Interventional Cardiologist: Catheter-based Procedures Enable Minimal Sedation, Quicker Recoveries

An interventional cardiologist specializes in diagnosing and treating blood vessel blockages and structural heart defects using nonsurgical, catheter-based procedures and specialized imaging techniques.

Nish Patel, M.D., who last year joined Baptist Health Miami Cardiac & Vascular Institute, is an interventional cardiologist and leader in the structural heart program development. Advances in catheter-based techniques will continue to move forward at the Institute with Dr. Patel’s expertise, which includes adopting “minimal sedation” which enables quicker and smoother recoveries for patients.

Nish Patel, M.D., interventional cardiologist at Baptist Health Miami Cardiac & Vascular Institute.

“This is how I explain to my patients what the interventional cardiologist does,” said Dr. Patel. “Essentially, we treat the blockages in the heart artery, or disease or disorder of the structure of the heart, with a catheter-based approach. That’s different than minimally invasive surgeries, which still qualify as surgeries where they have to make an incision and expose part of the heart muscle. Here we are not cutting. It's just the catheter-based procedures. Everything is done through the catheters.”

A primary care doctor may take care of general heart health and manage risk factors for heart disease, such as high cholesterol and high blood pressure. However, you may be referred to an interventional cardiologist if your primary finds or suspects a serious heart or blood vessel problem, such as blockage of a coronary artery.

With minimally invasive surgeries, patients can expect hospital stays of about four or five days or longer.

“But with the catheter-based procedures, usually the hospital stay is 24 hours,” explains Dr. Patel. “The patient comes in for the procedure. Let's say if they're having a structural heart procedure, such as valve replacement or repair. Then they stay overnight after the procedure and go home the next day. If we are treating blockages in the heart artery, which is also called coronary artery disease, usually the patient goes home the same day after treating their blockage with a stent placement.”

Minimal Sedation for Catheter-Based Procedures

After serving as the structural heart program director at St. Peter’s Health Partners in Albany, New York, Dr. Patel is implementing at the Institute what he achieved in his previous position: Using minimal sedation for virtually all catheter-based procedures. 

“The less you do to the patient, the better it is in the sense that you do the procedure with minimal sedation -- not using general anesthesia which is still a fairly common practice during TAVR (transcatheter aortic valve replacement),” explains Dr. Patel.

During “minimalist TAVR” the patient is in a state of “conscious sedation.” The same applies to coronary angioplasty, also called cardiac catheterization or percutaneous coronary intervention (PCI). During angioplasty, a long, thin tube (the catheter) is put into a blood vessel and guided to the blocked coronary artery. The catheter has a tiny balloon at its tip which is inflated at the narrowed area of the heart artery. This presses the plaque or blood clot against the sides of the artery, making more room for blood flow.

“The patients are awake and easily arousable, just like during cardiac catheterization,” said Dr. Patel. “When we do the catheterization, the patients are relaxed and pain free, but they're easily arousable. Let's say if I want the patient’s assistance, I’ll ask them: ‘Okay, take a nice deep breath.’ And they would be able to follow the command.”

Treating or Replacing Heart Valves

Everyone’s heart pumps with the vital help of four valves that direct blood in and out of each chamber. When the valves are diseased or structurally deficient, the result can be critical or even deadly for patients.

Pivotal advances in treating or replacing heart valves, many of them initiated as part of clinical trials, have been performed at Miami Cardiac & Vascular Institute for years. And they continue at a very steady pace.  Heart valve disease occurs if one or more of the heart valves — the tricuspid, pulmonary, mitral, and aortic valves — do not open fully or they allow blood to leak back into the chambers. Heart valves can have three basic kinds of problems: regurgitation, stenosis (narrowing), and atresia (lacking an opening for blood to flow through).

Somewhat similar to placing a stent in an artery, the TAVR approach delivers a fully collapsible replacement valve to the valve site through a catheter. Once the new valve is expanded, it pushes the old valve leaflets out of the way and the tissue in the replacement valve takes over the job of regulating blood flow.

Since 2006, the Institute also has been at the forefront of MitraClip procedures and involved in many clinical trials. As a result of the Institute’s success in these trials, the MitraClip and even more advanced devices are commonly used for patients with MVP (mitral valve prolapse), and other abnormalities that does not allow the mitral valve to close properly.

For patients with atrial fibrillation (AF), an irregular heart rate that commonly causes poor blood flow, there’s a left atrial appendage occlusion (LAAO) device. LAAO devices work by sealing off the left atrial appendage, a small “dog ear” shaped structure that attaches to the left atrium.  In patients with AF, the left atrial appendage is often the site of clot formation that may lead to stroke.  By sealing off the left atrial appendage with an occlusion device, the patient’s risk of stroke may be reduced.  

While the first TAVR procedure was 20 years ago, replacing or fully treating the other heart valves has seen slower but steady advances. The next phase in the “structural heart space” is going to involve catheter-based advances for the mitral and the tricuspid valves, said Dr. Patel. 

“I believe that in the next five to 10 years, we would have transcatheter options available to fix the tricuspid valve,” projects Dr. Patel. “For the mitral, we have a repair therapy available, which is a transcatheter-based. But in the future, in next five to 10 years, we might have some solution where we would be able to replace the mitral valve also by the catheter-based approach. There are multiple trials ongoing now and their results should be coming over the next few years. The next decade is going to see remarkable innovations involving the tricuspid and mitral valves.”