Cardiac catheterization in patients with end‐stage liver disease: Safety and outcomes

Introduction : Patients with end‐stage liver disease (ESLD) awaiting transplant are at increased risk of bleeding. Nevertheless, these patients routinely undergo cardiac catheterization for various indications. Safety and outcomes of cardiac catheterization in these patients are not well reported. Methods : In a case–control study 43 patients with ESLD who underwent angiography for liver transplant work‐up were compared to 43 age and gender‐matched controls with no liver dysfunction. In‐hospital outcomes and procedural variables were compared. Results : Patients with ESLD had a lower baseline hemoglobin (12.1 ± 2.1 vs. 13.7 ± 1.8, P < 0.0005), lower platelet counts (86.8 ± 66 vs. 247 ± 80, P < 0.0001) and higher international normalized ratio (INR) (1.4 ± 0.2 vs. 1.1 ± 0.2, P < 0.0001) than controls. Among ESLD group, five (11.6%) patients received platelet transfusions, one received blood transfusion, and three patients (7%) with INR > 1.6 received fresh frozen plasma (FFP) compared with none in the control group. Smaller size (four French) vascular sheaths were used more frequently in the group with ESLD (16% vs. 4%, P = 0.04). There were no significant vascular or bleeding complications in either group. Conclusions : Elective cardiac catheterization can be safely performed in patients with ESLD with outcomes (vascular and bleeding complications, length of hospital stay and in‐hospital mortality) similar to patients without liver disease despite significant thrombocytopenia and elevated INR in patients with ESLD. Practices such as platelet transfusion for platelets <60,000 μL, prophylactic FFP transfusion for INR ≥≥ 1.6, less frequent use of antiplatelet therapy and more frequent use of smaller vascular sheaths may have contributed to the safety of cardiac catheterization in ESLD patients. © 2010 Wiley‐Liss, Inc.     

Safety and efficacy of repeat transradial access for cardiac catheterization procedures.

To determine the safety and efficacy of repeat transradial cardiac catheterization, 1,362 consecutive transradial procedures were examined. Repeat transradial procedures were identified (group I, n = 73) and compared with index procedures (group II, n = 1,289). Baseline patient characteristics, procedure success rates (100% vs. 97.9%; P = NS), complication rates (0% vs. 0.08%; P = NS), and procedure times (23.9 +/- 27.3 min vs. 18.2 +/- 14.7 min; P = NS) were similar between groups. This study suggests that repeat transradial catheterization procedures can be performed safely and successfully in appropriately selected patients.     

Transradial cardiac catheterization: A Review of Access Site Complications

Transradial catheterization (TRC) has been associated with a lower incidence of major access site related complications as compared to the transfemoral approach. With the increased adoption of transradial access, it is essential to understand the potential major and minor complications of TRC. The most common complication is asymptomatic radial artery occlusion, which rarely leads to clinical events, owing to the dual collateral perfusion of the hand. Adequate anticoagulation, appropriate compression techniques, and smaller sheath size can minimize the risk of radial artery occlusion. Hand ischemia with necrosis has never been reported during TRC with thorough pre‐examination of intact collateral circulation. Radial artery spasm is relatively common, and can result in access and procedural failure. It can be prevented by the use of vasodilator cocktails and hydrophilic sheaths. Radial artery perforation can lead to severe forearm hematoma and compartment syndrome if not managed promptly. Careful observation, prompt detection of the hematoma, and management with a pressure bandage dressing are critical to avoid serious complications. Pseudoaneurym and arteriovenous fistula are rare complications, which can likely be managed conservatively without surgical intervention. Nerve injury occurring during access has been reported. Close observation for improvement is necessary, although symptoms usually improve over time. In summary, to prevent access site complications, avoidance of multiple punctures, gentle catheter manipulation, use of guided compression, coupled with careful observation for adverse warning signs such as hematoma, loss of pulse, pain, are critical for safe and effective TRC. © 2011 Wiley Periodicals, Inc.     

Utility of cardiac catheterization in pediatric cardiac patients on ECMO

Cardiac catheterization has been utilized rarely in children on extracorporeal membrane oxygenation (ECMO). We performed a retrospective review of 15 children with congenital heart disease who had undergone catheterization while on ECMO from December 1990–December 1995. The procedures, including four interventions, were successful in all patients with adequate evaluation of clinical questions. Unexpected diagnostic information of clinical importance was obtained in 40%, and clinical management of patients was significantly altered in 73%. All patients tolerated the procedure and transport well. The only significant complication was a retroperitoneal hemorrhage in one patient after approximately 12 hr. Although no patients died at catheterization, overall survival was poor, with 50% weaning from ECMO, 29% surviving to discharge, and 14% surviving at follow-up. We conclude that diagnostic and interventional catheterization may be performed in patients on ECMO with acceptable morbidity and mortality; however, long-term survival in this population is poor. Cathet. Cardiovasc. Intervent. 46:62–67, 1999. © 1999 Wiley-Liss, Inc.     

A comparison of arterial versus venous-activated clotting time in patients with congenital heart disease undergoing cardiac catheterization

Studies in adult patients undergoing percutaneous coronary angioplasty have demonstrated differences in measured activated clotting time (ACT) in venous vs. arterial blood samples. Ninety-two patients with congenital heart disease undergoing cardiac catheterization were prospectively evaluated to compare venous vs. arterial ACT values in monitoring heparin effect in this population. Simultaneous venous and arterial ACT samples were drawn at baseline, 10 min, 60 min, and every 30 min thereafter until each case was finished. ACT values were determined simultaneously with a dual-chambered Hemochron 801 instrument. At baseline and throughout the study up to 90 min, venous and arterial ACT values were not significantly different. They were also no different in the subgroup of cyanotic patients. Therefore, venous and arterial ACT values can be safely used alternatively to guide heparin dosing during cardiac catheterization in patients with congenital heart disease without the risk of undercoagulation. Cathet. Cardiovasc. Intervent. 46:194–196, 1999. © 1999 Wiley-Liss, Inc.     

Interruption of blood flow during compression and radial artery occlusion after transradial catheterization.

OBJECTIVES: To analyze the possible relationship between compression after transradial catheterization and radial artery occlusion. Background: Radial artery occlusion is an important concern of transradial catheterization. Interruption of radial artery flow during compression might influence the rate of radial artery occlusion at follow-up. METHODS: A prospective study including 275 consecutive patients undergoing transradial catheterization was conducted. Arterial sheaths were removed immediately after procedures and conventional compressive dressings were left in place for 2 hr. The pulse oximeter signal in the index finger during ipsilateral ulnar compression was used for the assessment of radial artery flow. RESULTS: Radial artery flow was absent in 174 cases (62%) immediately after entry-site compression. After 2 hr of conventional hemostasis, radial artery flow was absent in 162 cases (58%) before bandage removal. At 7-day follow-up, 12 patients (4.4%) had absent pulsations and radial artery flow was absent in 29 cases (10.5%). Patients with an occluded radial artery at follow-up had significantly smaller arterial diameters at baseline (2.23+/-0.4 mm vs. 2.40+/-0.5 mm; P=0.032) and more frequently had absent flow during hemostasis (90% vs. 54%, P<0.001). Stepwise logistic regression analysis revealed that absent flow before compressive bandages removal was the only independent predictor of radial artery occlusion at follow-up (OR=6.7; IC 95%: 1.95-22.9; P=0.002). CONCLUSIONS: Flow-limiting compression is a frequent finding during conventional hemostasis after transradial catheterization. Absence of radial artery flow during compression represents a strong predictor of radial artery occlusion.     

Mobile cardiac catheterization: Comparison with outpatient and inpatient catheterization at tertiary facilities

The study group included 1,553 consecutive patients from areas serviced by our mobile catheterization laboratories: 719 procedures were performed in the mobile unit at their local hospitals, 277 were performed at a tertiary hospital with less than a 24 hr hospital stay, and 557 were performed at a tertiary hospital as inpatients. The indications for mobile catheterization were predominantly atypical chest pain, angina pectoris, or positive treadmill stress test, whereas patients with less than 24 hr hospitalization at the tertiary center had their catheterization performed for additional reasons. The majority of the inpatient indications were for recent myocardial infarction or unstable angina. Using the American College of Cardiology/American Heart Association (ACC/AHA) criteria for outpatient catheterization, the mobile catheterizations were performed safely with a complication rate of only 0.7% compared to a complication rate of 3.1% for inpatients demonstrating that a low risk group of patients can be prospectively identified and catheterized safely in the mobile setting. An extremely high risk group of patients with ongoing unstable angina and recent myocardial infarction was also identified which should undergo catheterization only at a tertiary center.     

Model for end‐stage liver disease,model for end‐stage liver disease‐sodium and Child–Turcotte–Pugh scores over time for the prediction of complications of liver cirrhosis

Background/Aims: There has been no report concerning the predictive capability of each scoring system in determining the development of complications of liver cirrhosis such as variceal bleeding and/or hepatic encephalopathy. Methods: We retrospectively studied 128 patients with liver cirrhosis [92 males; mean (standard deviation) 54.2 (11.2) years] admitted to our institution from March 2004 to April 2006. Seventy‐three patients (57.0%, group 1) were admitted because of complications of cirrhosis and 55 patients (43.0%, group 2) were admitted for causes unrelated to complications of cirrhosis. We calculated values for model for end‐stage liver disease (MELD), MELD‐sodium (MELD‐Na) and Child–Turcotte–Pugh (CTP) scores on admission and at 3 and 6 months before admission. Each delta score was defined as the difference in the scores of 3 and 6 months before admission. Results: The relative risk for complications in the patients with ΔMELD/3 months ≥1.35, ΔMELD‐Na/3 months ≥1.35 and ΔCTP/3 months ≥1 was 2.05 [95% confidence intervals (CI) 1.47–2.85, P<0.01], 2.04 (95% CI 1.45–2.88, P<0.01) and 1.98 (95% CI 1.39–2.81, P<0.01) respectively. The area under the receiver‐operating characteristic curves of ΔMELD/3 months, ΔMELD‐Na/3 months and ΔCTP/3 months for the occurrence of cirrhotic complications were 0.691, 0.694 and 0.722 respectively. A higher ΔMELD/3 months (≥1.35), ΔMELD‐Na/3 months (≥1.35) and ΔCTP/3 months (≥1) was associated with decreased survival. Conclusions: Delta model for end‐stage liver disease/3 months, ΔMELD‐Na/3 months and ΔCTP/3 months were clinically useful parameters for predicting the occurrence of cirrhotic complications.     

Complications of cardiac catheterization and angiography in patients with valvular heart disease

Complications were surveyed prospectively in 2,029 catheterizations performed on 1,483 patients from the 13 centers participating in the VA Cooperative Study on Valvular Heart Disease. Complications were reported in 6.9% of 1,559 preoperative procedures of which 2.6% were major and 0.2% fatal. Clinical predictors of complications were hypertension and the precatheterization diagnosis of aortic stenosis. Nevertheless, patients with aortic stenosis successfully tolerated left ventriculography, which was routinely performed regardless of the magnitude of gradient. Procedural predictors of complication were brachial arteriotomy (vascular occlusion) and transseptal catheterization (tamponade). Among the 470 postoperative catheterizations performed solely for research purposes, there were six complications, of which five were bleeding events in patients taking warfarin. Transseptal catheterization was safer in postoperative patients with no cases of tamponade in 125 procedures.     

Dynamic arm exercise during cardiac catheterization in the assessment of stenotic valvular disease

Assessment of hemodynamic responses during some form of exertion or stress during cardiac catheterization is useful among patients suspected of having valvular stenosis who demonstrate normal or borderline valve gradients at rest. Leg raising exercise and drug administration are commonly used for this purpose, but each has inherent limitations. To evaluate the usefulness of dynamic arm raising exercise as a means of altering hemodynamics during cardiac catheterization, 23 such patients were studied. Measurements obtained during arm raising exercise were compared with those at rest. Heart rate rose by 34 +/- 4 beats/min (p less than 0.001), while cardiac output increased by 1.4 +/- 0.2 l/min (p less than 0.001). Stroke volume decreased slightly, although left ventricular filling pressures and pulmonary capillary wedge pressures rose in nearly all subjects. The change in valvular gradients was variable. These data were compared with those obtained in 11 similar patients receiving either dopamine or isoproterenol as an intervention. The changes in heart rate and cardiac output from the resting state were similar between the groups, with fewer side effects occurring during arm exercise. Dynamic arm exercise is a safe and effective maneuver which can be performed during cardiac catheterization in patients undergoing diagnostic evaluation of stenotic valvular disease.     

Cardiac perforation with tamponade during cardiac catheterization

Among 6,675 adult patients undergoing cardiac catheterization in our institution, three patients developed cardiac perforation and tamponade (incidence 0.04%). Two perforations involved the left atrium, and one the right atrium. Tamponade developed in the three patients. Hemodynamic confirmation of tamponade was available in two patients. Pericardiocentesis was performed in all three patients. Two patients required emergency surgery. All patients recovered.     

Is it safe to perform cardiac catheterizations on adults with congenital heart disease in a pediatric catheterization laboratory?

OBJECTIVE: To determine the complication rate during the catheterization in adults with congenital heart disease (CHD) in a pediatric catheterization laboratory (PCL). BACKGROUND: An increasing number of patients with CHD are surviving into adulthood, with diagnostic and interventional cardiac catheterization being essential for the management of their disease. The complication rate during the catheterization of adults with CHD has not been reported. METHODS: A retrospective chart review was performed on all adult patients (>18 years) with CHD who underwent diagnostic or interventional catheterization in our PCL within the past 8.5 years. RESULTS: A total of 576 procedures were performed on 436 adult patients (median age 26 years). Complex heart disease was present in 387/576 (67%) procedures. An isolated atrial septal defect or patent foramen ovale was present in 115/576 (20%) procedures, and 51/576 (9%) procedures were performed on patients with structurally normal hearts with arrhythmias. Interventional catheterization was performed in 378/576 (66%) procedures. There were complications during 61/576 (10.6%) procedures; 19 were considered major and 42 minor. Major complications were death (1), ventricular fibrillation (1), hypotension requiring inotropes (7), atrial flutter (3), retroperitoneal hematoma, pneumothorax, hemothorax, aortic dissection, renal failure, myocardial ischemia and stent malposition (1 each). The most common minor complications were vascular entry site hematomas and hypotension not requiring inotropes. Procedures performed on patients > or = 45 years of age had a 19% occurrence of complications overall compared with 9% occurrence rate in patients of age < 45 years (P < 0.01). CONCLUSIONS: The complication rate during the catheterization of adults with CHD in a PCL is similar to the complication rate of children with CHD undergoing cardiac catheterization. The older subset of patients are more likely to encounter complications overall. The encountered complications could be handled effectively in the PCL. With screening in place, it is safe to perform cardiac catheterization on most adults with CHD in a PCL.