Safety of outpatient cardiac catheterizations

Various approaches for peforming an outpatient coronary angiography

AIM

To study the safety and clinical efficacy of an outpatient coronary angiography in various groups of patients according to a 6-year experience of the laboratory of endovascular diagnostic and treatment methods in the outpatient setting of the NMRC of Cardiology.

MATERIALS AND METHODS

2166 patients which underwent an outpatient coronary agiography from March 2009 to December 2014 were included. The success criteria was the successful completion of the procedure without the occurrence of major cardiovascular complications (death, transmural myocardial infarction; acute cerebrovascular accident, emergency cardiac surgery).

RESULTS

All 2166 patients included in the study were divided into 2 groups: Group 1 - 1316 patients who were discharged home several hours after the study; Group 2 - 850 patients directed from hospitals without catheterization laboratories with the same-day discharge back to the referring hospital. From a clinical point of view, in the second group there were more severe patients. However, the study was successfully completed in all patients in both groups. There were no major adverse cardiovascular complications during the procedure and within 24 hours. In the 1st group, unplanned hospitalization occurred in 2.1% of cases, the cause of which in 93% of cases was the detection during angiography of a critical lesion ≥70% of the left main coronary artery.

CONCLUSION

In our work, the incidence of complications was extremely low and not significantly different in both groups of patients. This is due to the fact that in patients with a more severe symptoms underwent a preliminary stabilization of their clinical condition. The introduction of outpatient technologies will optimize the invasive diagnostics and reduce the costs associated with hospitalization.

Outpatient Endovascular Intervention: Is it Safe?

Purpose:

To evaluate the feasibility and safety of outpatient percutaneous endovascular intervention in the treatment of arterial occlusive disease.

Methods:

The records of 134 patients who underwent 151 outpatient endovascular procedures between 1992 and 1997 were reviewed retrospectively. According to established protocol, focal lower limb (n = 145) and subclavian (n = 6) arterial lesions requiring relatively straightforward endoluminal interventions were appropriate for outpatient management provided the patients were free of significant comorbidities. A percutaneous transfemoral approach was used for lower limb lesions, while subclavian angioplasty was performed via a brachial access. Heparin anticoagulation was administered conservatively. Patients were discharged 3 hours after sheath removal.

Results:

The majority (98%) of patients were discharged as planned. Three (2%) patients were observed overnight in the hospital for treatment of acute iliac artery thrombosis, puncture-site bleeding, and suboptimal angioplasty. No patient required hospitalization following discharge. Periprocedural morbidity Was confined to 2 (1.5%) groin hematomas and 1 (0.7%) femoral pseudoaneurysm.

Conclusions:

Outpatient endovascular intervention appears safe; however, proper case selection and technical excellence are inseparable components for the success of this strategy.

MDCT coronary angiography -- postprocessing, reading, and reporting: last but not least

Significant literature on MDCT coronary angiography (MDCT-CA) has emerged in the last decade concerning patient's selection, technical aspects of different generations of CT equipment, ECG gating, contrast material and beta-blockade administration, acquisition parameters, and radiation dose. However, the literature regarding postprocessing, reading, and reporting is not so extensive. This review highlights the main elements of MDCT-CA data analysis, thereby allowing the radiologist to take full advantage of this technology and enable a structured report to be generated, promoting best practice with high-quality results.

Coronary bypass graft patency cannot be determined by multidetector spiral computed tomography

OBJECTIVES

Angiography by selective catheterization is the reference standard for coronary bypass graft patency assessment but carries a risk of serious complications. We have investigated whether 16-slice multidetector spiral computed tomography (MDCT) can substitute for selective angiography.

DESIGN

Two to three years after coronary artery bypass grafting, 45 patients with a total of 156 bypasses (100 single and 28 sequential grafts) were examined with both MDCT and conventional selective angiography on the same day. The bypasses were classified as patent, stenotic or occluded.

RESULTS

The likelihood ratio for MDCT-detected occlusion was 40, reflecting a fairly high combined sensitivity and specificity. However, 24% of the distal anastomoses could not be evaluated by MDCT, mainly because of respiratory movements, artifacts due to metal clips, and small vessel dimensions. Moreover, seven out of 117 bypasses (6%) deemed evaluable by MDCT were wrongly classified by this method.

CONCLUSIONS

At present, 16-slice MDCT cannot replace selective angiography for assessment of coronary bypass graft patency since 24% of bypasses could not be evaluated by this method, and an error rate of 6% is unacceptable.

Coronary artery disease cannot be reliably evaluated by 16-slice multidetector spiral computed tomography

OBJECTIVES

Angiography by selective catheterization is the standard method for coronary artery imaging but carries a risk of rare, but serious complications. We investigated whether 16-slice multidetector spiral computed tomography (MDCT) could substitute for selective angiography for evaluation of coronary artery disease in surgically revascularized patients.

DESIGN

In a setting closely resembling routine clinical practice, 45 patients who had been operated with coronary artery bypass grafting 508-1135 (mean 811) days before were examined with MDCT and conventional selective angiography on the same day. The interpreters were blinded to the results of the parallel imaging modality.

RESULTS

Significant pathology (stenosis >/=50% or occlusion) in the larger coronary artery segments was detected by MDCT with a sensitivity of 70-98% (mean 87%) and a specificity of 0-37% (mean 21%). MDCT failed to identify three of ten left main stem stenoses.

CONCLUSION

Sixteen-slice MDCT cannot routinely replace selective angiography for evaluation of coronary artery disease.

Effect of positioning on back pain after coronary angiography

BACKGROUND

Coronary angiography is a routine cardiac diagnostic procedure in Hong Kong. Patients are restricted to bedrest after the procedure due to potential vascular complications from using a femoral approach. Many patients are required to remain on bedrest for up to 24 hours after the procedure. The effects of reducing this bedrest time is still under investigation. In the meantime, nursing interventions aimed at decreasing patient discomfort due to prolonged bedrest are feasible to implement.

AIMS

The aims of this study were to evaluate the severity of back pain related to bedrest duration after coronary angiography and to compare the effects of changing patients' position in bed on their perceptions of back pain and on vascular complications.

METHODS

An experimental design was used, with patients randomly assigned either to a control or experimental group. The control group received the usual care, remaining supine and flat for 8-24 hours, with the affected leg straight. The experimental group changed their body position hourly, varying between supine, right side-lying, and left side-lying during the first 7 hours after coronary angiography.

RESULTS

A total of 419 patients participated in the study (control, n = 213; experimental, n = 206). Regardless of group assignment, back pain intensity increased with longer time on bedrest. In addition, the control group reported higher levels of pain at all five assessment times. Vascular complications in terms of bleeding at the femoral site were not significantly different between the control and experimental groups.

CONCLUSION

The study findings suggest that patients may be able safely to change their position in bed earlier in the post-coronary angiography period than currently recommended in practice protocols. Changing position in bed may also reduce back pain, promote physical comfort, and possibly reduce patients' negative feelings toward coronary angiography.

Systematic use of a collagen-based vascular closure device immediately after cardiac catheterization procedures in 1,317 consecutive patients

Despite recent advances in interventional cardiology, vascular access complications continue to be a significant problem. Conventional manual compression of the femoral access site is associated with prolonged immobilization and significant patient discomfort. We investigated the performance of a collagen-based closure device applied immediately after catheterization and its complication rate in 1,317 consecutive patients undergoing cardiac catheterization or coronary angioplasty. Patients undergoing coronary angioplasty (n = 644) received more heparin than patients with diagnostic cardiac catheterization (n = 673; 9,675 +/- 1,144 IU vs. 6,419 +/- 2,211 IU; P < 0.0001). Deployment success rates of the closure device were comparable for patients undergoing diagnostic vs. interventional procedures (95.8% vs. 96.7%; P = 0.46). Complete hemostasis immediately after deployment of the device was achieved in > 90% of all patients, but was lower in the interventional group (93.7% vs. 90.6%; P = 0.05). Major complications including any vascular surgery, major bleeding requiring transfusion, retroperitoneal hematoma, thrombosis or loss of distal pulses, groin infections, significant groin hematoma, and death were observed in 0.53% of all patients, with no differences between diagnostic or interventional patients (0.62% vs. 0.45%; P = 0.953). Subgroup analysis revealed female gender as a predictor of access site complications. Systematic sealing of femoral access sites after both diagnostic and interventional procedures allows for immediate sheath removal with reliable hemostasis. The use of a collagen-based closure device is associated with a low rate of clinically significant complications.

Experience with Four French Catheters for Outpatient Coronary Angiography

Previous studies have demonstrated the efficacy and safety of outpatient cardiac catheterization on stable patients at low risk. We present our experience with four French catheters in 104 patients (72 male, 32 female, mean age 51 years old) with coronary angiography done as an outpatient procedure. No heparin was given during the procedure. After initial hemostasis had been attained, the patients returned to day center with vital signs monitored regularly. Patients were allowed ambulation after 4 hours' bed rest and were discharged the same afternoon. Normal coronary angiogram study was found in 76% of the study population. Single-vessel disease, double-vessel disease, triple-vessel disease, and left-main disease were found in 12%, 9.6%, 2%, and 1%, respectively. Nearly all of the patients demonstrated normal ventricular contraction (99%). Average procedural time was 20.2 +/- 4.4 minutes. Average hemostatic time was 8.4 +/- 3.1 minutes. No mortality directly attributed to the catheterization occurred in our study population. Moreover, there were no myocardial infarction, acute pulmonary edema, severe allergic reaction, and cerebrovascular accident. Femoral puncture site complication was only limited to superficial skin bruise. Quality of the cineangiogram was good in majority of the patients. Therefore, this study demonstrates that outpatient cardiac catheterization using four French Judkins catheter is a safe and cost-effective procedure.

Performance standards: piece of cake or pie in the sky?

BACKGROUND

Centrally mandated levels of performance are now common in the Veterans Health Administration. Performance standards for ambulatory procedures were developed based on HCFA data. The 11 procedures to be measured were arthroscopy, breast biopsy, eyelid procedures, lens/cataracts, bronchoscopy, endoscopy, colonoscopy, hernia repair, cystoscopy, laparoscopy, and cardiac catheterization. Were the performance standards for ambulatory procedures reasonable and achievable in a tertiary care VA?

METHODS

Ambulatory procedure performance standards for the 11 selected procedures were evaluated for Fiscal Year 1998 at one tertiary care VA and at each of the 22 Veteran's Integrated Service Networks (VISNs). Further review was undertaken for those procedures in which performance was below the fully successful level. This included chart reviews at the tertiary care VA and analysis of caseloads by VISN. Descriptive statistics were used as well as Student's t test to analyze the difference in means.

RESULTS

The tertiary care VA performed at the fully successful level for 6 procedures and at the exceptional level for 3 procedures. Performance levels for bronchoscopy and laparoscopy were below the preset goals. At the VISN level, 8 VISNs performed at the fully successful/exceptional level for all 11 procedures. The remaining 14 were deficient in 1 to 4 procedures. Eight of the VISNs were deficient in 2 or 3 procedures. Six VISNs were deficient in laparoscopy.

CONCLUSIONS

The majority of centrally mandated performance standards appear to be reasonable and achievable. One notable exception is laparoscopy. Surgeons should understand how performance standards are calculated at their institution and review the data carefully for any systematic errors. Underperformance can be used as an opportunity to improve both data collection and outcomes.

[Hemostatic closure of arterial puncture site using Angio-Seal after diagnostic heart catheterization or coronary intervention]

Conventional manual compression and subsequent application of pressure bandages is associated with prolonged immobility and significant patient discomfort. Routine anticoagulation as well as the use of new interventional devices and platelet inhibiting strategies lead to a higher incidence of local bleeding complications after diagnostic cardiac catheterization or coronary angioplasty. Immediate sheath removal increases patient comfort. The Angio-Seal system uses a biodegradable anchor and collagen plug for sealing of arterial puncture sites. Several studies showed the safety and efficacy of this device. Technical deployment success ranges between 88 and 100%. Significant reduction in time to hemostasis allows for earlier patient ambulation and shorter in-hospital stay compared to manual compression with peripheral complications not being increased.

A prospective randomized trial of early ambulation following 8 French diagnostic cardiac catheterization

This prospective randomized study was done to assess the safety of 4-hr ambulation after diagnostic cardiac catheterization with 8 French sheaths and catheters. In this selected group of patients, we found that early ambulation could be done without an increase in access site complications.

Safety of coronary arteriography in clinically stable patients following coronary bypass surgery. Post CABG Clinical Trial Investigators

The frequent use of diagnostic coronary arteriography and its importance in evaluating results of intervention in clinical trials emphasize the necessity of continued assessment of procedural risk. Several studies have described such risks, but they have often included a diverse group of patients with varying levels of clinical stability. Furthermore, this risk has not been well established in a population of patients with saphenous vein bypass grafts. There is need to define the risk of coronary arteriography in a group of patients who are both clinically similar and stable, and to evaluate the influence of improved technology and increased operator experience on the risk of the procedure. The National Heart, Lung, and Blood Institute-funded Post Coronary Artery Bypass Graft Trial offered the opportunity to evaluate the risk of elective diagnostic coronary arteriography in clinically stable patients studied at two points in time: pre-enrollment and 4-5 years after study entry. In this group of 2,635 angiograms from clinically stable patients over 5 years there were no deaths and the risk of myocardial infarction was 0.08%, while 0.7% had clinically important complications. Non-elective, urgent studies (311 angiograms) on unstable patients were more likely to include angioplasty and were associated with a risk of death of 0.6% and myocardial infarction of 1.3%. Complications did not vary with age or gender. Vascular trauma was more likely to occur using the brachial than the femoral artery entry sites. These results indicate that elective angiography on stable patients can be accomplished with a very low risk of mortality (0% in this study) or serious cardiovascular complication. This supports the safety and usefulness of angiography for clinical intervention trials.

Outpatient endovascular intervention: is it safe?

PURPOSE

To evaluate the feasibility and safety of outpatient percutaneous endovascular intervention in the treatment of arterial occlusive disease.

METHODS

The records of 134 patients who underwent 151 outpatient endovascular procedures between 1992 and 1997 were reviewed retrospectively. According to established protocol, focal lower limb (n = 145) and subclavian (n = 6) arterial lesions requiring relatively straightforward endoluminal interventions were appropriate for outpatient management provided the patients were free of significant comorbidities. A percutaneous transfemoral approach was used for lower limb lesions, while subclavian angioplasty was performed via a brachial access. Heparin anticoagulation was administered conservatively. Patients were discharged 3 hours after sheath removal.

RESULTS

The majority (98%) of patients were discharged as planned. Three (2%) patients were observed overnight in the hospital for treatment of acute iliac artery thrombosis, puncture-site bleeding, and suboptimal angioplasty. No patient required hospitalization following discharge. Periprocedural morbidity was confined to 2 (1.5%) groin hematomas and 1 (0.7%) femoral pseudoaneurysm.

CONCLUSIONS

Outpatient endovascular intervention appears safe; however, proper case selection and technical excellence are inseparable components for the success of this strategy.

Outpatient coronary angiography: indications, safety, and complication rates

In the years since the introduction of outpatient cardiac catheterization and coronary angiography, the indications for the use of these procedures have expanded rapidly with advancements in surgical and endovascular procedures. The safety of outpatient coronary angiography has been well established, comparing very favorably with that of inpatient procedures. At present, a variety of different outpatient facilities exist. Catheterization laboratories may adjoin a hospital or be free-standing; the safety and success of procedures performed in mobile cardiac catheterization laboratories has also been described. There are a variety of access techniques for cardiac catheterization in use today, and there are many types and sizes of catheters available. Miniaturization of equipment has reduced complications and allowed early ambulation and discharge from outpatient laboratories. In addition, the development and refinement of catheters and techniques for achieving hemostasis may allow further reductions in patient stay and complications. The complication rates of outpatient cardiac catheterization and coronary angiography are, in fact, quite low--in some cases, lower complication rates are seen in the outpatient population than in the inpatient population. Although this is certainly related in part to the fact that outpatients generally have more stable disease, it is clear that careful equipment choices, proper technique, and adequate monitoring have contributed to the success of these important outpatient procedures.

Early ambulation following 6 French diagnostic left heart catheterization: a prospective randomized trial

Outpatient cardiac catheterization is frequently performed, but the optimal recovery time after sheath removal has not been defined. Left heart catheterization was performed via the femoral artery utilizing 6 French catheters on 323 outpatients. One hundred thirty-five patients were randomized to ambulate at a mean of 2.5 hr (group 1) after puncture site compression, whereas 188 patients were randomized to ambulate at a mean of 4.1 hr (group 2). Telephone follow-up occurred within 48 hr. A small hematoma (< 5 cm) occurred in 2 (1.6%) patients in group 1 and in 4 (2.4%) patients in group 2. These results indicate that it is safe to ambulate patients 2.5 hr following 6 French diagnostic heart catheterization.

Mortality related to coronary angiography

Coronary angiography is in general regarded as a safe investigation with a low risk of serious complications. Unfortunately, a risk of serious complications exists, especially in patients with left main coronary artery disease or 3-vessel disease. The mortality rate ranges in different studies between 0.10% to 0.25%. The present series, reflecting nine years experience, shows an overall mortality of 0.16%. This figure is influenced by the relatively high mortality rate in the first year of the study. The recent mortality rate of 0.07% has not changed in the last 3 years and almost all deaths occurred in the patients known to be at higher risk.

Outpatient cardiac catheterisation

Cardiac catheterisation is increasingly performed in an outpatient setting. The majority of series of outpatient cardiac catheterisation are in laboratories with immediate access to cardiovascular surgery. However, some units may be sited more distantly, although still generally close to a hospital. Compared to an inpatient procedure, outpatient cardiac catheterisation increases bed availability and there are considerable financial rewards with suggested savings of 11-54% of inpatient costs. Most patients are satisfied with an outpatient procedure and, although a quarter may have unanswered questions afterwards, this level may not differ from that found with inpatients. No study has been large enough to detect differences in the major complication rate which occur infrequently in whichever setting, and there is considerable variation between studies in the incidence of minor complications after outpatient procedures. In the only study which randomised all eligible patients to an inpatient (189 patients) or outpatient (192 patients) procedure, seven outpatients (3.6%) suffered bleeding or developed haematomas at the site of percutaneous femoral artery puncture towards the end of the mobilisation period and one patient was syncopal. These events were thought to be a direct result of the procedure being carried out in the outpatient setting. The proportion of patients considered eligible for outpatient cardiac catheterisation varies widely between different series from 20% to more than 80%. Whereas some of this variation may result from the implementation of different exclusion criteria for patients with potentially severe disease, the differences are so large that it is likely that different populations were studied. Unplanned admission rates varied from less than 1% to nearly 19%. With the currently available data no absolute guidelines can be derived to exclude all patients at risk of complications, but the American College of Cardiology/American Heart Association (ACC/AHA) task force recently published guidelines which identified low risk patients suitable for outpatient procedures. These guidelines have been used to select patients for investigation in two mobile units in the USA, and only 0.9% required urgent transfer for clinical instability, and 0.6% developed major complications. However, most patients did not need referral to a tertiary centre for additional procedures and there may be less scope for selecting patients within the ACC/AHA guidelines in the UK compared with the USA.

Effects of modified positioning and mobilization of back pain and delayed bleeding in patients who had received heparin and undergone angiography: a pilot study

OBJECTIVE

To examine the effects that a modified positioning and mobilization routine had no back pain and delayed bleeding in patients who had received heparin and undergone cardiac angiography.

DESIGN

An experimental research design was used. Each patient was assigned randomly to either the control group, which required 6 hours of bed rest after cardiac angiography, or the experimental group. The experimental group had modified positioning, in which the head of the bed was elevated to a maximum of 45 degrees, and modified mobilization, in which they were ambulated briefly at the bedside 4 hours after angiography.

SETTING

Two cardiology units of a 700-bed urban teaching hospital in western Canada.

SAMPLE

All patients admitted for nonemergent cardiac angiography were approached for consent, to attain a sample of 29 patients, and were randomly assigned to the experimental or the control group.

METHOD

Each patient was randomly assigned before cardiac angiography. The assignment was confidential until the patient was admitted to the cardiac unit after angiography. A demographic tool and the McGill Present Pain Intensity Scale were used to collect data. Perception of pain was evaluated over four observation periods. A research assistant monitored sanguineous drainage on the dressing and hematoma to evaluate the presence of delayed bleeding.

DATA ANALYSIS

Demographic information was analyzed primarily through descriptive statistics. Results were analyzed to compare back pain and delayed bleeding between the two groups. Wilcoxon scores and t tests both were used for analysis and correlated well with each other.

RESULTS

The group with the modified positioning and mobilization routine experienced significantly less pain overall (p = 0.02), less pain at each interval, and significantly less pain intensity (p < 0.05). There was no difference in bleeding. One person in each group had an estimated blood loss of more than 100 ml through the pressure dressing.

CONCLUSION

This pilot study supports our hypothesis that modifying the immobilization of patients after cardiac angiography is associated with a reduction in back pain and with no increase of delayed bleeding at the femoral access site. The results support the need for further investigation of ambulation interventions after cardiac angiography.

Left ventriculography complicated by cerebral air embolism

Cerebral air embolism is a severe complication of various invasive medical procedures. Hyperbaric oxygen is the sole definitive therapy. We describe a 68-year-old patient who presented with upper left limb motor and sensory deficits following the injection of a contrast medium for left ventriculography. Numerous air bubbles were seen on cineangiography concomitantly with injection of the contrast medium. Immediate compression with hyperbaric oxygen resulted in complete resolution of all neurological symptoms. Iatrogenic cerebral air embolism is an underdiagnosed condition that may result from cardiac catheterization. Physician awareness will improve prevention, and prompt diagnosis and the use of hyperbaric oxygen will result in an optimal outcome if it does occur.

Randomized prospective evaluation of prolonged versus abbreviated intravenous heparin therapy after coronary angioplasty

OBJECTIVES

This study was designed to prospectively evaluate the routine use of continuous heparin therapy after successful uncomplicated coronary angioplasty.

BACKGROUND

The use of such therapy varies among institutions and may increase the incidence of complications. Evaluation of the risks and benefits of abbreviated heparin therapy combined with early sheath removal after coronary angioplasty is necessary to determine optimal postprocedure care.

METHODS

We prospectively studied 284 patients who were scheduled for elective coronary angioplasty. Historical, clinical, physiologic and angiographic data were gathered. All patients received an initial bolus of heparin and then were randomized during the procedure to receive either no additional heparin therapy or an adjusted 24-h infusion. On the basis of specific criteria, additional heparin was not withheld if procedural results suggested an increased risk for complications.

RESULTS

Two hundred thirty-eight patients completed the study; 46 others were excluded in the catheterization laboratory because of unfavorable procedural results. The patients with abbreviated (n = 118) and 24-h (n = 120) therapy did not differ with respect to demographic and angiographic findings. However, the former had fewer bleeding complications (0% vs. 7%, p < 0.001) and were discharged earlier (mean +/- SD 23 +/- 11 h vs. 42 +/- 24 h, p < 0.001). One patient in this group had a major complication shortly after angioplasty. The mean savings in hospital charges in the abbreviated therapy group was $1,370 ($6,093 +/- $1,772 vs. $7,463 +/- $1,782, p < 0.001).

CONCLUSIONS

Omission of routine heparin therapy after successful coronary angioplasty reduces bleeding complications without increasing patient risk. Earlier discharge and significant cost savings are possible under proper conditions.

Synergistic value of simultaneous stress dobutamine sestamibi single-photon-emission computerized tomography and echocardiography in the detection of coronary artery disease

The relative value of exercise electrocardiography, simultaneous dobutamine technetium 99m-sestamibi (MIBI) single-photon-emission computerized tomography (SPECT), and echocardiography were evaluated for the diagnosis of coronary artery disease in patients with chest pain. Sixty-one consecutive patients underwent exercise electrocardiography and simultaneous graded dobutamine echocardiography and MIBI imaging. All patients underwent coronary arteriography. The exercise electrocardiogram was found to be a poor predictor of coronary artery disease (p not significant). Individually, MIBI SPECT and echocardiography were significantly predictive of coronary artery disease (p < 0.001). According to logistic regression analysis, the combined imaging modalities significantly increased the prediction of coronary artery disease for any vessel (p < 0.001), for multiple vessels (p < 0.001), and for the left anterior descending (p < 0.001), for right coronary artery (p < 0.001), and for left circumflex arteries (p < 0.01), compared with either MIBI SPECT or echocardiography alone. The results suggest a synergism in the detection of coronary artery disease when MIBI SPECT and echocardiography are combined during dobutamine stress.

Mobile cardiac catheterization: comparison with outpatient and inpatient catheterization at tertiary facilities

The study group included 1,553 consecutive patients from areas serviced by our mobile catheterization laboratories: 719 procedures were performed in the mobile unit at their local hospitals, 277 were performed at a tertiary hospital with less than a 24 hr hospital stay, and 557 were performed at a tertiary hospital as inpatients. The indications for mobile catheterization were predominantly atypical chest pain, angina pectoris, or positive treadmill stress test, whereas patients with less than 24 hr hospitalization at the tertiary center had their catheterization performed for additional reasons. The majority of the inpatient indications were for recent myocardial infarction or unstable angina. Using the American College of Cardiology/American Heart Association (ACC/AHA) criteria for outpatient catheterization, the mobile catheterizations were performed safely with a complication rate of only 0.7% compared to a complication rate of 3.1% for inpatients demonstrating that a low risk group of patients can be prospectively identified and catheterized safely in the mobile setting. An extremely high risk group of patients with ongoing unstable angina and recent myocardial infarction was also identified which should undergo catheterization only at a tertiary center.

Mobile cardiac catheterization registry: report of the first 1,001 patients

The purpose of this study was to evaluate prospectively the efficacy and safety of mobile cardiac catheterization. Mobile cardiac catheterization was introduced into clinical practice in 1989, but there has been no systematic study of its performance and safety. A registry was established in 1989 to monitor outcomes with mobile cardiac catheterization and is reported here. Patients were screened for eligibility for mobile cardiac catheterization using the joint AHA/ACC criteria for outpatient angiography. Eligible patients underwent mobile catheterization at eight hospitals within 120 miles of the base tertiary center. Helicopter evacuation services were available at each mobile site. The indications, findings, dispositions, and complications of mobile cardiac catheterization were recorded by means of a checklist, telephone follow-up and chart review. A total of 1,001 consecutive patients were entered into the registry in the first 20 months of operation, including 436 females and 565 males aged 22 to 84 years. Angina (Canadian Classes II-IV) was the most frequent primary indication for catheterization (46.4%), followed by atypical chest pain (36.9%), or a positive exercise stress test (25.6%). Infrequent indications for catheterization included a history of myocardial infarction (5.6%), congestive heart failure (7.1%), arrhythmias (4.1%), and valvular heart disease (0.7%). Catheterization was accomplished in 99.9% of patients. Angiographically normal studies were observed in 22.8%, and mild (< or = 50%) coronary artery disease in 13.6% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Unplanned admissions after outpatient cardiac catheterization

Increasing numbers of patients are undergoing diagnostic catheterization as outpatients; however, a small proportion of patients requires hospital admission following the procedure. Unplanned admissions after consecutive outpatient cardiac catheterizations performed during 1 year were prospectively reviewed to determine the incidence of and reasons for admission. Among 847 patients undergoing outpatient cardiac catheterization, 130 patients (15%) required hospital admission after the procedure. Admitted patients were divided into four groups: patients undergoing immediate percutaneous transluminal coronary angioplasty (PTCA) (Group 1; 33%), patients with severe cardiac disease requiring urgent intervention (Group 2; 48%), patients suffering complications or hemodynamic instability (Group 3; 15%), and patients whose procedures were completed too late to allow same-day discharge (Group 4; 4%). Patients over 65 were more likely to require admission and women were more likely to be admitted with complications or hemodynamic instability. Findings are compared with results of other outpatient series, and implications regarding appropriate setting for outpatient catheterization are discussed.

Cardiac catheterization and coronary angiography using 5 French preformed (Judkins) catheters from the percutaneous right brachial approach: a comparative analysis with the femoral approach

This study describes a method for the performance of cardiac catheterization using 5 French preformed Judkins catheters from a percutaneous right brachial approach, and compares that technique to the more traditional percutaneous right femoral approach with 6 French catheters. One hundred consecutive patients requiring diagnostic left heart catheterization and selective coronary angiography were randomized according to femoral versus brachial arterial technique. Procedural efficiency, radiation exposure, and diagnostic film quality favored the femoral approach, while patient comfort, hemostasis time, time to ambulation, and decreased need for post-procedure nursing care favored the brachial approach. No differences were identified in complications. Cardiac catheterization from a right brachial artery percutaneous approach with 5 French preformed catheters has both advantages and disadvantages when compared with a more traditional femoral approach with 6 French catheters. Multiple factors should be considered before selecting an approach to diagnostic cardiac catheterization and each patient should be individually evaluated for determination of the optimal technique.

Early ambulation following diagnostic 7-French cardiac catheterization: a prospective randomized trial

There is a paucity of randomized studies concerning transfemoral cardiac catheterization and its complications, in particular that of 7F catheterization. Accordingly, we conducted a prospective, randomized trial comparing early ambulation (group A) 6 hr after diagnostic 7F cardiac catheterization versus late ambulation (group B) the following morning. A total of 273 patients were randomized in the study; 142 in group A and 131 in group B (NS). Except for a difference in the indications for catheterization, the baseline and procedure-related parameters were similar between the 2 groups. Early hematoma (formed within 6 hr) developed in 6 (4%) and 7 (5%) patients in groups A and B, respectively (NS). Similarly, there was no difference in the incidence of late hematoma formation (2% in each group). All hematomas detected were small and required no surgical intervention or extension of hospital stay. Our data showed that early ambulation following 7F left heart catheterization is feasible and safe. The access site complication rate is acceptably low and minor in nature.

A consumer guide for marketing medical services: one institution's experience

This paper describes the Cleveland Clinic Foundation's experience with the development and implementation of a 20-page quality indicator consumer guide for patients with or at risk of developing coronary artery disease. The guide, which provides six "quality indicators," was designed to enable patients to evaluate and compare quality-related information when choosing a provider. Design elements for the guide included a user-friendly format to offset the amount of information consumers are asked to absorb. Data on inquiries showed that the majority were women (53%) and adults under the age of 65 years (57%). Although the media criticized the guide as a marketing tool, it represents an effort to educate consumers about the importance of research when choosing a provider.

Outpatient cardiac catheterization: a report of 3,000 cases

A total of 3000 patients have had cardiac catheterization in the Andreas Gruentzig Cardiovascular Laboratory of the Emory Clinic. The purpose of this presentation is to describe the patient population selected for this procedure and our experience with this group. The concept of catheterization as an outpatient is attractive from the standpoint of cost savings and time conservation. Safety has been questioned. We have found that this technique can be performed safely in carefully selected outpatients. Careful selection attempted to eliminate those with unstable symptoms, recent myocardial infarction, severe diabetes, and renal failure. Small catheters were used to minimize the potential for bleeding. Excellent opacification of vessels was obtained with these catheters. Despite careful screening we found 2.2% had significant left main obstruction, 10.8% had triple-vessel disease, 16.0% had double-vessel disease, and 23.5% had single-vessel disease, and a similar percentage had normal coronary arteriograms. Our patients experienced ventricular fibrillation on five occasions, there were two small cerebral emboli with reversible neurologic defects, two episodes of pulmonary edema, and two episodes of severe allergic reactions. Only three patients had significant groin bleeding at home that required compression of the site. We subsequently did angioplasty on 323 patients, performed cardiac surgery (mostly coronary bypass) on 187 patients, and admitted 18.2% of the entire group. We conclude that this procedure can be done safely in this carefully designed setting and it saves time and offers cost savings. Patient selection is very important to minimize potential emergency situations and complications. The laboratory must be carefully set up and provide a close relationship with a hospital capable of attending to any unexpected emergency.

Nondiagnosed left main ostial stenosis partly due to the use of 5 French coronary angiographic catheters

Two cases have been reported in which the use of 5 F angiographic catheters is associated with a failure to diagnose an ostial stenosis of the left main coronary artery (LMCA). In both cases, the erroneous diagnosis led to an inappropriate indication for percutaneous transluminal coronary angioplasty (PTCA) on other stenosed vessels, and the ostial left main lesion was unexpectedly discovered when using 8F guiding catheters. It is supposed that the ability of performed 5F catheters to pass easily through an ostial lesion makes detection of such proximal stenosis much more difficult. We suggest that the choice of 5F catheters must be approached with caution when left main disease is potentially expected from the clinical features.

Feasibility and cost savings of outpatient electrophysiologic testing

The feasibility of outpatient electrophysiologic testing was examined by reviewing 100 consecutive outpatient tests performed in 95 patients. Seventy-one of the patients (75%) had no underlying heart disease. The electrophysiologic tests were performed to evaluate supraventricular tachycardias (n = 47), nonsustained ventricular tachycardia (n = 20), unexplained syncope (n = 21), palpitation (n = 9) or intermittent heart block (n = 2). A mean of 2.8 +/- 0.5 6F electrode catheters were inserted through a femoral vein. An electrode catheter was inserted into a subclavian or internal jugular vein in 28 tests and a 5F cannula was inserted into a femoral artery to monitor the blood pressure in 20 tests. The results of 61 tests (61%) were abnormal. Patients were monitored for a mean of 3.8 +/- 1.2 h after the procedure and then discharged. No complications occurred. For cost analysis a subgroup of 60 of these patients was matched for age, gender, heart disease and indication for electrophysiologic testing with a group of 60 patients who underwent electrophysiologic testing as inpatients. Physicians' fees for the two groups were similar; however, the mean hospital charge was $5,845 +/- 3,763 for the inpatient group compared with only $2,120 +/- 1,244 for the outpatient group (p less than 0.001). Thus, outpatient electrophysiologic testing is feasible and safe and results in substantial cost savings in patients without life-threatening arrhythmias.

Early ambulation after 5 French diagnostic cardiac catheterization: results of a multicenter trial

Because earlier ambulation and discharge after cardiac catheterization may result in the increased utilization of outpatient facilities, a prospective five center clinical pilot trial assessing the safety and outcome of early ambulation after routine left heart catheterization was performed in 287 patients. Catheterization routines at each clinical center were unchanged throughout the study. After the diagnostic catheterization using 5 French (F), preformed, large lumen catheters and arterial puncture compression (mean 15 min, range 5 to 52), 260 patients were ambulated by a physician at a mean time of 2.6 h (range 1.8 to 3.1) after catheterization. Follow-up examination or a phone call 24 to 72 h later was performed to assess late results. The mean age of the patients was 58 years (range 25 to 91); 166 (58%) were men. Left ventricular ejection fraction was 54 +/- 15%. One hundred twenty-seven patients (44%) received intravenous heparin (1,500 to 5,000 U as an intravenous bolus) and 136 (47%) received aspirin. Major complications included transient ischemic attack (one patient) and ventricular tachycardia requiring cardioversion during ventriculography (two patients). A small hematoma (less than 5.0 cm) after ambulation occurred early (from compression to standing) in 14 patients (5%; 9 received heparin, 8 were taking aspirin) and later (after standing to 72 h) in 9 patients (3%; 2 receiving heparin, 2 taking aspirin). Five patients with a hematoma had studies with a 6F sheath. No patient required surgical intervention for early or late hematoma. Only three patients (1%) needed a 7F or 8F catheter because of suboptimal 5F coronary angiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Significance of ventricular tachyarrhythmias complicating cardiac catheterization: a CASS Registry Study

Ventricular tachycardia and ventricular fibrillation are recognized complications of cardiac catheterization. Despite numerous reports documenting the frequency of these occurrences, their significance has not been systematically examined. Accordingly, the outcome of 108 patients who experienced either ventricular tachycardia or ventricular fibrillation during coronary angiography between 1975 and 1979 in the Coronary Artery Surgery Study (CASS) Registry were examined. There were 20,142 patients analyzed. Patients with ventricular tachyarrhythmias had more objective evidence of left ventricular impairment, clinical heart failure, and ventricular arrhythmia recorded as a clinical symptom. The overall 5-year survival rates were 83% and 88% for patients with and without ventricular tachyarrhythmias, respectively (p = 0.07). When ventricular function, age, gender, angina, and previous myocardial infarction were added in a stepwise Cox survival analysis, the presence of arrhythmias was not significant (p = 0.66). At 5 years, 80% of the medically treated patients and 82% of the surgically treated patients remained alive (p = 0.95). The only statistically significant differences in the patients with ventricular arrhythmias who were treated medically or surgically were age (medically treated patients 52 +/- 10 years, surgical patients 57 +/- 9 years, p = 0.01) and number of diseased vessels (p less than 0.001). In a stepwise Cox survival analysis, functional impairment secondary to congestive heart failure was the only significant covariate to affect survival in the medical and surgical groups (p = 0.0001). Surgical therapy itself was not significant (p = 1.00). The incidence of sudden death during 5 years for patients with and without ventricular tachyarrhythmias during catheterization was 5% and 4%, respectively (p = 0.28).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of 5F and 7/8F catheters for left ventricular and coronary angiography

Fifty-two patients were randomized into two groups of 26 to the use of either 5 or 7/8F catheters for their first left heart cardiac catheterization. Clinical characteristics for the two groups were similar. 5F catheters were significantly inferior to 7/8F catheters in terms of torque control (P less than .001), ease of engaging coronary ostia (P less than .001), and quality of angiograms (P less than .05). Nine patients in the 5F group required a change to 7/8F catheters for completion of the procedure. There was no difference in procedure time or fluoroscopy time between the groups. Time to haemostasis was significantly shorter in the 5F group (P less than .01), but there was no difference between groups with respect to haematoma formation or rebleed after haemostasis. We conclude the slight advantage of 5F catheters in terms of haemostasis is outweighed by many disadvantages. Their routine use in cardiac catheterization, at least at this time, cannot be recommended.

Feasibility and cost-saving potential of outpatient cardiac catheterization

To determine the feasibility and cost-saving potential of substituting outpatient for inpatient cardiac catheterization, 986 consecutive procedures were studied at a large referral hospital. Patients were classified prospectively as to their eligibility for outpatient cardiac catheterization according to published guidelines. Resource consumption was recorded, and cost savings were then calculated by analyzing the specific supply and personnel costs that could change as a result of inpatient versus outpatient status. Of the total of 986 patients who underwent diagnostic catheterization, 240 (24%) were outpatients, 279 (28%) were inpatients but had no exclusion criteria for outpatient catheterization and 467 (47%) were inpatients who had one or more exclusions for outpatient catheterization. The most common reasons for exclusion from outpatient catheterization were congestive heart failure (22%), unstable angina (15%), noncoronary heart disease (14%), recent myocardial infarction (11%) and severe noncardiac disease (9%). Inpatients with no exclusions for the outpatient procedure tended to be sicker than outpatients because they were older (p = 0.002), had a lower ejection fraction (p = 0.009) and had more triple vessel coronary artery disease (p less than 0.0001). The cost of the catheterization procedure itself was not different between inpatients and outpatients. Laboratory testing was more frequent among inpatients, however, and "room and board" costs were significantly higher. Although the difference in hospital charges for inpatients and outpatients was $580, a rigorous analysis indicated that the potential cost savings was only 38% of this amount, or $218 per eligible patient.(ABSTRACT TRUNCATED AT 250 WORDS)

Early hospital discharge after percutaneous transluminal coronary angioplasty

To determine the safety and efficacy of early hospital discharge after percutaneous transluminal coronary angioplasty (PTCA), 100 patients were studied prospectively. A telemetry observation unit was established to monitor patients having uncomplicated procedures. A total of 170 lesions were dilated, with a procedural success rate of 96% and a clinical success rate of 91%. There were no deaths or patients who required emergency bypass surgery. Four patients developed abrupt vessel closure in the catheterization laboratory. No major complications developed in the telemetry observation unit or after discharge. Patients with high-risk lesion morphology, based on the American College of Cardiology/American Heart Association Task Force guidelines, tended to have a lower success rate and more procedural complications. Coronary dissections were angiographically detected in 33 patients and stratified into 6 types. To reduce possible adverse sequelae, all patients with complex dissections were triaged in the catheterization laboratory to an in-patient monitored unit for additional management. Accordingly, 20 patients were admitted to an in-patient unit for extended observation. Excluding 4 patients with myocardial infarction, 75% (12 of 16) were discharged the next day. Initial experience with early discharge suggests that under proper conditions the procedure is safe and effective. Patients with complex coronary dissections who are at high risk for abrupt vessel closure can be promptly identified after dilatation and triaged to an appropriate monitoring area. Early discharge after PTCA offers more efficient use of hospital facilities and the opportunity to reduce hospital costs.

Study of the performance of 5 French and 7 French catheters in coronary angiography: a functional comparison

The functional efficacy of a conventional 7F (high flow) coronary catheter (hand injection) was compared with a 5F (high flow) catheter using hand and powered injection in 29 patients with ischemic heart disease. Patients were randomized to 5F or 7F catheters as the initial catheter. Consecutive comparative coronary angiograms were performed in the 15 degrees right anterior oblique (RAO) view using Judkin's technique. Visual diagnostic grade (Grade 1 = Diagnostic, Grade 2 = Equivocal, Grade 3 = Nondiagnostic), vessel filling, vessel density (using a densitometer and corrected for background), streaming, and dislodgement were all evaluated independently by two experienced angiographers with correlation of results. Mean diagnostic grade (1.31 +/- 0.48) was significantly better with the 7F compared to 5F (hand) 1.72 +/- 0.81 and 5F (power) 2.00 +/- 0.71 (P less than or equal to 0.05) for each. Streaming was seen in 55% of injections with 5F (hand) versus 88.5% with 5F (power) and 20.7% with 7F. Measured vessel density was not different for the two catheters. Coronary injection dislodgement occurred significantly more often with 5F power injections than with hand injection of either catheter. Finally, in 6 (30%) of 20 patients in which the 5F was randomly the second catheter used, the operator had to revert to the 7F catheter in order to obtain adequate images. In conclusion, angiographic quality is reduced with 5F catheters compared to 7F high flow in certain patients. Thus, to achieve optimal diagnostic angiograms, larger lumen catheters may be required during certain procedures initially begun with 5F catheters.

Day case cardiac catheterisation using the Sones technique

Cardiac catheterisation using the Sones technique was planned as a day case procedure in 855 of 1662 consecutive patients admitted for cardiac catheterisation. Of these, 810 (95%) were discharged the same day. Forty-five (5%) needed overnight hospitalization, 34 for reasons connected with the procedure and 11 for other reasons. No serious complications occurred and there were no deaths. The cost of day stay was approximately half that incurred using overnight stay. Thus, cardiac catheterisation using the Sones technique on a day case basis is safe and may produce significant cost efficiency.

Outpatient cardiac catheterizations: analysis of patients requiring admission

The purpose of this study was to review the results of the first 1,000 outpatient cardiac catheterizations performed at our hospital with special emphasis on patients who were hospitalized. Nearly all patients had percutaneous femoral artery catheterization using #8F catheters. There were no deaths. The major complications included two myocardial infarctions and four cerebral emboli. Surgery on the femoral artery was required in 2 patients (1 occlusion and 1 pseudoaneurysm), 7 patients developed unstable angina without subsequent infarction, and 4 patients had ventricular tachycardia or fibrillation. Complications requiring admission were found in 39 patients. Another 59 were admitted, 51 for revascularization procedures. Of the latter 51 patients, 27 had main left coronary stenosis of 50% of greater. We have found outpatient catheterization to be a safe procedure. Complications requiring admission occurred in 3.9% of the patients. The most common reason for admission was to perform urgent bypass surgery in patients with main left coronary stenosis in excess of 50%.

Percutaneous radial artery approach for coronary angiography

Percutaneous entry into the distal radial artery and selective coronarography using a French 5 sheath and preshaded catheters were attempted in 100 patients with a normal Allen test. Cannulation of the radial artery was not possible in ten patients, and selective catheterization of the coronary arteries was unsuccessful in two. Manipulation of catheters presented no problem, and arterial spasm was rarely observed, only before the use of a 23-cm-long sheath. Only two complications without symptoms were observed: arterial dissection of the brachial artery in one patient and occlusion of the radial artery in another. With experience, this approach may become as effective and possibly safer than the transbrachial entry.

Day case cardiac catheterisation--a safe and economic alternative

Cardiac catheterisation, as a day procedure, has been performed at the Royal Perth Hospital since November 1985. During the 23 month period from November 1985 to September 1987, there have been 1398 day procedures carried out. One hundred and twelve patients (8%) required overnight admission as a consequence of the procedure--39 patients for routine observation, 41 patients for minor hemorrhage from the brachial arteriotomy or femoral artery puncture site; 12 patients for severe angina: three patients with reversible ischemic neurological deficits; two patients with stroke; four patients with transient brachial artery occlusion; two patients with arrhythmias and eight patients for miscellaneous reasons. One patient discharged on the day of the procedure required subsequent re-admission for treatment of an acute myocardial infarction. There were no deaths. The financial cost saving to the hospital in real terms is estimated to be $41.50 per patient and to the community a further saving of $25 per patient due to a reduction in sick leave. The minimum total cost saving to the taxpayer for the 1,285 patients managed as day cases was $85,000. Cardiac catheterisation can be performed as a day procedure with low morbidity, low mortality and modest cost savings to a major hospital.

A prospective randomized trial of outpatient versus inpatient cardiac catheterization

To evaluate the safety and cost of outpatient cardiac catheterization, we conducted a randomized trial at three hospitals of outpatient (n = 192) as compared with inpatient (n = 189) cardiac catheterization in low-risk patients. Outpatients had the following complication rates as compared with inpatients: hematoma, 12 versus 8.5 percent; numbness or weakness of extremity, 0.5 versus 1.6 percent; cold or blue extremity, 1.6 versus 1.1 percent; and acute myocardial infarction, 1.6 versus 0.5 percent. None of these differences were statistically significant. No deaths or strokes occurred in either group. Twenty-three patients (12 percent) assigned to the outpatient group required hospitalization because of complications of catheterization. In the outpatient group, the relative risk for hematoma was 1.42 (95 percent confidence interval, 0.77 to 2.29), and the relative risk for myocardial infarction within one week was 2.95 (95 percent confidence interval, 0.3 to 28.1). There were no significant differences between the two groups in whether they resumed normal activities or in the rates of rehospitalization within one week of the procedure. Total catheterization-related charges per patient were $679 lower for outpatients, with a savings in total hospital charges (including charges for subsequent therapeutic procedures) of $885 per patient. We conclude that elective cardiac catheterization as an outpatient procedure for selected patients is feasible and safe. Given the small size of our sample, however, we urge caution in interpreting these findings, since they do not exclude a small increase in complication rates with outpatient cardiac catheterization.

Five French versus eight French catheters and the Judkins technique. Advantages and limitations for studying coronary artery disease

In order to compare 5 French versus 8 French catheters for assessing ischemic heart disease, we prospectively studied 2 groups of 100 patients each, one with 5 French (group I) and the other with 8 French (group II) catheters by the Judkins technique. Significant differences were found in the greater easiness to catheterize LV (p less than 0.05) and LCA (p = 0.01) in group II and in better quality image for LCA in group II (p less than 0.05), although all patients in both groups had acceptable image quality. Pressure curves quality was better in group II (p less than 0.01); X-ray exposure time was longer in group I (p less than 0.001) and arterial compression time in group II (p less than 0.0001). Group I showed 3 and group II 10 mild hematomas (p less than 0.05). The procedure could be completed by the elected first artery and type of catheter in 95 patients in group I and in 96 in group II. Thus, the Judkins technique with 5 French catheters is as valid as with 8 French for assessing ischemic patients, reducing arterial morbidity, although mildly increasing technical difficulty and mildly decreasing quality image.