Dr. Giuseppe Sangiorgi, FESC, FSCAI

1. Ruolo della cardiologia interventistica nel paziente con patologia extracoronarica complessa Dr. Giuseppe Sangiorgi, FESC, FSCAI Laboratorio di Emodinamica Università di Modena

2. Giuseppe Sangiorgi, MD CardiacCath Lab Modena Policlinic

3. L’idraulico dell’Extracoronarico • Quanti di voi hanno mai chiamato l’idraulico? • Avete chiamato l’idraulico per il gabinetto ed è arrivato uno specialista solo in docce? • Noi emodinamisti dovremmo saper riparare tutto?

4. 3

6. Chi vede il Paziente Affetto da Patologia Extracoronarica ? Medicina Interna Chirurgia Chirurgo Generale Cardiochirurgo Chirurgo Vascolare Neurochirurgo Radiologia Non-interventista Interventista Neuroradiologo MEDICINA DI BASE MEDICINA D’URGENZA Internista Cardiologo clinico Cardiologo interventista Angiologo Nefrologo Neurologo

8. My personal experience in developing an “open cath-lab platform”

9. In 15 Minutes • How all this developed in the places where I have been working up to now • and how this could develop in your place (I really hope your dreams comes true) • What you really need to make that happen • and what could be helpful in these days • How this will develop in the future • and where we should work on

10. 21 Years in 15 min

11. 1989 • University of Tor Vergata - Rome • Coronaryangiograms • PTCA • Coronaryangiograms • PTCA • Coronaryangiograms • PTCA

12. Max Sangiorgi: "Isthereanythingelse I could do?" • Senior Physician (Prof. Gioffrè): "Well, I have just gotthisballoonfromMeditech. Some crazy peoplehavestartedtodilatepulmonaryvalves"

13. Starting a pulmonary valvuloplasty program was pretty easy at that time • Doctor: "Listen, you have a blocked heart valve! We are going to balloon it" • Patient: "Great, please go ahead" • No ethical committee • No regulatory issues • No reimbursement issues • No paperwork at all

14. That's how we started to do something else beside coronaries 1989

15. If you are doing coronaries only … … could you start a pulmonary valvuloplasty program in your institution today?

16. Ofcourse!! Noproblem • You may just need … • some discussion with the general director of the hospital • some discussion with CADM • some discussion with administration • some discussion with pharmacy • some discussion with clinical engineer • a little bit more of discussion with the surgeons than we had in the 80ies • a dedicated 3 day training organized by the medical device company • a certificate from the scientific society of something • May be you will need IRB approval • and may be some other paper work

17. Needless to mention … … thatitis an absolute requirementthatyoualreadyhavedone 100 cases(forthegeneraldirectorand CADM) withexcellentoutcomebeforeyoustartyourprogram

18. 1990 • PTCA in a 68 y/o patient • I punctured the right femoral • and failed • I punctured the left femoral • and failed • I punctured the right brachial • and failed • I did not know about the radial approach • and punctured the left brachial • crossed a proximal stenosis of the left subclavian • … finally performed the PTCA • "Would be nice to have that subclavian artery open" • The cath lab nurse run into the radiology department for a 5 mm balloon • I did my first peripheral angioplasty • … and finally learned what turf battle means

19. Next morning in theofficeoftheheadofradiology • Head of radiology (Prof. Giovanni Simonetti): "How could you as a cardiologist do a peripheral angioplasty without permission?!?!What would you say if I as a radiologist would start coronary angiography?" • My answer: "I would be more than happy to train you" • Head of radiology: very angry with cardiologists after 20 years

20. We moved on with other procedures which required big balloons

21. … like aortic valvuloplasty

22. Angioplasty of coarctation 1992

23. Thereafter, we pushed the balloon forward .... Retrograde Mitral Valvuloplasty 1993

24. and transeptal mitral valvuloplasty with ugly balloons 1993

25. Later on we did this with umbrellas Rashkind-Okkluder

26. If you are familiar with... • transseptal puncture • the left atrium • umbrellas

28. So now you have some contacts to the pediatric world, so it is only a small step to become involved in VSD closure

29. Congenital Muscular VSD San Donato 1998

30. Of course, you are still involved in the sometimes boring coronary work So you will become involved in post-Myocardial infarction VSD closure

31. Post Myocardial Infarction VSD Device released Final angio

32. By the way: Do not forget the coronary fistulas

33. Only a small step to peripheral fistulas

34. Pulmonary AV-Fistula San Donato 2001

35. When you alreayd have experience with really large sheaths...

36. Anatomical landmarks to be considered prior to EVG intervention ANGIO DSA SPIRAL ANGIO CT Renal a. Accessory renal a. D1 IMA L2 Lumbar aa. D3 D4 D3 D4 D5 D5 D5 D : diameter L : length A : angulation

45. Giorgio S. Rx. 32421 18\10\2000 Selective injection of SMA fills back IMA up to the coil

46. Super-selective 3rd left lumbar a. arteriography through Fast Traker 325 Selective 3rd left lumbar a. arteriography

47. Catheter treatment of congenital heart disease Non-congenital heart defects Other cardiovascular diseases

48. If you have learned transseptalsand if you know where the left atrium is....