Pre-procedural Screening Research Articles

Abstract 245: Achieving Appropriate Use Metrics for Angioplasty

Background: With the development of appropriate use metrics for coronary angioplasty, application of these criteria to the NYS PCI data base resulted in 14.3% of PCIs in NYS being deemed “inappropriate”. While “inappropriate” has been changed to “rarely appropriate’’ in professional society guidelines, public interpretation of this designation, medicolegal issues, and reimbursement for procedures in this category remain concerns. Because the bulk of PCI procedures are ad hoc, appropriateness of treatment is largely determined by preprocedural documentation and treatment. Procedure: The 2010 SBUH “inappropriate” PCI rate from NYS was utilized as a baseline and compared with post intervention Qtr 4, 2012 - Qtr 3, 2013. Trained abstractors audited charts to identify patients that would potentially be classified “inappropriate” and determine which data elements were missing most frequently. A preprocedural screening tool was developed and implemented to establish PCI appropriateness as supported by adequate documentation and preprocedural medical therapy. Pretest outpatient NP screening identified and addressed concerns identified by using the preprocedural tool. A monthly meeting was organized where Physician Specific compliance reports that had been created were reviewed. Results: Baseline “inappropriate” interventions at SBUH comprised 24.8% of total PCI. Inappropriate classification was due to both inadequate documentation and less than optimal medical therapy. Implementation of the PCI AU tool resulted in a sustained decline in the “inappropriate” procedures to 1.6% (NCDR mean 2.5% for this time period). An additional unanticipated benefit of the process has been that the feedback provided to referring attendings continues to improve required documentation and medical therapy supporting PCI revascularization. The tool will be shared at presentation. Conclusions: The combination development of a PCI screening tool for potential ad hoc intervention patients and outpatient review of documentation and medical therapy allowed a substantial improvement in PCI appropriateness. Appropriate feedback to referring physicians augmented the effect of these process changes and improved appropriate utilization.

Expanding the indications for percutaneous mitral commmissurotomy in rheumatic mitral stenosis: look carefully at the commissures, and proceed cautiously and skilfully

This editorial refers to ‘Feasibility of percutaneous mitral commissurotomy in patients with commissural mitral valve calcification’[†][1], by J. Dreyfus et al ., on page 1617 Percutaneous balloon mitral valve commissurotomy (PMC) was introduced by Inoue in the 1980s, as an alternative to surgical closed commissurotomy.1 PMC is the first example of a transcatheter valve intervention replicating a surgical procedure, and the fact that Inoue is a surgeon underlines the influence of multidisciplinary efforts in the evolution of transcatheter therapies. Today PMC is the first-line therapy for most symptomatic patients with mitral valve stenosis with favourable clinical and anatomical characteristics (with a recommendation class IB by the latest European guidelines.2 The main objective of PMC is to delay surgery, particularly when this would imply the implantation of a valve prosthesis. In patients not amenable to PMC, in Western countries, closed mitral commissurotomy has been replaced by open mitral commissurotomy using cardiopulmonary bypass in selected patients. Subvalvar apparatus management is the main advantage of open commissurotomy leading to greater valve areas as compared with closed commissurotomy and with PMC in patients with papillo-commissural fusion.3 However, most patients with anatomy not amenable for PMC are also suboptimal candidates for surgical repair and mostly undergo valve replacement. Patient selection plays a key role in PMC, as is the case for other transcatheter interventions. More specifically, anatomical and clinical characteristics are predictive of early and long-term success of the percutaneous procedure. Echocardiography plays a central role in the contemporary decision-making process, and several scores have been developed to predict early and long-term outcomes of PMC.4,5 A contemporary focus of the pre-procedural echocardiographic screening for PMC should include a meticulous analysis of the commissures. The commissures are the … [1]: #fn-2

Relationship of Sternal Foramina to Vital Structures of the Chest: A Computed Tomographic Study

Sternal foramina are a well-known variant anatomy of the sternum and carry the risk of life-threatening complications like pneumothorax or even pericardial/cardial punction during sternal biopsy or acupuncture. There have been numerous studies numerous studies examinimg prevalence of sternal foramina, but the study of the exact anatomical relationship to intrathoracic structures has received little attention. In a retrospective study of 15 patients with sternal foramina, the topographical anatomy in respect to vital chest organs was examined. In most patients, the directly adjacent structure was the lung (53.3%) or mediastinal fat (33.3%). Only in three patients, the heart was located directly adjacent to a sternal foramen (20%). Theoretically, if the needle is inserted deep enough it will at some point perforate the pericardium in all examined patients. There was no correlation between the patient habitus (i.e., thickness of the subcutaneous fat) and the distance to a vital organ. In this sample, pericardial punction would have not occured if the needle is not inserted deeper than 2.5 cm. Given the preliminary nature of the data, general conclusions of a safe threshold for needle depth should be made with caution. To minimize the risk of hazardous complications, especially with sternal biopsy, preprocedural screening or image guidance is advocated.

Mdct imaging before transcutanous aortic valve implantation: rationale and measurements

Since its introduction in 2002, transcatheter aortic valve implantation (TAVI) has assumed growing importance in the treatment of patients with severe aortic stenosis (AS), because it offers a much less invasive alternative for those in high risk for surgery. Good early results and advances in percutaneous valve technology have led to a substantial increase in procedural success rate and number of patients undergoing this less invasive treatment. Pre-procedural screening of several anatomic factors to assess the feasibility of this technique is important. Multidetector row computed tomography (MDCT) is the technique of choice in assessing these factors.This technical note aims to describe and illustrate the key elements that need to be evaluated before the procedure.

Role of computed tomography imaging for transcatheter valvular repair/insertion

During the last decade, the development of transcatheter based therapies has provided feasible therapeutic options for patients with symptomatic severe valvular heart disease who are deemed inoperable. The promising results of many nonrandomized series and recent landmark trials have increased the number of percutaneous transcatheter valve procedures in high operative risk patients. Pre-procedural imaging of the anatomy of the aortic or mitral valve and their spatial relationships is crucial to select the most appropriate device or prosthesis and to plan the percutaneous procedure. Multidetector row computed tomography provides 3-dimensional volumetric data sets allowing unlimited plane reconstructions and plays an important role in pre-procedural screening and procedural planning. This review will describe the evolving role of multidetector row computed tomography in patient selection and strategy planning of transcatheter aortic and mitral valve procedures.

Procedural Sedation

In pursuit of Nursing Excellence, CNMC nurses are seeking Magnet Recognition through the American Nurses Credentialing Center (ANCC). As part of the Magnet process, nurses strive to improve performance related to Nurse Sensitive Indicators (NSIs). NSIs reflect the structure, process, and outcomes of nursing care (ANA, 2003). The purpose of this project was to increase patient compliance with preprocedure preparation and to improve family satisfaction with the overall experience. Collectively, the ambulatory nurse selected procedural sedation in the neurology clinic as the NSI. This involves implementing preprocedural education via telephone interaction 24 hours prior to the scheduled appointment for anxiolysis. Historically, the neurology nurse noticed an increased trend in patients arriving unprepared or ineligible for their Brainstem Auditory Evoked Response (BAERS) appointment. The registered nurse wanted to increase family compliance, decrease test failure, decrease wait times, and increase patient family satisfaction. Above all, the neurology clinic nurse wanted to maximize patient safety. The first step in assessing patient safety includes assessing whether the procedure and the patient are appropriate for the setting. To date, minimal published evidence related to anxiolysis in the outpatient pediatric arena exists. Beginning in February 2007, the neurology RN implemented calling all patients scheduled for the BAERs test 24 hours prior to the appointment. A pre-appointment assessment is conducted over the phone by the RN. Currently, there are 13 slots per week, 3 per day, Monday through Thursday. Since the RN initiated preassessment calls, the rate of successfully completed BAERs has increased from 55% to 90%. In addition, there have been no adverse events related to anxiolysis in the neurology clinic. The implementation of preprocedural screening is now a standard of nursing practice in the neurology clinic. In pursuit of Nursing Excellence, CNMC nurses are seeking Magnet Recognition through the American Nurses Credentialing Center (ANCC). As part of the Magnet process, nurses strive to improve performance related to Nurse Sensitive Indicators (NSIs). NSIs reflect the structure, process, and outcomes of nursing care (ANA, 2003). The purpose of this project was to increase patient compliance with preprocedure preparation and to improve family satisfaction with the overall experience. Collectively, the ambulatory nurse selected procedural sedation in the neurology clinic as the NSI. This involves implementing preprocedural education via telephone interaction 24 hours prior to the scheduled appointment for anxiolysis. Historically, the neurology nurse noticed an increased trend in patients arriving unprepared or ineligible for their Brainstem Auditory Evoked Response (BAERS) appointment. The registered nurse wanted to increase family compliance, decrease test failure, decrease wait times, and increase patient family satisfaction. Above all, the neurology clinic nurse wanted to maximize patient safety. The first step in assessing patient safety includes assessing whether the procedure and the patient are appropriate for the setting. To date, minimal published evidence related to anxiolysis in the outpatient pediatric arena exists. Beginning in February 2007, the neurology RN implemented calling all patients scheduled for the BAERs test 24 hours prior to the appointment. A pre-appointment assessment is conducted over the phone by the RN. Currently, there are 13 slots per week, 3 per day, Monday through Thursday. Since the RN initiated preassessment calls, the rate of successfully completed BAERs has increased from 55% to 90%. In addition, there have been no adverse events related to anxiolysis in the neurology clinic. The implementation of preprocedural screening is now a standard of nursing practice in the neurology clinic.

Percutaneous Treatment of Mitral Regurgitation

Percutaneous mitral valve therapy became a reality more than 25 years ago with the first description of balloon valvuloplasty for rheumatic mitral stenosis.1 More recently, percutaneous closure of paravalvular leaks after surgical valve implantation has been shown to have a potential, but limited, role.2–4 However, valvular mitral regurgitation (MR) remains largely the purview of surgery. Recently, the potential for less invasively replicating these successful surgical procedures without the need for thoracotomy or cardiopulmonary bypass has generated considerable interest. For the most part, these new approaches are modeled after established surgical strategies. Percutaneous approaches to mitral repair can be broadly divided into procedures that address the various components of the mitral valve. For purposes of discussion, the mitral valve can be considered to have several component parts: leaflets, subvalvular apparatus (chordate tendinae and papillary muscles), annulus, left atrium, and left ventricle.5 All are integral to the normal function of the mitral valve and each is a potential avenue for repair. Although many such avenues may not lead to an effective surgical option, it may be unwise to dismiss the possibility that others will achieve some measure of success. We briefly review the current percutaneous therapies being developed and evaluated for the management of MR. The current status of various percutaneous therapies is presented in Table 1. View this table: Table 1. Current Status of Percutaneous Mitral Valve Repair Procedures ### Leaflet Repair Complex leaflet repair is currently beyond the reach of a percutaneous approach. However, the relatively simple but, in selected patients, effective “double-orifice” surgical repair initially described by Alfieri and coworkers6 can be reproduced. In the surgical procedure, the free edges of the mitral leaflets are sutured together in the mid portion creating 2 separated orifices. Generally, surgical leaflet repair is combined with implantation of an annuloplasty ring. The surgical literature …

SCCT guidelines for performance of coronary computed tomographic angiography: A report of the Society of Cardiovascular Computed Tomography Guidelines Committee

The increasing use of coronary computed tomographicangiographic (CTA) requires the establishment of standardsmeant to ensure reliable practice methods and qualityoutcomes. The Society of Cardiovascular ComputedTomography Guidelines Committee was formed to developrecommendations for acquiring, interpreting, and reportingof these studies in a standardized fashion. Indications andcontraindications for specific services or procedures are notincludedinthescopeofthese documents.Theserecommen-dations were produced as an educational tool for practi-tioners to improve the diagnostic care of patients, in theinterest of developing systematic standards of practice forcoronary CTA based on the best available data. Because ofthe highly variable nature of individual medical cases, anapproach to scan performance that differs from these guide-lines may represent an appropriate variation based on alegitimate assessment of an individual patient’s needs.

Managing catheter ablation for atrial fibrillation: the role of echocardiography

Atrial fibrillation (AF) is a common arrhythmia associated with the serious clinical consequences of systemic thrombo-embolism and heart failure. Catheter ablation for AF is an evolving treatment option for patients with drug-refractory paroxysmal and persistent AF. The ablation procedure relies on precise knowledge of the left atrium, left atrial appendage, and pulmonary venous anatomy and function. Echocardiography is an integral component of multiple imaging modalities which contribute to its success. Both transoesophageal echocardiography and transthoracic echocardiography provide essential anatomical and functional information to guide all aspects of management. This article reviews the role of echocardigraphy in AF ablation, from appropriate patient selection and pre-procedural screening, to evaluating complications and determining the need for long-term anticoagulation.

The Design and Deployment of the HELEX Septal Occluder

The GORE HELEX Septal Occluder (W.L. Gore and Associates, Flagstaff, Ariz, USA) is the latest device to pursue U.S. Food and Drug Administration (FDA) approval for the closure of secundum atrial septal defects. The device is soft and compliant with comparatively little metal framework. It can be deployed and retrieved without damaging the device, and has a safety cord attached that allows retrieval even after it has been disconnected from the delivery mandrel. With FDA approval, operators will now have a choice of devices for the closure of atrial septal defects. Significant differences exist between the HELEX device and existing atrial septal occluders. This article explains the HELEX device design, provides recommendations for preprocedural screening and preparation, and discusses the deployment technique in detail. The device may be particularly advantageous for patients with small- to moderate-sized atrial septal defects.

Transcutaneous detection of aortic arch atheromas by suprasternal harmonic imaging

ObjectivesThe goal of the present study was to examine whether suprasternal harmonic imaging (SHI) (i.e., harmonic imaging from the suprasternal windows) can visualize protruding arch atheromas (PAAs) and reliably predict the presence or absence of significant lesions. BackgroundProtruding arch atheromas are a major source of cerebral and peripheral embolism and probably the most frequent cause of stroke during cardiac catheterization and open-heart surgery. Preprocedural screening by transesophageal echocardiography (TEE) would be desirable but is limited by the nature of the examination. MethodsOf 354 patients who underwent a TEE study in our laboratory during the study period, 106 were referred for detection of a source of embolism. Findings were classified based on the French Aortic Plaque study criteria as: 1) no or minimal atherosclerotic changes; 2) PAAs <4 mm; 3) PAAs ≥4 mm or presence of a mobile component. ResultsAdequate transcutaneous image quality could be achieved in 89 patients (84%). Protruding arch atheromas were present in 42 patients (47%) and absent in 47 (53%). Positive and negative predictive values for large PAAs on TEE were 91% and 98%, respectively. In one case, SHI detected a complex PAA inaccessible for TEE due to interposition of the left bronchus as demonstrated by dual helical computed tomography. Inter-observer agreement for SHI was 91%. ConclusionsSuprasternal harmonic imaging reliably predicted or excluded the presence of PAAs in a sizable, consecutive group of patients referred to TEE for detection of a source of embolism. It represents an excellent screening test and provides complimentary views of regions, which may be blind spots for TEE.

Transradial cardiac catheterization in patients with prior brachial artery cutdown

The safety and efficacy of transradial cardiac catheterization in patients with prior ipsilateral brachial cutdown is not known. Using standard techniques we performed transradial catheterization in 278 consecutive patients, of which 63 had prior brachial cutdown. All patients had a strongly palpable radial pulse and a negative Allen's test. Although patients with prior cutdown were older and had a higher incidence of hypertension and prior coronary artery bypass surgery, there was no significant difference in success rates for transradial catheterization (93.6% vs. 95.3%; P = NS). There were no periprocedural complications. Brachial artery occlusion was responsible for only two unsuccessful catheterization attempts. We conclude that, with careful preprocedural screening, ipsilateral transradial cardiac catheterization can be successfully performed in a majority of patients with prior brachial cutdown. Cathet. Cardiovasc. Intervent. 48:271–274, 1999. © 1999 Wiley-Liss, Inc.