Use of monorail PTCA balloon catheter for local drug delivery

We report the use of monorail coronary balloon as an infusion catheter to give bailout abciximab selectively into the site of stent thrombosis as an adjunct to plain old balloon angioplasty (POBA) in a patient of subacute stent thrombosis of the left anterior descending coronary artery. The balloon component (polyamide material) of the monorail balloon catheter was shaved off the catheter so that abciximab injected through the balloon port of the catheter exited out the shaft of the balloon catheter at the site from where the balloon material was shaved off. We believe that selective infusion with abciximab along with POBA established antegrade flow and relieved the patient's ischemia. In the absence of essential hardware to give intracoronary drugs in an emergency situation, one may employ our technique of infusion through a monorail balloon catheter after shaving the balloon component from the catheter.     

Initial experience with the "Big-Skinny" angioplasty catheter

We describe our initial experience with the "Big Skinny" angioplasty catheter, currently only available as an investigational device and in sizes of 4.5, 5, and 6 mm. Six patients with severe angina pectoris were successfully dilated with this angioplasty catheter and have remained asymptomatic up until a mean follow-up period of 6 months. However, because of the large profile of the catheter, sufficient back-up with an adequate guiding catheter should be obtained and predilation with a smaller angioplasty catheter should be performed. The use of this catheter may be a more simple alternative for the treatment of oversized vessel stenosis than the "hugging balloon" technique or directional atherectomy. Otherwise, it may be considered as an adjunct technique in order to optimize the angiographic result after stenting or directional arthrectomy in this particular indication.     

Erfolgreiche Ablation einer rechts-lateralen akzessorischen Leitungsbahn unter kombiniertem Einsatz einer langen intrakardialen Schleuse und eines intrakoronaren Mapping-Katheters in der rechten Kranzarterie

We present a patient with an accessory pathway difficult to ablate in the right free wall. Two prolonged and failed attempts at radiofrequency catheter ablation of this accessory pathway in other institutions led to a third attempt in our hospital. Successful outcome of accessory pathway ablation was achieved by mapping the right free wall using an intracoronary catheter in the right coronary artery. A long vascular sheeth was introduced in the right femoral vein, manipulated into the tricuspid anulus, which allowed a stable catheter position with adequate tissue contact of the ablation catheter at the target site. The combination of exact mapping and adequate tissue contact of the ablation catheter as described above facilitated successful outcome in this patient. Further investigation is necessary to determine the role of this technique as first choice therapy in patients prone to develop recurrence of accessory pathway conduction or primary failure of catheter ablation.     

Efficacy of enoxaparin,certoparin and dalteparin in preventing cardiac catheter thrombosis: an in vitro approach

Owing to its beneficial pharmacological profile, the low-molecular-weight heparin (LMWH) enoxaparin is increasingly being taken as an alternative to UFH in the treatment of ACS with an early invasive strategy and in elective percutaneous coronary interventions (PCI). Insufficient anticoagulation increases the risk of catheter thrombus formation during PCI. The aim of the present study was to test in vitro the hypotheses that (i) inhibiting thrombin or thrombin generation by administering LMWH is a critical intervention in preventing catheter thrombus formation and (ii) other LMWH such as certoparin or dalteparin are as effective as enoxaparin. Blood pre-treated with the anticoagulants of interest was continuously circulated through a guiding catheter by using a roller pump for a maximum experimental period of 60 min or until the catheter became occluded. Overall thrombus weight, anti-Xa activity and electron microscopic features such as deposits of platelets, erythrocytes and fibrin on the catheter surface were quantified as endpoints. All LMWH tested significantly reduced catheter thrombus generation comparable to UFH treatment whereas there was no difference between the specific LMWH with respect to catheter thrombus formation or deposition of platelets, erythrocytes and fibrin. Thrombus generation was found to negatively correlate with anti-Xa activity. The additional use of eptifibatide did not affect thrombus formation. These data suggest that modulating plasmatic coagulation by employing LMWH is critical for preventing catheter thrombus formation and at the same time offer a potential for administering LMWH other than enoxaparin, such as certoparin or dalteparin, in the setting of PCI.     

Rapid acquisition of high-resolution electroanatomical maps using a novel multielectrode mapping system

Purpose

Conventional electroanatomical mapping systems employ roving catheters with one or a small number of electrodes. Maps acquired using these systems usually contain a small number of points and take a long time to acquire. Use of a multielectrode catheter could facilitate rapid acquisition of higher-resolution maps through simultaneous collection of data from multiple points in space; however, a large multielectrode array could potentially limit catheter maneuverability. The purpose of this study was to test the feasibility of using a novel, multielectrode catheter to map the right atrium and the left ventricle.

Methods

Electroanatomical mapping of the right atrium and the left ventricle during both sinus and paced rhythm were performed in five swine using a conventional mapping catheter and a novel, multielectrode catheter.

Results

Average map acquisition times for the multielectrode catheter (with continuous data collection) ranged from 5.2 to 9.5 min. These maps contained an average of 2,753 to 3,566 points. Manual data collection with the multielectrode catheter was less rapid (average map completion in 11.4 to 18.1 min with an average of 870 to 1,038 points per map), but the conventional catheter was slower still (average map completion in 28.6 to 32.2 min with an average 120 to 148 points per map).

Conclusions

Use of this multielectrode catheter is feasible for mapping the left ventricle as well as the right atrium. The multielectrode catheter facilitates acquisition of electroanatomical data more rapidly than a conventional mapping catheter. This results in shorter map acquisition times and higher-density electroanatomical maps in these chambers.     

Condom versus indwelling urinary catheters: a randomized trial

OBJECTIVES: To compare condom and indwelling urinary catheters in terms of infection risk and patient satisfaction. DESIGN: A prospective, randomized, unblinded, controlled trial. SETTING: An academically affiliated Veterans Affairs Medical Center. PARTICIPANTS: Hospitalized men aged 40 and older who required a urinary collection device. MEASUREMENTS: The incidence of adverse outcomes (bacteriuria, symptomatic urinary tract infection (UTI), or death) and patient device-related satisfaction as determined according to a questionnaire. Dementia status was recorded to assess effect modification by the presence of dementia. RESULTS: Seventy-five subjects were randomized: 41 receiving an indwelling catheter and 34 a condom catheter. The incidence of an adverse outcome was 131/1,000 patient-days with an indwelling catheter and 70/1,000 patient-days with a condom catheter (P=.07). The median time to an adverse event was 7 days in the indwelling group and 11 days in the condom group. After adjusting for other risk factors, it was found that condom catheter use reduced adverse outcomes (P=.04). Patients without dementia who had an indwelling catheter were approximately five times as likely to develop bacteriuria or symptomatic UTI or to die (hazard ratio=4.84, 95% confidence interval=1.46-16.02) as those with a condom catheter (P=.01). Patients reported that condom catheters were more comfortable (P=.02) and less painful (P=.02) than indwelling catheters. CONCLUSION: The use of condom catheters is less likely to lead to bacteriuria, symptomatic UTI, or death than the use of indwelling catheters. This protection is especially apparent in men without dementia.     

Bronchoscopic protected catheter brush for the diagnosis of pulmonary infections

A new bronchoscopic-protected catheter brush (BPCB), designed to obtain uncontaminated bronchial secretions, was studied in vitro and in vivo. The device was composed of a standard biopsy brush, protected by a single catheter and occluded with an agar plug. Ejection of the plug was obtained neither by advancing the brush nor by advancing an inner cannula (as in a telescoping catheter brush), but instead, by an air flux, provided by a syringe which was connected to the proximal tip. In the first part of the study the ability of the BPCB to obtain uncontaminated specimens was tested in comparison with the reference telescoping catheter brush (BFW brush 10/70/90, Medi-Tech Corp Watertown, MA). Catheters of each type were successively passed through the inner channel of a bronchofiberscope which was contaminated with Klebsiella pneumonia. After ejection of the distal plug, sampling of bronchial secretions infected with a marker organism (Pseudomonas aeruginosa), was performed with the brush. Culture of brush specimens of each type of catheter grew the marker organism in pure culture and obtained the same amount of bronchial secretions (0.001 ml). The manual vortexing of the brush in the transport medium (Ringer's solution) proved to be as effective as the mechanical vortexing so that transecting of the brush was no longer mandatory. In the second part of this study, paired bronchial samplings from 27 patients were performed using both types of catheters and similar results for both were obtained. In these in vitro studies, completed by a clinical trial, our single-sheathed, plugged catheter brush proved to be as reliable as the double telescoping catheter brush. However, because of its relatively simple conception, making it easier to use and lower in cost than the double catheter brush, routine use of this sampling device should be considered.     

Initial characterization of Ikari Guide catheter for transradial coronary intervention

Ikari is a new guide catheter for transradial intervention (TRI) that produces stronger back-up force by utilizing an unfavorable angle between the subclavian and brachiocephalic arteries. We report the initial results of the Ikari guide catheter based on the experience of a single center. Six operators performed a total of 102 coronary interventions for 91 patients using the Ikari guide catheter, while 101 interventions were performed with the transfemoral approach (TFI) during the same period. A left Ikari catheter was used in 63 procedures, and a right Ikari catheter was used in 39. The success rate for the procedure was 97% with a 6 French Ikari catheter. All failures were due to tortuous brachiocephalic arteries. For the Ikari procedure, the average fluorescence time was 14.5 9.5 minutes and the dye volume used was 153 53 ml; these results were equal to or better than those of TFI during the same period (20.1 12.2 minutes and 184 61 ml, respectively). These preliminary data suggest that an acceptable success rate can be achieved in TRI using appropriate guides, such as an Ikari catheter.     

Pneumococcal bacteremia associated with an infected central venous catheter

Pneumococcus (Streptococcus pneumoniae) bacteremia is a serious infection. Pneumococcus has never been implicated as a cause of a central venous catheter-related bacteremia. It has been isolated from the catheter tip only twice before, and in one case caused the infection of an infusion port device. We report case of a 41-year-old woman who developed pneumococcal bacteremia after 6 days of an indwelling central venous catheter. The catheter tip grew > 300 cfu of S pneumoniae by the roll-plate method described by Maki and colleagues. No other focus of infection could be found in this patient. To the best of our knowledge, this is the first reported case of pneumococcal bacteremia associated with an infected central venous catheter.     

Acute Exacerbation of Idiopathic Interstitial Pneumonia Triggered by Cardiac Ablation: The First Case Report

Acute exacerbation of idiopathic interstitial pneumonia (AE-IIP) is associated with invasive procedures and respiratory infections. However, there have been no reports of AE-IIP triggered by catheter ablation. We herein report a case of AE-IIP after catheter ablation for atrial fibrillation in an 82-year-old man who was diagnosed with IIP. Cardiac ablation has become an increasingly common procedure for managing patients with arrhythmias. Considering that catheter ablation causes AE-IIP, a detailed clinical interview, physical examination, and chest radiography are necessary before catheter ablation. We should additionally consider AE-IIP as a differential diagnosis of respiratory failure after catheter ablation.     

Recording monophasic action potentials using a platinum-electrode ablation catheter.

AIMS: The monophasic action potential (MAP) is conventionally recorded using Ag-AgCl electrodes which are not suitable for delivering radiofrequency currents. To be able to use the sharp MAP upstroke for identifying the local activation, as a step towards the development of a MAP-guided catheter ablation technique, the possibility of recording MAP via platinum electrodes of an ordinary ablation catheter was explored. METHODS AND RESULTS: One hundred and forty-two MAP recordings from the endocardium were obtained via an ablation catheter in 40 patients undergoing electrophysiological study/catheter ablation. During sinus rhythm and pacing, 90% of the ventricular and 100% of the atrial MAPs had stable baselines. The amplitudes were 13 +/- 4.2 mV for ventricular and 2.4 +/- 0.8 mV for atrial MAPs. During mapping and ablation, MAPs and uni- and bipolar electrograms were recorded simultaneously using the same tip electrode in eight patients. The MAPs provided more distinct local activation than the electrograms. During 17 MAP recordings, additional MAPs were recorded simultaneously using an Ag-AgCl electrode catheter in the immediate vicinity of the ablation catheter. The MAPs taken with the ablation catheter had characteristics consistent with those taken with the Ag-AgCl catheter. CONCLUSIONS: (1) Platinum electrodes can be used for timely recording of MAPs in patients. (2) It is feasible to record MAPs and deliver radiofrequency currents via the same platinum-tip electrode. These findings suggest that MAP-guided catheter ablation is technically possible.     

Temporary hemodialysis catheters as a long-term vascular access in chronic hemodialysis patients

The objective was to review our experience with temporary, precurved, jugular catheters used for long-term vascular access in chronic hemodialysis patients. Thirty chronic hemodialysis patients, 14 men and 16 women, with an average age of 65.3 +/- 13.5 years (30-90 years), treated by dialysis for 1 month to 30 years (average +/- SD, 6.3 +/- 8.1 years), had single lumen, 'temporary' precurved non-tunneled jugular catheters placed into the right jugular vein as permanent vascular access, with 4% trisodium citrate as a locking solution and mupirocin at the exit site. Hemodialysis catheters were used for vascular access on average for 9.1 +/- 6.5 months, (1-22.7 months), and for a total of 271.7 months (8151 days). Average catheter functioning time was 3.1 +/- 1.9 months (0.5-10 months). The total number of side-effects was 55 (6.7/1000 catheter days), including 26 cases of thrombosis (3.2/1000 catheter days), 9 ruptures of the catheter (1.1/1000 catheter days), 15 catheter malfunctions (1.8/1000 catheter days), 2 exit site infections (0.2/1000 catheter days), 2 bacteremias (0.2/1000 catheter days), 1 avulsion of the catheter (0.1/1000 catheter days), and 2 catheters were removed because an AV fistula was successfully used. In 21 patients single-needle hemodialysis was performed, mean blood flow 251 +/- 16 mL/min (250-300), mean Kt/V 0.96 +/- 0.16 (0.72-1.27) and in 9 patients double-needle hemodialysis was performed (catheter and peripheral vein) with mean blood flow 252 +/- 14 mL/min (200-300), mean Kt/V 1.63 +/- 0.25 (1.21-1.96). 'Temporary' jugular single lumen non-tunneled hemodialysis catheters, with 4% citrate as locking solution and mupirocin ointment at the exit site provided good long-term vascular access with acceptable functioning time and low infection rate. The main reasons for catheter exchange or removal were malfunction and mechanical damage of the catheter.     

Efficiency and safety of optically modified fiber tips for laser angioplasty

To evaluate the safety and efficiency of optically modified fiber tips, craters were created in human cadaver atherosclerotic arterial walls using sapphire contact probes and lensed fibers connected to a continuous wave neodymium yttrium aluminum garnet (Nd-YAG) laser. Laser energy was emitted at a constant level of 50 J. The sapphire contact probe catheter consisted of a round 2.2 mm diameter synthetic sapphire attached to an 8F catheter into which a 0.2 mm diameter optical fiber was inserted with the distal tip maintained at 3 mm from the sapphire. The lensed fiber catheter consisted of a 0.2 mm optical fiber at the end of which a 1 mm diameter lens was made. The fiber was inserted into a 5F low profile balloon catheter with the lens maintained 3 mm beyond the catheter tip. During laser emissions the catheter tips were maintained in a stationary position in contact with tissue targets immersed in blood at an angle of 90 degrees. The diameter of holes at the entry and exit of craters, the depth of craters and thermal injury to adjacent tissue (rim of carbonization and vacuolization) were measured with microscopy. The volume of tissue removed was derived from these values. Controlled effect index was determined as the ratio of diameter of holes and the extent of thermal injury. Efficiency was determined as the ratio of volume of tissue removed and the energy required to vaporize tissue.(ABSTRACT TRUNCATED AT 250 WORDS)     

A New Peroral Cholecystoscopy Method Utilizing a Shape Memory Alloy Bending Catheter-Report of Two Cases

For the purpose of improving the ease and reliability of catheter insertion into the cystic duct and gallbladder, we developed a new combination method utilizing an ultrathin fiberscope (miniscope, 0.8 mm), a guidewire (0.25 inches) and a shape memory alloy, bendable, catheter (SMA catheter, 2.6 mm). The main feature of the SMA catheter, which incorporates a micro-actuator, is that its tip can be bent by remote control as desired. The SMA catheter could be inserted successfully into the cystic duct using a guide-wire under direct miniscope vision in two patients with gallbladder lesions. Moreover, after the miniscope had been inserted through the SMA catheter into the gallbladder, its maneuverability enhanced observation of the mucosa. This combination method should afford new diagnostic and therapeutic approaches to gallbladder disease.     

Successful release of entrapped circumferential mapping catheters in patients undergoing pulmonary vein isolation for atrial fibrillation

OBJECTIVES: The purpose of this study was to demonstrate a method for successful and safe release of an entrapped circular catheter. BACKGROUND: Segmental pulmonary vein (PV) isolation is widely practiced for patients with symptomatic drug-refractory atrial fibrillation. A circular mapping catheter is sometimes used with this technique to map the electrical connection between the left atrium (LA) and the PVs. This catheter reportedly can become entrapped in the mitral valve apparatus. Attempts to free the entrapped catheter can result in serious complications, including damage to the mitral valve chordae tendineae or fracture of the catheter itself. METHODS: Three patients were referred for PV isolation for atrial fibrillation. A circular mapping catheter was used to map the sites of LA-PV electrical connections. RESULTS: During the procedure, the circular mapping catheter became entrapped in the mitral valve apparatus in two patients and in the PV in one patient. A series of maneuvers, which included use of another catheter and guiding sheaths as well as pushing forward rather than pulling back on the entrapped catheter, allowed safe and successful release of the entrapped catheter in all patients. CONCLUSIONS: Entrapment of the circular mapping in the mitral valve apparatus or the PVs during PV isolation is a rare complication associated with use this catheter. We describe a series of maneuvers that may allow safe and successful release of the entrapped catheter.     

Nonsurgical removal of a kinked right coronary catheter

Cardiac catheterization is a commonly performed procedure affording valuable data. Catheter related complications such as catheter knotting, fracture, and collapse have been reported. Occasionally surgery is needed to extricate an entrapped catheter when nonsurgical means are unsuccessful. We describe a case of kinking of a right coronary catheter during transfemoral coronary arteriography, so that the catheter could not be withdrawn. A simple, nontraumatic method facilitated removal of the kinked catheter and permitted completion of the procedure, obviating the need for surgery.     

A new low profile balloon atrial septostomy catheter: initial animal and clinical experience

OBJECTIVE: To evaluate the safety and efficacy of a new low profile balloon septostomy catheter in neonatal animals as well as in one newborn infant. BACKGROUND: Balloon atrial septostomy remains one of the most commonly performed palliative procedures in pediatric cardiology. The currently available septostomy catheter requires a large introducer sheath (6 or 7F), does not have an end hole for confirmation of position or pressure measurement and is limited in patients with a small left atrium due to its large balloon inflated diameter. METHODS: Four neonatal piglets (average weight 3.9 kg) underwent percutaneous balloon atrial septostomy using the new balloon catheter inflated to 1 cc via a 5F sheath in the femoral vein. Two other piglets (average weight 4.9 kg) underwent septostomy with the conventional catheter inflated to 3.5 cc via a 6 or 7F sheath in the femoral vein. All animals underwent transthoracic echocardiography pre and post septostomy. All animals were sacrificed after the procedure and the size of the atrial defect created was measured. One neonate with Taussig-Bing anomaly underwent septostomy with the new balloon catheter. RESULTS: The left atrium was entered in all piglets. It was easier to enter the left atrium with an end hole catheter which was exchanged over a wire with the septostomy catheter. Septostomy was performed with the new or conventional catheters without complications. Echocardiography demonstrated a very small patent foramen ovale prior to the procedure and a large atrial defect after septostomy. The average size of the defect created by the new catheter was 11.3 x 10 mm in diameter and 11 x 10 mm using the conventional catheter. A 10 x 10 mm atrial communication was created in the neonate. CONCLUSIONS: This study demonstrates the safety and efficacy of this new catheter. This catheter will be of potential importance in patients with a small left atrium and in small neonates with congenital heart disease requiring septostomy.     

Multipurpose A2 catheter approach to left heart catheterization in severe aortic stenosis

An approach has been presented for the performance of right and left heart catheterization, left ventriculography, supravalvular aortography, and coronary arteriography utilizing a #8 French, A2 multipurpose catheter. Using the manipulations described herein, the left ventricle was entered in 96% of the patients. The multipurpose catheter is an excellent catheter for left ventriculography, negating the need for catheter exchange once the left ventricle has been entered. Likewise, this catheter provides excellent supravalvular aortography and selective coronary arteriography supplemented as needed with preformed coronary arteriographic catheters. This method provides a very safe, efficient approach to the performance of complete heart catheterization in patients with clinically significant aortic stenosis.     

Successful management of a distal vessel perforation through a single 8‐French guide catheter: Combining balloon inflation for bleeding control with coil embolization

Coronary perforation is an infrequent, but serious complication of percutaneous coronary intervention (PCI), and is more likely to occur with complex (such as chronic total occlusion) PCI and use of atheroablative devices. For main vessel perforations, the “dual catheter” technique is usually employed in which a balloon is delivered over the first guide catheter to stop bleeding, whereas the covered stent is delivered through a second guide catheter. This is required because the large profile of the currently commercially available covered stents precludes fitting within even an 8‐French guide together with a balloon. However, coil embolization for distal artery wire perforation and collateral vessel perforation can be achieved through a microcatheter that can fit along with a balloon within an 8‐French guide catheter, obviating the need for a second guide catheter. We describe a case in which a distal artery wire perforation was successfully treated using a single 8‐French guide catheter. © 2015 Wiley Periodicals, Inc.     

Catheter selection for ablation of the cavotricuspid isthmus for treatment of typical atrial flutter

Radiofrequency catheter ablation (RFA) represents the first line therapy of the cavotricuspid isthmus-dependent atrial flutter (CTI-AFL) with a high efficacy and low secondary effects. RFA of CTI-dependent AFL can be performed by using various types of ablation catheters. Recent evaluations comparing externally cooled tip RFA (ecRFA) catheters and large-tip (8 mm) catheters have revealed that these catheters have a higher efficacy for CTI-AFL ablation compared to 4-mm catheters. The reliability of RFA catheters for AFL is variable and an optimal catheter selection may enhance the RFA effectiveness. The main goal of this article is to review the elements that improve the management of CTI RFA. Preliminary examinations of histopathologic and anatomical elements that may interfere with conventional CTI RFA are presented. Experimental studies concerning the electrobiology of large-tip and cooled-tip catheters are compared. The different catheter designs between cooled-tip and 8-mm-tip catheters are examined (size of the deflectable curve, rotation stability, and size of the distal nonsteerable catheter part) because of their critical role in CTI RFA results. A thorough review of clinical trials of each catheter is presented, and comparison of both catheters in this clinical setting is analyzed. In addition, the role of CTI morphology on AFL RF duration is underlined such as the value of right atrial angiography as an adjunct tool for CTI RFA catheter selection. Based on randomized studies, 8-mm-tip catheters seem to be more effective for ablation in case of straight angiographic isthmus morphology. On the other hand, ecRFA catheters appear to be more effective in cases of complex CTI anatomy or difficult CTI RFA. To reduce X-ray exposition and RFA application time, few studies report that CTI angiographic evaluation before RFA allows a catheter selection based on both CTI morphology and length. Moreover, preliminary data of randomized studies showed that an angiographic isthmus evaluation may predict both the effectiveness of a RFA catheter and the risk of an expensive catheter crossover.