CLINICAL EVENTS CALENDAR
- StartMar 07,2010EndMar 12,2010Interventional Cardiology 2010: 25th Annual International Symposium: The Silvertree Hotel, Snowmass Village, COtinyurl.com/mg5olq
- StartMar 14,2010EndMar 16,2010American College of Cardiology Scientific Session and i2 Summit 2010: Atlanta, GAacc.org
- StartMar 22,2010EndMar 26,2010Baylor University and Hankamer School of Business present: The 4th annual Global Business Forumhttp://www.baylor.edu/business/international/
- StartMar 25,2010EndMar 26,2010Balancing Your Own Health While Caring for Patients: Cocoa, FL (accredited)www.thegoldenlights.com
Clinical Editor's Corner
The STEMI Box– Shorten D2B and Cath Lab Prep in the Emergency Department
There is no doubt that the national initiative to save lives by reducing the time to reperfusion in the acute myocardial infarction patient is working and in full swing for STEMI receiving center cath labs. Reducing the door-to-balloon time (D2B) has been discussed in Cath Lab Digest almost every other month for many years. CLD strives to inform, train, demonstrate, and encourage all parties involved to shorten D2B times. Multi-center studies and even some single-center studies reinforce the benefit of streamlining the process of moving the patient from his home through the emergency department (ED) to the cath lab for angioplasty. The American Heart Association has educated the community in an effort to shorten the time it takes for the patient to recognize symptoms and call EMS. The evaluation of the patient by EMS has been shortened in some centers with transmission of the ECG by fax, phone or email, and activation of the cath lab from the field.
How Many People Do You Need to Do a Cardiac Cath?
We changed the daily tour of duty for our cath lab team. Instead of 10-hour days with one shift to run 2 labs, we split overlapping 8-hour shifts. This brought up the question, “Exactly how many people (and what kind of training) should you have to do a cardiac cath?”
Dynamic Leadership in the Cath Lab: Balancing Taking Charge and Being Part of the Team
The Cath Lab Basics 2009 course series ended in Tampa the first Saturday in December. Dr. Mike Lim and I enjoyed conducting a one-day ‘cath conference’ with the 180 cath techs and nurses from the region. Sitting at lunch, I asked my table of nurses from Venice, Florida, “What is the single biggest problem you have in your lab?” I was expecting comments like, “It’s the hemodynamics” or “I struggle with coronary anatomy” or “I don’t like covering the on-call nights.” But I was surprised to learn from them that their biggest problem was the personal dynamics with one of the techs in their lab. It had slipped my mind that the biggest struggle in any workplace is the human relationships, not the hemodynamic recording technique or heparin dosing.
Changing Behavior and Culture in the Cath Lab: Addressing Motivations and the ODNT (Old Dog/New Trick) Syndrome
I was recently asked at our Cath Lab Basics 2009 course in Seattle, “What can the techs/nurses do to introduce a new and better way of doing something in the lab to the physicians and ultimately to the patients?” For example, how does one implement physicians changing to routinely using 6F rather than 8F guides for percutaneous coronary intervention (PCI), performing intravascular ultrasound (IVUS)/fractional flow reserve (FFR), or starting the radial approach? In other words, can you cure the “OD can’t learn NT syndrome” (remembering that some of the old dogs are not really so old)? This is a great question and interestingly, it goes in both directions; that is, how do you teach old cath lab techs/nurses new tricks? Both are tough questions and each is deserving of strong individual consideration as to where you stand in this philosophical battle front.
What motivates a change in behavior?
Working With Industry Representatives and Conflicts of Interest in the Cath Lab
Your cath lab director is on the speaker’s bureau for a pharmaceutical company that promotes antiplatelet agents. Does this mean you cannot buy this drug to use in the cath lab? Does this mean the doctor cannot perform a procedure with this drug because he has a perceived conflict of interest? Of course not, but it is important to understand and work with our industry and the conflicts of interest which inevitably occur in most businesses, including the business of medicine.
Industry and cath lab relationships
Is the Hybrid Cath Lab the Way of the Future?
Last fall, I visited Vanderbilt University Medical Center in Nashville, Tennessee, and was shown their marvelous hybrid cath lab/OR. An interventional procedure was underway, to be shortly followed by a left internal mammary artery (LIMA) procedure, without moving the patient off the table, just rearranging the equipment to bring the surgical team up to the patient. This “one stop” revascularization procedure was a technological tour-de-force. The concept of combining an operating suite with a cardiac cath lab — a hybrid cath lab [or if you’re a surgeon, a hybrid operatin room (OR)] — is not new, but it has been slow to catch on, probably for some good reasons. Enthusiasm for its use lies in the advancing new percutaneous approaches for aneurysm repair, valve replacements, and shunt closure devices.
Cost-Effective Health Care and Research: FAME Fits
In this issue of Cath Lab Digest, Dr. William Fearon from Stanford University talks about the FAME (Fractional flow reserve vs. Angiography in Multivessel Evaluation) study1 and how using fractional flow reserve (FFR) with a pressure wire was a highly successful approach to cost-effective stenting in patients with multivessel coronary artery disease (CAD) compared to using traditional angiography alone. FAME fits with cost-effective healthcare in a big way.
How does FAME make percutaneous coronary intervention (PCI) cost effective?
What is the SYNTAX Score and How Should We Use It?
In recent years, studies of multivessel coronary angioplasty randomized patients between surgery and intervention. The fairness of this randomization assignment has become a subject of great interest, since it may influence outcomes. One of the most prominent recent studies, the SYNTAX trial, compared multivessel percutaneous coronary intervention (PCI), including patients with left main narrowings, to coronary artery bypass surgery. The results of this randomized study demonstrated that patients who had SYNTAX scores >34 appeared to do much better with bypass surgery than those with lower SYNTAX scores, in whom PCI was just as good for major adverse cardiac events, with lower stroke rates.
What is the SYNTAX score?
Radial Artery Catheterization: The way to go
Last month, I visited Dr. Olivier Bertrand at Laval Hospital in Quebec City, Canada, to present a talk on coronary physiology. He and his team showed me their lab and method of performing radial artery catheterization for their 10,000 patients of 2008-2009, with 3,500 percutaneous coronary interventions (PCIs) from the same approach. They reported no retroperitoneal hematomas, femoral pseudo aneurysms, fistula or femoral artery bleeds, occlusions or emboli. The complications from radial artery access are trivial compared to femoral, with <4% loss of radial artery pulse as the worst of it. I was forced to reconsider my old ways. Why do I persist with femoral artery access when complications from radial access are so much lower? If I said, hypothetically, that the left femoral approach had 10 times the complications as the right, I would never go to the left. If I now say the femoral artery has 10 times the complications compared to the radial approach, why would I ever use the femoral?
Do We Need Platelet Function Testing in Percutaneous Coronary Intervention?
A 68-year-old man was admitted for acute ST-elevation inferior myocardial infarction after right coronary artery stenting (3.0 x 18mm drug-eluting stent) four months ago. He had been taking 81 mg of aspirin and 75 mg of clopidogrel orally on a daily basis. He is treated for hypertension and hypercholesterolemia, but not diabetes. He does not smoke. The angiogram demonstrated thrombosis in the stent. He underwent thromboaspiration, intravascular ultrasound of the thrombosed stent and balloon high-pressure inflations with a 3.5 x 15mm NC balloon. Did this patient have clopidogrel (Plavix)/aspirin (ASA) resistant platelets? Should the future doses of clopidogrel/ASA be increased over the standard doses on presumption of insufficient platelet response to dual antiplatelet therapy? Should platelet function be routinely tested?
Definition of Platelet Resistance
Cath Lab Surveys
Center for Education & Practice Development - Learning Module Femoral Artery Sheath Management(PDF) This learning module is designed for the Registered Nurse Division 1 working in areas where
patients are undergoing percutaneous cardiac catheterisation and interventions.
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