Interventional Cardiology Laboratory Research Articles

Assessing the Efficacy of RADPAD Protection Drape in Reducing Radiation Exposure to Operators in the Cardiac Catheterization Laboratory: A Systematic Review and Meta-Analysis.

One of the leading environmental hazards, ionizing radiation, is linked to several detrimental health consequences in the body. RADPAD(Worldwide Innovations & Technologies, Inc., Kansas City, Kansas) is a sterile, lead-free, lightweight, disposable radiation protection shield. We conducted a systematic review and meta-analysis to determine the effectiveness of RADPAD protection drapes in the cardiac catheterization lab and how they can aid interventional cardiologists in becoming subjected to less scatter radiation. PubMed, Embase, and Google Scholar were searched for studies discussing the efficacy of RADPAD protection drapes in reducing radiation exposure to operators in the cardiac catheterization laboratory. A random-effects model was used to pool odds ratios (ORs) and 95% confidence intervals (CIs) for endpoints: primary operator exposure dose, dose area product (DAP), relative exposure, and screening time. Our analysis included 892 patients from six studies. Compared to the No-RADPAD group, primary operator exposure dose (E) was significantly lower in the RADPAD group (OR: -0.9, 95% CI: -1.36 to -0.43, I2= 80.5%, p = 0.0001). DAP was comparable between both groups (OR: 0.008, 95% CI: -0.12 to -0.14, I2= 0%, p = 0.9066). There was no difference in the relative exposure (E/DAP) (OR: -0.47, 95% CI: -0.96 to 0.02, I2= 0%, p = 0.90) and screening time (OR: 0.13, 95% CI: 0.08 to 0.35, I2= 0%, p = 0.22) between the two groups. The interventional cardiology laboratory is exposed to significantly less scatter radiation during procedures owing to the RADPAD protective drape. Consequently, all catheterization laboratories could be advised to employ RADPAD protective drapes.

Working in interventional cardiology laboratories: The perceived impact of radiation exposure as a health and gender hazard. A NEXT generation ANMCO initiative

BackgroundGender-related discrepancies in personal and professional life have been reported among radio-exposed workers. We assessed this topic among cardiac catheterization workers in Italy, with a focus on gender and working position. MethodsRadio-exposed workers affiliated with the Italian Association of Hospital Cardiologists were invited to answer an online survey, which included 41 questions formatted as multiple choice. Results: Overall, 237 workers responded. The proportion of males was significantly higher than that of females in the population aged >50 years. A greater portion of females than males perceived female-gender discrimination regarding career advancement (77.2% vs 30.9%, p < 0.001) and work compensation (49.1% vs. 17.1%, p < 0.001). There was no difference in perceived gender- discrimination in terms of career advancement opportunities between physician and non-physicians. A larger portion of females than males experienced workplace discrimination (51.8% of females vs. 8.1% of males, p < 0.0001). Non-physician responders made up 38.8% of all respondents and reported a lower yearly radiation exposure than physicians. Non-physicians were more aware of the laws regulating lab access during pregnancy than physicians (93.5% vs. 48.3%, p < 0.0001). A greater percentage of female nurses than physicians communicate without hesitation the pregnancy status to their employers (45.6% vs 20%, p < 0.001). ConclusionsGender-based career disparities were perceived among physicians and non-physician staff of cardiology interventional laboratories. Strategies should be implemented to ensure gender equality in career opportunities and to increase knowledge of radioprotection and the laws regulating access to laboratories during pregnancy.

Radiation exposure and gender issues in interventional cardiology laboratories in Italy

Radiation exposure and gender issues in interventional cardiology laboratories in Italy

Calculation of Intracoronary Pressure-Based Indexes with JLabChart

The Fractional Flow Reserve (FFR) and instantaneous wave-Free Ratio (iFR) have been proposed and clinically validated to measure the pressure gradient across coronary stenoses. They provide quantitative information on stenosis severity. Both are used in coronary revascularization procedures to measure intracoronary pressure giving quantitative information to evaluate coronary diseases during angiographic procedures. We designed and implemented a tool able to acquire and measure iFR and FFR supporting the physicians studying and treating patients in interventional cardiology laboratories. We designed an extensive case study to assess the performance of the tool in (i) acquiring pressure signals from blood pressure measurement systems; (ii) calculating FFR and iFR; and (iii) filtering out extra-beats signals during realtime signal analysis phases. The tool, named JLabChart, is available online. We tested it on two sets of data for a total of 600 cycles from 201 pressure measurements performed on 65 patients, from the Interventional Cardiology Unit of Magna Graecia University. The recognition of cardiac cycles and keypoint of the pressure curve was effective in 100% of cases for proximal (aortic) pressure and in 99.2% for distal pressure. The FFR calculated by JLabChart had an excellent correlation (Rp=0.960; p&lt;0.001) with the FFR values obtained through the commercial systems. Similar results were obtained with iFR (Rp=0.998; p&lt;0.001). Finally, the tool measurement results were compared with a commercial tool proving JLabChart’s efficiency with real cases. It was also compared with measurements performed on synthetic vessels and stenosis designed using the Comsol commercial tool. JLabChart is able to provide reliable measurements of FFR and iFR indexes used to support decisions on interventional procedures. It represents a valuable open source support system that can be used in an interventional cardiology laboratory.

Uninterrupted DOACs Approach for Catheter Ablation of Atrial Fibrillation: Do DOACs Levels Matter?

Most patients present for catheter ablation of atrial fibrillation (CAAF) with residual or full effect of vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). In daily practice, it has been observed that the activated clotting time (ACT) was actually poorly sensitive to the effect of DOACs and that patients on DOACs required more unfractionated heparin (UFH) to achieve the ACT target of 300 s during the procedure, leading some authors to worry about potential overdosing. Conversely, we hypothesize that these higher doses of UFH are necessary to achieve adequate hemostasis during CAAF regardless of the residual effect of DOACs. During CAAF, thrombosis is promoted mainly by the presence of thrombogenic sheaths and catheters in the bloodstream. Preclinical data suggest that only high doses of DOACs are able to mitigate catheter-induced thrombin generation, whereas low dose UFH already do so. In addition, the effect of UFH seems to be lower in patients on DOACs, compared to patients on VKAs, explaining part of the differences observed in heparin requirements. Clinical studies could not identify increased bleeding risk in patients on DOACs compared to those on VKAs despite similar efficacy during CAAF procedures. Moreover, targeting a lower ACT was associated with an increased periprocedural thrombotic risk for both DOAC and VKA patients. Therefore, the low sensitivity of the ACT to the residual effect of DOACs should not be a major concern in its use in the interventional cardiology laboratory.

Right-to-Left Shunt Through Iatrogenic Atrial Septal Defect After MitraClip Procedure

ObjectivesThe aim of this study was to investigate the incidence, characteristics, hemodynamic conditions, and clinical significance of right-to-left (R-L) shunt through an iatrogenic atrial septal defect (iASD) after the MitraClip procedure. BackgroundR-L shunt through an iASD after the MitraClip procedure has not been well investigated. MethodsFrom 2014 to 2017, 385 consecutive patients with mitral regurgitation underwent the MitraClip procedure. iASD was assessed using intraprocedural transesophageal echocardiography. Right and left heart catheterization was used to assess the hemodynamic status of patients. All patients provided written informed consent for the procedure. All data for this study were collected from an established interventional cardiology laboratory database approved by the Cedars-Sinai Medical Center Institutional Review Board. ResultsR-L shunt was observed in 20 patients (5%). In 7 of these patients (35%), R-L shunt was accompanied by acute deoxygenation. Prevalence of severe tricuspid regurgitation (55% vs. 20%; p = 0.001), serum B-type natriuretic peptide (664 pg/ml [434 to 1,169 pg/ml] vs. 400 pg/ml [195 to 699 pg/ml]; p = 0.006), mean pulmonary artery pressure (38 mm Hg [34 to 45 mm Hg] vs. 29 mm Hg [22 to 37 mm Hg]; p < 0.001), and right atrial pressure (19 mm Hg [13 to 20 mm Hg] vs. 10 mm Hg [7 to 14 mm Hg]; p < 0.001) were significantly higher in patients with R-L shunt than in those with left-to-right shunt. Patients with R-L shunt also showed a more prominent reduction in the left atrial V-wave and mean pressure from baseline to post-procedure compared with those with left-to-right shunt (−22.8 ± 2.6 mm Hg vs. −11.8 ± 0.9 mm Hg [p = 0.002] and −7.9 ± 0.8 mm Hg vs. −4.0 ± 0.4 mm Hg [p = 0.003], respectively). ConclusionsR-L shunt through an iASD was observed in 5% of patients who underwent the MitraClip procedure and in one-third of patients with R-L shunt presented acute deoxygenation. Elevated right atrial pressure concomitant with pulmonary hypertension and significant reduction in left atrial pressure after MitraClip deployment were associated with R-L shunt.

Blood oozing: A cause of life-threatening bleeding without overt source after transcatheter aortic valve replacement

BackgroundPost-procedure non-access site-related bleedings have a significant impact on mortality in patients treated by transcatheter aortic valve replacement (TAVR). Notwithstanding, the source of these bleedings is frequently indeterminate, with potentially serious clinical implications related to lack of diagnosis and treatment. MethodsOut of 513 TAVR performed between June 2007 and January 2016 in the Interventional Cardiology Laboratory of the Department of Cardiac, Thoracic and Vascular Sciences, University Hospital of Padua, we identified few proven cases of concealed bleeding after TAVR due to blood oozing. ResultsWe report three cases of angiographically confirmed post-TAVR non-access bleedings related to spontaneous blood oozing, a life-threatening condition consisting of diffuse capillary hemorrhage developing from vessels not directly involved by the procedure. We hypothesize that spontaneous post-procedural blood oozing may account for a substantial proportion of non-overt, non-access site-related bleeding after TAVR. ConclusionThe possibility of post-TAVR blood oozing is largely neglected in the literature, and comprehensive categorization of non-access site bleedings in current standardized endpoints of TAVR studies is missing. Early assessment with arterial and venous contrast phase angio-MDCT scans in case of post-TAVR unexplained and persistent anemia may allow diagnosis and treatment of this subtle condition.

Effect of real time visual feedback on cardiologist’s radiation exposure with an established electronic real time radiation system

Introduction Real time visual feedback from electronic personal dosimeters has been shown to reduce occupational exposures when first introduced in an interventional cardiology setting [1] . In a recent paper by our group, we found that there was little difference one month and six months after the introduction of such a system. This study aims to assess the effect of removing the visual dose feedback on operator exposures. Materials and methods Occupational collar exposures were monitored for cardiologists ( n = 5) over a series of mixed case types ( n = 95) in a busy interventional cardiology laboratory [1] . For half the cases the visual feedback screen was switched off during the procedure depending on an assigned random number. The radiation exposure data was analysed using a Mann Whitney U test. Results/discussion There was no significant statistical difference in radiation exposure to the cardiologists between when the visual feedback system was switched off or on. Increased case numbers may point to differences between operators and case types. Conclusion This study suggests that real time visual feedback may not prove beneficial to dose reduction in an established electronic monitoring system.

Evaluation of scattered radiation and impact of local protective devices in an interventional cardiology laboratory

ABSTRACT Background Medical applications are the main source of ionizing radiation exposure, and in this context the issue of occupational risk is particularly important. Although the different organs of the human body present different radiation sensitivities, specific assessments of the impact on the different regions of the interventionist's body with diverse radioprotection devices are rare in Brazil. Methods A scattered radiation test was performed using an ionization chamber in a fluoroscopy station, with standard radioprotection accessory kit of the equipment (lower skirt and upper movable shield, in two different positions), at sequential distances from the source, using acrylic phantoms as human chest simulation. Results Differences in radiation were identified in relation to distance and use of radioprotection devices. The median radiation reduction was 50.6% (interquartile range – IQ from 39.42% to 51.05%) using the lower skirt shield, 71.3% (IQ from 67.66% to 77.05%) with the addition of an upper shield in angulated position, and 84.7% (IQ from 83.75% to 85.87%) with the addition of an upper shield aligned with the lower shield. Significant differences were also found regarding height and distance from the source. Conclusions The use of the assessed local radioprotection devices was effective in reducing the overall radiological impact to the interventionist. However, there were radiation escape routes, especially with non-ideal positioning, demonstrating the importance of the additional use of individual protection devices.

The role of real time three-dimensional transoesophageal echocardiography in acquired mitral valve disease

Summary Real time (RT) three-dimensional (3D) imaging is one of the most significant developments of the last decade and is now being used with increasing frequency in echocardiography and interventional cardiology laboratories. Improvements in transducer technologies and the development of a matrix array transducer were the most important achievements that lead to the new era of real time 3D transoesophageal echocardiography (TEE). RT 3D TEE is ideal for assessing the mitral valve (MV) because of its high spatial resolution altering in improved MV anatomic detail. This imaging modality provides images of high quality which is of a great clinical value inmaking diagnosis of MV disease and a valuable tool for surgeons and interventional cardiologists in planning and guiding interventional procedures. This review is intended to provide data about normal MV anatomy and clinical usefulness of RT 3D TEE in defining acquired MV pathology.

Is Monitoring of Total Beam-On Time a Sufficient Measure of Patient Radiation Exposure in the Interventional Cardiology Laboratories?

Is Monitoring of Total Beam-On Time a Sufficient Measure of Patient Radiation Exposure in the Interventional Cardiology Laboratories?

PMD73 - Health economic model to measure the impact of a stemi initiative in Romania

ST-segment elevation myocardial infarction (STEMI) is a leading cause of global morbidity and mortality, comprising 25-40% of MI presentations, with varying outcomes. 5-6% of patients die before leaving hospital, and 7-18% of discharged patients die within one year. In Romania, the annual mortality rate is 14.5% for admitted patients. An Excel-based model was developed to assess the clinical and economic impact of different treatment strategies for STEMI patients in Romania. This model uses data from the Romanian National Registry, Romanian Heart Foundation, and CC Iliescu Heart Institute to evaluate STEMI treatment scenarios based on disease awareness, timely hospital admissions, and treatment with PCI, versus alternative approaches such as thrombolytics or no reperfusion. 2009-2014 outcomes were modeled year-over-year for sequential STEMI cohorts. Prospective outcomes through 2019 were modeled to calculate the value of continued investment in STEMI management. Model inputs included morbidity and mortality, labor productivity (measured by average wage), direct treatment costs, and disease burden (measured by disability-adjusted life-years and value of a statistical life). Outputs were calculated up to one year after initial STEMI event, and calculated separately for hospital-admitted and non-admitted populations, with the latter group divided by treatment pathway: PCI, thrombolytics, no reperfusion, or CABG. From 2009-2014, an investment of 20.8 million € in interventional cardiology and catheterization laboratories resulted in 2,197 lives saved, with cost savings of 21.6 million € from improved productivity. Prospective calculations through 2019 show an investment of 14.2 million € would result in 1,528 lives saved, with cost savings of 12.3 million €. From 2009-2014, Romanian healthcare expenditures to improve STEMI management strategies showed favorable clinical outcomes when more patients were managed with PCI. This mortality reduction suggests that continued national investment in STEMI management could further improve these rates, with greater cost savings achieved as a result.

Benefits of an automatic patient dose registry system for interventional radiology and cardiology at five hospitals of the Madrid area.

The purpose of this article is to present the results of connecting the interventional radiology and cardiology laboratories of five university hospitals to a unique server using an automatic patient dose registry system (Dose On Line for Interventional Radiology, DOLIR) developed in-house, and to evaluate its feasibility more than a year after its introduction. The system receives and stores demographic and dosimetric parameters included in the MPPS DICOM objects sent by the modalities to a database. A web service provides a graphical interface to analyse the information received. During 2013, the system processed 10 788 procedures (6874 cardiac, 2906 vascular and 1008 neuro interventional). The percentages of patients requiring clinical follow-up due to potential tissue reactions before and after the use of DOLIR are presented. The system allowed users to verify in real-time, if diagnostic (or interventional) reference levels are fulfilled.

Occupational Health Hazards of Working in the Interventional Laboratory: A Multisite Case Control Study of Physicians and Allied Staff

BackgroundThe occupational hazards of working in the interventional laboratory have been inadequately studied for physicians and remain unaddressed for nonphysician personnel. ObjectivesThis study sought to determine whether the prevalence of work-related musculoskeletal pain, cancer, and other medical conditions is higher among physicians and allied staff who work in interventional laboratories compared with employees who do not. MethodsMayo Clinic employees who work in affiliated hospitals with interventional cardiology or interventional radiology laboratories took an electronic survey. Results were stratified on the basis of self-reported occupational exposure to procedures that involve radiation. ResultsThere were 1,543 employees (mean age 43 ± 11.3 years, 33% male) who responded to the survey (response rate of 57%), and 1,042 (67.5%) reported being involved with procedures utilizing radiation. These employees reported experiencing work-related pain more often than the control group before (54.7% vs. 44.7%; p < 0.001) and after adjustment for age, sex, body mass index, pre-existing musculoskeletal conditions, years in profession, and job description (odds ratio: 1.67; 95% confidence interval: 1.32 to 2.11; p < 0.001). Musculoskeletal pain varied significantly by job description, with the highest incidence reported by technicians (62%) and nurses (60%) followed by attending physicians (44%) and trainees (19%; p < 0.001). There was no difference in cancer prevalence between groups (9% vs. 9%; p = 0.96). ConclusionsMusculoskeletal pain is more common among healthcare workers who participate in interventional procedures and is highest in nonphysician employees. The diagnosis of cancer in employees who participate in procedures that utilize radiation was not elevated when compared to controls within the same departments, although any conclusion regarding causality is limited by the cross-sectional nature of the study, as well as the low overall prevalence of malignancy in our study group.

National DRLs for adult body CT scans based on body width

National DRLs for adult body CT scans based on body width

Utility of optical coherence tomography and intravascular ultrasound for the evaluation of coronary lesions

Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) are imaging methods used in the diagnosis of coronary lesions. IVUS is widely used in interventional cardiology laboratories, but OCT is now increasingly used. Conventional coronary angiography can identify different types of coronary lesions but sometimes is unable to diagnose them correctly. Both intravascular imaging methods are useful for better interpretation of these lesions, and can accurately diagnose ruptured plaques, thrombosis, stent restenosis and hazy images. However, the resolution of OCT is ten times higher than IVUS, and so an accurate diagnosis cannot always be achieved with ultrasound imaging. We present three cases in which IVUS was unable to identify the lesion causing the condition and OCT was required to obtain clearer images that helped to confirm the diagnosis. The advantages and disadvantages of each method are then discussed.

Utility of optical coherence tomography and intravascular ultrasound for the evaluation of coronary lesions

Optical coherence tomography (OCT) and intravascular ultrasound (IVUS) are imaging methods used in the diagnosis of coronary lesions. IVUS is widely used in interventional cardiology laboratories, but OCT is now increasingly used. Conventional coronary angiography can identify different types of coronary lesions but sometimes is unable to diagnose them correctly. Both intravascular imaging methods are useful for better interpretation of these lesions, and can accurately diagnose ruptured plaques, thrombosis, stent restenosis and hazy images. However, the resolution of OCT is ten times higher than IVUS, and so an accurate diagnosis cannot always be achieved with ultrasound imaging. We present three cases in which IVUS was unable to identify the lesion causing the condition and OCT was required to obtain clearer images that helped to confirm the diagnosis. The advantages and disadvantages of each method are then discussed.

All-cause readmission and repeat revascularization after percutaneous coronary intervention

Percutaneous coronary intervention (PCI) is one of the most frequently performed cardiac interventions. However, there is limited data regarding the cause of recurrent hospitalization and repeat revascularization. The aim of this study was to assess re-hospitalization and repeat revascularization within 30 days of the initial hospitalization for PCI, using data from Opolskie Voivodeship, National Health Fund (NHF) Registry. The study population consisted of all PCI patients treated in three interventional cardiology laboratories in Opolskie Voivodeship in Poland between 1 July 2008 and 30 June 2009. All PCI patients who died during the initial hospitalization or who were transferred to other units were excluded from the analysis. The study end-point comprised 30 day all-cause readmission and repeat revascularization. A total of 2,039 PCI patients were included in the analysis. The all-cause 30-day readmission rate was 14.6%. The 30-day readmission rate of acute coronary syndrome (ACS) patients was significantly higher compared to the stable coronary disease patients (ACS 15.8%, non-ACS 10.7%, p = 0.008). The 30-day readmission rate did not differ between the three cardiac laboratories. Approximately half (46.2%) of all readmitted patients underwent a repeat revascularization procedure, mainly in the form of PCI. The overall all-cause 30-day mortality rate was 0.8%. Compared to the PCI patients who did not require readmission, the readmitted patients had a significantly higher all-cause 30-day mortality rate (3.6% vs 0.3%, p < 0.001). Almost one in seven PCI patients requires readmission within 30 days of hospital discharge. Approximately 50% of all readmitted PCI patients resulted in a repeat revascularization procedure. PCI patients who were readmitted within 30 days of an index PCI procedure had a significantly higher all-cause 30-day mortality rate.

Current status of hybrid coronary revascularization

Hybrid coronary revascularization combines coronary artery bypass surgery with percutaneous coronary intervention techniques to treat coronary artery disease. The potential benefits of such a technique are to offer the patients the best available treatments for coronary artery disease while minimizing the risks of the surgery. Hybrid coronary revascularization has resulted in the establishment of new ‘hybrid operating suites’, which incorporate and integrate the capabilities of a cardiac surgery operating room with that of an interventional cardiology laboratory. Hybrid coronary revascularization has greatly augmented teamwork and cooperation between both fields and has demonstrated encouraging as well as good initial outcomes.

Increases in patient doses need to be avoided when upgrading interventional cardiology systems to flat detectors

The aim of this study was to evaluate patient doses in two interventional cardiology laboratories over a period of 1 y in which the imaging devices were changed from image intensifier (II) to flat detector (FD). Dosimetric data from a total of 1040 coronary angiography (CA) procedures and 1087 percutaneous transluminal coronary angioplasty (PTCA) procedures were gathered. During the period studied with II imaging, median values of dose area product were 28 Gy cm(2) for CA and 57 Gy cm(2) for PTCA. In the first half of the year with FD imaging, median values were 37 Gy cm(2) for CA and 89 Gy cm(2) for PTCA. A significant increase in patient doses was noticed in the early stages of use of FD technology for imaging IC procedures, while fluoroscopy time and number of images remained similar. A careful setting of the X-ray systems, after upgrading the imaging system, is essential to avoid unjustified increases in patient doses.