The PA views and RAO views >or=40 degrees , heretofore unconventional in clinical routine, should be favored over steep LAO projections >or=40 degrees whenever possible. Tube angulations that are radiation intensive to the patient exponentially increase the operator's radiation risk.
Background— Immunoadsorption capable of removing circulating autoantibodies represents an additional therapeutic approach in dilated cardiomyopathy (DCM). The role played by autoantibodies belonging to the immunoglobulin (Ig) subclass G-3 in cardiac dysfunction remains to be elucidated. Methods and Results— Patients with DCM (left ventricular ejection fraction <30%) participated in this case-control study. Nine patients underwent immunoadsorption with protein A (low affinity to IgG-3), and 9 patients were treated with anti-IgG, which removes all IgG subclasses. Immunoadsorption was performed in 4 courses at 1-month intervals until month 3. In the 2 groups, immunoadsorption induced comparable reduction of total IgG (>80%). IgG-3 was effectively eliminated only by anti-IgG adsorption (eg, during the first immunoadsorption course; protein A, −37±4%; anti-IgG, −89±3%; P <0.001 versus protein A). The β 1 -receptor autoantibody was effectively reduced only by anti-IgG ( P <0.01 versus protein A). Hemodynamics did not change in the protein A group. In the anti-IgG group during the first immunoadsorption course, cardiac index increased from 2.3±0.1 to 3.0±0.1 L · min −1 · m −2 ( P <0.01 versus protein A). After 3 months, before the last immunoadsorption course, cardiac index was 2.2±0.1 L · min −1 · m −2 in the protein A group and 3.0±0.2 L · min −1 · m −2 in the anti-IgG group ( P <0.01 versus protein A). Left ventricular ejection fraction increased only in the anti-IgG group ( P <0.05 versus protein A). Conclusions— Autoantibodies belonging to IgG-3 may play an important role in cardiac dysfunction of DCM. The removal of antibodies of the IgG-3 subclass may represent an essential mechanism of immunoadsorption in DCM.
Transradial coronary interventions (TCI) are occasionally limited by radial spasms and postprocedural radial occlusions, which are related to the radial diameter and which possibly may be reduced by the use of smaller guiding catheter. However, 5 Fr, 0.058" lumen diameter guiding catheter affords less strength, visibility, and backup. In a randomized study, we investigated procedural and clinical success and vascular access complications of 5 Fr in comparison to 6 Fr guiding catheter. One hundred seventy-one patients with coronary lesions suitable for at least 5 Fr transradial approach (i.e., normal Allen test, only balloon angioplasty and stent) were randomly assigned for 5 or 6 Fr TCI. The primary combined endpoint was procedural and clinical success, and secondary endpoints were vascular access complications and the occurrence of postprocedural radial occlusions at 1-month follow-up. Procedural success was achieved in 95.4% of 5 Fr and 92.9% of 6 Fr patients. Selective cannulation of the coronary ostium failed in 1.1% of 5 Fr and 4.8% of 6 Fr patients (P = 0.08). Minor hematomas without need for surgical repair or blood transfusions occurred in 1.1% (5 Fr) and 4.8% (6 Fr; P = 0.07); 1.1% of 5 Fr and 5.9% of 6 Fr patients (P = 0.05) suffered loss of radial pulse due to radial occlusion. Selected noncomplex coronary lesions can successfully and safely be treated either with 5 or 6 Fr guiding catheters. A tendency of higher procedural success rates and lower vascular access complications was documented after 5 Fr in comparison to 6 Fr TCI. This was particularly the case among patients with small radial diameters.
The goal of this study was to improve radiation dose reduction techniques in invasive cardiology and after patients' radiation data had approached minimal levels, to evaluate predictors of their radiation exposure resulting from invasive cardiac procedures. Over the course of 1 year (and 1996 procedures) we minimized cinegraphic frames and runs, as well as fluoroscopy time, and trained ourselves to achieve effective fluoroscopy-saving positioning of blinds and filters toward the regions of interest. We were consequently able to reduce the mean dose-area products (DAP) for coronary angiography and angioplasty, combined interventions, high-frequency rotational atherectomy, and excimer laser angioplasty: from levels of 53.9 Gy cm(2), 79.6 Gy cm(2), 112.3 Gy cm(2), 119.4 Gy cm(2), and 168.0 Gy cm(2) as currently reported in the literature, to 12.9 Gy cm(2), 13.3 Gy cm(2), 25.9 Gy cm(2), 33.0 Gy cm(2), and 27.1 Gy cm(2), respectively. The mean DAP due to interventions in acute myocardial infarction was 38.3 Gy cm(2). DAP was influenced by body mass index, complexity of coronary artery disease, tube angulation, documented structure, coronary recanalization, emergency circumstances, and the percutaneous transluminal coronary angioplasty (PTCA) target vessel involved, but not by stent implantation. By favouring radiation-reducing cranial posteroanterior views over standard left anterior oblique views for visualization of the left anterior descending and the diagonal artery, we consequently achieved mean PTCA-DAPs of 10.4 Gy cm(2) and 8.6 Gy cm(2), respectively: levels significantly lower than those for PTCA of the right coronary artery (13.3 Gy cm(2)), left circumflex artery (13.7 Gy cm(2)), and obtuse marginal branch (16.9 Gy cm(2)). In conclusion, enhanced knowledge of radiation dose-reduction techniques significantly reduces patient radiation hazards in invasive cardiology.
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