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The Cardiac Pump

Objectives 1. Learn how the microscopic and gross anatomy of the heart enables it to pump blood through the systemic and pulmonary circulations. 2. Indicate how electrical excitation of the heart is coupled to its contractions. 3. Elucidate the main factors that determine cardiac contractile force. 4. Describe and explain the pressure changes in the heart chambers and great vessels during a complete cardiac cycle. 5.…

Automaticity: Natural Excitation of the Heart

Objectives 1. Explain the basis of automaticity. 2. Describe the conduction of excitation through the heart. 3. Explain the basis of reentry. 4. Describe the components of the electrocardiogram. 5. Explain various cardiac rhythm disturbances. The Heart Generates its Own Pacemaking Activity The nervous system controls various aspects of cardiac function, including the frequency at which the heart beats and the vigor of each contraction. However,…

Excitation: The Cardiac Action Potential

Objectives 1. Characterize the types of cardiac action potentials. 2. Define the ionic basis of the resting potential. 3. Define the ionic basis of cardiac action potentials. 4. Describe the characteristics of the fast- and slow-response action potentials. 5. Explain the temporal changes in cardiac excitability. Experiments on “animal electricity” conducted by Galvani and Volta more than two centuries ago led to the discovery that electrical…

Overview of the Circulation and Blood

Objectives 1. Describe the general structure of the cardiovascular system. 2. Compare the compositions and functions of the blood vessels. 3. Compare the relationship of the vascular cross-sectional area to the velocity of blood flow in the various vascular segments. 4. Indicate the pressure changes and pathways of blood flow throughout the vasculature. 5. Describe the constituents of the blood and explain the functions of the…

Congenital Heart Disease

Open full size image Introduction Congenital heart disease (CHD) has an incidence of approximately 0.8% or approximately 8 out of every 1000 live births. These defects are derangements secondary to altered embryonic cardiovascular anatomy or the failure of a structure to progress beyond early stages of fetal development. Currently, nearly one million adults have CHD in the United States, and although many adults with CHD live…

Pericardiocentesis and Pericardial Intervention

Open full size image Introduction Pericardial disease reflects a wide range of clinical presentations and pathologies, from acute pericarditis to cardiac tamponade. Unlike coronary artery disease, heart failure, or valvular heart disease, however, there are few randomized clinical trial data to guide physicians and interventionalists in its management. There are currently no American College of Cardiology guidelines on management of pericardial disease, with only European Society…

Endomyocardial Biopsy

Dr. Deepak L. Bhatt discloses the following relationships: Advisory Board : Cardax, Elsevier Practice Update Cardiology, Medscape Cardiology, Regado Biosciences; Board of Directors : Boston VA Research Institute, Society of Cardiovascular Patient Care; Chair : American Heart Association Get With The Guidelines Steering Committee; Data Monitoring Committees : Duke Clinical Research Institute, Harvard Clinical Research Institute, Mayo Clinic, Population Health Research Institute; Honoraria : American College…

Interventions for Advanced Heart Failure

Open full size image Dr. Kapur has received preclinical research support from Heartware Inc. and Cardiac­Assist Inc. and has worked as a speaker and consultant for Maquet and Thoratec Inc. Introduction Heart disease remains the number one cause of mortality in the United States. Over the past 50 years, pharmacologic advancements for cardiovascular risk factors and device innovation for the management of coronary disease including acute…

Patent Foramen Ovale, Atrial Septal Defect, Left Atrial Appendage, and Ventricular Septal Defect Closure

Open full size image Patent Foramen Ovale Introduction A potential causal relationship between patent foramen ovale (PFO) and stroke was first described by Cohnheim in 1877. In the last two decades several studies have investigated the role of PFO in cryptogenic ischemic stroke, migraine headaches, platypnea-orthodeoxia, and decompression sickness. Percutaneous PFO closure has emerged as a treatment option in the last decade, with significant controversy around…

Hypertrophic Cardiomyopathy

Open full size image Introduction and Epidemiology Hypertrophic cardiomyopathy (HCM) is a complex cardiac disorder that has been the subject of intense scrutiny and scientific investigation for the past half century. HCM is a unique cardiac condition that has the potential to manifest during any phase of life, from infancy to the ninth decade. Despite the wide range of symptoms and ages of affected individuals, sudden…

Transcatheter Mitral Valve Intervention

Open full size image Section I: Mitral Stenosis Introduction Normal Mitral Valve Anatomy To appreciate the complexity of the mitral valve is to understand its intricate anatomical and physiologic properties. The mitral valve can be divided into several components, each one important in maintaining proper valve functionality. The mitral valve consists of two leaflets, a posterior leaflet with three distinct scallops and a corresponding, but much…

Aortic Valvuloplasty and Transcatheter Aortic Valve Replacement

Open full size image Introduction Balloon aortic valvuloplasty (BAV) was developed as one of the first minimally invasive approaches to treat symptomatic severe aortic stenosis (AS). Alain Cribier first described the procedure in 1986 in a case series of three patients with severe calcific aortic stenosis. While the procedure was initially intended to be a minimally invasive alternative to surgical aortic valve replacement (SAVR), recognition of…

Hemodialysis Access Intervention

Open full size image Introduction The primary purpose of vascular access is to facilitate hemodialysis for as long as possible at minimal risk of complications. To achieve this goal, vascular surgeons primarily use vascular accesses created from native tissue, but when suitable autogenous components are not available, prosthetic arteriovenous grafts are preferred over tunneled catheter systems. The creation of hemodialysis fistulas and grafts has become one…

Management of Chronic Venous Insufficiency

Open full size image Epidemiology and Risk Factors of Chronic Venous Disease Chronic venous disease (CVD) is a condition that affects the superficial and deep venous systems resulting in venous hypertension and a cascade of biochemical and vessel wall changes that lead to a spectrum of pathologies ranging from telangiectasias to venous stasis ulcerations. Chronic venous insufficiency (CVI) is an advanced form of CVD, generally presenting…

Interventional Management of Lower Extremity Deep Vein Thrombosis and Pulmonary Embolism

Open full size image Introduction Venous thromboembolic disease (VTE), comprised of deep vein thrombosis (DVT) and pulmonary embolism (PE), is morbid, expensive, and potentially fatal. It ranks as the third most common cardiovascular disease, and consumes significant health care dollars. Over the past several decades, the management of DVT and PE for many patients has been altered by the introduction of catheter-based therapies. Considerable data has…

Intracranial Intervention and Acute Stroke

Open full size image Introduction The management of cerebrovascular disease has often lagged behind the advances made in the management of cardiovascular disease. However those same technological advances in cardiovascular devices have facilitated the development of dedicated neurovascular devices, which have resulted in a narrowing of the treatment gap. Still there remain major differences primarily due to anatomical and physiological differences between the coronary and cerebral…

Carotid and Vertebral Intervention

Open full size image Carotid Intervention The Data When discussing the clinical data for outcomes in carotid artery stenting (CAS), there are several important outcomes to be detailed: periprocedural (30 day) safety, which is composed of death, all stroke, and myocardial infarction; 1-year stroke prevention efficacy composed of ipsilateral stroke rates from 30 to 365 days; and durability, which is measured by restenosis >70% to 80% in severity…

Endovascular Management of Aortic and Thoracic Aneurysms

Open full size image A Abdominal Aortic Aneurysm Introduction Abdominal aortic aneurysm (AAA) is defined as a 50% increase in the diameter of the aorta when compared with a normal segment. The average infrarenal aortic diameters for men and women are 1.5 cm and 1.7 cm, respectively. The universal standard for an infrarenal aneurysmal aorta is greater than 3.0 cm. Natural History An AAA is usually asymptomatic and is…

Renal Denervation

Open full size image Introduction Hypertension is a leading cause of death worldwide, with 13% of all deaths attributed to it in 2004 (World Health Organization, 2009). A prevalence of 29% (1.56 billion) has been predicted for 2025. In the United States, approximately 65 million individuals have hypertension. It is associated with cardiovascular and cerebrovascular morbidity and mortality with a direct relationship of blood pressure and…

Mesenteric Artery Intervention : Catheter-Based Therapy for Chronic Mesenteric Ischemia

Open full size image Introduction Prevalence The prevalence of mesenteric arterial stenoses is much more common than is the clinical manifestation of chronic mesenteric ischemia (CMI), likely due to the rich vascular communication among the three mesenteric vessels. CMI is twice as common in women than men. Asymptomatic mesenteric stenosis was documented angiographically in 40% of patients with an abdominal aortic aneurysm, 29% with aortoiliac obstructive…