Haroon Faraz, MD, Interventional Cardiologist at Hackensack University Medical Center, talks about shockwave therapy for the heart.
I wanted to start by asking you about shockwave therapy. What is it for our viewers and what is it designed to do?
FARAZ: Shockwave therapy is historically used to break calcified stones. Recently, the same technology was adopted for calcified vessels in the heart. And it’s a relatively newer technology which was recently approved, and we were lucky that Hackensack was one of the initial sites that was able to get the technology. We were able to help some of our patients who have severely calcified vessels. Historically, we used a device or technology called atherectomy which is a diamond bar that rotates around a central axis. Essentially, what you’re doing is you’re cleaning the inside vessel but you’re trying to scrape the calcium. The idea is that you’re changing the compliance of the wall of the vessel which is very hard. So, you’re trying to change the hardness. That way when we treat the vessel with a balloon, which is an angioplasty, and put a stent, the stent sits nicely, and we have a nice luminal again. Essentially, we decrease the blockage and clean up the artery. The shockwave therapy is somewhat unique. You’re not really scraping the lumen of the vessel. We inflate the balloon and then you emit these waves which are shattering the calcium which is in the wall of the vessel into tiny, tiny, pieces. The analogy would be if you have a rock wall, you’re basically converting it into a powdered rock wall. The vessel becomes very compliant and then it makes it easier for the treatment of the blockage with a stent and a balloon. So, then the stent can expand which is always a challenge when the vessel is very calcified.
What happens to that powder?
FARAZ: That’s the unique thing, it stays in the wall. Because the calcium is in the wall of the vessel and that’s the beauty of the technology is that when we treat it with atherectomy and we would scrape the wall, the debris would go downstream and at times, if the calcium burden would be high and we have to scrape, there’s a condition called no-reflow, meaning the blood flow gets compromised for a small duration because you’re clogging the microcirculation because this debris has to go somewhere. And I think the novelty of the shockwave therapy is that theoretically, you are just not allowing that debris to go anywhere, and it stays in the wall and you’re changing the compliance of the vessel wall.
When viewers hear something like, you know, breaking through that wall, I think of sand, you’re sandblasting my heart and arteries…How safe is it and how effective?
FARAZ: CAD III was the scientific study which looked into the safety, it’s a very safe technology and that’s how it got approved by the FDA. It has been used in Europe for a few years and now recently, as of last month, it was approved in the US. Sometimes when the vessels are very narrow, it becomes a little challenging to pass the balloon on which the shockwave treatment is doing. So normally, we pass a balloon before to the vessel so we can advance the shockwave balloon. I don’t think we have a lot of data to suggest that it’s harmful or if there are any side effects or any negative effects of the treatment.
I’m going to step back just a little bit, if you could talk to our viewers about these calcifications. What causes them and how prevalent are they in our population?
FARAZ: Calcification, is essentially in the wall of the vessel, so normally when we talk about blockages, it’s a process where we read the term atherosclerosis. Essentially, what that means is that there is a bulky, plaque buildup which narrows the lumen. Every time the plaque builds in the wall of the vessel, it causes an inflammatory burst. When that happens, it recruits some degree of calcium. So essentially, the older the person gets and if they have blockages, the higher the chance that that plaque or that fatty plaque is going to become calcified. So younger people, when we talk about heart disease, usually in their 60s, 70s, are less likely to have calcification. The older you get and if you do have fibro-fatty plaque, there is more likely chances that it’s going to become calcified.
When you have too much calcification, what does that lead to?
FARAZ: Calcified vessels; in our world where we fix blockages, because that’s my expertise as being an interventional cardiologist, we deal with people who have blockages, and we fix them. Anytime you have calcium, it is challenging because when we advance our instruments which are the balloons and stents, calcium doesn’t allow good or optimum reserves. And that’s where the shockwave treatment is novel in terms of trying to treat the vessel without disrupting the calcium and just keeping calcium within the wall of the vessel.
Could you just walk our viewers through how you do the procedure? Do you access through a vein or?
FARAZ: Correct. So, catheterization usually is done through an artery. The majority of the cases, go from the wrist these days. So, we go with a catheter, it’s a tube which is advanced through the wrist. You’re lying on the table and there’s a radiographic camera. The catheter is advanced from the wrist to the heart and we engage the circulation of the heart through that catheter and then we advance our equipment, which is the shockwave balloons over those wires. So, the majority of the time, procedures are done through the wrist. Sometimes when we have to use advanced therapies we have larger devices like mechanical support, which essentially, acts like a pump to maintain circulation when we do complex cases. In those circumstances, because the device is bulkier, we have to get access from the femoral artery which is in the groin because these devices are relatively larger and the wrist vessels are relatively small. Those procedures then go from the femoral artery. So, in Barbara’s case, she had a two-step procedure. Her original presentation was a surgical disease because she had a main blockage in the left main artery. Historically, it is treated with bypass surgery. She had tested COVID positive and was turned down. So, there was a concern with a COVID that if you go through a major surgery and you get intubated, it makes it challenging and if the COVID gets worse, extubating becomes a problem. Our first stage was a complex procedure where we went from the femoral artery with a mechanical circulatory support because we were treating her main artery which is the left main and we had to do a bypass to the extent of the left main artery with mechanical support. That went very well. And in that, some of the vessels were very calcified. At that time, we then decided we would bring her back in the second stage. Then we went from the wrist and were able to use the shockwave treatment and fix the other blockages.
How is she doing now?
FARAZ: Oh, she’s doing phenomenal. I mean, she’s feeling great. Her heart is now brand new. She’s getting amazing blood in all the territories of the heart muscle. I have seen her twice after the procedure and there’s a dramatic improvement in her overall energy levels. You know, her shortness of breath has resolved and she’s a totally new person.
So, she was supposed to get the bypass but because of COVID she did not. What was the procedure you did first?
FARAZ: So, the first procedure was, we call it a complex high-risk intervention. Essentially, these are procedures which you use some kind of a support because historically, left-brain disease which is the main artery, was not considered an option to be treated with stents. But in the last five years or 10 years, we have now established that theoretically, we can treat them with the stents, that distal left main where the artery divides into the main artery in the front of the heart which is the left anterior descending in the left-side complex, is still considered that surgical option is a better option. But in certain scenarios where surgery can be performed, in Barbara’s case, it was because of COVID and her age, we have a program in Hackensack where the team, the surgeons, the anesthesiologists, the interventionalists, the chair of the department, the vice chair, we all discuss patients and go over the whole algorithm of what would be the best treatment strategy. So, it’s called a coronary MDT, a multidisciplinary team meeting. We kind of discussed her case and we reviewed with the cardiothoracic surgeon, we reviewed with the chair, the vice chair, you know, there are multiple inputs. At that time, it was decided that it would be in her best interest to proceed and fix the blockages with the mechanical circulatory support.
How long after was the shockwave therapy?
FARAZ: I believe it was about a week later or a week or two weeks later.
Is there anything I didn’t ask you, that you would want to make sure that people know about this procedure?
FARAZ: Hackensack is a part of a few trials which is important, we are in the cutting-edge space of the coronary world. And there are few trials which are looking at these complex cases and trying to make it a level-one guidelines. Basically, the way treatments work in the world of medicine is there are classes of indications and class one is always considered the gold standard. Technology evolves over time and there’s a little catch-up period between what technology is available and what the guidelines, which are the major governing bodies, American Heart, American College of Cardiology, SCAI, which is society of cardiac angiography, so all these committees, they sit down and based on the scientific data, they then conclude different classes for treatments. So currently, what we did is a Class Two recommendation, meaning it’s not the gold standard. I think what happened is as science evolves, we are catching up and we change the guidelines and I think Hackensack is a part of trials, one of the trials is a protect Four Trial, which will be looking into the specific question of when you treat these complex patients, can you treat them without using the mechanical circulatory support? So again, I think we are lucky, it’s an advanced center and we have some advanced therapies which allows us to give our patients the best. And now I think we are also part of the scientific committee that’s going to look into it in a scientific fashion. Hopefully, change the guidelines from a Class Two to a Class One.
Interview conducted by Ivanhoe Broadcast News.
END OF INTERVIEW
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