Cath Lab Digest

Evolving clinical conundrums in modern cardiology require insights from many sources. In this spirit, I’d like to present another ‘conversation in cardiology’ about a real dilemma involving a woman, a stent, and dual anti-platelet therapy. My colleagues generously contributed their thoughtful opinions to assist the treating physician in his decision-making. The conversation addresses the pros and cons, and puts the issue into perspective for a best clinical decision. Let’s see what happened

Every year, we get a new group of cardiology fellows-in-training who are unfamiliar with angiograms and the angulations needed to best display the coronary arteries. Almost as frequently are the visitors to the cath lab or new trainees in the cath lab who are in need of an orientation to the angiogram, and its specific angulations and abnormalities.

I recently learned that I could see my real-time x-ray dose while doing a case. My x-ray system (Philips, Bothell, Wash.) has a display (see Figures) on the left side of the monitors that shows my table height, source-to-image distance (SID), and flat detector (FD) distance, and below it shows the fluoroscopy settings (low, normal), fluoro time, K mGy/min, patient dose area product (DAP) (I think) and air kerma (AK) in mGy. It was also interesting that by raising and lowering the tube, table, or fluoro setting, the operator can change dosage and know, in real time, in which direction.

Why do we talk so much and so often about quality?

It’s simple. We want the best for our patients. We want good care from top-rated physicians doing their work in top-rated facilities, with the most experienced and skilled cath lab staff, and with the best outcomes possible. I want my stenting performed in the best place and by the best physician, and likely, so do you. But how do we know what is the best place or even an acceptable place (or physician)? We have all read the papers about unnecessary procedures, including stents, performed in some places that were possibly not the best. Differences in “quality” are the top of the list of complaints about medical care.

Several weeks ago, Dr. Chris White from the Ochsner Clinic commented, “I need some help. I have a vasculopathic patient who was admitted with resting moderately severe angina. He had CABG [coronary artery bypass graft] surgery several years ago, and has had multiple coronary procedures over the following years. Although the first cath procedure he ever had was uneventful, every procedure since then has been complicated by honest-to-goodness, airway-obstructing, hypotensive, life-threatening contrast reactions.