Factors affecting radiation exposure during transradial cardiac catheterisation and percutaneous coronary intervention.

AIM: To evaluate the factors affecting radiation exposure using radial access (RA) including technical aspects and clinical characteristics. MATERIALS AND METHODS: Patients (n=6,967) who underwent coronary angiography (CA) with or without percutaneous coronary intervention (PCI), performed via a right or left RA were evaluated retrospectively. Data were evaluated in two different categories: diagnostic CA group and PCI group. The primary end-points of the study were fluoroscopy time (FT), dose-area product (DAP), and air kerma (AK). RESULTS: Male sex and left RA were characterised by increased DAP and AK, in both the CA and PCI groups. In the CA group, body weight, height, body surface area (BSA), left RA, and male sex were independent prognostic factors of increased radiation. In the PCI group, body weight, height, BSA, left RA, male sex, and older age were independent prognostic factors of increased radiation while older age and left RA were independent prognostic factors for increased FT. CONCLUSION: Radial side, gender, and the physical characteristics of the patients were factors that increased radiation exposure in patients undergoing transradial coronary procedures. Therefore, these factors should be taken into account to help minimise radiation exposure for both patients and operators.

ACE2-based capacitance sensor for rapid native SARS-CoV-2 detection in biological fluids and its correlation with real-time PCR.

The spread of the SARS-CoV-2 and its increasing threat to human health worldwide have necessitated the development of new technological tools to combat the virus. Particular emphasis is given to the development of diagnostic methods that monitor the spread of the virus rapidly and effectively. In this study, we report the development and testing of an antibody-free biosensor, based on the immobilization of ACE2 protein on the surface of gold interdigitated electrode. When the sensor was used in laboratory conditions for targeting the virus' structural spike protein, it showed a limit of detection [LOD] of 750 pg/µL/mm2. Thereafter, the response of the sensor to swab and saliva samples from hospitalized patients was examined. The virus presence in the samples was confirmed by electrical effective capacitance measurements executed on the biosensor, and correlated with real-time PCR results. We verified that the biosensor can distinguish samples that are positive for the virus from those that are negative in a total of 7 positive and 16 negative samples. In addition, the biosensor can be used for semi-quantitative measurement, since its measurements are divided into 3 areas, the negative samples, the weakly positive and the positive samples. Reproducibility of the experiments was demonstrated with at least 3 replicates and stability was tested by keeping the sensor standby for 7 days at 4 °C before repeating the experiment. This work presents a biosensor that can be used as a fast-screening test at point of care detection of SARS-CoV-2 since it needs less than 2 min to provide results and is of simple operation.

Level of patient and operator dose in the largest cardiac centre in Greece.

The objective of this study was to investigate the patient and staff doses in the most frequent interventional cardiology (IC) procedures performed in Onassio, the largest Cardiac Centre in Greece. Data were collected from three digital X-ray systems for 212 coronary angiographies, 203 percutaneous transluminal coronary angioplasties (PTCA) and 134 various electrophysiological studies. Patient skin dose was measured using suitably calibrated slow radiotherapy films and cardiologist dose using suitably calibrated thermoluminescent dosemeters placed on left arm, hand and foot. Patient median dose area product (DAP) (all examinations) ranged between 6.7 and 83.5 Gy cm2. Patient median skin dose in PTCA was 799 mGy (320-1660 mGy) and in RF ablation 160 mGy (35-1920 mGy). Median arm, hand and foot dose to the cardiologist were 12.6, 27 and 13 microSv, respectively, per procedure. The great range of radiation doses received by both patients and operators confirms the need for continuous monitoring of all IC techniques.

Patients with Acute Coronary Syndrome are at High Risk Prior to the Event and Lipid Management is Underachieved Pre- and Post- Hospitalization.

BACKGROUND: Current European Guidelines suggest the use of cardiovascular risk categories and also recommend using high-intensity statins for patients with acute coronary syndromes (ACS). OBJECTIVE: We examined the risk of ACS patients prior to the event, as well as the overall use and intensity of statins. METHODS: We enrolled 687 ACS patients (mean age 63 years, 78% males). Low-density lipoprotein cholesterol (LDL-C) levels upon admission were used to assess attainment of LDL-C targets. Patients were categorized as very high, high, moderate and low risk based on their prior to admission cardiovascular (CV) risk. We examined statin use and dosage intensity among patients discharged from the hospital. Patients were followed for a median period of 189 days. RESULTS: The majority of the patients (n=371, 54%) were at very high CV risk prior to admission, while 101 patients were at high risk (15%), 147 (21%) moderate risk and 68 (10%) low risk. Interestingly, LDL-C target attainment decreased as the risk increased (p<0.001). The majority (96%) of patients received statins at discharge; however, most of them (60.4%) received low/moderate intensity statins and just 35.9% received the suggested by the Guidelines high-intensity dose of statins. At follow-up, the rate of patients at high-intensity dose of statins remained similar (34.8%); 6% received no statins at all at follow-up. CONCLUSION: According to our study, the majority of ACS patients are already at high risk prior to their admission. Further, LDL-C targets are underachieved prior to the event and high-intensity statins are underutilized in ACS patients at, and post-discharge.

Swallow syncope in a patient with esophageal stenosis caused by an ascending aorta aneurysm: differential diagnosis from postprandial hypotension: a case report.

Swallow syncope is usually caused by organic or functional disorders of the esophagus due to abnormal vasovagal reflex. In elderly patients this situation could be confused with postprandial hypotension. We present a case of an elderly patient who presented with swallow syncope that was caused by a waist in the midportion of esophagus induced by an ascending aorta aneurysm.

A simple score for early risk stratification in acute heart failure.

INTRODUCTION: The use of many acute heart failure (AHF) risk scores is cumbersome. We therefore developed a simple AHF risk score (AHFRS) for early risk stratification. METHODS: The study consisted of a prospective derivation cohort (PDC; N=104; age, 77[21] years; LVEF (%), 35[29]) and a retrospective validation cohort (RVC; N=141; age, 76[15] years; LVEF (%), 35[25]). Clinical, echocardiography and laboratory assessment was performed at admission. The study end-point was death from any cause or HF-rehospitalization at 1year. RESULTS: In the PDC 46 (44.2%) patients experienced the end-point. Independent prognostic factors of outcome were hypertension (HTN) history, myocardial infarction (MI) history, and admission red cell distribution width (RDW). Multivariate logistic regression indicated 8-, 4-, and 3-times higher odds ratio for development of study end-point in patients without a HTN history, with MI history, and RDW≥15% (median) respectively. Thus in AHFRS, 2 points were assigned for absence of HTN history, 1 point for presence of MI history, and 1 point for RDW values ≥15% (0 best possible, whereas 4 worst possible score). The AHFRS identified patients who developed the end-point in the PDC with an area under the ROC curve (AUC) of 0.80 [95% C.I.: (0.71, 0.87)] denoting a high discriminative ability. These findings were confirmed in the RVC, in which the endpoint occurred in 52 (36.9%) patients and the AUC for the AHFRS was 0.82 [95% C.I.: (0.73, 0.89)]. CONCLUSIONS: AHFRS is easily obtained at admission and accurately risk stratifies AHF patients.

Angioplasty of a left anterior descending artery originating from the right sinus of Valsalva (discussion in decision making).

In this case report, we describe a successful percutaneous transluminal coronary angioplasty of an abnormally originating left anterior descending artery from the right sinus of Valsalva. We discuss about the decision making in this rare and challenging case, since there is more than one opinion as to which is the appropriate treatment in this group of patients.

Coronary microcirculation evaluation with transesophageal echocardiography Doppler in type II diabetics.

Evaluation of coronary microvascular function can be obtained through coronary flow reserve measurements. The aim of this study was to evaluate the coronary microvascular function by using transesophageal-Doppler echocardiographic assessment of coronary flow reserve. The study included 32 normotensive patients with type II diabetes mellitus (group A) of short duration (6.1+/-3.8 years) aged 55.4+/-9.4 years and 14 healthy volunteers matched for age, gender and BMI (group B). No patients had clinical evidence of coronary artery disease and all of them produced a negative recent stress ECG test. Excluded from the study were patients with anemia, left ventricular hypertrophy, arrhythmia, congenital, or acquired structural heart disease. All subjects underwent transesophageal-Doppler echocardiography. Satisfactory coronary blood flow velocity recordings could be obtained from the initial segment of the left anterior descending coronary artery in healthy volunteers and in 27 patients at baseline and 2 min after dipyridamole infusion (0.56 mg/kg, for 4 min). In the remaining 5 patients no satisfactory recordings were available. The indexes of coronary flow reserve, i.e. the ratios of dipyridamole over basal maximum and mean diastolic velocities were calculated. Dipyridamole/rest maximal coronary reserve (Table 3) was 1.946+/-0.743, while this ratio for the mean diastolic velocity was 1.969+/-0.805 in group A. The respective values for group B, were 2.811+/-0.345 (P=0.000 vs. group A) and 2.914+/-0.303 (P=0.000 vs. group A). Thus, the increase in coronary flow reserve although present in both groups, it was more impressive in the normal group. Multiple regression logistic analysis of: age, sex, smoking, glucosylated hemoglobin, duration of diabetes and type of therapy, did not show any correlation of these parameters with the above ratios. This study shows that coronary flow reserve, as measured with transesophageal echocardiography-Doppler, is severely impaired in normotensive patients with type II diabetes, with relatively short duration of the disease.

Stent implantation in patient with visible intracoronary thrombus and compromised left ventricular function, after local thrombolysis using the Dispatch catheter.

The case of a patient with unstable angina and angiographic findings of significant (approximately 90%) right coronary artery stenosis with an intracoronary thrombus next to the lesion, total left anterior descending and circumflex occlusion and an ejection fraction of approximately 22% is described. The case was treated with stent implantation after local thrombolysis with the use of the Dispatch infusion catheter.

Non-invasive evaluation of coronary reserve. Assessment of coronary reserve in patients with coronary artery disease by transesophageal-Doppler echocardiography.

We assessed coronary flow reserve using transesophageal Doppler echocardiography in patients with coronary artery disease. The study included 33 coronary artery disease patients who were undergoing coronary arteriography. The blood flow velocities of the left anterior descending artery before and after intravenous infusion (0.56 mg/min for 4 min) of dipyridamole were recorded using transesophageal Doppler echocardiography. Fourteen normal healthy individuals, matched for age, served as a control group. The index of coronary flow reserve, i.e. the ratio of dipyridamole to baseline maximum diastolic velocity, was calculated. Maximal coronary flow reserve in coronary artery disease patients was significantly lower than in the control group (1.4+/-0.2 vs. 2.8+/-0.3, P<0.001). The coronary artery disease patients were classified into three groups: Group A included 10 patients with <50% left anterior descending artery stenosis; Group B included seven patients with 50-69% left anterior descending artery stenosis; 16 patients with >70% left anterior descending artery stenosis constituted Group C. The maximum coronary flow reserve was significantly different for A vs. B and A vs. C. (A, 1.77+/-0.18; B, 1.51+/-0.1; C, 1.28+/-0.24). A strong and significant correlation was found between the maximum coronary flow reserve and the degree of proximal left anterior descending artery stenosis (r=0.78, P<0.001). Coronary artery disease patients without left anterior descending artery stenosis on the arteriogram exhibited lower maximum coronary flow reserve compared to the control subjects (1.78+/-0.19 vs. 2.8+/-0.3, P=0.000).

Successful management of right coronary air embolus after intracoronary administration of verapamil.

A case of a 50 year-old male with a coronary air embolism is described. The case was successfully treated with intracoronary administration of verapamil.

Detection of coronary artery disease in patients with severe aortic stenosis with noninvasive methods.

Exercise stress ECG testing is not generally recommended in patients with severe aortic stenosis. Analysis of the utility of exercise testing, both with and without the use of myocardial thallium-201 scintigraphy for the diagnosis of coronary artery disease (CAD), yielded low specificity. A noninvasive, safe, and accurate diagnostic modality to ascertain the presence of CAD is not available to date for patients with severe aortic stenosis. The aim of this study was to assess the safety and diagnostic accuracy of adenosine stress echocardiography (A-Stress-Echo) and of adenosine stress myocardial perfusion scintigraphy (A-SPECT), for the detection of CAD in patients with severe aortic stenosis. The study included 50 patients with severe aortic stenosis (maximal instantaneous aortic valve gradient >80 mmHg, range 81 to 144 mmHg, and aortic valve area <0.75 cm2). All patients were submitted to A-Stress-Echo, after a 6-minute infusion of adenosine (140 microg/kg body weight/min), and then (>3 days later) A-SPECT with the same dosage of adenosine as above. Coronary angiography was performed in all patients. No major complications were observed. The unpleasant symptoms were brief and did not necessitate cessation of the test. Both modalities showed the same sensitivity (85% for A-SPECT and 85% for A-Stress-Echo) angiographically diagnosed CAD while A-Stress-Echo yielded much higher specificity (96.7% vs 76.7%). Concordance of the two methods was found in 40 cases and the specificity for those patients was 100%. A-Stress-Echo and A-SPECT, either separately or in combination, constitute excellent and safe noninvasive diagnostic methods in detecting CAD in patients with severe aortic stenosis.

Elective intracoronary Micro-Stent II implantation without quantitative coronary angiography or intravascular ultrasound guidance and without subsequent anticoagulation: short- and long-term results.

Intracoronary stenting has been shown to reduce acute closure and restenosis rate in patients treated with coronary angioplasty. The use of high inflation pressures and intravascular ultrasound guidance allowed the substitution of anticoagulants with antiplatelet agents but increased the cost. The aim of this study was to investigate the effectiveness, safety, and long-term outcome of the elective implantation of a relatively new type of stent (Micro-Stent II), without the use of quantitative coronary angiography or intravascular ultrasound guidance and without subsequent anticoagulation. The study included 361 patients who underwent elective microstent implantation. Stent expansion was performed at 8 atm followed by higher inflation pressure at 14-20 atm. Heparin was given intraarterially only once immediately after the arterial sheath insertion. Ticlopidine was started at least 48 hours before the procedure and continued for 1 month while aspirin was continued indefinitely. All patients were followed up for 12.9 +/- 3.6 months. Short term outcome (first month): Stent implantation was successfully achieved in 361 of 366 patients (98.6%). Seven patients (1.9%) were excluded from the study and received anticoagulants because of a suboptimal result. In total, 423 stents were implanted. There was no subacute thrombosis, but acute vessel closure occurred in one patient (0.3%). Non-Q wave myocardial infarction occurred in six patients (1.7%), Q wave myocardial infarction occurred in one patient (0.3%), and only one death (0.3%) of nonischemic origin was reported. No major peripheral vascular complications were observed. Late results: Q or non-Q wave infarction occurred in 13 patients (3.6%), 26 patients (7.2%) underwent a repeat angioplasty, eight patients (2.2%) underwent coronary artery bypass grafting, and four patients (1.1%) died. Overall, 284 patients (78.7%) were free of symptoms, while 77 (21.3%) had recurrent coronary ischemia. In conclusion, Micro-Stent II implantation without quantitative coronary angiography or intravascular ultrasound guidance and without anticoagulation was found to be effective, safe, and with good long-term outcome.

Transesophageal echocardiographic Doppler study of coronary flow in a patient with myocardial bridging--a case report.

A case report of myocardial bridging of the left anterior descending artery is described. Coronary flow proximal to the myocardial bridge was studied with transesophageal echo Doppler. The patient, a 62-year-old farmer who sustained an anterior myocardial infarction, underwent thrombolysis and was admitted. He subsequently underwent coronary angiography and left ventriculography, which showed a severe myocardial bridge of the midshaft of the left anterior descending artery. The ejection fraction improved from 25 to 48% after thrombolysis, as measured by using echocardiography. Transesophageal Doppler study proximal to the myocardial bridge revealed a relative increase of the diastolic coronary flow velocity (increased acceleration), which reached its peak value in early diastole. Despite the presence of severe myocardial bridging, coronary flow reserve increased substantially two minutes after the infusion of dipyridamole (0.56 mg/kg iv for 4 minutes). Transesophageal Doppler study of coronary blood flow proximal to the myocardial bridge in the left anterior descending artery showed a characteristic waveform that may prove to be indicative of this condition.

Radiation dose measurements to the interventional cardiologist using an electronic personal dosemeter.

The aim of this study was to investigate the use of an electronic personal dosemeter (EPD) worn by a senior cardiologist in an Interventional Cardiology (IC) Laboratory of a busy cardiac centre and how the results could help in the evaluation of radiation protection equipment used. Patient samples consist of 28 patients (10 coronary angiographies (CAs) and 18 percutaneous transluminal coronary angioplasties (PTCAs)). Patient dose was measured with a dose-area product (DAP) meter. Cardiologist radiation dose value written on the EPD as well as the protective equipment used was collected. Between patient and cardiologist dose, a significant correlation was found in CA and a moderate correlation in PTCA. Mean cardiologist effective dose E per procedure was found to be 0.2 microSv in CA and 0.3 microSv in PTCA. EPD proved to be an easy, direct and straightforward way to measure the radiation dose that the cardiologist receives in an IC laboratory.

Radiation doses in a newly founded Interventional Cardiology department.

Coronary angiography (CA) and percutaneous transluminal coronary angioplasty (PTCA) radiation doses were investigated in a recently founded Interventional Cardiology (IC) department. The study includes 336 procedures (177 CAs and 159 PTCAs) carried out with a Philips digital flat detector monoplane system. Patient dose was measured in terms of kerma-area product (KAP) and cumulative dose. Using appropriate conversion factors, peak skin dose (PSD) and effective dose (E) were estimated. Median values of KAP (Gy cm(2)), PSD (mGy) and E (mSv) were: 34 478 and 6.1, respectively for CA and 80 885 and 14.4 for PTCA, within European and international reference levels. Only 1.5 % of patients received radiation dose over the 2 Gy threshold (PTCA procedures) for deterministic effects and none reported any skin effect. Radiation doses were within international standards and comparable with other radiological examinations. The percentage of the high-risk patients for radiation skin effects is extremely low.

Evaluation of radiation dose during pacemaker implantations.

The purpose was to evaluate patient radiation doses and compare with other interventional procedures. One hundred and twenty-eight procedures were carried out with a recently installed mobile undercouch C-arm machine with a 23-cm diameter image intensifier. The radiation dose is provided by the X-ray machine, in terms of cumulative dose (CD). Kerma-Area product (KAP) was then estimated from CD and the X-ray field size. Other patient parameters recorded were patient weight, age, kilovolt, milliampere and fluoroscopy time (T). Median (range) CD, KAP and T were 15.2 mGy (3.2-110 mGy), 6.3 Gy cm(2) (1.3-45.7 Gy cm(2)) and 5.2 (1.5-27.4 min) min, respectively. Median E was 1.1 mSv (conversion factor: 0.18 mSv per Gy cm(2)), which corresponds to approximately one lumbar spine X-ray radiography. The effective dose is much lower than a coronary angiography (8 mSv) or an electrophysiology study (6 mSv). Radiation dose is low compared with other interventional cardiology procedures.

What are the clinical and technical factors that influence the kerma-area product in percutaneous coronary intervention?

The purpose of the paper is to define predictors of the kerma-area product (KAP) in percutaneous coronary intervention (PCI). Two new digital X-ray interventional cardiology systems recently installed were included. A total of 398 PCI procedures were carried out by 6 board-certified senior interventional cardiologists with more than 15 years' experience and good knowledge of radiation protection measures. Clinical, radiation and procedural data were collected based on a detailed protocol developed by the SENTINEL cardiology subgroup. Correlation with clinical and procedure factors was then investigated. A significant correlation was found between fluoroscopy time and (i) lesion classification, (ii) the level of tortuosity and (iii) the number of vessels treated. No statistically significant differences were observed in the complexity of the case between operators. However, large differences were found in the KAP among operators, which were mostly attributed to the different number of frames taken by each operator. There was no statistically significant correlation between complexity and the total number of frames. The study showed that, in certain circumstances, the clinical need to successfully perform PCI takes precedence over radiation safety concerns.

Entrapment of angiographic catheter in the right coronary artery: a trap for the nonexperienced operator.

A case of angiographic catheter entrapment in the right coronary artery during coronary angiography in a patient with excessive tortuosity of the right iliac artery is described. Alternative manipulations in order to avoid this problem are presented.