Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

A unique and unexplained ricochet leak post PCI – Successfully treated with intra-coronary glue

We herein describe a unique case of coronary artery perforation treated with covered stent with repeat cardiac tamponade resulting out of a fresh unexplained leak from a remote vessel (Ricochet) and successfully treated with intra-coronary injection of sterile synthetic glue, cyanoacrylate

Efficacy of RADPAD protection drape in reducing radiation exposure in the catheterization laboratory—First Indian study

Background: Occupational radiation exposureis a growing problem due to increasing number and complexity of interventional procedures.The RADPAD is a lead-free sterile drape containing bismuth and barium that reduces scatter radiation during fluoroscopic procedures. We aimed to study the radiation exposure reduction to operators with the use of RADPAD and also measureradiation doses in different angiographic projections. Methods: 65 randomly selected patients undergoing elective complex percutaneous coronary intervention (PCI) procedures from January 2017 to 2017 were randomized in a 1:1 pattern with or without the RADPAD. Primary endpoint was the ratio of operator received dose in mrem to total radiation in Gyat the end of the procedure which was designated ‘’Relative operator exposure’’, with or without RADPAD. Results: Despite similar fluoroscopy times (20.4 ± 9.4 min with RADPAD vs. 19.4 ± 9.2 min without RADPAD, P = 0.871) and total radiation dose (3.4 ± 4.3 Gy with RADPAD vs. 2.3 ± 1.4 Gy, P = 0.198), the relative operator exposure was significantly less with RADPAD (1.39 ± 0.95) as compared to no RADPAD group (2.27 ± 1.4) (p = 0.004) amounting to a 39% reduction. Additionally mean radiation dose per shoot of recorded Left anterior oblique (LAO) oriented projections was 34.4 ± 15.7mGyvs 24.9 ± 12.9 mGy for a non LAO oriented projection. (p < 0.001). Conclusion: RADPAD significantly reduces radiation exposure to the primary operator during prolonged complex PCI procedures. Further, amongst all views, LAO views have significantly higher emitted radiation as compared to Non LAO views and need more radiation protection. Keywords: Chronic total occlusion, Left anterior oblique, Left main artery, Percutaneous coronary intervention, Roentgen equivalent ma

Left main PCI: An observational analysis from large single-centre experience

Background: Although trials have shown efficacy of unprotected left main percutaneous coronary intervention (uLMPCI), data from Indian subcontinent are lacking. Hence, we planned this observational analysis of single-center uLMPCI data. Objectives: To study long-term outcome after uLMPCI and identify predictors of adverse outcome. Methods: Case details of 62 consecutive patients of uLMPCI between 2006 and 2013 were retrieved from a computerized database wherein detailed records were maintained. Results: Mean follow-up duration was 669.8 ± 404.2 days. Procedural success rate was 98.4%. Primary endpoint was composite of major adverse cardiovascular and cerebrovascular events (MACCE), which included cardiac death (CD), cerebrovascular accident (CVA), myocardial infarction (MI), and need for repeat intervention (RI) at three years. MACCE occurred in 13 (20.9%) patients. Cardiac death (CD), (including possible stent thrombosis), RI, and CVA occurred in 6 (9.7%), 5 (8%), and 2 (3.2%) patients, respectively. Overall three-year MACCE-free survival rate was 76.7%. Event-free survival rate was similar among patients who underwent uLMPCI alone and patients who underwent uLMPCI along with additional one-vessel PCI [(88.9% vs 81.8%), p = 0.492], while survival rate was lower in patients who underwent uLMPCI along with PCI of additional two or more vessels (40%, p = 0.036). Patients with syntax score ≤32 had higher event-free survival rate than those with syntax score >32 [(87.1% vs 33.3%), p = 0.001]. Syntax score >32 was the only independent predictor of adverse outcome. Conclusion: uLMPCI is safe and effective alternative to CABG for LM alone and LM plus single-vessel disease with syntax score ≤32

Pharmacodynamic evaluation of clopidogrel reloading vs. switching to prasugrel or ticagrelor in clopidogrel resistant Indian patients

Objectives: To compare the pharmacodynamic effects of clopidogrel reloading vs. switching to prasugrel or ticagrelor in high on treatment platelet reactivity (HTPR) patients undergoing percutaneous coronary intervention (PCI). Methods: Prospective, single-centre study wherein consecutive patients undergoing nonemergent PCI showing HTPR on 600 mg clopidogrel loading were randomized to either clopidogrel reloading (300 mg load, 75 mg OD) or prasugrel (60 mg load, 10 mg OD-in patients > 60 kg) or ticagrelor (180 mg load, 90 mg BD). HTPR is defined as maximum platelet aggregation (MPA) > 46% assessed by 5 μmol/L adenosine diphosphate light transmission aggregometry (ADP-LTA) assay after more than 6 h of clopidogrel loading. Platelet function were assessed at baseline, 6 h or more after clopidogrel loading, 2 h after reloading, day 1 and day 30 post-PCI. Results: 107 patients enrolled in the study, 32 (29.9%) were found to have HTPR. 10 (9.3%) patients were reloaded with clopidogrel, 10 (9.3%) with prasugrel and 12 (11.2%) with ticagrelor. Mean MPA in clopidogrel, prasugrel and ticagrelor reloaded patients was 42.6 ± 12.5%, 15.8 ± 8.6% and 14.6 ± 7.2% respectively at 2 h after reloading and was 43.7 ± 13.5%, 15.4 ± 5.6% and 12.6 ± 4.6% on day 1 post-PCI. The MPA significantly reduced in prasugrel and ticagrelor cases and not in clopidogrel, also prasugrel and ticagrelor had almost similar MPA after the reload. There was no patient with continued HTPR with ticagrelor or prasugrel while 50% (5/10) of clopidogrel reloaded patients had HTPR. The pharmacodynamic efficacy of maintenance with prasugrel or ticagrelor was better than clopidogrel (MPA at day 30 post-PCI; 15 ± 9.7%, 13.9 ± 5.1% and 50.4 ± 13.1% respectively). Conclusion: In patients undergoing PCI exhibiting HTPR after clopidogrel loading, ticagrelor or prasugrel reloading produced improved platelet inhibition which was better than clopidogrel reload and this effect was sustained during maintenance phase

Left ventricular non-compaction with multiple ventricular septal defects

Left ventricular non-compaction (LVNC) is a congenital cardiomyopathy characterized by deep ventricular trabeculations thought to be due to an arrest of myocardial morphogenesis. Integration of various cardiac imaging modalities such as echocardiography, cardiac computed tomography and cardiac magnetic resonance imaging help in the diagnosis of this rare clinical entity. We describe a child with rare variant of LVNC with predominant involvement of interventricular septum resulting in multiple ventricular septal defects

Metabolic syndrome & Framingham Risk Score: Observations from a coronary angiographic study in Indian patients

Background & objectives: Metabolic syndrome (MS) is an important determinant of cardiovascular (CV) risk. Framingham Risk Scores (FRS) often underestimate the CV risk in Asians, younger patients and those with MS. Asians often develop coronary artery disease (CAD) at a younger age and also have a high prevalence of MS. Only limited data are available on the relationship between MS and FRS in such patients and the present study was undertaken to report on this aspect in an Indian patient population with angiographically documented CAD. Methods: Two hundred patients undergoing coronary angiography during a three months study period were included. Diagnosis of MS was based on modified south Asian guidelines. Results: Of the 200 patients (age 56.5 ± 8.6 yr) undergoing coronary angiography, MS was diagnosed in 77 per cent n=154; abdominal obesity, low HDL and hypertension were the commonest of the diagnostic criteria of MS, being present in >70 per cent cases. Patients with MS had significantly higher mean FRS than those without MS (15.1 vs 8.65, P10%) as estimated by FRS. The proportion of patients with MS progressively increased in those with low, intermediate and high FRS (61, 87 and 92%, respectively). Though the prevalence of MS was uniformly similar (74-84%) in all age groups ( 65 yr, respectively), amongst those <45 yr, none of the patients could be categorized as having high CV risk as estimated by FRS despite having angiographic CAD, highlighting the limitation of age dependence of FRS. Interpretation & conclusions: MS is common in Indian patients with angiographically documented CAD; most patients with MS have 10-year risk of >10 per cent as estimated by FRS. Though MS is uniformly prevalent across all age groups, using the FRS may underestimate the CV risk in Indian patients despite documented CAD. These findings have significant implications for Asian patients with CAD in whom onset of CAD is often at a younger age than their Western counterparts. There should be continued health care emphasis on detection of MS and intensification of targeted preventive strategies

Comparison of transradial and transfemoral artery approach for percutaneous coronary angiography and angioplasty: A retrospective seven-year experience from a north Indian center

Background: With the increasing prevalence of coronary artery disease, percutaneous coronary artery procedures have become even more important. Our study has compared transradial to transfemoral artery approach for coronary procedures in Indian population. Aims and objective: Comparison of transradial and transfemoral artery approach for percutaneous coronary procedures. Material & methods: 26,238 patients, who underwent percutaneous coronary artery procedures, were divided into two groups depending upon transradial and transfemoral artery approach and compared for the various demographic and clinical characteristics, risk factors profile, vascular access and procedural details. Results: 26,238 patients underwent percutaneous coronary procedures at our center. 81% were male and 19% were female. 55.65% and 44.35% procedures were done through transfemoral and transradial approach, respectively. 17,417 (66.38%) coronary angiographies were done, out of which 53.92% were transradial and 46.08% were transfemoral procedures. 8821 (33.62%) Percutaneous Transluminal Coronary Angioplasty (PTCA) were done, out of which 25.46% and 74.54% were done through transradial and transfemoral approach, respectively. Mean fluoroscopy time was 4.40 ± 3.55 min for transradial and 3.30 ± 3.66 min for transfemoral CAG (p < 0.001). For PTCA mean fluoroscopy time was 13.53 ± 2.53 min for transradial and 12.61 ± 9.524 min for transfemoral PTCA (p < 0.001). Minor and major procedure related complications and total duration of hospital stay were lower in transradial as compared to transfemoral group. Conclusion: The number of percutaneous transradial procedures have increased significantly with reduced complication rates and comparable success rate to transfemoral approach, along with the additional benefits to patient in terms of patient comfort, preference and reduced cost of health delivery