Introduction

The cardiac catheterization laboratory is an increasingly complex environment encompassing a range of procedures and care teams. Although diagnostic and therapeutic coronary artery procedures remain the backbone, increasing volumes and varieties of structural, endovascular, and electrophysiology cases are being performed in the cardiac catheterization laboratory, which expands multidisciplinary teams and staff training. Providing the highest quality of care with a patient-centered approach requires keeping current on medical evidence and regulatory and accreditation requirements. The 2021 update of the SCAI Expert Consensus Statement on best practices in the cardiac catheterization laboratory builds upon the previous statements and serves as a resource for physicians, administrators, and organizations invested in improving quality and value of care through process improvement and standardization.¹

Highlights From the Expert Consensus Statement

Although the focus of the update is on coronary artery procedures, many of the principles discussed have parallels to non-coronary procedures. The document is organized into five major sections; this document reviews the main takeaways from each section and supporting evidence.

Institutional and Operator Qualifications and Components of an Optimal Cardiac Catheterization Laboratory Procedural Team

• Physician credentialing requirements remain unchanged and include board certification, professional practice evaluations, participation in continuous quality improvement, minimum case volumes, and assessment of risk-adjusted outcomes.
• Non-physician staffing of procedures in the cardiac catheterization laboratory may be flexible, as opposed to a static ratio, and should be based on the needs and risks of the procedure and potential for moderate or deeper levels of sedation.
• Recommended percutaneous coronary intervention (PCI) operator volume remains 50 cases per year averaged over 2 years. National registry data suggest that up to 40% of operators perform less than the recommended PCI volume. Low-volume operators meeting other credentialing requirements may practice with appropriate monitoring and plan to assess competency.²
• PCI at freestanding ambulatory surgical centers, now reimbursed by the Centers for Medicare & Medicaid Services, is becoming more common and, as with programs without surgery onsite, must meet the same standards as acute care hospitals and have protocols in place for immediate consultation and transfer to tertiary care centers.³

Pre-Procedure Best Practices

• Tools that assist in estimating risk of PCI complications (like the PCI Risk Calculator) and shared decision making should be considered in the informed consent process.⁴
• Management of oral anticoagulants differs according to the indication for anticoagulation and procedure being performed. Continuation of anticoagulation is generally safe for electrophysiology procedures including device placement, generator changes, and atrial fibrillation ablations. However, brief interruption of anticoagulation is recommended for PCI if risk of stroke or thromboembolism is acceptable.

Intra-Procedure Best Practices

• Updated procedural checklists that have incorporated the latest evidence-based data and time-outs should be performed and compliance monitored to minimize risk of medical error and enhance team communication. Examples of checklists and time-out requirements are provided in the document.
• Collaboration between interventional cardiologists and electrophysiologists has grown over the years due to the complexity of procedures being performed. Some procedures, such as left atrial appendage occlusion, are performed by operators from both specialties.
• Coronary angiography is a necessary component of certain ablation procedures. Processes should be in place to anticipate when coronary angiography might be required in the electrophysiology laboratory so that informed consent is obtained and both operators and the necessary equipment are available to assist.

Post-Procedure Best Practices

• Patients with uncomplicated PCI procedures should be considered for same-day discharge after 4 or more hours of monitoring. Consensus documents provide guidance on patient selection and readiness for discharge.⁵ Many electrophysiology procedures are suitable for same-day discharge as well.^6,7

Catheterization Laboratory Governance

• Dyad partnerships between cardiac catheterization laboratory physician medical directors and an administrative or nursing director optimize collaboration with stakeholders, acquisition of resources, and maintenance of fiscal balance.
• Continuous quality assurance programs, including participation in quality registries that can be used for institutional- and operator-level benchmarking, are key to performance improvement.
• Catheterization laboratories must have the capability to respond to emergent or unexpected circumstances that can affect the safety of laboratory personnel or patients or alter procedural volume, such as was seen with the coronavirus disease 2019 pandemic.⁸

Limitations

The best practices document incorporates the latest medical evidence and expert opinion from cardiovascular society guidelines to assist stakeholders in the delivery of high-quality care in the cardiac catheterization laboratory. The recommendations are not intended to be proscriptive or punitive but to serve as a resource and a basis upon which institutional protocols can be based.

References

1. Naidu SS, Abbott JD, Bagai J, et al. SCAI expert consensus update on best practices in the cardiac catheterization laboratory. Catheter Cardiovasc Interv 2021;Apr 28:[Epub ahead of print].
2. Fanaroff AC, Zakroysky P, Wojdyla D, et al. Relationship Between Operator Volume and Long-Term Outcomes After Percutaneous Coronary Intervention. Circulation 2019;139:458-72.
3. Box LC, Blankenship JC, Henry TD, et al. SCAI position statement on the performance of percutaneous coronary intervention in ambulatory surgical centers. Catheter Cardiovasc Interv 2020;96:862-70.
4. Coylewright M, Dick S, Zmolek B, et al. PCI Choice Decision Aid for Stable Coronary Artery Disease: A Randomized Trial. Circ Cardiovasc Qual Outcomes 2016;9:767-76.
5. Rao SV, Vidovich MI, Gilchrist IC, et al. 2021 ACC Expert Consensus Decision Pathway on Same-Day Discharge After Percutaneous Coronary Intervention: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2021;77:811-25.
6. Budano C, Garrone P, Castagno D, et al. Same-day CIED implantation and discharge: Is it possible? The E-MOTION trial (Early MObilization after pacemaker implantaTION). Int J Cardiol 2019;288:82-6.
7. Deyell MW, Leather RA, Macle L, et al. Efficacy and Safety of Same-Day Discharge for Atrial Fibrillation Ablation. JACC Clin Electrophysiol 2020;6:609-19.
8. Welt FGP, Shah PB, Aronow HD, et al. Catheterization Laboratory Considerations During the Coronavirus (COVID-19) Pandemic: From the ACC's Interventional Council and SCAI. J Am Coll Cardiol 2020;75:2372-5.

Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, COVID-19 Hub, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Laboratories, Coronary Angiography, Percutaneous Coronary Intervention, Atrial Fibrillation, Benchmarking, Coronavirus, Coronavirus Infections, COVID-19, SARS-CoV-2, Coronary Vessels, Patient Selection, Quality Improvement, Physician Executives, Patient Discharge, Tertiary Care Centers, Pandemics, Decision Making, Atrial Appendage, Medicaid, Medicare, Cardiac Catheterization, Thromboembolism, Anticoagulants, Stroke, Medical Errors, Accreditation, Credentialing, Laboratory Personnel, Registries, Informed Consent, Referral and Consultation, Professional Practice, Reference Standards, Patient Care Team, Electrophysiology, Patient-Centered Care

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