Cath Lab Digest - September 2007 - (Page 4)

4 CLINICAL EDITOR’S CORNER SEPTEMBER 2007 EDITORIAL Is Crossing the Stenotic Aortic Valve Obsolete? MORTON KERN, MD Clinical Editor Clinical Professor of Medicine Associate Chief Cardiology University of California Irvine Orange, California LAURIE GUSTAFSON Executive Editor REBECCA KAPUR Managing Editor ELIZABETH MCTAMNEY Layout/Production Manager A recent dilemma was presented by our fellows when discussing the approach to a 75-year-old man with shortness of breath, exertional chest discomfort, heart murmur since the age of 50, mild hypertension, one pack per year smoking, and an echocardiogram which suggested significant aortic stenosis with estimated valve area of 0.7 cm2. Because of peripheral vascular disease, the question was, what would be the most appropriate cath technique to assess this patient? And more specifically, is it necessary to cross this patient’s aortic valve and just perform coronary angiography and be done with the study? HMP Communications The most recent concern for crossing the aortic valve in patients with aortic stenosis stems from a report in The Lancet by Omran et al who reported findings in their paper “Silent and apparent cerebral embolism after retrograde catheterisation of the aortic valve in valvular stenosis: a prospective, randomised study.”1 The authors suggest that catheterization via the retrograde approach for aortic stenosis is unnecessary and potentially dangerous. Of 152 patients with valvular aortic stenosis, 101 undergoing cardiac MORTON KERN, MD catheterization with and 51 without catheter passage through the aortic valve were compared to a control group of 32 patients enrolled for coronary Clinical Editor angiography alone. Detection of cerebral events was accomplished by magClinical Professor of Medicine netic resonance imaging and neurologic assessment two days before and after Associate Chief Cardiology the procedure. In 22 patients who had retrograde catheterization, evidence of University of California Irvine cerebral embolism existed, but only three had impaired neurologic function. Orange, California None of the others who underwent catheterization had such events. The mortonkern005@hotmail.com authors concluded that there was a substantial risk of ischemic brain injury with retrograde catheter passage across the stenotic aortic valve. The etiology of this particular mechanism is not completely understood. Considerations for the cerebral embolic events would include small thrombi on the guidewires used in attempting to cross, the release of particular matter from the calcific stenotic aortic valve, the generation of cavitational micro air bubbles as well as debris lifted from the aortic wall during catheter passage, and wire and catheter manipulations in the aortic root. Further complicating our decision to cross the stenotic aortic valve were the recommendations for cardiac catheterization in valvular heart disease for aortic stenosis. From the American College of Cardiology/American Heart Association 2006 guidelines for the management of patient valvular heart disease, a report of the task force chaired by Dr. Robert O. Bonow, (www.circulationaha.org, 2006, section 3.15), the indications for cardiac catheterization in patients with aortic stenosis are as follows: PAUL MACKLER President/CEO PETER NORRIS Executive Vice President/General Manager JEFFREY MARTIN Vice President/Group Publisher Cardiology Division ALEX SLONIM Vice President/Associate Publisher of Cardiology CARSON MCGARRITY National Account Manager NICK OTRANTO Account Manager LUCINDA BESKA Classified Advertising Sales Manager FRED KLUMPP Manager of Information Systems KATHY MURPHY Production Director STEFANIE TULEYA RENEE OLSZEWSKI Special Projects Editors KIMBERLY B. CHESKY Production Director, Special Projects PATRICIA LEVY Director of NACCME The authors concluded that there was a substantial risk of ischemic brain injury with retrograde catheter passage across the stenotic aortic valve. CIRCULATION: Bonnie Shannon Tel: (800) 237-7285, ext. 246 or (610) 560-0500 ext. 246 E-mail: BShannon@ hmpcommunications.com SUBSCRIPTION INFORMATION CATH LAB DIGEST is sent to all non-physician cath lab personnel working in the United States (international subscription is $60 for 1 year). If you are not receiving CATH LAB DIGEST and would like to, or have an address change, please complete the enclosed postage-paid subscription card and return to: HMP COMMUNICATIONS 83 General Warren Blvd., Suite 100 Malvern, PA 19355 POSTMASTER Send address changes to: Cath Lab Digest 83 General Warren Blvd., Suite 100 Malvern, PA 19355 PRINTED in the U.S.A. continued on page 6 Editorial Correspondence: Rebecca Kapur, Managing Editor, HMP COMMUNICATIONS Cardiology Editorial Offices, 7427 Winding Way, Brecksville, OH 44141 Tel. (800) 459-8657 Fax: (216) 393-0445 Email address: RKapur@hmpcommunications.com Circulation: Bonnie Shannon, BShannon@hmpcommunications.com, tel. (800) 237-7285, ext. 246 Advertising: Jeffrey Martin, Vice President/Group Publisher, tel. (800) 237-7285, ext. 238, Email: jmartin@hmpcommunications.com Alex Slonim, Vice President/Associate Publisher, tel. (800) 237-7285, ext. 245, Email aslonim@hmpcommunications.com Carson McBrayer, National Account Manager, tel. (800) 237-7285, ext. 234, Email: cmcbrayer@hmpcommunications.com Nick Otranto, Account Manager, tel. (800) 237-7285, ext. 270, Email: notranto@hmpcommunications.com Advertising address: HMP COMMUNICATIONS, 83 General Warren Blvd., Suite 100 Malvern, PA 19355 Tel. (800) 237-7285. Cath Lab Digest (ISSN# 1073-2667) is issued 12 times per year by HMP COMMUNICATIONS, 83 General Warren Blvd., Suite 100, Malvern, PA 19355. Periodicals postage paid at Malvern, Pennsylvania and additional mailing offices. Printed in USA at Publisher’s Press, 100 Frank E. Simon Ave., Shepherdsville, KY 40165

Table of Contents Feed for the Digital Edition of Cath Lab Digest - September 2007

St. Dominic Hospital The Genous Bio-engineered R Stent Percutaneous Treatment of Peripheral Arterial Chronic Total Occlusions: Device Options and Clinical Outcomes Contents Clinical Editor’s Corner Percutaneous Revascularization of Peripheral Chronic Total Occlusion — Which Patients, Why, and How? Myocardial Infarction and Syncope: A Manifestation of the “Raynaud-Prinzmetal Syndrome”? Essential Technical Components of the Transradial Approach If You Build It, Will They Come? Evidence-Based Medicine with Drug-Eluting Stents Back to School: The Value of Education in Cardiovascular Services The ACVP Standards and Competencies: Are You Using Them Effectively? What Do You Think? My Experience with Fibromuscular Dysplasia and Stroke A Brief Review of Fibromuscular Dysplasia Letter to the Editor A Look at On-the-Job Training: Perceptions, Reality and Our Profession Doing the Wave: Inventory Management with RFID The Ten-Minute Interview with… Paul Pinsker, RCIS CLD’s Annual Salary Survey Harrisburg Area Community College Volunteer Survey CEU Education Center SICP* Section Ask the Clinical Instructor: A Q&A Column for Those New to the Cath Lab Clinical & Industry News

Cath Lab Digest - September 2007

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