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Transcript
Cardiac Cath and
Angiocardiography
SPRING 2012
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
2
Principles of Cardiac
Catheterization
• Suspected or known coronary
• heart disease
Indications
• Myodcardial infarction
• Sudden cardiovascular death
• Valvular heart disease
• Congenital heart disease
• Aortic dissection
• Pericardial constriction
• Cardiomyopathy
• Initial and follow up
assessment for heart
transplant
4
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
5
Complications and Risks
•
•
•
•
•
•
•
•
Death
Myocardial infarction
CVA
Arrhythmia
Hemorrhage
Contrast
Hemodynamic
Perforation
6
Angiographic Supplies
and Equipment
•Catheters
•Contrast Media
•Pressure Injector
Catheters
• For LT cardiac cath
similar to those for
angio
• RT cath requires
specialized catheters
– Typically flow directed
catheters
– With manifolds
8
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.
9
Pressure injector
10
Imaging
•Image chain
•Digital Angiography imaging
equipment
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
12
Digital Angiography
Imaging equipment
• Long term storage of large amounts of
digital files has benefited from advances in
computer technology
• DICOM
13
Ancillary Equipment
and Supplies
•Physiologic Equipment
•Other equipment
Physiologic Equipment
• Equipment to monitor
– ECG
– Hemodynamic pressures
• Vital signs to
• record PT function
15
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
16
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
17
Catheterization Methods
and Techniques
Pre-Catheterization Care
•
•
•
•
•
•
•
•
•
Informed consent obtained
PT history
Physical exam
CXR
Blood work
ECG
Echocardiogram
Exercise stress test
Nuclear Medicine cardiac perfusion studies
19
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
20
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
21
Selinger Technique
Needle with cannula
inserted
Needle withdrawn
until there is blood flow
Catheter over guidewire
Needle removed
Inner cannula removed
& guidewire inserted
Guidewire removed
leaving catheter in
artery
22
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
23
Catherization Studies
and Procedures
•Adults
•Children
Basic Diagnostic Studies of the
Vascular System for Adults
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
26
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
27
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
28
Coronary Angiography
• Allows the extent of intracoronary stenosis to be
evaluated
29
Coronary Angiography
30
Coronary Angiography
LT coronary
artery
Normal LT coronary Artery
31
Cath of the RT side
of the heart:
ADULTS
32
Cath of the RT side of the heart:
ADULTS
• Pressure measurements
– Used to determine valvular heart disease
– Congestive heart failure
– Pulmonary hypertension
– Cardiomyopathies
33
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)
34
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
35
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
36
Bioptome Biopsies
• Used to monitor
cardiac transplants for
tissue rejection
• And to differentiate
between various
types of
cardiomyopathies
37
Studies of the Conduction System
for Adults & Children
Mulipolar catheters are inserted in
•High RT atrium near sinus node
•Atrioventricular apex
•Coronary sinus
38
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
39
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
40
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
41
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
42
PTCA
43
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
44
PTCA with Stenting
45
PTCA with Stent Placement
46
• Atherectomy devices
remove the fatty deposit
or thrombus material
within artery
Atherectomy
• 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
47
Percutaneous transluminal
coronary rotational atherectomy
• The tip is a football shape
and is embedded with
diamond particles
• Special torque guidewire
between 160,000200,000 rpm
• The plaque is pulverized
into particles the size of
RBC’s and removed by
the reticuloendothial
system
48
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
49
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
50
Interventional Procedures of the
Conduction System: Adults &
Children
• Antiarrhythmic
devices
– Pacemakers
– Implantable
cardioverter
defibrillators
51
CXR with Pacemaker
52
Post Catheterization Care
• Firm pressure is applied to puncture site for 1530 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
53
Cardiac Catheterization
Trends
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
55
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
56
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
57