MRI compatibility Up to 85% of patient with pacemakers will eventually have an indication for an MRI - Musculoskeletal and Neurologic reasons Pacemaker systems have not been MRI safe Lead Heating Unintended Cardiac Pacing Device Interactions

28 Revo MRI Device Dual Chamber Pacemaker Same functionality as a regular pacemaker 28

29 Cardiac Pacemaker Future Use for other diseases Sleep Apnea, Hypertension, GI Dysmotility Better diagnostic capability Battery- less pacemakers Lead- less pacemakers

30 Sudden Cardiac Death

31 Sudden Cardiac Death 350, ,000 people in the US die yearly Caused by lethal Ventricular Arrhythmias Treatments Automated External Defibrillators Take a BLS Course Internal Cardioverter Defibrillators

32 Cardiac ICD s Internal Cardioverter Defibrillator First implanted in 1980 for conversion of lethal ventricular arrhythmia s back to sinus rhythm using high energy shocks Large device Made with over the counter electronics Short lived Large 250 grams Not programmable Required Thorocotomy/Abdominal Implant

33 Cardiac ICD s 1980 s s Trials determined benefit for secondary prevention Devices became smaller, more effective, and better longevity are developed 2000 s Trials for Primary Prevention in high risk populations Cardiac Resynchronization ICD s become available

34 Cardiac ICD s Present Day ICD s are fairly small (~75 grams ~35 cc), highly programmable, safe and effective at preventing Sudden Cardic Death Longevity 5-7 years

35 Cardiac ICD s Present - Incidence of Inappropriate Shocks can be as high as 24% Shock reducing algorithms to reduce inappropriate shocks have been developed

36 Cardiac ICD s Future Advanced Patient Management Tools ICD s with diagnostic ability to measure Pulmonary Artery pressure as well as other clinical variables Treat or predict Congestive Heart Failure Episodes Treat or predict Heart Attacks Subcutaneous ICDs

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