Cardiac Catheterization Procedures Research Articles

Pulmonary Vein Stenosis: A Rare Disease with a Global Reach.

Pulmonary vein stenosis (PVS) is a rare, but high mortality and resource intensive disease caused by mechanical obstruction or intraluminal myofibroproliferation, which can be post-surgical or idiopathic. There are increasing options for management including medications, cardiac catheterization procedures, and surgery. We queried the International Quality Improvement Collaborative for Congenital Heart Disease (IQIC) database for cases of PVS and described the cohort including additional congenital lesions and surgeries as well as infectious and mortality outcomes. IQIC is a quality improvement project in low-middle-income countries with the goal of reducing mortality after congenital heart surgery. Three cases were described in detail with relevant images. We identified 57 cases of PVS surgery, with similar mortality to higher income countries. PVS should be recognized as a global disease. More research and collaboration are needed to understand the disease, treatments, and outcomes, and to devise treatment approaches for low resource environments.

Fontan-Associated Anatomical Variants and Hepatic Fibrosis.

We hypothesized that a relationship between post-Fontan hepatic fibrosis and anatomical variants might exist. Attempting to limit confounding variables, we analyzed data from living, stable, post-extracardiac Fontan patients who underwent cardiac catheterization and transvenous hepatic biopsy procedures between March 2012 and June 2020. We identified 120 patients who met the inclusion criteria. Of the 120, 35 (29%) had pulmonary artery stents. For the 35 with pulmonary artery stents, the average total fibrosis score was 3.2 ± 1.9 and the fibrosis progression rate was 0.36 ± 0.33, and for those with no pulmonary artery stents, the total fibrosis score was 2.6 ± 1.8 and the fibrosis progression rate was 0.27 ± 0.33 (P = .13 and P = .11, respectively). Of the 120, 65 had functional univentricles of right ventricular type. Of these 65, 27 had pulmonary artery stents. For the 27 with pulmonary artery stents, the average total fibrosis score was 3.4 ± 1.8 and the average fibrosis progression rate was 0.39 ± 0.30, and for the 38 without pulmonary artery stents, the average fibrosis score was 2.3 ± 1.5 and the average fibrosis progression rate was 0.23 ± 0.21 (P = .01 for comparison of both values). This study's findings suggest that a post-extracardiac Fontan with a functional univentricle of right ventricular type plus a pulmonary artery stent may have more advanced liver pathology than those without a pulmonary artery stent at similar Fontan duration years and ages at liver biopsy.

Virtual Reality Assisted Cardiac Catheterization.

Cardiac catheterization is a delicate strategy often used during various heart procedures. However, the procedure carries a myriad of risks associated with it, including damage to the vessel or heart itself, blood clots, and arrhythmias. Many of these risks increase in probability as the length of the operation increases, creating a demand for a more accurate procedure while reducing the overall time required. To this end, we developed an adaptable virtual reality simulation and visualization method to provide essential information to the physician ahead of time with the goal of reducing potential risks, decreasing operation time, and improving the accuracy of cardiac catheterization procedures. We additionally conducted a phantom study to evaluate the impact of using our virtual reality system prior to a procedure.

Music before undergoing cardiac catheterisation between preference and reality. A pilot study.

Previous studies have reported beneficial effects of music in the context of health care: anxiolytic, distracting, pain reliever, promoting nutrition, socialization and comfortable environment. In this pilot study, the patient's point of view before undergoing cardiac catheterization procedure was described. Attitudes to music, including habitual listening by genre and broadcasting were compared with its useful in hospital and in the specific pre-procedural condition. In this cross-sectional study, the interview was conducted through a semi-structured paper questionnaire, subjected to face validity. The sample consisted of patients waiting for the procedure (N=45) included by randomized sampling. A Spearman coefficient was conducted to observe statistically significant correlations. Data were analysed using 24.0 SPSS software. 80% of respondents prefer Italian pop music during procedural waiting, played by loudspeakers (71%). they think music can help them engage the wait (55.6%) and alleviate unpleasant feelings (33.3%). Favorable attitude to music in hospital (91.1%) is significantly correlated to its useful in hospital (p=0.01) but only 8.9% actually use it. Music Preferences support pre-recorded Italian pop music played with loudspeakers, recognized by the patient as the most desired activity while waiting for the procedure. The patient's choice to attribute to music the ability to alleviate unpleasant sensations before the procedure is due to the need for emotional support, to which it can effectively respond. Studies are needed to explore preferences before, during and after music listening and also educate stakeholders in the use of guidelines for music based interventions.

Anesthesia Management for Pediatrics with Congenital Heart Diseases Who Undergo Cardiac Catheterization in China

Objectives The goal of this study was to summarize anesthesia management for pediatrics with congenital heart diseases who undergo cardiac catheterization procedure in China. Methods The relevant articles were identified through computerized searches in the CNKI, Wanfang, VIP, and PubMed databases through May 2020, using different combinations of keywords: “congenital heart diseases,” “pediatric,” “children,” “anesthesia,” “cardiac catheterization,” “interventional therapy,” “interventional treatment,” “interventional examination,” and “computed tomography.” Results The database searches identified 48 potentially qualified articles, of which 25 (9,738 patients in total) were determined to be eligible and included. The authors collect data from the article information. Anesthesia methods included endotracheal intubation or laryngeal mask ventilation general anesthesia, monitored anesthesia care, and combined with sacral canal block. Anesthesia-related complications occurred in 7.41% of the patients and included dysphoria, respiratory depression, nausea, vomiting, cough, increased respiratory secretion, and airway obstruction. The incidence of procedure-related complications was 12.14%, of which the most common were arrhythmia and hypotension. Conclusions For pediatric patients with congenital heart diseases who undergo cardiac catheterization procedures in China, arrhythmia and hypotension are the most common procedure-related complications. Monitored anesthesia care is the commonly used anesthesia methods, and dysphoria, cough, nausea, vomiting, and respiratory depression are frequent complications associated with anesthesia.

COVID-19 Pandemic and Volume of Cardiac Catheterization Procedures in Jordan: Impact of Strict Lockdown.

Introduction:Global surge of COVID-19 forced most countries to impose variable measures to curb the disease. Jordan imposed one of the strictest lockdowns from mid-March through April 2020. Hospitals deferred elective cardiac catheterization procedures and most of those performed during that period were limited to urgent presentations. Our purpose is to evaluate the impact of strict lockdown on cardiac catheterization procedural volume.Methods and Results:We collected data about the numbers of all coronary angiography (CA) and percutaneous coronary intervention (PCI) procedures performed in 5 tertiary care hospitals in Amman, Jordan, from January through June 2020. We compared the volume of procedures performed in April 2020 (the strict lockdown month) to the corresponding period of prior year (April 2019) and to volumes performed prior to the lockdown in January–February 2020.There was a 64% decline in CA and PCI volumes in April 2020 compared to April 2019. Comparing number of procedures performed in April 2020 to those in January–February 2020, there was 59% decline in CA and a 60% decline in PCI volumes. Following partial lifting of lockdown in May–June 2020, procedural volumes increased gradually.Conclusion:Strict COVID-19-related lockdown in Jordan was associated with drastic declines in cardiac catheterization procedural volumes.

Doğuştan Kalp Hastalığı Olan Çocuklarda Kardiyak Kateterizasyon Sırasında Saptanan Üriner Sistem Anomalileri

Objective: Congenital heart diseases in childhood are an important cause of morbidity and mortality. The frequency of non-cardiac anomalies in children with congenital heart diseases is between 7-50%. Urinary system anomalies are an important risk factor in children with congenital heart diseases. The aim of this study was to evaluate the presence, types and frequency of urinary system anomalies detected during cardiac catheterization in children with congenital heart diseases. Methods: The cineurography records of 6000 patients who underwent cardiac catheterization due to congenital heart diseases were retrospectively analyzed. Urinary system anomalies detected were examined as renal agenesis, renal ectopia, renal fusion, dysplastic kidney, obstructive uropathy, vesicoureteral reflux, ureter anomaly and bladder anomaly. Patients were grouped as right ventricular outflow tract obstruction, left ventricular outflow tract obstruction, left-to-right shunted hearth disease and, cyanotic or complex heart diseases. The groups were compared in terms of urinary system anomaly types. Results: Seventy-six patients (47 male and 29 female) with urinary system abnormalities were detected. Obstructive uropathy was found in 43 (56.5%) patients, renal agenesis was found in 14 (18.4%) patients, ureter anomaly was found in 14 (18.4%) patients, renal fusion was found in 3 (3.9%) patients, renal ectopia was found 1 (1.3%) patient, vesicoureteral reflux was found in 1 (1.3%) patient. There was no significant difference in term of the urinary system anomaly types among the groups (p>0.05) Conclusion: Urinary system anomalies may also be frequently accompanied in children with congenital heart diseases, so urinary system should also be evaluated during the cardiac catheterization procedure.

Safety and effectiveness of strategies to reduce radiation exposure to proceduralists performing cardiac catheterization procedures: a systematic review.

The objective of this systematic review was to synthesize the best available evidence on the effect of various radiation protection strategies on radiation dose received by proceduralists performing cardiac catheterization procedures involving fluoroscopy. Cardiac catheterization procedures under fluoroscopy are the gold standard diagnostic and treatment method for patients with coronary artery disease. The growing demand of procedures means that proceduralists are being exposed to increasing amounts of radiation, resulting in an increased risk of deterministic and stochastic effects. Standard protective strategies and equipment such as lead garments reduce radiation exposure; however, the evidence surrounding additional equipment is contradictory. Randomized controlled trials that compared the use of an additional radiation protection strategy with conventional radiation protection methods were considered for inclusion. The primary outcome of interest was the radiation dose received by the proceduralist during cardiac catheterization procedures. A three-step search was conducted in MEDLINE, CINAHL, Embase, and the Cochrane Library (CENTRAL). Trials published in the English language with adult participants were included. Trials published from database inception until July 2019 were eligible for inclusion. The methodological quality of the included studies was assessed using the JBI critical appraisal checklist for randomized controlled trials. Quantitative data were extracted from the included papers using the JBI data extraction tool. Results that could not be pooled in meta-analysis were reported in a narrative form. Fifteen randomized controlled trials were included in the review. Six radiation protection strategies were assessed: leaded and unleaded pelvic or arm drapes, transradial protection board, remotely controlled mechanical contrast injector, extension tubing for contrast injection, real-time radiation monitor, and a reduction in frame rate to 7.5 frames per second. Pooled data from two trials demonstrated a statistically significant decrease in the mean radiation dose (P < 0.00001) received by proceduralists performing transfemoral cardiac catheterization on patients who received a leaded pelvic drape compared to standard protection. One trial that compared the use of unleaded pelvic drapes placed on patients compared to standard protection reported a statistically significant decrease (P = 0.004) in the mean radiation dose received by proceduralists.Compared to standard protection, two trials that used unleaded arm drapes for patients, one trial that used a remotely controlled mechanical contrast injector, and one trial that used a transradial protection board demonstrated a statistically significant reduction in the radiation dose received by proceduralists.Similarly, using a frame rate of 7.5 versus 15 frames per second and monitoring radiation dose in real-time radiation significantly lowered the radiation dose received by the proceduralist. One trial demonstrated no statistically significant difference in proceduralist radiation dose among those who used the extension tubing compared to standard protection (P = 1). This review provides evidence to support the use of leaded pelvic drapes for patients as an additional radiation protection strategy for proceduralists performing transradial or transfemoral cardiac catheterization. Further studies on the effectiveness of using a lower fluoroscopy frame rate, real-time radiation monitor, and transradial protection board are needed.

Fluoroscopy-induced chronic radiodermatitis: three cases presenting after cardiac catheterization

Fluoroscopy-induced chronic radiodermatitis is a rare complication that is now encountered more often owing to the increasing use of fluoroscopy in radiological procedures. The long duration between radiation exposure and development of condition, patient unawareness of exposure to radiation along with lack of clinical suspicion of the condition among dermatologists, all make the diagnosis difficult. We report three cases of male patients who presented with a clinical picture suggestive of fluoroscopy-induced chronic radiodermatitis backed up by history of cardiac catheterization procedures confirming the diagnosis. Awareness of this entity among dermatologists is important for early recognition and proper management.

The Effect of Radiation Exposure on Cancer Development Among Interventional Cardiologists: A Literature Review

Cardiac catheterisation procedures including coronary angiogram and angioplasty confer occupational health risks to performing interventional cardiologists. The aim of this review is to investigate the association between radiation exposure among interventional cardiologists and development of cancer.

Combination of InnoSEAL plus TR band compared with TR band alone for radial artery outcomes in patients undergoing transradial coronary intervention (InnoSEAL-II): an open-label randomised controlled trial (protocol)

IntroductionAbout 2%–30% of cardiac catheterisation procedures get complicated by radial artery occlusion (RAO). Ensuring patent haemostasis appears to be an important factor in reducing RAO. Currently employed method is a...

Interventional Cardiovascular Magnetic Resonance Imaging (iCMR) in an Adolescent with Pulmonary Hypertension

The interventional cardiac magnetic resonance imaging (iCMR) catheterization procedure is feasible and safe for children and adults with pulmonary hypertension and congenital heart defects (CHD). With iCMR, the calculation of pulmonary vascular resistance (PVR) in children with complex CHD with multilevel shunt lesions is accurate. In this paper, we describe the role of the MRI-guided right-sided cardiac catheterization procedure to accurately estimate PVR in the setting of multiple shunt lesions (ventricular septal defect and patent ductus arteriosus) and to address the clinical question of operability in an adolescent with trisomy 21 and severe pulmonary hypertension.

Abstract 16489: Comparison of Severity of Illness at Presentation and Outcomes for Patients With Acute Cardiovascular Syndromes Before and During Covid-19 Pandemic

Introduction: The New York Governor Andrew M. Cuomo’s executive order N202.25 on March 7, 2020, canceled all elective, semi-urgent procedures, including cardiovascular interventions such as coronary angiography and angioplasty due to SARS- Cov2 (COVID 19) pandemic. New York City was devastated by COVID 19 infection carrying the highest incidence, prevalence, and mortality rates in the US. Importantly, a 4. 4.83-fold increase in death rate at home was reported. We hypothesized that the COVID19 surge postponed the patient's decision to seek medical attention leading to an increase in cardiovascular-related hospital mortality. Methods: We conducted a retrospective observational study examining the incidence, prevalence, complication rate, and mortality from cardiovascular diseases in hospitalized patients during COVID 19 surge. We performed a patient chart review of a cohort with acute cardiovascular events (STEMI, NSTEMI, Stroke, CHF) during the COVID 19 surge who were hospitalized at Montefiore Medical Center between March 7, 2020, and April 21, 2020, and compared it to a similar cohort from the preceding year (March 7, 2019 and April 21, 2019). Results: During the dates (March 7- April 21, 2020), there was a significant decrease in NSTEMI, stroke, and CHF admissions (P&lt;0.05). (Figure 1) Respectively, fewer cardiac catheterization procedures were performed for patients presenting with NSTEMI, UA, and shock. There was no difference in the number of STEMI admissions. Troponin T levels at presentation were significantly higher (P&lt;0.05), and increased prevalence of wall motion abnormalities and LVEF &lt; 50% (P&lt;0.05). Mortality for HF asdmissions was 20% in 2020 compared to 0.02% in 2019. Conclusions: Montefiore Medical Center admitted and treated significantly fewer patients with acute cardiovascular syndromes during the COVID19 surge. Non-COVID patients presented with delayed MI. All HF patients (COVID+Non-COVID) carried a significantly higher mortality rate.

Abstract 15463: Pre-procedural Inr, Bleeding, and Mortality in the Catheterization Lab: Does INR Still Matter in the Radial First Era?

Background: Warfarin anticoagulation presents a common barrier to undergoing cardiac catheterization procedures. Using radial access and other bleeding mitigation strategies, it is not known if elevated INR truly portends an increased risk of adverse events. We sought to understand the relationship between in hospital mortality and bleeding with INR in patients undergoing coronary interventional catheterization procedures. Methods: The prospectively-collected Dartmouth Dynamic Registry was queried for all patients who underwent catheterization with coronary intervention from 2014 to 2018. Of the 5015 patients identified, 2120 patients had a recorded INR value within 24 hours of the procedure. Demographics, procedural variables, and in hospital outcomes were collected. Patients were divided into two groups: INR &amp;lt1.8 and INR &amp;gt1.8. Incidence of bleeding (access site hematoma &amp;gt5cm, post procedure blood transfusion) as well as in-hospital mortality were queried for each group. Stata was used to determine statistical significance, using chi-square analysis for categorical variables and standard t-test for continuous variables. Results: Of the 2120 patients with INR values, 1968 patients were identified with INR &amp;lt1.8 (median INR 1.1; range 0.7-1.7) and 152 patients with INR &amp;gt1.8 (median INR 2.2; range 1.8-11.1). Patients with elevated INRs had higher acuity (urgent or emergent cases) and were older. Other baseline and procedural characteristics were similar. Outcomes between those with elevated INR and those with lower INR values were similar, including access site injury, hematoma, and need for transfusion (Table I). Overall mortality did not differ between the two groups. Conclusion: When compared to patients with INR &amp;lt1.8, patients with INR &amp;gt1.8 are more likely to undergo coronary intervention on an urgent or emergent basis. Despite this, there is no difference in bleeding, need for transfusion, or overall in-hospital mortality.

Peripheral venous pressure accurately predicts central venous pressure in the adult Fontan circulation

BackgroundPatients with the Fontan circulation lack a subpulmonary ventricular pump and thus the main driver for pulmonary blood flow is a high central venous pressure. Peripheral venous pressure (PVP) measurement has been shown to be a reproducible and fairly accurate surrogate for central venous pressure (CVP), but not specifically for the adult Fontan circulation. This study aims to determine the relationship of PVP to CVP in adult Fontan patients. MethodsAll adult patients (≥18 yo) with a Fontan circulation undergoing cardiac catheterization were included. Both CVP and PVP were measured during the catheterization. The relationship between the peripheral venous and central venous pressures was assessed using simple linear regression and the Bland-Altman plot analysis for differences. ResultsThirty-eight adult Fontan patients (mean age 30.7 ± 8.5, range 18–52 years) undergoing 43 cardiac catheterizations were analyzed. The mean CVP was 17.3 +/− 4.7 mmHg. The mean PVP was 18.4 +/− 5 mmHg. CVP and PVP were highly correlated, with an R2 value of 0.83 (p < 0.001). The CVP can be estimated with PVP measurements using the formula CVP = (0.86 * PVP) + 1.3. A Bland-Altman plot for PVP and CVP demonstrated that the PVP overestimated CVP by a mean of 1.2 mmHg, with a 95% limit of agreement of −5.2 mmHg to 2.8 mmHg. ConclusionsIn adult Fontan patients, measuring PVP is a reliable, less-invasive, and accurate method of estimating the CVP during cardiac catheterization procedures. These findings may enable outpatient monitoring of Fontan hemodynamics.

Patient Experience After Risk Stratification and Follow-up for Acute Kidney Injury After Cardiac Catheterization: Patient Survey

BackgroundAcute kidney injury (AKI) after cardiac catheterization procedures is associated with poor health outcomes. We sought to characterize the experiences of patients after receiving standardized information on their risk of AKI accompanied by instructions for follow-up care after cardiac catheterization. MethodsWe implemented an initiative across 3 cardiac catheterization units in Alberta, Canada to provide standardized assessment, followed by guidance for patients at risk of AKI. This was accompanied by communication to primary care providers to improve continuity of care when patients transition from the hospital to the community. A structured survey from a sample of 100 participants at increased risk of AKI determined their perceptions of information provided and experiences with follow-up steps after the initiative was implemented in each cardiac catheterization unit in Alberta. ResultsThe mean age of participants was 72.4 (SD 10.4) years, 37% were female, and the mean risk of AKI was 8.8%. Most (63%) participants were able to recall the information provided to them about their risk of kidney injury, 68% recalled the education provided on strategies to reduce risk, and 65% believed their primary care practitioner had received enough information to conduct appropriate follow-up care. Eighty-six percent of patients were satisfied with their transition to the community, and 53% were reassured by the information and follow-up care they received. ConclusionsThese findings suggest that communicating risk information to patients, in combination with education and collaboration for follow-up with primary care providers, is associated with positive patient experiences and satisfaction with care.

Treatment with sacubitril/valsartan in European outpatients with chronic heart failure in Europe: results from ARIADNE registry

Abstract Background Recently, the angiotensin receptor neprilysin inhibitor (ARNI) sacubitril/valsartan (S/V) was introduced as a novel therapeutic option into European guidelines for the management of heart failure (HF). The Assessment of Real lIfe cAre –Describing EuropeaN hEart failure management (ARIADNE) registry provides real world information about its use and efficacy in real life in outpatients with heart failure with reduced ejection fraction (HFrEF) in Europe. Methods ARIADNE was a prospective registry of patients with HFrEF (NYHA II-IV, reduced EF) treated by office-based cardiologists or selected primary care physicians (recognized as HF specialists) in a real world setting. 9069 HFrEF patients were enrolled from 674 investigators in 17 European countries, and followed over 12 months. Out of 8787 patients fulfilling criteria for analysis, 52.5% of the patients received S/V treatment at baseline, whereas 47.5% continued on their previous individualized heart failure medication. Results of S/V patients are reported here. Results The mean age of patients prescribed S/V was 67.3 years, mainly NYHA class II or III (49.7% and 48.2%, respectively), and mean LVEF of 32.7%. Common documented comorbidities were arterial hypertension (63.7%), coronary heart disease (62.4%), dyslipidemia (50.3%), diabetes (32.5%), and chronic kidney disease (24.1%). Of the 4143 patients in the S/V group, 89.9% received S/V at baseline, 74.8% received S/V in combination with a β-blocker; 47.8% with a β-blocker and MRA. Within 6 months of the observational period, 693 (17.4%) of the S/V patients were hospitalized, of which 46.8% and 28.7%, had HF related and non-HF cardiovascular (CV) hospitalizations. Emergency room visits without hospitalization were documented for 3.4% of S/V patients in the same time period; stroke and myocardial infarction occurred in 22 (0.5%) and 24 (0.6%) of the S/V patients, respectively. Cardiac catheterization or coronary angiography procedures were applied to 1.7% and 2.8% of the S/V patients. Total mortality was 4.3% (S/V 3.8%; non-S/V 5.0%), cardiovascular mortality 1.9% (S/V 1.8%; non-S/V 2.2%), during the 12 month observational period. The proportion of S/V patients in NYHA class III or IV decreased in the course of the study from 44.6% to 24.0%. After 12 months of follow up, 46.3% of patients with NYHA class III had a reported improvement to NYHA class II. Consistently, mean LVEF increased to 37.9%. The percentage of S/V patients with LVEF &amp;lt;22.5% decreased from 11.5% to 5.8%. KCCQ overall summary score increased by 1.9 points. An improvement of ≥5 points, denoting a clinically meaningful increase, was reported for 36.2% of S/V patients. Conclusions Data from the ARIADNE prospective registry portray a diverse, multinational study cohort receiving sacubitril/valsartan under real-world conditions. Throughout the study, symptoms and quality of life improved with the use of S/V. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Novartis AG, Switzerland

A comparative study of intravenous combination of Dexmedetomidine and ketamine versus fentanyl and ketamine as sedative agents in children undergoing interventional Cardiac Catheterization procedures

Fentanyl is a highly selective mu-agonist (or MOP agonist); the MOP receptor appears to be specifically involved in the mediation of analgesia. Opioids appear to exert their effects by interacting with presynaptic Gi-protein receptors, leading to hyperpolarization of the cell membrane by increasing K+ conductance. Inhibition of adenylate cyclase, leading to reduced production of cAMP, and closure of voltage-sensitive calcium channels also occur. After institutional scientific and ethical committee approval, a written informed consent was obtained from parents. 70 paediatric patients, American Society of Anesthesiologists (ASA) physical status II and III, aged between 4 to 12 yrs with acyanotic congenital heart disease admitted for elective interventional cardiac catheterization procedures are included in this study. There is significant difference in the mean duration of sedation attained by group D and group F both statistically and clinically. The sedation time does include the procedure duration and duration from end of procedure to attainment of the steward score of 7.

Women With Spontaneous Coronary Artery Dissection Are at Increased Risk of Iatrogenic Coronary Artery Dissection

Spontaneous coronary artery dissection (SCAD) is a non-atherosclerotic cause of acute coronary syndrome (ACS) that affects women disproportionately. Previous case series have found that patients with SCAD undergoing cardiac catheterisation have high rates of iatrogenic coronary damage. We formally compared the rate of iatrogenic coronary artery dissection in women with and without SCAD undergoing cardiac catheterisation over a 11-year period. Women with SCAD were identified by a search of the cardiac catheterisation database 2007-2017 for the keywords 'SCAD', 'spontaneous coronary artery dissection', 'spontaneous coronary dissection', and 'spontaneous dissection'. For each identified case, the medical record and the coronary angiogram images were reviewed to confirm spontaneous coronary dissection. For cases of recurrent SCAD, duplicates were removed so that each patient was included only once in this analysis. For each identified case of SCAD, a control case was chosen from women aged <70 years, without SCAD, undergoing cardiac catheterisation for an ACS during the same 10-year period. One control case was chosen to match each SCAD patient as closely as possible for age and year of cardiac catheterisation. Iatrogenic coronary dissection was defined as new, proximal, flow limiting coronary artery dissection in a different coronary segment to the presenting spontaneous coronary dissection. Eighty-five (85) cases of women with SCAD were identified. Mean age was not different between SCAD and non-SCAD women (51±11 and 51±10 years, respectively). The SCAD group had lower rates of ST elevation myocardial infarction, lower rises in serum creatine kinase (CK) and troponin levels, lower rates of diabetes and smoking, and far less placement of stents during the procedure than the control group. The rate of additional iatrogenic dissection relating to the cardiac catheterisation procedure was 4 of 85 (4.7%) versus 0 of 85 (0%), p=0.04 in SCAD and control groups, respectively, despite a much lower rate of percutaneous coronary intervention in the SCAD group. No common factors could be identified regarding particular equipment or procedural factors associated with iatrogenic dissection. The rate of iatrogenic dissection in women with SCAD during cardiac catheterisation is confirmed to be high and significantly higher than a contemporaneous age-matched group of women without SCAD. This observation likely indicates generalised coronary fragility in this disease, and emphasises the importance of the utmost care in the engagement, injection and intervention involving the coronary arteries in this disease. Development of a non-invasive coronary imaging modality or biomarker able to diagnose SCAD non-invasively would be a great advance in the care of patients with this condition, because it would avoid the need for invasive coronary angiography for diagnosis.

Early and midterm results of ductal stent implantation in neonates with ductal-dependent pulmonary circulation: a single-centre experience.

We aimed to determine the early and midterm outcomes of ductal stenting in neonates with ductal-dependent pulmonary blood flow. Between January, 2014 and July, 2018, 102 patients who underwent 115 cardiac catheterisation procedures for ductal stent implantation in our department were retrospectively reviewed. The age of the neonates ranged from 3 to 30 days (median: 11 days) and their weights ranged from 1.8 to 5.8 kg (mean, 2.8 ± 0.53 kg). Fifty-two patients had functional single ventricle and 50 had biventricular physiology. Thirty-one patients' weights were <2,500 g (30.3%). The patent ductus arteriosus was vertical in 60 patients (58.8%). The mean ductal length was 12.4 ± 4.1 mm (range, 7.8-23 mm), and the mean narrowest ductal diameter was 2.1 ± 0.7 mm (range, 1.2-3.4 mm). The technical success rate was 85.2%. Procedure-related mortality occurred in three patients (2.9%). After the procedure, the aortic oxygen saturation increased from a mean of 73.1 ± 6.2% to a mean of 90.4 ± 4.3% (p < 0.001), and the ductus diameter increased from a mean of 2.1 ± 0.7 mm to a mean of 4.2 ± 0.9 mm (p < 0.001). Either transcatheter or surgical reinterventions were required in 35 patients (34.3%) during the follow-up period after a median of 101 days (2-356 days). Thirty-three patients (32.3%) were bridged to surgical repair after a median of 288 days (163-650 days). The median duration of palliation with ductal stents was 210 days (range, 2-525 days). Ductus arteriosus stenting may be a reasonable and effective alternative to surgery for the initial palliation procedure in neonates with ductus-dependent pulmonary flow.