Fluoroscopy vs. Traditional guided femoral arterial access and the use of closure devices: A randomized controlled trial

Objective: To compare the effectiveness of accessing the common femoral artery (CFA) using fluoroscopic guidance (FG) versus traditional anatomic landmark guidance (TALG) during cardiac catheterization and to determine the effect of the two modalities on the appropriateness for use of vascular closure devices (VCDs). Background: Previous studies have shown a consistent relationship between the head of the femur and the CFA, yet there is no prospective data validating the superiority of fluoroscopy‐assisted CFA access. Methods: A total of 972 patients were randomized to either FG or TALG access. The primary endpoint of the study was the angiographic suitability of the puncture site for VCD use. Secondary endpoints included arteriotomy location, time and number of attempts needed to obtain access, and the incidence of vascular complications. Results: Of these, 474 patients were randomized into the FG arm and 498 patients into the TALG arm. A total of 79.5% of patients in the fluoroscopy arm and 80.7% in the traditional arm (P = 0.7) were deemed angiographically suitable for VCD based on the arteriotomy. The fluoroscopy group had significantly less arteriotomies below the inferior border of the head of the femur (P = 0.03). Total time for sheath insertion (105.7 ± 130.7 vs. 106.5 ± 152.6 sec) and number of arterial punctures (1.1 ± 0.4 vs. 1.1 ± 0.5) did not differ among the FG and TALG, respectively. The rates of vascular complications were not different. Conclusion: The angiographic suitability for VCD was not different between FG and TALG groups. Fluoroscopy decreased the number of low arteriotomies. The time to sheath insertion, number of arterial punctures needed to obtain access, and the incidence of complications were also similar. © 2009 Wiley‐Liss, Inc.     

Effect of Dysphasia and Dysphagia on Inpatient Mortality and Hospital Length of Stay: A Database Study

OBJECTIVES: To examine the effect of dysphasia and dysphagia on stroke outcome. DESIGN: Retrospective database study. SETTING: Norfolk, United Kingdom. PARTICIPANTS: Two thousand nine hundred eighty‐three men and women with stroke admitted to the hospital between 1997 and 2001. MEASUREMENTS: Inpatient mortality and likelihood of longer length of hospital stay, defined as longer than median length of stay (LOS). Dysphagia was defined as difficulty swallowing any liquid (including saliva) or solid material. Dysphasia was defined as speech disorders in which there was impairment of the power of expression by speech, writing, or signs or impairment of the power of comprehension of spoken or written language. An experienced team assessed dysphagia and dysphasia using explicit criteria. RESULTS: Two thousand nine hundred eighty‐three patients (1,330 (44.6%) male), median age 78 (range 17–105), were included, of whom 77.7% had ischemic, 10.5% had hemorrhagic, and 11.8% had undetermined stroke types. Dysphasia was present in 41.2% (1,230) and dysphagia in 50.5% (1,506), and 27.7% (827) had both conditions. Having either or both conditions was associated with greater mortality and longer LOS (P<.001 for all). Using multiple logistic regression models controlling for age, sex, premorbid Rankin score, previous disabling stroke, and stroke type, corresponding odds ratios for death and longer LOS were 2.2 (95% confidence interval (CI)=1.8–2.7) and 1.4 (95% CI=1.2–1.6) for dysphasia; 12.5 (95% CI=8.9–17.3) and 3.9 (95% CI=3.3–4.6) for dysphagia, 5.5 (95% CI=3.7–8.2), 1.9 (95% CI=1.6–2.3) for either, and 13.8 (95% CI=9.4–20.4) and 3.7 (95% CI=3.1–4.6) if they had both, versus having no dysphasia, no dysphagia, or none of these conditions, respectively. CONCLUSION: Patients with dysphagia have worse outcome in terms of inpatient mortality and length of hospital stay than those with dysphasia. When both conditions are present, the presence of dysphagia appears to determine the likelihood of poor outcome. Whether this effect is related just to stroke severity or results from problems related directly to dysphagia is unclear.     

Newer Imaging Modalities in the Assessment of Heart Function in Single Ventricle Hearts

The limitations of geometry assumptions in 2-dimensional echocardiographic assessment of the single ventricle (SV) have been overcome by recent advances in 3-D echocardiography. Improved reproducibility for measuring ventricular volumes and ejection fraction using 3-D echocardiography makes it ideally suited for serial monitoring of SV systolic function and should be considered in routine echocardiography imaging protocols for SV. The moderate correlation of Doppler derived E/e' ratio with invasive ventricular end diastolic pressure in SV, suggests it might be useful in the assessment of SV diastolic function. Speckle tracking imaging is intensely studied and promises to be a simple and repeatable imaging tool for quantifying SV function. In contrast, the advances in cardiac magnetic resonance imaging techniques promise to offer insights into the pathogenesis of myocardial dysfunction in SV. Late gadolinium enhancement imaging is a robust tool in assessing macroscopic myocardial scarring and T₁ mapping and stress perfusion imaging are newer modalities that might improve understanding of the mechanisms in progressive myocardial dysfunction in SV hearts.     

Comparison of morphine/droperidol and tramadol/droperidol mixture for patient controlled analgesia (PCA) after cardiac surgery: a prospective, randomised, double-blind study

Aim: To determine whether a tramadol/droperidol PCA is as efficacious but causes less respiratory depression and sedation than a morphine/droperidol PCA in post cardiac surgical patients.Methods: A single centre, randomised double-blind study of 40 patients was performed. Group one or control (20) patients received a morphine/droperidol PCA and group two or experimental patients received a tramadol/droperidol PCA after cardiac surgery. PCA was commenced after extubation in the ICU, as is normal practice at this institution. Study continued for 24 h and the following data was collected; PCA consumption, pain, nausea and sedation scores as well as patient satisfaction/recovery (QoRS) score.Results: No difference between groups was detected for demographic variables. There was no statistically significant difference between groups for dose or duration of PCA use or in recorded pain scores. The morphine group had a significantly higher QoRS score. Both groups had a very low incidence of nausea.Conclusion: Tramadol/droperidol PCA does not confer a better recovery after cardiac surgery when compared to morphine/droperidol PCA.