Cardiac catheterization laboratory imaging quality assurance program.

With the recent approval of the National Electrical Manufacturers Association (NEMA) standard for "Characteristics of and Test Procedures for a Phantom to Benchmark Cardiac Fluoroscopic and Photographic Performance," comprehensive cardiac image assurance control programs are now possible. This standard was developed by a joint NEMA/Society for Cardiac Angiography and Interventions (SCA&I) working group of imaging manufacturers and cardiology society professionals over the past 4 years. This article details a cardiac catheterization laboratory image quality assurance and control program that includes the new standard along with current regulatory requirements for cardiac imaging. Because of the recent proliferation of digital imaging equipment, quality assurance for cardiac imaging fluoroscopy and digital imaging are critical. Included are the previous works recommended by the American College of Cardiology (ACC) and American Heart Association (AHA), Society for Cardiac Angiographers and Interventions (SCA&I), and authors of previous image quality subjects.

Redundant publication.

The following is a consensus statement from the Heart Editors Action Round Table Group concerning its policy on redundant publication. This statement is being published in journals represented on the panel beginning in July, 1997.

Quantification of coronary artery calcium using ultrafast computed tomography.

Ultrafast computed tomography was used to detect and quantify coronary artery calcium levels in 584 subjects (mean age 48 +/- 10 years) with (n = 109) and without (n = 475) clinical coronary artery disease. Fifty patients who underwent fluoroscopy and ultrafast computed tomography were also evaluated. Twenty contiguous 3 mm slices were obtained of the proximal coronary arteries. Total calcium scores were calculated based on the number, areas and peak Hounsfield computed tomographic numbers of the calcific lesions detected. In 88 subjects scored by two readers independently, interobserver agreement was excellent with identical total scores obtained in 70. Ultrafast computed tomography was more sensitive than fluoroscopy, detecting coronary calcium in 90% versus 52% of patients. There were significant differences (p less than 0.0001) in mean total calcium scores for those with versus those without clinical coronary artery disease by decade: 5 versus 132, age 30 to 39 years; 27 versus 291, age 40 to 49 years; 83 versus 462, age 50 to 59 years; and 187 versus 786, age 60 to 69 years. Sensitivity, specificity and predictive values for clinical coronary artery disease were calculated for several total calcium scores in each decade. For age groups 40 to 49 and 50 to 59 years, a total score of 50 resulted in a sensitivity of 71% and 74% and a specificity of 91% and 70%, respectively. For age group 60 to 69 years, a total score of 300 gave a sensitivity of 74% and a specificity of 81%. The negative predictive value of a 0 score was 98%, 94% and 100% for age groups 40 to 49, 50 to 59 and 60 to 69 years, respectively. Ultrafast computed tomography is an excellent tool for detecting and quantifying coronary artery calcium.

CO2 power-assisted hand-held syringe: better visualization during diagnostic and interventional angiography.

Recent technology has produced high-flow and large-lumen catheters as well as other angiographic accessories to enhance the visualization of the coronary arteries during diagnostic and percutaneous transluminal coronary angioplasty (PTCA) procedures. In spite of these technological advances, there are still many cases in which the quality of the coronary angiography could be significantly improved. This paper reports on a clinical evaluation of a hand-held power syringe. The syringe offers the ability to power inject contrast safely and effectively during routine angiograms as well as through guiding catheters with the balloon catheter present during PTCA. At the same time, control of the injection is equal to that associated with manual syringes.

New principles for optimum left ventriculography.

Left ventriculography has become the single most important procedure in the evaluation of cardiac function. This study reevaluated the refinements of catheter and power injector technology to assess recommendations of past years and establish new principles for optimum ventriculography. Ventriculograms from 102 patients undergoing left heart catheterization and coronary arteriography for coronary, valvular, and myocardial heart disease served as the test sample. Three styles of #7F high-flow 110-cm pigtail catheters were utilized. One had 12 sideholes while the other two had six sideholes positioned nearer the base of the curl. Analysis of ventriculographic quality of each angiogram was performed by three of the authors independently and subsequently together. Five variables were analyzed for their effect on the diagnostic quality of the angiogram: 6-hole catheters, 12-hole catheters, volume of contrast, flow rate, and location of injection. Once these analyses were complete, the effect of combinations of these variables was tested to determine their effect on angiographic quality. The first combination included contrast volume and flow rate. The second combination compared contrast volume and flow rate when utilized with 6- or 12-hole catheters. The third combination tested the 6- and 12-hole catheters in the apex or inflow locations. A multivariate contingency analysis was used to define relationships between the variables and the quality of the angiogram obtained. As independent variables, catheter style, volume of contrast, flow rate, and location of injection did not influence angiographic quality. However, the apex as a location of injection was the single most consistently important determinant of ventricular angiographic quality.(ABSTRACT TRUNCATED AT 250 WORDS)

Resolution of congestive failure, mitral regurgitation, and angina after percutaneous transluminal coronary angioplasty of triple vessel disease.

Congestive heart failure, unstable angina, and moderate mitral regurgitation improved after double-vessel angioplasty in a 41-year-old woman who was considered inoperable because of high risk of bypass surgery. With the concomitant use of balloon counterpulsation, angioplasty reduced the cross-sectional stenosis in the left anterior descending coronary artery from 98 to 20% and in the left circumflex coronary artery from 90 to 0%. The right coronary artery was completely occluded and angioplasty was not attempted. The ejection fraction was 17% prior to angioplasty and 50% 2 months later at follow-up.

Pseudo complications of cardiac catheterization: update.

This prospective study was performed to determine whether complications that occur immediately before or after the time of scheduled catheterization are as much disease-related as procedure-related. During 24 months all complications associated with 1,606 diagnostic cardiac catheterizations were recorded if they occurred from 24 hours before the time the procedure was scheduled to 72 hours later, longer if complications were clearly procedure-related. Pseudo complications are spontaneous medical or surgical incidents that occur during the 24-hour period before catheterization is scheduled to be performed. Procedure-related complications are incidents that occur during or after the catheterization procedure. There were 13 (0.81%) procedure-related complications but not deaths. There were 13 (0.81%) pseudo complications including 4 (0.24%) deaths. All complications were similar in nature except for 3 instances of vascular injury, which were procedure-related. Pseudo complications occur as commonly as procedure-related complications and at times are more severe. Complications occurring before catheterization are related to the underlying disease process and not medical intervention. It is likely that similar disease-caused incidents occur after a catheterization and are not necessarily procedure-related.

Papillary muscle rupture following nonpenetrating chest trauma: report of a case with hemodynamic and serial echocardiographic findings and successful surgical treatment.

The pre- and postoperative echocardiographic features of a patient with severe mitral incompetence due to rupture of a papillary muscle following nonpenetrating chest trauma are presented. The mitral valve echocardiogram showed chaotic diastolic flutter suggestive of a ruptured papillary muscle or ruptured chordae tendineae. The preoperative ultrasound recording of the left ventricle revealed left ventricular enlargement and excessive motion of the interventricular septum. The echocardiogram taken 7 weeks after mitral valve replacement showed considerable regression of the left ventricular enlargement.

Mitral valve replacement in medically unresponsive congestive heart failure due to papillary muscle dysfunction.

Forty patients with a mean age of 65 years (range 44-76 years) were operated on; 30 of 40 patients (75%) had prior myocardial infarction. All had severe therapy-resistant congestive heart failure, 75% (30 of 40 patients) were symptomatic at rest, and 25% (10 of 40 patients) were symptomatic on minimal exertion. Cardiac index ranged from 1.24-2.84 L/min/m2 (mean 1.99). Left ventricular end-diastolic pressure ranged from 3-36 mm Hg (mean 18). All patients had significant mitral insufficiency and contractility was reduced markedly to moderately in 63% (25 of 40 patients). Significant coronary artery disease (obstruction greater than or equal to 75%) was present in all patients. All had mitral valve replacement, 30 had bypass surgery, and 7 left ventricular aneurysmectomy. Five died during surgery or before discharge (early mortality 12.5%). After a mean follow-up period of 16 months, another eight patients died, two with causes not related to the cardiovascular system (total mortality 32.5%). Of 20 patients with a cardiac index greater than or equal to 1.5 L/min/m2 and an ejection fraction greater than or equal to 0.40, 17 survived surgery and improved postoperatively. Mitral valve replacement for this group of patients is recommended.