Cardiac Catheterization Suite Research Articles

Transvenous lead extraction: the jugular pull-through technique

Abstract Background Transvenous lead extraction (TLE) is vital to the management of cardiac implantable electronic devices (CIEDs). Evolving tools and techniques have contributed to an improvement in procedural safety and efficacy. The jugular access is advantageous in TLE, providing a linear, direct path to the heart for extraction sheaths. However, transfer of a lead with a deployed locking stylet from the subclavian to the jugular carries risk of cardiovascular injury. A novel jugular pull-through technique has been described for safe transfer of the lead and locking stylet from the native site to the jugular access, to facilitate TLE using a powered sheath. Purpose We report our early experience of the novel jugular pull-through technique which transfers a locking stylet and lead unit, from the subclavian to the jugular access for completion of TLE. Method The jugular pull-through technique entailed transfer of the deployed locking stylet with the lead via a long-sheath from the subclavian access to the jugular. In brief: a long wire positioned in the Superior Vena Cava via the jugular is snared and pulled from the subclavian site, permitting a long 8.5-french sheath to be railroaded through the jugular to surface at the subclavian access. The deployed locking stylet was fed through this long sheath to emerge at the jugular access; the sheath, locking stylet and lead were then pulled as a single entity to transfer the locking stylet and lead from the subclavian to the jugular. The rotational dissecting sheath was then advanced over the lead via the jugular in linear fashion to complete the lead extraction. Data for consecutive jugular pull-through procedures performed between 1/7/2022 – 31/12/2022 in our high-volume TLE institute were collected and evaluated for safety and efficacy. Results Three male patients aged 69.8±12.5 years with a left ventricle ejection fraction of 46.7±14.4%, underwent TLE for infection (67%). Of the 7 targeted leads, 4 (57%) were extracted using the jugular pull-through technique, all from the right ventricle (50% ICD) with 128±131.8 months dwell time. Of these 3 cases, 1 suffered diabetes, 1 hypertension, 1 ischaemic cardiomyopathy and 1 hypertrophic obstructive cardiomyopathy. All procedures were performed in the cardiac catheterisation suite under general anaesthesia using a locking stylet, compression coil, Evolution RL (13-french), a Needle’s Eye Snare, a loop snare and a long 8.5-french sheath with its 0.032 guidewire. The jugular pull-through technique facilitated 100% complete procedural success and 100% clinical success in the absence of any complications or procedural mortality; there was no 30-day mortality. Conclusion The jugular-pull-through technique allows safe transfer of a fully deployed locking stylet and lead from the subclavian to the jugular access, to facilitate jugular TLE.The jugular pull-through technique

Electrocardiographic deep learning for predicting post-procedural mortality: a model development and validation study

Preoperative risk assessments used in clinical practice are insufficient in their ability to identify risk for postoperative mortality. Deep-learning analysis of electrocardiography can identify hidden risk markers that can help to prognosticate postoperative mortality. We aimed to develop a prognostic model that accurately predicts postoperative mortality in patients undergoing medical procedures and who had received preoperative electrocardiographic diagnostic testing. In a derivation cohort of preoperative patients with available electrocardiograms (ECGs) from Cedars-Sinai Medical Center (Los Angeles, CA, USA) between Jan 1, 2015 and Dec 31, 2019, a deep-learning algorithm was developed to leverage waveform signals to discriminate postoperative mortality. We randomly split patients (8:1:1) into subsets for training, internal validation, and final algorithm test analyses. Model performance was assessed using area under the receiver operating characteristic curve (AUC) values in the hold-out test dataset and in two external hospital cohorts and compared with the established Revised Cardiac Risk Index (RCRI) score. The primary outcome was post-procedural mortality across three health-care systems. 45 969 patients had a complete ECG waveform image available for at least one 12-lead ECG performed within the 30 days before the procedure date (59 975 inpatient procedures and 112 794 ECGs): 36 839 patients in the training dataset, 4549 in the internal validation dataset, and 4581 in the internal test dataset. In the held-out internal test cohort, the algorithm discriminates mortality with an AUC value of 0·83 (95% CI 0·79-0·87), surpassing the discrimination of the RCRI score with an AUC of 0·67 (0·61-0·72). The algorithm similarly discriminated risk for mortality in two independent US health-care systems, with AUCs of 0·79 (0·75-0·83) and 0·75 (0·74-0·76), respectively. Patients determined to be high risk by the deep-learning model had an unadjusted odds ratio (OR) of 8·83 (5·57-13·20) for postoperative mortality compared with an unadjusted OR of 2·08 (0·77-3·50) for postoperative mortality for RCRI scores of more than 2. The deep-learning algorithm performed similarly for patients undergoing cardiac surgery (AUC 0·85 [0·77-0·92]), non-cardiac surgery (AUC 0·83 [0·79-0·88]), and catheterisation or endoscopy suite procedures (AUC 0·76 [0·72-0·81]). A deep-learning algorithm interpreting preoperative ECGs can improve discrimination of postoperative mortality. The deep-learning algorithm worked equally well for risk stratification of cardiac surgeries, non-cardiac surgeries, and catheterisation laboratory procedures, and was validated in three independent health-care systems. This algorithm can provide additional information to clinicians making the decision to perform medical procedures and stratify the risk of future complications. National Heart, Lung, and Blood Institute.

Adverse Events in the Pediatric Cardiac Catheterization Suite: Does Having Pediatric Cardiac Anesthesiologists Make a Difference?

It has been suggested that anesthesiologists with subspecialty expertise in pediatric cardiac anesthesia are best qualified to care for patients with complex congenital cardiac anomalies and manage the complex physiology frequently encountered in the pediatric cardiac catheterization lab. We evaluated the incidence of adverse events in our pediatric cardiac catheterization lab, comparing care provided by cardiac and noncardiac pediatric attending anesthesiologists. Data were collected on each anesthetic in the pediatric cardiac catheterization lab from January 1, 2016 to December 31, 2019. A generalized linear mixed effect model was used to identify associations between pediatric cardiac and noncardiac anesthesiologists and the presence of adverse events adjusting for age, American Society of Anesthesiologists physical status, emergency status, and interventional versus diagnostic procedures. A total of 3,761 procedures involving 1,729 patients were included in the study. There was no significant difference between noncardiac and cardiac anesthesia attendings for overall adverse events (odds ratio [OR], 1.2; 95% confidence interval [CI], 0.82 to 1.75 P=0.349). Specific respiratory adverse events (OR, 1.22; 95%, CI 0.73 to 2.03 P=0.443) or cardiac adverse events (OR, 1.26; 95% CI, 0.64 to 2.48 P=0.502) were also not significantly different with respect to noncardiac compared with cardiac attending anesthesiologists. In our analysis, the incidence of adverse events in the pediatric cardiac catheterization lab during the study period was not statistically different, whether anesthesia care was provided by a cardiac or a noncardiac anesthesiologist.

The Impact of Scripted Self-Hypnotic Relaxation on the Periprocedural Experience and Anesthesiologist Sedation Use in the Pediatric Cardiac Catheterization Suite: A Prospective Randomized Controlled Trial.

To assess the impact on children of self-hypnotic relaxation scripts read by trained staff prior to the induction of anesthesia and/or extubation on the periprocedural experience. A total of 160 children aged 7-18 years undergoing a cardiac catheterization intervention under general anesthesia were randomized into 4 groups: (1) a pre-procedure (PP-script) read prior to entering the procedural room, (2) a script read prior to extubation (PX-Script), (3) both PP- and PX-Scripts read and (4) no script read. Anxiety and pain were rated on self-reported 0-10 scales. The modified Yale Preoperative AnxietyScale was used for preoperative anxiety. The effect of script reading was associated with outcomes by linear regression for continuous variables, and logistic regression for binary variables in two-sided tests at a significance level of 0.05. Results are given in odds ratios (OR) and 95% confidence intervals (CI). Data were available for 158 patients. Reading the PP-Script prior to anesthesia was associated with a significant reduction in the use of intraoperative sedatives from 30% to 14% (OR 0.40; CI 0.18-0.88; p = 0.02) by the anesthesiologists, who were blinded to group attribution until extubation. This was despite the children not self-reporting significantly lower levels of anxiety or pain. The PX-Script did not change outcomes. Among groups, there was no significant difference in room time, postoperative recovery time and pain. Reading a PP-Script for guidance in self-hypnotic relaxation can result in less need for intravenous sedation in the judgment of the anesthesiologist, independent of the children's self-reported anxiety and pain. This raises interesting questions about subconscious patient-physician interactions affecting pain management. NCT02347748.

Interventions to prevent hypothermia in extremely preterm low-weight infants undergoing cardiac catheterisation

BackgroundIn January 2019, a new device called the Amplatzer Piccolo Occluder was approved by the US Food and Drug Administration for percutaneous closure of patent ductus arteriosus in infants weighing...

Transvenous lead extraction: the Tandem approach

Abstract Funding Acknowledgements Type of funding sources: None. Background Transvenous lead extraction (TLE) has become an important strategy in the management of patients with cardiac implantable electronic devices (CIEDs). A rising population of patients with CIEDs coupled with an expanding indication for TLE, has fuelled demand. There are notable procedural risks however development of techniques and tools have contributed to an improvement in the safety and efficacy of TLE. The mechanical rotational dissecting sheath is safe and efficacious whilst the Needle’s Eye Snare (NES) is an additional ‘bail-out’ strategy contributing to procedural success. Purpose We sought to evaluate the outcomes of TLE performed from the superior access in conjunction with counter-traction provided by snaring of the targeted lead via the femoral access. Method The ‘Tandem’ procedure consisted of the rotational powered sheath performing dissection of the adhesions encapsulating the leads (at the superior access), in ‘Tandem’ with the Needle’s Eye Snare providing countertraction via the femoral vein. In brief: after deployment of the locking stylet in the lead lumen, the NES was used to grasp the lead in the right atrium and hold it tort while a rotational sheath was used to dissect through the veins. Once the sheath reached the right atrium, the lead was released from the snare and the sheath was used to continue dissection toward the lead tip. Data for all consecutive ‘Tandem’ procedures performed between 1/1/2021 – 1/1/2022 in our high-volume TLE institute were collected and evaluated for safety and efficacy. Results Forty patients aged 69.2±16.3 (70% male), underwent TLE of 75 leads (45 right ventricle, 25, right atrium, 5 left ventricle) with dwell time of 150.1±80.3 months for a non-infectious indication (65%). Of the 40 cases, 27 were hypertensives, 14 had ischaemic heart disease whilst 5 suffered diabetes with a left ventricle ejection fraction of 46.8±10.2%; 12 (30%) were pacing dependent. Procedures were performed by cardiologists in the cardiac catheterisation suite under general anaesthesia (95%) using a locking stylet (100%) with an Evolution RL (11-french 58.7%); a NES 13 millimetres curve (88%) was used to successfully snare 91% of the targeted leads. Complete procedural success was achieved in 92% of leads with 98.7% clinical success. Minor complications occurred in 2 cases (pneumothorax, pocket haematoma requiring intervention), in the absence of any major complications or peri-procedural mortality; there was no 30-day mortality. Conclusion The ‘Tandem’ procedure provides an additional strategy to improve the safety and efficacy of TLE, especially in leads of a long dwell time.

Persistent left superior vena cava transvenous lead extraction: A European experience.

Transvenous lead extraction (TLE) is rising in parallel to cardiac implantable electronic device implantations. Persistent left side superior vena cava (PLSVC) is a relatively common anatomical variant in the healthy population; TLE in patients with a PLSVC is rare. Data were collated from 6 European TLE institutes of 10 patients who had undergone lead extraction with a PLSVC. Patient demographics, procedural challenges and outcomes were reported. Ten patients aged 73.4 ± 7.8 years (60% male) underwent TLE of 20 leads (3 left ventricle, 10 right ventricle, 7 right atrium) with dwell time of 82.95 ± 39.1 months. Of the 10 cases, 4 had an infection indication and 5 were biventricular system extractions; 25% of the extracted leads were defibrillator leads. The majority of the procedures were completed in the cardiac catheterization suite (80%) under general anaesthesia (60%) by cardiologists (80%) using a rotational powered sheath (65%). The Tandem approach was used successfully in 3 cases. Complete procedural success was obtained in 100% of cases in the absence of complications within 127.4 ± 74.7 min. There was no 30-day mortality. TLE in PLSVC is feasible albeit rare. Standard extraction techniques in experienced hands are associated with favorable outcomes; the Tandem procedure may be an additional technique to improve the safety and efficacy of TLE in PLSVC.

Berlin Heart Explantation Systematic Approach Protocol in a Single Center Experience

Introduction Berlin Heart EXCOR ventricular assist device (VAD) implantation in children is widely used as a bridge-to-heart transplantation. VAD support as a bridge-to-recovery is rare. There is scarcity of literature describing systematic evaluation of cardiac recovery employed in VAD explanation in children. Case Report A 13 month-old boy presented to the emergency department with acute congestive heart failure secondary to myocarditis. Echocardiogram demonstrated severely depressed left ventricular (LV) function with severe mitral regurgitation. He developed ventricular tachycardia with hemodynamic compromise necessitating institution of veno-arterial extracorporeal membranous oxygenation (ECMO). He was decannulated 11 days later after a successful trial off, but due to no further improvement in cardiac status, he underwent Berlin Heart EXCOR LVAD placement as a bridge-to-transplant. After 3 months of VAD support, we noted evidence of myocardial recovery and discussed the possibility of VAD explant. A weaning protocol was developed that consisted of two phases. The first phase consisted of a trial off with echocardiographic monitoring of biventricular function, atrioventricular valve regurgitation and LV diastolic dimension. The second phase was performed one week later in the cardiac catheterization suite, while monitoring hemodynamic measurements at baseline and with manual pumping followed by dobutamine challenge at the end of trial off. Clinical data was satisfactory and patient met established goals to undergo explant. Berlin explantation was succesfully performed the following day. His recovery was unremarkable and was discharged 2 weeks after explant. Patient was seen for follow-up at 1, 2 and 3 months post-discharge and he is doing well. Summary We established guidelines for trialing off VAD support to maximize the identification of potential candidates for VAD explantation. This protocol includes three main stages: screening, trial-off with echocardiography and trial-off in the catheterization suite. This case demonstrates that myocardial recovery can take longer than previously recognized in children with myocarditis and it highlights that strong consideration should be given to patients with a stable VAD course to remain inactive on the heart transplant waitlist to allow time for myocardial recovery and successful explantation.

Considerations for Pediatric Heart Programs During COVID-19: Recommendations From the Congenital Cardiac Anesthesia Society.

Considerations for Pediatric Heart Programs During COVID-19: Recommendations From the Congenital Cardiac Anesthesia Society.

Deep Tracheal Extubation Using Dexmedetomidine in Children With Congenital Heart Disease Undergoing Cardiac Catheterization: Advantages and Complications.

Objective. Deep tracheal extubation using dexmedetomidine is safe and provides smooth recovery in children with congenital heart disease undergoing cardiac catheterization. Design. Single-institution, retrospective study of prospectively collected data. Participants. All patients aged between 1 month and 5 years who underwent general endotracheal anesthesia for diagnostic and interventional cardiac catheterizations in the cardiac catheterization suite from January 2015 (change in standard operating procedure) through October 2016 (approval of institutional review board for study). Measurement and Main Results. One hundred and eighty-nine patients (81%) of the 232 patients who underwent cardiac catheterization during the study period were noted to undergo deep tracheal extubation. Cyanotic heart disease was present in 87 patients (46%), history of prematurity in 51 (27%), and pulmonary hypertension in 26 (14%) patients. A documented smooth recovery in the postoperative care unit (PACU) requiring no additional analgesics or sedatives was observed in 91% of the patients. The majority of patients required no airway support after deep extubation (n = 140, 74%, P = .136). The presence of pulmonary hypertension (odds ratio = 4.45, P = .035) and presence of a cough on the day of the procedure (odds ratio = 7.10, P = .03) were significantly associated with the use of oxygen or use of oral airway for greater than 20 minutes in the PACU. After extubation, there were no reported events of aspiration, the use of noninvasive positive pressure ventilation, reintubation, heart block, or systemic hypotension requiring treatment or cardiac arrest. Conclusions. Deep extubation using dexmedetomidine in infants and toddlers after cardiac catheterization is feasible and enables smooth postoperative recovery with minimal adverse effects.

Lessons learnt from the implementation of same-day discharge after percutaneous coronary intervention

BackgroundChange in healthcare organisations is constant and requires adequate resources for effective implementation. Same-day discharge after percutaneous coronary intervention has been found to be no different from the patients who stayed overnight after procedure; however, its uptake remains low. ObjectivesThe aim of the study was to identify what factors helped or hindered the implementation of same-day discharge. MethodsThis interpretive study was conducted in a cardiac catheterisation suite of an Australian tertiary hospital between June and December 2016. Semistructured individual interviews with 26 healthcare professionals were conducted to explore the factors that influenced the implementation. A deductive approach to content analysis was guided by the theoretical domains framework. FindingsFive domains, including beliefs about consequences, professional role and identity, resources, behaviour regulation, and optimism, were identified which were strongly related to the factors that impacted the implementation. The findings showed that participants believed same-day discharge benefits while also concerning about its safety and holding different opinions on eligibility criteria. The findings also showed that participants’ involvement in the change process varied with no clear roles and responsibilities and that their understanding about same-day discharge evidence and the guideline also differed. Lack of dedicated resources was also identified as the hindrance to the implementation. Behaviour regulation domain depicted how communication was managed and how the care for same-day discharge patients was improved. Despite several issues identified, participants were optimistic with achievement. Discussion and conclusionThis study has provided valuable insight into the factors that influenced the implementation, which will inform policymakers when designing interventions for future improvement. Plan for change and involvement of all stakeholders along with dedicated resources including time, people, and change management expertise are essential if hospitals want to see the success of change.

Fractional Flow Reserve Derived from Coronary Computed Tomography Angiography Datasets: The Next Frontier in Noninvasive Assessment of Coronary Artery Disease.

Fractional flow reserve (FFR) derived from coronary CTA datasets (FFRCT) is a major advance in cardiovascular imaging that provides critical information to the Heart Team without exposing the patient to excessive risk. Previously, invasive FFR measurements obtained during a cardiac catheterization have been demonstrated to reduce contrast use, number of stents, and cost of care and improve outcomes. However, there are barriers to routine use of FFR in the cardiac catheterization suite. FFRCT values are obtained using resting 3D coronary CTA images using computational fluid dynamics. Several multicenter clinical trials have demonstrated the diagnostic superiority of FFRCT over traditional coronary CTA for the diagnosis of functionally significant coronary artery disease. This review provides a background of FFR, technical aspects of FFRCT, clinical applications and interpretation of FFRCT values, clinical trial data, and future directions of the technology.

Management of hypoplastic left heart syndrome with intact atrial septum: a two-centre experience.

Introduction Hypoplastic left heart syndrome with an intact atrial septum is a poor predictor of outcomes. Prenatal assessment of pulmonary venous Doppler and emergent postnatal cardiac intervention may be associated with better outcomes. Materials and methods A retrospective review of all hypoplastic left heart syndrome patients in two centres over a 5-year period was performed. Group 1 included patients with adequate inter-atrial communication. Group 2 included patients with prenatal diagnosis with an intact atrial septum who had immediate transcatheter intervention. Group 3 included patients with intact atrial septum who were not prenatally diagnosed and underwent either delayed intervention or no intervention before stage 1 palliation. Primary outcome was survival up to stage 2 palliation. The incidence of hypoplastic left heart syndrome with a restrictive atrial communication was 11.2% (n=19 of 170). Overall survival to stage 2 or heart transplantation was 85% and 67% for Groups 1 and 2, respectively (n=129/151, n=8/12; p=0.03), and 0% (n=0/7) for Group 3. Survival benefits were observed between Groups 2 and 3 (p<0.001). Foetal pulmonary vein Doppler reverse/forward velocity time integral ratio of ⩾18% (sensitivity, 0.99, 95% CI, 0.58-1; specificity, 0.99, 95% CI, 0.96-1) was predictive of the need for emergent left atrial decompression. Using a multidisciplinary approach and foetal pulmonary vein Doppler, time-saving measures can be instituted by delivering prenatally diagnosed neonates with hypoplastic left heart syndrome with intact atrial septum close to the cardiac catheterisation suite where left atrial decompression can be performed quickly and safely that may improve survival.

Anesthesia and the pediatric cardiac catheterization suite: a review.

Advances in technology over the last couple of decades have caused a shift in pediatric cardiac catheterization from a primary focus on diagnostics to innovative therapeutic interventions. These improvements allow patients a wider range of nonsurgical options for treatment of congenital heart disease. However, these therapeutic modalities can entail higher risk in an already complex patient population, compounded by the added challenges inherent to the environment of the cardiac catheterization suite. Anesthesiologists caring for children with congenital heart disease must understand not only the pathophysiology of the disease but also the effects the anesthetics and interventions have on the patient in order to provide a safe perioperative course. It is the aim of this article to review the latest catheterization modalities offered to patients with congenital heart disease, describe the unique challenges presented in the cardiac catheterization suite, list the most common complications encountered during catheterization and finally, to review the literature regarding different anesthetic drugs used in the catheterization lab.

A Case Series of Real‐Time Hemodynamic Assessment of High Output Heart Failure as a Complication of Arteriovenous Access in Dialysis Patients

Congestive heart failure (CHF) is an important source of morbidity and mortality in end-stage renal disease patients. Although CHF is commonly associated with low cardiac output (CO), it may also occur in high CO states. Multiple conditions are associated with increased CO including congenital or acquired arteriovenous fistulae or arteriovenous grafts. Increased CO resulting from permanent AV access in dialysis patients has been shown to induce structural and functional cardiac changes, including the development of eccentric left ventricle hypertrophy. Often, the diagnosis of high output heart failure requires invasive right heart monitoring in the acute care setting such as a medical or cardiac intensive care unit. The diagnosis of an arteriovenous access causing high output heart failure is usually confirmed after the access is ligated surgically. We present for the first time, a case for real-time hemodynamic assessment of high output heart failure due to AV access by interventional nephrology in the cardiac catheterization suite.

Abstract 51: Can Wellens’ Sign be used to Predict Significant Proximal Left Anterior Descending Artery Lesion?

Background: Wellens’ sign (WS) has been reported as a sign of critical proximal left anterior descending (PLAD) artery lesion with lumen narrowing greater than 90%. Wellens’ ECG signs for critical PLAD lesion are characterized by two different electrocardiogram (ECG) patterns: 1) Deep T wave inversion in leads V2, V3 (approximately 76% of cases); and 2) Biphasic T wave in leads V2, V3 (approximately 24% of cases). The prevalence of the ECG feature of WS ranges from 14-18%. The prognostic significance of WS in detecting significant coronary artery lesion defined as a luminal narrowing of the coronary vessel by more than 70% has not been well studied. Our study’s goal was to evaluate if WS is present in all patients with critical and significant PLAD lesions and is a sensitive or specific sign for critical and significant (&gt;70% stenosis) PLAD lesions. Methods: All patients that underwent percutaneous coronary intervention (PCI) at an urban community hospital between January 2009 and December 2011 were included in the study. Log books from the cardiac catheterization laboratory were reviewed for all lesion types and corresponding demographics. The ECGs of patients with PLAD lesion were reviewed for T wave changes in precordial leads. Additionally, demographics such as age, gender and cardiovascular risk factors were recorded and analyzed. Descriptive statistics were used to analyze the data. Results: A total of 431 patients underwent PCI [emergent PCI 152 (35.3%), elective PCI 279 (64.7%)]. A total of 78 patients (18.1%) from both groups were found to have PLAD lesion. Fifty eight patients were male and 20 patients were female. The average age was 63.7 years. Critical PLAD lesion was present in 26 patients (33.3%) and 52 patients (66.7%) had PLAD lesion less than 90%. Of the 26 patients, 17 (65.4%) had WS. Wellens’ sign for predicting a critical PLAD had a sensitivity of 65.4%, a specificity of 69.2%, a positive predictive value (PPV) of 51.5% and a negative predictive value (NPV) of 80% (p = 0.0069, two-tailed Fisher’s exact test). Of the 42 patients who had PLAD lesion greater than 70%, 21 patients (50%) had WS. Of the 36 patients who had PLAD lesion less than 70%, 11 patients (30.6%) had WS. Wellens’ sign for predicting significant PLAD lesion in this cohort has a sensitivity of 50%, a specificity of 69.4%, a PPV of 65.6% and a NPV of 54.3% ( p = 0.1074). Conclusion: Our results corroborated prior studies showing that WS predicts the presence of critical (90%) PLAD lesion. Unfortunately, the value of WS for detecting/predicting significant CAD in PLAD was weak. Our results indicated that we were not able to predict the presence of significant (70%) PLAD lesion using WS. However, in appropriate clinical settings such as Non-ST elevation MI (NSTEMI) or unstable angina, Wellens’ sign may indicate the need for a more aggressive treatment strategy with patients proceeding to the cardiac catheterization suite sooner than later.

An analysis of radiation dose reduction in paediatric interventional cardiology by altering frame rate and use of the anti-scatter grid

The purpose of this work is to investigate removal of the anti-scatter grid and alteration of the frame rate in paediatric interventional cardiology (IC) and assess the impact on radiation dose and image quality. Phantom based experimental studies were performed in a dedicated cardiac catheterisation suite to investigate variations in radiation dose and image quality, with various changes in imaging parameters. Phantom based experimental studies employing these variations in technique identified that radiation dose reductions of 28%–49% can be made to the patient with minimal loss of image quality in smaller sized patients. At present, there is no standard technique for carrying out paediatric IC in the UK or Ireland, resulting in the potential for a wide variation in radiation dose. Dose reductions to patients can be achieved with slight alterations to the imaging equipment with minimal compromise to the image quality. These simple modifications can be easily implemented in clinical practice in IC centres.

A comparison between dual axis rotational coronary angiography and conventional coronary angiography

Coronary angiography remains the gold standard for the investigation of coronary artery disease, and is carried out in multiple, predefined stationary views, at different angulations around the patient, for both left and right coronary arteries. Dual axis rotational coronary angiography (DARA) is an alternative technique wherein the c-arm rotates around the patient in a preprogrammed single acquisition, exposing the entire coronary artery at different angulations. The DARA system has been recently installed in the Cardiac Catheterisation Suite at Mater Dei Hospital, Malta, where a monoplane and a biplane machine are available. This study was carried out in order to compare DARA with conventional single and biplane coronary imaging, with respect to radiation dose, contrast loads, and procedure time. This study was carried out over the period from September to December 2010. Four hundred sixty-three patients were studied. Patients referred for the investigation of native coronary anatomy, for whatever indication, were consented and included, and randomly assigned to one of four groups depending on which machine and modality was used: monoplane conventional, monoplane DARA, biplane conventional, and biplane DARA. DARA was statistically significantly superior in dose area product, fluoroscopy time, amount of contrast used, and procedure time. These reductions ranged between 12 (contrast used) and 71% (procedure time). The advantages of such systems are obvious to both patient and healthcare provider, and DARA may prove to be an important and useful tool in the refinement of diagnostic coronary angiography by reducing patient contrast and radiation doses and reducing procedure time.

Use of Emergency-Release, Uncrossmatched O Negative Red Blood Cells (RBCs) in a Tertiary Care Children's Hospital

Abstract 4341 Background:Transfusion services must offer means of issuing blood products quickly for emergent transfusions. At Lucile Packard Children's Hospital (LPCH), off-site refrigerators were installed in the Neonatal Intensive Care Unit (NICU), the LPCH operating room (OR) and the Cardiovascular Intensive Care Unit (CVICU) inventoried with uncrossmatched O negative RBCs for immediate emergency use. Uncrossmatched O negative RBCs are also provided to children undergoing cardiac catheterization at the discretion of the Pediatric Cardiologist, since these patients commonly do not have type and screen samples drawn until large vessel venous cannulation via insertion of the catheter. Uncrossmatched blood products are also provided for children per our massive transfusion protocol (MTP). The purpose of this study was to assess the utilization of these uncrossmatched blood products in children and its impact on transfusion service (TS) inventory of O negative RBCs. Methods:Orders received for emergency-release uncrossmatched RBCs for patients ages 0 days to 18 years including MTPs from January 1 2011 to March 31 2011 were evaluated retrospectively. Variables collected include: patient demographic information and diagnosis; blood products ordered, released and transfused; location of the patient and location from where blood was dispensed (off-site refrigerator versus [vs] TS). Results:Median patient age was 3.46 years (range 0 days to 15.62 years), and 82% of the patients had congenital heart disease. Sixty four RBCs were issued to 33 patients during the 3-month study period. Of those, 32 RBCs were transfused, 8 RBCs were wasted because temperature parameters were exceeded before return to the TS, and 24 RBCs (38%) were not transfused and returned to TS inventory. Nineteen of the 32 RBCs were transfused, representing 2% of the total 964 O negative RBC units transfused at our institution for that time period. Nineteen (58%) units were for children in the cardiac catheterization suite. Seven patients were in the CVICU, five children were in the NICU, and two were in the Pediatric Intensive Care Unit. Two units of O negative RBCs were dispensed from the emergency off-site refrigerator in the CVICU. Discussion:The majority of children (79%) who received emergency-release uncrossmatched O negative RBCs at LPCH were those with congenital heart disease undergoing cardiac catheterization or being cared for post-operatively in the CVICU. There were 2 instances of children requiring RBCs from off-site refrigerators for an emergent transfusion. Emergency-release, uncrossmatched O negative RBCs at LPCH either from the TS or from three off-site refrigerators caused no undue strain on our supply and inventory of donor O negative RBCs. Disclosures:No relevant conflicts of interest to declare.

Too Much To Ask?

A seventy-eight-year-old Chinese man is admitted to the hospital with a cerebral hemorrhage. Over the course of several weeks, his neurosurgeons repeatedly discuss his poor prognosis with his family, advising them to consider abandoning aggressive intervention in favor of comfort care. The only family member who speaks English is the man's son, who is a physician. He translates for the rest of the family, but whether they understand the gravity of the situation is unclear, as they interpret any sign of movement as a hopeful event. Eventually, after the man's family has tried a traditional Chinese herbal remedy that hasn't worked, a palliative care consultation is held in which they are again asked if they would consider discontinuing the catheters and ventilator. They seem agreeable, but they wish to consult with other family members before giving a final answer. After more time goes by, the team requests an ethics consultation with a translator present. It becomes clear that the family has understood neither the gravity of the situation nor the concept of comfort care. The family asks whether, if they agree to comfort care only, the man's body can remain untouched for eight hours after his death to conform to their Buddhist faith, which dictates that the deceased's body should remain undisturbed for a period of time after death to allow the soul to exit the body. On being assured that this wish will be honored, the family agrees to a do not attempt resuscitation/do not intubate order. The patient dies shortly thereafter. Because the death occurs so quickly, there is no time to move the man out of the intensive care unit as had been planned, but the family's request to leave the body undisturbed is nevertheless accommodated. During the time that the body is in the ICU, another physician attempts to get an acutely ill patient with severe gastrointestinal bleeding admitted, but a bed is not available. As a result, this patient must be directly admitted to the cardiac catheterization suite. (Neither the medical team caring for the Chinese man nor the hospital's ethics consultation service were aware that another patient needed the ICU bed.) Several days later, the physician who tried to admit the patient discovers that a corpse was occupying a bed in the ICU. He is incredulous. Can we justify allowing a body to occupy a bed needed by a living patient? Commentary by Lauren B. Smith and Patricia J. Lyndale Our country values religious freedom and is unique in its ethnic diversity. In spite of this, medical facilities have been slow to adopt culturally and religiously diverse approaches to patient care and end-of-life issues. However, in recent years, treatment teams have received additional training in cultural sensitivity, and if a cultural practice can be accommodated in the course of treatment, this is encouraged, as it builds rapport and recognizes the patient as an individual. Chaplain services are also widely available, and many faiths are now represented. Hospitals attempt to accommodate other types of requests as well, whether they are religious or cultural. For example, in our community, it is not uncommon for Muslim women to request a female practitioner for intimate examinations or for family members to ask that patients not be told of their terminal diagnoses to preserve hope. This case is unique in several respects. One could argue that the needs of the deceased took precedence over those of a critically ill living patient. In this type of situation, our societal and cultural values would support a different course of action in which we prioritize the sick; only once this has occurred can we focus on spiritual needs. However, this man's family agreed to withdraw care under this specific condition. If the condition had not been accommodated, the patient might still be alive and occupying the bed. The team made a promise to the family, so it would be difficult to justify a different course of action after death. …