What is Interventional Cardiology in structural and congenital pathology?
Interventional cardiology in structural and congenital pathology, also known as “non-coronary structural cardiac interventionism”, brings together a set of procedures that have in common percutaneous access (puncture through a blood vessel, generally an artery) to reach the heart and the use of devices of different types and degrees of complexity.
It is named after Dr. Martin León, an interventional cardiologist who grouped the indications and techniques under this name in 1998. It could be defined as the set of percutaneous therapeutic procedures on pathologies less prevalent than coronary pathology (congenital or acquired).
The initial objective of this approach was the diagnosis and treatment of coronary artery lesions, but in the 1980s interventional cardiology made a leap towards non-coronary pathologies and began to treat lesions of the aortic and pulmonary valves (valvulotomies), coarctation of the aorta or treatment of rheumatic stenosis of the mitral valve, among others, by means of catheter dilatation.
Why is it performed?
Fundamentally, the procedures covered by non-coronary structural cardiac interventionism are aimed at: a) dilating valves and vessels; b) occluding septal defects, vessels, atrial appendages or abnormal communications, both intra and extra cardiac. These procedures, classically performed by open surgery, avoid opening the thorax and its consequences.
In congenital processes, generally performed on a young population, surgery generates scarring and fibrosis processes that may condition or limit future interventions.
In the case of acquired or degenerative processes, open surgery involves an intervention with a high risk for the patient’s situation. Patients who would not have any therapeutic option due to high surgical risk or contraindication, can nowadays benefit from lower risk procedures, complications, shorter hospital stays and, therefore, a more favorable functional recovery.
What does it consist of?
Dilatations (valves/valves) are performed with a balloon catheter; depending on the type of lesion, stent implantation prevents possible restenosis.
Closures of septal defects, vessels, atrial appendages or abnormal communications are performed with various types of devices adapted to the type of lesion and anatomical characteristics of the area where they are implanted.
Preparation for interventional cardiology in structural and congenital pathology
The types of congenital heart disease susceptible to these procedures are diverse, with peculiarities for each of them, but with a common scheme that can be summarized as follows:
- Diagnosis: generally, the diagnosis of the pathology is carried out by imaging techniques, the most frequent and best known, transthoracic echocardiography. But for the exact grading of the defect (mild, moderate, severe), study of relevant anatomical structures and possible associated malformations, it is often necessary to perform additional imaging tests (sometimes more than one), such as: transesophageal echocardiogram, cardioresonance, angiotac, diagnostic catheterization (associates left catheterization, through an artery, to study left ventricle, aorta and/or coronary arteries, and right catheterization, to assess the state of right cavities and pulmonary artery pressure).
- Preoperative: although some of the procedures are performed under local anesthesia, the preoperative study is usually similar to that of an operation under general anesthesia. This avoids anxiety in children or the elderly, and favors prolonged transesophageal monitoring. The patient will undergo at least an electrocardiogram and blood tests; sometimes spirometry, chest X-ray or other examinations deemed appropriate by the anesthesiologist are added.
- On the day of the operation: some procedures can be performed with a short hospital stay (day hospital), while others require an overnight stay of at least one night (especially if performed in the afternoon). The patient should come to the hospital on an empty stomach and follow the instructions given regarding medication. The medication regimen with antiplatelet, anticoagulant and antidiabetic drugs, which may require a temporary modification in relation to the procedure, should be monitored with special attention. In addition, antibiotics may be prescribed to prevent infectious endocarditis.
It is recommended that the patient comes to the hospital accompanied by a close relative to whom he/she can inform about the evolution of the procedure and who can provide support at an important/delicate moment for the individual’s health.
Post-procedure care
During the first hours after the operation, the patient remains in a monitoring unit to watch for early potential complications. Femoral access of the catheters requires an inguinal incision with suturing of the blood vessel and skin. It is necessary to remain lying down until it is verified that there is no external bleeding from the vessel or suspicion of internal bleeding. Vascular complications are among the most frequent, so special vigilance is required.
Ambulation is usually resumed early, and it is known that prolonged bed rest does not favor the functional readaptation of the individual. The efficacy of the intervention is usually verified with an echocardiogram before hospital discharge.
It is important to follow the recommendations for activity, wound care, check-ups and medication. Temporary medications that may be added after these interventions include: low molecular weight heparins, antiplatelet agents (sometimes for a few months), antibiotics, analgesics.
Alternatives to this treatment
Alternatives to this treatment include:
- Absence of treatment: as mentioned above, the reason for performing these interventions is, in some cases, the high risk or surgical contraindication. The absence of treatment implies that the disease to be treated will continue its natural history. Generally, in the absence of intervention (surgical or programmed), these pathologies lead to a common final pathway of heart failure. Drugs are available to control the symptoms of heart failure or slow its progression, but they are not a curative therapy. Other complications in the clinical course of unrepaired pathology include thrombus formation (with risk of thrombosis, embolism), arrhythmias or sudden death.
- Surgical intervention: surgical intervention can solve many of the above-mentioned structural problems. However, functional recovery is usually slower and the sequelae (mediastinal fibrosis, sternotomy) may condition future interventions.
This article was written by Dr. Amelia Carro, cardiology specialist at the Corvilud Institute.