High-volume Catheterization Laboratory Research Articles

Impact of new-onset versus preexisting atrial fibrillation on short- and long-term mortality in patients with STEMI treated with primary PCI

Abstract Background Comparative data on the effects of new-onset vs. preexisting atrial fibrillation (AF) on long-term mortality in patients with ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) are scarce. Therefore, the aim of this study was to assess the impact of new-onset vs. preexisting AF on mortality over 5 years after primary PCI. Methods Our analysis included 7 955 patients referred to primary PCI in the period from 2009 to 2019, for whom data regarding the presence and type of AF were available, from a prospective electronic registry of a high-volume catheterization laboratory. Patients were stratified into three groups according to the AF status: no AF vs. new-onset vs. preexisting AF. Cumulative mortality was compared with Kaplan Meier curves. Cox regression models were created to assess the mortality hazard at 30 days and 5 years according to the presence of new-onset and preexisting AF with no AF as the reference group. 30-day follow-up was available for 7 738 and 5-year for 5 049 patients. Results Preexisting AF was found in 3.1% of patients (n=246) and new-onset AF was recorded in 7.0% (n=560). Both new-onset and preexisting AF were associated with higher crude mortality rates compared to patients without AF, at 30 days (14.4% vs 16.0% vs. 5.2%, respectively; p<0.001) and at 5 years as well (56.6% vs. 65.7% vs. 25.4%, respectively; p<0.001). Cumulative mortality rates were significantly higher for both new-onset and preexisting AF, as compared to patients with no AF (Log rank p<0.001, Figure). Patients with new-onset and preexisting AF were older and had a higher baseline risk profile including more frequently prior MI and stroke, more diabetes, hypertension, hyperlipidaemia, renal failure, Killip class ≥2 on admission and lower ejection fraction. When adjusted for these baseline differences, both new-onset and pre-existing AF independently predicted 5 year mortality (HR 1.6, 95%CI 1.4-1.9, p<0.001, and HR 2.2, 95%CI 1.8-2.8, p<0.001, respectively), but not at 30 days (HR 1.4, 95%CI 0.9-2.0, p=0.1, and HR 1.5 95%CI 0.9-2.5, p=0.1, respectively). Conclusion Both new-onset and pre-existing AF are independently associated with an increased risk of long-term mortality in patients with STEMI treated with primary PCI, whereas their impact on short-term mortality reflects the higher baseline risk profile of those patients.Cumulative mortality rates

Small buddy balloon catheter technique facilitates deliverability of other balloons or stents in challenging cases.

Despite improvements in balloon and stent technology, percutaneous coronary intervention (PCI) in calcified, tortuous, angulated or previously stented vessels is still a therapeutic challenge. The proper preparation of the vessel, confirmed by the smooth passage of smaller balloon catheters, often remains insufficient to deliver a larger, stiffer balloon or stent catheter in place of the target lesion. We describe a modified buddy balloon catheter technique that facilitates the deliverability of larger balloons or stents to these challenging lesions when the routinely used buddy wire technique as the first step fails. The small buddy balloon catheter technique is a simple extension of the buddy wire technique in which a small monorail uninflated balloon, of up to 1.5 mm, is positioned on the buddy wire distally or at the point where the balloon/stent becomes stuck. The small buddy balloon catheter appears to reduce the resistance of the rough surface, especially the angulated segment of the vessel, and facilitates other balloon or stent catheter passage. This does not concern a balloon inflation but rather catheter shaft properties. Since that technique is used in our high-volume catheterization laboratory with a surprisingly high success rate we think that it is worth sharing our experience with other operators. Consequently, we have decided to present these 2 cases.

Impact of a CTO in a non-infarct-related artery on long-term mortality in patients undergoing primary PCI

Abstract Background Previous studies showed increased mortality rates in patients with ST-elevation myocardial infarction (STEMI) and a chronic total occlusion (CTO) in a non-infarct-related artery, but long-term data are scarce. Purpose Our aim was to assess all-cause mortality during 5 years follow-up in patients with a remaining nonculprit CTO after being treated with primary PCI. Methods The study included 9504 patients admitted for primary PCI during 2009–2019, with available baseline angiography, from an electronic, prospective registry of a high-volume catheterization laboratory. Kaplan Meier cumulative mortality curves for non-culprit CTO vs. no CTO were compared with the log-rank test, with landmarks set at 30 days and then annually up to 5 years follow-up. Adjusted Cox regression models were constructed to assess 30-day and 5-year mortality risk of a non-culprit CTO. Median follow-up was 1507 days. Results Nonculprit CTO was present in 13.2% of patients (n=1253). Presence of a nonculprit CTO was associated with older age (64 vs. 61, p<0.001), more frequent history of cardiovascular disease including prior MI (33% vs. 14%, p<0.001), stroke (10.3% vs. 5.9%, p<0.001) and CABG (10.5% vs. 1.5%, p<0.001), higher rates of renal failure (10.7% vs. 4.8%, p<0.001), as well as more often Killip class 2–4 on admission (29% vs. 16%, p<0.001) and a lower ejection fraction (40% vs. 47%, p<0.001). Crude mortality rates were significantly increased in patients with a nonculprit CTO vs. no CTO, at both 30 days (15.7% vs. 5.6%, p<0.001) and 5 years (54.6% vs. 27.9%, p<0.001). After adjusting for the observed baseline differences, nonculprit CTO was still associated with an elevated mortality risk at both 30-days (HR 1.5, CI95% 1.1–1.9, p=0.007) and 5 years (HR 1.6, CI95% 1.4–1.9, p<0.001). Landmark analyses showed continuously increasing risk of mortality in the presence of a nonculprit CTO, as compared with primary PCI-treated patients with no CTO (30 days to 1 year 11.4% vs. 4.9%, p<0.001; 1st to 2nd year of follow-up 6.3% vs. 3.4%, p<0.001; 2nd to 3rd year 6.2% vs. 2.8%, p<0.001; 3rd to 4th year 7.4% vs. 3.0%, p<0.001; and 4th to 5th year 5.2% vs. 3.6%, p=0.1). Conclusions Presence of a nonculprit CTO is independently associated with 5-year mortality after primary PCI. Importantly, the mortality risk increases continuously with an average annual absolute difference of 3%, in patients with a nonculprit CTO vs. those with no CTO. Nonculprit CTO vs. no CTO Funding Acknowledgement Type of funding source: None

Cardiovascular Health in the COVID-19 Era: A Call for Action and Education

Cardiovascular Health in the COVID-19 Era: A Call for Action and Education

P849Comparison of long-term mortality risk assessed with recalculated (maximal) CADILLAC score vs. baseline (admission) CADILLAC score in STEMI patients undergoing primary PCI

Abstract Background Since patients with STEMI have high rate of adverse events not only during hospital stay, but also during short and long-term follow–up, appropriate risk stratification is a key part of the management of these patients following hospital discharge. CADILLAC score was derived and subsequently validated as accurate clinical tool for identifying patients with heightened risk following index event. Purpose We aimed to compare predictive value of recalculated, maximal, (M-) CADILLAC score vs. baseline (B-) CADILLAC score for long-term mortality in hospital survivors. Methods From a prospective electronic registry of a high-volume catheterization laboratory in a period from January 2009 to December 2017, a total of 5387 consecutive patients STEMI who underwent primary PCI were included in analysis. For each patient B-CADILLAC score was calculated, and for survivors, we recalculated M-CADILLAC score, incorporating changes in three variable score individual contributors (worsening of Killip class, anemia development and renal function deterioration). As in original score derivation, patients with cardiogenic shock were excluded from analysis. Discrimination of the two risk models was evaluated by the C-statistic, Net reclassification index (NRI) and Integrated Discrimination Improvement (IDI) index. Results For 111 (2.1%) patients that died in-hospital, B-CADILLAC very well predicted the event (AUC 0.87, 95% CI 0.86–0.88; p<0.0001) (Figure 1A). For hospital survivors, both evaluated scores showed good discriminative ability for long-term mortality (11.7%) but recalculated M-CADILLAC score was statistically better predictor of long-term mortality, as assessed by C-statistics (Table 1 & Figure 1B): NRI showed that 38% of patients were reclassified with M-CADILLAC with IDI slope 0.8% higher than in first model. Table 1 4723 pts (follow-up=90% pts, 41±27 months) AUC 95% CI p B-CADILLAC 0.756 0.744–0.768 p=0.018 M-CADILLAC 0.776 0.754–0.779 Figure 1 Conclusions Baseline CADILLAC score has very good predictive ability for in-hospital mortality, but recalculated, maximal CADILLAC score offers discriminative advantage in hospital survivors for prediction of long-term mortality in STEMI patients undergoing primary PCI.

P953Comparison of the original and updated ACTION risk scores for predicting in-hospital and one-year mortality in patients with acute myocardial infarction undergoing primary PCI

Abstract Background The Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get With The Guidelines (GWTG) AMI mortality model and risk score (ACTION) were introduced in 2011 to predict in-hospital mortality. In 2016 score was updated to enable a more accurate assessment, but, up-to-date, external validation in direct comparison was not performed. Purpose We aimed to externally validate and compare the prognostic value of original and updated ACTION score for in-hospital and one-year mortality. Method From a prospective electronic registry of a high-volume catheterization laboratory in a period from January 2009 to December 2017, a total of 5615 consecutive patients who underwent pPCI were available for analysis. For each patient, original (O-) and updated (U-) ACTION scores were calculated using required clinical and angiographic characteristics. In-hospital and one-year mortality (follow-up available for 91%) were assessed. Calibration and discrimination of the three risk models were evaluated by the Hosmer-Lemeshow (H-L) goodness-of-fit test and C-statistic, respectively. Results Mortality rates for in-hospital and one-year mortality were 4.2% and 9.6%, respectively. Both scores showed good model calibration as assessed by the H-L test and very good discriminative power for in-hospital and one-year mortality as assessed by C-statistics (Table 1 & Figure 1). Net reclassification index (NRI=1.06) showed that 48% of patients with in-hospital event and 58% without event, had their risk recalculated with U-ACTION with Integrated Discrimination Improvement slope 9.1% higher than in first model. Table 1 Risk score H-L H-L p value AUC 95% CI p value AUC 95% CI Significant p value O-ACTION 9.4 0.3 0.829 0.819 to 0.839 p<0.0001 0.781 0.769 to 0.792 p<0.0001 U-ACTION 10.9 0.2 0.918 0.911 to 0.925 0.838 0.827 to 0.848 Figure 1 Conclusion Updated ACTION score enables better prediction of in-hospital and one-year mortality in patients undergoing pPCI for acute myocardial infarction, thus it can be used preferentially over the original ACTION score for assessment of short and long-term mortality risks of this population.

P5481Predictors of mortality in patients with non-anterior ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention

Abstract Background Previous studies have indicated that patients with non-anterior ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) have a more favorable prognosis compared with anterior STEMI, especially in the short term. Purpose Our aim was to identify predictors of increased 30-day mortality in patients with non-anterior STEMI undergoing primary PCI. Methods This analysis included 8188 patients referred to primary PCI during 2009–2017, from a prospective electronic registry of a high-volume catheterization laboratory, for whom 30-day follow-up was available. Non-anterior infarction was defined as presence of ST-segment elevation in inferior and/or lateral ECG leads or true posterior MI. Multivariable Cox regression was used to assess the mortality risk at 30 days. Results 59.4% (n=4863) of the included patients presented with a non-anterior STEMI. Mortality rate was significantly lower in patients with non-anterior vs. anterior STEMI (4.2% vs. 8.3%, p<0.001). Older age (> median of 61, HR 2.2, p=0.002), baseline renal failure (eGFR <60, HR 4.0, p<0.001), Killip class ≥2 (HR 3.8, p<0.001), previous stroke (HR 1.8, p=0.004), non-culprit chronic total occlusion (CTO, HR 2.0, p<0.001) and final TIMI flow grade <3 in the infarct-related artery (HR 3.1, p<0.001) were independently associated with an increased risk of 30-day mortality in non-anterior STEMI. The presence of at least one of these high-risk factors was noted in 61.2% of patients with non-anterior STEMI and was associated with a significantly higher risk of 30-day mortality (HR 18.2, p<0.001), similarly to the overall risk associated with anterior STEMI (HR 22.9, p<0.001), as compared with patients with non-anterior STEMI but without any of the here identified high-risk factors (Figure). Figure 1 Conclusions Crude mortality rate was significantly lower in patients with non-anterior vs. anterior STEMI. However, the majority of non-anterior STEMI patients had at least one of the high-risk factors (older age, previous CVI, baseline renal failure, Killip class ≥2, non-culprit CTO or final TIMI flow <3), which predisposed these patients to a similar increase in short-term mortality risk as in patients with anterior STEMI.

P950Synergistic impact of renal failure and left ventricular dysfunction on short- and long-term mortality in patients with STEMI undergoing primary PCI

Abstract Background Impaired left ventricular function (LV) and renal failure (RF) have both been separately associated with increased risk of mortality in ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Purpose Our aim was to comparatively evaluate the relative impact of LV dysfunction and renal failure (RF) on the risk of mortality in primary PCI-treated STEMI patients. Methods 5878 patients admitted for primary PCI during 2009–2015, from a prospectively kept, electronic registry of a high-volume catheterization laboratory, were included in the analysis. LV dysfunction was defined as EF<40%, and RF as estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 according to Cockcroft-Gault formula. Adjusted Cox regression models were used to assess 30-day and 3-year mortality hazard, with patients with EF≥40% and normal renal function serving as the reference group. Results RF was documented in 17.1% (n=1006), whereas 36.5% had LV dysfunction (n=2141). LV dysfunction and RF were separately associated with increased crude mortality rates, whereas the concurrence of both resulted in the highest mortality rate at 30 days (0.7% if no RF and normal EF vs. 5.4% if RF alone vs. 3.9% if EF<40% alone vs. 12.6% if both RF and EF<40%; p<0.001), and at 3 years (5.7% if no RF and normal EF vs. 29.0% if RF alone vs. 19.0% if EF<40% alone vs. 47.4% if both RF and EF<40%; p<0.001). After multivariable adjustment for other significant mortality predictors, such as age, previous stroke, diabetes, hyperlipidemia, anemia and Killip≥2, RF and LV dysfunction were associated with a comparable increase in mortality risk at 30 days (HR=4.1 and HR=3.7, respectively, p<0.001 for both) and at 3 years (HR=2.8 and HR=2.7, respectively, p<0.001 for both). Importantly, the combined presence of RF and low EF was independently associated with a marked increase in both 30- day (HR=6.5, 95% CI 3.7–11.4, p<0.001), and 3-year mortality (HR=4.3, 95% CI 3.3–5.6, p<0.001). Kaplan Meier cumulative mortality curves Conclusion Apart from each being independently associated with an increased risk of mortality, the concurrence of renal failure and LV dysfunction had a synergistic negative impact on the prognosis of primary PCI-treated STEMI patients

P4619Comparison of the CRUSADE, ACUITY-HORIZONS, and ACTION bleeding risk scores for predicting in-hospital bleeding in acute myocardial infarction patients undergoing primary PCI

Abstract Background Considering clinical importance of bleeding complications in patients with acute myocardial infarction (AMI), bleeding risk stratification is a key part of the management of these patients. CRUSADE, ACTION and ACUITY-HORIZONS bleeding risk scores are available for predicting in-hospital major bleeding events in patients with acute myocardial infarction. Purpose We aimed to evaluate performance of the three above mentioned risk scores for predicting in-hospital bleeding events defined according to The Bleeding Academic Research Consortium (BARC) criteria. Methods From a prospective electronic registry of a high-volume catheterization laboratory in a period from January 2009 to December 2017, a total of 6505 consecutive patients with acute myocardial infarction who underwent pPCI were included in analysis. Calibration and discrimination of the three risk models were evaluated by the Hosmer-Lemeshow (H-L) goodness-of-fit test and C-statistic, respectively. Results Overall there were 372 (5.7%) bleeding events out of which 117 (1.8%) fulfilled stage BARC 3 or higher bleeding criteria. All three scores showed good model calibration as assessed by the H-Ls test and very good discriminative power for BARC 3 of higher bleeding events detection as assessed by C-statistics (Table 1 & Figure 1): Bleeding events stage BARC 3 or higher were statistically highly related with higher in-hospital mortality (13.7% vs. 3.5%; p<0.000). Table 1 Risk score H-L H-L p AUC 95% CI p CRUSADE 11.46 0.177 0.761 0.750–0.771 vs. ACUITY = ns vs. ACTION <0.000 ACUITY-HORIZONS 10.47 0.236 0735 0.724–0.745 vs. ACTION = ns ACTION 5.74 0.677 0.701 0.698–0.712 Figure 1 Conclusions All three evaluated scores showed very good discriminative capacity for predicting BARC 3 or higher bleeding events in patients undergoing pPCI for AMI.

Primary percutaneous coronary intervention without on-site cardiac surgery backup in unselected patients with ST-segment-Elevation Myocardial Infarction: The RIvoli ST-segment Elevation Myocardial Infarction (RISTEMI) registry

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for patients with ST-segment-elevation myocardial infarction (STEMI), but some concerns remain about its safety and efficacy in centers without on-site cardiac surgery (OCS). The Infermi Hospital in Rivoli, Italy, is a community hospital without OCS with a high volume catheterization laboratory (>800 PCI and >150 primary PCI per year), which provides a 24-hour primary PCI service to a population of 583.000 and is only 14 km far from the nearest OCS hospital. We analyzed clinical and procedural data, as well as 30-day outcome, of all STEMI patients treated by primary PCI within 12 hours from symptom onset. From September 2001 to June 2010, 1302 patients with a suspect of STEMI underwent urgent coronary angiography. Of these, 1251 (96.1%), underwent primary PCI. A successful myocardial revascularization was achieved in 1172 patients (93.7%). Thirty-day mortality occurred in 7.1%. Multivariate predictors of 30-day mortality were: age ≥75 years (OR 3.96, p=0.0003), left ventricular ejection fraction ≤40% (OR 35.0, p=0.02), cardiogenic shock at presentation (OR 33.4, p<0.0001), anterior STEMI (OR 1.82, p=0.036) and total ischemic time ≤3 hours (OR 0.55, p=0.05). Primary PCI is a reperfusion strategy feasible and effective in unselected high-risk STEMI patients even in hospitals without OCS with a high volume of routine and emergency interventional procedures.

Chronic low-dose radiation exposure from interventional cardiology procedures induces chromosomal abnormalities in originally genetically identical twins

Current radiation protection standards are based on the premise that even low dose of ionizing radiation may result in detrimental health effects, such as long-term development of cancer and hereditary disease [ [1] Committee on the Biological Effects of Ionizing Radiation Health effects from exposure to low levels of ionizing radiation. National Research Council, 2005 Google Scholar ]. Cardiovascular testing accounts for at least one-third of all ionising testing and invasive cardiologists working in a busy catheterization laboratory are the most exposed among professionally exposed physicians. Interventional cardiologists have an exposure per-head per year two to three times higher than that of radiologists [ 2 Cordella J, Faulkner K, Hopewell J, et al. Avoidance of radiation injuries from medical interventional procedures extracted from International Commission on Radiaton Protection.ICRP Publication 85. Ann. ICRP 30:2 (2000). Google Scholar , 3 Hirshfeld Jr., J.W. Balter S. Brinker J.A. et al. American College of Cardiology Foundation; American Heart Association; HRS; SCAI; American College of Physicians Task Force on Clinical Competence and Training. ACCF/AHA/HRS/SCAI clinical competence statement on physician knowledge to optimize patient safety and image quality in fluoroscopically guided invasive cardiovascular procedures: a report of the American College of Cardiology Foundation/American Heart Association/American College. Circulation. 2005; 111: 511-532 Crossref PubMed Scopus (208) Google Scholar ]. Chromosome aberration (CA)-based assays are considered the gold standard of biological dosimeter of radiation exposure and intermediate endpoints of cancer risk [ [4] International Atomic Energy Agency (IAEA) Cytogenetic analysis for radiation dose assessment. Technical Report. vol. 405. 2001 Google Scholar ]. We and others have recently reported that cardiologists working in a high-volume catheterization laboratory chronically exposed to low-dose radiation well within allowed limits show increased chromosomal damage versus non-exposed controls [ 5 Zakeri F. Assaei R.G. Cytogenetic monitoring of personnel working in angiocardiography laboratories in Iran hospitals. Mutat Res. 2004; 562: 1-9 Crossref PubMed Scopus (45) Google Scholar , 6 Andreassi M.G. Cioppa A. Botto N. et al. Somatic DNA damage in interventional cardiologists: a case-control study. FASEB J. 2005; 19: 998-999 Crossref PubMed Scopus (89) Google Scholar ]. However, from a case-control study, it is not completely possible to determine the role of other potentially confounding factors that appear to have great influence on the frequency of CA, such as age, smoking or individual genetic susceptibility.

Somatic DNA damage in interventional cardiologists: a case‐control study

Interventional cardiologists who work in cardiac catheterization laboratories are exposed to low doses of ionizing radiation that could pose a health hazard. DNA damage is considered to be the main initiating event by which radiation damage to cells results in development of cancer and hereditary disease. The aim of the present study was to assess the effects of chronic low-dose X-ray radiation exposure on somatic DNA damage of interventional cardiologists working in high-volume cardiac catheterization laboratories. For this analysis, we used peripheral lymphocytes and the assay for micronuclei (MNs), which is considered to be a reliable biological dosimeter for radiation exposure. We obtained peripheral blood from 62 physicians (mean age+/-se = 40.6+/-1.5 years): 31 interventional cardiologists (group I, exposed) and 31 age- and sex-matched clinical cardiologists (group II, nonexposed). Interventional cardiologists showed higher MN values (group I=20.5+/-1.6 vs. group II=12.8+/-1.3, P=0.001), although some overlap was apparent in the individual subject analysis. A correlation between years of professional activity and MN frequency value was detectable for interventional cardiologists (r=0.428, P=0.02) but not for clinical cardiologists (r=0.253, P=0.17). The results indicated that, overall, interventional cardiologists working in a high-volume catheterization laboratory have higher levels of somatic DNA damage when compared with clinical cardiologists working outside the catheterization laboratory. The amount of this damage varies and is only weakly related to the duration of professional exposure, which suggests that a dominant modulation of the underlying genetic substrate by environmental factors has a role in determining the harm in individual physicians.

Review of Subacute Stent Thrombosis Following Percutaneous Coronary Intervention at a Low‐Volume Catheterization Laboratory

The frequency of coronary stent subacute thrombosis (SAT) following percutaneous coronary intervention (PCI) with uncoated stents in recent studies is 0.5%-0.9%. Prior studies have indicated that complication rates are significantly higher when performed in low-volume centers. We sought to determine the incidence and outcomes of SAT following PCI with stent placement at a low-volume catheterization laboratory. We reviewed the Brooke Army Medical Center Interventional Database for all consecutive PCIs with stent implantation performed from January 1998 to December 2002. Clinical outcomes were obtained primarily through hospitalization records and clinic follow-up visits. There were 789 interventions with stenting on 750 patients over the specified time period, for an average of 158 procedures on 150 patients per year. There were seven cases of SAT, representing a rate of 0.89%. There was no difference in the clinical characteristics, procedural technique, or postprocedural antithrombotic therapy of the subjects with and without SAT. Of those with SAT, there were no subjects requiring surgical revascularization during index hospitalization, and all survived to index hospital discharge. Six of these seven subjects with SAT (85.7%) were alive at one year, with the single death noncardiovascular related. The incidence of thrombosis occurring within 30 days of intracoronary stent implantation is similar in low- and high-volume catheterization laboratories. In our low-volume laboratory experience, these events were not associated with significantly increased adverse outcomes.

Usefulness of intracardiac echocardiography in transseptal puncture during percutaneous transvenous mitral commissurotomy

P ercutaneous transvenous mitral commissurotomy has become an effective and safe alternative to surgical treatment in well-selected patients.’ Transseptal catheterization is a vital component of the procedure. Because of its technical complexity and difEculty, transseptal catheterization is recommended to be restricted to highvolume catheterization laboratories equipped with biplane fluoroscopy.2 Recently, usefulness of transthoracic 2dimensional echocardiography and transesophageal echocardiography‘t in guiding transseptal puncture has been reported. However, transthoracic 2-dimensional echocardiography may be limited by suboptimal interatria1 septum visualization. In addition, placement of the transducer on the patient’s chest not only interferes with the fluoroscopic images, but also poses a radiation hazard to the echocardiographer. Space limitations in the catheterization laboratory and a need to preserve a sterile field also make this examination cumbersome. Transesophageal echocardiography allows high-quality visualization of the interatrial septum in relation to surrounding cardiac structures, thus facilitating a safe transseptal puncture. However, it adds discomfort and stress to the patients, aside from the possible risk of esophageal injury and lung aspiration. Because of the disadvantages and limitations of transthoracic and transesophageal echocardiography, we investigated the feasibility and usefulness of intracardiac echocardiography using a commercially available 10 MHz over-the-wire intravascular ultrasound catheter to perform transseptal puncture. Seven patients with symptomatic severe mitral stenosis were studied including 2 men and 5 women aged 36 to 55 years (mean 45). Informed consent was obtained from each patient. After diagnostic catheterization, a IOFr 10 MHz ultrasound catheter was inserted into the superior vena cava over a preplaced 0.025inch guidewire through a IlFr sheath in the lef femoral vein. The catheter was interfaced with a real-time ultrasound imaging system (CVIS Inc., Sunnyvale, California). The ultrasound catheter was withdrawn caudally from the superior vena cava to the midright atrium to image the interatrial septum and the atria (Figure IA, lef panel). A 7Fr Mullins transseptal catheter with a Brockenbrough needle was inserted through the right femoral vein and its tip was set at the optimal transseptal puncture site. The latter was determined under f?on-tal fluoroscopic view according to landmark selection guidelines previously described.‘a5 The position of the catheter ultrasound transducer was adjusted so that the

Development and application of transseptal left heart catheterization.

The recent interest in transseptal left heart catheterization affords an opportunity to review the development and application of this procedure. This review briefly follows the history of right and left heart catheterization to the development of the transseptal procedure. A detailed description of the technique of transseptal catheterization is provided, as well as the indications and contraindications to its use. A learning curve is associated with this technique and is inversely related to the complication rate of the transseptal approach. Physicians working in high volume catheterization laboratories may gain the experience to safely perform transseptal left heart catheterization on carefully selected patients.