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

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

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

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

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

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

Catherization Studies and Procedures

•Adults

•Children

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

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