New directions and trends in interventional cardiology
Interventional cardiology continues to evolve, driven by rapid advancements in technology. Major paradigm shifts are being seen in structural heart disease with new devices and expansion into the trispid valve, and the movement toward coronary computed tomography angiography (CCTA) utilization continues. CCTA offers more detailed images to eliminate diagnostic catheterizations, and it allows preplanning of percutaneous coronary intervention (PCI).
To find out more about these trends, and others, Cardiovascular Business spoke with George D. Dangas, MD, PhD, director of cardiovascular innovation at Mount Sinai Hospital, 2023-24 president of Society for Cardiovascular Angiography and Interventions (SCAI) and director of the Transcatheter Cardiovascular Therapeutics (TCT) meeting, in a video interview at the American Heart Association 2024 meeting.
Structural heart advances, new generation bioresorbable stents and noninvasive imaging are some of the major trends he has his eye on.
"There is a very different way of thinking where noninvasive CT imaging can be utilized to understand if there is calcium of fat plaque. It also provides us with a lot of details in a very patient-specific approach, because everybody’s coronary arteries are very different, just like the fingerprints in many ways. So having all that information before an intervention can be utilized to plan the procedure," Dangas explained. "When the technology enables us to also detect some vulnerable plaques or some other plaque characteristics ahead of time, it is always going to pan out a better patient care."
About a decade ago, a major shift started in at the large annual TCT meeting, shifting from the traditional focus on stents and PCI techniques toward structural heart interventions. In recent years, a large amount of offices have shifted to the rapidly expanding area of transcatheter valves and repairs so patients can avoid open-heart surgery.
"Just few years ago, we used to mostly think about transcatheter aortic valve replacement (TAVR), but now there are many more types of valve replacement and valve repair that can take place now interventionally. New concepts like mitral valve repair and replacement, tricuspid valve repair and replacement ... it's a very dynamic field with a lot of things changing," Dangas said.
Recent U.S. Food and Drug Administration approvals for devices addressing tricuspid valve disease, including full valve replacements and clipping devices, underscore the field's momentum. Dangas noted that the accelerated regulatory processes have presented new opportunities and responsibilities, emphasizing the need for heart teams to determine which patients benefit most and how to integrate these therapies into everyday practice.
Shorter antiplatelet regimens
In coronary interventions, a major focus is now on adjunctive pharmacology and device design. According to Dangas, the duration of dual antiplatelet therapy has been dramatically reduced, offering greater flexibility for patients requiring additional medical procedures.
"We’ve moved from multi-year timelines to investigating one- to three-month timeframes," he said.
These shorter time frames for antiplatelet therapy can enable easier patient compliance, avoid elevated bleeding risks over the long term and help reduce healthcare costs. Dangas said this helps the patients, who often have multiple health issues and need to undergo minor surgeries.
New bioresorbable stents
He also said bioresorbable stents are also undergoing a renaissance and to expect seeing a lot more on that front in the years ahead. This technology allows blocked vessels to be revascularized without permanent metal hardware that can limit or complicate future interventions or cardiovascular surgery.
The first commercially available dissolving stent, the Abbott Absorb bioresorbable vascular scaffold (BVS), was enthusiastically welcomed into cardiology with FDA clearance in 2016 and originally thought to be the way of the future in stent technology. However, it was pulled off the market just a year later in September 2017 due to poor sales.
It had low market penetration due to its higher cost than medallic stents. New data after its release also showed its thicker struts made it difficult to navigate tortuous vessels and created poor outcomes in smaller vessels compared to metallic stents. Dangas said there were also delayed absorption times beyond what was originally expected.
However, Abbott took this stent technology and redeveloped it for use in historically difficult to treat peripheral artery disease (PAD) lesions below the knee, in what is now the commercially available Esprit BTK bioresorbable scaffold.
"Having understood and incorporated those lessons, which we learned rather bitterly in the initial run, hopefully we will have a very exciting and very successful second run," Dangas said.
Combining structural and coronary disease interventions at the same time
Another emerging trend is the convergence of coronary and structural heart diseases as combined strategies in hybrid procedures in clinical trials.
"We're talking a lot more about the combination of valve disease and coronary disease. In a trial, we often think that there's one disease and the study likes focus on one problem at a time. But in reality, the patients have many diseases, many problems," Dangas explains.
Intravascular imaging and pre-procedure planning
Numerous studies have shown that intravascular imaging technologies such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT) can optimizing outcomes in complex cases. There has been reluctance at some centers to embrace the use of these technologies because they may add cost and procedure time. However, Dangas said these trials have shown they can improve outcomes.
IVUS has critics because of its low image resolution and grainy images that are sometimes hard to interpret. OCT offers high-resolution imaging, but also has limited with lower tissue penetration to see structure further inside vessel walls, and the need to use saline or contrast to clear the blood column to allow the light-based technology to work. These limits might be part of the reason why cardiac CT is starting to see wider use as an additional aid to navigate cath lab procedures.
CCTA helps with planning ahead of PCI
Dangas said CCTA is being used more and more as it increases in availability across health systems. It is now playing a more important role in planning interventions, for example; CT images can show the vessels as well as the plaques and arterial wall remodeling, and it does so more clearly than angiography or intervascular imaging.
FDA-cleared artificial intelligence (AI) algorithms are also taking CCTA to the next level, allowing automated, detailed quantification for the entire coronary tree, assessment of the various types of plaque morphology so interventional cardiologists have much more information about what they are facing inside the vessels before they step into the cath lab. The AI can also detect and show vulnerable plaques and offer virtual fractional flow reserve (FFR-CT) assessments for the entire coronary tree that closely matches pressure wire based invasive FFR.
"Today we have AI technologies that actually look at these plaques that can point out the areas of interest that maybe you want to pay a little bit more attention to as an interventional cardiologist. And you can actually preplan your entire procedure, get all your vessel sizing, your true lumen sizing, all done before you even go into the cath lab with a patient," Dangas explained.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com