Letter from the Editor

New Ideas from Cardiac Cath Lab Staff

Morton Kern, MD
Morton Kern, MD

One of the most stimulating and fun activities in the cath lab is the discovery of a new way to do things. Despite more than 20 years working in the cath lab, I continue to learn something new almost every month. The source of this information comes from our cath lab staff, nurses on the floor and the cardiology fellows. This process of discovery must be nurtured and borne by those with curiosity and an inquisitive nature. After leaving the St. Louis University cath lab, the opportunity to work in different cath labs in southern California in the last several years has emphasized to me more than ever that new eyes looking in new places often bring new ideas to old problems. Over the years, my close association with cath lab nurses and technologists has produced a number of innovative products for and approaches to many of our common daily problems in performing cardiac catheterization.

Colored Syringes and Splash Containers
For example, in 1990, my head nurse at the St. Louis University cardiac cath lab, Robert Roth, and I discussed problems with labeling syringes for medications at the back table. We came up with the idea of adding colored tags to the syringes well before the Joint Commission asked us to label all products on the cath table. We spoke with our industry colleagues at Merit Medical and sure enough, colored pistons for syringes were produced, permitting us to use color-coded syringes and avoid medication errors. In 1991, Rob heard me complaining about bloody splash from forceful emptying of the waste syringes into an open bowl. Rob Roth created a small collection bowl filled with gauze and covered with a plastic lid with a hole in the middle to receive the bloody waste from the syringe and contain the backsplash. This idea was also picked up by industry and the Backstop waste bowl collector was then introduced and remains in use today.

Streamlining the Swan
After my move to California in 2005, I was working in Saddleback Hospital in Laguna Hills. CJ Wolfe, one of the cath lab nurses, had a great idea to use a needleless valve connector in place of a stopcock on the Swan Ganz catheter and eliminate the fishhook-like activity of moving this catheter across a field, catching the tubing and drapes with the stopcock. Again, this example illustrates that a brilliant idea from the cath lab staff should not go unappreciated (Kern MJ. Technical Pearl: Streamlining the Swan. Catheter Cardiovasc Interv 2007;70:160).

Fixing the Sheath
Last month in my lab at University of California-Irvine, Mr. Kent McAllister showed me two new tricks, which I know will be helpful to many labs around the country. The first new idea he showed me is used in radial artery catheterization. Kent demonstrated the use of a Tegederm 4x3-inch clear film plastic bandage. It is placed over the radial artery sheath and secures it in place. The “Kent” bandage permits easy visualization of the access site, and fixes the sheath and sidearm to the wrist, thus eliminating suturing the sheath to the skin and the associated problems with any suture approach. This novel method is widely available, and is a wonderful advance in the sheath securement department of our procedures. Biplane Coronary Angiography Made Easy Secondly, Kent taught our lab something new about biplane coronary angiography. Although many labs do not routinely use biplane imaging for coronary angiography, this modality is particularly helpful when you would like to limit the contrast load or in patients who have congenital anomalies or complex structural heart disease. As traditionally practiced, the anteroposterior (AP) and the lateral planes are moved into position with the heart placed in isocenter. The AP and lateral planes are then rotated together to the left anterior oblique (LAO) and right anterior oblique (RAO) angles, and then each rotated to cranial and caudal projections moving the C-arms in opposite directions. This setup is quite adequate for adult left ventriculography provided the heart is in isocenter when little or no panning is necessary. However, for coronary angiography, problems arise if panning is required and the heart is not in isocenter. In this case, panning into the LAO cranial projection will move the heart out of the imaging field of the RAO plane, and vice versa. Losing imaging data during panning produces a suboptimal study. Many operators avoid biplane coronary angiography for precisely this reason. Cath lab teams can spend considerable time setting up the biplane system and moving the table height to minimize panning and capture all the image data. This juggling of table height and plane position is frustrating and time-consuming. To overcome this problem, Kent suggested we place both the LAO and RAO planes in the cranial angulation, instead of the opposing cranial-caudal plane positions. In this configuration (cranial-cranial), when we pan, the coronary arteries stay in the appropriate field for both LAO and RAO planes and loss of information by panning out of the field is nearly impossible. This cranial-cranial or caudal-caudal set up for the LAO and RAO planes makes biplane coronary angiography easy, quick and complete, especially since panning is so often necessary. This setup was new to me, but I believe should be evaluated and widely used when performing biplane coronary angiography. I compliment Kent and many of my past and present cath lab associates and staff who have come up with many brilliant ideas, making great contributions through small steps. Identifying and sharing new ideas in the cath lab with our colleagues will improve our procedures and is one of the most stimulating and helpful cath lab staff activities. I still have an outstanding bet to pay to anyone who can figure out how to make the intravenous lines come to the patient from the head of the table without becoming entangled in the C-arm.

I’m sure many new ideas such as the ones described above have been discussed in labs around the country and may already be in place. I’d like to invite those of you who have good ideas to share them with our colleagues and readers in Cath Lab Digest. Who knows — the next great cath lab technique may come from your lab.