Dr Richard Bogle PhD FRCP FESC FACC DHMSA
Consultant Cardiologist
  • Home
  • NHS Practice
    • NHS Practice
    • St Helier Hospital
    • Epsom Cardiac Day Unit
    • St George's Hospital Radial Lounge
    • Echocardiography
  • Biography
    • Qualifications
    • About me >
      • Curriculum vitae
    • Appraisal and Revalidation
    • BCIS Angioplasty Audit
    • Publications
    • Recent abstracts
    • Research
    • Charitable activity
  • The Heart
    • Cardiac Investigations >
      • AliveCor ECG monitor
      • Guide to investigations for suspected angina
      • CT calcium scoring
      • Electrocardiogram (ECG)
      • Exercise treadmill test
      • Echocardiogram
      • Valve disease
      • Coronary Angiography
      • Pressure Wire Studies
      • Intra-vascular Ultrasound
    • Arrhythmias >
      • Atrial fibrillation >
        • Stroke Risk in AF
        • New Oral Anticoagulants
        • Presentations on AF
      • Atrial flutter
      • Pre-excitation syndromes
      • Ventricular ectopic beats
      • Ventricular arrhythmias
      • Pacemaker
      • DC Cardioversion
    • Cardiomyopathy
    • Coronary heart disease >
      • Cardiac syndrome X
      • Coronary Angioplasty
      • Coronary bypass surgery
    • Dizziness and blackouts
    • Fitness to fly
    • Fitness to drive
    • Heart Failure
    • Hypertension >
      • Patients guide to blood pressure medication
      • Home blood pressure monitors
      • Hypertension diet
      • Laragh's method
      • Renal sympathetic ablation for hypertension
      • Conn's Syndrome
    • Heart Screening >
      • Sports Cardiology
      • Cardiovascular Disease Risk
    • Medications >
      • Glyceryl trinitrate
    • Patient information leaflets
  • News and Links
  • Miscellany
    • History of Medicine
    • History of Coronary Angiography and Angioplasty
    • Stamps in Cardiology
    • A History of Medicine in 100 Objects
    • BSE Acceditation Course Introduction
    • BSE Acceditation Course Physics
    • BSE Acceditation Course Anatomy and Function
    • BSE Acceditation Course Mitral
    • BSE Acceditation Course Aortic
    • BSE Acceditation Course Congenital
    • BSE Acceditation Course Pericardium
  • Blog
  • RACPC Form
  • Cardiology Teaching St Helier Hospital

The aggregation of marginal gains

18/3/2014

0 Comments

 
Picture
In the Summer of 2012 David Brailsford presided over Team GB’s incredible haul of cycling medals in the Olympic games. What was the secret of this team’s success? The simple answer was there wasn’t one secret but as Dave Brailsford said it was the aggregation of marginal gains.  Performing a coronary angioplasty can take as little as 15 minutes but even with the simplest procedure there are many different choices which the operator needs to make and each of these influences the outcome of the procedure and the risk of complications. Close attention to detail, wise choices and the sum of the marginal gains makes the difference between getting a bronze and achieving gold.

Here is an example. The patient is a 75 year old obese man with diabetes and hypertension. He has a stenosis in the mid right coronary artery. The artery is mildly calcified and a somewhat tortuous. Dr Groin is a default femoral operator. With a 6F sheath, a right Judkin’s guide catheter and a hydrophilic guide wire most cases can be done. Groin access takes but a moment and the coronary artery is easily intubated, the wire glides through the vessel with its usual speed and hydrophilic coating. Within moments the lesion is pre-dilated with a balloon. Then comes the stent but there is a problem, the tortuousity and the calcification makes the stent difficult to track through the vessel. The JR4 catheter does not give any support and the stent cannot  be manoeuvred into the correct place. A buddy wire is passed but still the stent won’t track to the lesion. Further ballooning is performed in the vessel which results in a small dissection and without the ability to deliver a drug coated stent they try a bare metal stent which is finally deployed with a reasonable result. The procedure takes 75 minutes and there is 300ml contrast used.  An angioseal vascular closure device is deployed but does not quite seal the artery completely and the patient develops a haematoma. The patient eventually leaves the hospital 4 days later. His procedure was a success, the vessel was stented but was this as good as it could possibly be.

Dr Wrist usually takes the radial approach. A 5Fglideliner sheath and a 6F AL1 guide catheter are used because the vessel is calcified and somewhat tortuous and he thinks that extra support may be needed. The lesion is crossed with a supportive angioplasty wire, the wire is harder to manipulate than the hydrophilic coated wires but once in the distal vessel it gives excellent support and remains very stable. The vessel is tortuous but the AL-1 gives a really good back up support and the lesion is ballooned with a 2.5x12 balloon and then a 3.5x15 drug eluting stent is deployed with a good result. Because the lesion was calcified a further 3.5x12 non-compliant balloon inflation is made to high pressure with a very good angiographic result. The procedure takes 27 minutes and there is 60ml contrast used. A TR band is placed on the wrist with patent haemostasis and the patient is discharged from the hospital 6h later. His procedure was a success, the vessel was stented.

Both patients had a successful PCI on paper but Dr Wrist’s procedure was more successful for the patient. The sum of the small parts – access site, catheter choice, wire choice and ability to deliver devices. All of these single decisions feed into the outcome of the procedure for the patient.  Alone each one of these things may contribute only a fraction of a percent to a difference in outcome but when they are all put together they can add up and the sum of marginal gains leads to safer and more effective practice.

So how do we achieve these marginal gains in practice: Set audacious goals, work with others who share your vision. Focus, Focus, Focus. Collect high quality procedure data, outcomes data and learn from it. Be disciplined to capture every gain.


0 Comments

Your comment will be posted after it is approved.


Leave a Reply.

    RSS Feed

    Picture

    Dr Richard Bogle

    The opinions expressed in this blog are strictly those of the author and should not be construed as the opinion or policy of my employers nor recommendations for your care or anyone else's. Always seek professional guidance instead.

    Archives

    November 2019
    March 2016
    February 2016
    May 2015
    April 2015
    March 2015
    February 2015
    January 2015
    December 2014
    November 2014
    October 2014
    September 2014
    August 2014
    July 2014
    June 2014
    May 2014
    April 2014
    March 2014
    February 2014
    January 2014
    November 2013
    October 2013
    August 2013
    July 2013
    June 2013
    May 2013
    April 2013
    March 2013
    February 2013
    January 2013

    Categories

    All
    Ablation
    Acute Coronary Syndromes
    Acute Coronary Syndromes
    Adherence
    Angioplasty
    Anticoagulants
    Arrhythmia
    Association
    Atherosclerosis
    Atrial Fibrillation
    Auenbrugger
    Bergamot
    Brugada
    Calcium Channel Blockers
    Cancer
    Cardiovascular Risk
    Chest Pain
    Cholesterol
    Cleveland Street
    Clinical Examination
    Colchicine
    Compliance
    Concordance
    Congenital Heart Disease
    Coronary Artery Disease
    Coronary Artery Disease
    C-reactive Protein
    Decision Aids
    Diet
    Ectopics
    Eggs
    Ezetimibe
    Frailty
    Frank's Sign
    Guidelines
    Hawthorne Effect
    Heart Failure
    History Of Medicine
    Hypertension
    ICD
    Internet
    Interventional Cardiology
    Joseph Rogers
    Lipids
    Malaria
    Marathon
    Medicines
    Nice Guidelines
    Nitrovasodilators
    NOAC
    Nudge
    Nutrition
    OCT
    Palpitations
    Pharmacy
    Pressure Wire
    Proteus
    Salt
    Smoking
    Spironolactone
    Statins
    Statistics
    Stent
    Stress
    Stroke
    Syndrome X
    Takotsubo
    Valve-disease
    Vein Grafts
    Ventricular Ectopics
    VF/VT
    Warfarin
    Weekend Working
    Workhouse

    View my profile on LinkedIn
Return to home page

Privacy Statement
Disclaimer
© Dr Richard Bogle 2020
patient feedback
Photo used under Creative Commons from peddhapati