POKJA INTERVENSI KARDIOVASKULER INDONESIA

PELATIHAN KARDIOLOGI INTERVENSI

TINGKAT DASAR

LEARN by DOING• Endovascular procedures require a

combination of clinical knowledge and technical skills.

• To develope and intergrate the two necessitates a realistic training experience.

• Patients safety will always be a number one priority.

• The use simulators allows trainees to practice in a safe and realictic environtment w/o putting pts at risk

Educational Purpose A. Understand the indications, limitations, complications and

medical and surgical implications of the findings at cardiac catheterization and angiography, as well as a general understanding of related interventional procedures.

B. Understand the pathophysiology of cardiovascular disease and the ability to interpret hemodynamic and angiographic data and to use these data to select cases for surgical and catheterization-based therapeutic procedures.

C. Obtain a basic understanding of radiation physics, radiation safety, fluoroscopy and radiologic anatomy.

D. Understand the fundamental principles of shunt detection, cardiac output determination and pressure waveform recording and analysis.

Educational Purpose

E. Learn to perform pulmonary artery catheterization with flow-directed catheters by the percutaneous (subclavian, femoral and internal jugular) approach.

F. Learn the proper techniques of diagnostic left heart catheterization and angiography by percutaneous (brachial and femoral) approaches.

G. Learn to perform insertion and operation of temporary right ventricular pacemakers. H. Learn to perform and interpret the results of therapeutic pericardiocentesis. Learn intra-aortic balloon counterpulsation indications, insertion, and management.

GOALS

• They will have the knowledge and skills necessary to safely and competently perform these procedures.

• They will be versed in the indications, contra-indications and clinical judgment that is associated with the catheterizations procedures.

INDIKASI, KONTRA INDIKASI SERTA KOMPLIKASI PROSEDUR DIAGNOSTIK

INVASIF

OVERVIEW

• Right and left heart cath is a procedure where a catheter is inserted into the cardiac chambers and vessels

percutanously. • Pressure and saturation of each chambers and vessels were usually taken to obtain the diagnosis. • Angiography is frequently being done to visualize the

anatomical structure of the heart and vessels. It may also be used to assess the cardiac function and regurgitation severity.

Indications of Cardiac Catheterization

• To confirm the presence of clinically suspected condition.

• To define the anatomical and physiological severity of the diseases.• To determine the presence of associated condition or complication. • As a routine pre op assessment esp. for elderly patient.

DIAGNOSIS

TMT TMT ECHOECHO

CT scanCT scan NMRNMR

Cardiac Cardiac catheterizationcatheterization

Age and cardiac catheterization

• Patient age has a great influence on feasibility, risk and clinical impact of cardiac catheterization

• Feasibility is mostly influenced by patient size because of vascular approach and catheter manipulation

• Risks change according to patient size, clinical stability, anatomic complexity

NeonatesIndications

• Need of neonatal catheterization in “simple” heart malformations is exceptional, unless an interventional procedure can be anticipated (i.e. severe/critical pulmonary/aortic valve stenosis)

NeonatesIndications

• Any kind of duct dependance of pulmonary circulation (pulmonary atresia intact septum /+ VSD MACPAs / other complex anomalies) is the most common indication to cardiac catheterization in neonates

• Detailed knowledge of pulmonary circulatory supply is infact essential to plan any need and type of treatment in these patients

NeonatesIndications

• Patients with complex/uncommon anomalies of the systemic circulatory supply or with duct dependent circulation are less commonly candidates to diagnostic cardiac catheterization

• Need to define some critical anatomic details may lead to haemodynamic assessment in complex heart malformations

Neonates

• Patients requiring diagnostic cardiac catheterization in neonatal age are often complex, critically ill and candidates to interventional procedures

• A further risk is rapresented by low weight (SGA) and prematurity

NEONATES are the most NEONATES are the most difficult and fragile patientsdifficult and fragile patients

NeonatesImaging

• In neonates the fast injections of boluses of contrast medium (1-2 ml/Kg) can cause haemodynamic impairment because of the acute volume overload

• The minimum number of cineangiograms necessary to accomplish the diagnosis should be performed

• Accurate choice of projections and amount of contrast medium administered/ injection is mandatory, particularly in the unstable patient

• The total amount of 10 ml/Kg/examination should not be exceded

Infants & children Planning the procedure

• At least a rough presumptive diagnosis is necessary for a correct procedure

• Like for neonates, the echocardiographic diagnosis is nowadays quite accurate and cardiac catheterization is usually necessary only to clarify additional anatomical/functional details, necessary for the patient management

Infants & children Imaging

• Also in infants and small children the fast injections of boluses of contrast medium (1-2 ml/Kg) can cause haemodynamic impairment

• The minimum number of cineangiograms necessary to accomplish the diagnosis should be performed

• Accurate choice of projections and amount of contrast medium administered/ injection is mandatory, particularly in the unstable patient

• The total amount of 10 ml/Kg/examination should not be exceded

Adolescents & adults Planning the procedure

• At least a rough presumptive diagnosis is necessary for a correct procedure

• Unless for neonates and infants, the echocardiographic diagnosis can be unaccurate in adults with congenital heart disease, prticularly in postoperative patients, and cardiac catheterization is often necessary to clarify additional anatomical/functional details, necessary for the patient management

Cardiac Catheterization / Coronary Angiogram

Indications :• Unstable angina or Chest pain [uncontrolled with

medications or after a heart attack]• Heart attack• Before a bypass surgery• Abnormal treadmill test results• Determine the extent of coronary artery disease• Disease of the heart valve causing symtpoms (syncope,

shortness of breath)• To monitor rejection in heart transplant patients• Syncope or loss of consiousness in patients with aortic

valve disease

Contraindications cardiac catheterization

Absolut:• The refusal of mentally competent patients to consent the

prosedure• Incomplete equipment and cath facility

Contraindications cardiac catheterization

Relative:• Uncontrolled CCF, hypertension, arrhytmias• Recent CVA < 1month• Infection/fever• Electrolyte inbalance• Acute GI bleeding or anemia• On anticoagulation• Pregnancy• Uncooperative patient• Medication intoxication ( e.g digitalis etc)• Renal failure

Cardiac Catheterization / Coronary Angiogram

Relative contraindiciations :• Allergy to contrast (dye) medium• Uncontrolled Blood Pressure (Hypertension)• Problems with blood coagulation (Coagulopathy)• Kidney failure or dysfunction• Severe anemia• Electrolyte imbalance• Fever• Active systemic infection• Uncontrolled rhythm disturbances (arrhythmias)• Uncompensated heart failure• Transient Ischemic attack

Risks cardiac catheterizationCommon risks of cardiac catheterization are: • Bruising• InfectionRare risks include: • Heart attack • Stroke • Damage to the artery where the catheter was inserted • Irregular heart rhythms (arrhythmias) • Allergic reactions to the dye or medication • Tearing the tissue of your heart or artery • Kidney damage • Excessive bleeding • Infection • Blood clots mayo clinic

Risk of complication

• Listed below are the percentage of complication of cardiac catheterization in current era (not including intervention)* – Death <0.2% – AMI <0.5% – Stroke <0.07% – Serious Ventricular Arrhythmias <0.5%Morton J. Kern, The Cardiac Catheterization Handbook

Predisposing factor of higher risk of complications

• Known or suspected Left main coronary stenosis• Severe aortic stenosis• Severe CCF• LV dysfunction (EF<35%)• Diabetes• Advance age• Unstable angina• AMI• Aortic aneurysm• Prior CVA• Renal Impairment• Uncontrolled hypertension• Obesity• Newborn baby

COMPLICATIONS

Minor Complications of Cardiac Catheterization:• Temporary pain • Minor infections • Nausea and vomiting • Bleeding • Reaction to medications or dye • Allergic skin reaction to tape, dressing, or latex • Abnormal heartbeats • Bruising or scarring at the catheter entry site. • Pyrogen reactions

COMPLICATIONS

Major Cardiac Catheterization Complications:• death• Serious bleeding• Heart or lung problems, including irregular heart rhythms and

lung or heart failure• Stroke• Heart attack • Blood vessel, nerve, or organ damage• Blood clots in the legs, pelvis, or lungs • Failure of medical equipment• Reactions to medication or dye Kidney failure, with possible

dialysis needed • Other rare and unlikely events.

COMPLICATIONSMajor Cardiac Catheterization Complications:• VT/VF• Cerbro vascular accident• Peripheral arterial occlusion• Pericardial tamponade• CHF• Cardiogenic shock

COMPLICATIONS

• Cerebral Infarction FOCAL ASYMPTOMATIC (Radiology 2005;235:177-183.)

• Vascular Complications decreased

• coronary artery dissection Chest 1976;70;551-553

• stroke

COMPLICATIONS

vascular :• Bleeding:• Occlusion• Loss of distal pulse• Dissection• Pseudoaneurysm• AV fistula

Indication for cardiac catheterizationIndication1. Suspected or known coronary artery

diseasea. New-onset anginab. Unstable anginac. Evaluation before a major surgical

procedured. Silent ischemiae. Positive exercise tolerance testf. Atapycal chest pain2. Myocardial infarctiona. Unstable angina postinfarctionb. Failed thrombosisc. Schockd. Mechanical complications (ventricular

septal defect, rupture of wall or papilary muscle)

Procedures

LV.CORLV.CORLV.CORLV.COR,ERGOLV.COR,ERGOLV.COR,ERGO

LV, CORLV, COR,RHLV, COR,RHLV, COR,RH

3. Sudden cardiovascular death4. Valvular heart disease5. Congenital heart disease (before anticipated

corrective surgery6. Aortic dissction7. Pericardial constriction or tamponade8. Cardiomyopathy9. Initial and follow up assesment for heart

transplant

LV,COR, R+LLV,COR, R+L, AOLV,COR, R+L, AO

AO+ CORLV,COR, R+L, AOLV,COR, R+L, AO, BXLV,COR,R+L,AO, BX

AO, Aortography; BX, endomyocardial biopsy; COR, coronary angiography; ERGO, ergonovine provocation of coronary spasm; LV, left ventriculography; RH, Right heart oxygen saturations and hemodynamics (e.g. placement of swanz-ganz catheter); R+L, right and left heart hemodynamics

Contraindications to Cardiac Catheterization

Absolute contraindicationsInadequate equipment or catheterization facility

Relative ContraindicationsAcute gastrointestinal bleeding or anemiaAnticoagulation (or known, uncontrolled bleeding diathesis)Electrolyte imbalanceInfection and feverMedication intoxication (e.g. digitalis, phenothiazine)PregnancyRecent cerebrovascular accident (<1 month)Renal FailureUncontrolled congestive heart failure, high blood pressure,arrhythmiasUncooperative patient

Complication of cardiac catheterizationMajorCerebrovascular accidentDeathMyocardial infarctionVentricular tchycardia, fibrilation, or serious arrhytmia

OtherAortic dissectionCardiac perforation, tamponadeCongestive heart failureContrast reaction (anaphylaxis, nephrotoxicity)Heart block, asystoleHemorrhage (local, retroperitoneal, pelvic)InfectionProtamine reactionSupraventicular tachyarrhythmia, atrial fibrilationThrombosis, embolus, air embolusVascular injury, pseudoaneurysmVasovagal reaction

Major Complications of Diagnostic Catheterizations

Number Percent

Death 65 0.11Myocardial infarction 30 0.05Neurologic 41 0.07Arrhytmia 229 0.38Vascular 256 0.43Contrast 223 0.37Hemodynamic 158 0.26Perforation 16 0.03Other 166 0.28total (patients) 1184 1.98

Modified from Noto TJ, Johnson LW, Krone R, et al: Cardial cathetirazion 1990: a report of the registry of the society for cardiac angiography and interventions (SCA&I), Cathet cardiosvascular 24:75-83; in uretzk BF; Weinert HH; Cardiac catheterization: concepts, techniques and application, Walden, Mass, 1997, Blackwell Science

Conditions of patients at higher risk for compliactions of catheterization

Acute myocardial infarctionAdvance age (>75 years)Aortic aneurysmCongestic heart failureDiabetesExtensive three-vessel coronary artery diseaseLeft ventricular dysfunction (left ventricular ejection fraction <35%)ObesityPrior cerebrovascular accidentRenal insufficiencySuspected or known left main coronary stenosisUncontrolled hypertensionUnstable angina

Conditions requiring special preparationsCondition

1. Allergy

a. prior contrast studies

b. Iodine, fish

c. Lidocaine

2. Patients receiving anticoagulation (INR > 1.5)

3. Diabetes

a. NPH Insulin (protamin reaction

b. Renal function (prone to contrast-induced renal failure)

c. Metformin usage

Management

1. Allergy

a. Contrast premedication

b. Contrast reaction algorithm

c. Use Marcain (1mg/ml)

2. Defer procedure

a. Vitamin K; 10 mEg/hr

b. Fresh frozen plasma

c. Hold heparin

d. Protamin for heparin

3. Hydration to increase urine output >50ml/hr; metformin held 48 hours; if renal insufficiency postpone catheterization and consider urgency and risks of lactic acidosis

Conditions requiring special preparationsCondition

4. Electrolyte imbalance (K+, Mg2)

5. Arrhytmias

6. Anemia

7. Dehydration

8.Renal Failure

Management

4. Defer procedure, replenish or correct electrolytes

5. Defer procedure, administer antiarrhytmics

6. Defer procedure

a. Control bleeding

b. Transfuse

7. Hydration

8. Limit contrast

a. Maintain high urine output

b. Hydrate

Patient and clinical characteristics associated with increased mortality from cardiac catheterization

AgeInfants (<1 year old) and elderly (>65 years old)Elderly women seem to be higher risk than elderly man

Functional classMortality in class IV patients is more than10 times greater than in class I and

II patients

Severity of coronary obstructionMortality for patients with left main coronary artery disease is more than 10

times greater than for patients with one-or two- vessel diseases

Valvular Heart diseaseSevere valvular heart disease, especially severe aortic stenosis, is associated

with increased risk cardiac death

Patient and clinical characteristics associated with increased mortality from cardiac catheterization

Left ventricular dysfunctionMortality for patients with left ventricular ejection fraction <30% is more

than 10 times greater than in patients with ejection fraction ≥50%

Severe noncardiac diseaseIncreased risk of adverse events associated with following conditions:DiabetesSevere pulmonary diseaseAdvanced cerebrovascular of peripheral vascular diseaseRenal insufficiency

Modified from Grossman W: complication of cardiac catheterization: incidence, causes and prevention. In Grossman W, Editor: Cardiac catheterization and angiography, ed 3, Philadelphia, 1986, Lea & Febiger

Incidence of complication during diagnostic cardiac catheterization for varios clinical and angiographic variables

Death (%) MI(%) CVA(%) Arrhytmia (%)Age<60 0.07 0.07 0.05 0.43>60 0.12 0.02 0.12 0.53

NYHA ClassI 0.02 0.02 0.12 0.53II 0.02 0.03 0.05 0.32III 0.05 0.07 0.05 0.43IV 0.29 0.12 0.08 0.65

Incidence of complication during diagnostic cardiac catheterization for varios clinical and angiographic variables

Death (%) MI(%) CVA(%) Arrhytmia (%)Ejection Fraction>50% 0.03 0.04 0.05 0.3530%-49% 0.12 0.06 0.08 0.55<30% 0.30 0.12 0.09 0.94

Extent of CHD1 Vessel 0.05 0.06 0.04 0.422 vessels 0.07 0.08 0.08 0.453 vessels 0.12 0.08 0.09 0.53LM 0.55 0.17 0.13 0.66

Modified from Johnson LW, et al: Cathet cardiovasc diagn 17:5-10, 1989. CHD, Coronary heart disease; CVA, cerebrovascular accident; LM,left main disease; MI, myorcardial infarction; NYHA, New York Heart Association.

Conditions in which Nonionic, low-osmolality contrast agents should be used preferentially during high-risk cardiac catheterizationAcute myocardial infarctionCongestive heart failureEjection fraction ≤30%Suspected left main or three-vessel coronary artery

diseaseSevere aortic stenosisComplex or multiple ventricular arrhytmiasAcute or chronic renal insufficiencyAnticipated use of large contrast agent volume

Management of complications during cardiac catheterizationComplications and precautionsMyocardial Infarction (0.2%)

Cerebrovascular accident (0.1%)Systemic heparinizationCleaning of guidewires before useLimit guidewire-blood exposure (<2 min)Use guidewire to cross aortic arch (especially in atherosclerotic aortas, and especially for amplatz or bypass graft catheter)Aspirate and flush catheters frequentlyRemove air bubbles in any of tubing, solutions, or injection syringeEnsure all tubing and catheter connections are tight

TreatmentIntrocoronary nitroglycerin (rule out spasm)Consider intracoronaryThrombectomy or aspiration,Coronary angioplasty, or emergencyAortocoronary bypass

Management of complications during cardiac catheterizationComplications and precautionsDissestion (0.1%)Never advanced guidewire orcatheter againts resistance; catheter tip location confirmed by gentle contrast injection.Do not manipulate catheter in coronary ostium, monitoring pressure of catheter tip.Do not inject with damped pressure.

Acute pulmonary edemaTreat preexisting CHF optimallyLimit contrast medium in high risk; avoid LV angiography in severe aortic stenosis, marked CHF, or pulmonary hypertension.Use nonionic or low-osmolar contrast media agents.Avoid hypotensionLimit flush solution volumeMonitor LV filling pressure (PCW)

Treatment

No further coronary injectionsIf ischemia produced, stent or emergency aortocoronary bypass.If dissection associated with thrombus but no ischemia, use heparin(controvential) and consider coronary stenting.

Elevate patient’s trunk 30 to 45 degreesOxygen, morphine (2 to 5 mg IV), nitrates (100 to 200 µg IC), furosemide (20 to 100 mg IV); nitroprusside for afterload reduction; inotropic support with dopamine or dobutamineIntraaortic ballon pumping

Management of complications during cardiac catheterizationComplications and precautionsCardiogenic schockCareful patient selection: (1) left main coronary artery stenosis, (2) aoric stenosis at high risk, and (3) acute infarctionProphylactic IABP for high-risk left main coronary artery angiography; minimize number of injections; treat hypotensionStop procedure if hypotension persistAthopine, adequate volume expansion, Aramine ([Metaraminol] intraaortic injection of 0.125 to 0.250 mg) IABPRule out pericardial tamponade with RA and RV pressures; consider urgent echocardiogramMonitor filling pressure

Treatment

If schock caused by coronary occlusion, treat with emergency PTCA or CABG surgery

Vasopressor supprotIABPIntubation and mechanical ventilationPacemaker as needed

CABG, Coronary bypass graft, CHf, congestive heart failure, IABP,inaaortic ballon pump; IC, intracoronary; IV, intravenous; LV, left ventricular, PCW, pulmonary capilary wedge;PTCAM, percutaneous transluminal coronary angioplasty, RA, right atrial, RV, right ventricular

Management of complications during cardiac catheterizationComplications and precautionsVentricular tachycardia, asystole or fibrilations (0.6%)Use nonionic agents in high risk patientsDo not wedge coronary artery catheter; contrast material washout should be brisk; ECG and BP should be normal before next injectionDo not inject when catheter tip pressure is dampedUse atropine, volume expansion, or metaraminol (aramine for hypotensionLimit contrast medium injected into coronary arteries; avoid prolonged injections

Air EmbolismFor prevention and treatment see p.454

Treatment

Cough for temporary increase in BPRemove catheter from RV,LV or coronary ostiumCPR followed by prompt defibrilationDefiriblifation (200J)Lidocaine (50 mg bolus, 2 to 4 mg/min IV)Amiodarone (300 mg bolus) then infusionRefractory VF ususally as a result of extensive CAD; emergency percutaneous should be considered

Same as cerebrovascular accident

Management of complications during cardiac catheterizationComplications and precautionsHematoma in femoral artery (0.1% major, 1% major to 2 % Minor)Puncture below inguinal ligamentAttention to compressionProlonged compression if patient coughing, aortic insuffisiency, hypertension, or heparin not reservedVascular closure device

Retroperitoneal bleedingAvoid high (above inguinal ligament) femoral artery punctureWatch for hypotension, low abdominal or flank pain within 2-12 hous of procedureLow hematrocrit, tachycardia (if not receiving ß-blockers)

Treatment

Evacuation rarely requiredSurgical cosult for enlarging hematoma, compartment syndrome, or cool extrimity

Reserve anticoagulantsVolume replacemtTrasfusion if hematocrit <25Surgical consultationCT scan

Management of complications during cardiac catheterizationComplications and precautions

Cardiac TamponadeAvoid stiff catheters in RA or RV; pacing catheters handled gentlyAvoid posterior LA wall during transseptal catheterization

Contrast agent nephrotoxicityHydration and inonic contrast agentsContrast agent reactionvasovagal reaction

Treatment

Prompt pericardiocentesis with catheter drainageCardiovascular surgery consultationSurgical exploration and closure for persistant bleeding

Generally self-limited; dialysis rarely needed

Modified from Tilkian AG, Daily EK; Cardiovascular procedurs: diagnostic techniques and therapeutic procedures, St. Lois, 1986, Mosby

Premixing regimen used in the preparation of norepinephrine (levophed) for bolus therapy for blood support

1. Dilute 1 mg norepineoherine in 9 ml normal saline= 1000µg/10 ml= 100µg/ml2. Take 1 ml of above mixture and further dilute in another 9ml

normal saline= 100µg/10 ml= 10µg/ml3. Administer bolus doeses of 5µg (0.5ml) approximately every 5

minutes as needed. Blood pressure usually responds within 3 to 5 minutes

Treatment of severe anaphylactoid reactions: recommendations from society of cardiac angiography and interventionsInitial pharmacological therapyEphinephrine 10µg/min IV until desired blood pressure response, then 1 to 4

µg/min to maintain desired blood pressure, given simultaneously with large volumes of normal saline

Diphenhydramine (benadryl) 50 to 100 mg IVHydrocortisone 400mg IV

If unresponsive to initial therapyH2 blocker therapyCimetidine 300 mg in 20 ml normal saline administred IV over 15 minutesRanitidine 50 mg in 20 ml normal saline administred IV over 15 minutesDopamine 2 to 15 µg/kg/min IV infusion

Table of Contents Course 1: Basic Science Concepts for the Interventional Cardiologist Course 2: Cath Lab Basics Course 3: Valvular, Structural, and Congenital Heart Disease Course 4: Intracoronary Imaging V Physiology Course 5: Patient and Lesion-specific Approaches Course 6: Acute Myocardial Infarction & Thrombus Course 7: Anticoagulation in the Cath Lab Course 8: Coronary Stenting (i) Course 9: Coronary Stenting (ii): Drug-Eluting Stents Course 10: Advanced PCI Techniques & Devices Course 11: High Risk Groups and Complications Course 12: Cardiac Imaging Course 13: Peripheral Vascular Disease Course 14: Carotid Artery Disease

MODUL ICI/IFI SCAI http://www.scai.org/Courses/default.aspx

1: Fundamentals of Vascular Biology 2: Pathobiology of Vascular Disease 3: Cardiac Vascular Anatomy 4: Fundamentals of Cardiac Catheterization 5: Fundamentals of Cardiovascular Imaging 6: Interventional Pharmacotherapies 7: Coronary Interventional Equipment and Techniques 8: Patient-Specific Approaches and Guidelines 9: Lesion-Specific Approaches, Techniques, and Equipment 10: Procedure-Related Complications and Management 11: Valvular Heart Disease 12: Congenital Heart Disease 13: Structural Heart Disease 14: Peripheral Vascular Disease 15: Carotid and Cerebrovascular Disease 16: Post-Procedural Care 17: Miscellaneous Topics

ACC – CathSAP4www.cardiosourse.org