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Atrial septal defects (ASD) are among the most common congenital heart defects. As more ASDs are corrected by interventional catheterization instead of surgery, it is critical to understand the associated clinical and societal costs. The goal of this study was to use a national U.S. database to describe hospital charges and societal costs for surgical and catheter-based (ASD) closure. Retrospective review of hospital discharge data from the Kids’ Inpatient Database from January 2010 to December 2012. The database was queried for admissions for

Research on the association between schizophrenia and the quality of care and clinical outcomes of heart failure (HF) remains sparse. This nationwide study compared the quality of care and clinical outcomes of HF among Danish patients with and without schizophrenia. In a population-based cohort study, we identified 36,718 patients with incident HF with hospital contacts, including 108 with schizophrenia, using Danish registries between 2004 and 2013. High quality of HF care was defined as receiving >= 80% guideline-recommended process-performance measures of care. Potential predictors of HF care among patients with schizophrenia included patient-specific factors (age, gender, Global Assessment of Functioning [GAF] score, alcohol or drug abuse, duration of schizophrenia); provider-specific factors (quality of schizophrenia care); and system-specific factors (patient-volume defined as hospital departments and clinics yearly average patient-volume of patients with incident HF). Clinical outcomes included 4-week all-cause readmission and 1-year all-cause mortality after a first-time hospital contact with incident HF. Results showed that compared with patients with incident HF who have no schizophrenia, patients with incident HF who have schizophrenia had a lower chance of receiving high-quality HF care (relative risk 0.66, 95% confidence interval 0.48 to 0.91). A high GAF score was associated with a higher chance of receiving high-quality HF care among patients with incident HF who have schizophrenia. Patients with incident HF who have schizophrenia had a higher risk of 1-year mortality (adjusted hazard ratio 2.83, 95% confidence interval 1.59 to 5.04), but not a higher risk of readmission than patients with incident HF who have no schizophrenia. In conclusion, efforts are warranted to reduce the high mortality among patients with incident HF who have schizophrenia. (C) 2017 Elsevier Inc. All rights reserved.

Cardiac surgery was one of the first medical fields where outcome research was developed on the basis of large registries and databases. As early as in 1977, monitoring of survival rates after cardiac surgery began with voluntary submission of data to the Society of Cardiothoracic Surgery in Great Britain and Ireland (SCTS). A year later, the German Society for Thoracic and Cardiovascular Surgery (DGTHG) established a nationwide voluntary registry for cardiac procedures and mortality rates. About 10 years later, the Society of Thoracic Surgeons (STS) constituted its National Database (NDB) while US healthcare officials demanded for outcome—benchmarking. Activities of the European Association for Cardio-Thoracic Surgery (EACTS) started in the field of congenital cardiac surgery with the development of the EACTS Congenital Database in the late 1990s.

A mathematical formulation for intensity-based slice-to-volume registration is proposed. The approach is flexible and accommodates various regularization schemes, similarity measures, and optimizers. The framework is evaluated by registering 2D and 3D cardiac magnetic resonance (MR) images obtained in vivo, aimed at real-time MR-guided applications. Rigid-body and affine transformations are used to validate the parametric model. Target registration error (TRE), Jaccard, and Dice indices are used to evaluate the algorithm and demonstrate the accuracy of the registration scheme on both simulated and clinical data. Registration with the affine model appeared to be more robust than with the rigid model in controlled cases. By simply extending the rigid model to an affine model, alignment of the cardiac region generally improved, without the need for complex dissimilarity measures or regularizers.

© 2017 SPIE. Minimally invasive cardiac procedures requiring a trans-septal puncture such as atrial ablation and MitraClip® mitral valve repair are becoming increasingly common. These procedures are performed on the beating heart, and require clinicians to rely on image-guided techniques. For cases of complex or diseased anatomy, in which fluoroscopic and echocardiography images can be difficult to interpret, clinicians may benefit from patient-specific atrial models that can be used for training, surgical planning, and the validation of new devices and guidance techniques. Computed tomography (CT) images of a patient's heart were segmented and used to generate geometric models to create a patient-specific atrial phantom. Using rapid prototyping, the geometric models were converted into physical representations and used to build a mold. The atria were then molded using tissue-mimicking materials and imaged using CT. The resulting images were segmented and used to generate a point cloud data set that could be registered to the original patient data. The absolute distance of the two point clouds was compared and evaluated to determine the model's accuracy. The result when comparing the molded model point cloud to the original data set, resulted in a maximum Euclidean distance error of 4.5 mm, an average error of 0.5 mm and a standard deviation of 0.6 mm. Using our workflow for creating atrial models, potential complications, particularly for complex repairs, may be accounted for in pre-operative planning. The information gained by clinicians involved in planning and performing the procedure should lead to shorter procedural times and better outcomes for patients.

Objective We report a case series of robotic mitral valve replacement in patients with severe rheumatic mitral disease. Methods From March 2010 to June 2013, a total of 63 patients underwent robotic cardiac procedures. Robotic procedures were performed using the da Vinci Si surgical systems (Intuitive Surgical, Inc, Sunnyvale, CA USA). Eighteen of the patients (28.5%) underwent robotic mitral valve replacement. Rheumatic disease was the underlying pathology in all patients. The mean (SD) follow-up period was 18 (10) months. Results The mean (SD) age and EuroSCORE of the patients were 51.2 (11) years and 4.1% (4%), respectively. Seven patients (38.8%) had an additional cardiac procedure. No operative and hospital mortality were observed. The mean (SD) cross-clamp time and cardiopulmonary bypass time were 116 (30) and 178 (54) minutes, the mean (SD) drainage was 430 (350) mL, the mean intubation time was 9.4 (7) hours, the rate of patients extubated within 6 hours or less was 94.4%, and the mean (SD) intensive care unit stay time was 30 (12) hours. Sixteen of the patients (88.8%) were discharged from the intensive care unit within the first 24 hours postoperatively. During the intensive care unit stay, one patient (5.5%) needed inotropic support. There was one early reoperation for bleeding (5.5%), one (5.5%) intensive care unit readmission, and one (5.5%) hospital readmission observed. During the midterm follow-up, there was no mortality and no need for reoperation or reintervention. Conclusions Robotic mitral valve replacement for severe rheumatic mitral disease is technically feasible. Early results are encouraging. Patient selection criteria for robotic mitral valve surgery may be expanded to include valve replacements.

As increasing numbers of elderly people undergo cardiac surgery, neurologists are frequently called upon to assess patients with neurological complications from the procedure. Some complications mandate acute intervention, whereas others need longer term observation and management. A large amount of published literature exists about these complications and guidance on best practice is constantly changing. Similarly, despite technological advances in surgical intervention and modifications in surgical technique to make cardiac procedures safer, these advances often create new avenues for neurological injury. Accordingly, rapid and precise neurological assessment and therapeutic intervention rests on a solid understanding of the evidence base and procedural variables.

The advantages of intracardiac echocardiography (ICE) include shorter procedure times, reduced radiation exposure and the elimination of the need for general anesthesia. It is also effective in the safe performance of transseptal punctures. These have led to its increasing use in electrophysiology (EP) procedures. The use of ICE provides unrestricted access to the cardiac anatomy and guides interventional cardiac procedures by providing high-quality images of intracardiac structures and devices. As well as their use as imaging in catheter ablation of atrial fibrillation and other arrhythmias, ICE ultrasound catheters may be used in cardiac valve repair and the closure of atrial septal defects (ASDs). Integration of ICE catheters with electroanatomical mapping systems that construct three dimensional (3D) images have further increased the application of the technique. The use of magnetic navigation systems (MNS) have conferred further advantages including reduced exposure to fluoroscopy and increased operator comfort. This article presents four clinical cases and reviews clinical studies of these techniques.

The progression and expansion of treatments available for patients with cardiovascular disease depends on reliable, safe and effective arterial access. Owing to the superficial nature of the radial artery, major complications relating to cannulation occur less frequently and are simpler to manage. Therefore, radial access has become the favoured access site for angiography and angioplasty in many centres. However, maintenance of femoral access skills will always be a requirement, particularly in radial failure and in the growing field of structural intervention. Despite dramatic improvements in technique and equipment, large-calibre vascular access (usually femoral) remains an absolute requirement.

Background Percutaneous transcatheter device closure of left atrial appendage (LAA), patent foramen ovale (PFO) and atrial septal defect (ASD) are usually performed with unfractionated heparin (UFH) anticoagulation. Intravenous (IV) enoxaparin has shown a favorable safety/efficacy profile over UFH in percutaneous coronary intervention but has not been evaluated in structural heart procedures. Purpose The aim of the study is to report a first experience using IV enoxaparin without anticoagulation monitoring in transcatheter structural heart interventions performed in the left atrium. Methods This retrospective, non-controlled study included all consecutive and unselected patients who underwent percutaneous LAA, PFO or ASD closure at a tertiary care center using IV enoxaparin anticoagulation. The primary composite endpoint was the occurrence of in-hospital death, embolic complications (stroke, transient ischemic attack, and peripheral arterial embolism) and bleedings defined as type 3a or more according to Bleeding Academic Consortium Research definition. Results We enrolled 198 patients (mean age 60 ± 18 years, 55% males) with an indication for LAA (40.4%), PFO (34.3%) or ASD closure (25.3%). The majority of patients (n = 163, 82%) received a single IV enoxaparin dose of 0.5 mg/kg. The composite endpoint occurred in 6 (3%) patients including 4 (2%) type 3a bleedings, one (0.5%) transient ischemic attack and one (0.5%) death from sepsis. Median follow-up was of 3.7 (3.2–4.4) months with a cumulative rate of the composite endpoint of 5.8% over this period ( Table 1 , Fig. 1 ). Conclusion IV enoxaparin without monitoring appears as a safe, effective and easy-to-use alternative to UFH in percutaneous left atrial intervention.

The right atrium serves as a major conduit for the electroconductivity of the heart and is often targeted by interventional cardiologists for ablative procedures. As a result, descriptions of right atrial anatomy have gone under consistent evaluation to aid those managing cardiac pathology. With the advancements of minimally invasive procedures and interventional cardiology, minute details in anatomy have been consistently revised to improve outcomes. This literature review aims to provide a detailed description of the normal and variant anatomy for right atrial structures and the clinical implications of such structural variance in different cardiac procedures.

Transseptal puncture is a critical step in achieving left atrial (LA) access for many cardiac procedures. More recently, there has been an increasing need for LA access using large caliber sheaths, which presents a unique risk of perforation associated with the initial advancement into the LA due to

We commend Wadhera et al. [(1)][1] for exploring the burdens of public reporting for percutaneous coronary intervention (PCI). Given the lack of evidence that public reporting improves outcomes, it is reasonable to question the financial merits. Public reporting varies across participating states

We thank Dr. Kataruka and colleagues for their response to our study investigating the financial and administrative burden of public reporting for percutaneous coronary intervention in Massachusetts [(1)][1]. Washington State’s Cardiac Care Outcomes Assessment Program (COAP) offers an important

Hemostasis after transradial access is usually achieved with a mechanical compression device. This study investigated the efficacy of the QuikClot Radial pad (QCRP) on hemostasis times compared with mechanical compression with a TR Band. Patients undergoing cardiac procedures using the radial

The prevalence of atrial fibrillation (AF) is estimated to be 12 million by the year 2030. A subset of those patients fall into the category of post-operative atrial fibrillation (POAF) and either develop POAF after cardiac procedures [coronary artery bypass graft (CABG) and valvular procedures] or non-cardiac procedures. With the rise in surgical procedures, POAF represents a significant economic burden. POAF usually converts to sinus rhythm on its own, prompting questions about whether there is a need to treat it and if there is a need for anticoagulation. This review discusses risk factors, pathophysiology, complications of POAF, and mechanisms of risk stratifying patients to determine when to anticoagulate.

BACKGROUND Surveillance and prevention of surgical site infections (SSIs) is becoming increasingly important as the number of surgical procedures performed in the United States rise. Despite improvements in technology and infection prevention best practices, SSI's are major cause of morbidity and mortality. It is estimated that half of SSIs are preventable by applying evidence-based strategies, including systemic surveillance with attention to multiple factors, including patient risk factors, procedural risk factors, and risk factors related to the hospital environment. In one Minnesota hospital active surveillance for infections following coronary artery bypass grafts ceased at the end of 2017 due to low incidence of infection. The following fall, through passive surveillance, Infection Preventionists detected an increase in surgical site infections following cardiac procedures. Cases were analyzed for similarities and active surveillance was reinitiated. METHODS Through surveillance for methicillin-susceptible Staphylococcus aureus (MSSA) in sterile sites, two deep incisional primary SSI's were detected in patients in September 2018 following coronary artery bypass grafts (CBGs). Using the definitions provided by the National Healthcare Safety Network (NHSN) all cardiac procedures performed at this facility between April 1st and September 30th, 2018 were reviewed for additional infections. RESULTS The review revealed an additional four SSI's following CBGs: Two superficial incisional primary infections and one superficial incisional secondary infection. As a result, the SSI rate associated with CBG surgeries for that time period increased to 4.84/100 procedures, above the target rate of ≤1.0/100 procedures. Four of 6 (67%) infections were a result of Staphylococcus aureus raising concern for improper nasal decolonization practices prior to surgery. Infection Preventionists engaged the Cardiac Surgery Council to discuss infection prevention best practices before and during surgical procedures. CONCLUSIONS Continued surveillance for SSI's following cardiac procedures is a necessary means of preventing infections in a facility and detecting breaches in infection control during surgical procedures.

Purpose Patients with a history of previous sternotomy often pose difficult surgical challenges for subsequent cardiac procedures. We hypothesized that the less invasive complete sternal-sparing approach would demonstrate favorable outcomes compared to full sternotomy (FS) for patients with a history of previous sternotomy. Methods We retrospectively reviewed all patients implanted with a HeartMate 3 (HM3) at our institution from September 2017 through September 2018 (n=63). Patients were included if they had history of prior sternotomy and separated into groups based on LVAD implantation technique: CSS versus re-operative sternotomy. Preoperative characteristics and postoperative outcomes were compared between cohorts. Results Of the 17 (30%) HM3 patients with a history of previous sternotomy, 10 (59%) were implanted via CSS and 7 (41%) by re-operative sternotomy. The CSS cohort tended to be older (65±6 vs 56±11 years, p = 0.055) and more likely to have undergone CABG (80% vs 14%, p = 0.015) while the FS cohort was more likely to have undergone previous aortic valve replacement (71% vs 10%, p = 0.035) (Table). The CSS cohort demonstrated fewer overall complications (30% vs 86%, p = 0.050) including a decreased incidence of severe right ventricular failure (0% vs 57%, p = 0.015). There was a trend towards shorter ICU length of stay (median, [IQR]; 4 [3-6] vs 14 [4.5-32] days, p = 0.218), total hospital length of stay (13 [12-24] vs 32.5 [20.5-61.5] days, p = 0.104) and improved 30-day survival (90% vs 57%, p = 0.250) in the CSS cohort. Conclusion LVAD implantation via CSS approach demonstrates fewer complications and decreased incidence of severe right ventricular failure in patients undergoing re-operative cardiac surgery. The CSS approach is our preferred surgical implantation technique for this patient population.

Robotic C-arm cone beam computed tomography (CBCT) systems are playing an increasingly pivotal role in interventional cardiac procedures and high precision radiotherapy treatments. One of the main challenges in any form of cardiac imaging is mitigating the intrinsic motion of the heart, which causes blurring and artefacts in the 3D reconstructed image. Most conventional 3D cardiac CBCT acquisition techniques attempt to combat heart motion through retrospective gating techniques, whereby acquired projections are sorted into the desired cardiac phase after the completion of the scan. However, this results in streaking artefacts and unnecessary radiation exposure to the patient. Here, we present our Adaptive CaRdiac cOne BEAm computed Tomography (ACROBEAT) acquisition protocol that uses the patient's electrocardiogram (ECG) signal to adaptively regulate the gantry velocity and projection time interval in real-time. It enables prospectively gated patient connected imaging in a single sweep of the gantry. The XCAT digital software phantom was used to complete a simulation study to compare ACROBEAT to a conventional multi-sweep retrospective ECG gated acquisition, under a variety of different acquisition conditions. The effect of location and length of the acquisition window and total number of projections acquired on image quality and total scan time were examined. Overall, ACROBEAT enables up to a 5 times average improvement in the contrast-to-noise ratio, a 40% reduction in edge response width and an 80% reduction in total projections acquired compared to conventional multi-sweep retrospective ECG gated acquisition.

Availability of cardiac catheterization facilities at the admitting hospitals is an important determinant of receipt of invasive cardiac procedures such as coronary angiography (CA) and percutaneous coronary intervention (PCI). This study evaluates the receipt of invasive cardiac procedures and

Aim. To compare the effectiveness of poststernotomy mediastinitis treatment in 41 patients who underwent vacuum-assisted closure or closed irrigation treatment. Methods. A retrospective analysis of 41 cases of sternal wound infection identified in patients who underwent cardiac surgery between 2007 and 2012. 18 patients (the first group) were treated using closed irrigation, 23 patients (the second group) - using vacuum-assisted closure. We compared the time interval for wound healing and drainage, serum levels of C-reactive protein and blood leukocyte counts on admission and at different time points until discharge. Results. In patients who were treated using vacuum-assisted closure, wound debridement and healing were achieved at shorter terms, and lower rate of complications were observed. There were 8 (44.4%) relapses requiring repeated surgery and debridement in the first group compared to 3 (13%, p=0.01) in the second group. C-reactive protein level decreased more rapidly in patients who were treated using vacuum-assisted closure (p 0.02). The duration of hospital stay was 67±4.1 days in the first group compared to 29.6±8.4 days in the second group (p=0.019). Moreover, patients who were treated using vacuum-assisted closure did not experience any significant discomfort and stayed active. Histological examination of the soft tissues showed marked lymphoid and plasma-cell reaction and neoangiogenesis by the end of the second week of vacuum-assisted closure. Conclusion. The use of vacuum-assisted closure shortens the term of wound debridement, granulating tissue formation and the duration of hospital stay compared to closed irrigation treatment.

This study examined the effect of cardiac procedure and perceived social support on anxiety and depression among cardiac patients. The sample included 100 cardiac patients consisting of equal number of patients referred for coronary angiogram and coronary artery bypass surgery. They completed measures of perceived social support, hospital anxiety and depression. The results revealed a significant effect of cardiac procedure on perceived social support, anxiety, and depression. Perceived social support yielded significant negative impact on anxiety and depression.

Surgeries in general and cardiac procedures in particular are increasingly performed using catheter-based or minimally invasive techniques, often with sedation or general anesthesia. These new approaches require close cooperation and communication between the cardiologist and anesthesiologist to ensure patient safety. Anesthesia-related respiratory complications arising in the catheterization laboratory are more frequent and more severe than are seen in the operating room. The principals of safe anesthetic practice as they apply to procedures performed outside the operating room and suggestions to improve safety and outcome are reviewed in this article.

Background In our effort to reduce the use of blood products in cardiac operations in a health care system, we noted variations in transfusion practices among facilities. Interestingly, surgeons practicing at the same hospital had similar transfusion rates. We sought to quantitate the contribution of hospital influence on individual surgeons' transfusion practices. Methods Blood transfusion data for coronary artery bypass graft operations at 12 Providence Health & Services facilities between January 2008 and June 2011 were reviewed. Frequency of perioperative blood transfusion, amount of transfusion, components transfused, and timing of transfusions were compared. Variation among surgeons at the same institution vs between institutions was computed based on multilevel mixed-effect logistic and linear regression models. Intraclass correlation coefficients were calculated. Results A total of 5,744 nonemergency first-time coronary artery bypass graft procedures were performed by 42 not-low volume (n > 30 in 2.5 years) surgeons at 12 Providence Health & Services hospitals during the 3.5-year study period. Frequency, amount, timing, and blood component usage were different among facilities but relatively similar for surgeons within a facility. The variance of red blood cell transfusion rate among hospitals (.82) is more than two times that among surgeons practicing within the same hospital (.35). Thus, surgeons contribute 30% to the variation, and 70% of the total variation can be explained by the hospital effect. Conclusions In our multihospital system, the hospital that a surgeon practices at plays a larger role in determining blood utilization than the individual surgeon's preference.

Background Prior Canadian studies of cardiac procedure rates showed changes over time and regional variability, but more recent Canadian cardiac procedure rates are unknown. Methods We performed a study using the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry to evaluate the temporal trends and geographic distribution of cardiac procedures in Alberta from April 1, 2003 through March 31, 2010. Rates were age- and sex-standardized by means of the 1996 Canadian census. Results While the raw number of cardiac catheterizations in Alberta was nearly uniform through the study period, age- and sex-standardized cardiac catheterizations declined from a rate of 480 per 100,000 in 2003 to a rate of 430 per 100,000 in 2010. The percutaneous coronary intervention (PCI) rates also declined, from a rate of 186 per 100,000 in 2003 to 170 per 100,000 in 2010. The rates for coronary artery bypass grafts declined from 84 per 100,000 in 2003 to 42 per 100,000 in 2010. There was geographic variability, with northern regions characterized by rates that were higher than the provincial average rates, and southern regions characterized by rates lower than the provincial average. Conclusion During the study period, age- and sex-standardized rates of cardiac catheterization and PCI in Alberta declined, reversing previous trends of increasing PCI rates. The rates of coronary artery bypass grafts in Alberta declined significantly, suggesting a change in practice consistent with that seen elsewhere. There are geographic differences in rates of cardiac procedures. These data have implications for other regions of Canada, for which registry data may not be available.

The ability to perform catheter-based cardiac procedures has revolutionized cardiovascular care over the past several decades. Advances in 3D imaging techniques now allow the interventional cardiologist to visualize a 3D perspective of a variety of vascular and cardiac structures. This potentially allows not only for a better understanding of complex anatomy, but also acts as a tool to assist the operator in determining the proper size, orientation and placement of interventional devices used during percutaneous coronary intervention and structural heart disease interventions. This review details the development, evaluation, uses and potential future innovations relating to 3D imaging techniques and methods using C-arm based x-ray technology.

Background Centre volume is an important determinant of outcomes in patients requiring complex medical treatments or surgical procedures. Heart failure hospitalisation (HFH) has become an increasingly complex and resource intensive clinical event. We evaluated the effect of centre volume on mortality and costs in patients with HFH. Methods This was a retrospective registry-based analysis of adult patients discharged with a primary diagnosis of HF from hospitals across New York (NY) State over a 5-year period, between January 2009 and December 2013, using the Statewide Planning and Research Cooperative System inpatient discharge files. The primary outcome of interest was in-hospital mortality. All patients were followed from the day of admission to either in-hospital death or discharge alive. Results 300 972 HFHs from 198 facilities across NY State were included. Five-year centre volume was associated with a decrease in in-hospital mortality in unadjusted (HR=0.872, 95% CI 0.863 to 0.881, p Conclusions Higher centre volume was associated with lower HFH mortality but increased HFH costs and increased cardiac procedures in a cohort of Medicare and non-Medicare beneficiaries.

The ability of patients to accurately appraise healthcare quality is not well understood. Patient complaints and low satisfaction scores with physicians are associated with an increased risk of malpractice lawsuits and mortality, suggesting that patients can provide insight into healthcare quality.1–5 Physician rating websites have introduced a novel forum for patients to report their experiences. However, there are limited data on whether online ratings are associated with quality measures such as surgical outcomes. Previous studies investigating a link between patient satisfaction and healthcare outcomes are inconsistent.3,4,6–10 Thus, we investigated the association between online physician ratings and coronary artery bypass graft (CABG) mortality. We obtained surgeon-specific CABG outcomes from 2 publicly available sources: (1) the New York State Department of Health (https://www.health.data.ny.gov11) and (2) Pennsylvania’s Guide to Coronary Artery Bypass Graft Surgery (http://www.phc4.org/reports/cabg/1212). These databases have been well studied.13–16 We included 258 surgeons who met public reporting criteria for the most recent respective reporting periods (New York: n=135 and Pennsylvania: n=123). We focused on isolated CABGs as they are the most common cardiac procedure, and to minimize case-mix variation.11 ### New York This database provided the per-surgeon number of CABGs and mortalities, from discharged patients (December 2008–November 2011). Surgeons who performed at least 200 total cardiac procedures per time period and one or more operation per year of the time period were included.11 ### Pennsylvania This database provided the per-surgeon number of CABGs and mortalities, for discharged patients aged 30 and older (July 1, 2011–December 31, 2012). Surgeons who performed at least 30 CABGs annually were included.12 ### CABG Mortality Mortality for Pennsylvania was defined as death during the index hospitalization; for New York, mortality included death in hospital and within 30 days of discharge. Whereas New York provided both expected and adjusted …

Previous research found that the initiation of Hospital Compare (HC) quality reporting had little impact on patient outcomes. However little is known about its impact on hospital prices, which may be significant since insurers are positioned to respond to quality information when engaging hospitals in price negotiations. To explore this issue we estimate variants of difference-in-difference models allowing HC impacts to vary by levels of quality scores. We separately examine the effects of the three main scores (heart attack, heart failure, and combined mortalities) on transaction prices of two related cardiac procedures: bypass surgery and angioplasty. States which had mandated reporting systems preceding HC form the control group. Analyzing claims data of privately insured patients, we find that HC exerted downward pressure on prices, which we attribute to competitive pressures. However, hospitals ranked “above average” captured higher prices, thereby offsetting the overall policy effect. We conclude that HC was effective at constraining prices without penalizing high performers.

Dose optimization in radiological examinations is a mandatory issue: in this study local Diagnostic Reference Levels (lDRLs) for Clinical Mammography (MG), Computed Tomography (CT) and Interventional Cardiac Procedures (ICP) performed in our Radiology Department were established. Using a dose tracking software, we have collected Average Glandular Dose (AGD) for two clinical mammographic units; CTDIvol, Size-Specific Dose Estimate (SSDE), Dose Length Product (DLP) and total DLP (DLPtot) for five CT scanners; Fluoro Time, Fluoro Dose Area Product (DAP) and total DAP (DAPtot) for two angiographic systems. Data have been compared with Italian Regulation and with the recent literature. The 75th percentiles of the different dosimetric indices have been calculated. Automated methods of radiation dose data collection allow a fast and detailed analysis of a great amount of data and an easy determination of lDRLs for different radiological procedures.

INTRODUCTION The transaortic (TAo) approach has been proposed as an alternative to the transapical approach and can be used in concomitant procedures. We use the TAo transcatheter aortic valve replacement (TAVR) with other simultaneous cardiac procedures in high-risk patients who needed surgical management. MATERIALS AND METHODS Between September 2013 and September 2015, nine consecutive high-risk patients with severe aortic valve stenosis (AR) and combined tricuspid valve disease or coronary artery disease were treated with TAo TAVR and simultaneous tricuspid valve repair or coronary artery bypass grafting. RESULTS Mean postoperative pressure gradient at discharge was 13.4 ± 3.2 mmHg and AR grade >2/4 was observed in one case (11.1%). New pacemaker implantation was required in one case (11.1%). Device success was achieved in 88.9% (n = 8), 30-day mortality was in 11.1% (n = 1), and intermediate mortality was in 33.3% (n = 3). CONCLUSION TAo-TAVR approach offers definitive treatment to high-risk patients with coexisting complex cardiac lesions. Despite the relatively high 30-day and intermediate mortality, it is an option for selected high-risk patients.

Persistent left superior vena cava (PLSVC) is encountered occasionally during angiographic procedures. It usually coexists with right superior vena cava and drains to the right atrium through the coronary sinus, but multiple variations are described. Although PLSVC is extensively reported in the literature, there are very few articles addressing right heart catheterization in patients with isolated PLSVC. We present a patient with absent right superior vena cava and PLSVC draining to a dilated coronary sinus diagnosed during right heart catheterization in the setting of pulmonary hypertension. We were able to safely complete the procedure through the right internal jugular vein. Transthoracic echocardiography and chest CT scan were consistent with this finding. Although clinically silent most of the time, undiagnosed PLSVC can lead to catastrophic consequences when the patient undergoes invasive procedures. If PLSVC is suspected, the anatomy of the thoracic venous system must be identi-fied before invasive cardiac procedures.

Cardiac interventions often result in high radiation dose to patient's skin, so a reliable indicator in terms of a commonly used dose descriptor is required to monitor skin exposures. In the present study, Gafchromic XR-RV3 film was used to measure the peak skin dose (PSD) during 40 coronary angiography (CA) and 50 percutaneous transluminal coronary angioplasty (PTCA) procedures. Corresponding values of kerma-area product (PKA), fluoroscopy time (FT) and reference air-kerma (Ka,r) were recorded and correlated with PSD. Doses to patient's eyes and thyroid were also measured by using thermoluminescent dosimeters (TLDs) during PTCA procedures. The average dose to thyroid was about six times higher than the average dose to eyes. The mean values of PSD, PKA and FT were 1140 mGy, 97 Gy cm2 and 15.7 min for PTCA and 290 mGy, 21.1 Gy cm2 and 2.4 min for CA procedures, respectively. One in seven patients of PTCA procedure received PSD >2 Gy. With respect to FT, PKA may be used as a better predictor of skin exposures because the correlation of PSD with PKA was found better than with FT for both CA and PTCA procedures.

Delirium is an acute change in cognitive functioning, characterized by inattention and associated with alterations in awareness and fluctuation in arousal, disorganized thinking, or altered level that preferentially affects older adult patients. In the acutely ill cardiac patient, the incidence of delirium has been reported as high as 73%, depending on the type and sensitivity of delirium assessment. Cardiac patients with delirium experience higher rates of in-hospital and longer-term mortality and are at risk for progressive cognitive impairment, loss of functional independence, and increased hospitalization costs. As such, delirium represents an undesirable outcome in cardiac patients. Care improvements such as identifying risk of delirium at time of admission or in the preoperative setting; training cardiologist, surgeons, anaesthesiologists and nurses to screen for delirium; implementing delirium prevention programs; and developing standardized delirium treatment protocols might reduce the incidence of delirium and its associated morbidity.

Sometimes, cardiac catheterisation and electrophysiological procedures, diagnostic and interventional, require an anaesthesiological support. The anaesthesiologist receives radiation doses depending on various factors, such as type of procedure and exposure modality, anaesthesiological technique, individual protective devices and operator experience. The aim of this study was to investigate the dose per procedure, the exposure inhomogeneity and the effective dose, E, of a senior anaesthesiologist in the haemodynamic laboratory of Ospedali Riuniti, Bergamo. The dose monitoring was routinely performed with sets of several thermoluminescent dosemeters and an electronic personal dosemeter. The study covered 300 consecutive procedures over 1 y. The anaesthesiologist wore a protective apron, a thyroid collar and glasses (0.5 mm lead-equivalent).

increased frequency as well as in perioperative hemodynamic monitoring during noncardiac surgeries. Objectives: The aim of this analysis was to understand the evolution of the use of intraoperative TEE (iTEE) both in cardiac and noncardiac surgeries showing popular and challenging approaches in its use, and as a secondary goal, to understand the patterns to achieve competency. Methods: A literature review was carried out identifying relevant clinical studies published in last six years using the keywords listed below. Results: The quick acquisition of cardiac anatomy and function data give iTEE an importance in cardiac procedures that is undeniable, permitting refined diagnosis, detect unsuspected pathology, adjust both anesthetic and surgical plans and evaluate immediate surgical outcomes. Although, its use is less established in noncardiac surgery, the latest guidelines give an increasingly role for TEE in monitoring patients in high risk surgeries or in patients with several comorbidities that can compromise the hemodynamic status even in lower risk surgeries. iTEE is a multifaceted technical expertise and demonstration of competence is usually accomplished by successful conclusion of a training program and passing an examination. Restrictive factors to incorporating TEE proficiency into all anesthesia training include limited available equipment and trained operators. Conclusions: iTEE should be used as an auxiliary tool to have more comprehensive understanding of the patient's cardiovascular physiology and manage a most adequate anesthetic approach and surgical intervention. Meanwhile, it is advisable to have large systematic studies supporting its powerful value in both cardiac and noncardiac surgeries. Suitably, it is desirable an international adoption of TEE basic skills within anesthesia practice. Education is the most influential instrument to contribute in shifting the anesthesiology community’s standpoint of TEE use in daily clinical practice.

Noninvasive ventilation (NIV) is increasingly used in cardiac procedures such as percutaneous coronary revascularization in patients with pulmonary edema secondary to acute myocardial infarction, percutaneous cardiac valve procedures, electrophysiological procedures, and transesophageal echocardiography. Although some concerns regarding the use of NIV in these contexts may exist, a team well trained in managing NIV often safely carries out such procedures even in frail or high-risk patients.

Objectives Interventional cardiac procedures are traditionally performed using fluoroscopy, or, more recently, transesophageal echocardiography (TEE). Neither modality is widely available to practicing cardiologists worldwide. We examined whether balloon valvuloplasty of pulmonic stenosis (PS) and transarterial occlusion of patent ductus arteriosus (PDA) in dogs could be performed safely with transthoracic echocardiography (TTE). Animals A prospective consecutive case series of 26 client-owned dogs with PS ( n = 10) and PDA ( n = 16). Methods The cardiovascular procedures were performed using TTE. Each dog was positioned on a standard echocardiography table in right lateral recumbency (dogs with PS) or left lateral recumbency (dogs with PDA). Guide wires, balloon catheters, Amplatz ® Canine Ductal Occluder (ACDO) delivery sheaths, and ACDO were imaged by standard echocardiographic views optimized to allow visualization of the defects and devices. Results Procedures were performed successfully without major complications in 20 dogs. In 2 dogs (German shepherds) with Type III PDA, ACDO placement was unsuccessful; 2 other German Shepherds were excluded from the procedure because their ductal diameters, measured echocardiographically, exceeded the limits of the maximal ACDO size. Two dogs weighing ≤3.5 kg had suboptimal echocardiographic visualization of the PDA and were considered too small for safe ACDO deployment. All intravascular devices at the level of the heart and great vessels appeared hyperechoic on TTE image and could be clearly monitored and guided in real-time. Conclusions We have demonstrated that TTE monitoring can guide each step of pulmonic balloon valvuloplasty and PDA occlusion without fluoroscopy.

Summary Background: Since 1987, a nationwide annual survey of percutaneous cardiac interventions has been performed in Switzerland to assess trends in endovascular cardiac procedures. Methods: The volume and type of endovascular cardiac procedures performed during the year 2010 were collected by means of a standardised questionnaire from all adult cardiac intervention centres in Switzerland. Results: The number of coronary angiographies (2010: n = 42 648; +2.5% compared to 2009) and percutaneous coronary interventions (n = 19 925; +4.7%) continued to increase with a slight increase in the PCI/CA ratio (46.7%; 2009: 45.7%). After a decrease from 2006 to 2007 and a plateau from 2007 to 2009, the proportion of drug-eluting stents (DES) raised again to 79% in 2010 (2009: 72%). Apart from shunt closures which remained stable (closure of patent foramen ovale [n = 733; 2009: n = 728] and atrial septal defects [n = 142; 2009: n = 152]), the number of procedures for structural heart disease increased in 2010 mainly due to an increasing number of transcatheter aortic valve implantations (n = 382 performed in 11 centres; 2009: n = 277 performed in 8 centres) although the number of procedures for transcatheter mitral valve repair rose as well (n = 67; 2009: n = 33). Conclusions: The number of both CA and PCI procedures increased in Switzerland in 2010 compared with the previous year. However, the most expanding segment of percutaneous cardiac intervention involved those for structural heart disease, namely TAVI.

ObjectivesWe sought to determine whether radial artery access is associated with increased radiation exposure during cardiac catheterization and whether this relationship differs between operators, after adjustment for clinical and patient characteristics associated with greater radiation exposure.BackgroundAlthough previous studies have demonstrated a relationship between radial access and increased radiation exposure to the patient during fluoroscopy-guided cardiac procedures, such studies did not account for differences in operator technique or clustering of patients, procedure complexity, or patient size. Those studies included data from few operators.MethodsData were collected prospectively on 5,954 diagnostic cardiac catheterizations performed at a tertiary cardiac center. A multilevel regression analysis was used to determine the relationship between radial artery access and radiation exposure.ResultsAfter adjustment for multiple factors, radial access was associated with increased exposure (beta = 0.22, p < 0.0001) when compared with the use of femoral access, as measured using the logarithmically transformed air kerma (LogAK). On average, radial access accounted for a 23% increase in measured AK. This was consistent between operators. There were observed differences in the mean LogAK between operators (p = 0.0158), as well as substantial variation in measured LogAK between patients within each operator's practice (p < 0.001).ConclusionsRadial artery access cardiac catheterization was associated with increased radiation exposure to the patient when compared with femoral access. The measured AK was still far below the threshold for deterministic effects in most patients studied. Observed variations in AK between and within operators may point to better opportunities to reduce exposure.

Introduction and objectives: Minimally invasive approaches in less-complex cardiac procedures can avoid unpleasant cosmetic results. Moreover, surgery can be scheduled in younger patients. In previous papers, we compared submammary and midline sternotomy. We present our initial experience with an axillary, compared to submammary, approach to repair atrial septal defects under extracorporeal

Real time 3-dimensional transesophageal echo is a relatively new technology that enables online imaging that is highly accurate and precise for evaluating cardiac structures. Moreover, this methodology allows for accurate online guidance of interventional cardiac procedures for structural heart disease. In this report, we describe the use of real time, 3D transesophageal (TEE) for aortic valve replacement with percutaneous, bioprosthetic valves as well as for transcatheter mitral repair with the MitraClip device. For each procedure, we describe 3D evaluation of valvular structures prior to the procedure, and how 3D imaging is used to guide the procedure as well as to assess the results of the procedure. Use of 3D TEE has proven to be a substantial advance for evaluating patients prior to percutaneous heart valve procedures and especially for guiding and monitoring percutaneous, transcatheter heart valve procedures.