Technical aspects of the cardiac catheterization laboratory

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Parts of an Ideal Catheterization Laboratory

Although it may vary with technical equipment requirements and number of laboratories used in the hospital, there should be adequate space in every catheterization laboratory for following [1];

  • An acclimatized and properly sanitized procedure room with a scrub station
  • A separate, radiation free control room for supervising
  • A proper, humidity safe equipment room for catheters and other devices
  • A recovery room for patient preparation and holding.
  • A dressing room and toilet for patients
  • A staff room with dressing place and toilets
  • A temperature monitored refrigerator and proper space for pharmacy
  • A post procedural film reviewing station and medical reporting offices
  • Secured computer management and film archiving area
  • A power generator or an adequate power supply for uninterrupted workflow.
  • Portable monitors for invasive and non invasive evaluations
  • Adequate numbers of defibrillators
  • Height adjustable patient transfer beds
  • Intra aortic balloon pumps
  • A respirator / ventilator

Personnel Related Issues

  • Adequate training for procedural skills, and board certification in interventional cardiology for operators
  • Knowledge of recognition and management of complications
  • All team members should complete a basic CPR course (ideally certification in A.C.L.S.)

Procedural Issues

  • Patient preparation
  • Adequate sedation and relaxation required for all patients.
  • Preparation for possible "Contrast allergy"
  • Patients with renal function abnormalities (e.g. renal insufficiency)
  • Diabetic patients
  • Patients on antithrombotic and/or antiplatelet drugs
  • Patients with hearing impairment
  • Patients with prosthesis and amputated limbs
  • Operator safety during interventional procedures in patients with communicable diseases;
  • Using proper caps and masks
  • Careful disposal of needles, catheters, tubes and fluids from infected patients
  • Proper gloves (double gloves) and eye shields / facial shields
  • Disposable shoe covers
  • Procedure related performance
  • Proper catheter (size and curve type) selection
  • Assurance of bubble free connections and adequately flushed equipment
  • Injection of coronary arteries: The use of nurses, cardiovascular technicians, or physician’s assistants to inject the coronary arteries has become increasingly popular. It remains the responsibility of the individual invasive cardiologist to ascertain whether paramedical personnel or power injectors are capable of administering contrast into the coronary arteries. The responsibility for safety ultimately residing with the invasive cardiologist.
  • Adequate use of angiographic projections, filming time and visualizations of entire coronary tree, and vein and/or arterial bypasses in previously operated patients.
  • Careful monitoring of heart rate, rhythm, waveforms and pressures, and recording as required for postprocedural references and/or evaluation.

Radiation Safety

Every team members, even maintenance related person in catheterization laboratory should have adequate training on radiation safety and continuously controlled by a certified institute for acquired radiation dose.

Every procedure room should have separate (installed) dosimeter to control radiation safety of x-ray source.

Patients should also monitored regularly and informed for procedure related radiation dose issues.

All operators should avoid from unnecessary filming, and using longer radioscopy.

Patients with longer procedural time and higher radiation exposure should be referred for dermatology/oncology consultation and follow up.

2011 ACCF/AHA/SCAI Guidelines for Percutaneous Coronary Intervention (DO NOT EDIT)[2]

Quality and Performance Considerations (DO NOT EDIT)[2]

Class I
"1. Every PCI program should operate a quality-improvement program that routinely
i. reviews quality and outcomes of the entire program; (Level of Evidence: C)
ii. reviews results of individual operators; (Level of Evidence: C)
iii. includes risk adjustment; (Level of Evidence: C)
iv. provides peer review of difficult or complicated cases; and (Level of Evidence: C)
v. performs random case reviews. (Level of Evidence: C)"
"2. Every PCI program should participate in a regional or national PCI registry for the purpose of benchmarking its outcomes against current national norms. (Level of Evidence: C)"

Certification and Maintenance of Certification (DO NOT EDIT)[2]

Class IIa
"1. It is reasonable for all physicians who perform PCI to participate in the American Board of Internal Medicine interventional cardiology board certification and maintenance of certification program. (Level of Evidence: C)"

Operator and Institutional Competency and Volume (DO NOT EDIT)[2]

Class I
"1. Elective/urgent PCI should be performed by operators with an acceptable annual volume (greater than or equal to 75 procedures) at high-volume centers (more than 400 procedures) with on-site cardiac surgery.[3][4] (Level of Evidence: C)"
"2. Elective/urgent PCI should be performed by operators and institutions whose current risk-adjusted outcomes statistics are comparable to those reported in contemporary national data registries. (Level of Evidence: C)"
"3. Primary PCI for STEMI should be performed by experienced operators who perform more than 75 elective PCI procedures per year and, ideally, at least 11 PCI procedures for STEMI per year. Ideally, these procedures should be performed in institutions that perform more than 400 elective PCIs per year and more than 36 Primary PCI procedures for STEMI per year.[3][5][6][7][8] (Level of Evidence: C)"
Class III (No Benefit)
"1. It is not recommended that elective/urgent PCI be performed by low-volume operators (75 procedures per year) at low-volume centers (200 to 400 procedures per year) with or without on-site cardiac surgery. An institution with a volume of fewer than 200 procedures per year, unless in a region that is underserved because of geography, should carefully consider whether it should continue to offer this service.[3] (Level of Evidence: C)"
Class IIa
"1. It is reasonable that operators with acceptable volume (75 PCI procedures per year) perform elective/urgent PCI at low-volume centers (200 to 400 PCI procedures per year) with on-sitecardiac surgery.[3] (Level of Evidence: C)"
"2. It is reasonable that low-volume operators (75 PCI procedures per year) perform elective/urgent PCI at high-volume centers (more than 400 PCI procedures per year) with on-site cardiac surgery. Ideally, operators with an annual procedure volume of fewer than 75 procedures per year should only work at institutions with an activity level of more than 600 procedures per year. Operators who perform fewer than 75 procedures per year should develop a defined mentoring relationship with a highly experienced operator who has an annual procedural volume of at least 150 procedures. (Level of Evidence: C)"
Class IIb
"1. The benefit of primary PCI for STEMI patients eligible for fibrinolysis when performed by an operator who performs fewer than 75 procedures per year (11 PCIs for STEMI per year) is not well established. (Level of Evidence: C)"

References

  1. Bashore TM, Bates ER, Berger PB, Clark DA, Cusma JT, Dehmer GJ, Kern MJ, Laskey WK, O'Laughlin MP, Oesterle S, Popma JJ, O'Rourke RA, Abrams J, Bates ER, Brodie BR, Douglas PS, Gregoratos G, Hlatky MA, Hochman JS, Kaul S, Tracy CM, Waters DD, Winters WL Jr; American College of Cardiology. Task Force on Clinical Expert Consensus Documents. American College of Cardiology/Society for Cardiac Angiography and Interventions Clinical Expert Consensus Document on cardiac catheterization laboratory standards. A report of the American College of Cardiology Task Force on Clinical Expert Consensus Documents. J Am Coll Cardiol. 2001 Jun 15;37(8):2170-214. PMID 11419904
  2. 2.0 2.1 2.2 2.3 Levine GN, Bates ER, Blankenship JC, Bailey SR, Bittl JA, Cercek B, Chambers CE, Ellis SG, Guyton RA, Hollenberg SM, Khot UN, Lange RA, Mauri L, Mehran R, Moussa ID, Mukherjee D, Nallamothu BK, Ting HH (2011). "2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: Executive Summary A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions" (PDF). Journal of the American College of Cardiology. 58 (24): 2550–83. PMID 22070837. doi:10.1016/j.jacc.2011.08.006. Retrieved 2011-12-08.  Text "PDF" ignored (help); Unknown parameter |month= ignored (help)
  3. 3.0 3.1 3.2 3.3 Hannan EL, Wu C, Walford G, King SB, Holmes DR, Ambrose JA, Sharma S, Katz S, Clark LT, Jones RH (2005). "Volume-outcome relationships for percutaneous coronary interventions in the stent era". Circulation. 112 (8): 1171–9. PMID 16103238. doi:10.1161/CIRCULATIONAHA.104.528455. Retrieved 2011-12-16.  Unknown parameter |month= ignored (help)
  4. Post PN, Kuijpers M, Ebels T, Zijlstra F (2010). "The relation between volume and outcome of coronary interventions: a systematic review and meta-analysis". European Heart Journal. 31 (16): 1985–92. PMID 20511324. doi:10.1093/eurheartj/ehq151. Retrieved 2011-12-16.  Unknown parameter |month= ignored (help)
  5. Cannon CP, Gibson CM, Lambrew CT, Shoultz DA, Levy D, French WJ, Gore JM, Weaver WD, Rogers WJ, Tiefenbrunn AJ (2000). "Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction". JAMA :the Journal of the American Medical Association. 283 (22): 2941–7. PMID 10865271. Retrieved 2011-12-16.  Unknown parameter |month= ignored (help)
  6. Canto JG, Every NR, Magid DJ, Rogers WJ, Malmgren JA, Frederick PD, French WJ, Tiefenbrunn AJ, Misra VK, Kiefe CI, Barron HV (2000). "The volume of primary angioplasty procedures and survival after acute myocardial infarction. National Registry of Myocardial Infarction 2 Investigators". The New England Journal of Medicine. 342 (21): 1573–80. PMID 10824077. doi:10.1056/NEJM200005253422106. Retrieved 2011-12-16.  Unknown parameter |month= ignored (help)
  7. Srinivas VS, Hailpern SM, Koss E, Monrad ES, Alderman MH (2009). "Effect of physician volume on the relationship between hospital volume and mortality during primary angioplasty". Journal of the American College of Cardiology. 53 (7): 574–9. PMID 19215830. doi:10.1016/j.jacc.2008.09.056. Retrieved 2011-12-16.  Unknown parameter |month= ignored (help)
  8. Vakili BA, Kaplan R, Brown DL (2001). "Volume-outcome relation for physicians and hospitals performing angioplasty for acute myocardial infarction in New York state". Circulation. 104 (18): 2171–6. PMID 11684626. Retrieved 2011-12-16.  Unknown parameter |month= ignored (help)

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