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Cardiac Cath and Angiocardiography
SPRING 2012
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Definition of Cardiac Catherization
• Comprehensive term to describe minor surgical procedure for diagnostic evaluation or interventional (therapeutic) purposes
• Diagnostic– Collects data to evaluate PT’s condition
• Therapeutic– To intervene by mechanical means to treat disorders
of the vascular and conduction systems within the heart
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Principles of Cardiac Catheterization
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Indications• Suspected or known coronary • heart disease
• Myodcardial infarction
• Sudden cardiovascular death
• Valvular heart disease
• Congenital heart disease
• Aortic dissection
• Pericardial constriction
• Cardiomyopathy
• Initial and follow up assessment for heart transplant
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Contraindications
• Active GI bleed• Renal failure• Recent stroke• Fever from infection• Electrolyte imbalance• Anemia• Short life expectancy• Digitalis intoxication
• PT refusal• Uncontrolled
hypertension• Bleeding disorders• Pulmonary edema• Uncontrolled ventricular
arrhythmias• Aortic valve endocarditiis• Allergic to contrast
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Complications and Risks
• Death• Myocardial infarction• CVA• Arrhythmia• Hemorrhage• Contrast• Hemodynamic• Perforation
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Angiographic Supplies and Equipment
•Catheters
•Contrast Media
•Pressure Injector
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Catheters
• For LT cardiac cath similar to those for angio
• RT cath requires specialized catheters– Typically flow directed
catheters– With manifolds
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Contrast Media
• High Osmolar Ionic– Sometimes causes ECG changes
• Widely used– Non-ionic– Ionic low osmolar
• Restricted costs causes limited use of low osmolar contrast agents.
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Pressure injector
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Imaging
•Image chain
•Digital Angiography imaging equipment
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Image chain• Similar to angio suites
• High resolution imaging and recording
• C-arms must be able to be on for extended periods of time– Withstand great heat load– Multi focal-spot– High speed rotating fluoro tubes– Short exposure times– 15-30 frames per second
• Often have a video camera
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Digital Angiography Imaging equipment
• Long term storage of large amounts of digital files has benefited from advances in computer technology
• DICOM
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Ancillary Equipment and Supplies
•Physiologic Equipment
•Other equipment
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Physiologic Equipment
• Equipment to monitor– ECG – Hemodynamic pressures
• Vital signs to
• record PT function
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Other Equipment
• Crash cart• Oxygen and suction• Defibrillator• Temporary pacemaker• Pulse oximeter• Blood pressure cuff• Equipment to perform cardiac output studies• Activated clotting time (ACT) equipment
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Patient Positioning forCardiac Catheterization
• PT must be positioning so that they will not have to be moved during procedure
• Must be positioned so anatomic structures of interest are demonstrated
• PT is supine with shielding as appropriate
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Catheterization Methods and Techniques
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Pre-Catheterization Care
• Informed consent obtained• PT history• Physical exam• CXR• Blood work• ECG• Echocardiogram• Exercise stress test• Nuclear Medicine cardiac perfusion studies
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Pre-Catheterization Care
• IV started– Sedation and nausea
• Nothing to eat 4-6 hours before procedure• Records of procedure
– PT hemodynamic data– Fluoro times– Medications administered– Supplies used– Other pertinent information
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Catheter Introduction
• Prepare catheter introduction site with aseptic technique– Shaved and cleaned
• Can be at femoral (most common), brachial, radial, axillary, jugular and subclavian areas
• Selinger technique used
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Selinger Technique
Needle with cannula inserted
Needle withdrawnuntil there is blood flow
Inner cannula removed& guidewire inserted
Needle removedCatheter over guidewire Guidewire removed
leaving catheter in artery
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Data Collection
• Physiologic data unusually collected– Hemodynamic parameters
• Includes blood pressure • Cardiac output• Vascular pressures (inside & outside the heart)
– ECG– Oximetry readings– Cardiac output– Blood samples to measure oxygen
saturations levels in various parts of the heart
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Catherization Studies and Procedures
•Adults
•Children
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Basic Diagnostic Studies of the Vascular System for Adults
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Cath of the LT side of the heart: ADULTS
• Catheter introduced into the radial, brachial or femoral artery to the ascending aorta
• Aortic root angio is performed to document competence of the aortic valve
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Aorta Root Angiography
• Normal means backward flow of the contrast media into the LT ventricle during injection
• Atrial oximetry and blood pressure within aorta are measured
• Then advanced into the LT ventricle
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LT Ventriculography
• Provides info on valvular competence
• Interventricular septal integrity
• Efficiency of the pumping action of LT ventricle
• Pressure measurements are made
• When systolic (LT ventricle) does not match systolic (aorta)- could mean aortic stenosis
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Coronary Angiography
• Allows the extent of intracoronary stenosis to be evaluated
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Coronary Angiography
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Coronary Angiography
Normal LT coronary Artery
LT coronary artery
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Cath of the RT side of the heart:
ADULTS
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Cath of the RT side of the heart: ADULTS
• Pressure measurements– Used to determine valvular heart disease– Congestive heart failure– Pulmonary hypertension– Cardiomyopathies
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Exercise Hemodynamics
• For evaluation of valvular disease– When fatigue and dyspnea are present
• Simultaneous catherization is done and pressure measurements of RT & LT heart is taken– At rest– With exertion
• Catheter is placed in:– An artery (femoral or brachial)– Vein (femoral or basilic)
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Basic Diagnostic Studies of the Vascular System for Children
• For evaluation of specific hemodynamic data– Selected aspects of cardiac function– Congenital heart defects
• Methods are different according to age and size of the heart
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Advanced Diagnostic Studies of the Vascular System for Adults &
Children
• Biopsy catheter with bioptome tip is inserted into jugular or femoral vein into RT ventricle
• Jaws are opened and many biopsies are taken
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Bioptome Biopsies
• Used to monitor cardiac transplants for tissue rejection
• And to differentiate between various types of cardiomyopathies
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Studies of the Conduction System for Adults & Children
Mulipolar catheters are inserted in •High RT atrium near sinus node•Atrioventricular apex•Coronary sinus
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Studies of the Conduction System for Adults & Children
• Sometimes 3 introducer sheaths are placed in one vein– Femoral– Internal jugular vein– Subclavian vein
• Cathodes serve a dual function– Record electrical signals– Pace the heart
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Interventional Procedures of the Vascular System: Adults
• Percutaneous Transluminal Coronary Angioplasty (PTCA) – Also known as balloon angioplasty– Employs balloon to dilate the coronary
artery stenosis
• The placement of the catheter is placed much in the same way as standard coronary angiography
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PTCA cont
• Special steerable PTCA guidewire is used.
• Guidewire is advanced to stenotic area through the balloon catheter
• Balloon is pushed through to the stenotic area
• Balloon is inflated and compresses fatty deposits
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PTCA cont
• Followed by arteriography to make sure it blood is flowing
• This may be done repeated times to assure maximum dilatation
• Restenosis occurs in 30-50% of patients
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PTCA
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PTCA with Stent placement
• Similar to PTCA alone except a stent is placed
• Restenosis is lower for pt’s who do this rather than conventional angioplasty alone
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PTCA with Stenting
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PTCA with Stent Placement
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Atherectomy• Atherectomy devices remove the fatty deposit or thrombus material within artery
• Directional coronary atherectomy devices having a specialized cutting device to shave out the plaque
• There is a special nose cone that collect the free floating particles
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Percutaneous transluminal coronary rotational atherectomy
• The tip is a football shape and is embedded with diamond particles
• Special torque guidewire between 160,000- 200,000 rpm
• The plaque is pulverized into particles the size of RBC’s and removed by the reticuloendothial system
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Interventional Procedures of the Vascular System: Children
• Balloon Septostomy to enlarge a patent foramen ovale or preexisting atrial septal defect
• This allows mixing of RT and LT blood– Resulting in improved
arterial oxygenation
• Balloon is passed through atrial septal opening into the LT atrium, inflated with contrast and pulled back through the orifice– Causes septum to tear
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Balloon Septostomy with Transeptal System Approach
• When there is not a preexisting hole in the atrial septum– Transeptal approach is
used– Catheter with knife is
employed into LT atrium blade is opened and pulled back through RT atrium
– Then balloon septostomy may be performed to open the hole more
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Interventional Procedures of the Conduction System: Adults &
Children
• Antiarrhythmic devices– Pacemakers– Implantable
cardioverter defibrillators
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CXR with Pacemaker
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Post Catheterization Care
• Firm pressure is applied to puncture site for 15-30 minutes
• Wound sites are cleaned and dressed• The patient will be observed in recovery for 4-8
hours • The insertion site will be checked frequently for
signs of bleeding. • Medications and discharge instructions are
given• Lots of fluid should be taken in• Vital signs should be monitored for 24 hours
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Cardiac Catheterization Trends
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Trends
• Vascular brachytherapy- technique where radiation is delivered to an area of a previously stented artery using endovascular techniques
• Drug eluting stents- drug coated stents used for treatment of CAD to reduce restenosis
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MRI• Is becoming more sophisticated and
having greater detail and resolution
• Allows for is to be used more often for the cardiovascular system
• MRA is now able to assess anomalies in the coronary arteries– And identify calcifications in the coronary
arteries and bypass grafts
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Electron Beam CT
• Can detect heart disease at it earliest and most treatable stages– Measures the amount of coronary calcium,
• Electron Beam angiography is a simple and noninvasive technique that uses IV contrast media injection– Effective for visualization of great vessels,
carotid arteries and peripheral vasculature