Coping With Complications in the Catheterization Laboratory: A Step-by-Step Approach.

Background: Unit-Specific influences may determine the amount of sedation given to patients and lead to deviations in patient satisfaction and clinical outcomes due to vague guidelines (4). This study aims to compare medication utilization, clinical outcomes and patient satisfaction in order to determine safety and efficacy of nurse administrated conscious sedation. Methods: Data from outpatient procedures in Cardiac Catherization Lab (Cath Lab) and Interventional Radiology (IR) departments were collected including comorbidities, labs, procedural characteristics, clinical outcomes, and post-sedation questionnaires. Results: Mean age was 63 ± 14 years and 124 (54.9%) were males. Cath Lab n=132 and IR n=94. Procedure duration(min) was found to be longer in the Cath Lab 55 (37,81), than in IR 24 (16,45), p-value of <0.001. The American Society of Anesthesiologist (ASA) scores of Cath Lab 26(21%), IR 29(30.9%), p-value (0.1). Total amount of versed (mg) given in the Cath Lab 2 (1,2), significantly less than IR 3 (1,4.5) with a p-value of <0.01. Total amount of fentanyl (mcg) for Cath Lab 50(50,100), and IR 100 (50,100) with a p-value of <0.01. Median time between 1 st and 2 nd dose of versed in Cath Lab 0 (0,1), IR 9 (5, 16). Median time between 2 nd and 3 rd dose of versed for Cath Lab 0 (0,0), IR 6 (0,13.5) with a p-value <0.001. Median time between 1 st and 2 nd dose of fentanyl in Cath Lab 1 (0,14.8), IR 12.5 (6.8, 24) with a p-value <0.001. Median time between 2 nd and 3 rd dose of fentanyl for Cath Lab 0 (0,0), IR 0,(0,15), p-value <0.001. Median second dose of versed in Cath Lab 0 (0,1), IR 1 (1,1). Median second dose of fentanyl in Cath Lab 25 0 (0,25), IR 25 (25,50), p-value <0.001. Post-Sedation Questionnaire completed by 57 patients, Cath Lab n=30, IR n=27. Patients that felt uncomfortable during their procedure in Cath Lab 11(36.7%), compared to IR 1 (3.7%). The choice of sedation that patient would choose if undergoing a similar procedure again if under general anesthesia Cath Lab 6(20%), IR 0(0%), p-value 0.03. Patients stated that they would recommend conscious sedation to others based on their previous experience, Cath Lab 24 (80%), IR 27(100%). Conclusion: Patients receiving conscious sedation while undergoing procedures in both the Cath Lab and IR were found to have no adverse outcomes and were considered safe. The procedural duration of catheterization procedures was significantly longer than IR with no adverse outcomes, but patients in the Cath lab received less sedation medication and were found to be less satisfied with their procedure. Patients from Cath Lab received less initial sedation medication and rarely received an additional dose. Cath Lab patients were more likely to not recommended conscious sedation to others (20%), and 6 (20%) stated they would rather undergo a similar procedure under general anesthesia; 36.7% of Cath Lab patients stated that they were uncomfortable during the procedure.

Cardiac cath lab procedures are developing in numbers, complexities and in demands with good outcomes. The complexicity of procedures and high risk patient factors require efficient cardiac anaesthesiologist's care. They need good infrastructure and anaesthesia facilities. These facilities may be available at Metrocity superspeciality centres, but small units at district levels may not have all these facilities. There are many issues existing which make cardiac anaesthesiologists to prefer to work only in cardiac operation theaters than cath lab. They don't get the job satisfaction in cath lab because of higher stress levels to overcome with the lacunaes in cath lab working.Aim:We hypothesize that cath lab in various centres are run by cardiac anaesthesiologists in majority. To analyze the infrastructure and working conditions of cath lab in perspective of anaesthesiologist, we conducted this survey.Setting and Design:Online survey among IACTA members, through email available through IACTA site. The link was https://www.surveymonkey.com/r/9FKZ3TV.Subjects and Methods:We contacted 500 IACTA members through email addresses available with us. 116 members replied to the online questionnaire done using SurveyMonkey software. Total 12 questions asked and answers analysed. The identity of responders is not disclosed by Survey monkey.Results:Results were analysed in for options in percentage wise by Surveymonkey software.we compiled all responses and categorized the suggestions by responders.Conclusion:Role of anaesthesiologist and anaesthesia facilities should be given important priority in cath lab units. Healthy attitude of governing members of cathlab as well as standard guidelines for recommendation of infrastructure of cath lab, monitoring and patient care is need of the hour!

For several decades, SCAI has been the leader among cardiovascular professional societies in promoting quality outcomes in catheterization laboratories. The Cath Lab Survey Committee is, and has been, a very powerful tool applied very selectively to relatively few sites. My goal is to promote a much broader, grassroots approach to improving quality in catheterization laboratories across the country. The Quality Improvement Committee worked behind the scenes to develop and launch the SCAI Quality Improvement Toolkit (SCAI-QIT) at the Annual Scientific Sessions in Baltimore this May. As I approached my Presidential year, I chose to focus on the ability of this “grassroots” approach to develop, implement and measure the impact of the SCAI-QIT. Our goal is to recruit a cadre of “Quality Champions”: SCAI members who volunteer to champion quality improvement in their local hospitals. With the assistance and support of the Quality Improvement Committee, these local SCAI member-volunteers will be the “tip of the spear.” They will enable their local cardiac catheterization laboratories to implement specific quality improvement programs. SCAI will provide them with practical tools and resources (e.g., slidesets, handouts, checklists) to bolster quality improvement for their catheterization laboratories. Our overall goal is to demonstrate a measurable impact on the national Quality of Care in the catheterization laboratories that participate in the SCAI-QIT program. Initially, we will focus on “process improvement”—for example, greater frequency of biomarker surveillance following PCI, or institution of a monthly peer review conference. Subsequently, our focus will evolve to impact clinical outcomes, which directly reflect the quality of the invasive and interventional practice of cardiology. We have talked for a number of years about the need for interventionalists to “own” the quality improvement process in the catheterization laboratory. If physicians stand on the sidelines and do not actively participate in their local quality programs, then we are inviting government bureaucrats to fill this void. Clinicians know best how to care for patients, and clinicians understand how best to achieve and ensure the good outcomes their patients expect. SCAI's Quality Improvement Toolkit offers a unique opportunity for SCAI members to demonstrate their commitment to improving quality of care and to reassure our patients that their expectations of receiving the highest quality of care in the catheterization laboratory are being met. It's time for you to get involved. It's time for you to get to work. We can't wait for “somebody else” to do this for us. It's time to stop talking and start doing something about your local hospital's catheterization laboratory quality programs. Become an SCAI Quality Champion. It's not too late. Check out the website, www.SCAI.org/QIT and download the free toolkit. SCAI will continue to support you and all of the local Quality Champions with webinars and other support services to ensure your success. One year from now, we will have measured the successful implementation of quality programs across the nation. We need you to help SCAI demonstrate how successful we were in driving a quality program. Sign up today at www.SCAI.org/QIT. Your feedback and ideas would be appreciated. Please e-mail them to [email protected] The SCAI Quality Improvement Toolkit was developed with support from Daiichi Sankyo Lilly. The Society gratefully acknowledges this support, while taking sole responsibility for all content developed and disseminated through this effort.

Background: Aligned with the Health Sector Transformation Strategy of Saudi Vision 2030, the study analyzed the attitudes and behaviors of cardiologists toward change and identified factors that could either facilitate or hinder the success of leadership interventions. At our cardiac center, the cath lab department is at the forefront of operations, accounting for 80% of the procedures. Our team members may not be fully equipped with the necessary attitudes and behaviors to drive successful improvement projects. Therefore, our top priority is ensuring they remain productive and engaged throughout the process. This is especially crucial because 60% of our budget is allocated to the cath lab department.Objectives: The study aimed to assess the effectiveness of a leadership intervention on cardiologists' performance in terms of safety, speed, and cost. The research analyzed the behavior and attitude of cardiologists towards change and encouraged progress and collaborative learning between doctors, using benchmarking as a tool. Besides, the study sought to determine the contribution of the interventions used to overall efficiency in performing interventions. This case study focuses on four main aspects of the program. First, it aims to explore an innovative approach to improving the PSCCQ cath lab for patients. Second, it assesses the collective effort of all participants involved in the program. Third, it analyzes the program results and compares them with those of international experiences. And finally, it examines the program's potential benefits for our patients.Methods: The study's objectives were evaluated through qualitative analysis of in-depth interviews and quantitative data analysis of three variables in the cath lab: radiation dose, time, and inventory. The reason for using mixed methods was to comprehensively understand the same concept from different angles.Results: According to the study, participants improved the safety and effectiveness of our cath lab by reducing the radiation dose and its cost. The study revealed a 52% decrease in the radiation dose for diagnostic cases and an 11% decrease for interventional cases. Similarly, the cost of the radiation dose decreased by 28% for diagnostic cases and 11% for interventional cases. During the observation, it was noted that the participants were highly engaged and willing to adapt to the situation. Some even viewed it as an opportunity for personal growth and improvement in the cath lab. However, they stressed the significance of awareness as a crucial element in improving their behavior and reinforcing it as the foundation for maintaining progress. Furthermore, the study revealed that collaborative work among the participants could have been more optimal.Conclusion: The study concludes that implementing innovative improvements to the cath lab was a necessary yet complex undertaking. Participants were more inclined to embrace the changes when they were easily understandable and motivating. The study recommends the appointment of a change agent, the establishment of benchmarks, and the creation of a collaborative working environment between leaders and staff. Above all, the leader should support and sponsor the change to facilitate the transition at various levels.

During the last two decades, an increasing number of permanent pacemakers have been implanted outside of the operating room (OR) by nonsurgeons. Previous investigators have demonstrated that pacemakers can be safely implanted in the cardiac catheterization laboratory with no increase in complications or infections. This is the first study of its kind to simultaneously evaluate cost, length of hospitalization, and complications between pacemakers implanted in the OR by surgeons with those implanted in the catheterization laboratory by an electrophysiologist. A total of 254 consecutive pacemaker implants were analyzed over a 2-year period. The OR group consisted of 122 patients with a mean age of 64 +/- 21 years versus 132 patients in the catheterization laboratory group with a mean age of 65 +/- 17 years. The indication and type of pacemaker implanted were similar among both groups with 78% of OR patients and 73% of catheterization laboratory patients receiving dual chamber devices. The average cost for pacemaker implantation in our study was significantly higher in the OR group $5,464 +/- $1,670 versus $2,682 +/- $8 for the catheterization laboratory group (P < 0.001). There was a reduction in preimplant days in the catheterization laboratory group 3.16 +/- 12.40 days versus 5.65 +/- 9.54 days in the OR group (P < 0.05). Complications were minimal and there were no significant differences between the two groups. This study confirms that pacemakers can be safely implanted in the catheterization laboratory by nonsurgeons with no increase in complications and a significant reduction in hospital costs.

Cardiology Admissions from Catheterization Laboratory – Time Series Forecasting

Eptifibatide, a small-molecule glycoprotein IIb/IIIa inhibitor, is conventionally administered as a bolus plus infusion. A growing number of clinicians are using a strategy of catheterization laboratory-only eptifibatide (an off-label use) as procedural pharmacotherapy for patients undergoing percutaneous coronary intervention although the comparative effectiveness of this approach is unknown. We compared the in-hospital outcome of patients undergoing percutaneous coronary intervention across 47 hospitals and treated with eptifibatide bolus plus infusion with those treated with a catheterization laboratory-only regimen. We used optimal matching to link the use of catheterization laboratory-only eptifibatide with clinical outcomes, including mortality, myocardial infarction, bleeding, and need for transfusion. Of the 84 678 percutaneous coronary interventions performed during 2010 to 2011, and meeting our inclusion criteria, eptifibatide was administered to 21 296 patients. Of these, a catheterization laboratory-only regimen was used in 4511 patients, whereas 16 785 patients were treated with bolus plus infusion. In the optimally matched analysis, compared with bolus plus infusion, a catheterization laboratory-only regimen was associated with a reduction in bleeding (optimally matched adjusted odds ratio, 0.74; 95% confidence interval, 0.58-0.93; P=0.014) and need for transfusion (optimally matched adjusted odds ratio, 0.70; 95% confidence interval, 0.52-0.92; P=0.012), with no difference in mortality or myocardial infarction. A catheterization laboratory-only eptifibatide regimen is commonly used in clinical practice and is associated with a significant reduction in bleeding complications in patients undergoing contemporary percutaneous coronary intervention.

Introduction: Selected comatose survivors of out-of-hospital-cardiac arrest (OHCA) meet criteria for both emergent percutaneous coronary intervention (PCI) and induction of mild therapeutic hypothermia (MTH). It is unclear which should be performed first. We hypothesized that urgent catheterization prior to MTH may significantly prolong time to cooling. Methods: We conducted a retrospective cohort study, reviewing electronic medical records of all patients treated with MTH in the University of Michigan Emergency Department (ED) for OHCA. We identified whether the endovascular cooling device was inserted in the ED or catheterization lab and assessed time from ED arrival to cooling device insertion, to cooling initiation, and to reaching ≤33.5°C. Neurological outcomes were determined by Cerebral Performance Category (CPC) via chart review. Times were compared via Student’s t-tests. Results: Between 7/1/2006 and 9/14/2012, 123 consecutive patients were treated with MTH. Twenty-six (22%) had their device placed in the catheterization lab (14/26 received PCI) while 92 (77%) had theirs placed in the ED. There was no significant difference between catheterization lab v. ED device placement in time from ED arrival to device insertion, arrival to cooling initiation, and arrival to reaching target temperature (see table). Forty-six percent vs 39% of those whose devices were inserted in the catheterization lab vs ED survived past hospital discharge (OR 1.8; 95% CI 0.7-4.4), and 35% vs 39% had favorable 6-month neurological outcomes (OR 1.3; 95% CI 0.5-3.3). Conclusions: In our system, initiating cooling in the catheterization lab as opposed to the ED does not significantly delay cooling times. The resources and efficiencies involved in activation of the cath lab team may offset the time taken to perform angiography and potential subsequent PCI. These data support the practice of immediate cardiac catheterization in appropriate comatose survivors of cardiac arrest.

Keywords: percutaneous coronary intervention; structural heart disease intervention; congential heart disease; adults; congenital heart disease; pediatrics

Balloon atrial septostomy is performed in infants with dextro-transposition of the great arteries to improve oxygenation before surgery. It is performed in the catheterisation laboratory with fluoroscopy or at the bedside using echocardiography. It is unclear whether procedural safety and efficacy is superior in one location versus the other, although the bedside procedure may improve resource utilisation and present an opportunity for reducing cost. This study compares safety and efficacy of atrial septostomy performed at the patient's bedside versus the catheterisation laboratory. Neonates with dextro-transposition of the great arteries who underwent balloon atrial septostomy from October, 2000 to January, 2014 were included. Medical and procedural records, echocardiograms, and catheterisation data were reviewed. Comparisons between the two procedural locations included patient demographics, pre- and post-procedure oxygen saturations, and outcomes. Complications reviewed included bleeding, arrhythmia, cardiac trauma, stroke, and death. Coronary artery evaluations were recorded. T-tests were used for continuous variables, and Fisher's exact tests were used for all categorical variables. Wilcoxon rank sum and analysis of covariance modelling were used for time variables and oxygen saturation, respectively. A total of 88 infants met the inclusion criteria. Among them, 53 underwent septostomy at the bedside and 35 underwent septostomy in the catheterisation laboratory. No safety or outcome benefit was identified between the two procedural locations. Septostomy performed at the bedside and in the catheterisation laboratory had similar outcomes and efficacy. Further, bedside septostomy has the advantage of no radiation exposure, and obviating risks with patient transfer from the ICU to the catheterisation laboratory.

Introduction: Within the past decade, transcatheter aortic valve replacement (TAVR) has become the standard of care for the treatment of calcific aortic stenosis across the surgical risk spectrum. With increasing volumes of procedures, there has a shift in TAVRs into the cardiac catheterization lab and out of the hybrid operating room. A better understanding is needed regarding the impact this has on procedural success and outcomes. Methods: Patients undergoing transfemoral TAVR between April 2016 and April 2019 at the University of North Carolina were included retrospectively. Unpaired t-test, Fisher’s exact test, and chi square analysis were used to compare procedure characteristics and outcomes performed in the catheterization lab to TAVR performed in the OR. Results: A total of 160 transfemoral TAVRs were performed in the catheterization lab while 119 were performed in the OR. There were no significant differences in baseline or comorbidity characteristics. Table 1 includes data analysis finding no significant difference in procedure time, contrast volume, fluoroscopy time, anesthesia type, aborted procedures, conversions to open surgery, paravalvular leak, endocarditis, stroke, KCCQ-12 difference at 4-7 week follow up, and one year mortality. Figure 1 includes the location of transcatheter TAVR procedures at UNC over time. Conclusions: Transfemoral TAVR performed in the catheterization lab is as safe and efficacious as TAVR performed in the OR. This has significant implications for resource utilization, ability to expand this therapy, and the costs associated with TAVR.

Radiation Exposure During Transcatheter Valve Replacement: What Cardiac Surgeons Need to Know

Multisociety (AATS, ACCF, SCAI, and STS) Expert Consensus Statement: Operator and Institutional Requirements for Transcatheter Valve Repair and Replacement, Part 1: Transcatheter Aortic Valve Replacement

Background: Prior studies have assessed variation in radiation use and fluoroscopy times for patients undergoing coronary angiography (CA) and percutaneous coronary intervention (PCI); however, the extent that this varies by cath labs is unknown. Methods: We analyzed data from the VA National CART Program of patients undergoing CA and PCI between 2010 and 2011 (n=28,513). Radiation exposure was measured using fluoroscopy time. We fit a mixed effects linear regression using log fluoroscopy time as outcome, a random effect for site, and adjusted for procedural and patient characteristics. Empirical Best Linear Unbiased Predictors for sites were used to estimate adjusted site level medians. The intra-class correlation (ICC) for site random effect was calculated to estimate the proportion of variance explained by site adjusting for patient and procedural characteristics. Marginal residuals were aggregated to site and examined at quarterly intervals for 2 years to establish stability of site medians over time. Results: Overall site median fluoroscopy time was 6 minutes (IQR: 3.5, 10.2) for CA and 16.5 (IQR: 10.3,26.1) minutes for PCI. After adjusting for procedural and patient characteristics, site median fluoroscopy times ranged from 43% below to 57% above the median for CAs and 66% below to 75% above for PCIs (Figure). Sites in the top quartile of fluoroscopy time were above the overall median in 96% for CA and 99% for PCI of time periods assessed. Cath lab site accounted for a significant amount of variance in fluoroscopy times (11.9% for CA and 21.5% for PCI). Conclusion: There is significant variation in fluoroscopy times across VA cath labs for coronary angiographies and PCIs. Even after adjustment for patient and procedures factors, there remains significant variability at the cath lab level suggesting that there may be opportunities for quality improvement interventions to reduce fluoroscopy times and radiation exposure for patients undergoing these procedures.

Patient radiation doses in Cardiac Cath Lab