Download Cardiac Cath and Angiocardiography

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
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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
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Contraindications
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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
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Death
Myocardial infarction
CVA
Arrhythmia
Hemorrhage
Contrast
Hemodynamic
Perforation
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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
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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
Image chain
• Similar to angio suites
• High resolution imaging and recording
• C-arms must be able to be on for extended
periods of time
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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
Physiologic Equipment
• Equipment to monitor
– ECG
– Hemodynamic pressures
• Vital signs to
• record PT function
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Other Equipment
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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 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
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Catheterization Methods
and Techniques
Pre-Catheterization Care
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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 withdrawn
until there is blood flow
Catheter over guidewire
Needle removed
Inner cannula removed
& guidewire inserted
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
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
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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
LT coronary
artery
Normal 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 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
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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 160,000200,000 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 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
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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
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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
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