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It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced in the detection, management,

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ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease

This review will reconsider the current paradigm for understanding the critical, final steps in the progression of atherosclerotic lesions. That scheme, largely an outgrowth of observations of autopsy tissues by Davies and colleagues,1 2 asserts that the cause of death in atherosclerotic coronary artery disease is rupture of an advanced atherosclerotic lesion. Although this assumption may be partially true, recent autopsy studies suggest that it is incomplete.

To reconsider this paradigm, we reexamined the morphological classification scheme for lesions proposed by the American Heart Association (AHA).3 4 This scheme is difficult to use for 2 reasons. First, it uses a very long list of roman numerals modified by letter codes that are difficult to remember. Second, it implies an orderly, linear pattern of lesion progression. This tends to be ambiguous, because it is not clear whether there is a single sequence of events during the progression of all lesions. We have therefore tried to devise a simpler classification scheme that is consistent with the AHA categories but is easier to use, able to deal with a wide array of morphological variations, and not overly burdened by mechanistic implications.

The current paradigm is based on the belief that type IV lesions, or “atheromas,” described by the AHA are stable because the fatty, necrotic core is contained by a smooth muscle cell–rich fibrous cap. Virchow’s analysis5 in 1858 pointed out that historically, the term “atheroma” refers to a dermal cyst (“Grutzbalg”), a fatty …

Lessons From Sudden Coronary Death A Comprehensive Morphological Classification Scheme for Atherosclerotic Lesions

2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease) Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons

Thirty years ago, John French wrote a seminal review describing the unique properties of the arterial intima.1 His major point was that the smooth muscle cells of the intima have a unique morphology (Fig 1⇓). French also pointed out that intimal formation appeared during normal development and aging as well as in the response of arteries to almost any imaginable injury, including atherosclerosis.



 Figure 1. 
Top left, Histology of intima vs media. Coronary artery is from an adult patient with idiopathic dilated cardiomyopathy. In the absence of atherosclerosis, there remains diffuse intimal hyperplasia. The intima is several cell layers thick and composed of smooth muscle cells and is separated from the distinct media by the internal elastic lamina (arrows) (hematoxylin and eosin, original magnification ×200). Top right, Advanced atherosclerosis of the left circumflex coronary artery. This lesion was treated by percutaneous balloon angioplasty 23 days before the patient’s death. Note the complex nature of the lesion with a distinct fibrous cap (FC), intimal hyperplasia (IHP), intramural hemorrhage (H), and a necrotic core (NC) composed of inflammatory cells and accumulated lipid (hematoxylin and eosin, original magnification ×100). Bottom left, Myxomatous tissue. Directional coronary atherectomy specimen from a restenotic lesion shows stellate-shaped smooth muscle cells. Smooth muscle cells with this appearance are often regarded as evidence of proliferation. Note the homogeneity of these cells and the absence of inflammatory and endothelial cells in this region (hematoxylin and eosin, original magnification ×200). Bottom right, Directional coronary atherectomy specimen from a primary lesion. Again, note the presence of stellate-shaped smooth muscle cells but a denser connective tissue matrix (hematoxylin and eosin, original magnification ×200).



This article attempts to update French’s review. We will discuss the developmental origins of the intima and suggest that the arterial intima is a distinct tissue with a long and …

The Intima: Soil for Atherosclerosis and Restenosis

A prosthetic valve assembly for use in replacing a deficient native valve comprises a replacement valve supported on an expandable valve support. If desired, one or more anchor may be used. The valve support, which entirely supports the valve annulus, valve leaflets, and valve commissure points, is configured to be collapsible for transluminal delivery and expandable to contact the anatomical annulus of the native valve when the assembly is properly positioned. The anchor engages the lumen wall when expanded and prevents substantial migration of the valve assembly when positioned in place. The prosthetic valve assembly is compressible about a catheter, and restrained from expanding by an outer sheath. The catheter may be inserted inside a lumen within the body, such as the femoral artery, and delivered to a desired location, such as the heart. When the outer sheath is retracted, the prosthetic valve assembly expands to an expanded position such that the valve and valve support expand within the deficient native valve, and the anchor engages the lumen wall.

Prosthetic Valve For Transluminal Delivery

Apparatus for permanent placement across an ostium of a left atrial appendage in a patient, which includes a filtering membrane configured to extend across the ostium of the left atrial appendage. The filtering membrane has a permeable structure which allows blood to flow through but substantially inhibits thrombus from passing therethrough. The apparatus also includes a support structure attached to the filtering membrane which retains the filtering membrane in position across the ostium of the left atrial appendage by permanently engaging a portion of the interior wall of the left atrial appendage. The support structure may be radially expandable from a first configuration to a second configuration which engages the ostium or the interior wall of the left atrial appendage. The filtering membrane may define an opening therethrough that is configured to expand from a first size which inhibits the passage of thrombus therethrough to a second size which allows an interventional device, e.g., an expansion balloon, to pass therethrough, and wherein the opening is resiliently biased towards the first size.

Filter apparatus for ostium of left atrial appendage

The present invention provides an aortic valvuloplasty catheter which, in one preferred embodiment, has a tapered distal balloon segment that anchors within the left ventricle outflow track of the patient’s heart and a rounded proximal segment which conforms to the aortic sinuses forcing the valve leaflets open. In addition, this embodiment of the valvuloplasty catheter includes a fiber-based balloon membrane, a distal pigtail end hole catheter tip, and a catheter sheath.

Valvuloplasty devices and methods

A device 10 and method for replacing or restoring competence to incompetent valves. The device 10 is inserted percutaneously or surgically and is preferably constructed of a material capable of promoting cellular ingrowth such that, eventually, native biologic tissue completely covers the device 10 insulating the blood flow therefrom. The material is preferably bioabsorbable over time, allowing the device to harbor the regeneration of a valve structure and to later become absorbed by the body. The device is sized and arranged to mimic the valve it is replacing or repairing.

Venous valvuloplasty device and method

Methods and devices for percutaneous, in situ coronary bypass wherein a tissue puncturing catheter is used to form blood flow paths between an artery and an adjacent vein such that arterial blood will flow through a segment of the adjacent vein, thereby bypassing a lesion in the artery. The tissue puncturing catheter comprises a flexible catheter having a tissue puncturing apparatus such as a sharp tipped member, an electro-surgical apparatus or a laser beam passable therefrom to create the desired blood flow paths between the artery and vein. Stents are provided for facilitating blood flow through the blood flow paths and the segment of the vein used as the bypass conduit. One such stent is specially constructed to carry arterial blood in one direction through the vein segment while allowing venous blood to continue to flow in the opposite direction through that venous segment.

Percutaneous in-situ coronary bypass method and apparatus

A steerable catheter in which a guidewire can serve a dual purpose of deflecting a bendable element at a distal end of the steerable catheter and as a guidewire to facilitate the placement of a working catheter within the vascular system. The guidewire is adapted to be slidingly received within routing eyelets or the like where one of such eyelets is disposed at a distal end of the bendable element and another near the proximal end thereof. The guidewire can be readily advanced in the distal direction relative to the steerable catheter, but tensioning of the guidewire at its proximal end serves to deflect and bend the bendable element.

Robert S. Schwartz

Papers

Filter apparatus for ostium of left atrial appendage

Valvuloplasty devices and methods

Venous valvuloplasty device and method

Percutaneous in-situ coronary bypass method and apparatus

Steerable catheter with external guidewire as catheter tip deflector