Surge-in-Place: Conversion of a Cardiac Catheterization Laboratory Into a COVID-19 Intensive Care Unit and Back Again
Miguel Alvarez Villela, MD; Thomas Boucher, BSc; Juan Terre, MD; Barbara Levine, PA, MBA; Marianne O’Shea, RN, MPA; Joane Luma, MPA; Ulrich P. Jorde, MD; Mario Garcia, MD; Jose Wiley, MD, MPH; Mark Menegus, MD; Azeem Latib, MBBCh; Anna E. Bortnick, MD, PhD, MSc
In Spring 2020, the United States epicenter of COVID-19 was New York City, in which the borough of the Bronx was particularly affected. This Fall, there has been a resurgence of COVID-19 in Europe and the Midwestern United States. We describe our experience transforming our cardiac catheterization laboratories to accommodate an influx of COVID-19 patients so as to provide other hospitals with a potential blueprint. We transformed our pre/postprocedural patient care areas into COVID-19 intensive care and step-down units and maintained emergent invasive care for ST-segment elevation myocardial infarction using existing space and personnel.
Radial Access Technique
Patent Hemostasis Impact in Clinical Routine: Large Monocentric Echo-Doppler Study of Radial Artery Patency After Coronary Catheterization
Alain Rougé, MD; Benjamin Faurie, MD; Mohamed Abdellaoui, MD; Jacques Monségu, MD, PhD
Radial access is commonly the first line of access in interventional cardiology. Nevertheless, this technique exposes patients to a 1%-10% risk of radial artery occlusion based on series. We conducted a large-scale echo-Doppler evaluation of radial patency and prospectively examined all patients who underwent coronary angiography and/or angioplasty with radial catheterization at our center in 2018.
Radial Access Technique
Randomized Trial of VasoStat Versus TR Band Following Radial Artery Access for Catheterization Procedures
Robert L. Minor, Jr, MD; Thomas Maley, RCIS, CPHIMS; Diana Jenkins, MSN, RN; Ya-Huei Li, PhD
VasoStat (Forge Medical) is a recently developed radial artery compression device producing focused puncture-site pressure. We compared time to hemostasis and patient experience with VasoStat vs balloon compression with the TR Band (Terumo) in a randomized, prospective trial among subjects undergoing radial catheterization procedures with same-day discharge. Forty subjects without prior radial access undergoing elective coronary and/or endovascular diagnostic or interventional procedures were randomized to VasoStat or TR Band. Primary outcome was time to hemostasis enabling compression device removal. Secondary outcomes included patient satisfaction measuring subject-reported domains of pain, paresthesia, and swelling, number of device manipulations, and radial patency at follow-up duplex assessment.
Pulmonary Artery Intervention for Submassive Pulmonary Embolism From an Arm Superficial Venous Access
Hady Lichaa, MD
Pulmonary embolism (PE) endovascular interventions are often approached from an internal jugular or femoral venous access. There are multiple advantages of right basilic vein access for both patient and operator, especially in the setting of morbid obesity. We hereby describe the case of a 48-year-old, morbidly obese man who presented with acute respiratory insufficiency and was found to have bilateral submassive subocclusive PE, worse on the right. The right ventricular to left ventricular ratio was 2.1 and troponin was elevated. A 7 Fr sheath was placed in the RBV under ultrasound guidance. Selective bilateral pulmonary arteriography was then performed. An EKOS catheter was placed in the segment of highest thrombotic burden for a 6-hour protocol of catheter-directed ultrasound-facilitated thrombolytic therapy. The patient recovered well on a direct oral anticoagulant and his acute symptoms resolved.
Treating massive/submassive PE via RBV access offers the convenience and safety of superficial venous access (for patient and operator), better patient comfort, less venous stasis during therapy with ability to ambulate, less potential for bleeding and vascular complications, less potential for operator radiation exposure when compared with the jugular approach, and better operator ergonomics.
Peripheral Arterial Vessel Prepping With Intravascular Ultrasound and Atherectomy: An Interventionalist’s Perspective
Nicolas W. Shammas, MD, MS
Vessel prepping is an essential component of an optimal strategy in treating infrainguinal peripheral arterial disease. Vessel prepping with atherectomy can be aggressive in certain lesion morphologies such as severe calcium, total occlusions, or in-stent restenosis, and can target vessel compliance without aggressive debulking. Drug elution is likely to be enhanced by vessel prepping. Optimal vessel prepping requires precise imaging of the vessel size, plaque morphology, and lesion severity/length, which cannot be assessed adequately by angiography. Also, intravascular ultrasound is very helpful in every step of the procedure. It provides information post treatment on minimal luminal area gain, residual dissections, geometric miss, and stent apposition/expansion.
Congenital Heart Disease
Discordance Between Measured vs Calculated Oxygen Consumption in Adults With Congenital Heart Disease: Limitations and Clinical Implications
Pradyumna Agasthi, MD; William R. Miranda, MD; Alexander C. Egbe, MBBS, MPH
Oxygen consumption is frequently estimated using derived formulas for ease of use. We performed a prospective study to assess the correlation and limits of agreement between measured and assumed oxygen consumption in adults with congenital heart disease. Consecutive adults with congenital heart disease who underwent cardiac catheterization at Mayo Clinic Rochester from January 2018 to December 2019 were retrospectively enrolled in the study. Expired gas analysis was performed to measure oxygen consumption.
Transcatheter Aortic Valve Replacement
Development of the Minimalist Approach for Transcatheter Aortic Valve Replacement at a Veterans Affairs Medical Center
Matthew Y. Lum, MD; Sue X. Wang, MD; Andrew D. Wisneski, MD; Norah Liang, MD; Jeffrey Zimmet, MD, PhD; Kendrick A. Shunk, MD, PhD; Martin Stechert, MD; Martin J. London, MD; Liang Ge, PhD; Elaine E. Tseng, MD
While a minimalist transcatheter aortic valve replacement (TAVR) approach has shown safety and efficacy at civilian hospitals, limited data exist regarding this approach at Veterans Affairs medical centers (VAMCs). We implemented TAVR with minimalist approach using conscious sedation with transthoracic echocardiography and compared safety and outcomes with general anesthesia with transesophageal echocardiography at a university-affiliated VAMC.
Bioresorbable Vascular Scaffold With Optimized Implantation Technique: Long-Term Outcomes From a Single-Center Experience
Stefano Albani, MD; Francesco Giannini, MD; Satoru Mitomo, MD; Enrico Fabris, MD, PhD; Antonio Mangieri, MD; Francesco Ponticelli, MD; Arif A. Khokhar, BM, BCh; Marco Toselli, MD; Azeem Latib, MD; Antonio Colombo, MD
Previous randomized controlled trials demonstrated a higher rate of stent thrombosis with bioresorbable vascular scaffold (BVS) implantation as compared with second-generation drug-eluting stent in selected patients/lesions. However, long-term outcomes of BVS implantations that utilize an optimized technique (OIT) in unselected patients/lesions are lacking. The aim of this study was to assess the real-world, long-term clinical outcomes of BVS (Absorb; Abbott Vascular) with OIT.
Mitral Valve Disease
Feasibility of Same-Day Discharge Approach After Transcatheter Mitral Valve Repair Procedures
Konstantinos Marmagkiolis, MD; Ismail Dogu Kilic, MD; Ismail Ates, MD; Gulcan Kose, MD; Cezar Iliescu, MD; Mehmet Cilingiroglu, MD
Early-discharge strategies are increasingly adopted after percutaneous cardiac interventions. However, there is a paucity of data on early discharge after transcatheter mitral valve repair (TMVRep) procedures. In this report, we aimed to present our data on same-day discharge after MitraClip (Abbott Structural) procedures. A total of 82 patients who underwent TMVRep and were discharged the same day were included in this study. A next-day follow-up exam at the cardiology clinic was scheduled for all patients for removal of the groin access figure-of-eight subcutaneous sutures and for echocardiographic examination.
Drug-Eluting Balloon for Management of Coronary In-Stent Restenosis in a South Asian Population: Experience From a Tertiary-Care Hospital in Pakistan
Syed Waqar Ahmed, MBBS, FCPS; Bilal Hussain, MBBS; Bilal Ahmed, PharmD, MSc, MBBS, PhD; Nasir Rahman, MBBS, FCPS; Jamshed Ali, MBBS; Osman Faheem, MD
Emerging evidence suggests that the South Asian (SA) population has an increased rate of in-stent stenosis (ISR) after percutaneous coronary intervention (PCI) when compared with other ethnicities. Drug-eluting balloons (DEBs) have emerged as a viable option for the treatment of ISR. However, data describing the outcomes of DEB-PCI in the SA population are limited. Since the magnitude of the problem is high in the SA population, it is essential to evaluate the outcomes of DEB-PCI for ISR.
Letter to the Editor
Can History of Myocardial Infarction Reliably Indicate Myocardial Viability in Patients With a Coronary Chronic Total Occlusion and Good Collateral Circulation?
Ilias Nikolakopoulos, MD; Evangelia Vemmou, MD; Judit Karacsonyi, MD, PhD; Iosif Xenogiannis, MD, PhD; Bavana V. Rangan, BDS, MPH; Santiago Garcia, MD; M. Nicholas Burke, MD; Emmanouil S. Brilakis, MD, PhD
We read with interest the study by Shaikh et al reporting that none of the patients with coronary chronic total occlusions (CTOs) and a prior Q-wave myocardial infarction (MI) in the CTO-supplied territory had viable myocardium even in the presence of good collateral circulation. Based on our large, multicenter registry on CTO in percutaneous coronary intervention, PROGRESS-CTO, we believe viability testing may still be of value in patients with a CTO and a prior MI, especially if their ejection fraction is low and dyspnea is the predominant symptom.
Shockwave Lithotripsy vs Rotational Atherectomy: Mechanistic Differences From Optical Coherence Tomography
Ota Hlinomaz, MD, PhD; Miloslav Tejc, MD; Mahmoud Sabbah, MD, PhD
This case highlights that rotational atherectomy is merely paving the road and may help in superficial calcifications. It also showed the useful role of optical coherence tomography (OCT) for guiding the appropriate treatment strategy. Interrogation with OCT in angiographically visible severe calcification could save time, effort, radiation exposure, and contrast, as well as a lot of procedural costs. Intravascular lithotripsy offers a novel option for lesion preparation of severely calcified and undilatable de novo lesions and could be an appropriate alternative for rotational atherectomy.
Bilateral Distal Transradial Access for Ostial Left Anterior Descending Chronic Total Occlusion Recanalization
Marcos Danillo P. Oliveira, MD; Flavio G. Lyra, MD; Valter Trigueiro C. Neto, MD; Adriano Caixeta, MD, PhD
The adoption of distal transradial access (dTRA) as default approach for coronary angiography and interventions was recently published. As a refinement of conventional (proximal) TRA, this technique has many advantages in terms of patient and operator comfort, access-site bleeding, faster hemostasis, and risk of radial artery occlusion. Bilateral dTRA for complex chronic total occlusion percutaneous coronary intervention by experienced operators is feasible and safe.
Descending Aortic Thrombus Hanging by a Thread: Three-Dimensional Echocardiogram
Adil S. Wani, MD; M. Fuad Jan, MBBS (Hons), MD; Ijaz Malik, MD; A. Jamil Tajik, MD; Bijoy K. Khandheria, MD
Aortic thrombus is a rarely identified source of distal embolization. A conservative approach with anticoagulation alone carries a significant risk of embolization. Various open surgical approaches have been suggested as therapeutic options, but all of them carry a significant morbidity and mortality risk in this population subgroup. Contemporary endovascular approaches aimed at exclusion of the floating thrombus are now increasingly performed, and have significantly lower periprocedural complications compared with an open surgical approach.
Intravascular Ultrasound-Guided Coronary Lithotripsy Treatment of In-Stent Restenosis in Saphenous Venous Graft
Filippo Russo, MD; Alaide Chieffo, MD; Mauro Carlino, MD; Marco Bruno Ancona, MD; Barbara Bellini, MD; Luca Angelo Ferri, MD; Alessandro Beneduce, MD; Ciro Vella, MD; Abdulaziz Algethami, MD; Matteo Montorfano, MD
To the best of our knowledge, this is the first description of intravascular-ultrasound guided coronary lithotripsy on saphenous vein graft because of severely calcific in-stent restenosis, showing good result without procedural complications.
Stroke During Hip Surgery
Johann Auer, MD and Carina Primus, MD
During hip replacement, acetabular and femur bone preparation may cause bone marrow extravasation. Paradoxical fat embolism occurs when emboli pass from the pulmonary to the systemic circulation by either a patent foramen ovale or pulmonary capillaries. Impaired consciousness in the immediate postoperative period of orthopedic surgery frequently results from hypovolemia, anemia, or residual anesthesia. A high index of suspicion is required to consider the possibility of paradoxical fat embolism.
Don’t Ignore That Chest Pain: Positionally Dependent Coronary Subclavian Steal Syndrome
Michael Coles, MD; Chinmaya Mareddy, MD; Vishal Arora, MD
Coronary subclavian steal syndrome (CSSS) is a complication incurred after coronary artery bypass grafting (CABG), characterized by retrograde blood flow through the left internal mammary artery (LIMA) graft to the left subclavian artery (SCA) distal to a SCA stenosis, thereby compromising myocardial perfusion from the LIMA despite its patency. We present a 40-year-old female with a history of triple-vessel CABG who presented with crescendo angina, notably when elevating her arms above her head. Atypical angina related to arm activity following successful LIMA bypass should prompt angiography directed to the left SCA, as well as to the LIMA graft. Typically, cases of CSSS are claudication dependent and not positionally related. This suggests a two-pronged pathophysiological mechanism of both demand ischemia and mechanical obstruction, which is not well described in previous literature.