Effect of reduction of the pulse rates of fluoroscopy and CINE-acquisition on x-ray dose and angiographic image quality during invasive cardiovascular procedures.

BACKGROUND: Reducing digital pulse rates (PR) are known to reduce total energy during invasive cardiovascular procedures, which likely has benefits for patients and staff. Physicians may be reluctant to reduce these parameters because they fear a decline in image quality that could affect procedural outcomes. We sought to assess the effect of default rates of fluoroscopy (Fluoro) and CINE-acquisition (CINE) on total x-ray dose and image quality during invasive cardiovascular procedures. METHODS AND RESULTS: We retrospectively reviewed procedures done with 2 default PRs: a standard dose cohort (PR, 15 for Fluoro and CINE), and a reduced dose cohort (PR, 10 for Fluoro and CINE). Total x-ray dose, Fluoro time, and contrast use were compared between groups. A blinded angiographic image quality assessment was then performed using an objective 10-point angiographic quality score. There were no significant differences between cohorts for fluoroscopy time or contrast use. The reduced dose cohort has a significant reduction in mean total x-ray dose (PR 15, 1763.1 mGy; PR 10, 1179.1 mGy; P<0.0001). When adjusted for potential confounders, a 38% reduction in total x-ray dose was identified (P<0.0001). There was no difference in adjusted angiographic quality score between the cohorts (PR 15, 7.90; PR 10, 8.00; P=0.67), indicating no decline in image quality with PR reduction. CONCLUSIONS: Reducing default PRs during invasive cardiovascular procedures yields large and significant reductions in total x-ray energy with no decline in angiographic image quality.

Right heart catheterization using antecubital venous access: feasibility, safety and adoption rate in a tertiary center.

OBJECTIVES: To determine feasibility, safety, and adoption rates of right heart catheterization (RHC) using antecubital venous access (AVA) as compared to using the traditional approach of proximal venous access (PVA). BACKGROUND: RHC via PVA (i.e., internal jugular, femoral or subclavian) is generally a low risk procedure; however, complications may occur and are usually access site related. RHC via an antecubital approach has regained attention given the increase in transradial left heart catheterizations. METHODS: Patients undergoing RHC for any indication at a single large academic medical center were identified over a 5-year period (January 2008 to December 2012) from a database. Medical records were retrospectively analyzed for demographic, procedural and outcomes data. RESULTS: Two hundred seventy-two RHC procedures were included (106 AVA, 166 PVA). The adoption rate of AVA for RHC increased rapidly since its introduction in our laboratory in 2010 (100% PVA in 2008 and 2009, 85% AVA in 2012). All procedures were successful; however, 6% of procedures required additional, alternate access to the original site. Initial success rates were similar in the two groups (91 vs. 96% for AVA and PVA respectively, P = 0.12). Fluoroscopy time was shorter in the group of patients who underwent the procedure via AVA. The complication rate was 0% in the AVA group compared with 3% in the PVA group (P = 0.16). CONCLUSION: RHC via the AVA is a feasible and safe alternative to PVA. Our experience and rapid adoption support the use AVA as the access site of choice for RHC in uncomplicated patients.

Reduction in operator radiation exposure during transradial catheterization and intervention using a simple lead drape.

BACKGROUND: Transradial access for cardiac catheterization and intervention is a recognized method for reducing complications and improving patient comfort. However, there are concerns over possible increased operator radiation exposure. We tested the hypothesis that a simple lead drape would reduce operator exposure in transradial procedures. METHODS: Patients undergoing either diagnostic or interventional procedures using transradial access were assigned in an alternating manner to the use of a 0.5-mm lead apron across the patient's abdomen in addition to standard operator protection. Patients were divided into 4 groups: (left enhanced shielding vs left standard shielding; right enhanced shielding vs right standard shielding). Dosimeters were taped to the primary and secondary operators' left wrist and outside the thyroid guard. The operator exposure was measured for each site on every case in centigray. RESULTS: In standard shielded patients, there was no increase in operator exposure between the left and right approach patients at any measurement site. Measured exposure was reduced with enhanced shielding at all dosimeter sites except the secondary operator's collar (both left and right) and the primary operator's collar from the right. There was no significant difference in fluoroscopy, air kerma, or dose area product between standard and enhanced shielded patients. CONCLUSIONS: The use of a lead drape reduces the rate of operator radiation exposure at multiple measurement sites. Use of the left radial approach was not associated with an increase in operator exposure compared with the right radial approach.

Transradial arterial access for coronary and peripheral procedures: executive summary by the Transradial Committee of the SCAI.

In response to growing U.S. interest, the Society for Coronary Angiography and Interventions recently formed a Transradial Committee whose purpose is to examine the utility, utilization, and training considerations related to transradial access for percutaneous coronary and peripheral procedures. With international partnership, the committee has composed a comprehensive overview of this subject presented here-with.

Impella assisted transradial coronary intervention in patients with acute coronary syndromes and cardiogenic shock: case series.

Operators may feel apprehension when considering the transradial approach in patients with cardiogenic shock due to concerns of the need for femoral access for mechanical support. There is however potential benefit of transradial approach in this setting by reducing bleeding complications in patients on potent anticoagulant and antiplatelet agents. We report three cases of patients with cardiogenic shock with successful transradial intervention (TRI) whilst using unilateral femoral access for Impella (ABIOMED, Danvers, MA) mechanical support. In two cases, the need for mechanical support was not clear at the beginning of the procedure, and in the third there was a clear need to combine femoral and radial access due to pre-existing anatomic issues. Two patients required transfusion of red blood cells but otherwise there were no vascular access complications.

Comparison of procedural times, success rates, and safety between left versus right radial arterial access in primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction.

OBJECTIVE: To evaluate if there are differences in procedural times, success rates, and safety between left and right radial approach (LRA and RRA, respectively) in primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). BACKGROUND: Given conflicting reports of different procedural success with LRA vs. RRA, it is unclear if the side of radial access impacts in-room procedural times and success rates in primary PCI. At our institution the LRA has been commonly used in certain STEMI patients. Our clinical database was reviewed to see if routine use of the LRA could generate favorable technical success and reperfusion times as compared to the RRA. METHODS: We retrospectively analyzed 135 consecutive STEMI patients treated with primary PCI performed via the left and right radial approach at our institution. RESULTS: There were 50 cases in the LRA group and 85 in the RRA group. There was no difference in median procedural times including total procedure time (LRA 53.5 mins vs. RRA 52 mins, P = 0.95), room-to-cannulation (LRA 12 min vs. RRA 13 min, P = 0.40) or room-to-balloon times (LRA 30 min vs. RRA 31 min, P = 0.74). There were no significant differences in procedural success rates (LRA 100% vs. RRA 97.6%, P = 0.27), or procedure-related complications or death between the two groups. CONCLUSIONS: Left and right trans-radial approach for primary PCI have similar in room procedural times, success rates, and comparable safety. Trans-radial PCI through either arm is a feasible and safe approach in patients with STEMI.

Clinical characteristics of tako-tsubo cardiomyopathy.

Tako-tsubo cardiomyopathy (TTC) is increasingly diagnosed in the United States, especially in the Caucasian population. To evaluate the clinical features and outcome of patients with TTC, we evaluated 34 patients (32 women and 2 men) 22 to 88 years of age (mean 66 +/- 14) who fulfilled the following criteria: (1) akinesia or dyskinesia of the apical and/or midventricular segments of the left ventricle with regional wall motion abnormalities that extended beyond the distribution of a single epicardial vessel and (2) absence of obstructive coronary artery disease. Twenty-five patients (74%) presented with chest pain, 20 patients (59%) presented with dyspnea, and 8 patients (24%) presented with cardiogenic shock. Twenty-two patients (65%) had ST-segment elevation and 14 patients (41%) had T-wave inversion on presentation. Twenty-five patients (74%) reported a preceding stressful event. Cardiac biomarkers were often mildly increased, with a mean troponin I (peak) of 13.9 +/- 24. Mean +/- SD left ventricular ejection fractions were 28 +/- 10% at time of presentation and 51 +/- 14 at time of follow-up (p <0.0001). Two patients (6%) died during the hospital stay. Average duration of hospital stay was 6.6 +/- 6.2 days. In conclusion, TTC is common in postmenopausal women with preceding physical or emotional stress. It predominantly involves the apical portion of the left ventricle and patients with this condition have a favorable outcome with appropriate medical management. The precise cause remains unclear.

Single-center experience with the TandemHeart percutaneous ventricular assist device to support patients undergoing high-risk percutaneous coronary intervention.

UNLABELLED: We describe our experience of patients, from December 2005 through May 2007 who underwent percutaneous coronary intervention (PCI) with severely depressed left ventricle systolic function and complex coronary lesions. The complex coronary lesions included multiple vessel coronary artery disease, left main (LM) coronary artery disease, calcified coronary lesions and bypass graft disease. All patients were clinically assessed to be at too high of a risk for circulatory collapse without maximal hemodynamic support while they underwent high-risk PCI. The TandemHeart percutaneous ventricular assist device (THpVAD) may be able to provide the necessary circulatory support required to enhance procedural success and patient safety during high-risk PCI. METHODS AND RESULTS: We implanted the THpVAD in 6 patients who underwent high-risk PCI. There was unanimity among several physicians in our institution that each patient was an exceptionally high risk for circulatory collapse due to the anticipated procedural complexity. The average ejection fraction was 33% (range 15-65%). Five of the patients were considered to be at an unacceptably high risk for coronary artery bypass surgery. All 6 patients underwent multivessel PCI. Five of the 6 underwent unprotected LM PCI. One patient of the 5 underwent vein-graft PCI as well as a debulking procedure with rotational atherectomy and PCI of the LM. We had a 100% success rate with implantation of the THpVAD. Five of the 6 patients were alive at 30 days post procedure. One patient died 3 days after the procedure due to multiorgan failure. A vascular surgeon performed the removal of the devices with no associated complications. CONCLUSIONS: Our clinical experiences with the TandemHeart pVAD demonstrated that hemodynamic support could be achieved safely, efficiently and effectively by way of a percutaneous route in anticipation of high-risk PCI.

Prevalence of metabolic syndrome in patients < or =45 years of age with acute myocardial infarction having percutaneous coronary intervention.

The prevalence of metabolic syndrome (MS) was determined in patients aged < or =45 years who presented with acute myocardial infarction and underwent primary percutaneous coronary intervention. Two hundred twenty-three consecutive patients aged 18 to 45 years who underwent cardiac catheterization for acute myocardial infarction from June 2001 to December 2004 were reviewed. MS was diagnosed by National Cholesterol Education Program Adult Treatment Panel III guidelines (modified by substituting body mass index > or =28.8 kg/m2 for waist circumference). One hundred sixty-one patients met all 5 criteria for MS available for evaluation. Seventy-six of these patients (47%) met > or =3 of the 5 criteria for MS. Sixteen patients with MS (21%) and 5 patients without MS (6%) had diabetes mellitus. The prevalence of each criterion was significantly higher (p <0.05) in the MS group. Average Framingham risk scores were 7.0 and 4.5 for patients with and without MS, respectively. The prevalence of smoking, male gender, and family history of premature coronary artery disease were the same for the 2 groups. In conclusion, MS was highly prevalent in this population of young patients with acute myocardial infarction.

Myocardial infarction as a presentation of clinical in-stent restenosis.

BACKGROUND: In-stent restenosis is considered to be a gradual and progressive condition and there is scant data on myocardial infarction (MI) as a clinical presentation. METHODS AND RESULTS: Of 2,462 consecutive patients who underwent percutaneous coronary intervention between June 2001 and December 2002, clinical in-stent restenosis occurred in 212 (8.6%), who were classified into 3 groups: ST elevation MI (STEMI), non-ST elevation MI (NSTEMI) and non-MI. Of the 212 patients presenting with clinical in-stent restenosis, 22 (10.4%) had MI (creatine kinase (CK)>or=2xbaseline with elevated CKMB). The remaining 190 (89.6%) patients had stable angina or evidence of ischemia by stress test without elevation of cardiac enzymes. Median interval between previous intervention and presentation for clinical in-stent restenosis was shorter for patients with MI than for non-MI patients (STEMI, 90 days; NSTEMI, 79 days; non-MI, 125 days; p=0.07). Diffuse in-stent restenosis was more frequent in MI patients than in non-MI patients (72.7% vs 56.3%; p<0.005). Renal failure was more prevalent in patients with MI than in those without MI (31.8% vs 6.3%, p=0.001). Compared with the non-MI group, patients with MI were more likely to have acute coronary syndromes at the time of index procedure (81.8% vs 56.8%, p=0.02). CONCLUSION: Clinical in-stent restenosis can frequently present as MI and such patients are more likely to have an aggressive angiographic pattern of restenosis. Renal failure and acute coronary syndromes at the initial procedure are associated with MI.