Christopher T. Pyne

Transradial arterial access for coronary and peripheral procedures: executive summary by the Transradial Committee of the SCAI.

In response to growing U.S. interest, the Society for Coronary Angiography and Interventions recently formed a Transradial Committee whose purpose is to examine the utility, utilization, and training considerations related to transradial access for percutaneous coronary and peripheral procedures. With international partnership, the committee has composed a comprehensive overview of this subject presented herewith.

Best practices for transradial angiography and intervention: a consensus statement from the society for cardiovascular angiography and intervention's transradial working group.

Duke University Medical Center, Durham, North Carolina Stanford University Medical Center, Palo Alto, California Penn State Hershey Medical Center, Hershey, Pennsylvania Brigham and Women’s Hospital, Boston, Massachusetts Mayo Clinic, Rochester, Minnesota University of Illinois at Chicago/Jesse Brown VA Medical Center, Chicago, Illinois First Coast Heart and Vascular Center, Jacksonville, Florida G.V. (Sonny) Montgomery VA Medical CenterJackson, Mississippi. Stern Cardiovascular Foundation, Memphis, Tennessee Reid Heart Center at FirstHealth of the Carolinas, Pinehurst, North Carolina Deborah Heart & Lung Institute, Browns Mills, New Jersey Duke University Medical Center, Durham, North Carolina Lahey Clinic, Burlington, Massachusetts Geisinger Medical Center, Danville, Pennsylvania Apex Heart Institute, Seth N.H.L. Municipal Medical College, Ahmedabad, Gujarat, India The Wright Center for Graduate Medical Education, The Commonwealth Medical College, Scranton, Pennsylvania

Clinical Characteristics of Tako-Tsubo Cardiomyopathy

Tako-tsubo cardiomyopathy (TTC) is increasingly diagnosed in the United States, especially in the Caucasian population. To evaluate the clinical features and outcome of patients with TTC, we evaluated 34 patients (32 women and 2 men) 22 to 88 years of age (mean 66 +/- 14) who fulfilled the following criteria: (1) akinesia or dyskinesia of the apical and/or midventricular segments of the left ventricle with regional wall motion abnormalities that extended beyond the distribution of a single epicardial vessel and (2) absence of obstructive coronary artery disease. Twenty-five patients (74%) presented with chest pain, 20 patients (59%) presented with dyspnea, and 8 patients (24%) presented with cardiogenic shock. Twenty-two patients (65%) had ST-segment elevation and 14 patients (41%) had T-wave inversion on presentation. Twenty-five patients (74%) reported a preceding stressful event. Cardiac biomarkers were often mildly increased, with a mean troponin I (peak) of 13.9 +/- 24. Mean +/- SD left ventricular ejection fractions were 28 +/- 10% at time of presentation and 51 +/- 14 at time of follow-up (p <0.0001). Two patients (6%) died during the hospital stay. Average duration of hospital stay was 6.6 +/- 6.2 days. In conclusion, TTC is common in postmenopausal women with preceding physical or emotional stress. It predominantly involves the apical portion of the left ventricle and patients with this condition have a favorable outcome with appropriate medical management. The precise cause remains unclear.

Comparison of procedural times, success rates, and safety between left versus right radial arterial access in primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction.

Objective: To evaluate if there are differences in procedural times, success rates, and safety between left and right radial approach (LRA and RRA, respectively) in primary percutaneous coronary intervention (PCI) for ST‐elevation myocardial infarction (STEMI). Background: Given conflicting reports of different procedural success with LRA vs. RRA, it is unclear if the side of radial access impacts in‐room procedural times and success rates in primary PCI. At our institution the LRA has been commonly used in certain STEMI patients. Our clinical database was reviewed to see if routine use of the LRA could generate favorable technical success and reperfusion times as compared to the RRA. Methods: We retrospectively analyzed 135 consecutive STEMI patients treated with primary PCI performed via the left and right radial approach at our institution. Results: There were 50 cases in the LRA group and 85 in the RRA group. There was no difference in median procedural times including total procedure time (LRA 53.5 mins vs. RRA 52 mins, P = 0.95), room‐to‐cannulation (LRA 12 min vs. RRA 13 min, P = 0.40) or room‐to‐balloon times (LRA 30 min vs. RRA 31 min, P = 0.74). There were no significant differences in procedural success rates (LRA 100% vs. RRA 97.6%, P = 0.27), or procedure‐related complications or death between the two groups. Conclusions: Left and right trans‐radial approach for primary PCI have similar in room procedural times, success rates, and comparable safety. Trans‐radial PCI through either arm is a feasible and safe approach in patients with STEMI.

Effect of Reduction of the Pulse Rates of Fluoroscopy and CINE-Acquisition on X-Ray Dose and Angiographic Image Quality During Invasive Cardiovascular Procedures

Background—Reducing digital pulse rates (PR) are known to reduce total energy during invasive cardiovascular procedures, which likely has benefits for patients and staff. Physicians may be reluctant to reduce these parameters because they fear a decline in image quality that could affect procedural outcomes. We sought to assess the effect of default rates of fluoroscopy (Fluoro) and CINE-acquisition (CINE) on total x-ray dose and image quality during invasive cardiovascular procedures. Methods and Results—We retrospectively reviewed procedures done with 2 default PRs: a standard dose cohort (PR, 15 for Fluoro and CINE), and a reduced dose cohort (PR, 10 for Fluoro and CINE). Total x-ray dose, Fluoro time, and contrast use were compared between groups. A blinded angiographic image quality assessment was then performed using an objective 10-point angiographic quality score. There were no significant differences between cohorts for fluoroscopy time or contrast use. The reduced dose cohort has a significant reduction in mean total x-ray dose (PR 15, 1763.1 mGy; PR 10, 1179.1 mGy; P<0.0001). When adjusted for potential confounders, a 38% reduction in total x-ray dose was identified (P<0.0001). There was no difference in adjusted angiographic quality score between the cohorts (PR 15, 7.90; PR 10, 8.00; P=0.67), indicating no decline in image quality with PR reduction. Conclusions—Reducing default PRs during invasive cardiovascular procedures yields large and significant reductions in total x-ray energy with no decline in angiographic image quality.

Right heart catheterization using antecubital venous access: feasibility, safety and adoption rate in a tertiary center.

To determine feasibility, safety, and adoption rates of right heart catheterization (RHC) using antecubital venous access (AVA) as compared to using the traditional approach of proximal venous access (PVA).

Sterile granuloma formation following radial artery catheterization: too many Cooks?

We read with interest Drs. Sado and Witherow’s letter [1] with respect to sterile granuloma formation following radial catheterization using hydrophilic coated sheaths. Although we agree with their cautionary language about the use of this device, it seems that their conclusions are broad and that they may be doing their patients a disservice by exclusively using nonhydrophilic sheaths for radial artery access. This phenomenon was initially described in 2003 through reports published in Catheterization and Cardiovascular Interventions [2,3]. Dr. Subramanian et al. [2] described a single patient with ‘‘a prominent giantcell like reaction, and localized necrosis’’ at the radial access site following catheterization using a 5 Fr Cook (Bloomington, IN) hydrophilic sheath. Similarly, Dr. Kozak et al. [3] describe a case series of 33 patients returning with ‘‘violacious tender nodules’’ at the arteriotomy site. The Cook hydrophilic sheath was used exclusively for all of these patients. Now, Drs. Sado and Witherow report a comparable series of patients with sterile granuloma at the radial arteriotomy access site, again associated with the Cook hydrophilic sheath. Fortunately, after our own experience with sterile granuloma formation with the Cook hydrophilic sheath, we switched to a different hydrophilic sheath (Glidesheath, Terumo, Japan) and have not had a single recurrence in over 1000 combined procedures. Radial artery spasm is the principle cause of pain associated with transradial coronary intervention. It can cause difficult diagnostic and guide catheter manipulation and ultimately may lead to procedural failure. Hydrophilic sheaths have been shown to dramatically reduce the force required to remove the sheath [4,5] and allow for the use of longer sheaths, which covers the length of the radial artery, and thereby secures the easy passage of multiple catheters. Although the routine intra-arterial injection of vasodilators, such as verapamil [6] and nitroglycerin [7], can reduce the incidence of periprocedural spasm, severe spasm is not always completely relieved by these vasoactive drugs. Preventing its occurrence in the first place, with long sheaths, can enhance patient comfort and may lead to reduced procedural time. Although the use of the transradial approach in the United States remains low [8], there appears to be a recent surge in interest in the procedure. Low profile guides and devices along with modern hydrophilic sheaths allow experienced operators to perform a wide variety of coronary interventions with high success rates. The report by Drs. Sado and Witherow add to the body of literature on granuloma formation associated with the Cook hydrophilic sheath, but their personal preference not to further use hydrophilic sheaths should not be exaggerated and their findings should in no way reflect negatively on other devices.

Impella assisted transradial coronary intervention in patients with acute coronary syndromes and cardiogenic shock: case series.

Operators may feel apprehension when considering the transradial approach in patients with cardiogenic shock due to concerns of the need for femoral access for mechanical support. There is however potential benefit of transradial approach in this setting by reducing bleeding complications in patients on potent anticoagulant and antiplatelet agents. We report three cases of patients with cardiogenic shock with successful transradial intervention (TRI) whilst using unilateral femoral access for Impella (ABIOMED, Danvers, MA) mechanical support. In two cases, the need for mechanical support was not clear at the beginning of the procedure, and in the third there was a clear need to combine femoral and radial access due to pre‐existing anatomic issues. Two patients required transfusion of red blood cells but otherwise there were no vascular access complications.

CONGENITAL DOUBLE-CHAMBERED LEFT VENTRICLE PRESENTING AS MONOMORPHIC VENTRICULAR TACHYCARDIA

Left-sided double ventricle or double-chambered left ventricle (DCLV) is a rare congenital defect that generally remains asymptomatic without complications but can present with life-threatening arrhythmias. The differentiation between this rare congenital abnormality and acquired conditions such as postinfarction or posttraumatic pseudoaneurysm can pose a diagnostic challenge. The distinction is important because the presence of pseudoaneurysm typically requires surgical management. We report the case of a man who presented with monomorphic ventricular tachycardia and was ultimately diagnosed with DCLV. We also review previously reported cases in which patients were incidentally discovered to haveDCLVand various imaging studies used to diagnose this condition.

IMPACT ON ANGIOGRAPHIC IMAGE QUALITY OF A DECREASE IN DEFAULT LABORATORY PULSE RATES FOR FLULROSCOPY AND CINEANGIOGRAPHY DURING CORONARY PROCEDURES

In 2012, in an effort to reduce radiation exposure during coronary procedures, our institution reduced the standard setting for x-ray digital pulse rates (DPF) from 15 frames per second (FPS) to 10 FPS for fluoroscopy and cine-angiography. Previous work in our institution demonstrated this