restricted access 21. Iatrogenicity of Diagnostic and Therapeutic, Invasive and Noninvasive Cardiovascular Interventions, Devices, and Surgeries
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INTRODUCTION Structural heart disease (SHD) has been described this way: “. . . it seems that the term refers to non-­ coronary heart disease for which some therapy, surgical or percutaneous , exists (1).” This vague definition reveals the difficulty in clarifying a heterogeneous group of diseases in terms of pathophysiological background, diagnostic findings, and prognosis. SHD may affect the heart valves, ­ great heart vessels, and heart chambers, but atherosclerotic and ischemic cardiomyopathies commonly are excluded, whereas obstructive and nonobstructive hypertrophic cardiomyopathies are included. A further classification of SHD into congenital and acquired forms is useful. Although congenital SHD may affect pediatric and adult patients, acquired SHD is usually diagnosed in adult patients. A brief overview of the dif­ fer­ ent types of SHD is illustrated in Figure 21-1. The time of diagnosis may vary significantly among the dif­ fer­ ent types of SHD. Some diseases, such as transposition of the ­ great arteries, may become symptomatic immediately ­ after birth and require rapid treatment. Other forms, such as atrial septal defects (ASD) or acquired valvular SHD, may remain asymptomatic and not need treatment at all. Enormous improvements in the pathophysiological understanding , diagnostic modalities, and treatment strategies have been achieved in recent de­ cades. In the past, the diagnosis of clinically significant SHD almost always meant open heart surgery, but new catheter-­ based techniques offer a valuable alternative , especially in valvular heart diseases in adults. As an example, treatment of severe aortic stenosis by transcatheter aortic valve implantation (TAVR) is standard care for patients who are considered inoperable (2). Closure of atrial or ventricular septal defects is similarly well established in clinical practice (3). Diagnostic modalities have also improved rapidly. Cardiac MRI allows for mea­ sure­ ment of cardiac dimensions , volumes, and myo­ car­ dial perfusion, whereas cardiac CT is used for evaluation of valve geometry and noninvasive angiography along with other indications (4,5). CHAPTER 21 Iatrogenicity of Diagnostic and Therapeutic, Invasive and Noninvasive Cardiovascular Interventions, Devices, and Surgeries Michael Behnes, Tobias Becher, Stefan Baumann, Uzair Ansari, and Ibrahim Akin 244 / Iatrogenicity of Cardiovascular Interventions, Devices, and Surgeries appropriate diagnostic modality. Signs and symptoms of SHD include heart murmur, irregular heart beat, chest deformity, and extracardiac signs such as edema, clubbing, cyanosis, and plethora. The main diagnostics in SHD should always include an ECG and echocardiogram. The ECG may show signs of ischemic heart disease, acute infarction, heart rhythm abnormalities, or left ventricular hypertrophy. The echocardiogram allows for direct visualization of the heart chambers , heart valves, myocardium, and pericardium, and it may trigger additional testing. Further­ diagnostics can be divided into invasive and noninvasive modalities (see Figure 21-2). Generally speaking, an invasive examination almost always poses more risk to a patient than a noninvasive one. Noninvasive Diagnostics Noninvasive diagnostic testing for SHD includes echocardiography (transthoracic or transesophageal , both with or without stress testing), cardiac CT with perfusion, and cardiac MRI (with or without stress testing). Echocardiography is the examination of choice to gain an overview of left ventricular function, valve pathologies, and chamber abnormalities as well as detailed information about The complexity of SHD, together with the development of new treatment and diagnostic modalities, requires closer interdisciplinary cooperation among cardiologists, pediatric cardiologists , interventional cardiologists, radiologists, and heart surgeons. Even though new and modern techniques in medicine always hold the promise of more efficient and safer treatment, no one should forget the pos­ si­ ble hazards and pitfalls. Long-­ term follow-up on safety and efficacy is almost always missing for unpre­ ce­ dented techniques . Also, the introduction of new techniques into daily clinical practice requires a learning curve and may therefore increase the risk for complications . Physicians should always carefully weigh the pos­ si­ ble advantages of a modality against pos­ si­ ble complications and disadvantages. CARDIAC DIAGNOSTICS IN STRUCTURAL HEART DISEASE Cardiac diagnostics aim to provide information about the type, severity, and hemodynamic impact of SHD. They also play a pivotal role in intervention planning. A detailed anamnesis, including ­ family history and thorough clinical examination, is the first step in choosing the Structural heart disease Structural: Congenital Valvular: • Valvular stenosis • Valvular insufficiency Valvular: • Valvular stenosis • Valvular insufficiency Structural: • Atrial septal defect • Ventricular septal defect • Patent foramen ovale • Fallot’s tetralogy • Ebstein’s anomaly • Transposition of great arteries • Hypoplastic left heart syndrome • Patent ductus arteriosus • Other congenital structural heart defects • Heart tumors • Hypertrophic cardiomyopathy • Obstructive • Nonobstructive • Restrictive cardiomyopathy • Ventricular aneurysm Acquired FIGURE 21-1 ​ Structural heart disease can be divided into congenital and acquired forms and may affect the heart valves, ­ great vessels...