During the past four decades an evolution in cardiac catheterization has taken place. The role of the cardiac catheterization laboratory has progressed from study of cardiac function and anatomy for purposes of diagnosis to evaluation of candidates for surgery and finally to providing catheter-based, nonsurgical interventional treatment. This progress has stimulated an increase in demand for cardiac catheterization services. However, as a result of the need to decrease health care costs, there have also been major changes in the types of patients admitted to hospitals. Accordingly, an increasing proportion of catheterizations are being conducted in settings other than traditional hospital-based catheterization laboratories. As newer cardiac diagnostic and treatment modalities are developed, it is highly likely that the role of cardiac catheterization will continue to evolve. From this evolution a number of concerns have been raised about the ability of catheterization services to meet constantly changing patient care needs while maintaining patient safety and restricting possible overutilization.

Cross-sectional echocardiographic studies of the aortic arch and proximal descending aorta were performed in 18 patients with coarctation of the aorta and 20 normal subjects. In normals the aortic arch and proximal descending aorta appeared as an arcuate, echo-free structure curving across the plane of the scan. There were no localized changes in aortic diameter and the amplitude of aortic systolic pulsation was symmetrically maintained throughout the scan plane.

One of the uncommon complications of percutaneous coronary interventions is the inadvertent retention of interventional hardware in the coronary circulation. These materials include segments of wire, balloon, guide catheter, and stents. Transection of rotational atherectomy guide wire due to loss of coaxial alignment of the guide catheter and subsequent kinking of the guide wire has been previously reported [ [1] Foster-Smith K. Garrat K.N. Holmes Jr., D.R. Guidewire transection during rotational coronary atherectomy due to guide catheter dislodgement and wire kinking. Cathet Cardiovasc Diagn. 1995; 35: 224-227 Google Scholar ]. The frequency of inadvertently retained equipment has varied from 0.2 to 8.0% [ 2 Elsner M. Peifer A. Kasper W. Intracoronary loss of balloon-mounted stents: successful retrieval with a 2 mm Microsnare device. Cathet Cardiovasc Diagn. 1996; 39: 271-276 Google Scholar , 3 Foster-Smith K.W. Garrat K.N. Higano S.T. Holmes D.R. Retrieval techniques for managing flexible intracoronary stent misplacement. Cathet Cardiovasc Diagn. 1993; 30: 63-68 Google Scholar ].

Perforation of newly placed left internal mammary artery (LIMA) grafts due to stent deployment is an infrequent but potentially dangerous complication of coronary interventions. It may lead to brisk hemorrhage and massive cardiac tamponade requiring emergent pericardiocentesis and surgery. We report a case of a LIMA graft perforation following stent deployment with a high-pressure balloon 12 days after surgery, The patient was treated with emergent pericardiocentesis, rapid autotransfusion of the pericardial aspirate into the systemic circulation, and surgical repair of the ruptured vessel. Cathet. Cardiovasc Intervent. 47:199-292, 1999, (C) 1999 Wiley-Liss, Inc.

The incidence of thrombocytopenia with ticlopidine and clopidogrel when used in conjunction with abciximab has not been systematically addressed. We evaluated the rate of thrombocytopenia in patients undergoing intracoronary stent implantation receiving bolus plus infusion of abciximab and either ticlopidine or clopidogrel. We noted an incidence of 24% with the combination of 300-mg clopidogrel and abciximab. Other doses of ticlopidine (250 and 500 mg) and clopidogrel (75 mg) did not result in a statistically significant increase in thrombocytopenia over that of the 2.5%–5.2% reported incidence with abciximab alone. Length of hospital stay was 2.3 vs. 6.4 days in those developing thrombocytopenia (P = 0.06). Four (25%) developed thrombocytopenia requiring blood transfusion. Eight (50%) had no sequelae. The combination of 300-mg clopidogrel and abciximab results in a significant increase in the incidence of thrombocytopenia. This is an important clinical observation that merits further study. Cathet. Cardiovasc. Intervent. 50:426–430, 2000. © 2000 Wiley-Liss, Inc.

Aneurysms and ectasias of saphenous vein grafts are infrequent complications of coronary artery bypass surgery. They usually present as an expanding asymptomatic mediastinal mass on chest x-ray film or computed tomography scan. Though rare, they must be excluded from the differential diagnosis of mediastinal masses to avoid potentially dangerous needle biopsy. The authors describe ectasia of a saphenous vein graft in a 62-year-old man 14 years after coronary artery bypass surgery. The relevant literature is also discussed.

In this report, we describe an alternative method to the conventional arteriographic techniques of the left internal mammary artery (LIMA) graft using a balloon-tipped floatation catheter placed within the left subclavian artery. The floatation catheter will serve as both an occluder of the subclavian artery as well as a port for contrast injection. It may be effectively employed in the rare instances where direct cannulation of the LIMA graft is not possible.

Fifty-one consecutive patients underwent exercise echocardiography, angiography, and intracoronary ultrasound (ICUS) 2.5 years (range from 1 to 6) after cardiac transplantation. The average age of the donor was 29 years (range 13 to 50), and the average age of the recipient was 49 +/- 12 years. In total, 78 studies were performed, as 25 patients had >1 annual evaluation and 2 patients had 3 consecutive annual evaluations. Of the 78 angiographic studies, 40 (26 patients) had evidence of coronary artery disease, defined as a focal stenosis (>20%, n=4) or luminal irregularities (n=36). However, by ICUS all 51 patients had intimal thickening at some point, with 34 patients possessing diffuse disease and 17 focal intimal thickening only. Of the 25 serial studies, 12 progressed by at least 1 Stanford class. The sensitivity of angiography for determination of class III to IV intimal thickening was 64% and the specificity was 76%. On exercise echocardiography, 6 examinations revealed resting wall motions abnormalities, whereas 6 had inducible wall motion abnormalities with exercise. The sensitivity of exercise echocardiography to determine class III to IV intimal thickening was 15%, and the specificity was 85%. In conclusion, exercise echocardiography is an insensitive method for predicting transplant-mediated coronary artery disease, whereas luminal irregularities on angiography may predict the presence of Stanford grade III to IV intimal thickening.

This report represents the first guidelines for prevention, diagnosis, and treatment of anaphylactoid reactions to contrast media occurring specifically during cardiac catheterization. The incidence of contrast media complications in the catheterization laboratory is 0.23% with 1 death per 55,000. Anaphylactoid reactions are nonimmune mediated, but histamine release and other mediators produce a clinical presentation indistinguishable from anaphylaxis. In patients with known previous reactions, pretreatment with steroids and diphenhydramine and the use of nonionic contrast media have significantly reduced the potential of recurrent reaction. Minor reactions such as limited urticaria may be watched for progression or treatment with diphenhydramine, whereas more serious reactions such as angioedema or laryngeal edema require airway stability and ephinephrine administration. Shock should be vigorously treated simultaneously with intravenous epinephrine and large volumes of normal saline. If the patient can be stabilized, the study should be completed as histamine, leukotrienes, and other vasoactive products should be relatively depleted.

A modification of a previously described double balloon mitral valvuloplasty procedure is described. This involves dual femoral vein punctures with a single atrial septal puncture. After initial transseptal catheterization and predilatation of the interatrial septum with an 8-mm balloon, a second catheter is advanced through the resulting atrial septal defect allowing access to the left atrium and left ventricle through the mitral valve via two separate femoral vein puncture sites. In comparison with the previously described technique using two balloon catheters inserted through a single femoral vein puncture site, this modification has reduced the amount of bleeding from the femoral vein and the need for transfusion. Furthermore, the potential for subsequent interatrial shunting is less than with the alternative previously described technique utilizing two femoral vein punctures with two separate punctures in the interatrial septum. In utilizing two separate femoral vein punctures with only one atrial septal puncture this technique combines advantages of the two previously described techniques.

It is evident that the practice of cardiac catheterization has undergone, and continues to undergo, marked change. Most prominent are the recent very rapid proliferation of catheterization laboratories in general and the development of newer types of catheterization laboratory. No uniform definitions exist for these newer laboratories, so meaningful communication is difficult. The new settings are of particular concern because their location, mobility, organization, and ownership raise questions about the quality of patient care. Most difficult to address are the questions about patient safety and physician conflict of interest. There are no objective data in peer-reviewed literature to support the reported safety and cost savings of these newer settings. Through deliberations, surveys, interviews, and correspondence with the cardiology community embraced by the ACC and the AHA, the task force generally found that in freestanding catheterization laboratories, access to emergency hospitalization may be delayed, and appropriate oversight may be lacking. Additionally, opportunities for self-referral may be fostered and the perception of commercialism and entrepreneurial excess in practice created. All of these problems must be avoided. The growth and development of some freestanding facilities, particularly the mobile laboratories, do not seem to have been driven by an increased need in remote communities or for temporary support but rather almost exclusively by a desire to capture market share. Accordingly, a series of definitions, guidelines, and recommendations for the laboratories as well as for patient selection has been developed. The consensus was that a very restrictive and cautious attitude to the newer settings is appropriate at this time. The justification for development or expansion of cardiac catheterization services must be patient need. Documentation of this need must be based on objective estimates of the number of patients with known or suspected cardiac disease who meet generally accepted indications for laboratory study. Concerns about the lack of data from prospective clinical trials of patient safety in such a group necessitate a very cautious attitude toward any new catheterization services, in particular those without in-house cardiac surgical support. In view of the lack of appropriately controlled safety and need data for hospital-based, mobile, or freestanding laboratories operating without on-site (accessible by gurney) cardiac surgery facilities, the task force reaffirms the position that further development of these services cannot be endorsed at this time. In addition, there is reason for major concern that such proliferation in catheterization services may contribute to increasing costs and troubling ethical questions.

Post-PCI TIMI flow grade 3 in infarct-related artery not always is associated with follow-up improvement in myocardial perfusion and function. We compared the improvement in myocardial perfusion and function in cases of rapid and slow electrocardiographic (ECG) stage dynamics between patients with TIMI-3 flow after primary angioplasty for acute myocardial infarction (MI).Ten patients with post-PCI TIMI-3 flow were divided into group A (n = 50, no rapid change of ECG stages) and group B (n = 50, with a ≥2 ECG stages per 2 days change rate).There were no significant changes after 3 months in scintigraphic (ejection fraction 44.6 ± 9.3% vs. 42.0 ± 3.4%, P = 0.4; perfusion deficit severity 3.0 ± 0.7 vs. 2.3 ± 0.8, P = 0.1) and echocardiographic (dysfunction score 1.9 ± 0.2 vs. 1.6 ± 0.5, P = 0.2) data in group A. Scintigraphic data improved (ejection fraction 34.6 ± 3.9% vs. 52.0 ± 7.3, P = 0.03; perfusion deficit severity 2.8 ± 0.6 vs. 1.5 ± 0.8, P = 0.03) and changes in echocardiographic data were of borderline significance (dysfunction score 1.8 ± 0.2 vs. 1.4 ± 0.4, P = 0.06) in group B.There was not any change in myocardial perfusion and function in a case of slow change of ECG stages after reached post-PCI TIMI flow grade 3, while myocardial perfusion improved and function tended to improve in a case of the rate at least two ECG stages in 2 days after primary angioplasty for acute MI.

Exercise echocardiography was performed in 36 patients to evaluate functional improvement after coronary angioplasty. Thirty-one patients (86%) had provokable ischemia before angioplasty including 22 with an abnormal exercise electrocardiographic test (angina or ST depression), 25 with an abnormal exercise echocardiogram (exercise-induced wall motion abnormalities) and 16 with both tests abnormal. Nineteen patients had no induced ischemia after angioplasty. Seventeen (47%) continued to have ischemia that was limited in 12 to exercise-induced wall motion abnormalities, which were less severe compared with those of preangioplasty studies. Fifteen (65%) of 23 patients had improvement in rest wall motion abnormalities after angioplasty.

Regional left ventricular wall motion abnormalities were assessed using 2-dimensional echocardiography and contrast ventriculography within 12 hours of the onset of chest pain in 20 patients with acute myocardial infarction (AMI); 10 patients had anterior infarctions and 10 had inferior. End-diastolic and end-systole sinus beats from right anterior oblique contrast ventriculograms were analyzed using the center-line chord technique with both a standard overlap method of chord assignment and a nonoverlap method. Echocardiograms were obtained in parasternal long- and short-axis and apical 2- and 4-chamber views and analyzed using a 16-segment scoring system to derive anterior and infero-posterolateral wall motion indexes using both overlap (10 segments for anterior, 8 inferior) as well as nonoverlap (9 segments anterior, 7 inferior) methods of segment assignment. There was a significant inverse correlation between the standard (nonoverlap) echocardiographic analysis and the standard (overlap) angiographic analysis for infarct regions (y = −0.43 × + 1.11, r = −0.59, p < 0.05). Fifteen of 18 patients with angiographic infarct regional score <- −1 standard deviation/ chord had an echocardiographic index ≥1.5, while 15 of 16 patients with echocardiographic regional infarct index ≥1.5 had an angiographic score <-−1 standard deviation/chord. Correlation between the 2 methods for noninfarct territories was poor (r = −0.34) because the angiographic method assesses hyperkinesis while the echocardiographic method does not. For noninfarct regions, 13 of 16 patients with an angiographic score >−1 standard deviation/chord had an echocardiographic index <1.5, while 13 of 15 patients with an echocardiographic regional index of <1.5 had an angiographic score >−1 standard deviation/chord. In comparing overlap and nonoverlap methods, significant differences were found for noninfarct regions but not for infarct regions for both echocardiographic and angiographic analyses. Data indicate that 2-dimensional echocardiography, which is non-invasive and more easily repeatabte for serial studies, yields similar results to contrast angiography for the assessment of regional wall motion abnormalities after AMI.

Although global and regional left ventricular (LV) function has been demonstrated to improve after reperfusion in acute myocardial infarction (AMI), the timing of these changes has not been well established. In this study, serial 2-dimensional echocardiography was used to assess regional LV function in 23 patients with AMI in whom reperfusion was accomplished by thrombolysis alone, by coronary angioplasty alone or by both interventions within 6 hours after onset of chest pain. Echocardiograms were performed before or within 6 hours after reperfusion (n = 23) and at 1 (n = 19), 3 (n = 21) and 7 (n = 20) days after reperfusion. Wall motion index and percentage of normally functioning muscle were calculated using a 16-segment scoring system analyzed in blinded fashion without knowledge of patient identity, therapy or time of study. The mean wall motion index improved from 1.78 ± 0.48 to 1.56 ± 0.38 at 1 day (n = 19, p < 0.01), and to 1.48 ± 0.37 at 3–7 days (p < 0.01), with no significant difference between 3 days (1.49 ± 0.39) and 7 days (1.42 ± 0.30). There was a corresponding improvement in the percentage of normally functioning muscle, from 53 ± 24% at 6 hours to 62 ± 20% at 1 day (p < 0.05) and to 67 ± 18% at 3–7 days (p < 0.01), again with no significant difference between 3 days (67 ± 21) and 7 days (70 ± 20). The data indicate that in many patients with AMI and successful reperfusion there was a rapid improvement in LV wall motion abnormalities, often within 24 hours. In most patients maximal improvement was seen within 3 days.

Fifty patients undergoing successful reperfusion therapy (percutaneous transluminal coronary angioplasty 20, thrombolysis 10, combined 20) for acute myocardial infarction were evaluated with serial two-dimensional echocardiograms performed early (less than 24 hours, mean 8 hours) and late (greater than 3 days, mean 6 days) after presentation. Treatment occurred within 12 hours of the onset of symptoms with most patients achieving reperfusion in less than 6 hours (mean 4.7 hours) from the onset of pain. Reperfusion was demonstrated short-term by angiography in 42 of 50 patients (84%). Four patients had clinical signs of reperfusion and subsequent angiographic confirmation. An additional four patients with "stuttering" infarct courses were treated late by percutaneous transluminal coronary angioplasty. Echocardiograms were analyzed for global performance by calculation of fractional area change at the papillary muscle level and ejection fraction (biplane Simpson's rule) in 18 patients in whom this analysis could be performed. Measurements of regional function included fractional shortening at the base (n = 37), regional wall motion index (n = 50) and percent of normal functioning myocardium (n = 50). Overall there was a significant improvement in regional wall scores and percent of functioning myocardium (regional wall motion index 1.73 to 1.43, p less than 0.001 and percent of functioning myocardium 0.61 to 0.70, p less than 0.001) but only a trend toward improvement when global function was assessed by ejection fraction (0.42 to 0.48, p less than 0.14).(ABSTRACT TRUNCATED AT 250 WORDS)