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Oclusión Coronaria , Intervención Coronaria Percutánea , Humanos , Resultado del Tratamiento , Oclusión Coronaria/diagnóstico por imagen , Oclusión Coronaria/terapia , Angiografía Coronaria , Intervención Coronaria Percutánea/efectos adversos , Enfermedad Crónica , Factores de Riesgo , Sistema de RegistrosRESUMEN
BACKGROUND: Discordant physiology and anatomy may occur when nonsevere angiographic stenosis has positive physiology as well as the opposite situation. AIM: To underline the reasons behind the discrepancy in physiology and anatomy and to summarize the information that coronary imaging may add to physiology. METHODS: A review of the published literature on physiology and intravascular imaging assessment of intermediate lesions was carried out. RESULTS: The limitations of angiography, the possibility of an underlying diffuse disease, the presence of a "grey zone" in both techniques, the amount of myocardial mass that subtends the stenosis, and plaque vulnerability may play a role in such discrepancy. Intracoronary imaging has a poor diagnostic accuracy compared to physiology. However, it may add information about plaque vulnerability that might be useful in deciding whether to treat or not a certain lesion. CONCLUSIONS: Coronary revascularization is recommended for patients with ischemia based on physiology. Intracoronary imaging adds information on plaque vulnerability and can help on the decision whether to revascularize or not a lesion.
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Enfermedad de la Arteria Coronaria , Estenosis Coronaria , Reserva del Flujo Fraccional Miocárdico , Placa Aterosclerótica , Constricción Patológica/patología , Angiografía Coronaria , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/patología , Enfermedad de la Arteria Coronaria/terapia , Estenosis Coronaria/diagnóstico por imagen , Estenosis Coronaria/terapia , Vasos Coronarios , Reserva del Flujo Fraccional Miocárdico/fisiología , Humanos , Valor Predictivo de las Pruebas , Índice de Severidad de la Enfermedad , Resultado del TratamientoRESUMEN
INTRODUCTION: Despite of the wide evidence of use fractional flow reserve (FFR), isolated angiography evaluation is still the main tool to indicate percutaneous coronary intervention. Quantitative flow ratio (QFR) is a new functional index to assess functional significance. Recently, few studies have showed the capacity of QFR to predict significance stenosis. The aim of this research has been to describe the evidence of QFR in this clinical setting, to analyze the global diagnosis accuracy of QFR versus FFR and to compare the difference in feasibility between retrospective and prospective analysis. METHODS AND RESULTS: Systematic review of literature was performed. Eligible studies for the meta-analysis were considered those directly evaluating de QFR versus FFR. Pooled values of diagnosis test and summary receiver operator curve were calculated. Main causes of not-perform QFR analysis according to study design were also evaluated. Sixteen studies were included. Good correlation and agreement were showed. Global sensibility, specificity, PPV, and NPV were 0.84, 0.89, 0.80, and 0.92, respectively. Then, 18% of evaluated vessels could not be analyzed. Significant differences were found in the percentage of discarded vessels and the cause of nonperformed analysis between retrospective or prospective analysis. CONCLUSIONS: Excellent correlation and agreement between QFR and FFR was demonstrated. QFR assessment could be improved by its prospective analysis with a dedicated protocol.
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Estenosis Coronaria , Reserva del Flujo Fraccional Miocárdico , Angiografía Coronaria , Estenosis Coronaria/diagnóstico por imagen , Vasos Coronarios/diagnóstico por imagen , Humanos , Imagenología Tridimensional , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Valve-in-valve (ViV) procedures have emerged from an off-label procedure to a safe and efficient alternative to redo aortic valve replacement in the treatment of symptomatic structural valve deterioration (SVD). During ViV procedures, optimal placement of the transcatheter heart valve (THV) inside the degenerated bioprosthesis is of paramount importance regarding complications such as device embolization, coronary obstruction, periprosthetic regurgitation, residual gradients, and mitral valve injury, but also for the attainment of optimal hemodynamics. In the case of the Mosaic (Medtronic, Minneapolis, MN) valve, the limited radiopaque landmarks represent a challenge to a reproducible, optimal implantation. Such implantation may require multiple contrast injections and transesophageal echocardiogram (TEE) guidance. We herein describe a computer-assisted ViV procedure inside a deteriorated Mosaic valve, achieving reproducible optimal placement using a preacquired library of bioprostheses 3D models. Our approach suggests an evolving paradigm in ViV procedures, from safe and efficient toward optimal therapy for symptomatic SVD.
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Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Reemplazo de la Válvula Aórtica Transcatéter , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Diseño de Prótesis , Falla de Prótesis , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Resultado del TratamientoRESUMEN
The replacement of surgically corrected mitral valves, also known as percutaneous transcatheter repair, is a relatively young field. Even though these procedures are usually successful, they can present significant intraoperative or postoperative challenges. To our knowledge, we present the first case of acute focal dehiscence of mitral ring repair during the mitral valve-in-ring procedure.
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Cateterismo Cardíaco/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Prótesis Valvulares Cardíacas , Anuloplastia de la Válvula Mitral/instrumentación , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Anciano , Cateterismo Cardíaco/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Hemodinámica , Humanos , Masculino , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/fisiopatología , Anuloplastia de la Válvula Mitral/efectos adversos , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/etiología , Insuficiencia de la Válvula Mitral/fisiopatología , Falla de Prótesis , Recuperación de la Función , Resultado del TratamientoRESUMEN
BACKGROUND: Postdilatation after transcatheter heart valve (THV) implantation was associated with larger aortic valve areas in large-scale registries; however, the specific effects of postdilatation are poorly understood. METHODS AND RESULTS: Among a total of 224 consecutive patients who underwent transcatheter aortic valve replacement using SAPIEN 3, 121 patients (54.0%) underwent postdilatation (same contrast volume: N = 101, +1 ml: N = 17, +2 ml: N = 3). THV diameter was assessed (a) during, (b) after implantation, (c) during postdilatation, and (d) after postdilatation by quantitative fluoroscopy. In the overall patients (N = 224), acute recoil was observed from during implantation (23.0 ± 2.0 mm) to after implantation (22.5 ± 2.0 mm, p < .001) with an absolute recoil of 0.52 ± 0.25 mm. After postdilatation (N = 121), THV diameter significantly increased from 22.5 ± 2.0 mm to 22.9 ± 2.1 mm (p < .001), with smaller absolute recoil (0.39 ± 0.21 mm, p < .001). Compared with those who did not undergo postdilatation, patients who underwent postdilatation had larger postprocedural THV area assessed by multi-slice computed tomography (471.4 ± 78.1 mm2 vs. 447.5 ± 76.3 mm2 , p = .02) and larger effective orifice area (EOA) assessed by echocardiography throughout 1 year (at 30 day, 1.66 ± 0.33 cm2 vs. 1.45 ± 0.27 cm2 , p < .001; at 6 month, 1.66 ± 0.33 cm2 vs. 1.44 ± 0.29 cm2 , p < .001; at 1 year, 1.69 ± 0.38 cm2 vs. 1.47 ± 0.30 cm2 , p < .001). CONCLUSIONS: Postdilatation after implantation of the SAPIEN 3 valve produced a larger THV diameter with less acute recoil, followed by larger EOA throughout 1 year. Further studies are needed to evaluate the impact of postdilatation on long-term clinical outcomes.
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Estenosis de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Valvuloplastia con Balón , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Válvula Aórtica/fisiopatología , Insuficiencia de la Válvula Aórtica/etiología , Insuficiencia de la Válvula Aórtica/fisiopatología , Estenosis de la Válvula Aórtica/diagnóstico por imagen , Estenosis de la Válvula Aórtica/fisiopatología , Valvuloplastia con Balón/efectos adversos , Femenino , Prótesis Valvulares Cardíacas , Humanos , Masculino , Recuperación de la Función , Sistema de Registros , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Resultado del TratamientoRESUMEN
OBJECTIVES: To demonstrate coronary sinus (CS) retrograde catheterization as a practicable technique for delivering biologics into the heart. BACKGROUND: There are many options to deliver biologics into the heart. However, there is no single optimal technique when considering safety, biologic retention, and reproducibility. Retrograde delivery has the potential to address many of these concerns. This study evaluated retrograde CS infusion of luciferase-expressing plasmid in a porcine model using the Advance® CS Coronary Sinus Infusion Catheter and bioluminescence imaging to track the expression of the infused biological markers. METHODS: Plasmid was delivered retrograde into the CS in one of three infusion volumes. Twenty-four hours post-infusion, hearts were excised and underwent bioluminescence imaging to characterize the expression of the infusates. Heart and lung biopsies were also assessed for luciferase expression using RT-qPCR. RESULTS: Retrograde infusion was safe and successful in all nine test subjects. Luciferase detection was inconsistent in the low volume group. Bioluminescence was confined predominantly along the posterolateral left ventricle for medium volume infusions and was more broadly dispersed along the anterior side of the heart for high volume infusions. Tissue mRNA analysis corroborated the bioluminescence results, with the highest concentration of luciferase expression localized in the left ventricle. CONCLUSIONS: Retrograde CS infusion is a promising technique for delivering biological molecules to the heart. Specifically, this study demonstrated that the low pressure coronary venous system accommodates a wide range of infusion volumes and that biological infusates can be maintained in situ following the resumption of coronary venous flow.
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Cateterismo Cardíaco , Seno Coronario , Técnicas de Transferencia de Gen , Luciferasas/administración & dosificación , Plásmidos/administración & dosificación , Animales , Infusiones Intravenosas , Luciferasas/biosíntesis , Luciferasas/genética , Mediciones Luminiscentes , Modelos Animales , Miocardio/metabolismo , Plásmidos/biosíntesis , Plásmidos/genética , ARN Mensajero/biosíntesis , Sus scrofa , Factores de TiempoRESUMEN
The aim of this study was to compare the measures of luminal stenosis between the two-dimensional (2D) and three-dimensional (3D) Quantitative Vessel Analysis (QVA) generated by CAAS QVA software and intravascular ultrasound (IVUS). Invasive contrast angiography is considered gold standard for diagnostic imaging and intervention in both coronary and peripheral arterial disease. However, it is based on 2D images depicting complicated 3D arterial anatomy. To overcome these limitations, 3D QVA has been developed to bridge the gap between 2D QVA and endovascular imaging. Thirty porcine femoral angiograms (common, profunda and superficial) with matching intravascular ultrasound (IVUS) pullbacks featuring variable degree of stenosis were analysed by 2D QVA, 3D QVA and quantitative IVUS. All 3 modalities provided similar data regarding the length of the investigated segment. Median lumen diameter was nearly identical in IVUS (4.69 mm) and in 3D QVA (4.76 mm) but quite a bit lower in 2D QVA (4.47 mm, Kruskal-Wallis test p = 0.1648). Lumen area measured in 2D QVA was lower than in IVUS and in 3D QVA. Lumen areas rendered by IVUS and 3D QVA were similar. Bland-Altman plots showed that the lowest differences were observed between IVUS and 3D QVA. IVUS and 3D QVA results were consistently higher than 2D QVA. 3D QVA is a useful surrogate of IVUS for precise luminal morphology measurements of peripheral arteries, rendering results that are much closer to IVUS than 2D QVA can provide.
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Angiografía/métodos , Arteria Femoral/diagnóstico por imagen , Imagenología Tridimensional/métodos , Enfermedad Arterial Periférica/diagnóstico por imagen , Interpretación de Imagen Radiográfica Asistida por Computador/métodos , Ultrasonografía Intervencional , Animales , Constricción Patológica , Modelos Animales de Enfermedad , Valor Predictivo de las Pruebas , Reproducibilidad de los Resultados , Índice de Severidad de la Enfermedad , Sus scrofaRESUMEN
To stratify diverse procedure types into categories with similar radiation exposure in cardiac catheterization for congenital heart disease. Radiation exposures for a comprehensive list of specific procedure types and stratification of outcomes based on radiation risk are not currently available. Data between January 2014 and December 2015 were collected on all cases performed at sites participating in C3PO-QI (Congenital Cardiac Catheterization Outcomes Project-Quality Improvement Initiative) and 9 centers were included. Using expert consensus, 40 unique procedure types were defined by diagnostic characteristics or the intervention(s) performed, and dose area product (DAP) per kilogram of body weight (µGy × m2/kg) was summarized. Using empiric and consensus methods, three radiation risk categories were created. A total of 11,735 cases were included for analysis. Thirteen (n = 7918) procedure types with median DAP/kg < 100 were categorized in the low radiation exposure category (median DAP/kg 39). The medium exposure category (n = 1807) consisted of 16 procedure types with median DAP/kg values ranging 100 to < 200 (overall median DAP/kg 131). Finally, the high radiation exposure category (n = 1073) consisted of 11 procedure types with median DAP/kg ≥ 200 (overall median DAP/kg of 231). The radiation exposure risk categories created in this multi-center dataset are a critical step towards the development of a robust risk adjustment methodology for radiation exposure in catheterization for congenital heart disease.
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Cateterismo Cardíaco/efectos adversos , Fluoroscopía/efectos adversos , Cardiopatías Congénitas/cirugía , Exposición a la Radiación , Radiografía Intervencional/efectos adversos , Adolescente , Niño , Preescolar , Consenso , Humanos , Lactante , Estudios Prospectivos , Mejoramiento de la Calidad , Dosis de Radiación , Medición de Riesgo/métodos , Factores de Riesgo , Adulto JovenRESUMEN
OBJECTIVE: To evaluate contrast media (CM) volume (CMV) saved using the DyeVert™ Plus Contrast Reduction System (DyeVert Plus System, Osprey Medical) in patients undergoing diagnostic coronary angiogram (CAG) and/or percutaneous coronary interventional (PCI) procedures performed with manual injections. BACKGROUND: Current guidelines advocate for monitoring and minimization of the total volume of CM in chronic kidney disease (CKD) patients undergoing invasive cardiac procedures. The DyeVert Plus System is an FDA cleared device designed to reduce CMV delivered during angiography and permit real-time CMV monitoring. METHODS: We performed a multicenter, single-arm, observational study. Eligible subjects were ≥ 18 years old with baseline estimated glomerular filtration rate (eGFR) 20-60 mL/min/1.73 m2 . The primary endpoint was % CMV saved over the total procedure. A secondary objective was to evaluate adverse events (AEs) related to DyeVert Plus System or to CM use. RESULTS: A total of 114 subjects were enrolled at eight centers. Mean age was 72 ± 9 years, 72% were male, and mean body mass index was 29 ± 5. Baseline eGFR was 43 ± 11 mL/min/1.73 m2 . CAG-only was performed in 65% of cases. One hundred and five subjects were evaluable for the primary endpoint. Mean CMV attempted was 112 ± 85 mL (range 22-681) and mean CMV delivered was 67 ± 51 mL (range 12-403), resulting in an overall CMV savings of 40.1 ± 8.8% (95% CI 38.4, 41.8; P < 0.0001) per procedure. Image quality was maintained in all but one case where the system was turned off for one injection. No DyeVert Plus System-related AEs were reported. Acute kidney injury (AKI; defined as serum creatinine rise of >0.3 mg/dL from baseline) was reported in 11 cases with seven occurring in subjects with baseline eGFR < 30 and three AKI events were attributed to CM. AKI rates increased as CMV/eGFR ratios increased. CONCLUSIONS: These data suggest DyeVert Plus System use in CKD patients undergoing CAG and/or PCI results in clinically meaningful CMV savings while maintaining image quality.
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Lesión Renal Aguda/prevención & control , Medios de Contraste/administración & dosificación , Angiografía Coronaria/instrumentación , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Tasa de Filtración Glomerular , Riñón/efectos de los fármacos , Lesión Renal Aguda/inducido químicamente , Lesión Renal Aguda/diagnóstico por imagen , Lesión Renal Aguda/fisiopatología , Anciano , Anciano de 80 o más Años , Medios de Contraste/efectos adversos , Angiografía Coronaria/efectos adversos , Enfermedad de la Arteria Coronaria/complicaciones , Enfermedad de la Arteria Coronaria/terapia , Diseño de Equipo , Femenino , Humanos , Riñón/fisiopatología , Masculino , Persona de Mediana Edad , Intervención Coronaria Percutánea , Valor Predictivo de las Pruebas , Estudios Prospectivos , Factores Protectores , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/diagnóstico , Insuficiencia Renal Crónica/fisiopatología , Factores de Riesgo , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: Transcatheter aortic valve replacement (TAVR) exposes patients to radiation. OBJECTIVES: We sought to identify factors associated with higher radiation exposure and to quantify their relative influence, which may inform reduction of this hazard. METHODS: All TAVR procedures at Rhode Island Hospital between March 20, 2012 and February 12, 2017 were included. Procedures were performed by two co-primary operators using a Siemens Artis Zeego system. Radiation metrics were generated by the imaging system. The primary metric was dose-area product (DAP, Gy*cm2 ), and secondary metrics were reference point air kerma (mGy) and fluoroscopy time (minutes). Data collected for the STS/ACC TVT Registry were utilized to develop a multivariable linear regression model predicting DAP. RESULTS: In 294 TAVRs, median DAP was 169 Gy*cm2 [interquartile range (IQR) 106-238]. The r2 values for the full 27-variable DAP model and reduced eight-variable model were 0.457 and 0.420, respectively. Valve area, aortic insufficiency, and procedure year (suggesting absence of a learning curve) were non-significant predictors in the full model, while increasing weight, cutdown transfemoral access, higher pre-procedure creatinine and hemoglobin, and vascular complications predicted higher DAP in both models. Results were unchanged when DAP was log-transformed. Secondary models for air kerma and fluoroscopy time revealed similar predictors. CONCLUSION: Factors associated with increased procedural complexity and duration as well as radiation attenuation and scatter predict increased patient radiation exposure during TAVR. Modification of procedural technique, especially using percutaneous femoral vascular access, may facilitate reduction in exposure.
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Válvula Aórtica/cirugía , Dosis de Radiación , Exposición a la Radiación , Radiografía Intervencional , Reemplazo de la Válvula Aórtica Transcatéter , Anciano , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Femenino , Humanos , Masculino , Tempo Operativo , Seguridad del Paciente , Exposición a la Radiación/efectos adversos , Exposición a la Radiación/prevención & control , Protección Radiológica/métodos , Radiografía Intervencional/efectos adversos , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Dispersión de Radiación , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversosRESUMEN
OBJECTIVES: To describe a novel balloon sizing technique used during adult transcatheter patent ductus arteriosus (PDA) closure. In addition, to determine the clinical and procedural outcomes in six patients who underwent PDA balloon sizing with subsequent deployment of a PDA occluder device. BACKGROUND: Transcatheter PDA closure in adults has excellent safety and procedural outcomes. However, PDA sizing in adults can be challenging due to variable defect size, high flow state, or anatomical complexity. We describe a series of six cases where the balloon- pull through technique was successfully performed for PDA sizing prior to transcatheter closure. METHODS: Consecutive adult patients undergoing adult PDA closure at our institution were studied retrospectively. A partially inflated sizing balloon was pulled through the defect from the aorta into the pulmonary artery and the balloon waist diameter was measured. Procedural success and clinical outcomes were obtained. RESULTS: Six adult patients underwent successful balloon pull-through technique for PDA sizing during transcatheter PDA closure, since conventional angiography often gave suboptimal opacification of the defect. All PDAs were treated with closure devices based on balloon PDA sizing with complete closure and no complications. In three patients that underwent preprocedure computed tomography, the balloon size matched the CT derived measurements. CONCLUSION: The balloon pull-through technique for PDA sizing is a safe and accurate sizing modality in adults undergoing transcatheter PDA closure.
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Cateterismo Cardíaco/instrumentación , Catéteres Cardíacos , Conducto Arterioso Permeable/terapia , Adolescente , Adulto , Anciano , Función del Atrio Izquierdo , Cateterismo Cardíaco/efectos adversos , Conducto Arterioso Permeable/diagnóstico por imagen , Conducto Arterioso Permeable/fisiopatología , Diseño de Equipo , Femenino , Hemodinámica , Humanos , Masculino , Estudios Retrospectivos , Resultado del Tratamiento , Función Ventricular Izquierda , Adulto JovenRESUMEN
BACKGROUND: Smaller femoral arterial sheaths may be associated with fewer vascular complications. The 3.3 Fr Mongoose® Pediavascular pigtail catheter is a catheter that allows higher flow rates, potentially resulting in improved angiographic quality. We reviewed our experience with this small catheter during patent ductus arteriosus (PDA) closure. MATERIALS AND METHODS: Review of patients ≤20 kg in whom the Mongoose® catheter was used during PDA closure from 12/13 to 4/15. Angiographic efficacy and procedural details were compared to ten 4 Fr catheter cases. Comparisons were performed using Mann-Whitney U-test; P < 0.05 was statistically significant. RESULTS: Twelve (9 female) patients were catheterized with a 3.3 Fr Mongoose®. Median weight 10.5 kg (range 6.4-18.2), height 81 cm (range 37-111), and body surface area (BSA) 0.47 m2 (range 0.33-0.75) were similar to ten patients (3 females) in the 4 Fr control group (P = NS); median weight 9.9 kg (range 6-16.8), height 80 cm (range 64-102), and BSA 0.46 m2 (range 0.31-0.74). Angiographic quality was subjectively adequate with both with no difference in the median pixel density between the two techniques (3.3 Fr: 76.7 [range 33.5-90] and 4 Fr: [70; 38-102]; P = NS). Contrast used was similar between the groups (3.3 Fr: median 4.2 ml/kg and 4 Fr: 4.9 ml/kg; P = NS). Median radiation dose was similar in the two groups (3.3 Fr: 28.1 mGy [range 17.2-38] and 4 Fr: 38 mGy [range 20.4-58.5]; P = NS). All ducts were closed at latest follow-up (P = NS). No complications were encountered. CONCLUSIONS: The 3.3 Fr Mongoose® allowed similar angiography to the 4 Fr pigtail catheter, allowing safe and effective transcatheter PDA closure in small children.
RESUMEN
Here, we report a four-day old neonate presenting with cardiovascular collapse secondary to a descending aorta to right atrial fistula. Echocardiography was suggestive of the diagnosis and confirmed with computed tomographic (CT) imaging. The fistula was successfully occluded via cardiac catheterization using an Amplatzer Vascular Plug II implanted from the right atrial aspect. This report includes the first CT imaging of this extremely rare congenital defect as well as detailing the first successful transcatheter occlusion of this particular lesion.
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Aorta Torácica/anomalías , Cateterismo Cardíaco/instrumentación , Atrios Cardíacos/anomalías , Cardiopatías Congénitas/terapia , Fístula Vascular/terapia , Aorta Torácica/diagnóstico por imagen , Aorta Torácica/fisiopatología , Aortografía/métodos , Angiografía por Tomografía Computarizada , Angiografía Coronaria/métodos , Ecocardiografía Doppler en Color , Atrios Cardíacos/diagnóstico por imagen , Atrios Cardíacos/fisiopatología , Cardiopatías Congénitas/diagnóstico por imagen , Cardiopatías Congénitas/fisiopatología , Humanos , Recién Nacido , Masculino , Resultado del Tratamiento , Fístula Vascular/diagnóstico por imagen , Fístula Vascular/fisiopatologíaRESUMEN
OBJECTIVES: This study sought to update benchmark values to use a quality measure prospectively. BACKGROUND: Congenital Cardiac Catheterization Outcomes Project - Quality Improvement (C3PO-QI), a multi-center registry, defined initial radiation dose benchmarks retrospectively across common interventional procedures. These data facilitated a dose metric endorsed by the American College of Cardiology in 2014. METHODS: Data was collected prospectively by 9 C3PO-QI institutions with complete case capture between 1/1/2014 and 6/30/2015. Radiation was measured in total air kerma (mGy), dose area product (DAP) (µGy*M2 ), DAP per body weight, and fluoroscopy time (min), and reported by age group as median, 75th and 95th %ile for the following six interventional procedures: (1) atrial septal defect closure; (2) aortic valvuloplasty; (3) treatment of coarctation of the aorta; (4) patent ductus arteriosus closure; (5) pulmonary valvuloplasty; and (6) transcatheter pulmonary valve implantation. RESULTS: The study was comprised of 1,680 unique cases meeting inclusion criteria. Radiation doses were lowest for pulmonary valvuloplasty (age <1 yrs, median mGy: 59, DAP: 249) and highest in transcatheter pulmonary valve implantation (age >15 yrs, median mGy: 1835, DAP: 17990). DAP/kg standardized outcome measures across weights within an age group and procedure type significantly more than DAP alone. Radiation doses decreased for all procedures compared to those reported previously by both median and median weight-based percentile curves. These differences in radiation exposure were observed without changes in median fluoroscopy time. CONCLUSIONS: This study updates previously established benchmarks to reflect QI efforts over time. These thresholds can be applied for quality measurement and comparison. © 2017 Wiley Periodicals, Inc.
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Benchmarking/normas , Cateterismo Cardíaco/normas , Cardiopatías Congénitas/terapia , Pediatría/normas , Dosis de Radiación , Exposición a la Radiación/normas , Radiografía Intervencional/normas , Adolescente , Factores de Edad , Cateterismo Cardíaco/efectos adversos , Niño , Preescolar , Femenino , Cardiopatías Congénitas/diagnóstico por imagen , Humanos , Lactante , Masculino , Seguridad del Paciente/normas , Estudios Prospectivos , Exposición a la Radiación/efectos adversos , Exposición a la Radiación/prevención & control , Radiografía Intervencional/efectos adversos , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Estados UnidosRESUMEN
A patent foramen ovale (PFO) is a communication across the inter-atrial septum and a right atrial septal pouch (RASP) is an indentation of the atrial septum caused by an incomplete fusion of the septum primum and septum secundum with its base opening into the right atrium. A 63-year-old male who had a history of two strokes and episodes of transient neurological deficit was diagnosed to have a small right-to-left shunt. At the time of PFO closure, an angiogram of the atrial septum revealed a small PFO associated with a RASP. The small PFO was crossed with a straight-tipped guide wire and was closed using a 25-mm GORE CARDIOFORM Septal Occluder (W.L. Gore and Associates, AZ). It is hypothesized that stagnant blood in the RASP may generate a clot that can cross the PFO and cause an infarct. © 2015 Wiley Periodicals, Inc.
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Anomalías Múltiples , Tabique Interatrial/cirugía , Procedimientos Quirúrgicos Cardíacos/métodos , Foramen Oval Permeable/diagnóstico , Defectos del Tabique Interatrial/diagnóstico , Dispositivo Oclusor Septal , Angiografía , Tabique Interatrial/diagnóstico por imagen , Cateterismo Cardíaco , Ecocardiografía Transesofágica , Foramen Oval Permeable/cirugía , Defectos del Tabique Interatrial/cirugía , Humanos , Masculino , Persona de Mediana EdadRESUMEN
BACKGROUND: The AVERT(TM) Contrast Modulation System (AVERT) (Osprey Medical, MN) is designed to reduce contrast volume administration during angiography. The AVERT provides an adjustable resistance circuit which decreases the pressure head delivering contrast towards the patient. The AVERT has not been previously studied in patients undergoing peripheral digital subtraction angiography (DSA). The purpose of this study was (1) to evaluate contrast savings with the AVERT and (2) to evaluate the ability to generate clinically acceptable DSA images in the process. To better define the mechanism of action in the peripheral circulation, we also developed a bench model to study the effects of the AVERT on the hydrodynamics of contrast delivery. METHODS: Patients undergoing lower extremity DSA (diagnostic or intervention, sheath or catheter) were studied. The following variables were recorded for each injection: starting control syringe contrast volume, contrast volume injected towards patient, contrast volume returned to AVERT reservoir, net contrast administered to the patient and % savings. The AVERT resistance was adjusted manually based on operator's discretion--balancing image quality and contrast savings. RESULTS: About 408 DSA angiographic sequences were obtained in 22 patients undergoing 29 procedures. Almost 68% of the patients had chronic kidney disease. An 82% presented with critical limb ischemia, 18% had claudication. There was an overall 37% ± 14% savings of contrast (31% for diagnostic DSA, 40% for interventional procedures). Overall 91% of all images were acceptable for clinical decision making. Specifically, 94% of diagnostic and 87% of interventional images were acceptable. Injection through a 4 Fr catheter (77% acceptable) resulted in poorer image quality as compared to a 5 Fr catheter (96% acceptable). Image quality for 5, 6, and 7 Fr sheath injections was 86%, 91%, 98%, respectively. The bench model of peripheral angiography demonstrated a significant reduction in reflux of contrast proximal to the end of the catheter without loss of antegrade image quality - confirming the in vivo findings. CONCLUSIONS: We demonstrate that the use of the AVERT device during peripheral angiography results in significant contrast savings without compromising image quality.
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Angiografía de Substracción Digital/instrumentación , Cateterismo Periférico/instrumentación , Medios de Contraste/administración & dosificación , Procedimientos Endovasculares/instrumentación , Extremidad Inferior/irrigación sanguínea , Enfermedad Arterial Periférica/diagnóstico por imagen , Enfermedad Arterial Periférica/terapia , Dispositivos de Acceso Vascular , Anciano , Angiografía de Substracción Digital/efectos adversos , Cateterismo Periférico/efectos adversos , Medios de Contraste/efectos adversos , Procedimientos Endovasculares/efectos adversos , Diseño de Equipo , Femenino , Arteria Femoral/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Modelos Anatómicos , Modelos Cardiovasculares , Enfermedad Arterial Periférica/complicaciones , Valor Predictivo de las Pruebas , Punciones , Insuficiencia Renal Crónica/complicaciones , Insuficiencia Renal Crónica/diagnóstico , Factores de RiesgoRESUMEN
OBJECTIVES: To assess the occupational dose reduction effect of a new interventional cardiology shield for radial access combined with a scatter reducing drape. BACKGROUND: Transradial access for catheterization has been shown to increase occupational radiation dose. Current shielding techniques are primarily based on the femoral access. This article looks at the clinical occupational combined dose reduction effect of a commercially available shield and drape which is specific to access type. METHODS: The evaluation took place in a busy interventional cardiology laboratory, with a single plane 30×40 cm flat panel detector (Siemens Artis Zee, Germany). Radiation exposure to staff was measured using electronic personal dosimeters (Unfors RaysafeAB, Sweden) placed at the collar. Patient radiation exposure was assessed using screening time and dose area product per case. Both staff and patient radiation exposure were monitored for a number of case types and operators before, during, and after deployment of the new shield and drapes. RESULTS: The cardiologists' overall median collar badge reading per case reduced from 15.4 µSv per case without the shield/drape combination to 7.3 µSv per case with the shield drape combination in situ (P<0.001). The radiographers badge reading was reduced from 4.2 µSv per case without to 2.5 µSv per case with the shield drape combination in situ (P<0.001). There was no statistical difference in the cardiac technician's badge reading. Patient's dose area product was not significantly affected by the placement of the shield and drape combination. CONCLUSIONS: The shield/drape combination can significantly reduce operator exposure in a cardiac catheterization laboratory.
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Cateterismo Cardíaco/instrumentación , Cardiología/instrumentación , Exposición Profesional/prevención & control , Salud Laboral , Dosis de Radiación , Traumatismos por Radiación/prevención & control , Protección Radiológica/instrumentación , Radiografía Intervencional/instrumentación , Dispersión de Radiación , Cateterismo Cardíaco/efectos adversos , Diseño de Equipo , Humanos , Plomo , Personal de Laboratorio Clínico , Enfermeras y Enfermeros , Exposición Profesional/efectos adversos , Médicos , Polimetil Metacrilato , Arteria Radial/diagnóstico por imagen , Traumatismos por Radiación/etiología , Monitoreo de Radiación , Radiografía Intervencional/efectos adversos , Factores de Riesgo , Factores de TiempoRESUMEN
OBJECTIVES: To evaluate Fontan fenestration closure using the Amplatzer Duct Occluder II device (ADO2). BACKGROUND: Fontan fenestration closure is a well established catheter intervention. A range of occlusion devices developed for other interventions have been utilized. Most of these devices, and especially the most commonly used Amplatzer Septal Occluder, are relatively bulky. The ADO2 is a low profile, flexible, and inexpensive device which seems well suited to the Fontan fenestration. METHODS: This study details retrospective review of patients undergoing Fontan fenestration closure with an ADO2 device. Outcome measures included procedural success, pre- and post-procedural differences in oxygen saturation and mean pulmonary artery pressure and complications. RESULTS: Thirteen patients were eligible for inclusion during the 34 month study period. All procedures were technically successful. There was a significant increase in oxygen saturations (Mean=+12%, P<0.01) after fenestration closure but no significant change in mean pulmonary artery pressure (Mean=+0.5 mm Hg, P=0.08). There were no procedural complications. CONCLUSION: Fontan fenestration closure with the ADO2 device is a simple, short, and cost-effective procedure. The ADO2 characteristics recommend it to occlusion of varying sizes and morphologies of Fontan fenestration.
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Procedimiento de Fontan/instrumentación , Atrios Cardíacos/cirugía , Cardiopatías Congénitas/cirugía , Dispositivo Oclusor Septal , Adolescente , Cateterismo Cardíaco , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Masculino , Diseño de Prótesis , Estudios Retrospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
A congenital coronary cameral fistula (CCCF) is characterized by left ventricular dysfunction, electrocardiographic changes due to a reduced left coronary blood flow and impaired physical activity. CCCF's with a giant aneurysm are very rarely seen. The presence of a giant aneurysm imposes even greater health risks. We report a case of a CCCF from the left coronary artery to the right ventricle with a large distal aneurysm in a 20-year-old woman that we closed percutaneously with coils for the closure of ventricular septal defects (VSD) and persistent ductus arteriosus (PDA).