HeartNet

Cardiac Catheterization and Intervention: The Past, Present and Future Focusing on Southwest Virginia Timothy C. Ball, MD, PhD Assistant Professor of Medicine Coronary, Structural and Peripheral Intervention Medical Director Cardiac Catheterization Laboratory Associate Program Director Cardiovascular Disease Fellowship Virgina Tech Carilion School of Medicine 9/25/2015

Disclosures I have no relevant financial disclosures.

Objectives To present a historical overview of cardiac catheterization and coronary intervention To present the evolution of cardiac catheterization and intervention in Southwest Virginia To touch briefly on the currently available endovascular therapies To peer into the bright and potentially unlimited future of cardiac intervention.

Areas of Evolution Coronary Artery Bypass Surgery Coronary angiography, Coronary artery intervention Valve Surgery Trans catheter Valve Replacement (TAVR) Surgical management of Congenital heart disease Catheter based management of Structural heart disease Electrophysiology Studies, Ablations, Pacemakers and ICDs Surgical management of Peripheral Arterial Disease (PAD) Endovascular management of PAD Mechanical support of the failing ventricle Endovascular Management of Stroke

I will try to present a contemporary timeline of the evolution of cardiac catheterization and coronary intervention the current state of the art interventional cardiac catheterization laboratory and then speculate on the lab of the future.

Timeline 1929 1st cardiac catheterization of a Human Dr. Werner Forssman, Eberswald Germany 1941 1st cardiac ouput Andre Cournand and Dickins Richards 1953 Seldinger percutantous approach introduction of catheters. Sven-Ivar. Actaradiol (39) (5): 368-376 1953 1st open heart operation with bypass John Gibbon at Thomas Jefferson Hospital Philadelphia

Timeline 1958 Selective coronary angiography 1964 Dotter Technique Mason Sones – accident complicated by VF Texas Heart Inst J. 29(1):10-14. 1964 Dotter Technique Charles Dotter 1967 – Rene Favaloro – first SVG bypass angiography, Cleveland, OH 1967 –Commercialization of Judkins catheters

Sones and the 11 inch Image Intensifier used for the First Coronary Arteriogram

Cine Frame of the First Right Coronary Mason Sones October 30, 1968

Cine frame taken by F. Mason Sones, MD, of the first aortocoronary saphenous vein graft inserted by Rene Favaloro, MD.

Dr. Mason Sones, at left about 1960, performing early coronary angiography at the Cleveland Clinic. Sones, who was known for wearing a V-neck T-shirt in the operating room and rarely putting down his cigarette, had a habit of getting out of his seat and shouting at colleagues during medical conferences when he disagreed with their research findings or opinions. "You need to study the heart that's where all the excitement is," he told his fellow, Earl Shirey, in 1953

Timeline 1973 Gantries with Rotating U arms 1974 - Adreas Greuntzig – 1st peripheral balloon angioplasty 1977 – Greuntzig, Myler and Hanna – 1st coronary balloon angioplasty, San Francisco. 1977 – Adreas Greuntzig – 1st coronary balloon angioplasty (PTCA) in an awake patient, Zurich 1978 – Myler and Stertzler – 1st PTCA in the U.S. 1980 – Guiding catheters introduced.

Timeline 1982 Over the wire systems and steerable guide wires. 1986 1st coronary self expanding wall stents Jacques Puel and Ulrick Sigwart Toulose, France IVUS 1989 – Palmaz-Schatz stent developed 1992 First cath and PCI from the radial approach Dr Ferdinand Kiemeneis Driven by an effort to reduce bleeding complications from femoral access with post procedure anticoagulation

Timeline 1994 Palmz-Schatz BMS stent approved by FDA for use in the US 2003 Cypher DES approved by FDA 2004 Taxus DES approved by FDA

Timeline 1997 > 1 million angioplasties worldwide 1999 85% of patients with PCI received stent 2001 2 million angioplasties worldwide

Timeline 1977 to 1982 Balloon Angioplasty 63% Success rate 24% In hospital CABG rate 5% Myocardial Infarction rate 1985 to 1986 Bare Metal Stent 82% Success rate 6% CABG rate 30 to 35% Restenosis rate 2003 – Cypher DES approved 3.2% Restenosis rates

Structural Approvals ASD closure PFO closure PDA closure Edwards balloon expandable aortic valve Medtronic self expanding aortic valve Mitraclip Watchman left atrial appendage ocluder Ethanol Septal Ablation VSD occluder

Helmuth Hertz and Inge Edler The First Echocardiograph

Southwestern Virginia Cath Labs CRMH* Salem VA Lewis Gayle Lynchburg CNRV* Montgomery Regional Martinsville Bluefield Regional* * HeartNet Hospitals

Carilion Roanoke Memorial Hospital Date cath lab first opened under the direction of:  1972 Dr. Phillip Shiner First coronary angioplasty:    1985 Dr. Phillip Shiner and Dr. John Starr First coronary stent: 1991 First rotational atherectomy 1995 First pacemaker: First ICD: First Aflutter Ablation 1988 Procedural capabilities: Diagnostic cath PCI Pacemaker Implantation ICD Implantation Open Heart Surgery

Lewis Gayle Date cath lab first opened under the direction of: First coronary intervention:    First pacemaker: Procedural capabilities: Diagnostic cath PCI Pacemaker Implantation ICD Implantation Open Heart Surgery

Salem VAMC Date cath lab first opened under the direction of: 1984 First coronary intervention:    2002 First pacemaker: Procedural capabilities: Diagnostic cath PCI Pacemaker Implantation Year switched to digital 1997

Community Hospital Date cath lab first opened under the direction of: First coronary intervention:    First pacemaker: Procedural capabilities: Diagnostic cath PCI Pacemaker Implantation

HeartNet of the Virginias Est. 1989 Bath County Community Hospital Bedford County Memorial Hospital Bluefield Regional Medical Center Franklin Memorial Hospital Giles Memorial Hospital Radford Community Hospital Roanoke Memorial Regional Heart Center Tazewell Community Hospital Wythe County Community Hospital 1991 Stonewall Jackson Hospital 2000 Pocahontas Memorial Hospital Princeton Community Hospital 2013 Greenbrier Valley Medical Center

Bluefield Regional Medical Center Date cath lab first opened under the direction of:  August 1989 First coronary intervention:    October 2012 First pacemaker: Procedural capabilities: Diagnostic cath PCI Pacemaker Implantation ICD Implantation Open Heart Surgery

Date cath lab first opened under the direction of: 1990 Dr. Barnett, Dr. Wyne, Dr. Happell & Dr. Crafford First coronary intervention:    March 27, 2015 Dr. Shin lee Tan First pacemaker: May 1990 Dr. Uzair Wyne First ICD: July 24, 2013 Dr. Jose Rivero Procedural capabilities: Diagnostic cath PCI Pacemaker Implantation ICD Implantation

Danville Date cath lab first opened under the direction of: First coronary intervention:    First pacemaker: Procedural capabilities: Diagnostic cath PCI Pacemaker Implantation ICD Implantation Open Heart Surgery

Memorial Hospital Martinsville

Martinsville Date cath lab first opened under the direction of : Jan 1992 Dr. Nayan Bhattt Date of coronary intervention: 1993 Dr. Robert McQueen Date of first pacemaker in the cath lab: 2003 Dr. Dinesh Bhatt Procedural capabilities: Diagnostic cath PCI Pacemaker Implantation ICD Implantation

Cardiac Catheterizations Performed in Virgina

Spectrum of Structural Heart Disease