#Stitch Puncture .

#Definition.

Stitch effect is a rare complication where the needle pierces the intrapericardial space from the right atrial side and re-enter the left atria
#Mechanism.

•Alignment of IAS with reference to RA and LA is key a determinant

•Normally RA & LA Roofs lie in same plane & IAS makes their common wall

•In MS LA can outgrow RA , bringing superior aspect of LA in a different plane with reference to IAS
•The IAS puncture site may overshoot , enter the pericardial space and stitches the non IAS aspect of RA and LA together ,

& Entry into LA occurs through a false pericardial track
#Different Stitch Routes can occur

1.IAS-Pericardial space -LA roof

2.RA-Pericardial space -LA roof

3.RA-Pericardial space -Extra cardiac-Reenter LA
#Possible Bleeding Points;

There can be two sites of active bleeding .One from RA exit point and other from LA entry point of needle.Extra-cardiac oozing can also occur if the needle has pierced the outer pericardium before entering LA.
#When to Suspect.

If, after advancement of the catheter/needle, there is no recording of LA pressure, then there may have been perforation of the atrial wall.

#Management;

1.Urgent Shifting to Cardiac Surgery

2.Pericardiocentesis may be needed if Cardiac Temponade.
Guidelines

1 If only needle has perforated, it can be withdrawn safely (a situation similar to early pretransseptal techniques),

2 if much larger catheter has perforated, then major bleeding is inevitable and Pt should be sent for catheter removal at open thoracic surg.
Note.

To differentiate those two circumstances, a tiny amount (0.1-0.3 ml) of contrast can be injected through the needle. If this causes staining outside the atrial cavity, then needle perforation is confirmed. .
Needle can then be withdrawn to just within catheter tip while catheter remains absolutely static. A further injection of contrast is given via needle. If contrast swirls within atrial cavity, catheter has not exited the heart and can be withdrawn.
If further staining is seen, the patient requires surgery for safe catheter removal
@PCRonline
@TCTMD
@APSIC6
@GisGulf
@mmamas1973
@mirvatalasnag

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More from @shoaib9702

Nov 1
#Guidewire Structure
..
It has 3 Basic Components

1.Shaft (Central core )
2.Distal Tip with coils/ cover & sleeve
3.Surface coating

1.#Centeral Core

It is inner & longest portion of guidewire making it backbone .it extends from proximal to distal end where it tapers. Image
There are 3 important aspects regarding centeral core are

i) #Core material

•Stainless steel
•High tensile Stainless steel
•Nitinol

ii) #Core diameter

O.010"-0.018" (0.014"Most common )

iii) #Tapering towards tip

•Short Tappered

•Long Tappered
#Wire Tip

i Tip may be Tapered or Non Tapered

ii There are 3 Tip Design

•One Piece Core Design ( core -Tip design)

•Two Piece core Design (Shapping ribbon design )

Hybrid

iii Tip coils /Covers / sleeves

Tip may be covered with coils /polymer cover /nitinol sleeve
Read 6 tweets
Oct 29
#Pericardiocentesis Site of Puncture;

There are 3 Options .

1.Subxiphoid
2.Parasternal
3.Apical

Factors to choose site .

•It depends on location ,type (eg circumferential)

•In situation of cardiac arrest or emergency situation ,subxiphoid is best . Image
For other situations ,Apical is safest when performed under ultrasound guidance with biopsy line function of probe.

•Choose the location with probe with biopsy line ,avoiding any parallel structure (heart,liver,lung)
Puncture Canal or Axis .

If needle has long puncture Canal /axis in effusion it is safe .

1.Subxiphoid Approach;

•Puncture is always directed towards right heart so short part of Puncture axis within effusion

•subxiphoid puncture often passes through liver.
Read 4 tweets
Oct 29
#Classification of Guidewires
( very important Topic)
..........................

Guidewires have different properties ,it is classified on different parameters but most practical classification is ""Based on Lesion -Type Classification.
@PCRonline
@TCTMD
@mmamas1973
@Hragy
A.Based on Tip -Flexibility ( Tip -Load )

#Tip Load..Amount of force ( in grams) needed to buckle distal 1cm of Tip

1.Floppy wires (<1.5gm)
2.Intermediate wires (2-4gm)
3.Stiff wires (>4gm)
.............. ..............
B..#Based on Tip -Coating

1.Hydrophilic
2.Hydrophobic
3.No coating

....................

C..#Based on Tip -Tappering Design

1.Tapered
2.Non -Tapered

.............

D..#Based on Tip -Style

1.One Piece design
2.Two piece design
Read 16 tweets
Oct 29
#GulfPCR
@PCRonline
Program of 15 Dec 2022 Schedule Gulf -PCR
Venue:Grand Hyatt -Dubai

1.Room Baniyas
2.Room Almeera 
3.Case Corner 1
4.Case Corner 2.
Room Baniyas

1.Severe MR  &  TR
2.PCI in HBR Pts 
3.Essential drugs that every interventionalist needs to know
Room Almeera 

Complex LMS PCI

CABG vs PCI /Multivessel PCI

All you need to know on physiology

Optimal management of a patient with calcified lesions:

Challenging and complication cases
Read 5 tweets
Oct 29
#GulfPCR
@PCRonline
Program of 14 Dec 2022 Schedule Gulf -PCR
Venue:Grand Hyatt -Dubai

1.Room Baniyas
2.Room Almeera 
3.Case Corner 1
4.Case Corner 2.
Room Baniyas

1.TAVI challenging scenarios - LIVE case from Chest Diseases Hospital - Kuwait
2Imaging in TAVI challenging anatomy
3.Trial review 2022: my five most impactful clinical trials

4Multivessel disease PCI: LIVE case from Kuwait

5Challenging & complication cases
Room Almeera

How should I treat STEMI?

With the collaboration of the Saudi Arabian Cardiac Intervention Society (SACIS

Antegrade approach for CTO from cap penetration to completion

.....
Read 5 tweets
Oct 28
Antegrade Approach for #CTO Lesions #Cardiotwitter

Method A..Antegrade wire Escaltation ;

It consists of advancing various guidewires in antegrade direction to cross CTO while remaining within true lumen of vessel (True to True )
@mmamas1973
@mirvatalasnag
@Hragy
@PCRonline
#crossing proximal cap.

Wire escaltation

Wire Gear 1

For proximal cap penetration, tapered polymer GW with low-penetration power soft-tip (Fielder family guidewires; Ashai Intecc), allowing advancement along visible or invisible microchannels, are the first choice
Wire Gear 2

~If the operator encounters difficulties in crossing the lesion, they can switch to GW with greater penetration force. When proximal cap is blunt, GW with intermediate penetration force (Gaia 2nd–3rd [Ashai Intecc] or Pilot 200 [Abbott Vascular]) are used.
Read 15 tweets

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