Yashasvi Chugh

How to tackle complications in radial procedures: Tip and tricks.

Transradial interventions (TRI) are becoming increasingly popular because of accumulating recent evidence suggesting improved survival and reduced morbidity. Complications, though rare, do occur, especially for operators on their learning curve. The complications are best prevented by utilization of proper technique. Forearm hematoma are preventable and easy to treat, but a delay in detecting and managing them can lead to disastrous consequences compartment syndrome being the most dreaded one. This review deals with tips and tricks to prevent as also treat the common and rare complications.

Is 30-Day Mortality after Admission for Heart Failure an Appropriate Metric for Quality?

BACKGROUND The Centers for Medicare and Medicaid Services (CMS) model for publicly reporting national 30-day-risk-adjusted mortality rates for patients admitted with heart failure fails to include clinical variables known to impact total mortality or take into consideration the culture of end-of-life care. We sought to determine if those variables were related to the 30-day mortality of heart failure patients at Geisinger Medical Center. METHODS Electronic records were searched for patients with a diagnosis of heart failure who died from any cause during hospitalization or within 30 days of admission. RESULTS There were 646 heart-failure-related admissions among 530 patients (1.2 admissions/patient). Sixty-seven of the 530 (13%) patients died: 35 (52%) died during their hospitalization and 32 (48%) died after discharge but within 30 days of admission; of these, 27 (40%) had been transferred in for higher-acuity care. Fifty-one (76%) died from heart failure, and 16 (24%) from other causes. Fifty-five (82%) patients were classified as American Heart Association Stage D, 58 (87%) as New York Heart Association Class IV, and 30 (45%) had right-ventricular systolic dysfunction. None of the 32 patients who died after discharge met recommendations for beta-blockers. Criteria for prescribing angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and mineralocorticoid receptor blockers were not met by 33 of the 34 patients (97%) with heart failure with reduced ejection fraction not on one of those drugs. Fifty-seven patients (85%) had a do-not-resuscitate (DNR) status. CONCLUSION A majority of heart failure-related mortality was among patients who opted for a DNR status with end-stage heart failure, limiting the appropriateness of administering evidence-based therapies. No care gaps were identified that contributed to mortality at our institution. The CMS 30-day model fails to take important variables into consideration.

Safety and feasibility of 5 French Glidesheath Slender for complex transradial interventions in small diameter radial arteries

Transradial(TR) access has limitations in patients with small diameter radial arteries (SDRA) because of increased risk of radial artery(RA) spasm(RAS), access site crossover, procedure failure, and RA occlusion (RAO) despite adequate anticoagulation & patent hemostasis. A wide variation in RA diameter (RAD)have been reported in patients worldwide: from 2.4 to 3.2mm (SE Asia);1.8–1.9mm (India);1.8–2.8mm (North America). RAD is 1.5mm in 8–10% of our patients. The outer diameter of radial sheaths varies with manufacturers ( 2.4mm for 5F sheaths and 2.7mm for 6Fr sheaths). The Glidesheath Slender (GSS TM Terumo, Japan) has a thinner wall, that reduces its outer diameter to 4Fr & has the potential to minimize RA: Sheath size mismatch, which is associated with higher risk of RAS and RAO especially in patients with SDRA. This non-randomized prospective study was performed on consecutive patients who presented to the Mission hospital Durgapur, India for coronary angiograms and/or angioplasty in July 2015 with the aim of assessing the safety and feasibility of the 5 Fr-GSS for complex coronary interventions in patients with SDRA using 5Fr guiding catheters. All patients underwent ultrasound of arm arteries (UAA), to evaluate for internal diameters of bilateral RA and UA, cubital loops and vascular anomalies, to which the operators were blinded. Consenting patientswith right RAD<1.8mm& coronary lesions of AHA/ACC type B2 or C were included. The inclusion of patients with RAD <1.8mm was based on prior data showing that these patients had greater post-procedure (PP) RAO. Patients with RAD [20_TD

Transient Giant R Wave as a Marker for Ischemia in Unstable Angina

DIFF][19_TD

Redefining Valvular Atrial Fibrillation: Safety of Novel Oral Anticoagulants beyond Mitral Stenosis and Prosthetic Valves.

DIFF]31.8mm, acute ST elevation myocardial infarction, those with thrombotic lesions requiring thrombosuction (TRTS) or the presence of known bifurcation lesions with side branch >2mm (SB2); calcific lesions requiring rotablation & those unable to consent were excluded. Transradial intervention (TRI) was done using standard procedures via right radial access. PPhemostasis was achieved by manual compression after sheath removal when the activated clotting time was <160 s. Average time to hemostasis was 18+/–7min. UAA was repeated in patients at 0, 7 and 30days PP to detect RAO. Out of 19 consecutive patients, 9 met inclusion criteria {(Chronic total occlusion(n = 5),B2-lesions (n = 4)}; while 10 were excluded{TRTS (n = 3), SB2 (n =2), Lesion A/B1 (n = 3), RAD >1.8mm (n=2)}. The mean RAD (1.6 0.2mm) in our cohort was smaller than those from prior observational studies. PP-RAO occurred in one patient on day-0 with bilateral parallel RA and UA and high origin of the SDRA from the axillary artery. This patient also had intra-procedure grade 2 spasm. Another patient had a minor arm hematoma from injury by the tip of a 0.035” glidewire. This was contained by inflating a sphygmomanometer cuff. In one patient with a cubital loop, right radial access failed, necessitating access site change to left RA. In no case the GSS kinked or fractured. Although this initial study is too small for any conclusions on RAO; we found the new 5 Fr GSS, to be safe and feasible in the patients with SDRA (<1.8mm), who underwent complex TRI at our hospital without any major complications.

IMPROVING SUCCESS OF TRANSRADIAL INTERVENTIONS IN SMALL ARTERIES (IRIS): A RANDOMIZED STUDY USING “COMPRESSION OF THE ULNAR ARTERY TECHNIQUE” IN SMALL RADIAL ARTERIES TO IMPROVE PROCEDURAL OUTCOMES

Unstable angina is a clinical diagnosis that may present with or without electrocardiographic changes. The “giant R wave” on electrocardiogram has been reported as a manifestation of acute ischemia; however, it is a rare finding in current clinical practice. We describe a case of a patient with unstable angina and a transient “giant R wave” pattern with a culprit lesion in the right coronary artery.

Letter by Chugh et al Regarding Article, “The Rotterdam Radial Access Research: Ultrasound-Based Radial Artery Evaluation for Diagnostic and Therapeutic Coronary Procedures”

Re: Comment on Leef et al.’s1 original article: “Risk of Stroke and Death in Atrial Fibrillation by Type of Anticoagulation: A Propensity-Matched Analysis.” We congratulate the authors for shedding light on the differences in “real-life” outcomes among patients on warfarin and novel oral anticoagulants (NOACs). However, there may be limitations of this work that are not articulated by the authors and may have influenced the overall conclusions. Patients with significant valvular heart disease (VHD), defined by the authors as the presence of mitral stenosis, moderate to severe mitral regurgitation, aortic stenosis, tricuspid regurgitation, history of valve surgery or replacement, and the presence of mechanical or bioprosthetic valves, were excluded from the study, as the use of NOACs has not been adequately studied in these populations. Even though NOACs are contraindicated in “valvular” atrial fibrillation,2–4 we would like to elaborate that the definition of this term was different in the major NOAC trials: the ARISTOTLE2 and ROCKET-AF trials3 defined it as patients with mitral stenosis (moderate to severe) or prosthetic heart valves, whereas the RE-LY trial4 excluded all patients with hemodynamically relevant valvular disease and prosthetic heart valves. Further, as per a subanalysis, 14.1% of the 14,171 patients enrolled in the ROCKET-AF5 trial had severe VHD, while 26.8% of the 18,201 patients in the ARISTOTLE6 trial had moderate to severe VHD. The rates of stroke or systemic embolism were higher among patients with VHD in both the NOAC and warfarin arms of the trials, but did not reach statistical significance. Excluding patients with VHD (apart from mitral stenosis and prosthetic heart valves) from this study cohort may have underpredicted the rate of stroke/systemic embolism and might have resulted in an underrepresentation of a true “reallife” populations, as atrial fibrillation is often a physiological consequence of VHD7 and vice versa. The authors describe a significantly lower allcause mortality in their cohort on NOACs (the majority being patients on dabigatran or rivaroxaban), contrary to the original NOAC trials,2,3 where this mortality difference did not reach statistical significance. A plausible explanation could be the lower risk population cohort in this study (mean CHADS2 = 1.3), versus a higher risk in the RE-LY (mean CHADS2 = 2.2) and ROCKETAF trials (mean CHADS2 = 3.5), where the overall benefit of NOACs was not as evident. Further, a current lack of information on time in therapeutic range, as pointed out by the authors, may have further influenced this deviation toward favoring the NOAC group. We believe the safety of NOACs in the setting of VHD needs to be further studied through prospective randomized control trials.

Letter by Chugh and Chugh Regarding Article, “Comparison of Right and Left Upper Limb Arterial Variants in Patients Undergoing Bilateral Transradial Procedures”

Transradial access has gained popularity because of patient comfort and reduced vascular complications. However, small radial arteries still pose a major challenge as they are associated with procedural failure and increased post-procedure radial artery occlusion(PPRAO). We aimed to assess the

Bisphosphonates and Atrial Fibrillation in Elderly Men: Casual or Causal Association?

We would like to congratulate the authors for a comprehensive periprocedural ultrasound-based study1 of radial arteries to help understand the pathophysiology of radial arterial injuries and occlusion after transradial procedures. There are, however, a few limitations of this work that may have confounded the outcomes and conclusions of the study, which we would like to highlight. The authors found radial artery occlusion (RAO) in 3.4% of all cases at 3 hours postprocedure and 3.9% on a 30-day follow-up, which is higher compared with previous ultrasound-based studies.2 …

The dilemma of evaluating a continuous murmur in a patient of aneurysm of sinus of Valsalva and coronary cameral fistula presenting with supraventricular tachycardia

We would like to congratulate Burzotta et al1 for a well-designed and insightful study. However, there are a few limitations of this work not articulated by the authors, that we would like to highlight. The authors found right radial access to have significantly more access failures than the left side (Table 2).1 It is unclear from the article, as to what could lead to such a disparity. The presence of more anatomic variability on the right radial artery may contribute toward prolonging procedure duration, but would not influence access failures. However, radial artery size itself is a predictor of puncture failure,2,3 and …