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Johnsrud DO, Port SC. In 2023 invasive coronary angiography is preferred to PET myocardial perfusion imaging for the initial work-up of a symptomatic patient with a high coronary artery calcium score. J Nucl Cardiol 2023; 30:2269-2272. [PMID: 37845556 DOI: 10.1007/s12350-023-03385-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 09/06/2023] [Indexed: 10/18/2023]
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Chiabrando JG, Vescovo GM, Lombardi M, Seropian IM, Del Buono MG, Vergallo R, Burzotta F, Escaned J, Berrocal DH. Iatrogenic coronary dissection: state of the art management. Panminerva Med 2023; 65:511-520. [PMID: 36321941 DOI: 10.23736/s0031-0808.22.04781-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
Iatrogenic coronary artery dissections (ICAD) are rare but potentially devastating complications during coronary angiography and percutaneous coronary interventions (PCI). Intima media complex separation may be produced either by the catheter tip or during PCI. Patient characteristics and procedure related risk factors are intimately linked to catheter induced ICAD over diagnostic angiography. Moreover, the increasing complexity of patients undergoing PCI, which frequently involves treatment of heavily calcified or occluded vessels, has increased the likelihood of dissections during PCI. A prompt recognition, along with a prompt management (either percutaneous, surgical or even careful watching), are key in preventing catastrophic consequences of ICAD, such as left ventricular dysfunction, cardiogenic shock, periprocedural myocardial infarction (MI) or cardiac death. This review aims to summarize the main updates concerning the pathophysiology, highlight key risk factors and suggest recommendations in management and treatment of ICAD.
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Affiliation(s)
- Juan G Chiabrando
- Department of Interventional Cardiology, Italian Hospital of Buenos Aires, Buenos Aires, Argentina -
| | | | - Marco Lombardi
- Department of Cardiovascular and Thoracic Sciences, Sacred Heart Catholic University, Rome, Italy
| | - Ignacio M Seropian
- Department of Interventional Cardiology, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Marco G Del Buono
- Department of Cardiovascular and Thoracic Sciences, Sacred Heart Catholic University, Rome, Italy
| | - Rocco Vergallo
- Department of Cardiovascular and Thoracic Sciences, Sacred Heart Catholic University, Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular and Thoracic Sciences, Sacred Heart Catholic University, Rome, Italy
| | - Javier Escaned
- Department of Cardiology, San Carlos Clinical Hospital, Complutense University of Madrid, Madrid, Spain
| | - Daniel H Berrocal
- Department of Interventional Cardiology, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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Philibert R, Dogan TK, Knight S, Ahmad F, Lau S, Miles G, Knowlton KU, Dogan MV. Validation of an Integrated Genetic-Epigenetic Test for the Assessment of Coronary Heart Disease. J Am Heart Assoc 2023; 12:e030934. [PMID: 37982274 PMCID: PMC10727271 DOI: 10.1161/jaha.123.030934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/16/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Coronary heart disease (CHD) is the leading cause of death in the world. Unfortunately, many of the key diagnostic tools for CHD are insensitive, invasive, and costly; require significant specialized infrastructure investments; and do not provide information to guide postdiagnosis therapy. In prior work using data from the Framingham Heart Study, we provided in silico evidence that integrated genetic-epigenetic tools may provide a new avenue for assessing CHD. METHODS AND RESULTS In this communication, we use an improved machine learning approach and data from 2 additional cohorts, totaling 449 cases and 2067 controls, to develop a better model for ascertaining symptomatic CHD. Using the DNA from the 2 new cohorts, we translate and validate the in silico findings into an artificial intelligence-guided, clinically implementable method that uses input from 6 methylation-sensitive digital polymerase chain reaction and 10 genotyping assays. Using this method, the overall average area under the curve, sensitivity, and specificity in the 3 test cohorts is 82%, 79%, and 76%, respectively. Analysis of targeted cytosine-phospho-guanine loci shows that they map to key risk pathways involved in atherosclerosis that suggest specific therapeutic approaches. CONCLUSIONS We conclude that this scalable integrated genetic-epigenetic approach is useful for the diagnosis of symptomatic CHD, performs favorably as compared with many existing methods, and may provide personalized insight to CHD therapy. Furthermore, given the dynamic nature of DNA methylation and the ease of methylation-sensitive digital polymerase chain reaction methodologies, these findings may pave a pathway for precision epigenetic approaches for monitoring CHD treatment response.
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Affiliation(s)
- Robert Philibert
- Cardio Diagnostics IncChicagoILUSA
- Department of PsychiatryUniversity of IowaIowa CityIAUSA
- Department of Biomedical EngineeringUniversity of IowaIowa CityIAUSA
| | | | - Stacey Knight
- Intermountain Heart Institute, Intermountain HealthcareSalt Lake CityUTUSA
- Department of Internal MedicineUniversity of UtahSalt Lake CityUTUSA
| | - Ferhaan Ahmad
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of IowaIowa CityIAUSA
| | - Stanley Lau
- Southern California Heart CentersSan GabrielCAUSA
| | - George Miles
- Department of Molecular and Human GeneticsBaylor College of MedicineHoustonTXUSA
| | - Kirk U. Knowlton
- Intermountain Heart Institute, Intermountain HealthcareSalt Lake CityUTUSA
| | - Meeshanthini V. Dogan
- Cardio Diagnostics IncChicagoILUSA
- Department of Biomedical EngineeringUniversity of IowaIowa CityIAUSA
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Paez Perez Y, Rimm S, Bove J, Hochman S, Liu T, Catapano A, Shroff N, Lim J, Rimm B. Does the Electrocardiogram Machine Interpretation Affect the Ability to Accurately Diagnose ST-Elevation Myocardial Infarction by Emergency Physicians? Crit Pathw Cardiol 2023; 22:8-12. [PMID: 36812338 DOI: 10.1097/hpc.0000000000000310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Abstract
INTRODUCTION An ST-elevation myocardial infarction (STEMI) can portend significant morbidity and mortality to the patient and therefore must be rapidly diagnosed by an emergency medicine (EM) physician. The primary aim of this study is to determine whether EM physicians are more or less likely to accurately diagnose STEMI on an electrocardiogram (ECG) if they are blinded to the ECG machine interpretation as opposed to if they are provided the ECG machine interpretation. METHODS We performed a retrospective chart review of adult patients over 18 years of age admitted to our large, urban tertiary care center with a diagnosis of STEMI from January 1, 2016, to December 31, 2017. From these patients' charts, we selected 31 ECGs to create a quiz that was presented twice to a group of emergency physicians. The first quiz contained the 31 ECGs without the computer interpretations revealed. The second quiz, presented to the same physicians 2 weeks later, contained the same set of ECGs with the computer interpretations revealed. Physicians were asked "Based on the ECG above, is there a blocked coronary artery present causing a STEMI?" RESULTS Twenty-five EM physicians completed two 31-question ECG quizzes for a total of 1550 ECG interpretations. On the first quiz with computer interpretations blinded, the overall sensitivity in identifying a "true STEMI" was 67.2% with an overall accuracy of 65.6%. On the second quiz in which the ECG machine interpretation was revealed, the overall sensitivity was 66.4% with an accuracy of 65.8 % in correctly identifying a STEMI. The differences in sensitivity and accuracy were not statistically significant. CONCLUSION This study demonstrated no significant difference in physicians blinded versus those unblinded to computer interpretations of possible STEMI.
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Affiliation(s)
| | - Sarah Rimm
- Emergency Department, MedStar Franklin Square Medical Center, Baltimore, MD
| | - Joseph Bove
- Emergency Department, St. Joseph's University Medical Center, Paterson, NJ
| | - Steven Hochman
- Emergency Department, St. Joseph's University Medical Center, Paterson, NJ
| | - Tianci Liu
- Emergency Department, Harbor-UCLA Medical Center, Torrance, CA
| | - Anthony Catapano
- Emergency Department, St. Joseph's University Medical Center, Paterson, NJ
| | - Ninad Shroff
- Emergency Department, St. Joseph's University Medical Center, Paterson, NJ
| | - Jessica Lim
- Emergency Department, AdventHealth Apopka, Apopka, FL
| | - Brian Rimm
- Organizational Assessment, Uniformed Services University of the Health Sciences, Bethesda, MD
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Derya Ister E, Altinbaş Y. The Effect of Acupressure on Anxiety and Pain Among Patients Undergoing Coronary Angiography: A Randomized Controlled Trial. Holist Nurs Pract 2022; 36:E57-E63. [PMID: 36255344 DOI: 10.1097/hnp.0000000000000553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this study was to evaluate the effect of acupressure on anxiety and pain of patients undergoing coronary angiography procedures. This study was conducted in a cardiology clinic of the training and research hospital in of a province of southeast Turkey. A randomized control group design was used. Eighty patients who were undergoing coronary angiography were randomly enrolled in intervention and control groups. The intervention protocol included 11 minutes of acupressure that applied to Hegu, Shenmen, and Yintang acupoints. No intervention was applied to the control group. Spielberger's state-trait anxiety inventory and the visual analog scale were used as data-collecting tools. Data were analyzed using t test in independent groups and χ2 test. The mean score of state anxiety of the intervention group was 41.50 ± 3.88, and was statistically significantly lower than the score of the control group after acupressure (P = .000). VASP2 and VASP3 pain intensity of the intervention group was statistically significantly lower than that of the control group after the coronary angiography procedure (P = .000). Acupressure is an effective technique for reducing the pain severity and anxiety among patients undergoing coronary angiography.
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Affiliation(s)
- Emine Derya Ister
- Department of Nursing, Faculty of Health Science, Kahramanmaraş Sütçü İmam University, Kahramanmaraş, Turkey (Dr Ister); and Department of Nursing, Faculty of Health Sciences, Adıyaman University, Adıyaman, Turkey (Dr Altinbaş)
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Gopesh T, Wen JH, Santiago-Dieppa D, Yan B, Scott Pannell J, Khalessi A, Norbash A, Friend J. Soft robotic steerable microcatheter for the endovascular treatment of cerebral disorders. Sci Robot 2021; 6:6/57/eabf0601. [PMID: 34408094 PMCID: PMC9809155 DOI: 10.1126/scirobotics.abf0601] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 07/26/2021] [Indexed: 01/05/2023]
Abstract
Catheters used for endovascular navigation in interventional procedures lack dexterity at the distal tip. Neurointerventionists, in particular, encounter challenges in up to 25% of aneurysm cases largely due to the inability to steer and navigate the tip of the microcatheters through tortuous vasculature to access aneurysms. We overcome this problem with submillimeter diameter, hydraulically actuated hyperelastic polymer devices at the distal tip of microcatheters to enable active steerability. Controlled by hand, the devices offer complete 3D orientation of the tip. Using saline as a working fluid, we demonstrate guidewire-free navigation, access, and coil deployment in vivo, offering safety, ease of use, and design flexibility absent in other approaches to endovascular intervention. We demonstrate the ability of our device to navigate through vessels and to deliver embolization coils to the cerebral vessels in a live porcine model. This indicates the potential for microhydraulic soft robotics to solve difficult access and treatment problems in endovascular intervention.
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Affiliation(s)
- Tilvawala Gopesh
- Department of Mechanical and Aerospace Engineering, University of California San Diego, USA
| | - Jessica H. Wen
- Department of Mechanical and Aerospace Engineering, University of California San Diego, USA
| | | | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - J. Scott Pannell
- Department of Neurosurgery, University of California San Diego, USA
| | | | | | - James Friend
- Department of Mechanical and Aerospace Engineering, University of California San Diego, USA,Department of Surgery, University of California San Diego, USA,To whom correspondence should be addressed; , Medically Advanced Devices Laboratory, 9500 Gilman Drive, La Jolla, CA 92093, USA
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Tokumasu Y, Obata JE, Oka S, Hoshina K, Watanabe K, Nakamura J, Abe M, Watanabe A. Healing of iatrogenic double-barrel left main coronary artery dissection extending to the left anterior descending artery. J Cardiol Cases 2021; 24:64-67. [PMID: 34354780 DOI: 10.1016/j.jccase.2021.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 12/13/2020] [Accepted: 12/28/2020] [Indexed: 10/22/2022] Open
Abstract
Iatrogenic left main coronary artery (LMCA) dissection is a complication inadvertently caused by the interventional cardiologist and can have significant consequences. A 38-year-old man presented to hospital with non-ST-elevation myocardial infarction. Coronary angiography (CAG) revealed an obstructed proximal left circumflex artery (LCx) that was successfully treated with revascularization using a drug-eluting stent (DES). However, CAG after recanalization of the LCx demonstrated a spiral dissection of the left coronary artery from the mid-LMCA to the left anterior descending (LAD) artery and LCx. The dissection was classified as National Heart, Lung and Blood Institute type D in LAD and type F in LCx. Immediate exclusion stenting of the dissection flap by another DES and thrombolysis in myocardial infarction 3 flow were achieved in the LAD and LCx. The patient achieved hemodynamic stability with improvement in symptoms, despite residual dissection in the LAD. We, therefore, preferred careful observation over revascularization. The false lumen remained visible with a double-barrel appearance in the LAD on 6-month follow-up CAG, which disappeared at the 2-year follow-up. We report a rare case of a large double-barrel dissection that spontaneously occluded over time without any aggressive interventions. <Learning objective: Iatrogenic left main coronary artery (LMCA) dissection is a rare but potentially life-threatening complication, with the associated risk of serious outcomes. Immediately after suffering a LMCA dissection, treatment strategies (conservative therapy, percutaneous coronary intervention, or coronary bypass grafting etc.) should be determined according to patient's symptoms and hemodynamic status. However, treatment strategies for chronic LMCA dissection are uncertain. Our case indicates that conservative therapy appears to be a potential option for the treatment of chronic asymptomatic and hemodynamically stable LMCA dissection.>.
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Affiliation(s)
- Yoshinori Tokumasu
- Department of Cardiology Internal Medicine, Fujieda Municipal General Hospital, Fujieda City, Shizuoka, Japan
| | - Jyun-Ei Obata
- Department of Internal Medicine II, University of Yamanashi, Faculty of Medicine, Chuo, Yamanashi, Japan
| | - Satoshi Oka
- Department of Cardiology Internal Medicine, Fujieda Municipal General Hospital, Fujieda City, Shizuoka, Japan
| | - Katsuomi Hoshina
- Department of Cardiology Internal Medicine, Fujieda Municipal General Hospital, Fujieda City, Shizuoka, Japan
| | - Kazunori Watanabe
- Department of Cardiology Internal Medicine, Fujieda Municipal General Hospital, Fujieda City, Shizuoka, Japan
| | - Jun Nakamura
- Department of Cardiology Internal Medicine, Fujieda Municipal General Hospital, Fujieda City, Shizuoka, Japan
| | - Makoto Abe
- Department of Cardiology Internal Medicine, Fujieda Municipal General Hospital, Fujieda City, Shizuoka, Japan
| | - Akinori Watanabe
- Department of Cardiology Internal Medicine, Fujieda Municipal General Hospital, Fujieda City, Shizuoka, Japan
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Abstract
OBJECTIVE. At its advent, CT was too slow to image the heart. Temporal resolution improved with electron beam CT (EBCT); subsequently, the heart could be imaged, eventually leading to the discovery of prognostic information obtained from the coronary calcium score. In the early 2000s, EBCT was replaced by MDCT. In this review, we discuss the rise and fall of EBCT and explore its legacy in cardiac imaging. CONCLUSION. Although MDCT rendered EBCT obsolete, EBCT leaves a legacy in cardiac imaging regarding both diagnosis and prognosis. The creators of MDCT emulated the strengths of EBCT and learned from its weaknesses. Moreover, EBCT showed that imaging surrogates can predict outcomes, and the origins of substrate-guided treatment can be traced to EBCT.
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Hansmann G, Rich S, Maron BA. Cardiac catheterization in pulmonary hypertension: doing it right, with a catheter on the left. Cardiovasc Diagn Ther 2020; 10:1718-1724. [PMID: 33224785 DOI: 10.21037/cdt-20-483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Georg Hansmann
- Department of Paediatric Cardiology and Critical Care, Hannover Medical School, Hannover, Germany
| | - Stuart Rich
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Bradley A Maron
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Department of Cardiology, Boston VA Healthcare System, Boston, MA, USA
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Cost-Effectiveness Analysis of Stress Cardiovascular Magnetic Resonance Imaging for Stable Chest Pain Syndromes. JACC Cardiovasc Imaging 2020; 13:1505-1517. [DOI: 10.1016/j.jcmg.2020.02.029] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 02/19/2020] [Accepted: 02/25/2020] [Indexed: 01/04/2023]
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Zuo H, Zhang Y, Ma F, Li R, Wang Y, Li C, Wang H, Wang DW. Myocardial Deformation Pattern Differs between Ischemic and Non-ischemic Dilated Cardiomyopathy: The Diagnostic Value of Longitudinal Strains. ULTRASOUND IN MEDICINE & BIOLOGY 2020; 46:233-243. [PMID: 31718811 DOI: 10.1016/j.ultrasmedbio.2019.10.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 10/06/2019] [Accepted: 10/09/2019] [Indexed: 06/10/2023]
Abstract
Both ischemic cardiomyopathy (ICM) and non-ischemic cardiomyopathy (NICM) are characterized by left ventricular (LV) dysfunction and dilation. Differentiation between ICM and NICM using non-invasive image modalities is a clinical challenge. This study compared the myocardial deformation patterns of ICM and NICM using 2-D speckle tracking echocardiography (2-D STE) and sought to find parameters valuable in the diagnosis and management of dilated cardiomyopathy. The study population comprised 84 consecutive patients with LV end-diastolic dimension >55 mm and ejection fraction (EF) <45 %. Of these patients, 41 were diagnosed with ICM and 43 with NICM by coronary angiography. 2-D STE was performed in all patients. The LV dimension did not differ between ICM and NICM. Compared with patients with ICM, patients with NICM had lower EF (29.0% vs. 33.0%, p = 0.024), lower global longitudinal strain (-5.4 ± 2.6% vs. -7.0 ± 2.5%, p = 0.006) and lower global radial strain (7.5 ± 4.5% vs. 10.7 ± 4.7%, p = 0.019). In contrast, global longitudinal strains did not differ significantly. However, NICM patients had higher apical and lower basal longitudinal strains compared with those with ICM. The ratio of basal to sum of mid- and apical longitudinal strains could predict NICM with a sensitivity of 63.4% and specificity of 88.4% by receiver operating characteristic curve analysis (cutoff value: 0.47, area under the curve: 0.792). Moreover, the concomitant presence of non-significant coronary artery stenosis (>50% and <70%) had no significant influence on global longitudinal strain in NICM. In conclusion, LV dilation and systolic dysfunction, relative apical sparing and a basal worsening pattern of LV longitudinal strain by 2-D STE were observed in patients with NICM but not ICM. The ratio of basal to sum of mid- and apical longitudinal strains could help differentiate NICM from ICM.
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Affiliation(s)
- Houjuan Zuo
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Zhang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fei Ma
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Li
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chenze Li
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Dao Wen Wang
- Division of Cardiology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Ali A, Sakes A, Arkenbout EA, Henselmans P, van Starkenburg R, Szili-Torok T, Breedveld P. Catheter steering in interventional cardiology: Mechanical analysis and novel solution. Proc Inst Mech Eng H 2019; 233:1207-1218. [PMID: 31580205 PMCID: PMC6859597 DOI: 10.1177/0954411919877709] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 08/13/2019] [Indexed: 11/27/2022]
Abstract
In recent years, steerable catheters have been developed to combat the effects of the dynamic cardiac environment. Mechanically actuated steerable catheters appear the most in the clinical setting; however, they are bound to a number of mechanical limitations. The aim of this research is to gain insight in these limitations and use this information to develop a new prototype of a catheter with increased steerability. The main limitations in mechanically steerable catheters are identified and analysed, after which requirements and solutions are defined to design a multi-steerable catheter. Finally, a prototype is built and a proof-of-concept test is carried out to analyse the steering functions. The mechanical analysis results in the identification of five limitations: (1) low torsion, (2) shaft shortening, (3) high unpredictable friction, (4) coupled tip-shaft movements, and (5) complex cardiac environment. Solutions are found to each of the limitations and result in the design of a novel multi-steerable catheter with four degrees of freedom. A prototype is developed which allows the dual-segmented tip to be steered over multiple planes and in multiple directions, allowing a range of complex motions including S-shaped curves and circular movements. A detailed analysis of limitations underlying mechanically steerable catheters has led to a new design for a multi-steerable catheter for complex cardiac interventions. The four integrated degrees of freedom provide a high variability of tip directions, and repetition of the bending angle is relatively simple and reliable. The ability to steer inside the heart with a variety of complex shaped curves may potentially change conventional approaches in interventional cardiology towards more patient-specific and lower complexity procedures. Future directions are headed towards further design optimizations and the experimental validation of the prototype.
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Affiliation(s)
- Awaz Ali
- BioMechanical Engineering, Delft University of Technology (TU Delft), Delft, The Netherlands
| | - Aimee Sakes
- BioMechanical Engineering, Delft University of Technology (TU Delft), Delft, The Netherlands
| | - Ewout A Arkenbout
- BioMechanical Engineering, Delft University of Technology (TU Delft), Delft, The Netherlands
| | - Paul Henselmans
- BioMechanical Engineering, Delft University of Technology (TU Delft), Delft, The Netherlands
| | | | - Tamas Szili-Torok
- Electrophysiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Paul Breedveld
- BioMechanical Engineering, Delft University of Technology (TU Delft), Delft, The Netherlands
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Ifedili I, Bob-Manuel T, Kadire SR, Heard B, John LA, Zambetti B, Heckle MR, Thomas F, Haji S, Khouzam RN, Reed GL, Ibebuogu UN. Cocaine Positivity in ST-Elevation Myocardial Infarction: A True or False Association. Perm J 2019; 23:18-048. [PMID: 30939276 DOI: 10.7812/tpp/18-048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Every year, more than 500,000 US Emergency Department visits are associated with cocaine use. People who use cocaine tend to have a lower incidence of true ST-elevation myocardial infarction (STEMI). OBJECTIVE To identify the factors associated with true STEMI in patients with cocaine-positive (CPos) findings. METHODS We retrospectively analyzed 1144 consecutive patients with STEMI between 2008 and 2013. True STEMI was defined as having a culprit lesion on coronary angiogram. Multivariate and univariate analyses were used to identify risk factors and create a predictive model. RESULTS A total of 64 patients with suspected STEMI were CPos (mean age 53.1 ± 11.2 years; male = 80%). True STEMI was diagnosed in 34 patients. Patients with CPos true STEMI were more likely to be uninsured than those with false STEMI (61.8% vs 34.5%, p = 0.03) and have higher peak troponin levels (21.1 ng/mL vs 2.12 ng/mL, p = < 0.01) with no difference in mean age between the 2 groups (p = 0.24). In multivariate analyses, independent predictors of true STEMI in patients with CPos findings included age older than 65 years (odds ratio [OR] = 19.3, 95% confidence iterval [CI] = 1.2-318.3), lack of health insurance (OR = 4.9, 95% CI = 1.2-19.6), and troponin level higher than 0.05 (OR = 24.0, 95% CI = 2.6-216.8) (all p < 0.05). A multivariate risk score created with a C-statistic of 82% (95% CI = 71-93) significantly improved the identification of patients with true STEMI. CONCLUSION Among those with suspected STEMI, patients with CPos findings had a higher incidence of false STEMI. Older age, lack of health insurance, and troponin levels outside of defined limits were associated with true STEMI in this group.
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Affiliation(s)
- Ikechukwu Ifedili
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | | | - Siri R Kadire
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Britteny Heard
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Leah A John
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Benjamin Zambetti
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Mark R Heckle
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Fridtjof Thomas
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Showkat Haji
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Rami N Khouzam
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Guy L Reed
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
| | - Uzoma N Ibebuogu
- University of Tennessee Health Science Center College of Medicine, Memphis, TN
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14
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Performance of Coronary Risk Scores Among Patients With Chest Pain in the Emergency Department. J Am Coll Cardiol 2019; 71:606-616. [PMID: 29420956 DOI: 10.1016/j.jacc.2017.11.064] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/30/2017] [Accepted: 11/27/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Both the modified History, Electrocardiogram, Age, Risk factors and Troponin (HEART) score and the Emergency Department Assessment of Chest pain Score (EDACS) can identify patients with possible acute coronary syndrome (ACS) at low risk (<1%) for major adverse cardiac events (MACE). OBJECTIVES The authors sought to assess the comparative accuracy of the EDACS (original and simplified) and modified HEART risk scores when using cardiac troponin I (cTnI) cutoffs below the 99th percentile, and obtain precise MACE risk estimates. METHODS The authors conducted a retrospective study of adult emergency department (ED) patients evaluated for possible ACS in an integrated health care system between 2013 and 2015. Negative predictive values for MACE (composite of myocardial infarction, cardiogenic shock, cardiac arrest, and all-cause mortality) were determined at 60 days. Reclassification analyses were used to assess the comparative accuracy of risk scores and lower cTnI cutoffs. RESULTS A total of 118,822 patients with possible ACS were included. The 3 risk scores' accuracies were optimized using the lower limit of cTnI quantitation (<0.02 ng/ml) to define low risk for 60-day MACE, with reclassification yields ranging between 3.4% and 3.9%, while maintaining similar negative predictive values (range 99.49% to 99.55%; p = 0.27). The original EDACS identified the largest proportion of patients as low risk (60.6%; p < 0.0001). CONCLUSIONS Among ED patients with possible ACS, the modified HEART score, original EDACS, and simplified EDACS all predicted a low risk of 60-day MACE with improved accuracy using a cTnI cutoff below the 99th percentile. The original EDACS identified the most low-risk patients, and thus may be the preferred risk score.
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Claretti M, Lopez BS, Boz E, Martelli F, Pradelli D, Bussadori CM. Complications during catheter-mediated patent ductus arteriosus closure and pulmonary balloon valvuloplasty. J Small Anim Pract 2019; 60:607-615. [PMID: 31280488 DOI: 10.1111/jsap.13046] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 04/29/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To evaluate and illustrate complications of cardiac catheterisation and the associated risk factors of the most common cardiac intervention procedures. MATERIALS AND METHODS Retrospective study of clinical records of client-owned dogs presented to a cardiology referral centre between January 2006 and December 2017. RESULTS Five hundred and twenty-four dogs were included, 62 of which had complications. Complications were divided into technical complications and those due to unexpected additional anatomical abnormalities. Seven procedures (1.33%) were interrupted; five dogs (0.95%) subsequently underwent surgery, and four dogs died during the interventional procedure, indicating a mortality rate of 0.76% CLINICAL SIGNIFICANCE: There is a low risk of complications following closure of patent ductus arteriosus or pulmonary balloon valvuloplasty when carried out by a trained team using standardised procedures in a referral centre.
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Affiliation(s)
- M Claretti
- Department of Cardiology, Clinica Veterinaria Gran Sasso, 20131, Milan, Italy
| | - B S Lopez
- Department of Cardiology, Clinica Veterinaria Gran Sasso, 20131, Milan, Italy
| | - E Boz
- Department of Cardiology, Clinica Veterinaria Gran Sasso, 20131, Milan, Italy
| | - F Martelli
- Department of Cardiology, Clinica Veterinaria Gran Sasso, 20131, Milan, Italy
| | - D Pradelli
- Department of Cardiology, Clinica Veterinaria Gran Sasso, 20131, Milan, Italy
| | - C M Bussadori
- Department of Cardiology, Clinica Veterinaria Gran Sasso, 20131, Milan, Italy
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Effect of Tube Voltage on Diagnostic Performance of Fractional Flow Reserve Derived From Coronary CT Angiography With Machine Learning: Results From the MACHINE Registry. AJR Am J Roentgenol 2019; 213:325-331. [PMID: 31039021 DOI: 10.2214/ajr.18.20774] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE. Coronary CT angiography (CCTA)-based methods allow noninvasive estimation of fractional flow reserve (cFFR), recently through use of a machine learning (ML) algorithm (cFFRML). However, attenuation values vary according to the tube voltage used, and it has not been shown whether this significantly affects the diagnostic performance of cFFR and cFFRML. Therefore, the purpose of this study is to retrospectively evaluate the effect of tube voltage on the diagnostic performance of cFFRML. MATERIALS AND METHODS. A total of 525 coronary vessels in 351 patients identified in the MACHINE consortium registry were evaluated in terms of invasively measured FFR and cFFRML. CCTA examinations were performed with a tube voltage of 80, 100, or 120 kVp. For each tube voltage value, correlation (assessed by Spearman rank correlation coefficient), agreement (evaluated by intraclass correlation coefficient and Bland-Altman plot analysis), and diagnostic performance (based on ROC AUC value, sensitivity, specificity, positive predictive value, negative predictive value, and accuracy) of the cFFRML in terms of detection of significant stenosis were calculated. RESULTS. For tube voltages of 80, 100, and 120 kVp, the Spearman correlation coefficient for cFFRML in relation to the invasively measured FFR value was ρ = 0.684, ρ = 0.622, and ρ = 0.669, respectively (p < 0.001 for all). The corresponding intraclass correlation coefficient was 0.78, 0.76, and 0.77, respectively (p < 0.001 for all). Sensitivity was 100.0%, 73.5%, and 85.0%, and specificity was 76.2%, 79.0%, and 72.8% for tube voltages of 80, 100, and 120 kVp, respectively. The ROC AUC value was 0.90, 0.82, and 0.80 for 80, 100, and 120 kVp, respectively (p < 0.001 for all). CONCLUSION. CCTA-derived cFFRML is a robust method, and its performance does not vary significantly between examinations performed using tube voltages of 100 kVp and 120 kVp. However, because of rapid advancements in CT and postprocessing technology, further research is needed.
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Mulukutla SR, Babb JD, Baran DA, Boudoulas KD, Feldman DN, Hall SA, Jennings HS, Kapur NK, Rao SV, Reginelli J, Schussler JM, Yang EH, Cigarroa JE. A quality framework for the role of invasive, non‐interventional cardiologists in the present‐day cardiac catheterization laboratory: A multidisciplinary SCAI/HFSA expert consensus statement. Catheter Cardiovasc Interv 2018; 92:1356-1364. [DOI: 10.1002/ccd.27841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Accepted: 07/29/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Suresh R. Mulukutla
- Department of Medicine, UPMC Heart and Vascular InstituteUniversity of Pittsburgh Pittsburgh Pennsylvania
| | - Joseph D. Babb
- East Carolina Heart InstituteEast Carolina University, Brody School of Medicine Greenville North Carolina
| | - David A. Baran
- Advanced Heart Failure and TransplantSentara Heart Hospital Norfolk Virginia
| | | | - Dmitriy N. Feldman
- Division of Cardiology, Department of MedicineWeill Cornell Medical College New York
| | - Shelley A. Hall
- Baylor Scott & White Heart and Vascular HospitalBaylor University Medical Center Dallas Texas
| | - Henry S. Jennings
- Division of Cardiovascular MedicineVanderbilt University Heart and Vascular Institute Nashville Tennessee
| | - Navin K. Kapur
- Division of Cardiology, Department of MedicineTufts Medical Center Boston Massachusetts
| | - Sunil V. Rao
- The Duke Clinical Research InstituteDuke University Health System Durham North Carolina
| | | | - Jeffrey M. Schussler
- Baylor Scott & White Heart and Vascular HospitalBaylor University Medical Center Dallas Texas
- Division of CardiologyTexas A&M College of Medicine Dallas Texas
| | - Eric H. Yang
- Division of Cardiology, Department of MedicineUniversity of California Los Angeles Los Angeles California
| | - Joaquin E. Cigarroa
- Knight Cardiovascular InstituteOregon Health and Science University Portland Oregon
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Fanari Z, Mohammed AA, Bathina JD, Hodges DT, Doorey K, Gagliano N, Garratt KN, Weintraub WS, Doorey AJ. Inadequacy of Pulse Oximetry in the Catheterization Laboratory. An Exploratory Study Monitoring Respiratory Status Using Arterial Blood Gases during Cardiac Catheterization with Conscious Sedation. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:461-467. [PMID: 30100406 DOI: 10.1016/j.carrev.2018.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 07/08/2018] [Accepted: 07/23/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Benzodiazepines and opioids are commonly used for conscious sedation (CS) in cardiac catheterization laboratory (CCL) patients. Both drugs are known to predispose to hypoxemia, apnea and decreased responsiveness to PCO2, resulting in decreased arterial pH and PO2, as well as increased PCO2. We want to determine the effects of CS on arterial blood gas (ABG) in CCL patient, and identify if pulse oximetry monitoring is adequate. METHODS We enrolled 18 subjects undergoing elective catheterization. Measurement of ABGs at one-minute intervals was done from the moment of arterial access until case end. The results of ABGs were not available to the clinician who administered sedation. Relationships of pH, PCO2, PaO2 and SaO2 were studied by plotting time series graphs. Significant changes were defined as pH <7.30, SaO2 < 90, and PCO2 > 50 mmHg. RESULTS No significant change in pH, PCO2, PaO2 and SaO2 was noted in 4/18 (22%) subjects. A significant drop in SaO2 was noted in 4/18 (22%). A significant change in PCO2 and/or pH was noted in 10/18 (55%) cases. Among the 16 (16/18) subjects receiving supplemental oxygen, 7 (7/18, 39%) had no drop in SaO2, but developed respiratory acidosis. At the end of the case, 5/18 (28%) subjects had respiratory acidosis with normal PaO2. CONCLUSION Significant hypercarbia and acidosis occurred frequently in this small study during CS in patients undergoing cardiac catheterization. Relying on pulse oximetry alone especially with patients on supplemental oxygen may lead to failure in detecting respiratory acidosis in a significant number of patients.
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Affiliation(s)
- Zaher Fanari
- Division of Cardiology, Christiana Care Health System, Newark, DE, United States of America; Heartland Cardiology/Wesley Medical Center, University of Kansas School of Medicine, Wichita, KS, United States.
| | - Asim A Mohammed
- Division of Cardiology, Christiana Care Health System, Newark, DE, United States of America; Division of Cardiology, Medical College of Wisconsin, Milwaukee, WI, United States of America
| | - Jaya D Bathina
- Division of Cardiology, Christiana Care Health System, Newark, DE, United States of America
| | - Desiree T Hodges
- Division of Cardiology, Christiana Care Health System, Newark, DE, United States of America
| | - Kelsey Doorey
- Division of Cardiology, Christiana Care Health System, Newark, DE, United States of America
| | - Nicholas Gagliano
- Division of Cardiology, Christiana Care Health System, Newark, DE, United States of America
| | - Kirk N Garratt
- Division of Cardiology, Christiana Care Health System, Newark, DE, United States of America
| | - William S Weintraub
- Division of Cardiology, MedStar Washington Hospital Center, Washington, DC, United States of America
| | - Andrew J Doorey
- Division of Cardiology, Christiana Care Health System, Newark, DE, United States of America
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Manchuelle A, Pontana F, De Groote P, Lebert P, Fertin M, Baijot M, Hurt C, Lamblin N, Debry N, Schurtz G, Pentiah AD, Sudre A, Remy-Jardin M, Lancellotti P, Van Belle E, Bauters C, Lemesle G, Delhaye C. Accuracy of cardiac magnetic resonance imaging to rule out significant coronary artery disease in patients with systolic heart failure of unknown aetiology: Single-centre experience and comprehensive meta-analysis. Arch Cardiovasc Dis 2018; 111:686-701. [PMID: 29861294 DOI: 10.1016/j.acvd.2018.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 04/06/2018] [Accepted: 04/09/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND Coronary artery disease (CAD) is the leading cause of systolic heart failure (HF). Cardiac magnetic resonance imaging (CMR) is a non-invasive technique that detects a myocardial infarction scar as subendocardial or transmural late gadolinium enhancement (st-LGE). AIM We sought to evaluate whether a lack of st-LGE could rule out CAD in new-onset systolic HF of unknown aetiology. METHODS We included 232 consecutive patients with new-onset HF and left ventricular ejection fraction ≤35% who underwent both coronary angiography and CMR to assess HF aetiology. CAD was defined as the presence of coronary artery stenosis≥50% on a coronary angiogram. We assessed sensitivity, specificity, and positive and negative likelihood ratios (PLR and NLR) of the presence of st-LGE to detect underlying CAD. A complementary meta-analysis of 11 studies (including ours) was also performed. RESULTS In our study, 49 (21.1%) patients had CAD. The sensitivity and specificity of the presence of st-LGE to detect CAD were 69 and 92%, respectively. PLR and NLR were 8.47 and 0.33, respectively. In the meta-analysis, 1227 patients were included, and the prevalence of CAD ranged from 19.2 to 68.3%. Sensitivity, specificity, PLR and NLR were 87% (95% confidence interval [CI] 0.80-0.92), 93% (95% CI 0.89-0.96), 12.91 (95% CI 7.70-21.64) and 0.14 (95% CI 0.09-0.22), respectively. Altogether, 55 patients presented CAD with no st-LGE; inversely, 75 patients presented st-LGE with no CAD. CONCLUSION With a CMR specificity of 93%, the absence of st-LGE rules out significant underlying CAD in patients with systolic HF of unknown aetiology in most cases.
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Affiliation(s)
- Aurélie Manchuelle
- Service de cardiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France
| | - François Pontana
- Service de radiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France; Faculté de médecine de Lille, université de Lille, 59000 Lille, France; Institut Pasteur de Lille, 59000 Lille, France; Inserm U1011, 59000 Lille, France
| | - Pascal De Groote
- Service de cardiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France; Institut Pasteur de Lille, 59000 Lille, France; Inserm U1167, 59000 Lille, France
| | - Paul Lebert
- Service de radiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France
| | - Marie Fertin
- Service de cardiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France
| | - Marine Baijot
- Service de cardiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France
| | - Christopher Hurt
- Service de cardiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France
| | - Nicolas Lamblin
- Service de cardiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France; Faculté de médecine de Lille, université de Lille, 59000 Lille, France; Institut Pasteur de Lille, 59000 Lille, France; Inserm U1167, 59000 Lille, France
| | - Nicolas Debry
- Service de cardiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France
| | - Guillaume Schurtz
- Service de cardiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France
| | - Anju Duva Pentiah
- Service de cardiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France
| | - Arnaud Sudre
- Service de cardiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France
| | - Martine Remy-Jardin
- Service de radiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France; Faculté de médecine de Lille, université de Lille, 59000 Lille, France
| | - Patrizio Lancellotti
- Department of Cardiology, Heart Valve Clinic, University of Liège Hospital, GIGA Cardiovascular Sciences, CHU Sart Tilman, 4000 Liège, Belgium; Gruppo Villa Maria Care and Research, Anthea Hospital, 70124 Bari, Italy
| | - Eric Van Belle
- Service de cardiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France; Faculté de médecine de Lille, université de Lille, 59000 Lille, France; Institut Pasteur de Lille, 59000 Lille, France; Inserm U1011, 59000 Lille, France
| | - Christophe Bauters
- Service de cardiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France; Faculté de médecine de Lille, université de Lille, 59000 Lille, France; Institut Pasteur de Lille, 59000 Lille, France; Inserm U1167, 59000 Lille, France
| | - Gilles Lemesle
- Service de cardiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France; Faculté de médecine de Lille, université de Lille, 59000 Lille, France; Institut Pasteur de Lille, 59000 Lille, France; Inserm U1011, 59000 Lille, France
| | - Cédric Delhaye
- Service de cardiologie, institut cœur poumon, centre hospitalier régional et universitaire de Lille, 59000 Lille, France.
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Powell AC, Price SE, Nguyen K, Smith GL, Long JW, Deshmukh UU. Prior Authorization for Elective Diagnostic Catheterization: The Value of Reviewers in Cases with Clinical Ambiguity. AMERICAN HEALTH & DRUG BENEFITS 2018; 11:168-176. [PMID: 30464785 PMCID: PMC6207309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 02/05/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND In many situations, evidence-based guidelines cannot provide definitive guidance on the appropriateness of diagnostic catheterization. One specialty benefit management company has taken a 2-step approach to address this ambiguity by evaluating the appropriateness of diagnostic catheterization orders using a rule-based decision support system, and then having reviewers provide input through the consult system of a nondenial prior authorization program that involves peer discussion. OBJECTIVE To describe the outcomes of a 2-step approach to evaluating the appropriateness of elective diagnostic catheterization orders. METHOD This program evaluation used data from elective diagnostic catheterization orders from 2015 that pertained to 1 health insurer's Medicare Advantage plans. The classifications of orders by the rule-based system and the approval rates after review by the consult system are presented for these plans. Chi-square tests were conducted to examine whether classifications of the orders by the rule-based and consult systems were independent of plan type, specialty of the ordering physician, or state of residence of the patient. RESULTS A total of 3808 orders for elective diagnostic catheterization in 2015 met the inclusion criteria. Inadequate initial justification was provided for 699 (18.4%) of the orders; after inquiry through the consult system, 509 (72.8%) of the remaining orders were approved. Among the 344 (9%) orders that were deemed potentially nonindicated according to the rule-based system, the consult system approved 298 (86.6%). Of the 2765 (72.6%) orders that were deemed potentially appropriate by the rule-based system, the consult system approved 2740 (99.1%). Chi-square tests did not show a significant association between plan type or physician specialty and the classification produced by the rule-based system or the consult system. The patients' state of residence was significantly associated with the classification of orders for the rule-based system (P <.001), but not for the consult system. CONCLUSION Rule-based decision support can be combined with consult-based peer discussion to determine whether care is appropriate when guidelines are ambiguous. Poorly justified orders are often supportable after gathering information on the patient's presentation.
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Affiliation(s)
- Adam C Powell
- Director, Outcomes Research, HealthHelp, Houston, TX
| | - Stephen E Price
- Consultant, Clinical Vendor Oversight and Trend Management, Humana, Louisville, KY
| | - Khoa Nguyen
- Analyst, Medical Economics & Informatics, HealthHelp
| | - Gary L Smith
- Vice President, Medical Economics & Informatics, HealthHelp
| | - James W Long
- Director, Clinical Vendor Oversight and Trend Management, Humana
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Tanaka A, Node K. Prediction of Stroke After Cardiac Catheterization: No Reason, No Stroke. J Atheroscler Thromb 2018; 25:221-223. [PMID: 28931783 PMCID: PMC5868507 DOI: 10.5551/jat.ed086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University
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22
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Cazelli JG, Camargo GC, Kruczan DD, Weksler C, Felipe AR, Gottlieb I. Prevalence and Prediction of Obstructive Coronary Artery Disease in Patients Undergoing Primary Heart Valve Surgery. Arq Bras Cardiol 2017; 109:348-356. [PMID: 28977048 PMCID: PMC5644215 DOI: 10.5935/abc.20170135] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 06/13/2017] [Indexed: 11/20/2022] Open
Abstract
Background The prevalence of coronary artery disease (CAD) in valvular patients is
similar to that of the general population, with the usual association with
traditional risk factors. Nevertheless, the search for obstructive CAD is
more aggressive in the preoperative period of patients with valvular heart
disease, resulting in the indication of invasive coronary angiography (ICA)
to almost all adult patients, because it is believed that coronary artery
bypass surgery should be associated with valve replacement. Objectives To evaluate the prevalence of obstructive CAD and factors associated with it
in adult candidates for primary heart valve surgery between 2001 and 2014 at
the National Institute of Cardiology (INC) and, thus, derive and validate a
predictive obstructive CAD score. Methods Cross-sectional study evaluating 2898 patients with indication for heart
surgery of any etiology. Of those, 712 patients, who had valvular heart
disease and underwent ICA in the 12 months prior to surgery, were included.
The P value < 0.05 was adopted as statistical significance. Results The prevalence of obstructive CAD was 20%. A predictive model of obstructive
CAD was created from multivariate logistic regression, using the variables
age, chest pain, family history of CAD, systemic arterial hypertension,
diabetes mellitus, dyslipidemia, smoking, and male gender. The model showed
excellent correlation and calibration (R² = 0.98), as well as excellent
accuracy (ROC of 0.848; 95%CI: 0.817-0.879) and validation (ROC of 0.877;
95%CI: 0.830 - 0.923) in different valve populations. Conclusions Obstructive CAD can be estimated from clinical data of adult candidates for
valve repair surgery, using a simple, accurate and validated score, easy to
apply in clinical practice, which may contribute to changes in the
preoperative strategy of acquired heart valve surgery in patients with a
lower probability of obstructive disease.
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Affiliation(s)
| | | | - Dany David Kruczan
- Instituto Estadual de Cardiologia Aloysio de Castro, Rio de Janeiro, RJ, Brazil
| | - Clara Weksler
- Instituto Nacional de Cardiologia, Rio de Janeiro, RJ, Brazil
| | | | - Ilan Gottlieb
- Instituto Nacional de Cardiologia, Rio de Janeiro, RJ, Brazil
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Burgers LT, Redekop WK, Al MJ, Lhachimi SK, Armstrong N, Walker S, Rothery C, Westwood M, Severens JL. Cost-effectiveness analysis of new generation coronary CT scanners for difficult-to-image patients. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2017; 18:731-742. [PMID: 27650359 DOI: 10.1007/s10198-016-0824-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 08/04/2016] [Indexed: 06/06/2023]
Abstract
AIMS New generation dual-source coronary CT (NGCCT) scanners with more than 64 slices were evaluated for patients with (known) or suspected of coronary artery disease (CAD) who are difficult to image: obese, coronary calcium score > 400, arrhythmias, previous revascularization, heart rate > 65 beats per minute, and intolerance of betablocker. A cost-effectiveness analysis of NGCCT compared with invasive coronary angiography (ICA) was performed for these difficult-to-image patients for England and Wales. METHODS AND RESULTS Five models (diagnostic decision model, four Markov models for CAD progression, stroke, radiation and general population) were integrated to estimate the cost-effectiveness of NGCCT for both suspected and known CAD populations. The lifetime costs and effects from the National Health Service perspective were estimated for three strategies: (1) patients diagnosed using ICA, (2) using NGCCT, and (3) patients diagnosed using a combination of NGCCT and, if positive, followed by ICA. In the suspected population, the strategy where patients only undergo a NGCCT is a cost-effective option at accepted cost-effectiveness thresholds. The strategy of using NGCCT in combination with ICA is the most favourable strategy for patients with known CAD. The most influential factors behind these results are the percentage of patients being misclassified (a function of both diagnostic accuracy and the prior likelihood), the complication rates of the procedures, and the cost price of a NGCCT scan. CONCLUSION The use of NGCCT might be considered cost-effective in both populations since it is cost-saving compared to ICA and generates similar effects.
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Affiliation(s)
- L T Burgers
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands.
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - W K Redekop
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - M J Al
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - S K Lhachimi
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Research Group for Evidence-Based Public Health, BIPS -Leibniz-Institute für Prevention Research und Epidemiology, Bremen, Germany
| | | | - S Walker
- Centre for Health Economics, University of York, York, UK
| | - C Rothery
- Centre for Health Economics, University of York, York, UK
| | - M Westwood
- Kleijnen Systematic Reviews Ltd, York, UK
| | - J L Severens
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Smilowitz NR, Devanabanda AR, Zakhem G, Iqbal SN, Slater W, Coppola JT. Comparison of Clinical and Electrocardiographic Predictors of Ischemic and Nonischemic Cardiomyopathy During the Initial Evaluation of Patients With Reduced (≤40%) Left Ventricular Ejection Fraction. Am J Cardiol 2017; 119:1650-1655. [PMID: 28341355 DOI: 10.1016/j.amjcard.2017.02.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 02/08/2017] [Accepted: 02/08/2017] [Indexed: 01/18/2023]
Abstract
Invasive coronary angiography is routinely performed during the initial evaluation of patients with suspected cardiomyopathy with reduced left ventricular function. Clinical and electrocardiographic (ECG) data may accurately predict ischemic cardiomyopathy (IC). Medical records of adults referred for coronary angiography for evaluation of left ventricular ejection fraction ≤40% from 2010 to 2014 were retrospectively reviewed. Patients with myocardial infarction (MI), previous coronary revascularization, cardiac surgery, or left-sided valvular disease were excluded. IC was defined as ≥70% diameter stenosis of the left main, proximal left anterior descending, or involvement of ≥2 epicardial coronary arteries. A risk model was developed from logistic regression coefficients, with a dichotomous cut-point based on the maximal Youden's index from the receiver-operating characteristic curve. A total of 273 patients met study inclusion criteria. Mean age was 56.8 ± 11.6 and 68.1% were men. IC was identified in 41 patients (15%). Patients with IC were more likely to have ECG evidence of Q-wave MI (34% vs 13%, p <0.001) and less likely to have left bundle branch block (2% vs 15%, p = 0.03) than non-IC. A model including age, hypertension, diabetes mellitus, tobacco use, ECG evidence of ST or T-wave abnormalities concerning for ischemia, and previous Q-wave MI, yielded a 95% negative predictive value for IC. In conclusion, at an urban referral hospital, the prevalence of IC was low. Left bundle branch block on electrocardiography was rarely associated with IC. A risk score incorporating clinical and ECG abnormalities identified patients at a low likelihood for IC.
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Affiliation(s)
- Nathaniel R Smilowitz
- Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Arvind R Devanabanda
- Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York
| | - George Zakhem
- Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York
| | - Sohah N Iqbal
- Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York
| | - William Slater
- Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York
| | - John T Coppola
- Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, New York.
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Non-invasive cardiac pacing with image-guided focused ultrasound. Sci Rep 2016; 6:36534. [PMID: 27827415 PMCID: PMC5101517 DOI: 10.1038/srep36534] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 10/17/2016] [Indexed: 11/11/2022] Open
Abstract
Currently, no non-invasive cardiac pacing device acceptable for prolonged use in conscious patients exists. High Intensity Focused Ultrasound (HIFU) can be used to perform remote pacing using reversibility of electromechanical coupling of cardiomyocytes. Here we described an extracorporeal cardiac stimulation device and study its efficacy and safety. We conducted experiments ex vivo and in vivo in a large animal model (pig) to evaluate clinical potential of such a technique. The stimulation threshold was determined in 10 different ex vivo hearts and different clinically relevant electrical effects such as consecutive stimulations of different heart chambers with a single ultrasonic probe, continuous pacing or the inducibility of ventricular tachycardia were shown. Using ultrasonic contrast agent, consistent cardiac stimulation was achievable in vivo for up to 1 hour sessions in 4 different animals. No damage was observed in inversion-recovery MR sequences performed in vivo in the 4 animals. Histological analysis revealed no differences between stimulated and control regions, for all ex vivo and in vivo cases.
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De Geer J, Sandstedt M, Björkholm A, Alfredsson J, Janzon M, Engvall J, Persson A. Software-based on-site estimation of fractional flow reserve using standard coronary CT angiography data. Acta Radiol 2016; 57:1186-92. [PMID: 26691914 DOI: 10.1177/0284185115622075] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 11/16/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND The significance of a coronary stenosis can be determined by measuring the fractional flow reserve (FFR) during invasive coronary angiography. Recently, methods have been developed which claim to be able to estimate FFR using image data from standard coronary computed tomography angiography (CCTA) exams. PURPOSE To evaluate the accuracy of non-invasively computed fractional flow reserve (cFFR) from CCTA. MATERIAL AND METHODS A total of 23 vessels in 21 patients who had undergone both CCTA and invasive angiography with FFR measurement were evaluated using a cFFR software prototype. The cFFR results were compared to the invasively obtained FFR values. Correlation was calculated using Spearman's rank correlation, and agreement using intraclass correlation coefficient (ICC). Sensitivity, specificity, accuracy, negative predictive value, and positive predictive value for significant stenosis (defined as both FFR ≤0.80 and FFR ≤0.75) were calculated. RESULTS The mean cFFR value for the whole group was 0.81 and the corresponding mean invFFR value was 0.84. The cFFR sensitivity for significant stenosis (FFR ≤0.80/0.75) on a per-lesion basis was 0.83/0.80, specificity was 0.76/0.89, and accuracy 0.78/0.87. The positive predictive value was 0.56/0.67 and the negative predictive value was 0.93/0.94. The Spearman rank correlation coefficient was ρ = 0.77 (P < 0.001) and ICC = 0.73 (P < 0.001). CONCLUSION This particular CCTA-based cFFR software prototype allows for a rapid, non-invasive on-site evaluation of cFFR. The results are encouraging and cFFR may in the future be of help in the triage to invasive coronary angiography.
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Affiliation(s)
- Jakob De Geer
- Department of Radiology and Department of Medical and Health Sciences, Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden
| | - Mårten Sandstedt
- Department of Radiology and Department of Medical and Health Sciences, Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden
| | | | - Joakim Alfredsson
- Department of Cardiology and Department of Medical and Health Sciences, Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden
| | - Magnus Janzon
- Department of Cardiology and Department of Medical and Health Sciences, Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden
| | - Jan Engvall
- Department of Clinical Physiology and Department of Medical and Health Sciences, Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden
| | - Anders Persson
- Department of Radiology and Department of Medical and Health Sciences, Center for Medical Image Science and Visualization, CMIV, Linköping University, Linköping, Sweden
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Liu PY, Lin WY, Lin LF, Lin CS, Lin WS, Cheng SM, Yang SP, Liou JT. Chest Pain with Normal Thallium-201 Myocardial Perfusion Image - Is It Really Normal? ACTA CARDIOLOGICA SINICA 2016; 32:328-36. [PMID: 27274174 DOI: 10.6515/acs20150517a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Thallium-201 myocardial perfusion image (MPI) is commonly used to detect coronary artery disease in patients with chest pain. Although a normal thallium-201 MPI result is generally considered to be a good prognosis and further coronary angiogram is not recommended, there are still a few patients who suffer from unexpected acute coronary events. The aim of this study was to investigate the clinical prognosis in patients with normal thallium-201 MPI. METHODS From January 2006 to August 2012, a total 22,003 patients undergoing thallium-201 MPI in one tertiary center were screened. Of these, 8092 patients had normal results and were investigated retrospectively. During follow-up, 54 patients underwent coronary angiogram because of refractory typical angina pectoris or unexpected acute coronary events. These 54 patients were divided into 2 groups: group I consisted of 26 (48.1%) patients with angiography-proven significant coronary artery stenosis, and group II consisted of 28 (51.9%) patients without significant stenosis. RESULTS Patients in group I had a higher prevalence of prior coronary stenting and electrocardiographic features of ST depression compared with patients in group II. The multivariate analysis demonstrated that both prior coronary stenting and ST depression were risk predictors of unexpected acute coronary events in the patients with normal thallium-201 MPI [odds ratio (OR), 5.93; 95% confidence interval (CI): 1.03-34.06, p = 0.05 and OR, 7.10; 95% CI: 1.28-39.51, p = 0.03,respectively]. CONCLUSIONS Although there is a low incidence of unexpected acute coronary events in patients with chest pain and normal thallium-201 MPI, physicians should be aware of the potentials risk in certain patients in this specific population.
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Affiliation(s)
- Pang-Yen Liu
- Division of Cardiology, Department of Internal Medicine
| | - Wen-Yu Lin
- Division of Cardiology, Department of Internal Medicine
| | - Li-Fan Lin
- Department of Nuclear Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | | | | | | | | | - Jun-Ting Liou
- Division of Cardiology, Department of Internal Medicine
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Sueda S, Kohno H. Overview of complications during pharmacological spasm provocation tests. J Cardiol 2016; 68:1-6. [PMID: 27234219 DOI: 10.1016/j.jjcc.2016.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/01/2016] [Accepted: 03/04/2016] [Indexed: 12/13/2022]
Abstract
Pharmacological spasm provocation tests are invasive methods and we always have the potential to encounter complications when performing these tests. In 1980, Buxton et al. reported three deaths when they performed intravenous ergonovine testing. However, we now employ the intracoronary ergonovine test instead of the intravenous injection of ergonovine from a safety procedure point of view. Past serious major complications of intravenous ergonovine tests, intracoronary ergonovine tests, and intracoronary acetylcholine tests were 0.31% (26/8419), 0.51% (11/2173), and 0.95% (148/15,527), respectively. Selective intracoronary testing had the serious major complications in 0.89% of patients including just one death (0.006%) and two acute myocardial infarctions (0.01%). Selective spasm provocation tests had no additional risks compared with performing diagnostic coronary angiography alone. In the Western countries, the pharmacological spasm provocation tests are not familiar in the clinic except for some specialized institutions. We need international clinical studies using the same protocol of spasm provocation tests to compare the frequency, clinical features, and prognosis of acetylcholine- or ergonovine-provoked coronary spasm between Western and Asian countries. And we hope that Western guidelines give spasm provocation testing a class I indication similar to Japanese Circulation Society guidelines because coronary artery spasm may have fewer racial differences and borders.
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Affiliation(s)
- Shozo Sueda
- Department of Cardiology, Ehime Prefectural Niihama Hospital, Ehime, Japan.
| | - Hiroaki Kohno
- Department of Cardiology, Tsukazaki Hospital, Hyogo, Japan
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Doris MK, Newby DE. How should CT coronary angiography be integrated into the management of patients with chest pain and how does this affect outcomes? EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2016; 2:72-80. [PMID: 29474622 PMCID: PMC5862023 DOI: 10.1093/ehjqcco/qcv027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Indexed: 01/19/2023]
Abstract
When examining the role of a diagnostic test in clinical practice, consideration must be placed not only on the accuracy of the result, but also its impact on patient care and outcomes. Proving a direct effect on outcomes may be difficult because the impact of the diagnostic test largely depends on the clinician's interpretation and consequent actions as well as the patient's response to changes in their diagnosis, investigations, and treatment. Recent major clinical trials of symptomatic patients with suspected coronary heart disease (CHD) have shown that computed tomography coronary angiography (CTCA) can markedly clarify the diagnosis and lead to major changes in patient investigation and management including the use of invasive angiography, preventative therapies, and coronary revascularization. Thus, when added to our existing clinical tools, such as exercise electrocardiography, CTCA represents a powerful method of identifying and excluding CHD. Furthermore, it can identify patients with prognostically relevant non-obstructive CHD and, with recent technological advances, will be able to assess the functional impact of anatomically detected coronary artery stenoses. Overall, the routine integration of CTCA into the investigation of patients with chest pain improves clinical diagnostic certainty that has led to better targeting of investigations and evidence-based treatments that have ultimately translated into improved clinical outcomes.
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Affiliation(s)
- Mhairi K. Doris
- Centre for Cardiovascular Science, University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
| | - David E. Newby
- Centre for Cardiovascular Science, University of Edinburgh, 49 Little France Crescent, Edinburgh EH16 4SB, UK
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Lee KE, Seo YJ, Kim GB, An HS, Song YH, Kwon BS, Bae EJ, Noh CI. Complications of Cardiac Catheterization in Structural Heart Disease. Korean Circ J 2016; 46:246-55. [PMID: 27014356 PMCID: PMC4805570 DOI: 10.4070/kcj.2016.46.2.246] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 08/25/2015] [Accepted: 09/22/2015] [Indexed: 01/15/2023] Open
Abstract
Background and Objectives Cardiac catheterization is used to diagnose structural heart disease (SHD) and perform transcatheter treatment. This study aimed to evaluate complications of cardiac catheterization and the associated risk factors in a tertiary center over 10 years. Subjects and Methods Total 2071 cardiac catheterizations performed at the Seoul National University Children's Hospital from January 2004 to December 2013 were included in this retrospective study. Results The overall complication, severe complication, and mortality rates were 16.2%, 1.15%, and 0.19%, respectively. The factors that significantly increased the risk of overall and severe complications were anticoagulant use before procedure (odds ratio [OR] 1.83, p=0.012 and OR 6.45, p<0.001, respectively), prothrombin time (OR 2.30, p<0.001 and OR 5.99, p<0.001, respectively), general anesthesia use during procedure (OR 1.84, p=0.014 and OR 5.31, p=0.015, respectively), and total procedure time (OR 1.01, p<0.001 and OR 1.02, p<0.001, respectively). Low body weight (OR 0.99, p=0.003), severe SHD (OR 1.37, p=0.012), repetitive procedures (OR 1.7, p=0.009), and total fluoroscopy time (OR 1.01, p=0.005) significantly increased the overall complication risk. High activated partial thromboplastin time (OR 1.04, p=0.001), intensive care unit admission state (OR 14.03, p<0.001), and concomitant electrophysiological study during procedure (OR 3.41, p=0.016) significantly increased severe complication risk. Conclusion Currently, the use of cardiac catheterization in SHD is increasing and becoming more complex; this could cause complications despite the preventive efforts. Careful patient selection for therapeutic catheterization and improved technique and management during the peri-procedural period are required to reduce complications.
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Affiliation(s)
- Ko Eun Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Yeon Jeong Seo
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Gi Beom Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Hyo Soon An
- Department of Pediatrics, Seoul National University Boramae Hospital, Seoul, Korea
| | - Young Hwan Song
- Department of Pediatrics, Bundang Seoul National University Hospital, Seongnam, Korea
| | - Bo Sang Kwon
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Eun Jung Bae
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Chung Il Noh
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
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da Silveira JS, Scansen BA, Wassenaar PA, Raterman B, Eleswarpu C, Jin N, Mo X, White RD, Bonagura JD, Kolipaka A. Quantification of myocardial stiffness using magnetic resonance elastography in right ventricular hypertrophy: initial feasibility in dogs. Magn Reson Imaging 2015; 34:26-34. [PMID: 26471513 DOI: 10.1016/j.mri.2015.10.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 10/07/2015] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Myocardial stiffness is an important determinant of cardiac function and is currently invasively and indirectly assessed by catheter angiography. This study aims to demonstrate the feasibility of quantifying right ventricular (RV) stiffness noninvasively using cardiac magnetic resonance elastography (CMRE) in dogs with severe congenital pulmonary valve stenosis (PVS) causing RV hypertrophy, and compare it to remote myocardium in the left ventricle (LV). Additionally, correlations between stiffness and selected pathophysiologic indicators from transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging were explored. METHODS In-vivo CMRE was performed on nine dogs presenting severe congenital PVS using a 1.5T MRI scanner. T1-MOLLI, T2-prepared-bSSFP, gated-cine GRE-MRE and LGE (PSIR) sequences were used to acquire a basal short-axis slice. RV and LV-free-wall (FW) stiffness measurements were compared against each other and also correlated to ventricular mass, RV and LV FW thickness, T1 and T2 relaxation times, and extracellular volume fraction (ECV). Peak transpulmonary pressure gradient and myocardial strain were also acquired on eight dogs by TTE and correlated to RV-FW systolic stiffness. Potential correlations were evaluated by Spearman's rho (rs). RESULTS RV-FW stiffness was found to be significantly higher than the LV-FW stiffness both during end-systole (ES) (p=0.002) and end-diastole (ED) (p=0.029). Significant correlations were observed between RV-FW ES and LV-FW ED stiffness versus ECV (rs=0.75; p-value=0.05). Non-significant moderate correlations were found between LV-FW ES (rs=0.54) and RV-FW ED (rs=0.61) stiffness versus ECV. Furthermore, non-significant correlations were found between RV or LV-FW stiffness and the remaining variables (rs<0.54; p-value>0.05). CONCLUSION This study demonstrates the feasibility of determining RV stiffness. The positive correlations between stiffness and ECV might indicate some interdependence between stiffness and myocardial extracellular matrix alterations. However, further studies are warranted to validate our initial observations.
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Affiliation(s)
- Juliana S da Silveira
- Department of Radiology, OSU College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Brian A Scansen
- Department of Veterinary Clinical Sciences, OSU College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Peter A Wassenaar
- Department of Radiology, OSU College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Brian Raterman
- Department of Radiology, OSU College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Chethan Eleswarpu
- College of Biomedical Engineering, The Ohio State University, Columbus, OH, UTSA
| | - Ning Jin
- Siemens Medical Solutions, Malvern, PA USA
| | - Xiaokui Mo
- Center for Biostatistics, The Ohio State University, Columbus, OH, USA
| | - Richard D White
- Department of Radiology, OSU College of Medicine, The Ohio State University, Columbus, OH, USA; Department of Internal Medicine/Division of Cardiovascular Medicine, OSU College of Medicine, The Ohio State University, Columbus, OH, USA
| | - John D Bonagura
- Department of Veterinary Clinical Sciences, OSU College of Veterinary Medicine, The Ohio State University, Columbus, OH, USA
| | - Arunark Kolipaka
- Department of Radiology, OSU College of Medicine, The Ohio State University, Columbus, OH, USA; Department of Internal Medicine/Division of Cardiovascular Medicine, OSU College of Medicine, The Ohio State University, Columbus, OH, USA.
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Abdollahi AA, Mehranfard S, Behnampour N, Kordnejad AM. Effect of Positioning and Early Ambulation on Coronary Angiography Complications: a Randomized Clinical Trial. J Caring Sci 2015; 4:125-34. [PMID: 26171374 DOI: 10.15171/jcs.2015.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 10/12/2014] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION After coronary angiography to prevent potential complications, patients are restricted to 4-24 hours bed rest in the supine position due to the complications. This study was designed to assess the effect of changing position and early ambulation on low back pain, urinary retention, bleeding and hematoma after cardiac catheterization. METHODS In this clinical trial, 140 patients by using a convenience sampling randomly divided into four 35-individual groups. The patients in the control group were in the supine position for 6 hours without a movement. Change position was applied to the second group (based on a specific protocol), early ambulation was applied to the third group and both early ambulation and change position were applied to the fourth group. Then, severity of bleeding, hematoma, back pain and urinary retention were measured at zero, 1, 2, 4, 6, and 24 hours after angiography. The data was collected through an individual data questionnaire, Numerical Rating Scale (NRS) of pain and Kristin Swain's check list was applied to evaluate the severity of bleeding and hematoma. RESULTS None of patients developed vascular complications. Incidence of urinary retention was higher in the control group, although this difference was not significant. The mean of pain intensity in the fourth and sixth hours showed a significant difference. CONCLUSION Based on the findings of this study, changing patients' position can be safe and they can be ambulated early after angiography.
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Affiliation(s)
- Ali Akbar Abdollahi
- Department of Nursing, Ischemic Disorders Research Center, Golestan University of Medical Sciences, Golestan, Iran
| | - Shahzad Mehranfard
- Department of Nursing, Faculty of Nursing & Midwifery, Dezful University of Medical Sciences, Dezful, Iran
| | - Nasser Behnampour
- Department of Biostatistics, Golestan University of Medical Sciences, Golestan, Iran
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Wild J, Arrigo M, Isenring BD, Buergi U, Kurowski T, Schuurmans MM, Huber LC, Benden C. Coronary Artery Disease in Lung Transplant Candidates: Role of Routine Invasive Assessment. Respiration 2015; 89:107-11. [DOI: 10.1159/000368368] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 09/03/2014] [Indexed: 11/19/2022] Open
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Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ, Fonarow GC, Lange RA, Levine GN, Maddox TM, Naidu SS, Ohman EM, Smith PK, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Thorac Cardiovasc Surg 2014; 149:e5-23. [PMID: 25827388 DOI: 10.1016/j.jtcvs.2014.11.002] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ, Fonarow GC, Lange RA, Levine GN, Maddox TM, Naidu SS, Ohman EM, Smith PK. 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. Circulation 2014; 130:1749-67. [DOI: 10.1161/cir.0000000000000095] [Citation(s) in RCA: 388] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Fihn SD, Blankenship JC, Alexander KP, Bittl JA, Byrne JG, Fletcher BJ, Fonarow GC, Lange RA, Levine GN, Maddox TM, Naidu SS, Ohman EM, Smith PK. 2014 ACC/AHA/AATS/PCNA/SCAI/STS focused update of the guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2014; 64:1929-49. [PMID: 25077860 DOI: 10.1016/j.jacc.2014.07.017] [Citation(s) in RCA: 554] [Impact Index Per Article: 55.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Zeb I, Abbas N, Nasir K, Budoff MJ. Coronary computed tomography as a cost–effective test strategy for coronary artery disease assessment – A systematic review. Atherosclerosis 2014; 234:426-35. [DOI: 10.1016/j.atherosclerosis.2014.02.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Revised: 02/10/2014] [Accepted: 02/13/2014] [Indexed: 10/25/2022]
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Bostan M, Satiroğlu O, Erdoğan T, Durakoğlugil ME, Uğurlu Y. A rare complication: Undeflatable balloon of the stent. Interv Med Appl Sci 2013; 5:43-5. [PMID: 24265889 DOI: 10.1556/imas.5.2013.1.9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Accepted: 01/07/2013] [Indexed: 11/19/2022] Open
Abstract
Percutaneous coronary intervention is an important modality in the treatment of coronary artery disease. These procedures are usually completed successfully, but occasionally serious complications are encountered. In this paper, we present the case of an undeflatable stent balloon, which is an extremely rare complication that has not been described in the literature.
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Affiliation(s)
- Mehmet Bostan
- Department of Cardiology, Medical School, Recep Tayyip Erdoğan University Rize Turkey
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Fröhlich GM, Schoch B, Wolfrum M, Osranek M, Enseleit F, Herzog BA, Hasun M, Lüscher TF, Meier P, Gaemperli O, Kaufmann PA, Corti R. The impact of modern noninvasive cardiac imaging on coronary intervention rates. J Interv Cardiol 2013; 27:50-7. [PMID: 24410715 DOI: 10.1111/joic.12079] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES It remains still unclear whether the use of modern noninvasive diagnostic modalities for evaluation of coronary artery disease (computed tomography coronary angiography (CTCA), nuclear myocardial perfusion imaging (MPI)) were able to change the "diagnostic yield" of invasive coronary angiography (ICA). METHODS The total number of ICA in the years 2000-2009 was related to the number of percutaneous interventions (PCIs) and we assessed whether there was a significant trend over time using time series analyses. We compared these data with the number of patients undergoing CTCA and nuclear MPI in the same time period. RESULTS During the 10-year observational period, 23,397 ICA were performed. The proportion of purely diagnostic ICA (without PCI) remained stable over the whole study period (tau = -0.111, P = 0.721). A CTCA program was initiated in 2005 and 1,407 examinations were performed until 2009. Similarly, the number of nuclear MPI increased from 2,284 in the years 2000-2004 to 5,260 in the years 2005-2009 (P = 0.009). CONCLUSION Despite increasing availability, noninvasive testing modalities did not significantly alter the rate of purely diagnostic ICA, and still are underused as gatekeeper to ICA. Further effort is needed to optimize the use of noninvasive imaging modalities in the work-up process for coronary artery disease.
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Affiliation(s)
- Georg M Fröhlich
- Cardiovascular Center, Cardiology and Cardiac Imaging, Nuclear Medicine, University Hospital Zurich, Zurich, Switzerland; The Heart Hospital London, University College London, London, United Kingdom
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Oliveira RKF, de Oliveira RKF, Ferreira EVM, Ramos RP, Messina CMS, Kapins CEB, Silva CMC, Ota-Arakaki JS. Usefulness of pulmonary capillary wedge pressure as a correlate of left ventricular filling pressures in pulmonary arterial hypertension. J Heart Lung Transplant 2013; 33:157-62. [PMID: 24268673 DOI: 10.1016/j.healun.2013.10.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 08/29/2013] [Accepted: 10/08/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Pulmonary arterial hypertension (PAH) is characterized by a pulmonary capillary wedge pressure (PCWP) of ≤15 mm Hg, given a normal left ventricular filling pressure (LVFP). However, recent studies have shown that, in PAH patients, diagnosis based on PCWP can erroneously classify a significant number of patients compared with diagnosis based on left ventricular end-diastolic pressure (LVEDP). Therefore, we sought to compare the diagnostic accuracy of end-expiratory PCWP and LVEDP measurements in patients suspected of having pulmonary hypertension (PH). METHODS We reviewed the hemodynamic data from 122 patients suspected of having PH who underwent simultaneous right- and left-side heart catheterizations at a PH referral center from 2006 to 2011. RESULTS PH was diagnosed in 105 patients, 79% of whom (n = 83) showed a pre-capillary pattern according to the LVEDP measurement. Ninety percent of patients with PCWP ≤15 mm Hg were correctly classified as having pre-capillary PH. However, 39% of patients with a PCWP >15 mm Hg had LVEDP ≤15 mm Hg and would have been erroneously diagnosed with pulmonary venous hypertension based on their PCWP measurements alone. The sensitivity and specificity was 0.89 and 0.64, respectively. A Bland-Altman analysis of the PCWP and LVEDP measurements revealed a mean bias of 0.3 mm Hg with 95% limits of agreement of -7.2 to 7.8 mm Hg. CONCLUSIONS A PCWP ≤15 mm Hg was found to be a reliable indicator of normal LVFP in pre-capillary PH patients. When measured properly and analyzed in the clinical context, PCWP is a valuable tool for accurate diagnosis of PAH.
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Affiliation(s)
| | - Rudolf K F de Oliveira
- Pulmonary Vascular Group, Division of Respiratory Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Eloara V M Ferreira
- Pulmonary Vascular Group, Division of Respiratory Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Roberta P Ramos
- Pulmonary Vascular Group, Division of Respiratory Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Carolina M S Messina
- Pulmonary Vascular Group, Division of Respiratory Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Carlos E B Kapins
- Hemodynamic Unit, Division of Cardiology, Federal University of São Paulo, São Paulo, Brazil
| | - Célia M C Silva
- Hemodynamic Unit, Division of Cardiology, Federal University of São Paulo, São Paulo, Brazil
| | - Jaquelina S Ota-Arakaki
- Pulmonary Vascular Group, Division of Respiratory Medicine, Federal University of São Paulo, São Paulo, Brazil.
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Westwood M, Al M, Burgers L, Redekop K, Lhachimi S, Armstrong N, Raatz H, Misso K, Severens J, Kleijnen J. A systematic review and economic evaluation of new-generation computed tomography scanners for imaging in coronary artery disease and congenital heart disease: Somatom Definition Flash, Aquilion ONE, Brilliance iCT and Discovery CT750 HD. Health Technol Assess 2013; 17:1-243. [PMID: 23463937 DOI: 10.3310/hta17090] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Computed tomography (CT) is important in diagnosing and managing many conditions, including coronary artery disease (CAD) and congenital heart disease. Current CT scanners can very accurately diagnose CAD requiring revascularisation in most patients. However, imaging technologies have developed rapidly and new-generation computed tomography (NGCCT) scanners may benefit patients who are difficult to image (e.g. obese patients, patients with high or irregular heart beats and patients who have high levels of coronary calcium or a previous stent or bypass graft). OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of NGCCT for diagnosing clinically significant CAD in patients who are difficult to image using 64-slice computed tomography and treatment planning in complex congenital heart disease. DATA SOURCES Bibliographic databases were searched from 2000 to February/March 2011, including MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), NHS Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA) database and Science Citation Index (SCI). Trial registers and conference proceedings were searched. REVIEW METHODS Systematic review methods followed published guidance. Risk of bias was assessed using QUADAS-2. Results were stratified by patient group. Summary sensitivity and specificity were calculated using a bivariate summary receiver operating characteristic, or random effects model. Heterogeneity was assessed using the chi-squared statistic and I(2)-statistic. Cost-effectiveness of NGCCT was modelled separately for suspected and known CAD, evaluating invasive coronary angiography (ICA) only, ICA after positive NGCCT (NGCCT-ICA), and NGCCT only. The cost-effectiveness of NGCCT, compared with 64-slice CT, in reducing imaging-associated radiation in congenital heart disease was assessed. RESULTS Twenty-four studies reported accuracy of NGCCT for diagnosing CAD in difficult-to-image patients. No clinical effectiveness studies of NGCCT in congenital heart disease were identified. The pooled per-patient estimates of sensitivity were 97.7% [95% confidence interval (CI) 88.0% to 99.9%], 97.7% (95% CI 93.2% to 99.3%) and 96.0% (95% CI 88.8% to 99.2%) for patients with arrhythmias, high heart rates and previous stent, respectively. The corresponding estimates of specificity were 81.7% (95% CI 71.6% to 89.4%), 86.3% (95% CI 80.2% to 90.7%) and 81.6% (95% CI 74.7% to 87.3%), respectively. In patients with high coronary calcium scores, previous bypass grafts or obesity, only per-segment or per-artery data were available. Sensitivity estimates remained high (> 90% in all but one study). In patients with suspected CAD, the NGCCT-only strategy appeared most cost-effective; the incremental cost-effectiveness ratio (ICER) of NGCCT-ICA compared with NGCCT only was £71,000. In patients with known CAD, the most cost-effective strategy was NGCCT-ICA (highest cost saving, dominates ICA only). The ICER of NGCCT only compared with NGCCT-ICA was £726,230. For radiation exposure only, the ICER for NGCCT compared with 64-slice CT in congenital heart disease ranged from £521,000 for the youngest patients to £90,000 for adults. LIMITATIONS Available data were limited, particularly for obese patients and patients with previous bypass grafts. All studies of the accuracy of NGCCT assume that the reference standard (ICA) is 100% sensitive and specific; however, there is some evidence that ICA may sometimes underestimate the extent and severity of stenosis. Patients with more than one criterion that could contribute to difficulty in imaging were often excluded from studies; the effect on test accuracy of multiple difficult to image criteria remains uncertain. CONCLUSIONS NGCCT may be sufficiently accurate to diagnose clinically significant CAD in some or all difficult-to-image patient groups. Economic analyses suggest that NGCCT is likely to be considered cost-effective for difficult-to-image patients with CAD, at current levels of willingness to pay in the NHS. For patients with suspected CAD, NGCCT only would be most favourable; for patients with known CAD, NGCCT-ICA would be most favourable. No studies assessing the effects of NGCCT on therapeutic decision making, or subsequent patient outcomes, were identified. The ideal study to address these questions would be a large multi-centre RCT. However, one possible alternative might be to establish a multicentre tracker study. High-quality test accuracy studies, particularly in obese patients, patients with high coronary calcium, and those with previous bypass grafts are needed to confirm the findings of our systematic review. These studies should include patients with multiple difficult to image criteria. FUNDING The National Institute for Health Research Health Technology Assessment programme. This project was funded by the HTA programme, on behalf of NICE, as project number 10/107/01.
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Affiliation(s)
- M Westwood
- Kleijnen Systematic Reviews, Escrick, York, UK
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Aïssou L, Pop N, Goudot FX, Meune C. An unusual complication of coronarography: delayed catheter migration to the vertebral artery. Int J Cardiol 2013; 167:e81-2. [PMID: 23651818 DOI: 10.1016/j.ijcard.2013.03.162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 03/30/2013] [Indexed: 10/26/2022]
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Walker S, Girardin F, McKenna C, Ball SG, Nixon J, Plein S, Greenwood JP, Sculpher M. Cost-effectiveness of cardiovascular magnetic resonance in the diagnosis of coronary heart disease: an economic evaluation using data from the CE-MARC study. Heart 2013; 99:873-81. [PMID: 23591668 DOI: 10.1136/heartjnl-2013-303624] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE To evaluate the cost-effectiveness of diagnostic strategies for coronary heart disease (CHD) derived from the CE-MARC study. DESIGN Cost-effectiveness analysis using a decision analytic model to compare eight strategies for the diagnosis of CHD. SETTING Secondary care out-patients (Cardiology Department). PATIENTS Patients referred to cardiologists for the further evaluation of symptoms thought to be angina pectoris. INTERVENTIONS Eight different strategies were considered, including different combinations of exercise treadmill testing (ETT), single-photon emission CT (SPECT), cardiovascular magnetic resonance (CMR) and coronary angiography (CA). MAIN OUTCOME MEASURES Costs expressed as UK sterling in 2010-2011 prices and health outcomes in quality-adjusted life-years (QALYs). The time horizon was 50 years. RESULTS Based on the characteristics of patients in the CE-MARC study, only two strategies appear potentially cost-effective for diagnosis of CHD, both including CMR. The choice is between two strategies: one in which CMR follows a positive or inconclusive ETT, followed by CA if CMR is positive or inconclusive (Strategy 3 in the model); and the other where CMR is followed by CA if CMR is positive or inconclusive (Strategy 5 in the model). The more cost-effective of these two rests on the threshold cost per QALY gained below which health systems define an intervention as cost-effective. Strategy 3 appears cost-effective at the lower end of the threshold range used in the UK (£20 000 per QALY gained), while Strategy 5 appears cost-effective at the higher end of the threshold range (£30 000 per QALY). The results are robust to various sources of uncertainty although prior likelihood of CHD requiring revascularisation and the rate at which false negative patients are eventually appropriately identified do impact upon the results. CONCLUSIONS The CE-MARC study showed that CMR had superior diagnostic accuracy to SPECT and concluded that CMR should be more widely used in the investigation of patients with CHD. The economic evaluation results show that using CMR is also a cost-effective strategy and supports the wider adoption of this modality.
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Affiliation(s)
- Simon Walker
- Centre for Health Economics, University of York, Alcuin A Block, Heslington, York YO10 5DD, UK.
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Gallino A, Stuber M, Crea F, Falk E, Corti R, Lekakis J, Schwitter J, Camici P, Gaemperli O, Di Valentino M, Prior J, Garcia-Garcia HM, Vlachopoulos C, Cosentino F, Windecker S, Pedrazzini G, Conti R, Mach F, De Caterina R, Libby P. “In vivo” imaging of atherosclerosis. Atherosclerosis 2012; 224:25-36. [DOI: 10.1016/j.atherosclerosis.2012.04.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 04/18/2012] [Accepted: 04/18/2012] [Indexed: 12/20/2022]
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Mori Y, Takahashi K, Nakanishi T. Complications of cardiac catheterization in adults and children with congenital heart disease in the current era. Heart Vessels 2012; 28:352-9. [PMID: 22457096 DOI: 10.1007/s00380-012-0241-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 02/17/2012] [Indexed: 12/13/2022]
Abstract
The number of adults with congenital heart disease (CHD) requiring diagnostic and/or therapeutic cardiac catheterization has been increasing. However, there have been few studies on the complications of performing cardiac catheterization in adults with CHD. The aim of this study was to determine the incidence of complications during congenital cardiac catheterization in both adults and pediatric patients. A total of 2134 consecutive cardiac catheterizations performed between 2003 and 2008 were prospectively analyzed. Complications were graded from 1 to 5 based on severity and these, with ≥ grade 3 being defined as major. During the study period, 576 procedures (393 diagnostic, 90 interventional, and 93 electrophysiological) were performed in adult patients (≥ 18 years). Complex heart disease was present in 435 of 576 procedures (75.6 %). A total of 65 complications (11.3 %) with 13 major complications including 1 death (2.3 %) were encountered. The most common complications were arrhythmias. The majority of complications were successfully treated or temporary, and all but one of the patients were without residua. Of the 1558 pediatric procedures performed during the same period, we found a total of 229 complications (14.7 %), of which 89 (5.7 %) were major complications including 5 deaths. The safety of performing cardiac catheterization for adult CHD appears to be similar to that for pediatric patients. The complication rates in adults with CHD are low, but not negligible.
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Affiliation(s)
- Yoshiki Mori
- Department of Pediatric Cardiology, The Heart Institute, Tokyo Women's Medical University, Tokyo, Japan.
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Downstream resource utilization following hybrid cardiac imaging with an integrated cadmium-zinc-telluride/64-slice CT device. Eur J Nucl Med Mol Imaging 2011; 39:430-6. [DOI: 10.1007/s00259-011-1999-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Accepted: 11/07/2011] [Indexed: 10/15/2022]
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Miller CA, Chowdhary S, Ray SG, Sarma J, Williams SG, Yonan N, Mittal TK, Schmitt M. Role of Noninvasive Imaging in the Diagnosis of Cardiac Allograft Vasculopathy. Circ Cardiovasc Imaging 2011; 4:583-93. [PMID: 21934085 DOI: 10.1161/circimaging.110.961425] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Christopher A. Miller
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Saqib Chowdhary
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Simon G. Ray
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Jaydeep Sarma
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Simon G. Williams
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Nizar Yonan
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Tarun K. Mittal
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
| | - Matthias Schmitt
- From the North West Regional Heart Centre and Heart and Lung Transplant Unit, University Hospital of South Manchester, Wythenshawe, Manchester, United Kingdom (C.A.M., S.C., S.G.R., J.S., S.G.W., N.Y., M.S.); and Harefield Hospital, Royal Brompton and Harefield NHS Trust, Middlesex, London, United Kingdom (T.K.M.)
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Dual-Energy Computed Tomography for the Detection of Late Enhancement in Reperfused Chronic Infarction. Invest Radiol 2011; 46:450-6. [DOI: 10.1097/rli.0b013e3182145b4f] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Uchida T, Popma J, Stone GW, Ellis SG, Turco MA, Ormiston JA, Muramatsu T, Nakamura M, Nanto S, Yokoi H, Baim DS. The clinical impact of routine angiographic follow-up in randomized trials of drug-eluting stents: a critical assessment of "oculostenotic" reintervention in patients with intermediate lesions. JACC Cardiovasc Interv 2010; 3:403-11. [PMID: 20398868 DOI: 10.1016/j.jcin.2010.01.010] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2009] [Revised: 12/08/2009] [Accepted: 01/08/2010] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The aim of this study was to study the long-term clinical effects of routine angiographic follow-up and related reintervention after drug-eluting stenting. BACKGROUND Prior stent trials have shown that protocol-mandated angiographic follow-up increases repeat interventions compared with clinical follow-up alone. The long-term clinical impact of this practice is unknown. METHODS Long-term outcomes of patients assigned to routine angiographic follow-up in 3 large-scale TAXUS (Boston Scientific, Natick, Massachusetts) trials were compared with patients assigned to clinical follow-up alone, in a propensity score-adjusted patient-level meta-analysis. Outcomes were also compared in patients with treated versus untreated nonischemic intermediate lesions (quantitative angiographic stenosis between >or=40% and <70%) detected at angiographic follow-up. RESULTS Target lesion revascularization (TLR) rates at 5 years were significantly higher in the angiographic compared with clinical follow-up cohort (18.3% vs. 11.1%, p < 0.001). This was due to more frequent treatment of intermediate lesions, but there was no associated reduction in rates of cardiac death or myocardial infarction (8.9% vs. 8.8%, p = 0.93). Of patients with nonischemic intermediate lesions, 17% who were not revascularized at the time of angiographic follow-up had a subsequent TLR, whereas 7% of patients who had TLR at this follow-up angiogram required additional revascularization during long-term follow-up. CONCLUSIONS A strategy of routine angiographic follow-up increases oculostenotic revascularization of nonischemic intermediate lesions without affecting subsequent rates of cardiac death or myocardial infarction, and TLR was not required in 83% of those lesions. A conservative approach, in which repeat angiography is limited to patients with recurrent ischemia or progressive symptoms, minimizes repeat revascularization of nonischemic intermediate lesions and optimizes long-term event-free survival after drug-eluting stent implantation.
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Affiliation(s)
- Takahiro Uchida
- Innovations in Interventional Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 01752, USA.
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