Diagnostic Coronary Procedures Research Articles

Simulation training for invasive cardiovascular procedures: the Heart-SIMS-1 study

Abstract Introduction Interventional cardiology training has a long learning curve and exposes patients and clinicians to undesirable procedural risks. We aim to assess whether mentored simulation-based training with three dimensional (3D) printed models can improve the procedural skills and safety performance of beginners in coronary diagnostic procedures. Methods Twenty-nine final-year medical students from a single centre were lectured in the basic principles of invasive coronary angiography (ICA) for one-hour, and then randomized to conventional training or simulation training. Conventional training (n=15) consisted in watching a 20-minute video demonstrating all ICA steps in a 3D-printed coronary simulator. Simulation training (n=14) offered the same explanations in a hands-on training session with the 3D-printed model, in pairs, for 20 minutes. The co-primary endpoint was efficacy and safety of performing a simulated ICA in the 3D-printed simulator, installed under sterile drapes, in a conventional angiography suite. Efficacy and safety were graded by a blinded investigator using a pre-specified performance checklist, including the identification of procedural "red flags", graded 0-100%. The secondary endpoint was theoretical knowledge, assessed in a 25-question multiple-choice quiz, graded 0-100%. Results All participants completed the training and evaluation phases. Both elements of the co-primary endpoint were superior in the simulation group: efficacy score of 91.5 ± 3.8 vs 64.6 ± 8.3% and safety score 100.0 (100.0-100.0) vs 62.5 (20.8-79.2) %, p<0.001. The median number of "red flags" were 2 (1-4) in conventional and 0 (0-0) in simulation training recipients (p<0.001). Secondary endpoint was higher in simulation training: 85.7 ± 9.0 vs 76.8 ± 12.7% (p=0.039). Conclusion Mentored simulation-based training of medical students in ICA with 3D-printed models resulted in improved performance regarding efficacy, procedural safety, and theoretical knowledge.ResultsSimulation and evaluation setup

Frequency and predictors of access site complications of the transfemoral diagnostic coronary procedures

Objectives: Access site complications (ASC) remain important and common adverse events after coronary angiography. The aim of this study was to evaluate the frequency and predictors of ASC in patients undergoing diagnostic coronary angiography (DCA) via the femoral artery. Methods: In this prospective analytical cross sectional study, DCA was performed in 3972 patients by transfemoral approach. The femoral access site hemostasis was obtained by manual compression in all patients. Demographic characteristics of the patients, size of the arterial sheaths, duration of compression time, patients blood pressure, medications, hemoglobin and platelet levels were recorded. All patients were evaluated for ASC (pseudoaneurysm, bleeding, dissection, hematoma). The ASC rate was calculated and ASC predictors were determined by multivariate analysis. Results: The ASC rate was 1.3% (53 of 3972 patients). The complications were more frequent in female (female: 29 of 53 [54.7%] vs male: 24 of 53 [45.3%]; p = 0.007) and chronic renal failure (CRF) patients (103 of 3919 [2.6%] vs 4 of 53 [7.5%]; p = 0.02). Hemoglobin level was lower (13.40 ± 1.73 vs 12.86 ± 1.75; p = 0.02) and manual compression time was longer (9.19 ± 3.28 min vs 14.53 ± 6.47 min; p < 0.001) in the ASC group. Clopidogrel (188 of 3919 [4.8%] vs 7 of 53 [13.2%]; p = 0.005) and low molecular weight heparin (LMWH) using were more frequent (37 of 3919 [0.9%] vs 7 of 53 [13.2%]; p < 0.001) in the ASC group. According to multivariate analysis; female gender; OR: 2.13, 95% CI: 1.14-3.99 (p = 0.017), presence of CRF; OR: 3.15, 95% CI: 1.06-9.29 (p = 0.038), manual compression time; OR: 1.23, 95% CI: 1.17-1.30 (p < 0.001) and LMWH using; OR: 15.68, 95% CI: 6.05-40.61 (p < 0.001) were predictors of ASC. Conclusions: The incidence of femoral ASC rate was 1.3% in patients with DCA. Female gender, presence of CRF, using LMWH and long manual compression time were predictors of ASC.

TCT CONNECT-193 Radiation Exposure, Safety and Clinical Outcomes Following Interventional Coronary Diagnostic Procedures When Performed Without Planned Coronary Stenting

TCT CONNECT-193 Radiation Exposure, Safety and Clinical Outcomes Following Interventional Coronary Diagnostic Procedures When Performed Without Planned Coronary Stenting

Impact of One-Catheter Strategy with TIG I Catheter on Coronary Catheterization Performance and Economic Costs.

BackgroundCoronary angiography with two catheters is the traditional strategy for diagnostic coronary procedures. TIG I catheter permits to cannulate both coronary arteries, avoiding exchanging catheters during coronary angiography by transradial access.ObjectiveThe aim of this study is to evaluate the impact of one-catheter strategy, by avoiding catheter exchange, on coronary catheterization performance and economic costs.MethodsTransradial coronary diagnostic procedures conducted from January 2013 to June 2017 were collected. One-catheter strategy (TIG I catheter) and two-catheter strategy (left and right Judkins catheters) were compared. The volume of iodinated contrast administered was the primary endpoint. Secondary endpoints included radial spasm, procedural duration (fluoroscopy time) and exposure to ionizing radiation (dose-area product and air kerma). Direct economic costs were also evaluated. For statistical analyses, two-tailed p-values < 0.05 were considered statistically significant.ResultsFrom a total of 1,953 procedures in 1,829 patients, 252 procedures were assigned to one-catheter strategy and 1,701 procedures to two-catheter strategy. There were no differences in baseline characteristics between the groups. One-catheter strategy required less iodinated contrast [primary endpoint; (60-105)-mL vs. 92 (64-120)-mL; p < 0.001] than the two-catheter strategy. Also, the one-catheter group presented less radial spasm (5.2% vs. 9.3%, p = 0.022) and shorter fluoroscopy time [3.9 (2.2-8.0)-min vs. 4.8 (2.9-8.3)-min, p = 0.001] and saved costs [149 (140-160)-€/procedure vs. 171 (160-183)-€/procedure; p < 0.001]. No differences in dose-area product and air kerma were detected between the groups.ConclusionsOne-catheter strategy, with TIG I catheter, improves coronary catheterization performance and reduces economic costs compared to traditional two-catheter strategy in patients referred for coronary angiography.

Smokeless tobacco, snus, at admission for percutaneous coronary intervention and future risk for cardiac events

ObjectiveTo assess the risk of future death and cardiac events following percutaneous coronary intervention (PCI) in patients using smokeless tobacco, snus, compared with patients not using snus at admission for...

Diagnostic value of lead aVR in electrocardiography for identifying acute coronary lesions in patients with out-of-hospital cardiac arrest

AimThere is no simple clinical tool that reliably indicates the presence of acute coronary lesions in out-of-hospital cardiac arrest (OHCA) patients without typical ST-segment elevations. ST-segment elevation in electrocardiographic lead aVR suggests global subendocardial ischemia. This study aimed to evaluate the diagnostic value of lead aVR for identifying acute coronary lesions following resuscitation from OHCA. MethodsA total of 74 patients without evidence of ST-segment elevations, who were resuscitated from OHCA, were examined. The degree of ST-segment elevation in lead aVR was measured directly after return of spontaneous circulation (ROSC) and at early follow-up. Coronary angiograms were retrospectively reviewed. ResultsAcute coronary lesions were detected in 20 patients (27%). No difference in ST-segment elevation in lead aVR directly after ROSC was observed between patients with or without acute coronary lesions. However, ST-segment elevation values significantly decreased at early follow-up (median, 137 min) in patients without acute coronary lesions. An ST-segment elevation ≥0.5 mm in lead aVR at early follow-up was associated with a higher prevalence of multivessel coronary artery disease and was an independent indicator of the presence of acute coronary lesions (odds ratio, 4.41; 95% confidence interval, 1.12–17.4; p = 0.034). ConclusionST-segment elevation in lead aVR at early follow-up was associated with the presence of acute lesions accompanied by severe coronary artery disease in post-cardiac arrest patients without other ST-segment elevations. The analysis of ST-segment elevation in lead aVR may aid in the identification of patients who will benefit from further invasive coronary diagnostic procedures.

Is Radiation Exposure with the Transradial Approach Still a Concern

Compared with the transfemoral approach, the transradial approach for diagnostic and interventional coronary procedures reduces bleeding complications

Nephrotoxicity of iodixanol versus iohexol inpatients with chronic kidney disease and diabetes mellitus undergoing coronary angiographic procedures

Background: The choice of radiographic contrast media for use in patients at increased risk of contrast-induced nephropathy is of ongoing interest. Materials and Methods: The current study is a prospective, randomized in which comparison of nonionic, isoosmolal agent, iodixanol, versus the nonionic, low-osmolal agent, iohexol, on the renal effects was carried out. A total of 526 subjects with impaired baseline renal functionand diabetes mellitus underwent diagnostic and/or therapeutic coronary angiographic procedures. The coprimary end points were the peak increase in serum creatinine and the incidence of contrast-induced nephropathy, that is, ≥0.5 mg/dl in serum creatinine from baseline within 72 h of receiving contrast media. Results: Of the 129 patients, 97 received iodixanol and 97 received iohexol randomly. The median peak increase in serum creatinine in the iodixanol arm was 0.10 mg/dl; whereas in the Iohexol arm, the median peak increase was 0.09 mg/dl (P = 0.13). The overall contrast-induced nephropathy incidence was 10.5% in the iodixanol arm and 9.8% in the iohexol arm (P = 0.7). The volume of contrast media, volume of saline administered, frequency of coronary interventional procedures, and severity of baseline kidney disease and of diabetes mellitus were similar between treatments. Conclusions: In the present study, the overall rate of contrast-induced nephropathy in patients with chronic kidney disease and diabetes mellitus undergoing coronary angiographic procedures was 10.5%. There was no significant difference between iodixanol and iohexol in either peak increase in serum creatinine or risk of contrast-induced nephropathy.

Emerging and Evolving Roles for CT in Screening for Coronary Heart Disease

Coronary heart disease (CHD) is highly prevalent and is the primary cause of death for both men and women, worldwide. Because the disease develops over many years, there are opportunities to intervene and alter the course of CHD, assuming that there are reliable means for determining which individuals with coronary atherosclerosis will develop symptomatic CHD. CT provides 2 distinct means for coronary artery disease assessment--coronary artery calcium (CAC) measurement using noncontrast CT and coronary CT angiography (cCTA). The recent refinement of electrocardiographic triggering and gating with CT has enabled these techniques to be performed with greater reliability and substantially lower radiation exposure. This has led to widening availability of these diagnostic techniques and rapid expansion of our understanding of their potential clinical use. Within the context of CHD, 2 applications are particularly compelling--risk stratification of asymptomatic individuals with the intent of targeting therapy to prevent CHD and as gatekeeper to cardiac catheterization to minimize unnecessary invasive diagnostic coronary procedures. This review highlights key insights from recent investigations of CHD development and CT application toward the management of individuals at risk of developing or suspected of having CHD.

Registro de la Actividad Hemodinámica y Cardiología Intervencionista en Andalucía durante el año 2009

Introduction and objectivesAn analysis is presented on the results from the Registry of Haemodynamic and Interventional Cardiology Activity of the Spanish Cardiology Society in Andalusia during 2009. In this article, the number of coronary diagnostic procedures and interventions in Andalusia are determined and compared with the overall nationwide average and with previous years. ResultsDuring the year 2009, an estimated 2,480 coronary angiographies/million inhabitants were carried out in Andalucía and 2,649 nationwide. There were 1,350 percutaneous coronary interventions (PCI)/million inhabitants performed in Andalusia compared to 1,366 at national level. Of these, 238 were due to an acute myocardial infarction (AMI), and 108 were as primary angioplasty, compared to 290 and 202, respectively, at national level. There was an increase of 51.2% in the number of coronary catheterisations, and 59.3% in PCIs compared to 2004. The percentage use of pharmaceutically active stents was similar to the national average (58%), and the use of the radial artery in vascular access techniques was somewhat lower (39% vs 45%). The number of percutaneous aortic prostheses implants performed was the same as the national average. ConclusionsThe 2009 statistics, together with the increased number of coronary angiographies and PCIs/million inhabitants bring the Andalusian statistics closer to the national average. However, as regards AMI, the number of PCIs, particularly primary CPI's in Andalusia is still lower than the national average.

Transradial approach (left vs right) and procedural times during percutaneous coronary procedures: TALENT study

most of the studies assessing transradial approach for coronary angiography (CA) have been performed through right radial approach (RRA). Our aim was to evaluate the safety and efficacy of left radial approach (LRA) compared with RRA for coronary procedures. from January 2009 to December 2009, in 2 hospitals, 1,540 patients were randomized to RRA (770 patients) or LRA (770 patients) for percutaneous coronary procedures. The primary end point was fluoroscopy time for CA and for percutaneous coronary intervention (PCI) evaluated independently. Prespecified subgroup analyses according to patient age and operator experience were planned. in 1,467 patients (732 RRA and 735 LRA), a CA (diagnostic group) was performed, and in 688 (344 each for RRA and LRA), a PCI. In the diagnostic group, LRA was associated with significantly lower fluoroscopy time (149 seconds, interquartile range [IQR] 95-270 seconds) and dose area product fluoroscopy (10.7 Gy cm(2), IQR 6-20.5 Gy cm(2)) compared with the RRA (168 seconds, IQR 110-277 seconds, P = .0025 and 12.1 Gy cm(2), IQR 7-23.8 Gy cm(2), P = .004, respectively). In the PCI group, there were no significant differences in fluoroscopy time (614 seconds, IQR 367-1,087 seconds for LRA and 695 seconds, IQR 415-1,235 seconds, P = .087 for RRA) and dose area product fluoroscopy (53.7 Gy cm(2), IQR 29-101 Gy cm(2) for LRA and 63.1 Gy cm(2), IQR 31-119 Gy cm(2), P = .17 for RRA). According to subgroup analyses, the differences between LRA and RRA were confined to older patients (≥ 70 years old) and to operators in training. left radial approach for coronary diagnostic procedures is associated with lower fluoroscopy time and radiation dose adsorbed by patients compared with the RRA, particularly in older patients and for operators in training.

A New Vascular Closure Device for the Transradial Approach: The D Stat Radial System

The transradial approach is associated with low complication rates. The D Stat Radial vascular closure system offers hemostatic pressure locally at the puncture site with residual venous flow. We prospectively included 113 consecutive patients presenting between August 2006 and December 2006. Diagnostic coronary procedures were performed using 4 Fr or 5 Fr sheaths, while 6 Fr devices were used for PCI. In every case at least 5.000 IU heparin was given. Compression with the retention strap was planned for approximately 3 hours before the pad was fixed using a medical strip. All data were entered into a database after a two-dimensional ultrasound examination study of the puncture site. The mean age was 65 years (+/-SD 10.3), with 62% being male. Patients presenting with acute coronary syndrome amounted to 6.2%, where 5r F sheaths were usually used with these patients (64.6%). PCI was carried out in 21.2% of cases. The system was applied successfully in all patients. The mean duration of compression was 4.6 hours (+/-SD 1.4). Bleeding after removal of the system occurred in 18.6% of cases, which resulted in prolonged compression in 17.7%. A hematoma >5 cm was seen in 4.4% of the sample. Ultrasound examinations revealed closure of the radial artery in 6.2%. We conclude that this new device operates efficiently, but bleeding occurred in 18.6%. Compression time should be extended to 6 hours.

Safety of intracoronary Doppler flow measurement

Background With the introduction of Doppler-tipped guide wires, intracoronary Doppler flow measurement has been increasingly accepted as an additional diagnostic approach in the catheterization laboratory. However, the safety of intracoronary Doppler flow measurement has not been well-investigated. The purpose of our study was to evaluate the safety of intracoronary Doppler flow measurement using the Doppler FloWire (Cardiometrics, Mountain View, Calif). Methods and Results A total of 906 patients were examined by intracoronary Doppler with a 0.014-inch or an 0.018-inch Doppler FloWire. For coronary flow reserve measurement, intracoronary injection of adenosine or papaverine was used. Of the patients studied, 77 were cardiac transplant recipients and 829 were patients who had not received a transplant, of whom 617 had undergone diagnostic coronary procedures and 212 had coronary interventions. In 27 (2.98%) of 906 patients adverse cardiac events were observed. Fifteen (1.66%) of 906 patients had severe transient bradycardia develop (asystole or second- to third-degree atrioventricular block) after intracoronary administration of adenosine, 14 of which occurred in the right coronary artery and 1 in the left anterior descending artery. Nine (0.99%) of 906 patients had coronary spasm during the passage of the Doppler wire (5 in the right coronary artery, 4 in the left anterior descending artery). Two (0.22%) of 906 patients had ventricular fibrillation during the procedure. Hypotension with bradycardia and ventricular extrasystole each occurred in 1 (0.11%) of 906 patients. The incidence of complication was significantly higher in transplant recipients than in patients who underwent either diagnostic or interventional procedures (12.99% vs 2.43% vs 0.94%, P <.001). The Doppler measurements in the right coronary artery were associated with a higher incidence of complications, especially bradycardia, compared with the left anterior descending and the left circumflex arteries (right coronary, 5.87% vs left anterior descending, 1.05% vs left circumflex, 0.17%; P <.001). All complications were cured medically. Conclusion Intracoronary Doppler flow measurement with Doppler wires and intracoronary administration of adenosine is a safe method. However, severe complications such as bradycardia and coronary spasm can occur. Attention should be paid to the examination of the right coronary artery, especially in heart transplant recipients. (Am Heart J 2000;140:502-10.)

The significance of coronery reserve in clinical heart disease

The clinical syndrome “coronary insufficiency with normal coronary arteriogram” is found in approximately 10% to 20% of patients with exercise-induced coronary insufficiency. In most of these cases, disturbances of the coronary microcirculation are present. They can appear in vascular diseases (arterial hypertension, systemic immunopathies, immune complex vasculitis), in rheologic diseases (paraproteinemia, hyperlipoproteinemia, polyglobulia) and in disturbances of transport and diffusion of oxygen (carbon monoxide intoxication, methemoglobinemia).The clinical diagnosis is based on the usual diagnostic procedures (electrocardiogram, exercise electrocardiogram, responsiveness to nitroglycerin), as well as on newer functionally oriented diagnostic procedures (determinations of coronary blood flow and coronary vascular reserve, production of lactate, serologic findings, histology and histology of peripheral arteries, measurements of viscosities in both plasma and blood). Many clinically relevant disturbances in the coronary microcirculation can thus be detected and treated on a rational basis by management of the underlying main disease, that is, by treatment of the vascular, rheologic and metabolic disorders.Persistent angina pectoris in the presence of a normal coronary arteriogram does not represent an end to coronary diagnostic procedures, but introduces the clinical task of using all diagnostic possibilities to enable functional and therapeutic assessment of the coronary microcirculation.