1. #1006 New Approaches to Cardio Re-vascularization October 26 to October 29 Robert E. Michler, MD Professor of Surgery Chief, Division of Thoracic and Cardiovascular Surgery The Ohio State University Medical Center Gregory M. Eaton, MD Assistant Professor of Clinical Internal Medicine Division of Cardiology The Ohio State University Medical Center

2. Gregory M. Eaton, MD Assistant Professor of Clinical Internal Medicine Division of Cardiology The Ohio State University Medical Center 1

3. PTCA 1997 - 20th anniversary Tremendous growth Relieves angina Comparable to CABG in select patient population Effective in acute myocardial infarction 1997 - 20th anniversary Tremendous growth Relieves angina Comparable to CABG in select patient population Effective in acute myocardial infarction 2

4. BARI, CABRI, EAST, GABI And RITA: Coronary Angioplasty On Trial Balloon angioplasty initially developed: - To support a technique of myocardial revascularization which is minimally invasive - Performed via a percutaneous approach with little patient discomfort - Shorter hospital stays Balloon angioplasty initially developed: - To support a technique of myocardial revascularization which is minimally invasive - Performed via a percutaneous approach with little patient discomfort - Shorter hospital stays 3

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8. Advances In coronary Stenting Less intense anticoagulation More flexibility in deployment Better patency Safer deployment Less intense anticoagulation More flexibility in deployment Better patency Safer deployment 7

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10. Intracoronary Brachytherapy Prevention of restenosis after intervention remains greatest therapeutic challenge in interventional cardiology Pre-clinical trials using ionizing radiation shows significant reduction in neointimal proliferation Prevention of restenosis after intervention remains greatest therapeutic challenge in interventional cardiology Pre-clinical trials using ionizing radiation shows significant reduction in neointimal proliferation 9

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12. Intracoronary Brachytherapy High risk for restenosis: - Restenotic lesions - Diffuse or multifocal disease - Smaller arteries - Recanalized chronic total occlusion - ? Diabetes High risk for restenosis: - Restenotic lesions - Diffuse or multifocal disease - Smaller arteries - Recanalized chronic total occlusion - ? Diabetes 11

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14. NOGA Endomyocardial Mapping Evaluating patients with ischemic heart disease needs to accurately define presence and nature of dysfunctional myocardial tissue Nature of dysfunctional but viable tissue important component of the clinical assessment of patients with chronic CAD Evaluating patients with ischemic heart disease needs to accurately define presence and nature of dysfunctional myocardial tissue Nature of dysfunctional but viable tissue important component of the clinical assessment of patients with chronic CAD 13

15. NOGA Endomyocardial Mapping Designed to acquire, analyze and display real time electromechanical maps of the human heart Accurate 3D mapping Non-flouroscopic location System uses magnetic technology to accurately determine location and orientation of catheter Designed to acquire, analyze and display real time electromechanical maps of the human heart Accurate 3D mapping Non-flouroscopic location System uses magnetic technology to accurately determine location and orientation of catheter 14

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18. NOGA 3D geometry constructed real time Electrophysiologic information superimposed on electroanatomical map Non-fluoroscopic guidance - Transmyocardial revascularization - Gene therapy 3D geometry constructed real time Electrophysiologic information superimposed on electroanatomical map Non-fluoroscopic guidance - Transmyocardial revascularization - Gene therapy 17

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20. Transmyocardial Laser Revascularization Surgical or percutaneous approach Investigational therapeutic strategy to enhance myocardial perfusion by applying laser source into ischemic myocardium Preliminary surgical trials significant reduction in angina, improved quality of life, some improved perfusion Surgical or percutaneous approach Investigational therapeutic strategy to enhance myocardial perfusion by applying laser source into ischemic myocardium Preliminary surgical trials significant reduction in angina, improved quality of life, some improved perfusion 19

21. Transmyocardial Laser Revascularization Mechanism of benefit unknown: - Long-term patency of channels conflicting - “Anesthetic effect” from vaporization of myocardial nerve fibers - Angiogenesis with enhanced collateral development and increased myocardial perfusion Mechanism of benefit unknown: - Long-term patency of channels conflicting - “Anesthetic effect” from vaporization of myocardial nerve fibers - Angiogenesis with enhanced collateral development and increased myocardial perfusion 20

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23. Robert E. Michler, MD Professor of Surgery Chief, Division of Thoracic and Cardiovascular Surgery The Ohio State University Medical Center 30

24. Profile Mike 47 year old male Father, grandfather Symptoms - Chronic history of fatigue - Bee sting - Self-injected epinephrine - Seen at ER - acute EKG changes Mike 47 year old male Father, grandfather Symptoms - Chronic history of fatigue - Bee sting - Self-injected epinephrine - Seen at ER - acute EKG changes 31

25. Profile Mike Diagnosis: High-grade lesion; left anterior descending artery Recommended: FDA approved minimally invasive surgical procedure Mike Diagnosis: High-grade lesion; left anterior descending artery Recommended: FDA approved minimally invasive surgical procedure 31 A

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28. Conventional CABG Surgery Proven safety and efficacy Recovery time Pain / discomfort Neurologic disorders CPB sequelae Proven safety and efficacy Recovery time Pain / discomfort Neurologic disorders CPB sequelae 34

29. Principle Causes Of Morbidity And Mortality In CABG Cardiopulmonary bypass Sternotomy Cardiopulmonary bypass Sternotomy 35

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31. Minimally Invasive Direct Coronary Artery Bypass Definition: Limited coronary artery bypass grafting without sternotomy, cardiopulmonary bypass or manipulation of the ascending aorta, usually using arterial conduits. Definition: Limited coronary artery bypass grafting without sternotomy, cardiopulmonary bypass or manipulation of the ascending aorta, usually using arterial conduits. 37

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33. Advantages Of MIDCAB Avoidance of sternotomy Avoidance of cardiopulmonary bypass Shorter or no stay in ICU Shorter hospitalization Quicker convalescence Lower cost Avoidance of sternotomy Avoidance of cardiopulmonary bypass Shorter or no stay in ICU Shorter hospitalization Quicker convalescence Lower cost 39

34. Expanded Indications For MIDCAB “Culprit vessel” revascularzation Previously complicated sternotomy Substernal patent IMA graft Inordinate risk of cardiopulmonary bypass High risk for aortic manipulation “Culprit vessel” revascularzation Previously complicated sternotomy Substernal patent IMA graft Inordinate risk of cardiopulmonary bypass High risk for aortic manipulation 40

35. VADCAB Decreases the amount of post-operative pain Anterior Thoracotomy Site can be centered over target vessel No rib resection is required Sequential anterior wall grafting can be performed with longer ITA mobilization Decreases the amount of post-operative pain Anterior Thoracotomy Site can be centered over target vessel No rib resection is required Sequential anterior wall grafting can be performed with longer ITA mobilization 41

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37. Advantages Of MIDCAB / VADCAB No risk of stroke No neurocognitive changes No coagulopathy Reduced hospitalization and disability More cosmetic incision No risk of stroke No neurocognitive changes No coagulopathy Reduced hospitalization and disability More cosmetic incision 43

38. MIDCAB Disadvantages Incomplete revascularization (analogous to PTCA) Unproven survival benefit in multivessel disease Acceptable short term follow-up Difficult management of intraop ischemia and hemodynamic instability Incomplete revascularization (analogous to PTCA) Unproven survival benefit in multivessel disease Acceptable short term follow-up Difficult management of intraop ischemia and hemodynamic instability 44

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43. Trans Myocardial Laser Revascularization For diffuse small vessel disease Higher cardiac event-free survival Fewer cardiac-related rehospitalizations Improved exercise tolerance Similar one-year survival (84% vs 89%) HCFA approved reimbursement For diffuse small vessel disease Higher cardiac event-free survival Fewer cardiac-related rehospitalizations Improved exercise tolerance Similar one-year survival (84% vs 89%) HCFA approved reimbursement 49

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46. Profile Mike Treatment - Minimally invasive heart surgery - FDA approved robotic procedure Mike Treatment - Minimally invasive heart surgery - FDA approved robotic procedure 52

47. Profile Mike Evaluation - Operation went smoothly - Post Op coronary angiogram - 3 rd day post op - symptom free, went home - 2 weeks post op - back to work part time Prognosis: Good Mike Evaluation - Operation went smoothly - Post Op coronary angiogram - 3 rd day post op - symptom free, went home - 2 weeks post op - back to work part time Prognosis: Good 52 A

48. #1007 3rd Annual G.I. Quiz November 2 to 5 Sheryl A. Pfeil, MD Assistant Professor of Clinical Internal Medicine Division of Digestive Diseases The Ohio State University Medical Center Robert Murray, MD Associate Professor of Pediatrics Section of Gastroenterology Children’s Hospital & The Ohio State University Medical Center NEXT WEEK