1. Cardiac Cath and Angiocardiography
SPRING 2012

2. 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

3. Principles of Cardiac Catheterization

4. 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

5. Contraindications PT refusal Uncontrolled hypertension Active GI bleed
Bleeding disorders
Pulmonary edema
Uncontrolled ventricular arrhythmias
Aortic valve endocarditiis
Allergic to contrast
Active GI bleed
Renal failure
Recent stroke
Fever from infection
Electrolyte imbalance
Anemia
Short life expectancy
Digitalis intoxication

6. Complications and Risks
Death
Myocardial infarction
CVA
Arrhythmia
Hemorrhage
Contrast
Hemodynamic
Perforation

7. Angiographic Supplies and Equipment
Catheters
Contrast Media
Pressure Injector

8. Catheters For LT cardiac cath similar to those for angio
RT cath requires specialized catheters
Typically flow directed catheters
With manifolds

9. Contrast Media High Osmolar Ionic Widely used
Sometimes causes ECG changes
Widely used
Non-ionic
Ionic low osmolar
Restricted costs causes limited use of low osmolar contrast agents.

10. Pressure injector

11. Image chain Digital Angiography imaging equipment

12. 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

13. Digital Angiography Imaging equipment
Long term storage of large amounts of digital files has benefited from advances in computer technology
DICOM

14. Ancillary Equipment and Supplies
Physiologic Equipment
Other equipment

15. Physiologic Equipment
Equipment to monitor
ECG
Hemodynamic pressures
Vital signs to
record PT function

16. 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

17. Patient Positioning for Cardiac 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

18. Catheterization Methods and Techniques

19. Pre-Catheterization Care
Informed consent obtained
PT history
Physical exam
CXR
Blood work
ECG
Echocardiogram
Exercise stress test
Nuclear Medicine cardiac perfusion studies

20. 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

21. 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

22. Selinger Technique Inner cannula removed Needle withdrawn
until there is blood flow
Inner cannula removed
& guidewire inserted
Needle with cannula
inserted
Guidewire removed
leaving catheter in
artery
Catheter over guidewire
Needle removed

23. Data Collection Physiologic data unusually collected
Hemodynamic parameters
Includes blood pressure
Cardiac output
Vascular pressures (inside & outside the heart)
ECG
Oximetry readings
Blood samples to measure oxygen saturations levels in various parts of the heart

24. Catherization Studies and Procedures
Adults
Children

25. Basic Diagnostic Studies of the Vascular System for Adults

26. 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

27. 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

28. 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

29. Coronary Angiography
Allows the extent of intracoronary stenosis to be evaluated

30. Coronary Angiography

31. Coronary Angiography
LT coronary
artery
Normal LT coronary Artery

32. Cath of the RT side of the heart: ADULTS

33. Cath of the RT side of the heart: ADULTS
Pressure measurements
Used to determine valvular heart disease
Congestive heart failure
Pulmonary hypertension
Cardiomyopathies

34. 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)

35. 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

36. 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

37. Bioptome Biopsies
Used to monitor cardiac transplants for tissue rejection
And to differentiate between various types of cardiomyopathies

38. Studies of the Conduction System for Adults & Children
Mulipolar catheters are inserted in
High RT atrium near sinus node
Atrioventricular apex
Coronary sinus

39. 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

40. 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

41. 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

42. 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

43. PTCA

44. 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

45. PTCA with Stenting

46. PTCA with Stent Placement

47. 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

48. Percutaneous transluminal coronary rotational atherectomy
The tip is a football shape and is embedded with diamond particles
Special torque guidewire between 160, ,000 rpm
The plaque is pulverized into particles the size of RBC’s and removed by the reticuloendothial system

49. 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

50. 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

51. Interventional Procedures of the Conduction System: Adults & Children
Antiarrhythmic devices
Pacemakers
Implantable cardioverter defibrillators

52. CXR with Pacemaker

53. Post Catheterization Care
Firm pressure is applied to puncture site for 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

54. Cardiac Catheterization Trends

55. 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

56. 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

57. 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