Iin last night’s Public Radio news, there was a story on
"right-heart" catherizations causing an unexpected 20% in the
death rate in the first 30 days after the proceedure. This
morning’s paper also ran the same story but with a little more
detail. It appears this cath uses the neck artery vs. the groin
area, but I’m curious if that’s the only difference ( having
just recently had the "standard" procedure less than 2 weeks
ago, it has understandably tweaked my curiousity). Does anyone
have some info on this report?
ted
(ted.w…@columbiasc.ncr.com)
I understand that the citation for this article is:
Connors-A-F. Et. Al. "Effectiveness of right heart catheterization in the
initial care of critically ill patients." JAMA. Sept 18, 276(11): 889-897.
- Hide quoted text — Show quoted text -
On Wed, 18 Sep 1996, webbte wrote:
> Iin last night’s Public Radio news, there was a story on
> "right-heart" catherizations causing an unexpected 20% in the
> death rate in the first 30 days after the proceedure. This
> morning’s paper also ran the same story but with a little more
> detail. It appears this cath uses the neck artery vs. the groin
> area, but I’m curious if that’s the only difference ( having
> just recently had the "standard" procedure less than 2 weeks
> ago, it has understandably tweaked my curiousity). Does anyone
> have some info on this report?
> ted
> (ted.w…@columbiasc.ncr.com)
In a previous article, ted.w…@columbiasc.ncr.com (webbte) says:
>Iin last night’s Public Radio news, there was a story on
>"right-heart" catherizations causing an unexpected 20% in the
>death rate in the first 30 days after the proceedure. This
>morning’s paper also ran the same story but with a little more
>detail. It appears this cath uses the neck artery vs. the groin
>area, but I’m curious if that’s the only difference ( having
>just recently had the "standard" procedure less than 2 weeks
>ago, it has understandably tweaked my curiousity). Does anyone
>have some info on this report?
>ted
>(ted.w…@columbiasc.ncr.com)
If you mean an angiogram when you say "the most commonly used cath procedure",
there are major differences.. Catheterization for an angiogram does
_not_ enter the heart, but enters the arteries supplying the heart
muscles. This process has been widely used for years; in experienced
hand, less than 2% of patients have effecxts which require emergency
bypass surgery, and less than ).5% die. In the hospital where I
received several such treatments, a stand-by OR team is always ready during
catheterization procedures.
If you had balloon angioplasty (PTCA) there is an additional
delayed "risk" of having the artery re-close and requiring further
treatment — they say 30-50% within six months. I suspect that
now, the regular prescription of "statins" will reduce this
occurrence.
Stewart Rowe sr…@tso.cin.ix.net
>On Wed, 18 Sep 1996, webbte wrote:
>> Iin last night’s Public Radio news, there was a story on
>> "right-heart" catherizations causing an unexpected 20% in the
>> death rate in the first 30 days after the proceedure. This
>> morning’s paper also ran the same story but with a little more
>> detail. It appears this cath uses the neck artery vs. the groin
>> area, but I’m curious if that’s the only difference.
Neck vs. groin is a NONdifference, as it happens.
Catheterization for workup of coronary artery disease involves
entering the left (arterial) side of the circulation. This is now
routinely done via the femoral artery, entering in the groin, but the
definining characteristic is the set of vessels you end up in, not how
you get there. Left-sided catheterization also sometimes crosses the
aortic valve to look at the left ventricle (the most common site of
heart-attack damage) and at the mitral & aortic valves. Left-sided
catheterization is associated with a small but nonzero mortality (say,
0.1%), but since it’s used in defining who should get which surgery,
and since the surgery is associated with mortality that’s at least an
order of magnitude more frequent, left-sided catheterization is taken
seriously, and it’s probably not done often in people who will not (on
average) benefit from it.
Right-sided catheterization involves entering the venous side of the
circulation. The vein of entrance is probably now most commonly one
of those in the neck, but some physicians prefer to use the subclavian
vein (just under the collarbone), and a few get in via a vein in the
arm. The main use of right-sided catheterization involves getting the
catheter tip all the way through the right side of the heart and out
the other side into the pulmonary circulation, where transducer-tipped
catheters allow one to do pressure & flow measurements. These are
often sought in patients with serious, unstable heart disease.
The numbers that come out of right-sided catheterization are
fascinating, and it’s easy to believe that they allow patients to be
better managed. On the other hand, everyone who’s done more than a
few has some horror stories about procedure-related disasters. The
recent paper — which I’ve heard about, but not actually seen — is
not the first to present data suggesting that the disasters are real,
and the improved management may be illusory or, at the very least,
outweighed.
Robert R. Fenichel, M.D.
On 20 Sep 1996 22:13:48 GMT, ae…@yfn.ysu.edu (Stewart Rowe) wrote:
> If you had balloon angioplasty (PTCA) there is an additional
>delayed "risk" of having the artery re-close and requiring further
>treatment — they say 30-50% within six months. I suspect that
>now, the regular prescription of "statins" will reduce this
>occurrence.
The actual figures are more like 20-30% nowadays. There is certainly
plenty of operator-to-operator and center-to-center variability,
however! Also, the use of HMGCoA reductase-inhibitors (the "statin"
type drugs) hasn’t been shown to reduce restenosis after PTCA. Most
unfortunately, not much HAS been shown to reduce the restenosis rate
— the only thing that I’m aware of is the use of intracoronary
stents.
____________________________________________________________
Chris Klugewicz
Fellow, Div. of Cardiology
University of Maryland
____________________________________________________________
webbte <ted.w…@columbiasc.ncr.com> wrote:
>Iin last night’s Public Radio news, there was a story on
>"right-heart" catherizations causing an unexpected 20% in the
>death rate in the first 30 days after the proceedure. This
>morning’s paper also ran the same story but with a little more
>detail. It appears this cath uses the neck artery vs. the groin
>area, but I’m curious if that’s the only difference ( having
>just recently had the "standard" procedure less than 2 weeks
>ago, it has understandably tweaked my curiousity). Does anyone
>have some info on this report?
>ted
>(ted.w…@columbiasc.ncr.com)
Heart Procedure for Seriously Ill is Faulted
By Lawrence K. Altman
NEW YORK TIMES NEWS SERVICE
A standard procedure used more than a million times a year on
seriously ill patients in this country offers no benefit and may kill
some people, according to a new study that is causing consternation
among many doctors.
For 25 years, doctors working in the high-technology world of
intensive-care units have relied on the procedure to diagnose, monitor
and treat very sick patients, such as those experiencing heart, lung
or multiorgan failure.
The procedure involves inserting a thin tube into the heart through a
neck vein to collect data to guide minute-to-minute therapeutic
decisions. The information concerns actions of the heart and lungs,
the amount of fluids in the body and other bodily functions.
But the authors of the study, led by Dr. Alfred F. Connors Jr. of Case
Western Reserve University in Cleveland, said doctors had never tested
the procedure in a large randomized controlled trial, the most
scientifically rigorous type of study.
This study was not that type of trial, and some excepts immediately
challenged the study’s findings. Nevertheless, the authors said it
offered compelling evidence though not proof of the procedure’s
dangers. They also said they could not determine precisely why the
procedure might be dangerous. They said the procedure led to several
billion dollars’ worth of medical bills each year.
"This is an instance where the technology exists and provides the
information it was designed for, but the benefit to the patient is not
clear," said Dr. William A. Knaus, an expert in critical-care medicine
at the University of Virginia and a co-author of the study.
The procedure is known as pulmonary artery catheterization, or
right-heart catheterization, and the controversy over the technique
results from a study and an editorial in today’s issue of The Journal
of the American Medical Association.
The study’s findings have been known to some experts for weeks.
The study found that patients who underwent the procedure in the first
24 hours of their stay in an intensive-care unit had a higher death
rate, longer hospital stays and larger medical bills than those who
did not receive it.
The study involved more than 5,700 patients at five teaching hospitals
and is believed to be the largest, most detailed study ever done on
the procedure. But some experts in critical-care medicine criticized
the method used in the study as being less precise than that used in a
randomized controlled trial.
In the editorial, Dr. James E. Dalen of the University of Arizona and
Dr. Roger C. Bone, the journal’s consulting editor, demanded that
either the National Heart, Lung and Blood Institute immediately
subject the procedure to a randomized controlled trial or the Food and
Drug Administration declare a moratorium on its use.
Dr. Claude Lenfant of the National Heart, Lung and Blood Institute
said he was disinclined to sponsor a randomized trial.
The procedure relies on a device developed by Dr. H.J.C. Swan and Dr.
William Ganz in 1970. Other doctors quickly adopted the technique in
the belief that its benefits were obvious.
Dr. Peter F. Pasternack, a cardiologist at New York University, said
many experts believed that the devices were used too often and left in
place too long, risking infection and the formation of dangerous blood
clots. Additional complications can result from the need for a patient
to remain immobile while the Swan-Ganz catheter is in place. This can
last days.
Previous calls for a moratorium have gone unheeded, and attempts to
conduct randomized controlled trials have failed because many doctors,
believing the procedure to be helpful, have said it would be unethical
to put patients in a control group that would not get the treatment.
Reposting article removed by rogue canceller.
webbte <ted.w…@columbiasc.ncr.com> wrote:
>Iin last night’s Public Radio news, there was a story on
>"right-heart" catherizations causing an unexpected 20% in the
>death rate in the first 30 days after the proceedure. This
>morning’s paper also ran the same story but with a little more
>detail. It appears this cath uses the neck artery vs. the groin
>area, but I’m curious if that’s the only difference ( having
>just recently had the "standard" procedure less than 2 weeks
>ago, it has understandably tweaked my curiousity). Does anyone
>have some info on this report?
>ted
>(ted.w…@columbiasc.ncr.com)
Heart Procedure for Seriously Ill is Faulted
By Lawrence K. Altman
NEW YORK TIMES NEWS SERVICE
A standard procedure used more than a million times a year on
seriously ill patients in this country offers no benefit and may kill
some people, according to a new study that is causing consternation
among many doctors.
For 25 years, doctors working in the high-technology world of
intensive-care units have relied on the procedure to diagnose, monitor
and treat very sick patients, such as those experiencing heart, lung
or multiorgan failure.
The procedure involves inserting a thin tube into the heart through a
neck vein to collect data to guide minute-to-minute therapeutic
decisions. The information concerns actions of the heart and lungs,
the amount of fluids in the body and other bodily functions.
But the authors of the study, led by Dr. Alfred F. Connors Jr. of Case
Western Reserve University in Cleveland, said doctors had never tested
the procedure in a large randomized controlled trial, the most
scientifically rigorous type of study.
This study was not that type of trial, and some excepts immediately
challenged the study’s findings. Nevertheless, the authors said it
offered compelling evidence though not proof of the procedure’s
dangers. They also said they could not determine precisely why the
procedure might be dangerous. They said the procedure led to several
billion dollars’ worth of medical bills each year.
"This is an instance where the technology exists and provides the
information it was designed for, but the benefit to the patient is not
clear," said Dr. William A. Knaus, an expert in critical-care medicine
at the University of Virginia and a co-author of the study.
The procedure is known as pulmonary artery catheterization, or
right-heart catheterization, and the controversy over the technique
results from a study and an editorial in today’s issue of The Journal
of the American Medical Association.
The study’s findings have been known to some experts for weeks.
The study found that patients who underwent the procedure in the first
24 hours of their stay in an intensive-care unit had a higher death
rate, longer hospital stays and larger medical bills than those who
did not receive it.
The study involved more than 5,700 patients at five teaching hospitals
and is believed to be the largest, most detailed study ever done on
the procedure. But some experts in critical-care medicine criticized
the method used in the study as being less precise than that used in a
randomized controlled trial.
In the editorial, Dr. James E. Dalen of the University of Arizona and
Dr. Roger C. Bone, the journal’s consulting editor, demanded that
either the National Heart, Lung and Blood Institute immediately
subject the procedure to a randomized controlled trial or the Food and
Drug Administration declare a moratorium on its use.
Dr. Claude Lenfant of the National Heart, Lung and Blood Institute
said he was disinclined to sponsor a randomized trial.
The procedure relies on a device developed by Dr. H.J.C. Swan and Dr.
William Ganz in 1970. Other doctors quickly adopted the technique in
the belief that its benefits were obvious.
Dr. Peter F. Pasternack, a cardiologist at New York University, said
many experts believed that the devices were used too often and left in
place too long, risking infection and the formation of dangerous blood
clots. Additional complications can result from the need for a patient
to remain immobile while the Swan-Ganz catheter is in place. This can
last days.
Previous calls for a moratorium have gone unheeded, and attempts to
conduct randomized controlled trials have failed because many doctors,
believing the procedure to be helpful, have said it would be unethical
to put patients in a control group that would not get the treatment.
Reposting article removed by rogue canceller.
On 20 Sep 1996 22:13:48 GMT, ae…@yfn.ysu.edu (Stewart Rowe) wrote:
> If you had balloon angioplasty (PTCA) there is an additional
>delayed "risk" of having the artery re-close and requiring further
>treatment — they say 30-50% within six months. I suspect that
>now, the regular prescription of "statins" will reduce this
>occurrence.
The actual figures are more like 20-30% nowadays. There is certainly
plenty of operator-to-operator and center-to-center variability,
however! Also, the use of HMGCoA reductase-inhibitors (the "statin"
type drugs) hasn’t been shown to reduce restenosis after PTCA. Most
unfortunately, not much HAS been shown to reduce the restenosis rate
— the only thing that I’m aware of is the use of intracoronary
stents.
____________________________________________________________
Chris Klugewicz
Fellow, Div. of Cardiology
University of Maryland
____________________________________________________________
Reposting article removed by rogue canceller.
>On Wed, 18 Sep 1996, webbte wrote:
>> Iin last night’s Public Radio news, there was a story on
>> "right-heart" catherizations causing an unexpected 20% in the
>> death rate in the first 30 days after the proceedure. This
>> morning’s paper also ran the same story but with a little more
>> detail. It appears this cath uses the neck artery vs. the groin
>> area, but I’m curious if that’s the only difference.
Neck vs. groin is a NONdifference, as it happens.
Catheterization for workup of coronary artery disease involves
entering the left (arterial) side of the circulation. This is now
routinely done via the femoral artery, entering in the groin, but the
definining characteristic is the set of vessels you end up in, not how
you get there. Left-sided catheterization also sometimes crosses the
aortic valve to look at the left ventricle (the most common site of
heart-attack damage) and at the mitral & aortic valves. Left-sided
catheterization is associated with a small but nonzero mortality (say,
0.1%), but since it’s used in defining who should get which surgery,
and since the surgery is associated with mortality that’s at least an
order of magnitude more frequent, left-sided catheterization is taken
seriously, and it’s probably not done often in people who will not (on
average) benefit from it.
Right-sided catheterization involves entering the venous side of the
circulation. The vein of entrance is probably now most commonly one
of those in the neck, but some physicians prefer to use the subclavian
vein (just under the collarbone), and a few get in via a vein in the
arm. The main use of right-sided catheterization involves getting the
catheter tip all the way through the right side of the heart and out
the other side into the pulmonary circulation, where transducer-tipped
catheters allow one to do pressure & flow measurements. These are
often sought in patients with serious, unstable heart disease.
The numbers that come out of right-sided catheterization are
fascinating, and it’s easy to believe that they allow patients to be
better managed. On the other hand, everyone who’s done more than a
few has some horror stories about procedure-related disasters. The
recent paper — which I’ve heard about, but not actually seen — is
not the first to present data suggesting that the disasters are real,
and the improved management may be illusory or, at the very least,
outweighed.
Robert R. Fenichel, M.D.
Robert R. Fenichel (hedge…@cais.com) wrote:
> Right-sided catheterization involves entering the venous side of
> the circulation. The vein of entrance is probably now most commonly
> one of those in the neck…
Is this the Swan-Ganz catheter technique ?
Bye,