1. Coronary Angiography, PCI & Cinemaps / Coronary Tree Diagrams Mike McAleer, Charge Nurse Manager CardioVascular Unit (CVU) July 2009

2. WHAT? WHY? HOW?

6. What does Angiography do? It looks at: coronary vessel anatomy (abnormalities, narrowings, occlusions, smoothness, filling defects) what part of the heart muscle the vessel provides supply to (left / right dominance, evidence of collateralisation) pressures, oxygen saturations and cardiac output (by inference) from measurements within the chambers most appropriate treatment (angioplasty or surgery)

7. Left Heart (arterial side) Angiography (femoral access)

8. Coronary Arteries Right Coronary Ostia Left Coronary Ostia Aortic Valve Cusps Left Subclavian Left Common Carotid Brachiocephalic

13. Diagnostic Catheters A multi-layered plastic tube used to inject contrast medium into coronary structures. A variety of catheter shapes are available for cannulating right and left coronary arteries. Exit port

16. Left Heart (arterial side) Angiography (radial access)

18. LCA RAO Projection

23. RCA LAO Projection

31. Right Heart (venous side) Angiography

32. Normal Pressures within Chambers & Vessels

34. Pulmonary Capillary Wedge Pressure - physics

35. Pressure Tracings

36. Grafts: saphenous vein (SVG) radial artery Left Internal Mammary Artery (LIMA)

41. Radial Artery Graft

44. A particularly ugly looking coronary system

45. Cinemaps / Coronary Tree Diagrams

46. 1 = Diagonal Surface 2 = Obtuse Marginal 3 = Inferior Surface 4 = Posterior Septum 5 = Anterior Septum Diagram looks upwards from Apex of heart

48. Percutaneous Coronary Intervention (PCI)

49. Angioplasty / PCI (Percutaneous Coronary Intervention) Using a balloon & stent (wire coil) to open narrowings (stenoses) Uses same approach (wider lumen catheters to facilitate passage of wire and balloon) Less invasive than surgery, faster recovery time Bane of angioplasty / PCI is re-stenosis (re- narrowing)

53. THE ACUTE SCENARIO TIME IS MUSCLE **FOR BEST OUTCOME, TIME FROM FIRST SYMPTOMS TO BALLOONING OF ARTERY IS LESS THAN TWO HOURS**

54. Angiography in Unstable Angina

55. Angiography in Acute MI

57. Sinus Rhythm: Rate = 90 bpm, P waves evident, PR Interval shortened 0.12 secs (Normal 0.17- 0.2), QRS normal (0.08-0.12 secs) Axis: normal ST Elevation: Lateral Leads (I, aVL, V5-6); Anterior Leads (V1-4) ST Depression: Reciprocal changes in Inferior Leads (II, III, aVF) ACUTE ANTERIOR-LATERAL MYOCARDIAL INFARCTION

58. Heart Rate: 40 bpm, PR Interval = 0.2 secs 9normal), QRS = 0.08 secs (normal) Axis: normal ST Elevation: Inferior Leads (II, III, aVF) ST Depression: (V2-3) ?Posterior Leads, Lateral Leads (I, aVL, V5-6) reciprocal changes ACUTE INFERIOR-POSTERIOR MYOCARDIAL INFARCTION

59. Other percutaneous instruments of torture

61. It may help to use one of these...

62. … to prevent this clagging the coronary arteries resulting in transient ischaemia or artery occlusion