Guidelines for internal peer review in the cardiac catheterization laboratory. Laboratory Performance Standards Committee, Society for Cardiac Angiography and Interventions.

The Laboratory Performance Standards Committee of the Society for Cardiac Angiography and Interventions has proposed guidelines for establishing an internal peer review program in the cardiac catheterization laboratory. The first step is to establish a committee and a data base. This data base should include quality indicators that reflect: physician qualifications, outcomes of procedures, and processes of care. The outcomes must be risk-adjusted to account for the variable severity of illness. Data should be collected by catheterization laboratory personnel and entered into a laboratory-specific computerized data base. These data must be analyzed and organized into profiles that reflect the quality of care. Based on this information, the Committee would institute the following interventions to improve physician performance: education, clinical practice standardization, feedback and benchmarking, professional interaction, incentives, decision-support systems, and administrative interventions. The legal aspects of peer review are reviewed briefly.

Guidelines for continuous quality improvement in the cardiac catheterization laboratory. Laboratory Performance Standards Committee of the Society for Cardiac Angiography & Interventions.

The Laboratory Performance Standards Committee of the Society for Cardiac Angiography and Interventions has compiled guidelines for a quality improvement program for the cardiac catheterization laboratory. The first step is to identify "quality indicators" in order to quantify the results. The indicators must be risk-adjusted to assure validity of comparative data. The second step is development of a data collection process that continues after the patient has left the catheterization laboratory. The third step, data evaluation, requires determination of normal ranges of occurrence rates and identification of adverse events that exceed these rates. An investigation should be undertaken to determine the processes and systems that may produce the undesirable outcome. The fourth step is creation of a solution to correct the deficiency. This may involve education, administrative intervention, or feedback. The final step is reassessment of the quality indicators to determine if the corrective action has been effective.

Steal-prone coronary anatomy and myocardial ischemia associated with four primary anesthetic agents in humans.

To examine the relationship between myocardial ischemia in patients with steal-prone coronary anatomy and the administration of isoflurane anesthesia, we reviewed coronary angiograms of 955 patients who had participated in a randomized trial of the use of one of four primary anesthetics for coronary artery bypass operations. Steal-prone anatomy was found in 31.8% of patients who had received enflurane; 40.0%, halothane; 32.6%, isoflurane; and 31.7%, sufentanil. Detected by greater than or equal to 0.1 mV ST segment displacement, ischemia during anesthesia occurred in 290 (30.4%) of all patients with no difference in the incidence among the four primary anesthetics (27.5%-32.9%). Patients with steal-prone anatomy did not suffer more ischemia than patients who needed coronary artery bypass surgery but with other varieties of coronary anatomy. In patients with steal-prone coronary anatomy, the incidence of myocardial ischemia by primary anesthetic was 24.0% with enflurane, 34.4% with halothane, 32.1% with isoflurane, and 38.2% with sufentanil. Systolic blood pressure less than 90 mm Hg during anesthesia occurred in 416 (45.6%) patients and was twice as common during administration of volatile anesthetics than during that of sufentanil. Hypotension did not increase ischemia frequency in patients with steal-prone anatomy with use of any of the four primary anesthetics including isoflurane. Ischemia was temporally related to hypotension in only 9 patients (0.9%). In none of the 42 patients who had steal-prone anatomy and hypotension during isoflurane anesthesia was ischemia temporally related to hypotension.(ABSTRACT TRUNCATED AT 250 WORDS)

First human use of the Hemopump, a catheter-mounted ventricular assist device.

The Hemopump, a catheter-mounted, temporary ventricular assist device, consists of an external electromechanical drive console and a disposable, intraarterial axial-flow pump (21F). Power is transmitted percutaneously to the pump by a flexible drive shaft within the catheter. The device is positioned in the left ventricle by way of the femoral artery approach or through the ascending aorta. Blood is drawn from the left ventricle through the transvalvular inlet cannula and pumped into the aorta. As of December 1988, the Hemopump had successfully supported the circulation of 7 patients (5 men, 2 women) ranging in age from 44 to 72 years (mean age, 59 years) and suffering from cardiogenic shock (cardiac index less than 2.0 L/min/m2). Indications for use included failure to be weaned from cardiopulmonary bypass in 4 patients, acute myocardial infarction in 1, severe cardiac allograft rejection in 1, and donor heart failure in 1. Duration of support ranged from 26 to 113 hours (mean, 66 hours). Although 5 patients demonstrated transient hemolysis, none experienced infection, thrombosis, or vascular injury. Hemodynamic variables improved in all patients during support by the device. As of December 1988, 5 of the 7 patients were alive more than 30 days after support had been discontinued, and 3 of these patients were discharged from the hospital. On the basis of our initial clinical results, the Hemopump, which does not require a major surgical procedure for insertion, provides effective, temporary circulatory support in patients with potentially reversible cardiac failure.

Unilateral gynecomastia associated with thoracotomy following resection of carcinoma of the lung.

A 66-year-old man developed right painful gynecomastia following resection of a well-differentiated squamous cell carcinoma from the right upper lobe. In 1979, he had a well-differentiated squamous cell carcinoma resected from the left lower lobe. Extensive investigation did not reveal any definite indication of metastases or residual carcinoma. There was no evidence for thyroid, liver, or renal disease. His plasma testosterone was 400 ng/dl, estradiol was 43 pg/ml, LH 3.5 ng/ml, FSH 13.1 mIU/ml and HCG less than 5 mIU/ml. Since no other cause of gynecomastia was apparent , it was attributed to the right thoracotomy.

Percutaneous transluminal coronary angioplasty: a review of current balloon dilatation systems.

The interventional cardiologist is faced with an expanding armamentarium for performing percutaneous transluminal coronary angioplasty (PTCA). Because of rapid advances in technology, new devices are produced on a regular basis, making it difficult to maintain a working knowledge of what is available. Although several excellent textbooks about PTCA have been written, descriptions of available equipment are usually obsolete by the time publication occurs. In order to provide succinct specifications of equipment, we have documented data on balloon catheters, guiding catheters, and guidewires. This information may be useful in the selection of appropriate equipment for PTCA procedures. In addition, the publication of such data in a monthly periodical may provide a more current overview of equipment; information may be occasionally updated as new equipment is released.

Cyanosis after surgical correction of pulmonary valve stenosis: an old problem revisited.

The presence of cyanosis following repair of congenital cardiac defects may result from several different mechanisms. We report two patients in whom early postoperative arterial hypoxemia manifested by cyanosis was caused by right-to-left interatrial shunting. Two-dimensional contrast echocardiography correctly identified the site and direction of shunting, leading to surgical correction of the complication.

Restenosis after transluminal coronary angioplasty detected with exercise-gated radionuclide ventriculography.

Forty-one patients were evaluated with exercise-gated radionuclide ventriculography before and within 4 days after successful transluminal coronary angioplasty and 4 to 12 months later. Patients were subgrouped according to the degree of restenosis demonstrated angiographically at 4 to 12 months (Group I [n = 23]: less than or equal to 20%; Group II [n = 10]: greater than 20% but less than 50%; Group III [n = 8]: greater than or equal to 50%). Patients with abnormal findings on gated radionuclide ventriculography (less than 5 point increase in ejection fraction or wall motion deterioration) early after angioplasty were eventually found to have a greater degree of restenosis than were patients with normal findings (41.2 +/- 30.3 versus 19.0 +/- 25.4% restenosis, p less than 0.0001). The accuracy of abnormal radionuclide ventriculography in predicting 50% or greater restenosis was 73% immediately after angioplasty and 77% at the time of follow-up angiography. Gated radionuclide ventriculographic results were abnormal in 5% of Group I patients compared with 75% of Group III patients (p less than 0.01) early after angioplasty; at late follow-up, they were abnormal in 27% of Group I patients compared with 88% of Group III patients (p less than 0.01). Group I patients had a greater increase in ejection fraction than did Group III patients at early (+11.3 +/- 7.5 versus + 3.5 +/- 6.5 points, p less than 0.01) and late (+11.8 +/- 7.8 versus -1.9 +/- 8.7 points, p less than 0.0005) follow-up. It is concluded that gated radionuclide ventriculography is useful in predicting coronary restenosis after transluminal coronary angioplasty.

Left stellate ganglionectomy for the long Q-T interval syndrome: nine-year follow-up of a patient.

Ventricular arrhythmias in patients with the long Q-T interval syndrome remain difficult to treat. In 1972, the first left stellate ganglionectomy was performed successfully to alter the pattern of ventricular recovery with control of ventricular arrhythmias. To date, no long-term evaluation has been carried out in any patients who have undergone left stellate ganglion removal for control of life-threatening arrhythmias. We report the case of a 52-year-old woman previously afflicted with idiopathic prolongation of the Q-T and syncope 9 years after successful partial ablation of the left stellate ganglion for the control of ventricular tachyarrhythmia.

Atypical late cardiac tamponade after mitral valve replacement: case presentation with hemodynamic and echocardiographic observations.

A patient developed oliguria, peripheral edema, and dyspnea 5 days after mitral valve replacement. Chest roentgenogram and echocardiogram suggested pericardial effusion. Although pulsus paradoxus was absent, cardiac tamponade was suspected and subsequently confirmed during pericardiocentesis. Before pericardiocentesis right and left ventricular diastolic pressures were equal, as well as intrapericardial and right atrial pressures. The left ventricular cavity was reduced in size on the echocardiogram. Interventricular septal motion was normal. Pericardiocentesis normalized the hemodynamics and allowed the left ventricle to reexpand. Certain atypical features are tentatively explained as the combined effect of constrictive and effusive components caused by intrapericardial hemorrhage.