Lead Cap Use in Interventional Cardiology: Time to Protect Our Head in the Cardiac Catheterisation Laboratory?

Background: Radiation exposure is an occupational hazard for interventional cardiologists and cardiac catheterisation laboratory staff that can manifest with serious long-term health consequences. Personal protective equipment, including lead jackets and glasses, is common, but the use of radiation protective lead caps is inconsistent. Methods: A systematic review qualitative assessment of five observational studies using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines protocol was performed. Results: It was concluded that lead caps significantly reduce radiation exposure to the head, even when a ceiling-mounted lead shield was present. Conclusion: Although newer protective systems are being studied and introduced, tools, such as lead caps, need to be strongly considered and employed in the catheterisation laboratory as mainstay personal protective equipment.

Cardiovascular Outcomes of Transulnar Versus Transradial Percutaneous Coronary Angiography and Intervention: A Regression Matched Meta-Analysis.

Transradial access (TRA) and transulnar access (TUA) are in close vicinity, but TRA is the preferred intervention route. The cardiovascular outcomes and access site complications of TUA and TRA are understudied. Databases, including MEDLINE and Cochrane Central registry, were queried to find studies comparing safety outcomes of both procedures. The outcome of interest was in-hospital mortality and access site bleeding. Secondary outcomes were all-cause major adverse cardiovascular events, crossover rate, artery spasm, access site large hematoma, and access site complications between TUA and TRA. A random-effect model was used with regression to report unadjusted odds ratios (ORs) by limiting confounders and effect modifiers, using software STATA V.17. A total of 4,796 patients in 8 studies were included in our analysis (TUA = 2,420 [50.4%] and TRA = 2,376 [49.6%]). The average age was 61.3 and 60.1 years and the patients predominantly male (69.2% vs 68.4%) for TUA and TRA, respectively. TUA had lower rates of local access site bleeding (OR 0.58, 95% confidence interval 0.34 to 0.97, I2 = 1.89%, p = 0.04) but higher crossover rate (OR 1.80, 95% confidence interval 1.04 to 3.11, I2 = 75.37%, p = 0.04) than did TRA. There was no difference in in-hospital mortality, all-cause major adverse cardiovascular events, arterial spasm, and large hematoma between both cohorts. Furthermore, there was no difference in procedural time, fluoroscopy time, and contrast volume used between TUA and TRA. TUA is a safer approach, associated with lower access site bleeding but higher crossover rates, than TRA. Further prospective studies are needed to evaluate the safety and long-term outcomes of both procedures.

Chronic Total Occlusion Interventions in Patients with Reduced Ejection Fraction.

PURPOSE OF THE REVIEW: The goal of this paper is to review the current evidence surrounding CTO PCI in patients with low EF, the most high-risk population to treat. We also present pertinent case examples and offer practical tips to increase success and lower complications when performing CTO PCI in patients with low EF. RECENT FINDINGS: In a prospective randomized control study, greater improvement in angina frequency and quality of life, assessed by the Seattle Angina Questionnaire, was achieved by CTO PCI compared to optimal medical therapy. Furthermore, after successful CTO PCI, improvements in health status were similar in patients with both low and normal EF. CTO PCI can not only ameliorate symptoms of angina in patients with low EF but may also potentially improve EF in carefully selected populations. However, information regarding treatment of this high-risk population is lacking and large-scale studies targeting patients with severely reduced EF remain necessary.

Incidental Finding of Giant Coronary Artery Aneurysms Successfully Treated with Medical Therapy.

We report a case of a 30-year-old male who presented with signs and symptoms of respiratory infection with left lower lobe consolidation and cardiomegaly on a chest radiography. The presence of cardiomegaly lead to further cardiac evaluation revealing giant coronary aneurysms. The patient was treated conservatively with Coumadin and aspirin and has done well at four years of follow-up.

Comparative analysis of technical success rates and procedural complication rates of bedside inferior vena cava filter placement by intraprocedural imaging modality.

OBJECTIVE: Transabdominal duplex ultrasound, intravascular ultrasound (IVUS), and fluoroscopy have been used to assist with inferior vena cava filter (IVCF) placement since the late 1990s. We sought to compare the technical success and procedural complications of bedside placement of IVCF by the three commonly used modalities, namely, duplex ultrasound, IVUS, and combined IVUS and fluoroscopy. METHODS: All published reports including prospective and retrospective cohort studies and case series with a minimum of 10 patients from inception to August 2017 were identified by an electronic search of PubMed and Embase. The studies were then pooled to create a sample of patient data for statistical analysis. Bonferroni correction was used for comparison of the three groups. Values of P < .017 (two tailed) were considered statistically significant for the pairwise comparisons. RESULTS: A total of 21 studies comprising 2166 patients were identified. No significant differences were found in technical success and complication rates between the duplex ultrasound and IVUS arm, the combined IVUS and IVUS with fluoroscopy arm, or the duplex ultrasound and the combined IVUS with fluoroscopy arm. However, there was a trend toward decreased complication rates in the duplex ultrasound arm compared with the other two arms. A trend toward increased technical success was also observed in the combined IVUS and fluoroscopy arm compared with the other two arms. CONCLUSIONS: There are no significant differences in the technical success and complication rates between the three commonly used modalities of bedside IVCF placement.

Comparative analysis of cerebrovascular events in transcatheter and surgical aortic valve replacement: a systematic review and meta-analysis of randomised trials.

AIMS: Transcatheter aortic valve replacement (TAVR) has become the procedure of choice for inoperable patients and a safe alternative to surgical aortic valve replacement (SAVR) among moderate-risk patients. We used meta-analysis to compare the incidence of cerebrovascular events amongst patients undergoing TAVR and SAVR in randomised controlled trials (RCT). METHODS AND RESULTS: Our search revealed five RCT published between 2011 and 2017 with a total of 5,414 patients. Data were summarised as Mantel-Haenszel relative risk (RR) and 95% confidence intervals (CI). The risk of major stroke (RR 0.89, 95% CI: 0.53-1.51), all strokes (RR 0.85, 95% CI: 0.59-1.22) and all cerebrovascular events (RR 0.94, 95% CI: 0.75-1.17) was comparable between patients undergoing TAVR and SAVR at 30 days of follow-up. The risk of all strokes (RR 0.92, 95% CI: 0.69-1.22), major stroke (RR 0.92, 95% CI: 0.62-1.37) and all cerebrovascular events (RR 1.03, 95% CI: 0.79-1.33) was comparable between TAVR and SAVR at one year of follow-up. The incidence of major stroke (RR 1.02, 95% CI: 0.64-1.61), all strokes (RR 1.12, 95% CI: 0.78-1.62) and all cerebrovascular events (RR 1.23, 95% CI: 0.91-1.66) was comparable between TAVR and SAVR between 30 days and one year of follow-up. CONCLUSIONS: In our meta-analysis of RCT comparing TAVR and SAVR, we showed comparable risk of major stroke, all stroke and all cerebrovascular events.

Non-sustained microvolt level T-wave alternans in congenital long QT syndrome types 1 and 2.

BACKGROUND: Patients with long QT syndrome (LQTS) are predisposed to polymorphic ventricular tachycardia (VT) during adrenergic stimulation. Microvolt T-wave alternans (MTWA) is linked to vulnerability to VT in structural heart disease. The prevalence of non-sustained MTWA (NS-MTWA) in LQTS is unknown. METHODS: 31 LQT1, 42 LQT2, and 80 controls underwent MTWA testing during exercise. MTWA tests were classified per standardized criteria, and re-analyzed according to the modified criteria to account for NS-MTWA. RESULTS: LQT1 and LQT2 patients had a significantly higher frequency of late NS-MTWA (26% and 12%) compared to controls (0%). There was no significant difference between the groups with respect to sustained and early NS-MTWA. Late NS-MTWA was significantly associated with QTc. CONCLUSION: LQT1 and LQT2 patients had a higher prevalence of late NS-MTWA during exercise than matched controls. NS-MTWA likely reflects transient adrenergically mediated dispersion of repolarization, and could be a marker of arrhythmic risk in LQTS.

Aspirin Resistance Predicts Adverse Cardiovascular Events in Patients with Symptomatic Peripheral Artery Disease.

Antiplatelet therapy reduces the risk of myocardial infarction, stroke, and vascular death in patients who have symptomatic peripheral artery disease. However, a subset of patients who take aspirin continues to have recurrent cardiovascular events. There are few data on cardiovascular outcomes in patients with peripheral artery disease who manifest aspirin resistance. Patients with peripheral artery disease on long-term aspirin therapy (≥4 wk) were tested for aspirin responsiveness by means of the VerifyNow Aspirin Assay. The mean follow-up duration was 22.6 ± 8.3 months. The primary endpoint was a composite of death, myocardial infarction, or ischemic stroke. Secondary endpoints were the incidence of vascular interventions (surgical or percutaneous), or of amputation or gangrene caused by vascular disease. Of the 120 patients enrolled in the study, 31 (25.8%) were aspirin-resistant and 89 (74.2%) were aspirin-responsive. The primary endpoint occurred in 10 (32.3%) patients in the aspirin-resistant group and in 13 (14.6%) patients in the aspirin-responsive group (hazard ratio=2.48; 95% confidence interval, 1.08-5.66; P=0.03). There was no significant difference in the secondary outcome of revascularization or tissue loss. By multivariate analysis, aspirin resistance and history of chronic kidney disease were the only independent predictors of long-term adverse cardiovascular events. Aspirin resistance is highly prevalent in patients with symptomatic peripheral artery disease and is an independent predictor of adverse cardiovascular risk. Whether intervening in these patients with additional antiplatelet therapies would improve outcomes needs to be explored.

Comparative efficacy of different modalities for treatment of right heart thrombi in transit: a pooled analysis.

The objective was to compare the efficacy of treatment options for right heart thrombi (RHT) in transit. All published reports between 1992 and 2013 were identified and pooled. We analyzed 328 patients with RHT and pulmonary embolism (PE). The treatments administered were none in 11 patients (3.4%), anticoagulation (AC) with heparin in 70 patients (21.3%), thrombolytics in 122 patients (37.2%), catheter-related treatments in five patients (1.5%) and surgical embolectomy in 120 patients (36.6%). The overall short-term mortality for the entire cohort was 23.2%. The mortality rate associated with no therapy was highest at 90.9%. The mortality associated with AC alone was significantly higher than surgical embolectomy or thrombolysis (37.1% vs 18.3% vs 13.7%, respectively). In univariate analysis, any therapy was better than no therapy with a favorable odds of 16.92 (95% CI 2.05-139.87) for AC, 61.76 (95% CI 7.42-513.81) for thrombolysis and 44.54 (95% CI 5.42-366.32) for surgical embolectomy. In multivariate analysis with age and hemodynamic status entered as covariates, thrombolytic therapy was better than AC with favorable odds of 4.83 (95% CI 1.52-15.36). Similarly, there was a trend in favor of surgical embolectomy with an odds of 2.61 (95% CI 0.90-7.58). The estimated probability of survival in hemodynamically unstable patients with AC, surgical embolectomy and thrombolysis was 47.7%, 70.45% and 81.5%, respectively. There was no significantly increased risk of complications with thrombolytic therapy. In conclusion, left untreated, patients with RHT and PE have very high mortality. Aggressive management with thrombolysis or surgical thrombectomy may be more effective than AC alone in the management of these patients.

Invasive hepatocellular carcinoma with recurrent pulmonary embolism: use of AngioVac cannula thrombectomy device for mechanical aspiration.

Right atrial and vena cava thrombus is a challenging clinical problem with limited treatment options for percutaneous extraction. We describe the use of a novel AngioVac venous extracorporeal bypass system (AngioDynamics) to remove a part of large right atrial tumor and thrombus in a patient with recurrent pulmonary embolism from hepatocellular carcinoma infiltrating into the inferior vena cava and the right atrium.

Influence of transcatheter aortic valve replacement strategy and valve design on stroke after transcatheter aortic valve replacement: a meta-analysis and systematic review of literature.

OBJECTIVES: The study undertook a systematic review to establish and compare the risk of stroke between the 2 widely used approaches (transfemoral [TF] vs. transapical [TA]) and valve designs (CoreValve, Medtronic, Minneapolis, Minnesota vs. Edwards Valve, Edwards Lifesciences, Irvine, California) for transcatheter aortic valve replacement (TAVR). BACKGROUND: There has been a rapid adoption and expansion in the use of TAVR. The technique is however far from perfect and requires further refinement to alleviate safety concerns that include stroke. METHODS: All studies reporting on the risk of stroke after TAVR were identified using an electronic search and pooled using established meta-analytical guidelines. RESULTS: 25 multicenter registries and 33 single-center studies were included in the analysis. There was no difference in pooled 30-day stroke post-TAVR between the TF and TA approach in multicenter (2.8% [95% confidence interval (CI): 2.4 to 3.4] vs. 2.8% [95% CI: 2.0 to 3.9]) and single-center studies (3.8% [95% CI: 3.1 to 4.6] vs. 3.4% [95% CI: 2.5 to 4.5]). Similarly, there was no difference in pooled 30-day stroke post TAVR between the CoreValve and Edwards Valve in multicenter (2.4% [95% CI: 1.9 to 3.2] vs. 3.0% [95% CI: 2.4 to 3.7]) and single-center studies (3.8% [95% CI: 2.8 to 4.9] vs. 3.2% [95% CI: 2.4 to 4.3]). There was a decline in stroke risk with experience and technological advancement. There was no difference in the outcome of 30-day stroke between TAVR and surgical aortic valve replacement. CONCLUSIONS: Our findings suggest that the risk of 30-day stroke after TAVR is similar between the approaches and valve types. There has been a decline in stroke risk after TAVR with improvements in valve technology, patient selection, and operator experience.

A case of recurrent bleeding stomal varix controlled using embolization with a liquid copolymer: an effective therapy for palliation.

BACKGROUND: Bleeding stomal varices (BSV) is a common problem in patients undergoing an ileostomy or colostomy. The diagnosis is often delayed as blood loss occurs in small amounts over a period of time, usually from minor anastamosing blood vessels at the ostomy site making it hard to diagnose. Treatment options can be limited in terms of modalities and efficacy. CASE: We describe a case of recurrent bleeding from a superior mesenteric vein (SMV) that was inadvertently sewn into the ileostomy site during surgery. Bleeding was initially controlled with percutaneous SMV coil embolization, but the bleeding persisted, only to be controlled finally by embolization using a liquid copolymer. Though the patient was terminally ill, his quality of life significantly improved thereafter, he did not have any further bleeding episodes during 10 months of follow-up. CONCLUSION: Embolization of a recurrent bleeding stomal varix with a liquid copolymer may be an effective therapeutic option.