The Changing Face of Interventional Cardiology

Intraoperative Acute Cardiac Tamponade as a Result of Intracardiac Perforation Requiring Emergency Continuous Pericardiocentesis and Open Sternotomy: A Case Report and Literature Review of a Rare but Fatal Complication

Intraoperative acute cardiac tamponade associated with iatrogenic intracardiac perforation from percutaneous interventional cardiac procedures is a rare but potentially catastrophic complication. We report a case of intraoperative acute hemopericardium caused by a left atrial (LA) perforation resulting in cardiac tamponade in a patient undergoing a baffling procedure for the correction of two anomalous pulmonary veins draining into her superior vena cava (SVC) that required continuous pericardiocentesis with autologous blood transfusion via the femoral vein and an emergency intraoperative transfer from the interventional cardiology cath lab to the cardiac operating room for an open sternotomy and primary repair. An 86-year-old female with known right-ventricular (RV) failure with preserved ejection fraction (left ventricular ejection fraction (LVEF): 50-55% on transesophageal echocardiography (TEE) one week prior) and atrial fibrillation was admitted for her third heat failure exacerbation in two months despite being adherent to her aggressive diuresis medication regimen. Upon her readmission and due to her symptomatic and seemingly refractory heart failure, the patient underwent a cardiac computer tomography (CT) with 3D reconstruction that showed previously undiagnosed partial anomalous pulmonary venous return (PAPVR) of two of her four pulmonary veins aberrantly draining into the SVC. This anatomic pathology was deemed to be the likely etiology of her repeated episodes of recurring heart failure exacerbations, shortness of breath, peripheral edema, and fatigue. The patient was counseled and consented to a percutaneous baffle of the two anomalous veins to redirect more of the returning pulmonary venous blood away from the SVC and to the LA. While under general endotracheal anesthesia (GETA) with a TEE in place during the procedure, the patient suddenly developed acute hypotension, tachycardia, and a reduction in expired carbon dioxide (EtCO2) was noted quickly followed by evidence of a rapidly accumulating hemopericardium on TEE. Cardiothoracic surgery was urgently consulted to the interventional cardiology cath lab while the patient underwent an emergency pericardiocentesis that momentarily alleviated her hemodynamic instability, cardiac tamponade physiology, and deteriorating overall clinical picture. While performing continuous pericardiocentesis with autologous return of the aspirated blood via femoral venous access the patient was urgently transported to the cardiac operating room and prepped for emergency sternotomy for primary repair of the LA. Following primary repair via sternotomy, multiple drains were placed and the thoracic cavity was closed with wires. The patient was immediately transported to the surgical intensive care unit (SICU) intubated, mechanically ventilated, and sedated. During this time, the patient progressively required additional vasoactive and inotropic agents to support her mean arterial pressure (MAP), and following a multidisciplinary discussion with the patient's family regarding her goals of care, the decision was made to withdraw further resuscitation efforts and the patient expired four hours later.

Scope of Practice of US Interventional Cardiologists from an Analysis of Medicare Billing Data

The contemporary scope of practice of interventional cardiologists (ICs) in the United States and recent trends are unknown. Using Medicare claims from 2013 to 2017, we categorized ICs into 4 practice categories (only percutaneous coronary intervention [PCI], PCI with noninvasive imaging, PCI with specialized interventions [peripheral/structural], and all 3 services) and evaluated associations with region, hospital bed size and teaching status, gender, and graduation year. Of 6,083 ICs in 2017, 10.9% performed only PCI, 68.3% PCI with noninvasive imaging, 5.7% PCI with specialized interventions, and 15.1% all 3 services. A higher proportion of Northeast ICs (vs South ICs) were performing only PCI (24.8% vs 7.3%) and PCI with specialized interventions (12% vs 3.4%), but lower PCI and noninvasive imaging (53.8% vs 71.7%) and all 3 services (9.3% and 17.6%). Regarding ICs at larger hospitals (bed size >575 vs <218), a higher proportion was performing only PCI (23.8% vs 5.2%) or PCI with specialized interventions (13.5% vs 1.7%) and lower proportion was performing PCI with noninvasive imaging (48.8% vs 78%), similar to teaching hospitals. Female ICs (vs male ICs) more frequently performed only PCI (18.9% vs 10.6%) and less frequently all 3 services (8.3% vs 15.4%). A lower proportion of recent graduates (2001 to 2016) performed only PCI (9.8% vs 13.8%) and PCI with noninvasive imaging (66.3% vs 72.6%) but a higher proportion performed all 3 services (18% vs 8.4%) than earlier graduates (1959 to 1984). From 2013 to 2017, only PCI and PCI with noninvasive imaging decreased, whereas PCI and specialized interventions and all 3 services increased (all p <0.001). In conclusion, there is marked heterogeneity in practice responsibilities among ICs, which has implications for training and competency assessments.

Fractional flow reserve, quantitative flow ratio, and instantaneous wave-free ratio: a comparison of the procedure-related dose of ionising radiation

INTRODUCTION

The development of interventional cardiology increases the number of invasive procedures which are inevitably associated with increased exposure to ionizing radiation and associated risks. A percutaneous coronary intervention (PCI) substantiated by evaluation of the coronary artery lesion's functional significance is recommended by both European and American cardiologists. Nevertheless, the prevalence of physiology-guided PCIs does not exceed 10% all over the globe.

AIM

To identify the physiology evaluation method which is associated with the lowest exposure to ionising radiation.

MATERIAL AND METHODS

Anonymised data of 421 patients with stable angina pectoris for whom elective coronary artery angiography followed by physiological assessment of intermediate coronary artery stenosis was performed were prospectively included in this study. Only diagnostic-procedure-related data of dose of ionizing radiation were analysed. Physiological assessment of coronary artery lesions was performed by fractional flow reserve (FFR), quantitative flow ratio (QFR), or instantaneous wave-free ratio (iFR).

RESULTS

Compared to FFR as a reference, fluoroscopy time (FT) was almost half in QFR and almost double in iFR, p < 0.001. QFR was associated with more than 3 times shorter FT compared to iFR. The dose area product was 663.87 ±260.51 cGy/cm2 (p = 0.03) lower in QFR compared to iFR.

CONCLUSIONS

QFR is associated with significantly reduced exposure to ionising radiation compared to both FFR and iFR. Therefore, wider QFR application in clinical practice could eliminate any additional exposure to ionising radiation and increase the prevalence of physiology-guided coronary artery revascularization.

Senior interventional cardiologists are exposed to higher effective doses than other staff members

Those working in interventional cardiology are exposed to varying radiation doses during diagnostic and interventional procedures. The work presented in this paper aimed to monitor the effective doses received by different categories of medical staff members practicing interventional cardiology procedures including senior cardiologists, junior cardiologists, anesthetists and nurses. Thermo-luminescence dosimeter (TLD) badges that consisted of lithium fluoride doped with magnesium and titanium were used to quantify radiation doses. Measurements were performed with the dosimeters mounted under and above leaded aprons worn by medical staff. The results revealed that the effective doses to senior cardiologists were the highest compared to those to other participating staff members, due to their position close to the X-ray tube. The average daily effective doses for senior cardiologists, junior cardiologists, anesthetists and nurses were higher for dosimeters located above the aprons than those for dosimeters located under the aprons. Above the apron, the average effective doses accumulated during the study period were 0.44 ± 0.06, 0.34 ± 0.05, 0.29 ± 0.03 and 0.29 ± 0.04 mSv, respectively; whereas, under the apron, they were 0.20 ± 0.02, 0.18 ± 0.02, 0.17 ± 0.02 and 0.18 ± 0.02, respectively. Also, the fluoroscopy time was correlated with the dose acquired, especially for senior cardiologists. It is concluded that doses to senior cardiologists are quite high, and that many variables can affect staff exposure such as distance, direction, procedure and skills.

CONTEMPORARY RADIATION DOSES IN INTERVENTIONAL CARDIOLOGY: A NATIONWIDE STUDY OF PATIENT DOSES IN FINLAND

The amount of interventional procedures such as percutaneous coronary intervention (PCI), transcatheter aortic valve implantation (TAVI), pacemaker implantation (PI) and ablations has increased within the previous decade. Simultaneously, novel fluoroscopy mainframes enable lower radiation doses for patients and operators. Therefore, there is a need to update the existing diagnostic reference levels (DRLs) and propose new ones for common or recently introduced procedures. We sought to assess patient radiation doses in interventional cardiology in a large sample from seven hospitals across Finland between 2014 and 2016. Data were used to set updated national DRLs for coronary angiographies (kerma-air product (KAP) 30 Gycm2) and PCIs (KAP 75 cm2), and novel levels for PIs (KAP 3.5 Gycm2), atrial fibrillation ablation procedures (KAP 25 Gycm2) and TAVI (KAP 90 Gycm2). Tentative KAP values were set for implantations of cardiac resynchronization therapy devices (CRT, KAP 22 Gycm2), electrophysiological treatment of atrioventricular nodal re-entry tachycardia (6 Gycm2) and atrial flutter procedures (KAP 16 Gycm2). The values for TAVI and CRT device implantation are published for the first time on national level. Dose from image acquisition (cine) constitutes the major part of the total dose in coronary and atrial fibrillation ablation procedures. For TAVI, patient weight is a good predictor of patient dose.

A Unique All-Payer Rate-Setting System Controls the Cost but Not the Racial Disparity in Lower Extremity Revascularization Procedures

BACKGROUND

Patients with peripheral arterial disease often have high comorbidity burden that may complicate post-interventional course and drive increased health-care expenditures. Racial disparity had been observed in lower extremity revascularization (LER) patterns and outcomes. In 2014, Maryland adopted an all-payer rate-setting system to limit the rising hospitalization costs. This resulted in an aggregate payment system in which hospital compensation takes place as an overall per capita expenditure for hospital services. We sought to examine racial differences and other patient-level factors that might lead to discrepancies in LER hospital costs in the State of Maryland.

METHODS

We used International Classification of Diseases, Ninth Revision codes to identify patients who underwent infrainguinal open bypass (open) and endovascular repair (endo) in the Maryland Health Services Cost Review Commission database (2009-2015). Multivariable generalized linear model regression analysis was conducted to report cost differences adjusting for patient-specific demographics, comorbidities, and insurance status. Logistic regression analysis was used to assess quality metrics: intensive care unit (ICU) admission, 30-day readmission, protracted length of stay (pLOS) (endo: pLOS >9, open: pLOS > 10 days) and in-hospital mortality.

RESULTS

Among patients undergoing open, costs were higher for nonwhite patients (African-American [AA]: $6,092 [4,682-7,501], other: $3,324 [437-6,212]; both P ≤ 0.024), diabetics ($2,058 [837-3,279]; P < 0.001), and patients with Medicaid had an increased cost over Medicare patients by $4,325 (1,441-7,209). Critical limb ischemia (CLI) was associated with $5,254 (4,014-6,495) risk-adjusted cost increment. In addition, AA patients demonstrated higher risk-adjusted odds of ICU admission (adjusted odds ratio [aOR] [95% confidence interval {CI}]:1.65 [1.46-1.86]; P < 0.001) and pLOS (aOR [95% CI]: 1.56 [1.37-1.79]; P < 0.001) than their white counterparts. For patients undergoing endo, costs were higher for nonwhite patients (AA: $2,642 [1,574-3,711], other: $4,124 [2,091-6,157]; both P < 0.001). Patients with CLI and heart failure had increased costs after endo. AA patients were more likely to be readmitted or stayed longer after endo (1.16 [1.03-1.29], 1.34 [1.21-1.49]; both P < 0.010, respectively). The overall cost trend was rapidly increasing before all-payer rate policy implementation but it dramatically plateaued after 2014.

CONCLUSIONS

This study showed that the all-payer rate-setting system has curbed the LER rising costs, but these costs remained disproportionally higher for disadvantaged populations such as AA and Medicaid communities. This underpins the existing racial disparity in LER. AA patients had higher LER costs, most likely driven by extended hospitalization and ICU admission. Efforts could be directed to evaluate the contributing socioeconomic factors, invest in primary prevention of comorbid conditions that had shown to be associated with prohibitive costs, and identify mechanisms to overcome the existing racial disparity in LER within the promising cost-saving payment system at the State of Maryland.

Interventional Echocardiography: Field of Advanced Imaging to Support Structural Heart Interventions

Multimodality imaging, particularly echocardiography, is paramount in planning and guiding structural heart disease interventions. Transesophageal echocardiography remains unique in its ability to provide real-time 2D and 3D imaging of valvular heart disease and anatomic cardiac defects, which directly impacts the strategy and outcome of these procedures. This review summarizes the role of transesophageal echocardiography in patients undergoing the most common structural heart disease interventions.

Cost-effectiveness of transcatheter versus surgical management of structural heart disease

Transcatheter management of valvular and structural heart disease is the most growing aspect of interventional cardiology. While the early experience was limited to patients who were not candidate for surgery, the continuous improvement in the efficacy and safety expanded its use to different degree depending on the procedure and the disease involved. The cost of these procedures is a major concern for health care in developed world. Cost-effectiveness of these transcatheter structural procedures varies depending on the procedure itself, the burden of the underlying disease, the feasibility and cost of both the Transcatheter and surgical procedures. In this review, we turn now to a specific discussion of the medical economics of percutaneous valvular and structural interventions.

Cost-effectiveness of medical, endovascular and surgical management of peripheral vascular disease

Peripheral arterial disease (PAD) is responsible for 20% of all US hospital admissions. Management of PAD has evolved over time to include many medical and transcatheter interventions in addition to the traditional surgical approach. Non-invasive interventions including supervised exercise programs and antiplatelets use are economically attractive therapies that should be considered in all patients at risk. While surgery offers so far a clinically and economically appropriate option, the improvement of percutaneous transluminal angioplasty (PTA) technique with the addition of drug-coated balloons offers a reasonably clinically and economically attractive alternative that will continue to evolve in the future.