Environmental Sustainability in the Cardiac Catheter Laboratory.

The health care sector contributes to nearly 5% of global carbon emissions with the exponential growth of medical waste posing a significant challenge to environmental sustainability. As the impact of climate change on individuals and population health becomes increasingly more apparent, the health care system's significant impact on the environment is also raising concerns. Hospitals contribute disproportionately to health care waste with the majority arising from resource intensive areas such as operating theatres and cardiac catheter labs (CCLs). Despite the growing volume of cardiac procedures worldwide, initiatives to reduce waste from CCLs have received limited attention, overlooking opportunities for significant reduction in operational costs and carbon footprint. We aim to raise awareness of the current landscape of waste management in CCLs. We identify areas of resource optimisation and highlight practical strategies and frameworks employed elsewhere in health care to reduce waste. Importantly, we hope to empower health care workers in CCLs to make a meaningful change to their practice and contribute towards a more sustainable future.

Exploring decision making 'noise' when interpreting the electrocardiogram in the context of cardiac cath lab activation.

In this commentary paper, we discuss the use of the electrocardiogram to help clinicians make diagnostic and patient referral decisions in acute care settings. The paper discusses the factors that are likely to contribute to the variability and noise in the clinical decision making process for catheterization lab activation. These factors include the variable competence in reading ECGs, the intra/inter rater reliability, the lack of standard ECG training, the various ECG machine and filter settings, cognitive biases (such as automation bias which is the tendency to agree with the computer-aided diagnosis or AI diagnosis), the order of the information being received, tiredness or decision fatigue as well as ECG artefacts such as the signal noise or lead misplacement. We also discuss potential research questions and tools that could be used to mitigate this 'noise' and improve the quality of ECG based decision making.

A case series of transcatheter Potts Shunt creation in a pediatric population affected with refractory pulmonary artery hypertension: focus on the role of ECMO.

PURPOSE: Patients with suprasystemic idiopathic pulmonary hypertension (S-PAH) have a poor prognosis. Therapeutic options are limited. Reverse Potts shunt creation modifies physiology transforming patients with PAH into Eisenmenger physiology with a better outcome. Percutaneous transcatheter stent secured aortopulmonary connection (transcatheter Potts Shunt, TPS) is a feasible very high-risk procedural option in such patients. We report our experience with patients undergoing TPS at our institution requiring extracorporeal membrane oxygenation (ECMO) support. METHODS: A prospective observational study of patients with drug-refractory PAH, worsening NYHA class, and right ventricular failure undergoing TPS. Two patients required rescue ECMO for cardiac arrest during the procedure. Subsequently, "standby ECMO" was available in all the following cases and elective support was provided in patients with extremely poor conditions. RESULTS: Ten pediatric patients, underwent TPS at our institution. Two patients were rescued by ECMO after cardiac arrest during the shunt creation. This occurred as a result of the acute loading of the left ventricle (LV) after retrograde aortic arch filling through the Potts shunt. Following this, another two patients underwent elective ECMO after the uneventful induction of anesthesia. They all died postoperatively despite a successful TPS procedure. The causes of death were not related to the use of ECMO, but the complication of severe PAH. Six patients with successful TPS did not require ECMO and survived. CONCLUSIONS: TPS is a pioneering procedure offering the opportunity to treat high-risk idiopathic drug-refractory PAH patients. Acute LV failure is a complication of TPS in patients with S-PAH. Elective ECMO, an option to avoid circulatory arrest and acute profound hypoxia secondary to exclusive right-to left shunt systemic perfusion by Potts shunt and LV dysfunction with resulting pulmonary edema, may be used at the early stage of the learning curve, but it does not influence the prognosis of these patients which remains poor.

Risk Factors for Red Blood Cell Transfusions in Children Undergoing Cardiac Catheterization.

OBJECTIVE: To identify risk factors associated with risk of red blood cell transfusions (RBCTs) following pediatric cardiac catheterizations. STUDY DESIGN: We performed a review of all pediatric cardiac catheterizations from 2012 to 2017. The primary endpoint was RBCT within 72 hours of pediatric cardiac catheterization. Patient and procedural factors were reviewed. Generalized linear modelling was performed to describe interactions among relevant risk factors. RESULTS: In total, 831 RBCTs occurred within 72 hours of 6028 pediatric cardiac catheterizations (13.8%). Univariate analysis revealed that the prevalence of RBCT was highest among infants (37.6% incidence of RBCT) and among those with higher estimated blood loss as a percent of blood volume (P = .03). Among infants, multivariate analysis revealed that weight (OR 0.72; 95% CI 0.63-0.81), complex 2-ventricle (OR 3.14, 95% CI 2.18-4.57), and single ventricle status (OR 5.21, 95% CI 3.42-8.01) were associated with risk of RBCT. Inpatient infants from intensive care (OR 4.74; 95% CI 3.49-6.49) or stepdown units (OR 2.33; 95% CI 1.58-3.46) were at higher risk. Length of procedure (OR 2.57; 95% CI 2.03-3.26) and oxygen saturation (OR 0.98; 95% CI 0.97-0.99; P < .01) were also associated with RBCTs. CONCLUSIONS: Hospitalized infants with single ventricle or complex 2-ventricle anatomy are at highest risk of RBCT. Length of procedure, blood loss, and oxygen saturations are additional risk factors associated with RBCT. Operators should consider these factors when planning pediatric cardiac catheterizations, particularly when exposure to RBCT is undesirable.

Anesthetic management of catheter-based patent ductus arteriosus closure in neonates weighing <3 kg: A Retrospective Observational Study.

BACKGROUND: The patent ductus arteriosus is a cardiac lesion commonly found in premature neonates. Though surgical closure via thoracotomy is the most definitive treatment option, it is associated with significant morbidity. New catheter-based closure options offer a potentially safer alternative treatment, even in premature neonates. However, no literature reports the anesthetic techniques, challenges, and risks associated with this procedure in this population. AIM: This study documents the anesthetic challenges and potential complications associated with the management of catheter-based closure of the ductus arteriosus in neonates under 3 kg. METHODS: This single-center, retrospective study examined patients who underwent catheter-based ductus arteriosus closure between August 2015 and February 2019. A clinical protocol for anesthetic management of these patients was utilized throughout the study period. Clinical outcomes considered were new hemodynamic instability or vasoactive medication requirements, hypothermia, prolonged intubation (>3 days postoperatively), postprocedure acute kidney injury, perioperative red blood cell transfusion, and accidental extubation. RESULTS: Seventy-six neonates underwent 78 procedures. No patient developed perioperative hemodynamic instability, vasoactive medication requirements, or acute kidney injury. Four patients (5%) required red blood cell transfusion, two (3%) became hypothermic, and one (1%) was accidentally extubated. Closure was achieved in 73 patients (96%) on the first attempt. However, 17 patients (40%) required prolonged periods of mechanical ventilation following the procedure. CONCLUSION: Despite multiple clinical and logistical challenges, anesthetic risk associated with catheter-based PDA closure in small neonates can be effectively managed through standardized and multidisciplinary care.

Mechanical chest compressions for cardiac arrest in the cath-lab: when is it enough and who should go to extracorporeal cardio pulmonary resuscitation?

BACKGROUND: Treating patients in cardiac arrest (CA) with mechanical chest compressions (MCC) during percutaneous coronary intervention (PCI) is now routine in many coronary catheterization laboratories (cath-lab) and more aggressive treatment modalities, including extracorporeal CPR are becoming more common. The cath-lab setting enables monitoring of vital physiological parameters and other clinical factors that can potentially guide the resuscitation effort. This retrospective analysis attempts to identify such factors associated with ROSC and survival. METHODS: In thirty-five patients of which background data, drugs used during the resuscitation and the intervention, PCI result, post ROSC-treatment and physiologic data collected during CPR were compared for prediction of ROSC and survival. RESULTS: Eighteen (51%) patients obtained ROSC and 9 (26%) patients survived with good neurological outcome. There was no difference between groups in regards of background data. Patients arriving in the cath-lab with ongoing resuscitation efforts had lower ROSC rate (22% vs 53%; p = 0.086) and no survivors (0% vs 50%, p = 0.001). CPR time also differentiated resuscitation outcomes (ROSC: 18 min vs No ROSC: 50 min; p = 0.007 and Survivors: 10 min vs No Survivors: 45 min; p = 0.001). Higher arterial diastolic blood pressure was associated with ROSC: 30 mmHg vs No ROSC: 19 mmHg; p = 0.012). CONCLUSION: Aortic diastolic pressure during CPR is the most predictive physiological parameter of resuscitation success. Ongoing CPR upon arrival at the cath-lab and continued MCC beyond 10-20 min in the cath-lab were both predictive of poor outcomes. These factors can potentially guide decisions regarding escalation and termination of resuscitation efforts.

A quality project for radiation reduction in the cath lab.

The radiation exposure in the cath lab of patients, cardiologists, and nurses was measured during three consecutive periods of 8 weeks. The first 8 weeks the baseline radiation exposure was obtained. In the second period standard incidences for coronarography and frame rate were changed, without compromising the image quality of the examination. In the third period, a pelvic shield covered the lower part of the patient. This pilot quality project demonstrates that further significant reduction in radiation exposure of 37% is possible for patients. A significant reduction in radiation exposure of 53 and 62% was obtained among cardiologists and nurses working in the cath lab, even with the already diminished radiation exposure over the last years by better equipment and general radioprotection measures.

Understanding cardiac shunts.

Most patients with congenital heart disease have a cardiac shunt whose direction and magnitude can have a major impact on cardiorespiratory physiology and function. The dynamics of the shunt can be significantly altered by anesthetic management and must be understood in order to provide optimal anesthetic care. Given that there are now more adults than children with congenital heart disease and that the majority of nonpediatric patients are cared for in centers without special expertise in congenital heart disease, it is imperative that all anesthesia providers have a general understanding of the subject. This educational review describes a technique to explain this complex subject using simple pictorial diagrams.

Left bundle branch block, chest pain and catheterization laboratory activation: an unavoidable cascade reaction?

Identification of acute myocardial infarction (AMI) in the presence of left bundle branch block (LBBB) remains challenging. European guidelines recommend prompt reperfusion therapy in patients with suspected ongoing myocardial ischemia and new or presumably new LBBB, whereas AHA/ACC guidelines state that LBBB should not be considered diagnostic of AMI in isolation. Sgarbossa criteria and their recent modified version with the introduction of ST/S ratio can be helpful in this setting. A clinical-instrumental algorithm to manage suspected AMI in the presence of LBBB has been recently proposed. We present five paradigmatic clinical cases.

Working in interventional cardiology laboratories: The perceived impact of radiation exposure as a health and gender hazard. A NEXT generation ANMCO initiative.

BACKGROUND: Gender-related discrepancies in personal and professional life have been reported among radio-exposed workers. We assessed this topic among cardiac catheterization workers in Italy, with a focus on gender and working position. METHODS: Radio-exposed workers affiliated with the Italian Association of Hospital Cardiologists were invited to answer an online survey, which included 41 questions formatted as multiple choice. RESULTS: Overall, 237 workers responded. The proportion of males was significantly higher than that of females in the population aged >50 years. A greater portion of females than males perceived female-gender discrimination regarding career advancement (77.2% vs 30.9%, p < 0.001) and work compensation (49.1% vs. 17.1%, p < 0.001). There was no difference in perceived gender- discrimination in terms of career advancement opportunities between physician and non-physicians. A larger portion of females than males experienced workplace discrimination (51.8% of females vs. 8.1% of males, p < 0.0001). Non-physician responders made up 38.8% of all respondents and reported a lower yearly radiation exposure than physicians. Non-physicians were more aware of the laws regulating lab access during pregnancy than physicians (93.5% vs. 48.3%, p < 0.0001). A greater percentage of female nurses than physicians communicate without hesitation the pregnancy status to their employers (45.6% vs 20%, p < 0.001). CONCLUSIONS: Gender-based career disparities were perceived among physicians and non-physician staff of cardiology interventional laboratories. Strategies should be implemented to ensure gender equality in career opportunities and to increase knowledge of radioprotection and the laws regulating access to laboratories during pregnancy.

Assessing the Efficacy of RADPAD Protection Drape in Reducing Radiation Exposure to Operators in the Cardiac Catheterization Laboratory: A Systematic Review and Meta-Analysis.

One of the leading environmental hazards, ionizing radiation, is linked to several detrimental health consequences in the body. RADPAD (Worldwide Innovations & Technologies, Inc., Kansas City, Kansas) is a sterile, lead-free, lightweight, disposable radiation protection shield. We conducted a systematic review and meta-analysis to determine the effectiveness of RADPAD protection drapes in the cardiac catheterization lab and how they can aid interventional cardiologists in becoming subjected to less scatter radiation. PubMed, Embase, and Google Scholar were searched for studies discussing the efficacy of RADPAD protection drapes in reducing radiation exposure to operators in the cardiac catheterization laboratory. A random-effects model was used to pool odds ratios (ORs) and 95% confidence intervals (CIs) for endpoints: primary operator exposure dose, dose area product (DAP), relative exposure, and screening time. Our analysis included 892 patients from six studies. Compared to the No-RADPAD group, primary operator exposure dose (E) was significantly lower in the RADPAD group (OR: -0.9, 95% CI: -1.36 to -0.43, I2 = 80.5%, p = 0.0001). DAP was comparable between both groups (OR: 0.008, 95% CI: -0.12 to -0.14, I2 = 0%, p = 0.9066). There was no difference in the relative exposure (E/DAP) (OR: -0.47, 95% CI: -0.96 to 0.02, I2 = 0%, p = 0.90) and screening time (OR: 0.13, 95% CI: 0.08 to 0.35, I2 = 0%, p = 0.22) between the two groups. The interventional cardiology laboratory is exposed to significantly less scatter radiation during procedures owing to the RADPAD protective drape. Consequently, all catheterization laboratories could be advised to employ RADPAD protective drapes.

Outcomes with intracoronary vs. intravenous epinephrine in cardiac arrest.

BACKGROUND: Advanced Cardiovascular Life Support (ACLS) guidelines recommend intravenous (IV) and intraosseous (IO) epinephrine as a basic cornerstone in the resuscitation process. Data about the efficacy and safety of intracoronary (IC) epinephrine during cardiac arrest in the catheterization laboratory are lacking. OBJECTIVE: To examine the efficacy and safety of IC vs. IV epinephrine for resuscitation during cardiac arrest in the catheterization laboratory. METHODS AND RESULTS: This is a prospective observational study that included all patients who experienced cardiac arrest in the cath lab at two tertiary centres in Egypt from January 2015 to July 2022. Patients were divided into two groups according to the route of epinephrine given; IC vs. IV. The primary outcome was survival to hospital discharge. Secondary outcomes included rate of return of spontaneous circulation (ROSC), time-to-ROSC, and favourable neurological outcome at discharge defined as modified Rankin Scale (MRS) <3. A total of 162 patients met our inclusion criteria, mean age (60.69 ± 9.61), 34.6% women. Of them, 52 patients received IC epinephrine, and 110 patients received IV epinephrine as part of the resuscitation. Survival to hospital discharge was significantly higher in the IC epinephrine group (84.62% vs. 53.64%, P < 0.001) compared with the IV epinephrine group. The rate of ROSC was higher in the IC epinephrine group (94.23% vs. 70%, P < 0.001) and achieved in a shorter time (2.6 ± 1.97 min vs. 6.8 ± 2.11 min, P < 0.0001) compared with the IV group. Similarly, favourable neurological outcomes were more common in the IC epinephrine group (76.92% vs. 47.27%, P < 0.001) compared with the IV epinephrine group. CONCLUSION: In this observational study, IC epinephrine during cardiac arrest in the cath lab appeared to be safe and may be associated with improved outcomes compared with the IV route. Larger randomized studies are encouraged to confirm these results.

Temporary transvenous cardiac pacing in cathlab - myocardial infarction versus other causes - differences, complications, and prognosis. Data from a single-center retrospective analysis.

BACKGROUND: Transvenous temporary cardiac pacing (TTCP) is a lifesaving procedure, but the incidence of complications and prognosis depends on the underlying cause. The aim of this study was to compare the characteristics, complications, and prognosis in patients with myocardial infarction (MI) requiring TTCP vs. patients with TTCP due to other causes. METHODS: The present analysis involved 244 cases in whom TTCP was performed between 2017 and 2021 in a high-volume cathlab. All the procedures were performed by an interventional cardiologist. MI constituted 46.3% of the patients (n = 113), including 63 ST-segment elevation MI patients (55.75%). Non-MI patients (control group) consisted of patients with any cause of bradycardia requiring TTCP. RESULTS: Myocardial infarction patients requiring TTCP are younger and have a higher prevalence of hypertension and heart failure. The pacing lead is more frequently inserted during asystole/resuscitation, and pacing was needed for a longer time. MI patients required cardiac implantable electronic device implantation less frequently than in other causes (22% vs. 82%, p < 0.01). The incidence of TTCP complications did not differ. The incidence of in-hospital death was 6.5-fold higher in TTCP patients with MI. Logistic regression showed MI to be a strong predictor of in-hospital death (odds ratio: 8.1; 95% confidence interval: 1.3-57.9). CONCLUSIONS: In-hospital mortality in MI patients requiring TTCP is 6.5-fold higher than in other patients with bradycardia. The complication rate of TTCP is similar in MI and non-MI patients. It is not TTCP but the severity of MI itself and the fact that a pacing lead is frequently implanted in asystole or during resuscitation that is responsible for the higher mortality rate.

Distribution of catheterisation laboratories in Indonesia 2017-2022: a nationwide survey.

Background: Geographical terrains of Indonesia pose a major hindrance to transportation. The difficulty of transportation affects the provision of acute time-dependent therapy such as percutaneous coronary intervention (PCI). Also, Indonesia's aging population would have a significant impact on the prevalence of acute coronary syndrome in the next decade. Therefore, the analysis and enhancement of cardiovascular care are crucial. The catheterisation laboratory performs PCI procedures. In the current study, we mapped the number and distribution of catheterisation laboratories in Indonesia. Methods: A direct survey was used to collect data related to catheterisation laboratory locations in July 2022. The population data was sourced from the Ministry of Home Affairs. The recent growth of catheterisation laboratories was examined and evaluated based on geographical areas. The main instruments for comparing regions and changes throughout time are the ratio of catheterisation laboratories per 100,000 population and the Gini index (a measure of economic and healthcare inequality. Gini index ranges from 0 to 1, with greater values indicating more significant levels of inequality). Regression analysis was carried out to see how the number of catheterisation laboratories was affected by health demand (prevalence) and economic capacity (Gross Domestic Regional Product [GDRP] per Capita). Findings: The number of catheterisation laboratories in Indonesia significantly increased from 181 to 310 during 2017-2022, with 44 of the 119 new labs built in an area that did not have one. Java has the most catheterisation laboratories (208, 67%). The catheterisation laboratory ratio in the provinces of Indonesia ranges from 0.0 in West Papua and Maluku to 4.46 in Jakarta; the median is 1.09 (IQR 0.71-1.18). The distribution remains a problem, as shown by the high catheterisation laboratory Gini index (0.48). Regression shows that distribution of catheterisation laboratories was significantly affected by GDRP and the prevalence of heart disease. Interpretation: The number of catheterisation laboratories in Indonesia has increased significantly recently, however, maldistribution remains a concern. To improve Indonesia's cardiovascular emergency services, future development of catheterisation laboratories must be better planned considering the facility's accessibility and density. Funding: Airlangga Research Fund - Universitas Airlangga.

A multicentre survey of knowledge and implementation of radiation protection techniques in cardiac cath-lab medical personnel.

BACKGROUND: Awareness of radiation hazards and methods to reduce radiation dose is a sine qua non for all staff working in the cath-lab for their own safety and their patient's safety. RESULTS: There were large variations in the implementation of radiation protection techniques with overall inadequate radiation risk knowledge. Some members of the cath-lab team are at higher risk of radiation-induced side effects, including the fellows, nurses, technicians, and anaesthesiologists because they spent longer time in the cath-lab and/or their position in relation to the source of radiation. About 10% of the participants have reported different health problems potentially induced by radiation exposure. CONCLUSIONS: There is lack of radiation risks knowledge with inadequate radiation protection practice among cath-lab team. Some members such as fellows, nurse, technicians, and cardiac anaesthesiologist are at higher risks. They represent the forgotten members of the Cath-Lab team.

Best Practices for Cardiac Catheterization Laboratory Morbidity and Mortality Conferences.

Cardiac catheterization laboratory (CCL) morbidity and mortality conferences (MMCs) are a critical component of CCL quality improvement programs and are important for the education of cardiology trainees and the lifelong learning of CCL physicians and team members. Despite their fundamental role in the functioning of the CCL, no consensus exists on how CCL MMCs should identify and select cases for review, how they should be conducted, and how results should be used to improve CCL quality. In addition, medicolegal ramifications of CCL MMCs are not well understood. This document from the American College of Cardiology's Interventional Section attempts to clarify current issues and options in the conduct of CCL MMCs and to recommend best practices for their conduct.

Impact of Percutaneous Mitral Valve Repair on Left Atrial Strain and Atrial Fibrillation Progression.

Transcatheter edge-to-edge repair (TEER) currently represents a valuable therapeutic option for patients with severe mitral regurgitation (MR) considered at high surgical risk. Besides symptoms and left ventricular (LV) echocardiographic improvements upon TEER, it has been postulated that left atrial (LA) function plays a prognostic role. The aims of our study were to evaluate LA changes after TEER, measured by two-dimensional speckle-tracking echocardiography analysis (2D-STE), their association with atrial fibrillation (AF) occurrence, and relative arrhythmic burden. We considered in a single-center study 109 patients affected by symptomatic severe MR undergoing TEER from February 2015 to April 2022. By 2D-STE, LA reservoir (R_s), conduct (D_s), and contractile (C_s) strains were assessed along with four-chamber emptying fraction (LAEF-4CH) before, 1, 6, and 12 months following TEER. Statistical analysis for comparison among baseline, and follow-ups after TEER was carried out by ANOVA, MANOVA, and linear regression. Successful TEER significantly improved LV dimensions and LA performances, as indicated by all strain components, and LAEF-4CH after 1 year. Strikingly, a significant reduction in arrhythmic burden was observed, since only one case of subclinical AF detected by a previously implanted cardiac electronic device was found in the cohort of sinus rhythm patients (n = 48) undergone TEER; in addition, ventricular rate was reduced in the AF cohort (n = 61) compared to baseline, together with few episodes of nonsustained ventricular tachycardias (5/61, 8.2%) after MR improvement. Overall, TEER was associated with improved cardiac performance, LA function amelioration, and reduced arrhythmic burden.

Spontaneous Coronary Artery Dissection (SCAD) in an Atypical Patient Without Risk Factors and Prior Asymptomatic COVID-19 Infection.

Spontaneous coronary artery dissection (SCAD) is a condition primarily seen in young women and is characterized by non-atherosclerotic arterial damage. It can occur with or without conventional risk factors for coronary heart disease and is often associated with chronic inflammatory conditions. Here, we present a unique instance of a 67-year-old woman without known risk factors who developed sudden onset chest pain in the setting of an asymptomatic coronavirus 2019 (COVID-19) infection three weeks earlier. Subsequent evaluation revealed SCAD in the distal left anterior descending (LAD) artery.

Minimizing scattered radiation dose in cardiac catheterization laboratory during interventional procedures using lead free drape - MILD study.

OBJECTIVE: RADPAD is a lead-free sterile drape that reduces scattered radiation during fluoroscopic procedures. We aimed to study the effect of using RADPAD on primary operator (PO) and secondary operator (SO) during coronary angiography (CAG) as well as percutaneous coronary intervention (PCI). METHODS: 137 patients undergoing elective CAG and PCIwere randomized in a 1:1 pattern with or without the RADPAD. The ratio of PO received dose in mrem to total Air Kerma (AK) in mGy, Dose Area Product (DAP) in mGycm2 and Cine Adjusted Screening Time (CAST) in minute, at the end of the procedure with or without RADPAD were measured and designated as dose relative to AK, DAP and CAST. The exposure ratios were compared for both cohorts. RESULTS: There was no significant difference in CAST, DAP and AK between the two patient cohorts. PO radiation dose relative to CAST was 0.15 ± 0.18 mrem/min for RADPAD cohort and 0.43 ± 0.31 mrem/min for No RADPAD cohort (p < 0.00001). PO dose relative to DAP was 0.00042 ± 0.00049 mrem/mGycm2 for RADPAD cohort and 0.0011 ± 0.0013 mrem/mGycm2 for No RADPAD cohort (p = 0.000014). PO dose relative to AK was 0.0030 ± 0.0037 mrem/mGy for RADPAD cohort and 0.0071 ± 0.0049 mrem/mGy for No RADPAD cohort (p < 0.00001). All PO doses relative to CAST, DAP and AK were significantly reduced in the RADPAD cohort compared to the No RADPAD cohort. Similar findings were observed for the SO also. CONCLUSION: RADPAD significantly reduces radiation exposure to both PO and SO during CAG and PCI.

Cinefluoroscopy for assessment of mechanical heart valves with suspected dysfunction.

Background: Mechanical heart valves (MHVs) are preferred prosthesis types in many, especially younger patients who need surgical valve replacement. Although echocardiography is most frequently performed for prosthesis assessment during follow-up, ultrasound artifacts usually preclude a precise investigation of prosthesis function. Cinefluoroscopy (CF) is a simple and effective method to analyze and quantify opening and closing of prosthesis leaflets but requires careful visualization of the valve using optimal viewing angles. Here, we investigated the quality of CF studies in clinical routine and their suitability for quantitative analysis of prosthesis function. Methods and results: We retrospectively identified 94 patients with 118 cinefluoroscopies performed by 31 different investigators in one tertiary center from 2012 to 2021. Of 150 MHVs (98% bi-leaflet prostheses), 87 (58%) were aortic, 53 (34%) mitral, 7 (5%) tricuspid, and 5 (3%) pulmonary valve prostheses, respectively. CF studies were categorized by their suitability to quantitatively assess opening and closing angles. Visualization of valve function was "sufficient" in 23%, "suboptimal" in 46%, and "unsuitable" in 31% of the cases. Conclusion: In clinical routine, only one-fourth of CF studies allow for a complete assessment of leaflet motion of MHVs. Although this may be in part due to the varying experience of operators, the high number of unsuitable studies suggests that optimal viewing angles may not be achievable in all patients. Further research is required to investigate standard viewing angles and anatomy after MHV implantation to improve the quality of CF studies and reduce radiation exposure of patients and operators.