Routine Cardiac Catheterization Research Articles

The Aorta in Osteoporosis

An 86-year-old woman with severe symptomatic aortic stenosis was referred for routine preoperative cardiac catheterization. During the procedure, pronounced tortuosity of the catheter was noted. Subsequent administration of intravenous contrast material revealed the presence of a markedly tortuous thoracic and abdominal aorta with no evidence of a localized aneurysm (Panel A) and with a clearly visible Judkins catheter (arrow) and venous catheter (arrowhead). The peripheral circulation was normal in both upper and lower limbs at physical examination, and the kidney function was not comprimised. Chest radiography showed multiple vertebral compression fractures and pronounced kyphosis (Panel B). Two photographs of the . . .

Cardiac magnetic resonance versus routine cardiac catheterization before bidirectional glenn anastomosis in infants with functional single ventricle: a prospective randomized trial.

Routine preoperative catheterization is standard practice in patients with single-ventricle physiology before bidirectional Glenn anastomosis. Because catheterization is invasive and exposes patients to ionizing radiation, cardiac magnetic resonance (CMR) may be a safe and effective alternative. We conducted a prospective, randomized, single-center clinical trial comparing catheterization with CMR in patients considered for bidirectional Glenn operation from February 2003 to June 2006. End points were frequency of adverse events of the preoperative evaluation and a composite score of clinically successful surgery. Of 92 eligible patients, 82 were enrolled on the basis of screening echocardiogram, fulfillment of inclusion criteria, and informed consent. Patients were randomized to catheterization (n=41) or CMR (n=41). There were no baseline differences between groups. Four treatment crossovers occurred, 3 to catheterization and 1 to CMR. Catheter interventions were performed in 17 patients (41%). Catheterization resulted in more minor adverse events (78% versus 5%; P<0.001), longer preoperative hospital stays (median, 2 versus 1 day; P<0.001), and higher hospital charges ($34 477 versus $14 921; P<0.001). There was 1 major adverse event in the CMR group (P=1.0). The operative course and frequency of postoperative complications were similar between the 2 groups. The proportion of patients who had a successful bidirectional Glenn operation was similar (71% versus 83%; P=0.3). At the 3-month follow-up, there were no differences in clinical status, oxygen saturation, or frequency of reinterventions. CMR is a safe, effective, and less costly alternative to routine catheterization in the evaluation of selected patients before bidirectional Glenn operation. Further studies are necessary to determine whether there are long-term benefits from transcatheter interventions in these patients.

Abstract 2315: Markedly Enhanced Activity of Endothelin-1 in Transplant Coronary Arteriosclerosis

Background: Coronary arteriosclerosis is the principal complication limiting long-term survival after heart transplantation. In humans, the mediators responsible for vascular proliferation and vasoconstriction typical of TCA are unknown. Endothelin-1 (ET-1) is a potent vasoconstrictor and mitogen derived primarily from endothelial and mononuclear cells. We tested the hypothesis that ET-1’s biological activity is increased in TCA and that it may contribute to the pathogenesis and manifestations of TCA. We inhibited the ET A receptor by administering a specific antagonist BQ-123 into the coronary arteries in heart transplant recipients undergoing routine annual cardiac catheterization. We compared the coronary vasomotor responses to BQ-123 in subjects with angiographic evidence of TCA and subjects free of angiographic evidence of TCA. Methods: BQ-123 was infused into one proximal coronary artery (40nmol/min for 60min) of 18 subjects, age 18 –75, 6 +/− 4 years after transplantation. In each patient 3 coronary segments were studied in both the infused and in a non-infused control coronary artery (Total 108 segments). Changes from baseline in diameters of the infused arterial segments were compared to those of non-infused arterial segments at 15 minute intervals. Contribution of ET-1 to coronary constrictor tone was assessed by comparing vasodilation from BQ-123 infusion to dilation from intracoronary nitroglycerin (200μg bolus). Results: BQ-123 induced dilation in coronary arteries of transplanted patients (8.4% at 60 minutes, vs. −0.4% in noninfused arteries, p&lt;0.001). Dilation was greater for arteries with TCA defined as angiographic diameter stenosis ≥15% (dilation 15.2% with TCA, n=10, vs. 0.6% without TCA, n=8, p=0.004). As compared to dilation from nitroglycerin indicative of overall vascular tone, ET-1 was responsible for 53.2% of vascular tone in TCA arteries but only 12.9% in arteries without TCA. Conclusions: The endogenous biological activity of ET-1 is markedly increased in humans with TCA compared to those without evidence of TCA. This supports a role for ET-1 in the pathogenesis of TCA and suggests that therapeutic targeting of ET-1 may slow the development and manifestations of TCA in cardiac transplant recipients.

Evaluation of Cardiac Function in the Clinical Scene

Pulmonary arterial catheterization (PAC) has been quite often used for bedside evaluation of hemodynamics and cardiac function in Japan. Forrester's subsets based on hemodynamic data obtained by PAC are widely used to predict patients prognosis and to determine the choice of treatment. However, since PAC is an invasive procedure, new classification by Nohria et al. derived from non-invasive physical examination is rather recommended in recently published guidelines. In routine diagnostic cardiac catheterization, most useful index of systolic function is left ventricular ejection fraction. This index is however, dependent on loading conditions and is not a pure index of contractility. As for the index of LV contractility, peak positive dP/dt and its derivatives are used. High fidelity pressure data obtained by catheter-tip manometer is necessary to calculate these indexes. Emax is the most reliable index of contractility although this is not practical for routine evaluation. As for the indexes of relaxation, peak negative dP/dt and tau are calculated from high fidelity pressure data. The ratio of LVEDP to LVEDV is a simple index for diastolic distensibility. For further evaluation of diastolic function, cubersome plotting of left ventricular pressure and volume data is required.

Cerebral Near Infrared Spectroscopy Is a Reliable Marker of Systemic Perfusion in Awake Single Ventricle Children

Clinical assessment of systemic perfusion in single ventricle patients with parallel circulation can be difficult in the outpatient setting. Near infrared spectroscopy (NIRS) is a noninvasive measure of cerebral oximetry. We measured vital signs, pulse oximetry, and NIRS in 20 single ventricle patients with parallel circulation prior to routine cardiac catheterization. These variables were evaluated to determine the best noninvasive predictor of the superior vena cava saturation (SVC(sat)) as a marker for the adequacy of systemic oxygen delivery. The mean age was 6.7 months [standard deviation (SD), 8.6] and mean weight was 6.5 kg (SD, 2.2). Diagnoses were hypoplastic left heart syndrome (8), tricuspid or pulmonary atresia (10), and double-outlet right ventricle variants (2), all prior to cavo pulmonary anastomoses or complete repairs. Stepwise multiple regression analysis generated a model in which only NIRS was a significant independent predictor of SVC(sat) (p = 0.009). These results support the conclusion that NIRS can be a useful tool to evaluate awake single ventricle patients in the outpatient setting.

Efficacy of nitroglycerin inhalation in reducing pulmonary arterial hypertension in children with congenital heart disease

There has been a renewed interest in nitric oxide donor drugs, such as nitroglycerin, delivered by the inhalational route for treatment of pulmonary arterial hypertension (PAH). We investigated the acute effects of inhaled nitroglycerin on pulmonary and systemic haemodynamics in children with PAH associated with congenital heart disease. Nineteen children with acyanotic congenital heart disease and a left to right shunt with severe PAH, undergoing routine diagnostic cardiac catheterization were included in this study. Systolic, diastolic and mean systemic as well as pulmonary artery pressures, right atrial pressure and pulmonary capillary wedge pressure (PCWP) were recorded and systemic vascular resistance index (SVRI) and pulmonary vascular resistance index (PVRI) were calculated at room air, following 100% oxygen as well as after nitroglycerin inhalation in all patients. Systolic, diastolic and mean pulmonary artery pressure and PVRI decreased significantly, whereas heart rate, systolic, diastolic and mean systemic arterial pressure, PCWP and SVRI did not change significantly following 100% oxygen or inhalation of nitroglycerin. Inhaled nitroglycerin significantly decreases systolic, diastolic and mean pulmonary artery pressure as well as PVRI without affecting systemic haemodynamics, and thus can be used as a therapeutic modality for acute reduction of PAH in children with congenital heart disease.

Echocardiographic evaluation of coronary artery fistula connecting the right coronary artery to the coronary sinus: a case report

Coronary artery fistula is a rare incidental finding during routine cardiac catheterization. It is usually congenital but it may also be a consequence of chest trauma or iatrogenic procedures. Patients may be asymptomatic or experience signs and symptoms of myocardial ischemia. In this article we report a casual echocardiographic finding of a coronary artery anomaly in an asymptomatic patient who underwent successful surgical closure and remained well several years after the procedure.

Appropriate invasive and conservative strategies for patients with non-ST elevation acute coronary syndromes

This review focuses on recent developments in three controversial areas of management of acute coronary syndromes. There are potential benefits of an early invasive treatment strategy (routine cardiac catheterization and revascularization when appropriate) in the elderly, who are at high risk for adverse outcomes and treatment-related complications following acute coronary syndromes. There are developments in the role of low-molecular-weight heparin agents in management of acute coronary syndromes in the modern treatment era, in which early coronary revascularization and use of other potent antiplatelet and antithrombin agents are common. Finally, this review looks at emerging data and controversy regarding the effects of intensive lipid-lowering treatment early after acute coronary syndrome. Recent clinical trials have yielded contradictory results. This paper evaluates recent evidence in acute coronary syndromes regarding early invasive revascularization strategies in high risk elderly patients, and also discusses controversies regarding the role of low molecular weight heparin and intensive statin regimens.

Automated Technique for Angiographic Determination of Coronary Blood Flow and Lumen Volume

Visual interpretation of angiographic images has been shown to be inadequate for assessing the severity of intermediate coronary stenoses. An approach for evaluating both the anatomic and functional impact of a stenosis is needed. An automated technique for determining both coronary blood flow and lumen volume based on a first-pass analysis (FPA) of coronary angiograms and a template matching algorithm was evaluated. Coronary angiograms of a swine animal model were obtained during power injections of contrast material into the left coronary ostium. Background anatomy was subtracted with an automated phase matching program. A template matching algorithm and first-pass analysis were then used to quantify coronary blood flow and lumen volume. Coronary blood flow and lumen volume measurements were validated with a transit-time ultrasound flow probe and a polymer cast of the coronary arteries, respectively. In 14 independent comparisons, the mean coronary blood flow measured with FPA showed strong correlation with the mean flow measured with the ultrasound flow probe (Q(FPA) = 0.88Q(probe) - 1.99; r = 0.977; standard error of estimate = 3.23 mL/minute). The lumen volumes determined with FPA and cast measurements demonstrated excellent correlation and can be related to each other by V(FPA) = 0.95V(C) - 0.01 (r = 0.997; standard error of estimate = 0.01 mL). The proposed automated method for accurate determination of coronary blood flow and lumen volume can supplement visual evaluation of coronary anatomy with quantitative physiologic data. This automated technique potentially offers a clinically feasible method of quantifying coronary blood flow and lumen volume in conjunction with routine cardiac catheterization.

An uncommon coronary artery fistula

Coronary fistulae are considered rare and potentially dangerous coronary anomalies [1–3], causing different symptoms depending on the severity of both the shunt and the coronary steal. Treatment should be reserved for patients with Qp/Qs N1.5 and/or signs of significant reduction of the coronary reserve [4,5]. Sometimes, coronary fistulae may have a very uncommon course and drainage that make their management problematic. A 65-year-old hypertensive man was admitted to our center for a routine cardiac catheterization and coronary angiography secondary to repeated episodes of chest pain. The echocardiographic evaluation showed moderate ipokinesia of the anterior region of the left ventricle; no impairment of the coronary reservewas evidenced by the ergometric test, but the test was clearly positive for symptoms. The left coronary angiography revealed a fistulous vessel, originating directly from the aortic wall slightly above the left main ostium, draining into both the middle left anterior descending coronary artery (LAD) and the pulmonary artery. A moderate stenosis of the LAD, beyond the drainage site of the fistula, was detected (Fig. 1A–B). The right cardiac catheterization failed to demonstrate any significant shunt through the fistulae (Qp/Qs=1.1). The patient was discharged under medical treatment. He was asymptomatic at the 3-month follow-up.

Is Routine Cardiac Catheterization Necessary in the Management of Patients with Single Ventricles Across Staged Fontan Reconstruction? No!

With the advent of cardiac magnetic resonance imaging and high-resolution echocardiography, cardiac catheterization is unnecessary in clinical protocols in the "routine" single ventricle patient. Catheterization adds little to clinical care in these cases, and there are significant risks and costs associated with it. Catheterization should be reserved for cases in which noninvasive evaluations are equivocal, conflictory, demonstrate deterioration, or needed for intervention. This article delineates the role of noninvasive evaluations relative to cardiac catheterization in the routine single ventricle patient.

Invasive versus noninvasive management of ST-elevation acute myocardial infarction: A review of clinical trials and observational studies

Despite decades of research, it is still unclear whether patients with uncomplicated ST-segment elevation acute myocardial infarction (AMI) should be managed with an invasive or a noninvasive approach after successful thrombolysis. We reviewed randomized trials in which patients were randomized to a strategy of routine cardiac catheterization after thrombolysis (invasive) or a strategy whereby patients received cardiac catheterization only if they demonstrated reversible ischemia by noninvasive testing (noninvasive). We also reviewed observational studies that compared outcomes for patients who were admitted to hospitals with and without availability of cardiac catheterization facilities or in different geographic regions. Evidence to date suggests that invasive approach does not result in mortality or reinfarction benefits for patients with uncomplicated ST-segment elevation AMI. However, all except one of the trials performed are dated in view of recent treatment advances, and long-term outcomes for the recent trial have not been published. Several observational studies suggest that the invasive approach may improve "softer" outcomes such as quality of life and functional status. In conclusion, there is currently no evidence to support widespread use of the invasive approach among patients with uncomplicated ST-segment elevation AMI. However, trials with long-term follow-up should be repeated in the current clinical context and should include both hard and softer outcome measures.

The optimal insertion length of central venous catheter via the femoral route for open‐heart surgery in infants and children1

The recommended insertion length of central venous (CV) catheter via the internal jugular or subclavian vein has been determined in infants and children. However, the insertion length via the femoral vein has not been well-studied. This study determined the optimal insertion length of CV catheter via the femoral vein. Infants and children, who had undergone cardiac catheterization via the right femoral vein, were the subjects of the study. After routine cardiac catheterization, the distance from the femoral puncture site to the third lumbar vertebral body (L3) level, was measured and recorded. The femoral-L3 length was termed as the optimal insertion length. This length was measured in 78 infants and children (age: 1-101 months, weight: 3.1-33.8 kg). The body weight of the patient and the length correlated well: the optimal insertion length (cm) = 0.45 x body weight (kg) + 8.13, coefficient of determination (R2) = 0.84. It has been recommended to place the tip of the catheter below the level of renal veins to avoid blocking free flow of those veins. Therefore, we chose the mid-point, L3 level as the optimal tip position of the femoral venous catheter. The length derived from the above formula could be used as a guideline for CV catheter insertion via the femoral vein in infants and children.

Cephalad origin of the superior vena cava and the level of the central venous catheter tip on chest radiographs

There are suggested radiographic landmarks for the lower margin of the superior vena cava (SVC), but none for the cephalad origin of the SVC in children. Therefore, we determined the cephalad origin of the SVC in relation to the level of thoracic vertebrae in children. Sixty-five patients (2-96 months) scheduled for routine diagnostic cardiac catheterization were the subjects of the study. Vena cavogram was obtained. The crossing point between the SVC and the innominate vein was considered as the cephalad origin of the SVC, then this point was related to the level of the thoracic vertebra as a radiographic landmark. In approximately 90% of the patients studied the proximal origin of the SVC was situated above the level of Th4/5 interspace. We would like to suggest that the position of the tip of central venous line, when inserted via the right internal jugular vein, should optimally be at the level of Th4/5 interspace on the postoperative chest radiograph.

Coronary artery fistula presenting as bacterial endocarditis

Coronary artery fistula is often considered to be a benign and rare congenital anomaly. It is usually an incidental finding encountered during routine cardiac catheterization. We report a case of a patient presenting with endocarditis involving a large coronary artery fistula connecting an aneurysmal circumflex coronary artery to the coronary sinus. The diagnosis was initially made by echocardiography and confirmed by cardiac catheterization. In addition, we briefly discuss the literature on management of this coronary anomaly.

Greater Benefit of Early Invasive Strategy for Unstable Angina and Non-ST Elevation Myocardial Infarction in United States Compared With Non-United States Patients

The TACTICS-TIMI 18 (Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy - Thrombolysis in Myocardial Infarction 18) trial compared routine invasive to conservative care for the management of patients with unstable angina and non ST-elevation myocardial infarction, and included the routine use of the platelet glycoprotein IIb/IIIa inhibitor tirofiban in the initial medical stabilization of all patients. Because previous trials utilizing IIb/IIIa inhibition for acute coronary syndrome (ACS) patients have demonstrated different outcomes in non-US and US patients, the authors sought to determine whether differences in baseline characteristics and practice patterns between 1844 US and 376 non-US patients and physicians would affect outcomes in the TACTICS-TIMI 18 trial. Event rates were stratified by treatment strategy and adjusted for baseline and treatment differences between cohorts. Although US subjects were more likely women, hypertensive, and diabetic, the US and non-US patients did not differ with respect to low, intermediate, or high TIMI risk scores. For US patients, the primary composite end point of death, myocardial infarction (MI), and rehospitalization for ACS was reduced with an invasive strategy by 40% (95% CI: 0.43-0.83) at 30 days and by 30% (95% CI: 0.55-0.88) at 180 days. Non-US patients managed conservatively had 35% fewer events at 180 days than their invasive counterparts resulting in no benefit for the invasive strategy (P = 0.016 for the interaction term between country and treatment group). Similar results were observed for the additional outcome of death and MI, and in troponin-positive patients. Adjustment for baseline characteristics, medications during the initial hospitalization, and the use of cardiac procedures suggested that a higher cross-over rate from conservative to invasive care in non-US patients (59% versus 49%, P = 0.02) was the most likely explanation for the lower event rate in the conservatively managed patients outside the US. US patients treated with tirofiban and early routine cardiac catheterization had a 30% reduction in major cardiac events by 6 months compared with those treated with tirofiban and a conservative (selective invasive) approach. Non-US patients treated conservatively had fewer events than US patients, which appears to be related to a higher rate of cross-over to invasive care. These findings emphasize the importance of both risk stratification and invasive management for ACS patients.

Cytomegalovirus infection status predicts progression of heart-transplant vasculopathy.

Transplant vasculopathy (TVP) is the most common cause of death and retransplantation after heart transplantation. Human cytomegalovirus (HCMV) infection has been linked to atherosclerosis and to the development of TVP. A prospective study evaluating the relation between CMV infection and progression of TVP is lacking thus far. The purpose of the present study was to investigate the influence of CMV infection status on the progression of TVP within 1 year. We enrolled 103 consecutive heart-transplant recipients who underwent routine cardiac catheterization and intracoronary ultrasound examination at study entry and after 1 year. Plaque progression determined by quantitative intracoronary ultrasound was used to define the severity of disease at baseline and at 1-year follow-up. At study entry, HCMV infection status was evaluated by immunological assays and reverse-transcriptase polymerase chain reaction (RT-PCR). HCMV immunoglobulin (Ig)G/IgM seropositivity was found in 34 (33%) of transplant recipients, 11 of whom were HCMV PCR positive. The HCMV-positive group showed more advanced, calcified lesions (64.7% vs. 27.5%, P=0.002), and the maximal plaque thickness was significantly different from the HCMV IgG/IgM-negative group (median [quartile] 1.36 [0.85, 1.88] vs. 1.05 [0.58, 1.34], P=0.02). In a logistic regression model, we demonstrate that HCMV IgG/IgM positivity is a predictor for the progression of TVP independent of cardiovascular risk factors, inflammatory markers, and platelet activation (P=0.038). In addition, HCMV PCR positivity even increases the risk for accelerated TVP (P=0.017) and, consecutively, transplant failure. HCMV infection status in transplant patients detects patients with increased risk for transplant failure caused by TVP.

Estimation of central aortic pressure by SphygmoCor requires intra-arterial peripheral pressures.

Central arterial pressure, measured close to the heart, may be of more patho-physiological importance than conventional non-invasive cuff blood pressure. The technique of applanation tonometry using SphygmoCor has been proposed as a non-invasive method of estimating central pressure. This relies on mathematically derived generalized transfer functions, which have been previously validated using invasive peripheral pressure measurements. We compared simultaneous estimates of central aortic pressure using this technique with those measured directly during the routine diagnostic cardiac catheterization of 30 subjects (age range 27-84 years), half of whom were aged 65 years or more. This was done by applanating the left radial artery and recording the non-invasive brachial cuff blood pressure to generate a central aortic pressure estimate, using the SphygmoCor radial transfer function. The comparative results were analysed using Bland-Altman plots of mean difference. SphygmoCor, on average, underestimated systolic central arterial pressure by 13.3 mmHg and overestimated diastolic pressure by 11.5 mmHg. The results were similar in patients aged under and above 65 years. Furthermore, non-invasively measured brachial pressures were seen to give an overall closer estimate of the central arterial pressure than the SphygmoCor system. The transfer function has been validated from invasively measured arterial pressures and the current use by the system of non-invasive measures may explain the discrepancies. However, age, drugs and arterial disease would also be expected to play a role.

Clinical outcomes and utility of cardiac catheterization prior to superior cavopulmonary anastomosis

Objectives We sought to characterize the outcomes of routine catheterization prior to superior cavopulmonary anastomosis and to determine if some patients were unlikely to benefit from catheterization and thus might be evaluated preoperatively with noninvasive methods alone. Background Congenital heart disease patients with single ventricle physiology undergo routine echocardiography and cardiac catheterization prior to superior cavopulmonary anastomosis to determine anatomic and hemodynamic suitability for this procedure. Methods We performed a retrospective review of all infants (n = 114) evaluated for potential superior cavopulmonary anastomosis at our institution from January 1997 to June 2000. Results Patients’ median age was 5.5 months. Full echocardiograms were obtained in 79 patients (69%). At catheterization a total of 41 interventions were performed in 35 patients (31%). Twenty-seven patients (24%) were transfused, 18 patients (17%) required cardiac intensive care unit admission, and median length of stay following catheterization was 1 day (range 0 to 22). Complications occurred in 28 patients (25%), most transient. Of 51 patients who had complete echocardiograms without indication for catheterization, none subsequently had significant interventions and only 2 had new findings at catheterization. Three candidates were excluded from operation; all 111 others underwent successful procedures and survived to hospital discharge. Conclusions Interventions were frequent at catheterization prior to superior cavopulmonary anastomosis, but transient complications, transfusion, intensive care unit admission, and prolonged hospital length of stay were common. For patients in whom no issues indicating need for catheterization are identified by echocardiogram, routine catheterization rarely results in new information or intervention. These patients may be more safely evaluated preoperatively using exclusively noninvasive techniques.

Echocardiographic predictors of aortopulmonary collaterals in infants with tetralogy of fallot and pulmonary atresia

ObjectivesThis study was designed to identify echocardiographic predictors of aortopulmonary collaterals (APCs) in infants with tetralogy of Fallot and pulmonary atresia (TOF/PA) and to prospectively validate these predictors. BackgroundIn patients with TOF/PA, routine preoperative diagnostic cardiac catheterization is usually performed to determine the presence and distribution of APCs and the anatomy of the branch pulmonary arteries. MethodsThe clinical and diagnostic imaging data of infants with TOF/PA treated between 1990 and 2000 were reviewed. Patients were classified into two groups based on cineangiographic findings: 1) no APCs (n = 34), and 2) ≥1 APCs (n = 59). Echocardiographic variables were examined for their ability to identify patients having ≥1 APCs. ResultsMedian branch pulmonary artery diameter Z scores were significantly larger in patients without APCs compared with those having ≥1 APCs: −0.56 versus −3.24 for the left pulmonary artery and −0.76 versus −3.46 for the right pulmonary artery (p < 0.001). The presence of a branch pulmonary artery diameter Z score ≤−2.5 was 88% sensitive and 100% specific for the presence of ≥1 APCs. Detection of APCs by color Doppler was 93% sensitive and 91% specific. A combination of branch pulmonary artery diameter Z score ≤−2.5 or patent ductus arteriosus diameter ≤2 mm was 97% sensitive and 100% specific for the presence of ≥1 APCs. The diagnostic accuracy of these echocardiographic variables was subsequently validated in a prospective study of 11 infants. ConclusionsEchocardiography is a sensitive and specific test for the detection of ≥1 APCs in infants with TOF/PA. These data can be used to select patients who can undergo complete repair of TOF/PA without further preoperative diagnostic imaging.