Interventional Cardiology Unit Research Articles

The development of a Hub & Spoke network for transcatheter aortic valve replacement procedures: the operational model of the Interventional Cardiology Unit at the IRCCS San Raffaele Hospital (OSR Hub-Spoke)

Recently, an increase in the number of patients with severe aortic stenosis eligible for transcatheter aortic valve implantation (TAVI) has been observed worldwide. In order to reduce waiting lists, provide to all patients referred to us equal access to care and to further improve the collaboration with spoke centers, we developed a specific Hub & Spoke specific protocol for TAVI. According to our protocol, a clinical selection (with echo and computed tomography scan) is done by Spoke centers, the case is discussed with a multidisciplinary team online and the procedure is planned (access, valve type size). At day 0, the patient is admitted in Spoke centers where blood samples are taken; at day 1, the patient is transferred to a Hub center for the TAVI procedure and after 2 h of observation, if no adverse events are registered, the patient is transferred back to the Spoke center. Since 2019, an agreement among our center and two hospitals has been signed. According to this Hub & Spoke model, a total of 72 patients with aortic stenosis were treated with TAVI (mean age 83 years, 48.6% female, median Society of Thoracic Surgeons risk 2.4 ± 1.1%, left ventricular ejection fraction 58.0 ± 7.75%). More frequently CoreValve Evolut R (47.2%) was used. Only 2 patients had a prolonged admission at Hub and were not transferred at day 1 (1 vascular complication and 1 intra-procedural resuscitated cardiac arrest). This Hub & Spoke model guaranteed shortening of waiting lists, more effective turnover of bed, equal access to care to patients referred to our center. In addition, it helped also to increase Awareness and education as well as appropriate training of the teams from spoke facilities.

DEVELOPMENT OF A HUB–SPOKE NETWORK FOR TRANSCATHTER AORTIC VALVE IMPLANTATION: THE INTERVENTIONAL CARDIOLOGY UNIT OF IRCCS SAN RAFFAELE HOSPITAL (OSR HUB–SPOKE)

Abstract Background The growing prevalence of aortic stenosis determined in recent years an increase in candidates for percutaneous aortic valve replacement (TAVI), bringing out a difficult access to this procedure. In order to reduce waiting lists and to guarantee the training of the Interventional Cardiologists of Centers not equipped with on–site cardiac surgery, we implemented a TAVI protocol with one Hub center, the Interventional Cardiology Unit of IRCCS San Raffaele Scientific Institute, Milan, and two participating Spoke Centers: the ASST–Franciacorta Chiari Center and Valduce Hospital, Como.The aim of this study is to report in hospital outcomes of patients treated using this model of Hub–Spoke Network. Methods Patients included in this model were selected in the Spoke center where baseline clinical evaluation with echocardiography and CT scan were performed (inclusion and exclusion criteria attached). The cases were then discussed with a multidisciplinary team on–line and the procedure planned (access, valve type size). Once the procedure was scheduled, the patients underwent a single day transport to the Hub Center where they underwent TAVI and a same day return to the Spoke Center. A bailout hospitalization in the Hub Center was available in case of major complication. All Spoke Centers patients who underwent TAVI procedures in our Center according to our protocol were included in this analysis. The primary study objective was in hospital major adverse cardiac events (all cause or cardiovascular mortality, stroke, myocardial infarction); secondary study objectives were technical success, prolonged recovery in Hub Center and major vascular complications. Results Since 2019, a total of 69 patients underwent TAVI with the Hub and Spoke model. Mean age was 83 years ± 6 and mean ejection fraction was 59% ± 7%. Two patients (2.9%) had a prolonged hospitalization in the Hub center for a major vascular complication and an intra–procedural cardiac arrest, successfully resuscitated. Technical success was reached in 97.1% of patients. One patient experimented an ischemic stroke after the return in the spoke center: in hospital MACE was than 1.4%. Conclusion Considering the growing prevalence of aortic stenosis, The Hub Spoke Model for TAVI guarantees reduction in waiting lists, "access to care" for patients referred to Spoke centers, involvement and improvement of skills of their Interventional Cardiologists, keeping a high level of safety and efficacy.

Acute Coronary Syndrome in Women at the CHU le Luxembourg of Bamako

Introduction: Acute coronary syndromes have been very little studied in the female population in black Africa. Our series showed an increase in the prevalence of acute coronary syndromes in the female population compared to previous studies. Through this retrospective study, we evaluated the epidemiological, clinical, paraclinical, therapeutic and evolutionary specifications of acute coronary syndromes in women. Methodology: This was a retro and prospective study, concerning patients admitted for an acute coronary syndrome over a period of 3 years from September 1, 2019, to August 30, 2022, in the interventional cardiology unit at the CHU le Luxembourg of Bamako. Results: During the study period, 74 patients’ files were collected out of 251 patients, i.e., a frequency of ACS in women of 29.5%. The average age of the patients was 59.31 ± 10.89 years (37 and 83 years) and the age group 45-65 years was the most affected. The risk factors were essentially high blood pressure 66.2% (n=49), physical inactivity 66.2% (n=49) and diabetes 59.5% (n=44). The predominant functional signs were atypical chest pain in 56.8% of cases (n=42). The electrical aspect was mainly persistent ST-segment elevation in 61% (n=45). Seventy-six percent (n=56) of patients were treated 12 hours after the first medical contact. The approach for coronary angiography was radical in 93%. Coronary angiography was pathological in 92% (n=68). Lesions were single vessel in 29.7% of cases and multi-vessel in 62.2% of cases. Conclusion: Acute coronary syndrome in women is characterized by atypical of symptoms with a delay in diagnosis and management. Coronary lesions are characterized by multi-vessel involvement in the majority of cases.

Radial Versus Femoral Access in Percutaneous Coronary Intervention in Acute Coronary Syndrome

Background: Although it safeguards patients from hemorrhagic disorders during cardiac procedures, the radial route is technically more challenging than the femoral approach. Aim: To evaluate the hypothesis that radial approach is the preferred strategy in ACS patients, and identifying independent predictors of the choice to choose radial access. Methods: Between August 2021 and January 2022, this prospective study was conducted in the interventional cardiology unit of Hayatabad Medical Complex Peshawar. The study included all ACS (unstable angina or myocardial infarction) patients who had previously had invasive diagnostic or therapeutic cardiac procedures. Patients who opted out of the trial were excluded. Results: Those in group 1 had a lower mean GRACE score (112±31 versus 127±40; p<0,001), improved renal function according to cretanine level (0.9±0.3 versus 1.1±1.0; p < 0.001) and a reduced prevalence of indications of left ventricular failure (6% versus 21%, p 0.003) when compared to patients in group 2. There was no difference in the groups at the time of admission for the type of ACS heart rate (69±15 Vs 75±16), systolic arterial pressure (148±31 Vs 151±33), positive troponin 59(79.7%) Vs 51(68.9%), electrocardiographic ischemia 23(31%) Vs 19(25.7%), three-vessel disease (30, 40.5%) VS 25(33.8%) Practical implication: The variables that determined the preference for radial approach reflect the clinical status and severity of the patients, demonstrating that the convenience of the approach is more valued in extremely complex patients than its antihemorrhagic effectiveness. Conclusion: The trend for radial access to be preferred over femoral access during coronary intervention was not primarily influenced by the patient population's risk of bleeding. Keywords: Angioplasty, Coronary Artery Disease, Radial Artery, Femoral Artery.

Chemotherapy delivering port catheter fracture and migration into the heart: a life-threatening accident during neck dissection

Objectives: port catheter fracture and migration could be an iatrogenic life-threatening complication. We aimed to sensitize head and neck surgeons to this complication. Observation: a 61-years old man was referred to our surgery department for management of T3N0M0 laryngeal cancer after failure of preservative treatment. The patient had received 2 cycles of chemotherapy and was judged a bad responder. A total laryngectomy with bilateral neck dissection was indicated. The port catheter was kept in place for possible further chemotherapy treatment. During neck dissection the catheter fractured and migrated. Post operative CT scan showed the distal part of the catheter bulging in the right cardiac chambers. The patient was transferred to an interventional cardiology unit where the foreign body was successfully retrieved using femoral venous access. Conclusion: port catheters are a real potential danger because of the risk of fracture and migration of the distal part. Removal of these devices should be performed in collaboration with medical care oncologists before every neck intervention.

Changes to the editorial board: new co-editor for EHJ.

All correspondence relating to this article should be sent to cardiopulse@unicatt.it. Marco Roffi, MD, is professor of medicine, vice-chair of cardiology, and director of the Interventional Cardiology Unit at the University Hospitals of Geneva, Switzerland. Following training in interventional cardiology with Bernard Meier at the University Hospital of Bern, Switzerland, and with Eric Topol at the Cleveland Clinic, United States, he worked alongside Thomas Lüscher in Zurich, Switzerland. He has been a member of the international editorial board of EHJ since 2013 and has held a wide range of roles across the ESC working to ensure the Society’s reach, authority, and impact (Figure 1). Filippo Crea created a team of EHJ co-editors with the task of being EHJ ambassadors across the continents. The purpose is to approach cardiologists from all over the world and introduce them to the Journal. The fact that EHJ is one of the leading cardiovascular journals worldwide may be a barrier to many cardiologists, especially for the younger generation. My job as EHJ co-editor for Western Europe will be to try to reduce the barriers in this part of the world. On behalf of the EHJ leadership, I would like to take the opportunity to thank William Wijns, who preceded me in this function, for all his work.

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<0.001) with the FFR values obtained through the commercial systems. Similar results were obtained with iFR (Rp=0.998; p<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.

Patients Present with Left Bundle Branch Block and its Cardiac Structure Disease during Trans Thoracic Echocardiography

Background and Purpose: Left bundle branch block (LBBB) is a communal electrocardiographic (ECG) finding that may or may not be associated with overt heart disease at diagnosis. The current study was performed to determine the clinical picture and structural abnormalities of the heart diagnosed by transthoracic echocardiography in patients with left bundle branch block. Methods: This cross-sectional observational study was conducted over a six-month period in the Interventional Cardiology Unit Liaquat University Hospital Hyderabad from July 2021 to December 2021. Adult patients of both sexes with LBBB, symptomatic or asymptomatic, were recruited from an outpatient hospital setting and underwent elective Transthoracic echocardiography (TTE) after demographic / clinical data and informed consent were obtained. The TTE results were recorded and presented as frequency and percentage. Results: 120 patients were examined; 74 men and 46 women. The study population mean age was 52.7 ± 1.5 years, range (22-76) years. In a history, 10 (8.3%) patients had mild dyspnoea (NYHA class I-II) and 9 (7.5%) severe dyspnoea (NYHA class III-IV). Echocardiograms of only 11 (9.2%) patients were normal. The structural abnormalities observed included abnormal septal motion in 96 (80%), mitral regurgitation in 16 (13.3%), and left ventricular dilatation with left ventricular end-diastolic dimension> 60 mm in 23 (19.2%). LVEF was normal in 80 (66.7%) cases (> 50%); 18 (15%) had a LVEF of 25-35% and 12 (10%) had a LVEF of 35-50%. Conclusion: The possibility of structural cardiac abnormalities on echocardiography is high in patients with LBBB. Keywords: Transthoracic echocardiography, Left bundle branch block (LBBB), Structural heart disease.

Interventional cardiology in times of COVID-19: impact on a terciary centre

IntroductionCardiovascular diseases are the leading cause of death worldwide and the pandemic caused by coronavirus disease 2019 (COVID-19) has forced profound changes in the care of patients with cardiac conditions. In Portugal, an increase in mortality beyond that attributed solely to COVID-19 was observed. We aimed to realize how COVID-19 has changed the activity of our Interventional Cardiology Unit.MethodsWe retrospectively assessed all patients submitted to any interventional procedure in 2019 and 2020 in our hospital. A total of 7621 patients and 9163 procedures were evaluated. The mean weekly numbers of coronarography, angioplasty, right heart catheterization and structural heart intervention during 2019 were assessed and were compared with the first COVID-19 wave (comprising March and April 2020) and the second COVID-19 wave (including the time period from October to end of December 2020).ResultsMean age was 65.2±16.6 years with 72% being male. In the first COVID-19 wave there was a significant reduction in the mean weekly numbers of all procedures, with a 64% decline in coronarographies (30.9±29.3 vs 87.2±12.9, P<0.001), 48% in angiographies (15.7±10.9 vs 30.2±5.7, P=0.004), 51% in right heart catheterizations (5.3±5.9 vs 10.9±4.5, P=0.002) and 57% in structural heart interventions (1.1±1.9 vs 2.6±2, P=0.044). Although there was an evident recovery in activity (figure 1), comparing to 2019, the second wave also showed a significant lower number of procedures, with 24% fewer coronarographies (66.6±20.6 vs 87.2±12.9, P=0.003) and 13% fewer angiographies (26.4±7.6 vs 30.2±5.7, P=0.004). Contrariwise, in the second wave there was no difference in the number of right heart catheterizations (7.3±6.1 vs 10.9±4.5, P=0.055) or structural heart interventions (1.6±1.6 vs 2.6±2, P=0.106).ConclusionsIn our Interventional Cardiology Unit, COVID-19 led to a significant reduction of procedures in the first and second pandemic waves. The effect on the increase in morbidity and mortality has yet to be determined. Health authorities should focus attention in defining measures to amend the consequences of this documented activity reduction.Funding AcknowledgementType of funding sources: None. Figure 1

Sleep Quality in Patients Undergoing Transcatheter Aortic Valve Implantation (TAVI).

The present study aimed to analyze sleep quality and quality of Life (QoL) in patients undergoing Transcatheter Aortic Valve Implantation (TAVI). It was conducted at the Interventional Cardiology Unit of the Department of Cardiac, Thoracic, Vascular Sciences and Public Health of the University of Padova on 27 adult patients who underwent TAVI via the transfemoral approach. Patients completed two validated instruments, i.e., the Pittsburgh Sleep Quality Index (PSQI) and the EuroQoL (EQ-5D-5L), on the day of discharge and one month after the hospital discharge. Twenty-seven patients were enrolled with a severe aortic stenosis diagnosis, treated with transfemoral TAVI procedure. The study population included seventeen poor sleepers and ten good sleepers with a median age of 81.92 years overall. The global PSQI evaluation revealed a small significant improvement at follow-up (p-value 0.007). Small positive changes were detected in the Self-care and Usual activity domains of the EQ-5D-5L and the EQ-VAS. No correlation was detected between EQ-5D-5L and sleep quality. The present study confirms the importance of sleep quality monitoring in patients who undergo TAVI procedure for aortic stenosis treatment.

Evaluation of the Factors Affecting the Length of Stay in Hospital of Transcatheter Aortic Valve Implantation (TAVI) Cases

Introduction: In the treatment of inoperable patients with severe aortic stenosis or at high surgical risk, transcatheter aortic valve implantation (TAVI) is applied as an alternative to surgical aortic valve replacement. In our study, it was aimed to evaluate the factors affecting the length of stay in hospital of TAVI cases. Method: After obtaining the approval of the ethics committee, the patients who received TAVI between 09.06.2012-19.01.2018 in the Interventional Cardiology unit of Dokuz Eylül University were retrospectively screened. A total of 243 patients were included in the study. Demographic data, preoperative accompanying diseases and echocardiographic results of the cases, the type of anesthesia applied, the duration of postoperative coronary intensive care, and a hospital stay were recorded. The analysis of the data was carried out in the SPSS 22.0 statistical package program, Results: 53.5% of the patients who underwent transcatheter aortic valve implantation received general anesthesia, 46.5% received local anesthesia and sedation. 93.8% of the patients were discharged upon recovery. There was a significant difference between the postoperative length of stay in the hospital and the type of anesthesia (p=0.008). It was shown that patients who underwent general anesthesia were discharged later than patients who underwent sedation. Discussion and Conclusion: Due to the high risks of surgery, it is of vital importance to shorten the length of stay in hospital in high-risk patients over 65 years of age who undergo TAVI.

234 The role of preprocedural assessment of aortic valve calcium volume for the optimization of percutaneous aortic bioprosthesis implantation (TAVI)

Abstract Aims Paravalvular leaks (PVL) and conduction disorders requiring permanent pacemaker implantation (PPI) in patients with severe Aortic Valvular Stenosis (SA) undergoing percutaneous aortic valve prosthesis (TAVI) still have a significant and unacceptable incidence for patients at medium and low surgical risk, who represent, with increasing scientific evidence, the prevalent population. The appearance of these complications seems to be related to clinical, anatomical and procedural factors, which influence the decision-making process of the type and size of bioprosthesis to be implanted. Particular attention has been paid to the role of the volume of calcium present at the native aortic valve (VCA) as a predictor of these complications, in order to optimize the percutaneous procedure. The VCA can be quantified using algorithms derived from Multilayer Computed Computed Axial Tomography (MSCT), an examination that has become a pivotal element in the evaluation of the patient's eligibility for TAVI.The aim of our study was to document the pre-procedural added value of VCA in terms of possible containment of adverse events and how much it may affect the choice of the type of bioprosthesis to be implanted. Methods and results 111 patients underwent TAVIs at the Interventional Cardiology Unit of the AOU S. Giovanni di Dio and Ruggi D'Aragona, between 2017 and 2020, subsequently divided into 2 groups: group A (self-expandable bioprosthesis, Medtronic Evolut R or Evolut Pro) and group B (balloon expandable bioprosthesis, Edward Sapien 3).The clinical, electrocardiographic, echocardiographic and anatomical parameters of the enrolled patients were analyzed, and the VCA in the preprocedural phase was quantified for each of them, using an algorithm extracted from the MSCT reading software, OsiriX (OsiriX-MD v.2.8.2 64-bit). A univariate logistic regression analysis was performed for the risk of developing the composite event of significant PVL and IPP.In Group B, no significant variables were found, while in Group A, the VCA (OR: 1.001; 95% CI, 1.000-1.002; p &amp;lt; 0.043) and incomplete left branch block (OR: 5.781; 95% CI, 0.013-32.988; p &amp;lt; 0.048) were significant. Subsequently, these two variables were tested in a multivariate regression model according to which only the VCA emerged as an independent predictor for the composite event (OR: 1.001; 95% CI, 1.000-1.002; p &amp;lt; 0.039). Conclusion VCA is significantly associated with the risk of moderate to severe PVL and rhythm disturbances requiring PPI, in the group of patients in whom a self-expandable bioprosthesis was implanted, unlike patients who received a balloon-expandable bioprosthesis where this association is not significant.

Provisional versus 2-stent strategies for coronary bifurcations: is a bird in the hand worth two in the bush?

Abstract Background Among all subsets of coronary artery lesions, bifurcations stand out due to high incidence, demanding percutaneous interventions (PCIs) and poor outcomes. Amid the different PCI strategies, the provisional (PS) approach is generally recommended over 2-stent (TS) techniques, but this paradigm has been challenged. Purpose To compare PS with TS for PCI of coronary bifurcation lesions, concerning procedural aspects and both immediate and long-term patient outcomes. Methods Retrospective study encompassing patients consecutively referred to a tertiary interventional cardiology unit for coronary angiography, who were found to have at least 1 native bifurcation lesion. According to operator experience and angiographic features, patients were managed with PS or/(and) TS. Procedural aspects regarding radiological variables, angiographic success and immediate complications were reviewed, as were in-hospital outcomes. Besides, clinical follow-up, by clinic appointment or telephone calling, was performed targeting stent failure, target vessel revascularization (TVR), acute coronary syndromes (ACS), heart failure and mortality. Results From January 2010 to June 2017, 404 patients with 433 bifurcation lesions were included. Median age was 70 (62–77) years and 25.3% were female. Median follow-up was 2 (1–3) years. Chronic angina was the dominant PCI context (61.3%) with 9.7% presenting with ST-segment elevation myocardial infarction (MI). Medina class 1,1,1 was documented in 54.1% and 64.9% of lesions were hailed as true bifurcations. 303 patients underwent PS, whereas 67 were managed with TS, with TAP (43.3%) and mini-crush (34.3%) as the leading techniques. True bifurcations were more frequently approached with TS (p&amp;lt;0.001), whereas PCI context did not influence procedure selection. Fluoroscopy time (p&amp;lt;0.001), radiation dose (p=0.003) and contrast volume (p=0.009) were higher in the TS subgroup. OCT guidance (p=0.039) was also more common with TS. Angiographic success was uniformly high (95.1% for PS and 97% for TS), while procedural complications, including iatrogenic coronary dissections (7.4%, mostly minor) and slow-reflow (3.5%), were homogenously low. Acute kidney injury and type 4a MI occurred in 14.5% and 32.3%, respectively, also with no difference between groups. As for long-term outcomes, stent failure, encompassing both stent thrombosis (1 event) and restenosis (4.2%), occurred more often with TS (p=0.046), with ACS events (9.5%) following the same trend (p=0.08). In turn, rates of TVR (12.5%), heart failure hospitalization (6.2%) and mortality, regardless of its cardiovascular nature, were similar. Conclusion PS outperforms TS during follow-up, particularly due to lower stent failure odds. Thus, this study further supports the concept of PS as the standard approach for coronary bifurcation lesions. Funding Acknowledgement Type of funding source: None

The Obstacle Course of Reperfusion for ST-Segment-Elevation Myocardial Infarction in the COVID-19 Pandemic.

The Obstacle Course of Reperfusion for ST-Segment-Elevation Myocardial Infarction in the COVID-19 Pandemic.

P022] Assessment of the detectability of a moving guidewire in fluoroscopically-guided procedures using a mathematical model observer

Purpose Fluoroscopically-guided procedures are among the most irradiating medical interventions. Thus, a fair amount of pressure is put on reducing patient exposure. This can be achieved by adapting the unit’s protocols, and by using technical upgrades. However, it is important to check if any image information content is lost. To our knowledge, there is no existing metric able to objectively assess the detectability of moving structures in fluoroscopic images. This work proposes a new method to assess image quality for a clinically relevant detection task in dynamic conditions using a mathematical observer. Methods A thin PMMA plate, supporting a 0.014” guidewire, was attached to a motion simulation engine via a cantilever, allowing motion with velocities and amplitudes representative of coronary arteries. The guidewire was placed at the unit’s isocenter, while 20 cm of PMMA around it simulated a patient. Images were acquired using pre-defined fluoroscopy quality levels (low, medium, and high) on two different units: One dedicated for interventional cardiology (IC), (Philips AlluraClarity FD10) the other for a broader purpose range (Philips Veradius Neo). Regions of interest were extracted from the images, either in the homogenous zones (signal-absent), or along the guidewire (signal-present). A mathematical model observer computed a decision variable for each signal-absent and signal-present image. The signal-to-noise ratio (SNR) between both decision variable distributions was taken as the figure of merit of the guidewire detectability. Dose rates were measured at the entrance of the PMMA using a pencil ionisation chamber. Results Preliminary results show that, for the IC unit, the SNR is equal to 3.5, 4.1 and 4.9 for respectively low (reference dose rate), medium (×1.6 rate) and high (×3.7 rate) quality fluoroscopy settings. In comparison, the same measurement on the non IC-dedicated unit yields a SNR of only 2.0 (high quality setting), at a dose rate comparable (11.5 vs. 12.2 mGy min−1) to medium quality fluoroscopy on the IC unit. Conclusions We have shown the feasibility of using a model observer to assess the detectability of a moving coronary guidewire. Further developments will include the fine tuning of the model, and matching between human observer results.

What’s Ideal? A case study exploring handoff routines in practice

BackgroundHandoffs of care in the healthcare system between responsible providers have traditionally been conceptualized and studied at the point of patient transfer. Thus, clinical practice and associated information systems are designed with the concept of the handoff as a solitary event. This viewpoint does not consider the routine activities necessary for a successful handoff. We propose expanding the analysis of the handoff beyond the single point of transfer to include a routine of interrelated activities leading up to the transfer of responsibility. We used this expanded definition of handoffs to identify exceptions from standard practice as identified by ideal-type handoff routines. MethodWe used an ethnographic case method to study handoffs in an interventional cardiology unit in a Midwestern community hospital. This involved examining handoffs and their supporting routines. We conducted thematic analysis of the handoffs using NVivo, a qualitative software analysis program. These analyses include categorization of the types and causes of differences in practice and exceptions from ideal-type handoffs. ResultsObserved handoffs that took place within the clinical unit did not consistently align with the ideal-type routine, yet this variation did not necessarily lead to exceptions. However, for handoffs between clinical units, although more likely to follow the ideal-type routine, differences from the standardized routine more often led to exceptions. We found that problems with performing the routine activities leading up to the handoff and the context in which the handoff occurred affected whether the handoff was successful. ConclusionsConsidering the handoff as a routine rather than simply the point of transition gives broader insight about how care transitions function. Such consideration helps clinicians better understand how variations occur and how differences from ideal-type handoffs can lead to potential exceptions such as missing information. This analysis can be used to develop information systems that better support handoffs.

Electronic Cigarettes: An Evidence-Based Analysis.

Kochurani S. Joseph, MSN, ANP-C, has been with Columbia-Presbyterian Medical Center in New York, NY, for 15 years, first as a clinical nurse in the Interventional Cardiology Unit and for the last 5 years as a nurse practitioner in the Internal Medicine Clinic managing patients on anticoagulation. Her extensive experience includes work in medical centers in Bahrain, Arabian Gulf, and Bombay, India. She is licensed as a registered professional nurse in both New York and New Jersey. Ms. Joseph received her bachelor of science degree from the College of Nursing, Kottayam, Kerala, India, and her master of science in Nursing-Adult Nurse Practitioner Degree at Saint Peter's University in Jersey City, NJ, and is presently a Doctor of Nursing Practice Candidate at the Englewood Cliff's campus. Ms. Joseph can be contacted by e-mail at: [email protected] Address correspondence to Lynn S. Muller, RN, BA-HCM, CCM, JD, Muller & Muller, 15 West Main Street, Suite C, P.O. Box 164, Bergenfield, NJ 07621 ([email protected]). Disclaimer: The information contained in this department is for educational purposes only. It is not legal advice, which can only be given by an attorney admitted to practice in the jurisdiction/state(s) in which you practice. Do you have a question or issue you would like addressed here? Questions are always welcome. We encourage ALL readers to submit questions and/or manuscripts, as well as topics they would like to see addressed in this department. Questions and other inquiries are accepted by e-mail at: [email protected]. The author reports no conflicts of interest.

Frequency of anatomic variations of radial artery in patients undergoing transradial heart catheterisation

Over the last ten years, transradial cardiac catheterisation has been increasingly applied, primarily because of its lower incidence of complications compared to the femoral approach. However, one of the greatest flaws of the transradial approach is a relatively high incidence of catheterisation failure (1-5%). Anatomic variations of the radial artery are ranked second among the reasons for this. Previous studies have not provided unambiguous data on the frequency of them. It is therefore the aim of this study to determine the frequency of anatomic variations using routine angiographies of the radial artery (RA) during the left heart catheterisation at the Interventional Cardiology Unit of the University Hospital Centre Zagreb in 2013. Seven hundred and fortynine such cardiac catheterisations were carried out during the studied period. All the images were examined and, after selection, 602 remained for further research. The process of selection required all patients to be of age and to have an accurate image of radial artery angiography. Correctly performed radial artery imaging involved the imaging of the division of the brachial artery into the ulnar and radial arteries. It also implied the visibility of at least half of the radial and half of the brachial artery. Anatomic variations are classified in accordance with the classification provided by Burzotta et al. Of the total of 602 patients, 414 (68.8%) were men and 188 were women. The youngest patient was 18 and the oldest one was 87 (mean±SD; 64±10.78), with a normal distribution of subjects across the age groups. In 538 (89.4%) of patients, cardiac catheterisation was performed through the right arm. The frequency of anatomic variations of RA was 8.8%, exclusive of tortuosities whose frequency was 12.7%. The most frequent anatomic variation was the high origin of the radial artery, found in a total of 31 (5.1%) subjects. Radioulnar loops, being one of potential contraindications for the procedure, were reported in 2% of the cases. Regression analysis revealed that age (p<0.001), female sex (p=0.015) and high origin (p=0.034) statistically significantly contributed to the development of tortuosity. The results indicate that the incidence of tortuosity increases linearly with age. Although this is not a contraindication for continuing with the procedure, we recommend that elderly patients should have angiography performed at the beginning of the procedure due to a higher frequency of tortuosity.

Primary angioplasty in Portugal: door-to-balloon time is not a good performance index

Despite primary angioplasty being the recommended treatment for patients with acute myocardial infarction with ST-elevation, recent studies have shown a great heterogeneity in the access to this form of treatment in Europe. The project "Stent for Life", an initiative of the European Society of Cardiology which Portugal joined in February 2011, aims to improve this situation. The objective of this study was to re-evaluate the basic Portuguese performance indicators for primary angioplasty. A national survey called "Moment Zero" was implemented for a one-month period for this purpose. Nineteen Portuguese centres of interventional cardiology, where primary angioplasty is carried out, were invited to participate in this study. From 9th May to 8th June 2011, 14 centres participated in this study and 185 patients were included with a mean age of 62±14 years, of which 76.8% were male. 17.5% of the patients presented with a medical history of diabetes mellitus, 8.4% had previous percutaneous coronary intervention, 7.6% myocardial infarction and 1.1% coronary artery bypass surgery. Only 29% of the patients used the single national number for medical emergencies (112) to call for support. The median patient delay was 120 (73-240) minutes. The median pre-hospital transportation system delay was 104 (73-240) minutes. The median door-to-balloon delay (D2B) was 64 (30-110) minutes and was not significantly different between patients who contacted the National Institute for Medical Emergency (INEM) and patients who did not contact this service: 69 (30-109) minutes versus 60 (30-111) minutes. In 56% of the cases, patients entered a local hospital before transferring to a hospital with primary angioplasty facilities. The time between the admission to the local hospital and admission to a hospital with an interventional cardiology unit was 109 (73-173) minutes. The main barriers to a better performance of the primary angioplasty programme in Portugal, as revealed by "Moment Zero", are the low number of patients who contacted the INEM and the high number of patients who attended centres without interventional cardiology units, resulting in long delays spent in secondary transportation to the institutions with such services. The D2B delay, although close to the 90 minutes recommended by the guidelines, is not a good indicator of the overall performance of primary angioplasty in Portugal.

043 Does routine measurement of ankle brachial index ameliorates the assessment of coronary risk level in patients with known or suspected coronary artery disease. The ABICARD study

Ankle-brachial pressure index (ABI) is an independent predictor of the extent of coronary atherosclerosis and cardiovascular events. To date ABI measurement is not part of the routine examination in patient admitted for coronary angiography. Our objective was to establish ABI measurement as a routine procedure in our interventional cardiology unit to ameliorate the assessment of coronary risk level for patients admitted for scheduled coronary angiography. ABI measurement was performed on admission using a doppler ultrasonic instrument. Patients with past medical history of peripheral arteriopathy were excluded. Cardiovascular risk factors and clinical findings were collected. Correlations and multivariate analysis were performed on R software. In the pilot study, 40 consecutive patients were included between February and April 2009. 79% were males and the mean age was 66+/-12 years. ABI < 0.9 was found in 6 patients. Significant multivessel disease was found in 10 patients: 6 with ABI<0.9 and 4 with ABI≥0.9. Patients with ABI<0.9 were significantly older 75+/-11 vs 64+/-12 (p=0.04) and had a trend for lower glomerular filtration rate MDRD=61+/-21 vs 77+/-20 mL/min/1.73m_ (p=0.08). 5-years probability of cardiovascular death was 12+/-7.4% in patients with ABI<0.9 vs 7.2+/-7.6 in patients with ABI≥0.9 (p=ns). Multivariate analysis showed that ABI remains a significant predictor of multivessel disease after adjustment on other risk factors. Low ABI was significantly correlated with 5 years probability of cardiovascular death (spearman = −0.36, P=0.03). ABI was an independent predictor of coronary multivessel disease and 5 years probability of cardiovascular death. Routine ABI measurement in patients with known or suspected coronary artery disease provides additional information regarding patient's risk and may be taken into account to establish optimal care strategy.