2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions expert consensus document on cardiac catheterization laboratory standards update: A report of the American College of Cardiology Foundation Task Force on Expert Consensus documents developed in collaboration with the Society of Thoracic Surgeons and Society for Vascular Medicine

Clinical outcomes of percutaneous coronary intervention for acute coronary syndrome between hospitals with and without onsite cardiac surgery backup

BACKGROUND

Based on the 2011 American College of Cardiology/American Heart Association percutaneous coronary intervention (PCI) guideline, it is recommended that PCI should be performed at hospital with onsite cardiac surgery. But, data suggest that there is no significant difference in clinical outcomes following primary or elective PCI between the two groups. We examined the impact of with or without onsite cardiac surgery on clinical outcomes following PCI for acute coronary syndrome (ACS).

METHODS AND RESULTS

From August 2008 to March 2011, subjects (n=3241) were enrolled from the Kumamoto Intervention Conference Study (KICS). Patients were assigned to two groups treated in hospitals with (n=2764) or without (n=477) onsite cardiac surgery. Clinical events were followed up for 12 months. Primary endpoint was in-hospital death, cardiovascular death, myocardial infarction, and stroke. And we monitored in-hospital events, non-cardiovascular deaths, bleeding complications, revascularizations, and emergent coronary artery bypass grafting (CABG). There was no overall significant difference in primary endpoint between hospitals with and without onsite cardiac surgery [ACS, 7.6% vs. 8.0%, p=0.737; ST-segment elevation myocardial infarction (STEMI), 10.4% vs. 7.5%, p=0.200]. There was also no significant difference when events in primary endpoint were considered separately. In other events, revascularization was more frequently seen in hospitals with onsite surgery (ACS, 20.0% vs. 13.0%, p<0.001; STEMI, 21.9% vs. 14.5%, p=0.009). We performed propensity score matching analysis to correct for the disparate patient numbers between the two groups, and there was also no significant difference for primary endpoint (ACS, 8.6% vs. 7.5%, p=0.547; STEMI, 11.2% vs. 7.5%, p=0.210).

CONCLUSIONS

There is no significant difference in clinical outcomes following PCI for ACS between hospitals with and without onsite cardiac surgery backup in Japan.

Reducing radiation in chronic total occlusion percutaneous coronary interventions

The field of percutaneous intervention for chronic total occlusion (CTO) has enjoyed significant innovations in the recent years. Novel techniques and technologies have revolutionized the field and have resulted in considerably higher success rates even in patients with high anatomical complexity. Successful CTO recanalization is associated with significant clinical benefits, such as the improvement of angina and quality of life, reduced rates of surgical revascularization, improvement of left ventricular function and decreased mortality rates. However, complex CTO procedures often require prolonged x-ray exposure which have been associated with adverse long term outcomes.

The Effect of Low Frame Rate Fluoroscopy on the X-ray Dose during Coronary Intervention

Objective The aim of this study was to investigate whether the use of low frame rate fluoroscopy at 7.5 frames per second during coronary intervention could reduce radiation exposure in Japanese patients. Methods From December 10, 2014 to March 20, 2015, 84 consecutive patients with coronary artery disease who underwent coronary intervention in our institution were retrospectively collected and then divided into two groups: the LR group (fluoroscopy at 7.5 frames per second) and the OR group (fluoroscopy at 15 frames per second), according to the frame rate of fluoroscopy that was used in their treatment. Results There were no differences in the patient backgrounds or the procedural characteristics of the two groups. Although there were no differences in the contrast volume or fluoroscopy time, the total air kerma at the interventional reference point, which is used to monitor the patient's radiation dose, was significantly lower in the LR group than in the OR group (701.4±427.9 vs. 936.8±623.9 mGy, p=0.02). Conclusion Low frame rate fluoroscopy at 7.5 frames per second is safe and feasible for use during coronary interventions and an easy and useful strategy for reducing the radiation to which patients are exposed during coronary intervention.

Long-Term Outcomes and Causes of Death in Patients With Renovascular Disease Undergoing Renal Artery Stenting

Renovascular disease (RVD) can lead to hypertension and chronic kidney disease (CKD). Patients with advanced peripheral arterial disease (PAD) have a 5-year mortality of ∼30%. Rate and causes of death in patients with significant RVD, who share similar risk factors with patients having PAD, are not well defined. We assessed consecutive patients with RVD who underwent renal artery stenting at our institution over 6 years. Specific causes of death were ascertained, and the probability of survival was estimated. Cox models were fit to identify predictors of outcomes. We identified 281 patients with RVD who underwent renal stenting. Follow-up was available for all patients (median 5.1 years). All-cause mortality was 24.2% at 5 years and 33.7% at 7 years (compounded annualized death rate: 5.5%). Of the 68 deaths, 36 (52.9%) were cardiovascular (13.2% acute myocardial infarction, 13.2% stroke, 11.8% sudden death, and 10.3% congestive heart failure) and 32 (47.1%) deaths had noncardiovascular causes. In patients with RVD undergoing stenting, cardiovascular events are the most common causes of death. Compared to patients with advanced PAD, RVD may have a lower 5-year mortality.

Risk of Bleeding in End-Stage Liver Disease Patients Undergoing Cardiac Catheterization

Patients with end-stage liver disease frequently have baseline coagulopathies. The international normalized ratio is in common use for the estimation of bleeding tendency in such patients, especially those undergoing an invasive procedure like cardiac catheterization. The practice of international normalized ratio measurement-followed by pharmacologic (for example, vitamin K or fresh frozen plasma) or nonpharmacologic intervention-is still debatable. The results of multiple randomized trials have shown the superiority of the radial approach over femoral access in reducing catheterization bleeding. This reduction in bleeding in turn decreases the risk and cost of blood-product transfusion. However, there is little evidence regarding the use of the radial approach in the end-stage liver disease patient population specifically. In this review, we summarize the studies that have dealt with cardiac catheterization in patients who have end-stage liver disease. We also discuss the role of the current measurements that are used to reduce the risk of bleeding in these same patients.

Interventional cardiology. Nonprimary PCI at centres without onsite surgical backup

A new systematic review and meta-analysis by Lee and colleagues confirms the safety of nonprimary percutaneous coronary intervention (PCI) at centres without onsite surgical backup. In daily clinical practice at PCI centres without onsite surgical facilities, quality assurance and improvement programmes are important to ensure high-quality care.

Cardiac catheterization laboratory inpatient forecast tool: a prospective evaluation

OBJECTIVE

To develop and prospectively evaluate a web-based tool that forecasts the daily bed need for admissions from the cardiac catheterization laboratory using routinely available clinical data within electronic medical records (EMRs).

METHODS

The forecast model was derived using a 13-month retrospective cohort of 6384 catheterization patients. Predictor variables such as demographics, scheduled procedures, and clinical indicators mined from free-text notes were input to a multivariable logistic regression model that predicted the probability of inpatient admission. The model was embedded into a web-based application connected to the local EMR system and used to support bed management decisions. After implementation, the tool was prospectively evaluated for accuracy on a 13-month test cohort of 7029 catheterization patients.

RESULTS

The forecast model predicted admission with an area under the receiver operating characteristic curve of 0.722. Daily aggregate forecasts were accurate to within one bed for 70.3% of days and within three beds for 97.5% of days during the prospective evaluation period. The web-based application housing the forecast model was used by cardiology providers in practice to estimate daily admissions from the catheterization laboratory.

DISCUSSION

The forecast model identified older age, male gender, invasive procedures, coronary artery bypass grafts, and a history of congestive heart failure as qualities indicating a patient was at increased risk for admission. Diagnostic procedures and less acute clinical indicators decreased patients' risk of admission. Despite the site-specific limitations of the model, these findings were supported by the literature.

CONCLUSION

Data-driven predictive analytics may be used to accurately forecast daily demand for inpatient beds for cardiac catheterization patients. Connecting these analytics to EMR data sources has the potential to provide advanced operational decision support.

Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper

Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.

How Slow Can We Go? 4 Frames Per Second (fps) Versus 7.5 fps Fluoroscopy for Atrial Septal Defects (ASDs) Device Closure

Radiation exposure remains a significant concern for ASD device closure. In an effort to reduce radiation exposure, the default fluoroscopy frame rate in our Siemens biplane pediatric catheterization laboratory was reduced to 4 fps in November 2013 from an earlier 7.5 fps fluoro rate. This study aims to evaluate the components contributing to total radiation exposure and compare the procedural success and radiation exposure during ASD device closure using 4 versus 7.5 fps fluoroscopy rates. Twenty ASD device closures performed using 4 fps fluoro rate were weight-matched to 20 ASD closure procedures using 7.5 fps fluoro rate. Baseline characteristics, procedure times and case times were similar in the two groups. Device closure was successful in all but one case in the 4 fps group. The dose area product (DAP), normalized DAP to body weight, total radiation time and fluoro time were lower in the 4 fps group but not statistically different than the 7.5 fps. The number of cine images and cine times were identical in both groups. Fluoroscopy and cineangiography contributed equally to radiation exposure. Fluoroscopy at 4 fps can be safe and effective for ASD device closure in children and adults. There was no increase in procedure time, cine time, fluoro time or complications at this slow fluoro rate. There was a trend toward decreased radiation exposure as measured by indexed DAP although not statistically significant in this small study. Further study with multiple operators using 4 fps fluoroscopy for simple interventional procedures is recommended.

Iliofemoral deep vein thrombosis: Percutaneous endovascular treatment options

Venous thromboembolism is defined as an acute venous thrombotic event that targets two disease entities: deep vein thrombosis (DVT), pulmonary embolism, or both. The most common site of DVT origin is in the lower extremities, with 50% of patients exhibiting no symptoms. Although anticoagulation is the gold standard for DVT, early clot removal, especially of proximal iliofemoral DVT, is felt to reduce the incidence of postthrombotic syndrome (PTS) by preserving valve function. Up to one-half of all patients with an iliofemoral DVT treated only with anticoagulation subsequently develop long-term complications, including PTS. Beside anticoagulation, DVT treatment options may include pharmaceutical and/or mechanical therapies. Mechanical therapies consist of either endovascular percutaneous catheter-directed (PCD) interventions or open operative thrombectomy. There are several different PCD procedures available, consisting of catheter-directed thrombolysis, mechanical thrombectomy, combination pharmacomechanical devices, and postthrombus extraction (angioplasty and/or stenting). Endovascular therapies in the management of acute iliofemoral DVT are evolving with a variety of devices available to treat this disease entity. The purpose of this article is to provide an overview of the PCD therapies used when treating patients experiencing an acute iliofemoral DVT along with associated nursing considerations. Off-label device use is not included.

When is rotational angiography superior to conventional single-plane angiography for planning coronary angioplasty?

Objectives

To investigate the value of rotational coronary angiography (RoCA) in the context of percutaneous coronary intervention (PCI) planning.

Background

As a diagnostic tool, RoCA is associated with decreased patient irradiation and contrast use compared with conventional coronary angiography (CA) and provides superior appreciation of three‐dimensional anatomy. However, its value in PCI remains unknown.

Methods

We studied stable coronary artery disease assessment and PCI planning by interventional cardiologists. Patients underwent either RoCA or conventional CA pre‐PCI for planning. These were compared with the referral CA (all conventional) in terms of quantitative lesion assessment and operator confidence. An independent panel reanalyzed all parameters.

Results

Six operators performed 127 procedures (60 RoCA, 60 conventional CA, and 7 crossed‐over) and assessed 212 lesions. RoCA was associated with a reduction in the number of lesions judged to involve a bifurcation (23 vs. 30 lesions, P < 0.05) and a reduction in the assessment of vessel caliber (2.8 vs. 3.0 mm, P < 0.05). RoCA improved confidence assessing lesion length (P = 0.01), percentage stenosis (P = 0.02), tortuosity (P < 0.04), and proximity to a bifurcation (P = 0.03), particularly in left coronary artery cases. X‐ray dose, contrast agent volume, and procedure duration were not significantly different.

Conclusions

Compared with conventional CA, RoCA augments quantitative lesion assessment, enhances confidence in the assessment of coronary artery disease and the precise details of the proposed procedure, but does not affect X‐ray dose, contrast agent volume, or procedure duration. © 2015 Wiley Periodicals, Inc.

Primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction in a patient taking dabigatran for chronic anticoagulation

Interventional cardiologists have few data on which to base clinical decisions regarding optimal care for ST-segment-elevation myocardial infarction patients who are taking therapeutic chronic oral anticoagulation. We present what we believe to be the first reported case of emergency coronary angiography and primary percutaneous coronary intervention in an ST-segment-elevation myocardial infarction patient who was on a dabigatran regimen for atrial fibrillation. The patient tolerated the procedures well and had no observable bleeding sequelae. In addition to the patient's case, we discuss the current evidence regarding the periprocedural management of oral anticoagulation in patients who need coronary angiography and percutaneous coronary intervention.

Occupational health hazards of interventional cardiologists in the current decade: Results of the 2014 SCAI membership survey

BACKGROUND

Interventional cardiologists and staff are subject to unique physical demands that predispose them to distinct occupational health hazards not seen in other medical disciplines.

METHODS

To characterize the prevalence of these occupational health problems, The Society for Cardiovascular Angiography and Interventions (SCAI) surveyed its members by email. Inquiries included age, years of invasive practice, and diagnostic and interventional cases per year. Questions focused on orthopedic (spine, hips, knees, and ankles) and radiation-associated problems (cataracts and cancers).

RESULTS

There were 314 responses. Responders were on average busy and experienced, performing a mean of 380±249 diagnostic and 200±129 interventional cases annually. Of the responders, 6.9% of operators have had to limit their caseload because of radiation exposure and 9.3% have had a health-related period of absence. Furthermore, 153 (49.4%) operators reported at least one orthopedic injury: 24.7% cervical spine disease, 34.4% lumbar spine problems, and 19.6% hip, knee or ankle joint problems. Age was most significantly correlated with orthopedic illnesses: cervical injuries (χ2=150.7, P<0.0001); hip/knee or ankle injuries (χ2=80.9, P<0.0001); lumbar injuries (χ2=147.0, P<0.0001); and any orthopedic illness (χ2= 241.2, P<0.0001). Annual total caseload was also associated: the estimated change in the odds of orthopedic illness for each additional total caseload quintile is 1.0013 (1.0001, 1.0026). There is a small but substantial incidence of cancer.

CONCLUSIONS

These findings are consistent with, and extend the findings, of a prior 2004 SCAI survey, in documenting a substantial prevalence of orthopedic complications among active interventional cardiologists, which persists despite increased awareness.

Coronary Artery Calcium Assessment in CKD: Utility in Cardiovascular Disease Risk Assessment and Treatment?

Coronary artery calcification (CAC) is a strong predictor of cardiovascular event rates in the general population, and scoring with multislice computed tomography commonly is used to improve risk stratification beyond clinical variables. CAC is accelerated in chronic kidney disease, but this occurs as a result of 2 distinct pathologic processes that result in medial (arteriosclerosis) and intimal (atherosclerosis) deposition. Although there are data that indicate that very high CAC scores may be associated with increased risk of death in hemodialysis, average CAC scores in most patients are elevated at a level at which discriminatory power may be reduced. There is a lack of data to guide management strategies in these patients based on CAC scores. There are even fewer data available for nondialysis patients, and it is uncertain whether CAC score confers an elevated risk of premature cardiovascular morbidity and mortality in such patients. In this article, we review the evidence regarding the utility of CAC score for noninvasive cardiovascular risk assessment in individuals with chronic kidney disease, using a clinical vignette that highlights some of the limitations in using CAC score and considerations in risk stratification.

Transradial vascular access: a growing trend

The transradial route for coronary angiography is a growing trend in the United States. Nurse practitioners (NPs) are an essential part of the preprocedural assessment and management of patients. This article will outline the benefits and risks of transradial access as well as methods for NPs to assess arterial hand circulation.

A Practical Approach to Preventing Renal Complications in the Catheterization Laboratory

Kidney injury following cardiac catheterization is an infrequent, though persistent, complication, which in some cases may be preventable. Patients at increased risk for renal complications following catheterization can be identified through individual and procedural risk factors, and several risk-prediction models are readily available. The authors advocate for the development of an easily implemented and standardized protocol, readily accessible to catheterization laboratory staff, for the identification and treatment of those patients who may be at increased risk for renal complications following cardiac catheterization.

Does a patent foramen ovale matter when using a remote-controlled magnetic system for pulmonary vein isolation?

BACKGROUND

Pulmonary vein isolation (PVI) takes longer when using a patent foramen ovale (PFO) compared with a transseptal puncture in paroxysmal atrial fibrillation (AF) with manual catheter ablation. To our knowledge, no data exist concerning the impact of a PFO on AF ablation procedure variables when using a remote magnetic navigation (RMN) system.

AIM

To assess the impact of a PFO when using an RMN system in patients requiring AF ablation.

METHODS

Between December 2011 and December 2012, catheter ablation was performed remotely using the CARTO(®) 3 system in 167 consecutive patients who underwent PVI for symptomatic drug-refractory AF. The radiofrequency generator was set to a fixed power ≤ 35 W. The primary endpoint was wide-area circumferential PVI confirmed by spiral catheter recording during ablation for all patients and including additional lesion lines (left atrial roof) or complex fractionated atrial electrograms for persistent AF. Secondary endpoints included procedural data.

RESULTS

Mean age 58±10 years; 18% women; 107 (64%) patients with symptomatic paroxysmal AF; 60 (36%) with persistent AF; CHA2DS2-VASc score 1.2 ± 1. The PFO presence was evidenced in 49/167 (29.3%) patients during the procedure but in only 26/167 (16%) by transoesophageal echocardiography. Median procedure time 2.5 ± 1 hours; median total X-ray exposure time 14 ± 7 minutes; transseptal puncture and catheter positioning time 7.5 ± 5 minutes; left atrium electroanatomical reconstruction time 3 ± 2.3 minutes; catheter ablation time 3 ± 3 minutes. No procedure time or X-ray exposure differences were observed between patients with or without a PFO during magnetic navigation catheter ablation. X-ray exposure time was significantly reduced using a PFO compared with double transseptal puncture access.

CONCLUSIONS

A PFO does not affect magnetic navigation during AF ablation; procedure times and X-ray exposure were similar. Septal catheter probing is mandatory to limit X-ray exposure and prevent potential complications.

Current application and bioavailability of drug-eluting stents

INTRODUCTION

Drug-eluting stents (DES) were developed to reduce the restenosis rate of bare metal stents (BMS) and comprises three main components: i) a metallic scaffold; ii) an antiproliferative drug to reduce or abolish the formation of the neointima; and iii) the polymer, which both enables and controls drug elution into the vessel wall. Over the years, growing evidence has been reported on the safety and efficacy for different indications of DES.

AREAS COVERED

Since the introduction of first-generation DES, the technology has been refined, including changes in the alloy, stent design, polymer, drug and drug dose. In 2014, we will usher in a third generation of DES, which will include biodegradable polymers, polymer-free DES and bioabsorbable scaffolds.

EXPERT OPINION

In recent years, considerable progress has been made in DES development. The BMS platform set the groundwork for the development of metal scaffolds with drug-eluting capability to prevent restenosis. Importantly, extensive research has shown long-term safety and efficacy of the newer generation DES. Available data suggest that DES can be safely and effectively used to treat a complex subset of patients and lesions, including patients presenting with acute myocardial infarction, lesions in saphenous vein grafts, chronic total occlusions, multivessel disease, small vessels, long lesions and bifurcations. One of the safety targets is to eliminate stent thrombosis.

Drug-drug interactions in cardiovascular catheterizations and interventions

Patients presenting for invasive cardiovascular procedures are frequently taking a variety of medications aimed to treat risk factors related to heart and vascular disease. During the procedure, antithrombotic, sedative, and analgesic medications are commonly needed, and after interventional procedures, new medications are often added for primary and secondary prevention of ischemic events. In addition to these prescribed medications, the use of over-the-counter drugs and supplements continues to rise. Most elderly patients, for example, are taking 5 or more prescribed medications and 1 or more supplements, and they often have some degree of renal insufficiency. This polypharmacy might result in drug-drug interactions that affect the balance of thrombotic and bleeding events during the procedure and during long-term treatment. Mixing of anticoagulants, for instance, might lead to periprocedural bleeding, and this is associated with an increase in long-term adverse events. Furthermore, the range of possible interactions with thienopyridine antiplatelets is of concern, because these drugs are essential to immediate and extended interventional success. The practical challenges in the field are great-some drug-drug interactions are likely present yet not well understood due to limited assays, whereas other interactions have well-described biological effects but seem to be more theoretical, because there is little to no clinical impact. Interventional providers need to be attentive to the potential for drug-drug interaction, the associated harm, and the appropriate action, if any, to minimize the potential for medication-related adverse events. This review will focus on drug-drug interactions that have the potential to affect procedural success, either through increases in immediate complications or compromising longer-term outcome.

Nonemergency PCI at hospitals with or without on-site cardiac surgery

BACKGROUND

Emergency surgery has become a rare event after percutaneous coronary intervention (PCI). Whether having cardiac-surgery services available on-site is essential for ensuring the best possible outcomes during and after PCI remains uncertain.

METHODS

We enrolled patients with indications for nonemergency PCI who presented at hospitals in Massachusetts without on-site cardiac surgery and randomly assigned these patients, in a 3:1 ratio, to undergo PCI at that hospital or at a partner hospital that had cardiac surgery services available. A total of 10 hospitals without on-site cardiac surgery and 7 with on-site cardiac surgery participated. The coprimary end points were the rates of major adverse cardiac events--a composite of death, myocardial infarction, repeat revascularization, or stroke--at 30 days (safety end point) and at 12 months (effectiveness end point). The primary end points were analyzed according to the intention-to-treat principle and were tested with the use of multiplicative noninferiority margins of 1.5 (for safety) and 1.3 (for effectiveness).

RESULTS

A total of 3691 patients were randomly assigned to undergo PCI at a hospital without on-site cardiac surgery (2774 patients) or at a hospital with on-site cardiac surgery (917 patients). The rates of major adverse cardiac events were 9.5% in hospitals without on-site cardiac surgery and 9.4% in hospitals with on-site cardiac surgery at 30 days (relative risk, 1.00; 95% one-sided upper confidence limit, 1.22; P<0.001 for noninferiority) and 17.3% and 17.8%, respectively, at 12 months (relative risk, 0.98; 95% one-sided upper confidence limit, 1.13; P<0.001 for noninferiority). The rates of death, myocardial infarction, repeat revascularization, and stroke (the components of the primary end point) did not differ significantly between the groups at either time point.

CONCLUSIONS

Nonemergency PCI procedures performed at hospitals in Massachusetts without on-site surgical services were noninferior to procedures performed at hospitals with on-site surgical services with respect to the 30-day and 1-year rates of clinical events. (Funded by the participating hospitals without on-site cardiac surgery; MASS COM ClinicalTrials.gov number, NCT01116882.).