A talk I did at OpenMic in Cambridge about my experiences so far of starting a consultancy to develop Android applications. Thoughts on being a startup and how we adapted our business models and kept our minds open to new opportunities.
A talk I did at OpenMic in Cambridge about my experiences so far of starting a consultancy to develop Android applications. Thoughts on being a startup and how we adapted our business models and kept our minds open to new opportunities.
This presentation was developed and delivered in early 2009 based on a blog post I authored (All Media Is Social — http://thoughts.birdahonk.com/2008/10/media-has-always-been-social.html) in the fall of 2008.
App Inventor Concept Cards provide a quick way to learn new App Inventor code and concepts. Each of the cards can be printed out, folded in half, and used to prompt students to explore a concept in App Inventor such as timers, sounds, movement, math, multi screens, making colors, etc.
Los días 29 y 30 de mayo de 2010 tendrá lugar en Madrid un encuentro exclusivo para alumnos y antiguos alumnos de Esden.
Serán unas jornadas en las que los asistentes compartirán experiencias, además de asistir a las conferencias de personalidades de primer orden a nivel internacional.
The Hillel Yaffe Medical Center adopted a trans-radial approach for primary PCI in all new STEMI patients referred since January 2007. In a study of 98 STEMI patients who underwent primary PCI via the trans-radial approach, full patency restoration was achieved in all patients with no major bleeding complications. Procedure times, fluoroscopy times, and contrast volumes were similar to or better than worldwide benchmarks for primary PCI.
This presentation was developed and delivered in early 2009 based on a blog post I authored (All Media Is Social — http://thoughts.birdahonk.com/2008/10/media-has-always-been-social.html) in the fall of 2008.
App Inventor Concept Cards provide a quick way to learn new App Inventor code and concepts. Each of the cards can be printed out, folded in half, and used to prompt students to explore a concept in App Inventor such as timers, sounds, movement, math, multi screens, making colors, etc.
Los días 29 y 30 de mayo de 2010 tendrá lugar en Madrid un encuentro exclusivo para alumnos y antiguos alumnos de Esden.
Serán unas jornadas en las que los asistentes compartirán experiencias, además de asistir a las conferencias de personalidades de primer orden a nivel internacional.
The Hillel Yaffe Medical Center adopted a trans-radial approach for primary PCI in all new STEMI patients referred since January 2007. In a study of 98 STEMI patients who underwent primary PCI via the trans-radial approach, full patency restoration was achieved in all patients with no major bleeding complications. Procedure times, fluoroscopy times, and contrast volumes were similar to or better than worldwide benchmarks for primary PCI.
This document summarizes a presentation on transradial access for cardiac catheterization and percutaneous coronary intervention (PCI). It discusses the history and increasing adoption of transradial access worldwide over the past few decades. Data is presented showing benefits of transradial access compared to transfemoral access, including reduced bleeding, need for transfusions, and mortality. Meta-analyses of randomized controlled trials and observational studies comparing the two approaches are summarized. Barriers to further adoption are addressed as well as strategies to continue increasing use of transradial access.
This case report describes a late pseudoaneurysm that developed at the puncture site in a 30-year old male with systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APLA) who underwent coronary angiography. Two weeks after the procedure, an enlarging pulsatile bulge was detected at the puncture site. Ultrasound-guided thrombin injection resolved the pseudoaneurysm. The authors speculate that patients with chronic inflammatory diseases treated with anticoagulation and steroids may be predisposed to late pseudoaneurysm formation due to vessel wall weakness. Close follow-up is recommended for high-risk patients.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
This document summarizes the techniques used at the presenter's center for treating bifurcation lesions through radial versus femoral access. It provides examples of bifurcation cases treated through radial access using provisional stenting or two-stent techniques. The conclusions state that most bifurcations can be treated through radial access but femoral access may be considered if backup support is suboptimal or simultaneous implantation of two stents is needed, such as for conventional mini-crush or V stenting.
This document discusses minimizing radial artery injury from transradial PCI procedures. It notes that radial artery occlusion rates can be reduced by using heparin and removing compression devices early. Factors like artery to sheath ratio, smoking, and multiple catheters can increase injury. Radial artery function is impaired after the procedure but recovers after 3 months. Smaller catheters and identifying/addressing risk factors may help reduce vascular damage.
This document outlines nursing protocols for transradial catheterization procedures. It discusses pre-admission preparation including medication changes, testing, and education. It also details catheterization lab setup, the procedure, post-procedure care including wound dressings and recommendations, and follow-up phone calls. The goal is to provide concise guidance to nurses on the key steps and considerations for transradial catheterization patients.
The document provides guidance on patient setup and arterial access for right and left radial cardiac catheterization. It recommends using a board to position the patient comfortably, accessing from the right or left radial artery, using hydrophilic sheaths to prevent spasm, anticoagulating patients, and administering a spasmolytic cocktail. It emphasizes that training staff is important for successful radial procedures.
This document discusses Lankenau Medical Center's transition from femoral to radial artery access for cardiac catheterization procedures. It describes how the medical center trained physicians and staff, increased radial artery procedures over time, and significantly reduced major vascular complications as a result of the transition. Rates of radial artery procedures grew from 10% in early 2010 to over 75% in 2011. The medical center's vascular complication rate dropped from 0.91% prior to the transition to 0% after adopting radial artery access.
This document summarizes a presentation on the radial approach for PCI procedures. It provides evidence from randomized trials and observational studies showing that the radial approach significantly reduces bleeding complications compared to the femoral approach, with a nearly 80% reduction in major bleeding events. The radial approach also reduces the need for blood transfusions. While early death rates were similar between the two approaches in randomized trials, the observational studies suggested a potential 20% reduction in mortality with the radial approach. The presentation concludes that transradial access provides benefits for physicians, health systems, and patients, and its use is expected to continue increasing significantly in the coming years.
This document describes the case of an 82-year-old man with chest pain and pulmonary edema who was found to have multi-vessel coronary artery disease including a distal left main lesion. Due to his advanced age and high surgical risk, percutaneous coronary intervention (PCI) was chosen over coronary artery bypass grafting (CABG). The staged PCI procedure involved initially stenting the right coronary artery, followed by a complex multi-stent strategy including a mini-crush stent for the left main lesion and additional stents in the circumflex and left anterior descending arteries. The final result demonstrated successful revascularization.
Transradial Access is the Best Access for Percutaneous Coronary Intervention in Acute Coronary Syndrome with ST Elevation: Results from the RIVAL Trial, SCAAR Registry and Czech NRKI Registry
This document discusses radial artery access for cardiac catheterization procedures. It covers patient evaluation and setup, arterial access technique, options for venous access, hemostasis methods, and tips for salvaging failed access. The benefits of the radial approach include lower bleeding risks and more comfortable recovery for patients compared to femoral access. Radial access is now commonly used at many medical centers and continues to grow in popularity worldwide due to these advantages.
This document summarizes a presentation on techniques for transradial cardiac catheterization. It discusses common problems encountered such as unsuccessful puncture, radial artery spasm, and wire advancement issues. It provides tips for successful puncture including proper patient preparation, local anesthesia techniques, and treating spasm. Causes of failed wire advancement like radial loops and tortuosity are reviewed. Solutions emphasized are avoiding force, using contrast to understand the anatomy, hydrophilic wires, and external compression.
This document discusses managing anomalous origins of coronary arteries using the transradial approach. It notes that while the transradial and transfemoral approaches present similar issues for accessing the aortic root and correctly visualizing coronary arteries, there are no published data on how the arterial route impacts managing anomalous origins. The presentation provides information on classifying and identifying anomalous origins and courses using different imaging modalities like CT, MRI, and IVUS to determine the highest risk anomalies and best treatment approach. A clinical case example is presented of an anomalous right coronary artery identified on angiography and IVUS as having a surface-reducing intramural segment.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help boost feelings of calmness, happiness and focus.
The document discusses the benefits of using sheathless guide catheters for transradial percutaneous coronary interventions. Sheathless guide catheters provide the benefits of large guide catheters while using a smaller arterial access size. This reduces complications compared to traditional guide sheaths. The document outlines techniques for using sheathless guides and shows examples of complex cases such as bifurcation lesions and thrombus extraction that were successfully treated using sheathless guide support.
This document summarizes Tim Fischell's presentation on innovation in cardiovascular medicine. It discusses Fischell's history of medical device innovations, including the Arrow-Fischell sheath, brachytherapy devices, stents, and the AngelMed Guardian system. It provides guidance on developing new ideas into real innovations, including evaluating intellectual property, regulatory pathways, prototype testing, and clinical trials. Fischell emphasizes the importance of understanding unmet clinical needs and having a team approach to translating ideas into impactful new technologies.
This document discusses opportunities for developing and manufacturing medical devices in Latin America, including coronary stents with an estimated $500M annual market. It outlines the roadmap needed to design, test, manufacture, and gain regulatory approval for a novel stent concept, including requirements for structure and flow, deployability and patency, and clinical performance. Design considerations are discussed such as structural rigidity, flexural rigidity, surface finish, and hemodynamic simulations. The potential for low-cost manufacturing and animal studies are also mentioned.
This document summarizes the evidence from multiple randomized clinical trials that support a Class IA recommendation for the use of radial artery access (TRA) over femoral artery access (TFA) for cardiac catheterization procedures. The data show that TRA is associated with lower rates of major vascular complications and major bleeding compared to TFA, with numbers needed to treat of 21 and 47 respectively. TRA may also reduce mortality in patients with acute coronary syndrome, with a number needed to treat of 100. Both the 2018 AHA guidelines and ESC/EACTS guidelines were updated to strongly recommend a radial-first approach in light of the overwhelming data demonstrating benefits of TRA over TFA.
This document discusses best practices for same day discharge after cardiac procedures. It provides an overview of the history and evidence supporting same day discharge. Key points include:
- Same day discharge has been shown to be safe and effective in studies dating back to the 1990s.
- Dedicated lounges and infrastructure improve outcomes for same day discharge by allowing for close monitoring and care in the immediate post-procedure period.
- The author's hospital has successfully performed over 7,000 same day discharge procedures over 10 years using a dedicated radial lounge with trained nursing staff who provide care and arrange discharge. Complication rates are low with their protocol.
This document describes a case of critical hand ischemia treated through multiple endovascular interventions over several years. Initially, the patient underwent brachial artery recanalization and stenting from left radial access, but presented two days later with stent thrombosis. A second procedure recanalized the stent and treated a brachial dissection with another stent. However, two years later the patient returned with re-occlusion of arm vessels and iliac arteries. Further interventions were needed to recanalize stenosed iliac and brachial arteries over time. In conclusion, long term patency of arm interventions is unknown, and stent CTO recanalization in the arms poses similar challenges to the legs.
This document discusses expanding the FDA indication for protected PCI procedures using the Impella heart pump. Key points include:
1. A study of 891 patients found that those with mildly/moderately reduced ejection fraction (LVEF >35%) undergoing protected PCI had favorable outcomes similar to those with severely reduced LVEF, despite being older with more comorbidities and complex coronary disease.
2. Protected PCI with Impella led to improved LVEF and quality of life in multiple studies. The Protect II trial showed Impella reduced MACCE by 29% compared to IABP at 30 days.
3. Guidelines recommend protected PCI for patients with severe/moderate/mild reduced LVE
This document summarizes the findings of a study analyzing 19,482 left main stem percutaneous coronary intervention (LMS-PCI) procedures from the British Cardiovascular Intervention Society National Database between 2007-2014:
1) Use of radial artery access for LMS-PCI increased significantly over time and radial access was associated with reduced vascular complications, major bleeding, and shorter hospital stays.
2) Radial access was independently associated with lower in-hospital mortality and major adverse cardiac and cerebrovascular events (MACE) compared to femoral access.
3) Independent predictors of 12-month mortality following LMS-PCI included acute kidney injury, older age, chronic renal failure, acute coronary syndrome presentation, and
This document discusses accessing the right heart and central venous system through the radial vein as a safer alternative to traditional femoral access. It provides tips for establishing venous access through the forearm, including using ultrasound or no-touch technology to locate veins and heparin locks to improve efficiency. Challenges like low venous pressure, valves, and junctions are addressed. Images demonstrate techniques for navigating the radial artery into the right atrium, including using flushes of saline. Potential contraindications like arm trauma or breast cancer are noted. The document argues learning both arterial and venous radial techniques will improve cardiologist skills and safety.
This document discusses techniques for radial artery puncture for cardiovascular procedures. It notes that the radial artery is smaller in diameter than the femoral artery. Successful radial access requires correctly positioning and securing the wrist. Ultrasound guidance can help find and access the radial artery, especially for trainees. The initial puncture approach can be anterior wall only or use a counterpuncture technique. Sheath size, length, and coating impact radial artery spasm and occlusion. Cocktails including nitroglycerine and calcium channel blockers are commonly used but acid in the cocktail may damage the artery if felt by the patient.
This document summarizes a presentation given by Dr. Olivier Bertrand on post-PCI FFR measurement. It discusses studies showing that a post-PCI FFR of 0.90 or higher is associated with lower rates of re-PCI and major adverse cardiac events. It then outlines the proposed PREDICT randomized study to evaluate whether routine post-PCI FFR measurement can guide PCI strategy and completion. The study would measure FFR after successful PCI in all-comers and randomize patients to clinical follow-up alone or with guidance from the post-PCI FFR results. The goal is to establish if physiology-guided PCI optimization can improve outcomes and reduce costs.
This document summarizes lessons learned from the DEFINE-FLAIR and iFR-SWEDEHEART clinical trials. The trials found:
1) Decision-making based on instantaneous wave-free ratio (iFR) was non-inferior to fractional flow reserve (FFR) for guiding revascularization and reducing major adverse cardiac events over 1-2 years.
2) iFR-guided decisions resulted in significantly less revascularization procedures compared to FFR.
3) Subgroup analysis found increased event rates among diabetic patients evaluated with FFR compared to iFR.
4) iFR has been upgraded to a Class IA recommendation in European Society of Cardiology guidelines based on these trials
1. The document discusses the use of physiology in acute coronary syndrome (ACS) patients, including trials evaluating fractional flow reserve (FFR) and index myocardial resistance (IMR) measurements.
2. Several trials showed that FFR-guided revascularization in multivessel disease STEMI patients reduced major cardiac events compared to culprit-only PCI or medical therapy. Ongoing trials are further evaluating FFR in ACS.
3. IMR predicts mortality and heart failure in STEMI patients and adversely remodeling post-STEMI.
4. Incomplete revascularization is common in ACS and associated with worse outcomes; FFR may help guide more complete revascularization. The clinical utility of physiology in ACS
This document discusses the potential use of 4 French (4F) catheters for fractional flow reserve (FFR) measurements as a less invasive alternative to larger catheters. It notes that 4F catheters have a smaller profile but can lack the ability to directly perform percutaneous coronary intervention if needed. The document outlines key considerations for using 4F catheters, including ensuring the catheter lumen is well flushed and the pressure transducer is not damped. It concludes that improvements are still needed, such as reducing friction between the pressure wire and catheter, in order to maximize the benefits of using the smallest catheter size possible.
This document discusses using fractional flow reserve (FFR) to evaluate ambiguous left main coronary artery disease. It presents a case of an 82-year-old woman with chest pain and a recent stent in the circumflex artery. FFR measurements of the left main and left anterior descending artery were 0.64, indicating significance. Intravascular ultrasound also suggested significance. The left main and proximal left anterior descending artery were stented, and post-procedure FFR measurements improved. The document reviews evidence that FFR can safely guide decisions about revascularization of ambiguous left main lesions.
This document summarizes a presentation on CT-derived fractional flow reserve (FFR-CT). It discusses how FFR-CT increases the positive predictive value of coronary CT angiography (CTCA). Several landmark studies are summarized that evaluated the diagnostic accuracy of FFR-CT compared to CTCA. The PACIFIC trial findings showing high diagnostic accuracy of FFR-CT are described. Ongoing and upcoming clinical trials using FFR-CT like PRECISION and DECISION are mentioned. Novel applications of FFR-CT for biomechanics analysis and PCI planning are presented. Finally, new methods like user-generated CT-FFR that may reduce processing time are introduced, though accuracy needs further evaluation.
This document summarizes the results of a study evaluating the diagnostic accuracy of quantitative flow ratio (QFR) compared to fractional flow reserve (FFR) as the reference standard. The study included 317 lesions in 273 patients. Key results included:
- QFR showed superior sensitivity and specificity for detecting functionally significant lesions compared to 2D quantitative coronary angiography.
- QFR values correlated well with invasive FFR measurements.
- QFR could be computed within a similar time frame as FFR measurements.
- A hybrid approach using QFR and FFR may allow pressure wire-free assessment in 68% of lesions while maintaining high diagnostic accuracy.
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