Catheterization Laboratory Research Articles

A virtual patient authoring tool for transcatheter aortic valve replacement.

Computer-based medical training scenarios, derived from patient's records, often lack variability, modifiability, and availability. Furthermore, generating image datasets and creating scenarios is resource-intensive. Therefore, patient authoring tools for rapid dataset-independent creation of virtual patients (VPs) is a pressing need. An authoring tool and a virtual catheterization laboratory environment were developed. The tool allows customised VP generation through a real-time morphable heart model and Euroscore parameters. The generated VP can be examined inside the vCathLab using a fluoroscopy and monitoring device, both on desktop and immersive virtual reality. Seven board-certified experts evaluated the proposed method from three aspects, i.e. System Usability Scale, qualitative feedback, and its performance in VR. All participants agreed that this method could provide the necessary information and is anatomically correct within an educational context. Its modifiability, variability, and simplicity were well recognised. The prototype achieved excellent usability score and considerable performance results. We present a highly variable VP authoring tool that enhances variability in medical training scenarios. Although this work does not aim to explore didactic aspects, the potential of using this approach in an educational context has been confirmed in our study. Accordingly, these aspects can benefit from a thorough investigation in the future. In addition, our tool can be improved to provide more realistic parameter ranges for procedure-specific cases.

Accuracy of dynamic stress CT myocardial perfusion in patients with suspected non-ST elevation myocardial infarction.

Coronary CT angiography (CCTA) and dynamic stress CT myocardial perfusion (CT-MPI) are established modalities in the analysis of patients with chronic coronary syndromes. Their role in patients with suspected non-ST elevation myocardial infarction (NSTEMI) is unknown. CCTA with CT-MPI might assist in the triage of NSTEMI patients to the Cath lab. We investigated the correlation of significant epicardial lesions by CT-MPI in addition to CCTA compared to invasive coronary angiography (ICA) with fractional flow reserve (FFR) in patients with NSTEMI. Twenty NSTEMI patients scheduled for ICA were enrolled in this study with planned ICA. CCTA and CT-MPI was performed pre-ICA. For each coronary artery, the presence or absence of significant lesions was interpreted by CCTA with CT-MPI, using an FFR of ≤ 0.8 or angiographic culprit (stenosis > 90%, suspected plaque rupture) as reference. The main outcome was the per-vessel correlation. Sixteen out of 20 patients had a culprit lesion that required immediate revascularization. CCTA with ≥ 50% stenosis demonstrated a per vessel sensitivity and specificity for the detection of significant stenosis of respectively 100% (95% CI: 86-100%) and 75% (95% CI: 58-88%). CCTA with CT-MPI showed a lower sensitivity 90% (95% CI: 70-99%) but higher specificity of 100% (95% CI: 90-100%). CCTA with CT-MPI exhibits a strong correlation for identifying significant CAD in patients with NSTEMI. Thereby, it might assist in the triage of ICA in NSTEMI patients.

Scattered radiation exposure to primary operator, secondary operator and primary technician and protection offered by radiation protection drape in cath lab procedures.

Scattered radiation exposure to primary operator, secondary operator and primary technician and protection offered by radiation protection drape in cath lab procedures.

SoutheAsTern eUrope microciRculATION (SATURATION) registry - Design and rationale.

A considerable number of symptomatic patients leave the cardiac catheterization lab without a definitive diagnosis for their symptoms because no epicardial stenoses are found. The significance of disorders of coronary microvasculature and vasomotion as the cause of symptoms and signs of ischemia has only recently been appreciated. Today we have a wide spectrum of invasive coronary physiology tools but little is known about when and how these tools are used in clinical practice. SoutheAsTern eUrope microciRculATION (SATURATION) registry will study the regional practice of patient selection for coronary function testing, indications, non-invasive ischemia testing, medications, procedural aspects of invasive physiology evaluation, and treatment changes after testing. The registry is expected to include 1600 patients in participating centers in Southeastern Europe from 2024 to 2029, using the thermodilution technique for evaluation of microcirculation. Major adverse cardiovascular events as well as patient-centered outcomes such as burden of angina and quality of life using Seattle Angina Questionnaire (SAQ) and EQ-5D-5L will be recorded. The study will include patients with different stages of coronary artery disease (presence of disease or degree of stenosis) to elucidate the effect of coronary microcirculation on the outcomes in this broad group. The registry will provide information regarding the current practice of invasive coronary physiology assessment in populations at high cardiovascular risk in Southeastern Europe. This could lead to a better understanding of coronary microvascular dysfunction and its relationship to various degrees of coronary atherosclerosis together with potential interventions that can be beneficial.

A Pilot Rapid Triage Process for Prehospital ST-Segment Myocardial Infarction Patients Direct to the Catheterization Lab

A Pilot Rapid Triage Process for Prehospital ST-Segment Myocardial Infarction Patients Direct to the Catheterization Lab

Highlights of Transesophageal Echocardiography During Interventions for Adult Congenital Heart Disease.

Significant advances in the diagnosis and treatment of congenital heart disease have transformed patient outcomes, leading to an expanding adult congenital heart disease population. Many of these adults require lifelong procedural interventions, frequently performed in catheterization labs under the guidance of echocardiography. This review explores the transesophageal echocardiographic aspect in key catheterization-based procedures.

Clinical validation of a wearable ultrasound sensor of blood pressure.

Options for the continuous and non-invasive monitoring of blood pressure are limited. Cuff-based sphygmomanometers are widely available, yet provide only discrete measurements. The clinical gold-standard approach for the continuous monitoring of blood pressure requires an arterial line, which is too invasive for routine use. Wearable ultrasound for the continuous and non-invasive monitoring of blood pressure promises to elevate the quality of patient care, yet the isolated sonographic windows in the most advanced prototypes can lead to inaccurate or error-prone measurements, and the safety and performance of these devices have not been thoroughly evaluated. Here we describe validation studies, conducted during daily activities at home, in the outpatient clinic, in the cardiac catheterization laboratory and in the intensive care unit, of the safety and performance of a wearable ultrasound sensor for blood pressure monitoring. The sensor has closely connected sonographic windows and a backing layer that improves the sensor's accuracy and reliability to meet the highest requirements of clinical standards. The validation results support the clinical use of the sensor.

Safety and accuracy of the computer interpretation of normal ECGs at triage.

ECGs performed at ED triage are mandatorily assessed by an emergency physician contributing to task interruptions, decreased quality of care and increased error risk. Recent literature suggests that a triage ECG interpreted as normal by the ECG machine software correlates with benign interpretation from attending cardiologists.Ambiguity persists regarding the safety of the normal computerized ECG interpretation and whether real-timephysician review is needed. In this prospective cohort study, we evaluated the GE Marquette 12SL ECG software's clinical accuracy for normal triage ECGs. We compared machine interpretation, ED physicians' real-time interpretation and management as well as cardiologists systematic but delayed review of the ECGs to establish diagnostic accuracy and safety of a normal software interpretation. Additional data were collected from the emergency department patient tracking system and charts to determine patient outcomes when machine normal interpretation differed from ED physicians and cardiologists' analysis. Between November 16th 2020 and November 19th 2021, we collected 1220 machine-normal ECGs performed at Charles-Le Moyne Hospital ED triage. 1051 ECGs were eligible for inclusion. ED physicians agreed with the machine for 1028 normal diagnoses (97.8% IC (0.95): 96.7-98.5) and cardiologists agreed with the machine for 1037 ECGs (98.7% IC (0.95) 97.8-99.2). Relevant changes in ED management were recorded in three patients (0.29% IC (0.95): 0.1-0.8) whose ECGs were read as normal by the software: two emergent referrals to the catheterization lab and one emergent transfer to the resuscitation bay with next day coronarography. A normal ECG interpretation from the GE Marquette 12SL ECG software at ED triage has a very high accuracy and a very low probability of clinically relevant change in patient outcome and ED trajectory.

Abstract 4138310: Successful Endovascular Closure of Ascending Aortic Pseudoaneurysm Using Atrial Septal Defect Occluder

Introduction: Ascending aortic pseudoaneurysms are mostly related to either surgery or non-surgical trauma. Any pseudoaneurysm arising from graft anastomoses, regardless of size or location, must be repaired due to the potential for catastrophic rupture. Traditional surgical intervention has a high mortality rate, but percutaneous treatment has emerged as an alternative. We present such a case of pseudoaneurysm treated by percutaneous intervention using a 6-mm Amplatzer device. Case: A 77-year-old female with a history of type A aortic dissection s/p emergent repair with a 32 mm tube graft one year ago presented with chest pain radiating to her back. Initial vital signs showed a BP of 185/105, SaO2 98% on RA, 98.3 F, HR 98 bpm, and RR 24/min. A chest CT scan suggested a pseudoaneurysm at the proximal anastomotic site of the aortic graft (Figs. 1A and B). Serial troponin and EKGs were unremarkable for acute ischemia. Multiple quaternary centers declined intervention due to the high risk of redo sternotomy for open repair and patient frailty. After multidisciplinary discussions, it was felt that percutaneous closure with an Amplatzer device was possible without coronary obstruction. In the catheterization lab, a TEE probe was placed to visualize the pseudoaneurysm of the ascending aorta (Fig. 1C). Angiography showed the aneurysm coming off the posterior aorta just above the noncoronary cusp, with the neck measuring ~6 mm (Fig. 1D). The aneurysm was successfully engaged using an 8-French sheath and an 8-French AL1. Based on measurements from the TEE and the angiogram, a 6 mm ASO device was used. After device deployment and release, aortograms showed that the pseudoaneurysm was excluded (Fig. 1H). Assessment with TEE and CTA showed no residual flow in the pseudoaneurysm (Fig. 1 E–G). Conclusion: Using an atrial septal occluder, endovascular intervention may be a safe and effective alternative to surgery for treating the ascending aortic pseudoaneurysm, especially in patients with a high prohibitive surgical risk. Longitudinal follow-ups are needed to comment on long-term mortality benefits for these individuals.

Abstract 4119470: ST-Elevation Myocardial Infarction as a Complication of Granulomatosis with Polyangiitis

Description of Case: A 19-year-old female with history of granulomatosis with polyangiitis (GPA) presented to the emergency department after a syncopal episode at a concert. She reported a prodrome of feeling hot and dizzy prior to the event, followed by epigastric discomfort, nausea, and vomiting after regaining consciousness. She had been diagnosed with GPA one year prior to presentation based on serology and biopsy results. Because her disease was felt to be well-controlled on azathioprine, she had been tapered off of prednisone one month prior to presentation. Initial vitals included blood pressure of 90/60 mmHg, and heart rate of 94 bpm. A 12-lead EKG revealed ST segment elevation in leads I, II and aVF with T wave inversions in the lateral leads ( Figure 1 ). Initial bloodwork was notable for troponin I of 0.11ng/mL (upper limit of normal 0.034 ng/mL). A diagnosis of inferior ST-elevation myocardial infarction was made. She was treated with oral aspirin and prasugrel load as well as intravenous heparin and taken urgently to the catheterization laboratory. Diagnostic coronary angiography was significant for single vessel coronary artery disease (CAD) of the right coronary artery (RCA), with acute complete occlusion of the mid-RCA ( Figure 2A-B ). She was treated successfully with primary percutaneous coronary intervention and implant of two overlapping drug eluting stents in the mid-RCA ( Figure 2C ). Discussion: GPA is a systemic necrotizing vasculitis associated with antineutrophil cytoplasmic antibodies (ANCA) that predominantly affects small to medium sized vessels in the respiratory tract and kidneys. Cardiovascular manifestations in GPA are uncommon, but include pericarditis, myocarditis, and coronary arteritis. GPA can affect the coronary arteries either primarily through inflammatory changes in the arterial wall or via systemic inflammation leading to accelerated atherosclerosis. No standardized criteria exist to establish the diagnosis of coronary arteritis and to differentiate it from accelerated atherosclerosis. Long-term treatment of vasculitis patients with coronary involvement is also poorly supported by evidence. Optimization of cardiovascular risk factors is advocated as per standard of care, and vasculitis control may slow disease progression. This case not only raises awareness of cardiac complications in GPA, but highlights the current lack of evidence surrounding secondary prevention in young patients with vasculitis and cardiac complications.

Abstract 4128201: Reducing Blood Product Waste in a Pediatric Cardiac Catheterization Laboratory – A Quality Improvement Initiative

Background/Aim: Transfusion can be a life-saving intervention, however routine pre-procedural blood products frequently go unused. Recent national blood product shortages highlight the importance of blood product stewardship. In our pediatric cardiac catheterization laboratory (PCCL), packed red blood cells (pRBCs) were ordered prior to all cases. These units are rarely transfused and sometimes cannot be reallocated, resulting in waste. As a quality improvement project, we set a primary aim to reduce the percentage of monthly pRBC waste from a baseline mean of 7.4% to <5% over 12 months. Methods: Baseline data on all cardiac catheterization cases, excluding electrophysiology, lymphatic, and hybrid cases, were collected from 1/1/2022 to 2/28/2023. Interventions (Table 1) were implemented and outcomes measured from 3/1/2023 to 3/31/2024. Primary outcome measures were monthly percentage of blood wasted, and percent of unused pRBC orders. Emergency blood product activation was measured as a balancing metric. Statistical process control charts were used to display and analyze data. Results: During the intervention period 1,318 cases were performed of which 32% met low-risk criteria for pRBC order de-implementation. The percent of blood that was subsequently wasted was reduced from 7.4% to 5.5% (Figure 1A), primarily driven by the reduction in the anecdotal practice of pRBC unit splitting in patients <1 year old (Figure 1B). The percent of unused pRBC orders was reduced from 97% to 79% with sustained improvement following two cycles of routine blood order de-implementation for low-risk cases. No emergency blood activation occurred (0%, 97.5% CI: 0-0.28%). Conclusion: De-implementation of default pRBC orders for low-risk catheterization procedures and reduction in unit splitting reduced the percent of blood wasted in our PCCL, saving time and cost without compromising patient safety. A data-driven approach to blood stewardship may be broadly applicable across procedural areas.

Abstract 4137708: Implementation of a Standard Hydration Protocol Improves Compliance of Pre-procedural Hydration, Reducing the Incidence of Contrast-Induced Acute Kidney Injury (CI-AKI) After Percutaneous Coronary Intervention (PCI)

Introduction: Intravenous hydration and contrast media volume reduction are the most important preventive factors against CI-AKI after PCI. Multiple studies have demonstrated the effectiveness of intravenous hydration before PCI, however, varied hydration protocols have rather complicated standardization. Doctors’ preferences and local institutional factors further hinder protocol implementation, resulting in reduced compliance. Hypothesis: Standardizing hydration protocol increases the compliance rate of preprocedural hydration orders and administration, reducing the incidence of CI-AKI. Methods: A team at Memorial Hermann The Woodlands Medical Center, comprising a cardiovascular nurse coordinator, catheterization laboratory director, pharmacist, information technologist, and hospital administrators, was formed to improve PCI outcomes through a multi-faceted approach. This involved a standardized hydration protocol with direct education, continuous monitoring, and repeated internal feedback, reviewed monthly. The new protocol included normal saline pre- and post-procedure maintenance fluids, with a 250 ml normal saline bolus pre-operatively. Maintenance fluids were set at 75 ml/hr, and 20 ml/hr for patients with congestive heart failure and an ejection fraction ≤ 40%. The team reviewed 233 patients under the old protocol and 281 under the new protocol. Compliance rates of pre-procedural intravenous hydration were compared and CI-AKI incidence, defined as a >50% increase or a 0.3 mg/dL increase in creatinine levels within 5 days post-procedure, was assessed. Chi square tests and t-tests were used to compare cohorts on 12 parameters and CI-AKI incidence assessment, with a p-value of 0.05. Results: Compliance with pre-procedural hydration significantly increased under the new protocol (86.1% vs 55.4%, p<0.05). CI-AKI incidence was lower in the new protocol group (7.5% vs 9.9%, p=0.33). Although statistically insignificant in this preliminary analysis, the results were still promising due to a relative CI-AKI reduction of 24.3%. A sample size of 352 patients per group is needed to achieve a power of 0.8. Conclusion: The new standardized hydration protocol, coupled with education, increased compliance with pre-procedural hydration and showed a promising trend towards reducing CI-AKI among PCI patients. The final report will be presented upon study completion.

Abstract 4136274: A Case of Myocardial Infarction with Non-obstructive Coronary Arteries (MINOCA) Complicated by a Ventricular Septal Defect (VSD)

Case: A 69-year-old woman with a history of hypertension and tobacco use disorder presented with acute chest pain. The patient was found to have classic anterior ST elevation myocardial infarction (STEMI) pattern on electrocardiogram (ECG) with high-sensitivity troponin of 12,772 ng/L and was taken emergently to the catheterization laboratory. Coronary angiography showed tortuous coronary vessels though without evidence of obstructive coronary artery disease, plaque rupture, ulceration, dissection, or vasospasm. Transthoracic echocardiogram showed an apical ventricular septal defect (VSD) with normal left ventricular systolic function of 60%. Cardiac computed tomography (CT), confirmed a discrete apical VSD that was 7.93 mm in diameter and multiple small VSDs distally in the septum. Right heart catheterization revealed severe left-to-right shunting with a ratio of pulmonary blood flow to systemic blood flow (Qp:Qs) of 2.8. Early surgical repair of the apical VSD was pursued despite known high operative risk given the hemodynamic significance of the shunt. The patient developed ongoing hemodynamic instability from cardiogenic shock with inability to ween from intra-aortic balloon pump (IABP). Unfortunately, because of the location of the residual VSDs and elevated panel-reactive antibody testing of 98%, the patient was deemed to not be a candidate for percutaneous closure or heart transplantation, respectively. Discussion: An acquired ventricular septal defect (VSD) is a rare and catastrophic complication of myocardial infarction, typically with a culprit obstructive coronary artery lesion identified on coronary angiography. Acquired VSDs in myocardial infarction with nonobstructive coronary arteries (MINOCA) is an even more rare phenomenon. Possible causes include low flow, inflammation, intimal disruption, or vasospasm of coronary arteries. Our case highlights that MINOCA can present with life-threatening complications similar to obstructive STEMI. The timing of intervention and treatment approach of acquired VSDs remains an area of debate. The life-threatening effects of VSDs make it critical to manage in a multidisciplinary manner involving advanced imagers, interventional cardiologists, cardiothoracic surgeons, and heart failure specialists. This case emphasizes the importance of maintaining a high index of suspicion for abnormal coronary anatomy, even in patients with MINOCA, and prompt interdisciplinary decision making to reduce mortality.

Abstract 4134935: Impact of COVID-19 on Cardiology Fellows and Faculty in the United States: Two Years Later

Introduction: Recent data demonstrated that the COVID-19 pandemic adversely affected cardiovascular fellows in training (cFIT) and faculty in terms of educational disruption and search for job prospects, respectively. However, less is known about the pandemic's effect on cFIT and faculty in terms of general well-being, shifts in personal and professional priorities, quantitative measures of stress levels, and research productivity. Methods: A national survey targeting cFIT and faculty was developed to assess the effect of the pandemic two years later on these parameters. Fifty-four participants, including 21 cFIT and 33 faculty, responded to the survey. The survey was distributed between October 2021 and May 2022 to program directors of ACGME-accredited general cardiology fellowship programs in the United States. Results: 30% of cFITs perceived impaired clinical training during the pandemic; 36% of fellows experienced a decline in their clinical skills in the cardiac catheterization lab, while 27% experienced a decrease in their echocardiographic skills. Additionally, a significant percentage of cFIT reported negative interference in their competencies in nuclear cardiology (27%) and electrophysiology (12%). Most participants (76%), including faculty and fellows, reported several health issues such as sleep problems, low energy, changes in appetite, difficulty concentrating, and restlessness due to the pandemic. 43% of the faculty and 61% of cFIT reported high rates of impaired short-term productivity (Figure). Conclusion: In this national survey, we found that two years after the onset of the COVID-19 pandemic, cardiology fellows and faculty continued to experience significant concerns for decreased hands-on training and diminished research productivity. While faculty were not distressed regarding decreased clinical competencies, concerns about short-term and long-term research productivity persisted. Faculty and fellows all experienced increased stress levels and impaired productivity. Although limited by a small sample size, which can introduce bias, these results signal the importance of performing a follow-up study on the impact of COVID-19 on wellness as well as the impact on career.

Safety of pediatric cardiac catheterisation procedures performed in rural India in a catheterisation lab setup for adult work

Introduction: The congenital heart disease (CHD) makes the largest group of congenital defects children are born with. The conservative estimate points towards 1% prevalence of CHD among the newborn. In India, each year approximately 2.4 lakh children are born with CHD, which is largest in the world. There are very centres offering paediatric cardiology services in India and they are unevenly distributed. Because of this, a lot of paediatric patients with CHD get treated at an adult cardiology facility, not always equipped with proper setup to handle complexities associated with paediatric cardiology work. The study aims to assess the safety and complications associated with paediatric cardiology catheterization-based procedures in a Cath lab is primarily used for adult cardiology work.Methods: The current study is a retrospective review of pediatric cardiac cath-lab-based procedures performed between April 2018 and March 2021.Results: During the study, 110 pediatric patients underwent 110 cath-lab-based procedures. A total of 20 procedures were performed as an emergency, and 90 were performed as planned procedures. Out of 110 procedures performed, 86.4% were completed without complications. Minor complications were observed in 9.1% of the procedure. Major complications were seen in 3 patients, and two patients died.Conclusion: The analysis shows that the complications associated with pediatric cardiac procedures performed on rural-based cath-lab oriented toward adult cardiology work are comparable to those of other large-volume pediatric cardiac centres.

Successful Transcatheter Closure of an Iatrogenic Axillary Arteriovenous Fistula in a Young Girl: A Delayed Complication of Intervention in a Resource-limited Setup

Abstract Arteriovenous fistula (AVF) is a well-known complication in the adult population following cardiac interventions. Data on the pediatric age group are lacking. Furthermore, there are no guidelines for the management of the pediatric population. We present a case of successful endovascular device closure of iatrogenic axillary AVF in a limited resource setup. A 9-year-old girl had palliative ductal stenting through the left axillary artery for complex congenital cyanotic heart disease 6 months back. She presented with an iatrogenic axillary AVF. We planned to close the defect in catheterization laboratory. After successful device deployment, there was a complete occlusion of the arterial system. To maintain arterial patency stenting was performed subsequently. Successful device closure of complicated axillary AVF in the pediatric population can be achieved even in a recourse-limited setup.

Improving the non-ST-segment elevation acute coronary syndrome (NSTEACS) pathway using quality improvement methodology

BackgroundThe National Institute for Health and Care Excellence (NICE) guideline quality standard for non-ST-segment elevation acute coronary syndrome (NSTEACS) pathway states that adults who have an intermediate or higher risk...

BEST PRACTICE FOR OPTIMIZATION AND RADIATION SAFETY IN THE CARDIOVASCULAR CATHETERIZATION ROOM (CATHLAB) OF SENTRA MEDIKA CIBINONG HOSPITAL

Scattered radiation generated during fluoroscopy increases the potential for patients and staff to receive radiation doses, so it is necessary to take optimization steps for radiation safety to minimize the risk of exposure to scattered X-ray radiation. This study aims to implement radiation protection in cardiac and vascular catheterization laboratories and summarize best practices for implementing efforts to minimize radiation exposure. The method used was qualitative and quantitative from 2023 to 2024; with this qualitative approach, the supervision activities in TLD badges for radiation workers, the level of diagnostic guidance for patients, and the use of radiation protection equipment were observed. For the quantitative approach, measuring the dose rate was carried out, and optimizing the positioning of the distance between the patient's table and the radiation source was carried out by direct measurement. Based on research data, the observation results obtained that the apron is still by the minimum thickness, which is 0.35-0.5 mm Pb for intervention, the results of exposure tests around the cathlab room are around 0.08-0.12 μSv/hour still below the dose constraint value, Mapping the rate of exposure in the work area during the intervention procedure obtained an optimal safe distance of around 60-70 cm from the X-ray tube. The setup of the effective distance position for intervention patients is at a distance of 80 cm from the X-ray tube to the patient table, which can reduce the absorbed dose to the patient by around 30%, the use of low dose mode (7.5 fps) with pulsed fluoroscopy during the intervention obtained the absorbed dose received by the patient reduced by 70-72% for PCI procedures and 25-29% for the type of CAG procedure. It is hoped that the protocol that uses this best practice can minimize the risk of exposure to scattered radiation and optimize medical exposure. Keywords: cathlab, best practices radiation protection, dose rate, radiation exposure, patient radiation dose.

An Audit of Recyclable and Contaminated Waste From Invasive Cardiac Procedures

BackgroundWaste generation from health care facilities is significant. Quantifying and minimizing waste from cardiac catheterization laboratories (CCL) and cardiac operating theaters (COT) has received little attention in an effort to lessen its environmental impact. The purpose of this study was to assess the quantity of contaminated and recyclable waste resulting from invasive cardiac procedures. MethodsTo assess the potential impact of recycling, quantify the amount of waste that ends up in landfills, and determine how much contaminated material needs to be managed, we audited the amount of hazardous and nonhazardous medical waste produced from CCL and COT in our cardiac center. ResultsEvery year, our cardiac center performs 350 cardiac surgeries and 2900 interventional cases. We estimated that annually 11,000 kg of recyclable waste and 30,000 kg of contaminated waste are generated. If this is extrapolated to all the CCL and COT globally, the anticipated annual waste production from invasive cardiac procedures is 150 million kg (150,000 metric tons). ConclusionsCardiologists and cardiac surgeons must embrace sustainability as a critical need and join the effort to prevent global warming. One tiny action that each of us can take to improve the environment is to try to decrease waste while encouraging recycling.

Right bundle branch block in suspected acute coronary syndromes: Diagnostic challenges, treatment and prognosis

BackgroundThere is still conflicting evidence regarding the prognostic implications of right bundle branch block (RBBB) in the general population but also in patients with heart diseases like acute coronary syndromes (ACS). In accordance with current guidelines, RBBB in ACS patients is considered as STEMI equivalent. However, recent studies indicate that further differentiation is necessary in this group, as we will outline below. Methods and resultsA literature search was conducted in PubMed and Google Scholar.In previous studies, RBBB in the general population were mostly considered benign changes of the electrical conduction system. However, recent studies indicate that both complete and incomplete RBBB are associated with increased cardiovascular morbidity and mortality. In addition, among unselected patients with suspected ACS presenting to the emergency department, the prevalence of RBBB was 3 % and it was associated with elevated mortality. The subsequent angiographic identification of a culprit coronary artery stenosis leading to stent implantation was similar at approximately 2 % regardless of the initial ECG presentation with narrow QRS complexes, left bundle branch block (LBBB), or RBBB.Finally, in a group of high-risk patients for ST-elevation myocardial infarction (STEMI), the prevalence of RBBB was 12 %. While RBBB was associated with poor outcome compared to non-BBB and LBBB patients, diagnostic accuracy of STEMI criteria was not affected by the presence of RBBB. However, RBBB patients without distinct STEMI signs in ECG often showed acute STEMI on angiography indicating a potential benefit from immediate transfer to the cardiac catheterization laboratory. ConclusionIn the general population, patients with RBBB and risk factors may need further evaluation. Regarding ACS patients, recent studies support current guidelines that recommend acute invasive evaluation for high-risk ACS patients with RBBB, regardless of ST-T deviations. However, in an unselected group of ACS patients, differential diagnoses should also be investigated through additional diagnostic procedures.