Comparison of percutaneous coronary intervention safety before and during the establishment of a transradial program at a teaching hospital.

This study sought to examine the safety of percutaneous coronary intervention (PCI) before and during de novo establishment of a transradial (TR) program at a teaching hospital. TR access remains underused in the United States, where cardiology fellowship programs continue to produce cardiologists with little TR experience. Establishment of TR programs at teaching hospitals may affect PCI safety. Starting in July 2009 a TR program was established at a teaching hospital. PCI-related data for academic years 2008 to 2009 (Y1) and 2009 to 2010 (Y2) were prospectively collected and retrospectively analyzed. Of 1,366 PCIs performed over 2 years, 0.1% in Y1 and 28.7% in Y2 were performed by TR access. No major complications were identified in 194 consecutive patients undergoing TR PCI, and combined bleeding and vascular complication rates were lower in Y2 versus Y1 (0.7% vs 2.0%, p = 0.05). Patients treated in Y2 versus Y1 and by TR versus transfemoral approach required slightly more fluoroscopy but similar contrast volumes and had similar procedural durations, lengths of stay, and predischarge mortality rates. PCI success rates were 97% in Y1, 97% in Y2, and 98% in TR cases. TR PCIs were performed by 13 cardiology fellows and 9 attending physicians, none of whom routinely performed TR PCI previously. In conclusion, de novo establishment of a TR program improved PCI safety at a teaching hospital. TR programs are likely to improve PCI safety at other teaching hospitals and should be established in all cardiology fellowship training programs.

Chronic total occlusion angioplasty in the United States.

Coronary chronic total occlusions (CTOs) are commonly encountered complex lesions identified in 15% of all patients referred for coronary angiography. Chronic total occlusion remains the most powerful predictor of referral for coronary bypass surgery. The benefits of CTO percutaneous coronary intervention (PCI) include symptom relief, improved left ventricular function, and potentially a survival advantage associated with success when compared with failed CTO-PCI. Data from the NCDR (National Cardiovascular Data Registry) suggest that CTO-PCI attempt rates in the U.S. have not changed over the past 5 years despite significant advances in techniques and technology, some of which we review here. Additionally, these data highlight a major disparity in attempt rates based on operator PCI volume. Remaining barriers to attempting CTO-PCI in the U.S. include operator inexperience, the perception of increased risk of CTO-PCI, and financial disincentives to operators and hospitals. To overcome operator inexperience, participation in CTO clubs, the invitation of guest operators, and a dedicated CTO day can be implemented at institutions committed to learning advanced CTO-PCI techniques so that operators can overcome the barriers and offer patients access to percutaneous therapy when it is clinically indicated.

Health disparities and social determinants of health among African-American women undergoing percutaneous coronary interventions (PCI).

This review of minority health describes the existing health disparities, the barriers to healthcare access and utilization, the role of three social determinants of health [i.e., (1) socioeconomic status, (2) education, and (3) stress and/or depression], the existing public-policies; and a health literacy strategy addressing social determinants of health to reduce disparities and improve outcomes in African-American women undergoing Percutaneous Coronary Intervention (PCI). Insurance, geography, facility-types, physician referral-bias, and cultural-differences pose as potential significant barriers to healthcare access and utilization. Likewise, lower socioeconomic-status, lack of education, and higher stress and/or depression is associated with adverse health-outcomes for this population. Although the elimination of health disparities is a national priority, comprehensive educational approaches focusing on cross-cultural communication, language barriers, cultural-sensitivity, and cultural-competence are needed.

Overview of the transradial approach in percutaneous coronary intervention.

Thirteen years have passed since the first percutaneous coronary intervention was performed at Onze Lieve Vrouwe Gasthuis in Amsterdam using the transradial approach (TRA). Since then TRA has spread through the interventional community and many centres have now adopted TRA as the arterial access of choice. This review is focused on the hot issues and the latest developments in this field. The following subjects will be addressed and discussed: drawbacks and learning curve, procedural technique, indications (with particular attention to acute coronary patients), complications, contraindications, nurse workload, patient management, and economics.

Learning and the evolution of medical technologies: the diffusion of coronary angioplasty.

This study uses longitudinal data on patients receiving percutaneous transluminal coronary angioplasty (PTCA) to examine changes in outcomes and costs. All hospitals achieved substantial reductions in inpatient mortality and emergency bypass surgery over time, regardless of the number of procedures performed. Annual hospital procedure volume was also associated with improved outcomes, although the effect is small. There was no evidence that learning by doing (cumulative PTCA volume) influenced outcomes. The high correlation between annual and cumulative procedure volume precludes a point estimate of the effect of learning by doing on costs, although the upper bound on the potential learning effect is sizeable. The results suggest that centralizing provision of PTCA may lead to lower costs, but only small outcomes improvements.