Importance of Adjunct Delivery Techniques to Optimize Deployment Success of Distal Protection Filters During Vein Graft Intervention.

OBJECTIVES: This study assessed the impact of adjunct delivery techniques on the deployment success of distal protection filters in saphenous vein grafts (SVGs). BACKGROUND: Despite their proven clinical benefit, distal protection devices are underutilized in SVG interventions. Deployment of distal protection filters can be technically challenging in the presence of complex anatomy. Techniques that facilitate the delivery success of these devices could potentially improve clinical outcomes and promote greater use of distal protection. METHODS: Outcomes of 105 consecutive SVG interventions with attempted use of a FilterWire distal protection device (Boston Scientific) were reviewed. In patients in whom filter delivery initially failed, the success of attempted redeployment using adjunct delivery techniques was assessed. Two strategies were utilized sequentially: (1) a 0.014" moderate-stiffness hydrophilic guidewire was placed first to function as a parallel buddy wire to support subsequent FilterWire crossing; and (2) if the buddy-wire approach failed, predilation with a 2.0 mm balloon at low pressure was performed followed by reattempted filter delivery. RESULTS: The study population consisted of 80 men and 25 women aged 73 ± 10 years. Mean SVG age was 14 ± 6 years. Complex disease (American College of Cardiology/American Heart Association class B2 or C) was present in 92%. Initial delivery of the FilterWire was successful in 82/105 patients (78.1%). Of the 23 patients with initial failed delivery, 8 (35%) had successful deployment with a buddy wire alone, 7 (30%) had successful deployment with balloon predilation plus buddy wire, 4 (17%) had failed reattempt at deployment despite adjunct maneuvers, and in 4 (17%) no additional attempts at deployment were made at the operator's discretion. Deployment failure was reduced from 21.9% initially to 7.6% after use of adjunct delivery techniques (P<.01). No adverse events were observed with these measures. CONCLUSIONS: Deployment of distal protection devices can be technically difficult with complex SVG disease. Adjunct delivery techniques are important to optimize deployment success of distal protection filters during SVG intervention.

An update on management of the patient presenting with non-ST-elevation acute coronary syndromes.

Over 780,000 patients in the United States are diagnosed with an acute coronary syndrome (ACS) each year. As physicians, it is our responsibility to provide prompt workup, diagnosis and management of these patients. After identification of the patient with ACS and confirming there is not ST-segment elevation MI requiring immediate revascularization, physicians should pursue a work-up for non-ST-elevation acute coronary syndrome (NSTE-ACS). It is important to understand the latest best practice guidelines in the treatment and management of patients with NSTE-ACS who carry high rates of in-hospital mortality. Physicians must integrate the clinical history and examination, electrocardiogram and laboratory findings in order to properly diagnose an NSTE-ACS. Early treatment with guideline directed medical therapy is imperative even in the setting of an early invasive strategy with cardiac catheterization and percutaneous coronary intervention. The focus of this review is to discuss the appropriate strategies for evaluation and management of patients with NSTE-ACS based on the most recent ACC/AHA practice guidelines.

Prompt Recognition of Left Ventricular Free-Wall Rupture Aided by the Use of Contrast Echocardiography.

In the modern period of reperfusion, left ventricular free-wall rupture occurs in less than 1% of myocardial infarctions. Typically, acute left ventricular free-wall rupture leads to sudden death from immediate cardiac tamponade. We present the case of a 59-year-old woman who sustained a posterior-wall myocardial infarction and subsequent cardiac arrest with pulseless electrical activity. A bedside transthoracic echocardiogram showed pericardial effusion with cardiac tamponade. Emergency pericardiocentesis yielded 500 mL of blood, and spontaneous circulation returned. Contrast-enhanced echocardiograms revealed inferolateral akinesis and a new, small myocardial slit with systolic extrusion of contrast medium, consistent with left ventricular free-wall rupture. During immediate open-heart surgery, a small hole in an area of necrotic tissue was discovered and repaired. This case highlights the usefulness of bedside contrast-enhanced echocardiography in confirming acute left ventricular free-wall rupture and enabling rapid surgical treatment.

Self-directed study using MP3 players to improve auscultation proficiency of physicians: a randomized, controlled trial.

INTRODUCTION: Studies of physicians at all levels of training demonstrate significant deficiencies in cardiac auscultation skills. The best instructional methods to augment these skills are not known. METHODS: This study was a randomized, controlled trial of 83 noncardiologist volunteers exposed to a 12-week lower cognitive load self-study group using MP3 players containing heart sound audio files compared to a group receiving a 1-time 1-hour higher cognitive load multimedia lecture using the same audio files. The primary outcome measure was change in 15-question posttest score at 4 and 12 weeks as compared to pretest on recognition of identical audio files introduced during training. In the self-study group, the association of total exposure and deliberate practice effort (estimated by standard deviation of files played/mean) to improvement in test score was measured as a secondary end point. RESULTS: Self-study group participants improved as compared to pretest by 4.42 ± 3.41 answers correct at 12 weeks (5.09-9.51 correct, p < .001), while those exposed to the multimedia lecture improved by an average of 1.13 ± 3.2 answers correct (4.48-5.61 correct, p = .03). In the self-study arm, improvement in the posttest was positively associated with both total exposure (ß = 0.55, p < .001) and deliberate practice score (ß = 0.31, p = .02). DISCUSSION: A lower cognitive load self-study of audio files improved recognition of cardiac sounds, as compared to multimedia lecture, and deliberate practice strategies improved study efficiency. More investigation is needed to assess transfer of learning to a wider range of cardiac sounds in both simulated and clinical environments.