Selected Podcast
Breakthrough for Coronary Artery Disease Patients
Interventional cardiologist who performed the first commercial procedure in Texas using the Shockwave Intravascular Lithotripsy System explains its use for challenging coronary calcifications.
Featured Speaker:
Robert Stoler, MD, FACC, FSCAI
Dr. Stoler is board certified by the American Board of Internal Medicine in Interventional Cardiology. He is the Co-Medical Director of Cardiology and the Medical Director of the Cardiac Catheterization Lab at Baylor Heart and Vascular Hospital. He was appointed Associate Professor, Department of Internal Medicine at Texas A&M Health Science Center College of Medicine. He has published multiple cardiology related articles in peer reviewed medical journals and books, and he continues to be a principal investigator in many national clinical trials. Since 2006, Dr. Stoler has appeared annually on D Magazine's list of "Best Doctors" in Dallas as voted by his peers and as a "Super Doctor" in Texas Monthly magazine. Dr. Stoler was also recently named "Best of the Best" by Patients' Choice Award for his consistantly high ratings by his patients. After receiving his undergraduate and medical degree from Duke University, Dr. Stoler served his internship and residency in Internal Medicine at University of Texas Southwestern Medical Center in Dallas. He completed his fellowship in Cardiology and Interventional Cardiology at Beth Israel Hospital, Harvard Medical School in Boston. Dr. Stoler is recognized as a Fellow of the American College of Cardiology and The Society for Cardiovascular Angiography and Interventions. He is an active member of Dallas County Medical Society and Texas Medical Association. His professional interest and expertise lie in the various percutaneous treatments for coronary and structural heart disease. Transcription:
Breakthrough for Coronary Artery Disease Patients
Caitlin Whyte: On our HeartSpeak Podcast, the podcast from Baylor Scott & White Heart and Vascular Hospital, Dallas and Fort Worth, we've covered many heart and vascular topics. Today, we have the Co-medical Director of Cardiology and Medical Director for Cardiac Catheterization Lab at Baylor Scott & White Heart and Vascular Hospital Dallas, Dr. Robert Stoler. We will discuss a new procedure available to interventional cardiologists and patients..
Dr Stoler, welcome. Before we get into the technology itself, can you tell us a bit about calcified coronary artery disease? What does it mean to have calcium in the artery?
Robert Stoler, MD, FACC, FSCAI: So when the old timers described hardening of the arteries, what they're really talking about is atherosclerosis. And the hardening part of the arteries is the accumulation of calcium that builds up along with plaque in the patient's coronary arteries. And that calcium is the same calcium that you find in bone or that you find in an egg shell. And it makes the arteries stiff and hard and difficult to work with and fragile and crackable. Those are some of the ways that patients present with different kinds of chest discomfort or acute coronary syndrome, like heart attacks that we need to treat percutaneously along with medications that we use.
Caitlin Whyte: So this new technology is called shockwave IVL. Can you tell us more about how it works?
Robert Stoler, MD, FACC, FSCAI: So for a long time, we've known that treating calcified coronaries is the most difficult of the coronary blockages to treat. And in fact, outcomes in those blockages are often worse over time than outcomes and blockages that do not have calcium. So part of the problem is when we try to balloon a calcified coronary, sometimes we can't balloon it. We can't get it open because the calcium is so rock hard that it won't give, it won't crack and allow us to open the artery up. Sometime we crack the calcified blockage and the crack extends into other parts of the artery, which makes it more dangerous for patients when we're having to treat those patients.
So we've needed a technology that helps us deal with deep calcium that's in the walls of the coronary arteries. So along comes this device called shockwave. It works through what we call intravascular lithotripsy. People have probably heard of lithotripsy who has had kidney stones and that's when they put you in the bathtub, turn that ultrasonic lithotripsy device on, and it sends waves through the tub that you're sitting in to crack the calcified kidney stone that you have and let you pass that kidney stone.
Well, in a similar kind of way, when we have these heavy calcium buildup in patient's coronary arteries, this shockwave device has ultrasound crystals that are embedded in a balloon. And we can put this balloon in the artery across the blockage. We can blow it up at a very low pressure. And then we plug this shockwave device in and the operator like me has a little handle and we press the button and we can see as it gives the pluses of the ultrasound waves, the shockwaves, if you will, the lithotripsy waves into that coronary and we can watch with the contrast dye as the balloon has a tight pinch in it. And as we give these pulsations, the pinch in the balloon, which really represents the blockage keeping the balloon from expanding, the pinch in the balloon will go away. The balloon expands and all the sudden, the artery is open and it does this in a way without providing a severe crack or a problem that we would otherwise have to deal with. So it is an absolutely brand new technology that works in a different way from any other technology we've been able to use. And there are a host of blockages now that we can treat with this intravascular lithotripsy device that we couldn't open up in the past. So it's been really a game changer for us and for patients that we treat.
Caitlin Whyte: Now, why is this technology such a game changer for coronary artery disease patients?
Robert Stoler, MD, FACC, FSCAI: So there were a few different things that we tried to use for calcified coronaries before shockwave. One is special kinds of balloons that either have little blades attached to them or little external wires attached to them to try and cut or score the calcified blockage. Those were tried extensively, they flat out pretty much don't work.
For the calcium that's at the very tip of the blockage, we have two kinds of devices that partly helped with those. And they're a technique that we call atherectomy and they are a little burr of sorts or a little football-shaped head that spins at 180,000 RPMs. And that literally lets us drill through a tight blockage with calcium on the inside of the vessel. One of those is called rotational atherectomy, which is also called Rotablator. The other is called orbital atherectomy and that's called Diamondback. One drills a hole that is perfectly circular. The other drills a hole that is in an ellipse. And those work reasonably well for calcium that's on the inside of the plaque but not for calcium that's deep in the wall of the artery.
The other thing about those two what we call ablative techniques or atherectomy techniques is the complication rates are higher with those than they are with the shockwave device. There's a little higher risk that you could poke a hole in the artery. There's a little higher risk that you could tear the artery or shower clot or plaque downstream that a patient wouldn't tolerate very well.
When we need those atherectomy devices, they're infinitely helpful and they work, but they don't address the calcium that's deep in the walls of the artery that might still keep a balloon from expanding. And in fact, those techniques are probably going to be complimentary to the shockwave device, because some of these calcified blockages are so tight and so calcified on the inside that it takes the Rotablator or the CSI device to burr a hole through it, so we can get the shockwave inside it and then open up the deep calcium.
So the shockwave is very different from those atherectomy devices. And it's the only thing that really addresses the deep calcium and it addresses it in a safer way than many of the other technologies that we've had so far.
Caitlin Whyte: Now, before we started recording, you mentioned new stent tech is always evolving. How do you see all of this new technology working together and developing and progressing in the future?
Robert Stoler, MD, FACC, FSCAI: The evolution of technology in interventional cardiology is unbelievable. I've been at Downtown Baylor for 24 years. I've run the cath lab there for the last about 15. And I've been a part of every basically new technology and the evaluation that's come into our space in the last 20 years.
Stents have evolved, techniques like the atherectomy devices have evolved like we were saying, and shockwave has come along. But stent technology continues to get better and better. We went from metal stents that had no coating to drug-coated or drug-eluting stents that have a medicine embedded in them to keep the blockage from growing back to now new stent designs with the drug coatings on them that are tailored to specific vessels and specific blockages.
We have a brand new large vessel stent that's extra-scaffolded and has drug-eluting in it. And it's called Megatron. We have another very thin struts, low complication rate stent that's very deliverable called Orsiro. And stents are now becoming more and more tailored to specific arteries and specific situations. So along with the balloon and atherectomy technology evolution that we get, stents continue to get better and continue to have better outcomes as well.
Caitlin Whyte: Well, Dr. Stoler, is there anything else you'd like to add to our conversation today?
Robert Stoler, MD, FACC, FSCAI: Well, I think what we're seeing more and more as the population gets older. We're seeing older, still very functional patients who come in with coronary disease and prefer to try and avoid bypass surgery, if at all possible. Bypass is still an excellent operation, but as patients age and have more other what we call co-morbidities or other illnesses, the risk of an operation gets higher and higher in those patients. So what we've got now is a better arsenal of technology to help treat these older calcified patients and their older calcified lesions safely and effectively without having to send them to bypass surgery.
So for patients, this is a big win. And as you age, we have more and more technology and ability to treat your more complex coronary disease than we've ever had. And the studies and the technology evolution continues to go forward. And it's only going to get better from here.
Caitlin Whyte: Well, thank you so much for your time. That's Dr. Robert Stoler, an interventional cardiologist, the Co-medical Director of Cardiology and Medical Director for the Cardiac Catheterization Lab at Baylor Scott & White Heart and Vascular Hospital Dallas.
Thanks for checking out this episode of HeartSpeak. To find a specialist on the medical staff at Baylor Scott & White Heart and Vascular Hospital, Dallas or Fort Worth, please visit bswhealth.com/dfwheartdoctors or call (844) 279-3627. That's (844) 279-3627.
If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we'll talk next time.
Baylor Scott & White Heart and Vascular Hospital, Dallas and Fort Worth, joint ownership with physicians.
Breakthrough for Coronary Artery Disease Patients
Caitlin Whyte: On our HeartSpeak Podcast, the podcast from Baylor Scott & White Heart and Vascular Hospital, Dallas and Fort Worth, we've covered many heart and vascular topics. Today, we have the Co-medical Director of Cardiology and Medical Director for Cardiac Catheterization Lab at Baylor Scott & White Heart and Vascular Hospital Dallas, Dr. Robert Stoler. We will discuss a new procedure available to interventional cardiologists and patients..
Dr Stoler, welcome. Before we get into the technology itself, can you tell us a bit about calcified coronary artery disease? What does it mean to have calcium in the artery?
Robert Stoler, MD, FACC, FSCAI: So when the old timers described hardening of the arteries, what they're really talking about is atherosclerosis. And the hardening part of the arteries is the accumulation of calcium that builds up along with plaque in the patient's coronary arteries. And that calcium is the same calcium that you find in bone or that you find in an egg shell. And it makes the arteries stiff and hard and difficult to work with and fragile and crackable. Those are some of the ways that patients present with different kinds of chest discomfort or acute coronary syndrome, like heart attacks that we need to treat percutaneously along with medications that we use.
Caitlin Whyte: So this new technology is called shockwave IVL. Can you tell us more about how it works?
Robert Stoler, MD, FACC, FSCAI: So for a long time, we've known that treating calcified coronaries is the most difficult of the coronary blockages to treat. And in fact, outcomes in those blockages are often worse over time than outcomes and blockages that do not have calcium. So part of the problem is when we try to balloon a calcified coronary, sometimes we can't balloon it. We can't get it open because the calcium is so rock hard that it won't give, it won't crack and allow us to open the artery up. Sometime we crack the calcified blockage and the crack extends into other parts of the artery, which makes it more dangerous for patients when we're having to treat those patients.
So we've needed a technology that helps us deal with deep calcium that's in the walls of the coronary arteries. So along comes this device called shockwave. It works through what we call intravascular lithotripsy. People have probably heard of lithotripsy who has had kidney stones and that's when they put you in the bathtub, turn that ultrasonic lithotripsy device on, and it sends waves through the tub that you're sitting in to crack the calcified kidney stone that you have and let you pass that kidney stone.
Well, in a similar kind of way, when we have these heavy calcium buildup in patient's coronary arteries, this shockwave device has ultrasound crystals that are embedded in a balloon. And we can put this balloon in the artery across the blockage. We can blow it up at a very low pressure. And then we plug this shockwave device in and the operator like me has a little handle and we press the button and we can see as it gives the pluses of the ultrasound waves, the shockwaves, if you will, the lithotripsy waves into that coronary and we can watch with the contrast dye as the balloon has a tight pinch in it. And as we give these pulsations, the pinch in the balloon, which really represents the blockage keeping the balloon from expanding, the pinch in the balloon will go away. The balloon expands and all the sudden, the artery is open and it does this in a way without providing a severe crack or a problem that we would otherwise have to deal with. So it is an absolutely brand new technology that works in a different way from any other technology we've been able to use. And there are a host of blockages now that we can treat with this intravascular lithotripsy device that we couldn't open up in the past. So it's been really a game changer for us and for patients that we treat.
Caitlin Whyte: Now, why is this technology such a game changer for coronary artery disease patients?
Robert Stoler, MD, FACC, FSCAI: So there were a few different things that we tried to use for calcified coronaries before shockwave. One is special kinds of balloons that either have little blades attached to them or little external wires attached to them to try and cut or score the calcified blockage. Those were tried extensively, they flat out pretty much don't work.
For the calcium that's at the very tip of the blockage, we have two kinds of devices that partly helped with those. And they're a technique that we call atherectomy and they are a little burr of sorts or a little football-shaped head that spins at 180,000 RPMs. And that literally lets us drill through a tight blockage with calcium on the inside of the vessel. One of those is called rotational atherectomy, which is also called Rotablator. The other is called orbital atherectomy and that's called Diamondback. One drills a hole that is perfectly circular. The other drills a hole that is in an ellipse. And those work reasonably well for calcium that's on the inside of the plaque but not for calcium that's deep in the wall of the artery.
The other thing about those two what we call ablative techniques or atherectomy techniques is the complication rates are higher with those than they are with the shockwave device. There's a little higher risk that you could poke a hole in the artery. There's a little higher risk that you could tear the artery or shower clot or plaque downstream that a patient wouldn't tolerate very well.
When we need those atherectomy devices, they're infinitely helpful and they work, but they don't address the calcium that's deep in the walls of the artery that might still keep a balloon from expanding. And in fact, those techniques are probably going to be complimentary to the shockwave device, because some of these calcified blockages are so tight and so calcified on the inside that it takes the Rotablator or the CSI device to burr a hole through it, so we can get the shockwave inside it and then open up the deep calcium.
So the shockwave is very different from those atherectomy devices. And it's the only thing that really addresses the deep calcium and it addresses it in a safer way than many of the other technologies that we've had so far.
Caitlin Whyte: Now, before we started recording, you mentioned new stent tech is always evolving. How do you see all of this new technology working together and developing and progressing in the future?
Robert Stoler, MD, FACC, FSCAI: The evolution of technology in interventional cardiology is unbelievable. I've been at Downtown Baylor for 24 years. I've run the cath lab there for the last about 15. And I've been a part of every basically new technology and the evaluation that's come into our space in the last 20 years.
Stents have evolved, techniques like the atherectomy devices have evolved like we were saying, and shockwave has come along. But stent technology continues to get better and better. We went from metal stents that had no coating to drug-coated or drug-eluting stents that have a medicine embedded in them to keep the blockage from growing back to now new stent designs with the drug coatings on them that are tailored to specific vessels and specific blockages.
We have a brand new large vessel stent that's extra-scaffolded and has drug-eluting in it. And it's called Megatron. We have another very thin struts, low complication rate stent that's very deliverable called Orsiro. And stents are now becoming more and more tailored to specific arteries and specific situations. So along with the balloon and atherectomy technology evolution that we get, stents continue to get better and continue to have better outcomes as well.
Caitlin Whyte: Well, Dr. Stoler, is there anything else you'd like to add to our conversation today?
Robert Stoler, MD, FACC, FSCAI: Well, I think what we're seeing more and more as the population gets older. We're seeing older, still very functional patients who come in with coronary disease and prefer to try and avoid bypass surgery, if at all possible. Bypass is still an excellent operation, but as patients age and have more other what we call co-morbidities or other illnesses, the risk of an operation gets higher and higher in those patients. So what we've got now is a better arsenal of technology to help treat these older calcified patients and their older calcified lesions safely and effectively without having to send them to bypass surgery.
So for patients, this is a big win. And as you age, we have more and more technology and ability to treat your more complex coronary disease than we've ever had. And the studies and the technology evolution continues to go forward. And it's only going to get better from here.
Caitlin Whyte: Well, thank you so much for your time. That's Dr. Robert Stoler, an interventional cardiologist, the Co-medical Director of Cardiology and Medical Director for the Cardiac Catheterization Lab at Baylor Scott & White Heart and Vascular Hospital Dallas.
Thanks for checking out this episode of HeartSpeak. To find a specialist on the medical staff at Baylor Scott & White Heart and Vascular Hospital, Dallas or Fort Worth, please visit bswhealth.com/dfwheartdoctors or call (844) 279-3627. That's (844) 279-3627.
If you found this podcast helpful, please share it on your social channels and be sure to check out the entire podcast library for topics of interest to you. Thanks and we'll talk next time.
Baylor Scott & White Heart and Vascular Hospital, Dallas and Fort Worth, joint ownership with physicians.