Faculty Bibliography

BACKGROUND:Transradial access (TRA) is a standard approach to cardiac catheterization. Following the procedure, air-filled compression bands are often used to achieve hemostasis at the access site. Despite research supporting early, gradual deflation to minimize complications, there is no established best practice for band deflation. At our urban academic medical center, the lack of a standardized compression band deflation protocol resulted in varied start times and amounts of air removed with each attempt, as well as inconsistent documentation. PURPOSE/OBJECTIVE:The aim of this quality improvement project was to develop and implement an evidence-based practice (EBP) initiative to standardize TR compression band deflation and documentation. METHODS:Nurses, who were primarily responsible for the TRA procedure, organized a multidisciplinary team to critically evaluate the literature, identify gaps in clinical practice, and develop and implement a practice change. EBP interventions centered on a TR compression band deflation algorithm that included specified wait times based on the procedure type and anticoagulation received and the criteria for reinserting air based on bleeding status. A standardized documentation process was also instituted. Deflation was initiated at 30 minutes for patients undergoing diagnostic procedures or receiving up to 5,000 units of heparin and at 60 minutes for patients undergoing advanced diagnostic procedures or percutaneous coronary intervention (PCI) and receiving more than 5,000 units of heparin or IV bivalirudin. Demographics, documentation, complications, time to remove the compression band, length of stay (LOS), patient satisfaction, and opportunity benefit were analyzed. RESULTS:The preintervention (n = 214) and postintervention (n = 255) groups were comparable in age, gender distribution, procedure type, and anticoagulant use. Following the rollout of the EBP initiative, there was a statistically significant reduction in the time required for successful compression band removal for both diagnostic procedures (P < 0.001) and PCIs (P < 0.001). LOS decreased across all procedure types. Specifically, diagnostic procedures had a statistically significant postintervention reduction in LOS (P < 0.001). In addition, clinical documentation (encompassing air removed, air reinserted, and complications) showed significant postintervention improvement (P < 0.001). Regarding safety outcomes, over 85% of patients in the postintervention group experienced no recorded complications during band removal, while 100% had no major bleeds or hematomas. CONCLUSIONS:This EBP initiative confirms that an early band deflation algorithm reduces time for band removal and LOS across diagnostic, advanced diagnostic, and PCI procedures without compromising patient safety. Furthermore, the initiative improved documentation, ensuring consistent monitoring and nursing transitions. These findings provide a clinical basis for adopting early compression band deflation for TRA procedures.

OBJECTIVE:Hybrid coronary revascularization is a clinical strategy that uses a combination of surgical revascularization and percutaneous coronary intervention (PCI). Data on the hybrid approach for coronary artery disease involving the left main (LM) are scarce. We analyzed our cohort of hybrid coronary revascularizations with minimally invasive direct coronary artery bypass (MIDCAB) using robotic left internal mammary artery harvesting and PCI for multivessel disease with and without LM involvement. METHODS:= 40, 64.5%). RESULTS:= 0.699). CONCLUSIONS:Hybrid robotic MIDCAB for patients with and without LM disease can be performed with acceptable results in selected patients. However, it is not possible to draw definitive conclusions regarding safety and efficacy compared with conventional coronary artery bypass grafting.

Secondary mitral regurgitation is one of the most common valve diseases. The disease is a result of left atrial or left ventricular dysfunction. It is generally classified into stages based on its severity. While surgical intervention does not confer improved survival in this subset of mitral disease, recent advances in transcatheter interventions have resulted in improved survival and symptomatology in carefully selected patients. In this review, the multimodality imaging evaluation of the mitral valve and secondary mitral regurgitation is discussed. Commercially available and investigational transcatheter interventions for secondary mitral regurgitation management are also reviewed.

Coronary artery obstruction caused by sinus sequestration is well described after transcatheter aortic valve implantation in failed bioprosthetic valves, which usually occurs during or shortly after the transcatheter aortic valve implantation procedure. We report the presentation, management, and outcomes of 2 cases of very late sinus sequestration in native aortic annuli, which has not been described before to our knowledge. (Level of Difficulty: Advanced.).

Structural heart disease is a rapidly evolving field. However, training in structural heart disease is still widely variable and has not been standardized. Furthermore, integration of trainees within the heart team has not been fully defined. In this review, we discuss the components and function of the heart team, the challenges of current structural heart disease models, and possible solutions and suggestions for integrating trainees within the heart team.

PURPOSE OF REVIEW/OBJECTIVE:Percutaneous structural interventions have provided patients with an effective therapeutic option, and its growth has been aided by echocardiography. We describe the vital role that transesophageal echocardiography (TEE) plays in screening patients prior to their procedure. RECENT FINDINGS/RESULTS:A multimodality imaging approach is employed by the valve team, but TEE plays a unique role in diagnosis and planning. Utilization of all TEE views and features such as biplane, 3D imaging, and multiplanar reconstruction ensures accurate assessment of the structural lesion of interest. The role of TEE remains essential in the planning of structural interventions, and these studies should be performed in a systematic and comprehensive manner.

BACKGROUND:Women have a higher rate of adverse events after mitral valve surgery. We sought to evaluate whether outcomes after transcatheter edge-to-edge repair intervention by sex have similar trends to mitral valve surgery. METHODS:The primary outcome was 1-year major adverse events defined as a composite of all-cause mortality, stroke, and any bleeding in the overall study cohort. Patients who underwent transcatheter edge-to-edge repair for mitral regurgitation with the MitraClip system in the Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy registry were evaluated. Linked administrative claims from the Centers for Medicare and Medicaid Services were used to evaluate 1-year clinical outcomes. Associations between sex and outcomes were evaluated using a multivariable logistic regression model for in-hospital outcomes and Cox model for 1-year outcomes. RESULTS:<0.001) and had a lower adjusted odds ratio of device success (adjusted odds ratio, 0.78 [95% CI, 0.67-0.90]), driven by lower odds of residual mitral gradient <5 mm Hg (adjusted odds ratio, 0.54 [CI, 0.46-0.63]) when compared with males. At 1-year follow-up, the primary outcome did not differ by sex. Female sex was associated with lower adjusted 1-year risk of all-cause mortality (adjusted hazard ratio, 0.80 [CI, 0.68-0.94]), but the adjusted 1-year risk of stroke and any bleeding did not differ by sex. CONCLUSIONS:No difference in composite outcome of all-cause mortality, stroke, and any bleeding was observed between females and males. Adjusted 1-year all-cause mortality was lower in females compared with males.