Inside the heart: ultrasound now breaks up plaque that hardened arteries – 6/21/2022

When a plaque is in the blood’s path to impede its passage, people usually say that it is made of fat, almost to simplify life.

But between us, the sign is made of a lot of things. Fat, yes, without a doubt. But also, for example, fiber and calcium. Oh, yes, she can have plenty of this mineral, which builds up there over the years, slowly, without a hint of haste.

“Because of this delay and as people are living longer, we find calcified coronary disease on a daily basis with increasing frequency”, observes cardiologist Pedro Lemos, referring to the network of arteries that supply the heart. And how he depends on them!

“The heart is a muscle that, if you could take a small piece and look under the microscope, you would see that it is very similar to that of the thigh”, compares the doctor, who is coordinator of the Cardiovascular Intervention Center at Hospital Israelita Albert Einstein, in São Paulo. Paulo, and owner of a rare ability to talk about Medicine as if telling a good story.

Where the similarity ends: the heart muscle beats about 80 times a minute. “If I asked anyone to lift their thigh 80 times in that same minute, they wouldn’t last long,” he says.

Of course, to be that athlete kept in our chest, the heart incessantly requires a lot of energy, demanding a beautiful supply of oxygen at every moment. This supply service is done precisely by the coronaries. Hence, it doesn’t take more than seconds for him to feel resentful if they are obstructed by such signs.

“If you join a clot to one of them, this obstruction is abrupt. We have a heart attack”, says the cardiologist. “Now, if it happens slowly, making the blood path narrower and narrower because of the overgrown plaque, the person feels the pain of angina.”

One way or another, at these times something has to be done — or the heart won’t take the suffocation. That’s when, with balloons and stents, Pedro Lemos and his colleagues enter the scene by navigating through the vessels to the problem area, performing the famous angioplasty. But no one thinks twice about the trouble that calcification can mean that day.

“Well, the fat is all soft, spongy”, describes the cardiologist. “But calcium is the ingredient that we find in bones and teeth.”

It’s easy to deduce where this story is going: when the mineral accumulates on the walls of the vessels, they become more and more hardened. “And it’s ok if they are rigid, that is, as long as there is blood in a reasonable volume through there”, comments Pedro Lemos. “The problem is when that stops happening.”

Until last week, for the doctor, cases like this were synonymous with trouble. “To unclog the coronary, I need to dilate it, that’s for sure”, he says, giving the basic principle. “But how can I dilate a vessel that is hard? stent Do not do that. It’s just a support that keeps the coronary I just dilated open. So, I repeat, what would I do if this artery wasn’t dilatable?”

Yes, there were alternatives. But the ideal answer to this question only came last week, when Pedro Lemos and his colleagues at Einstein (in the picture), in an unprecedented procedure in the country, they used ultrasound and, with it, they simply broke all that calcium in the coronary artery, which was hard as a stone.

how was it before

In addition to not being able to properly dilate the obstructed area to reestablish blood flow, taking a balloon with the help of a catheter to inflate it well at that point, the doctors had the following challenge: getting to this area itself, if by chance they found several other calcified stretches along the way.

“It was like walking on roller skates on a cobbled street”, recalls Pedro Lemos. In fact, a blood vessel without so many plaques could look like a paved road, which the cardiologist was able to navigate with the catheter as smoothly as possible. However, calcifications create indentations that often hinder the device from moving forward.

“It could happen that I couldn’t even reach the injury”, reveals the doctor. Therefore, he had to make do with poorly navigable and poorly dilatable arteries. By the way, to complete: no matter how much they ask for tests before the procedure, cardiologists only really feel the stiffness of the patient’s coronary arteries when touching them, at the moment.

“If they are very rigid, it is not always a case of stopping what was being done in the middle. But if we continue, the result of the unblocking is never so good”, observes the doctor.

Alternatives that weren’t perfect

There are high-pressure balloons that, let’s say, dilate the calcified coronary artery. “To give you an idea, normal blood pressure, which is 120 by 80 mmHg, or millimeters of mercury, would be equivalent to 1/6 or 1/5 of 1 atmosphere, which is another unit of pressure measurement”, teaches Pedro we read. “And we have balloons that reach 24, 25 atmospheres. Not even at the bottom of the sea there is that pressure.” Could walls made of concrete from calcified coronary arteries withstand so much? Not always. There is a risk.

Interventional cardiologists can also use microscopic slides, making equally tiny cuts in the calcium-filled plaques. For you to visualize the effect of this: “It’s like a watermelon where I just have to spear it with a knife and it opens.”

Finally, another strategy is ablation, which works like interventional cardiologists sanding, so to speak, the hardened plaque. “It is extremely safe and has been used for many years”, says the doctor. “But the equipment needs to touch the plaques, and naturally it can only do that on the inner surface of the coronary artery, while some calcifications, perhaps most, are deep because they infiltrate the artery wall.”

Result: the person even improves, but we cannot say leave with the coronary arteries completely unobstructed. She still has some degree of the problem that landed her in the hospital. “But it was the arsenal we had until then”, says Pedro Lemos.

The ultrasound inside the chest

The new technology that lands at the Einstein in the same week as it does in Japan — being carried out for four years in Europe and one year ago in the United States — solves a good part of all these limitations.

Doctors call it lithotripsy, a name that says a lot because it means something like “breaking stones”. Urologists have been pronouncing it for a long time. It is not new that they use this very high energy sound wave, with a frequency above what we can hear, to make kidney stones vibrate until they burst. “It’s like when a very loud sound shatters a crystal glass”, Pedro Lemos makes another comparison.

In this case, however, the kidney stones turn to sand and fulfill their destiny of being eliminated through the urine. “The coronary calcium is not going anywhere”, explains the cardiologist. “Only, that big plate breaks into a thousand pieces, making a mosaic, and the wall of the vase becomes flexible.” Then, with peace of mind, the angioplasty balloon can do its job.

The advantages of novelty

As soon as he arrived, the ultrasound had already entered the routine of the São Paulo hospital. This is because, according to the various clinical tests carried out, it presents a rare combination in newly launched devices.

“It is common for a new procedure in Medicine to be more efficient than the one that existed previously, but paying a price: that of being more invasive or less safe”, notes Dr. Pedro Lemos.

The opposite can also happen: a new treatment will bring more safety, but not have a result as good as the one obtained before. “But, in the case of lithotripsy of the coronary arteries, it provides the conditions for the clearance to be excellent and, at the same time, it is much safer for the patient”, guarantees the cardiologist.

According to him, an angioplasty takes about an hour and a half when there are no such calcified plaques. However, the duration of the procedure is unpredictable when calcifications are very present. “Sometimes, navigating with the catheter through the vessels, we take a long time just to go through a minimum stretch of the route”, says the doctor.

To give you an idea, with the ultrasound leaving the plates in pieces — including on the way to the lesion, when necessary — the procedure takes an hour in a half again. Quickly, the coronary arteries lose their rigidity and the angioplasty proceeds as usual. A day later, the person is usually at home, with the arteries clear. And, I risk, much more flexible, giving full support to those 80 beats per minute that fill us with life.

About Jenni Smith

She's our PC girl, so anything is up to her. She is also responsible for the videos of Play Crazy Game, as well as giving a leg in the news.

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