1. CORONARY ANGIO CARDIAC CATH & Ablation Procedures Lecture # 3 A Cardiac Anatomy & Circulation & Pathology Review # 3B
Principles of Cardiac Catheterization
General indications, contraindications, and risks are associated with diagnostic and interventional cardiac catheterizations.
The physician must consider these factors when attempting to determine the appropriateness of any type of catheterization.
RT 255 (rev 2010) Dawn Charman, M.Ed,R.T
Reference:
Frank. Merrill's Atlas of Radiographic Positioning and Procedures, 11th Ed. Mosby

2. Coronary angiography is often included together with cardiac cath
What is cardiac cath?
Procedure which involves placement of a catheter into RT or LT side of heart.
Invasive
Coronary angiography is often included together with cardiac cath
Diagnostic procedure and/or
a therapeutic procedure
Adults & Children
Coronary angiography – injection of a contrast material into the coronary vessels with guidance or fluoroscopy.
-- since the catheter is done almost always intravenously( small incision to the skin) it is considered to be a invasive procedure.
-- primarily considered to be only a diagnostic procedure.
-- With the modern technology, many of the procedures done today are said to be therapeutic catheterization.
Cardiac catheterization is performed to identify the anatomic and physiologic condition of the heart.
The data gathered during catheterization provide the physician with information to develop management strategies for patients who have cardiovascular disorders.
Coronary angiography is currently the most definitive procedure for visualizing the coronary anatomy. The anatomic information gained from this procedure may include the presence and extent of obstructive coronary artery disease, thrombus formation, coronary artery collateral flow, coronary anomalies, aneurysms, and spasm. Coronary artery size can also be determined.
In children, diagnostic heart catheterization is employed in the evaluation of congenital and valvular disease, disorders of the cardiac conduction system, and selected cardiomyopathies.
CARDIAC CATHETERIZATION
Cardiac catheterization is a comprehensive term used to describe a minor surgical procedure involving the introduction of specialized catheters into the heart and surrounding vasculature for the purpose of diagnostic evaluation and therapy (intervention) associated with a variety of cardiovascular-related disorders in both children and adults.
Therefore cardiac catheterization is classified as either a diagnostic procedure or an interventional procedure.
The primary purpose of diagnostic procedures is to collect data necessary to evaluate the patient's condition.
Cardiac interventional procedures involve the application of therapeutic measures through catheter-based systems or other mechanical means to treat disorders of the vascular and conduction systems within the heart.
Check out procedure Video:

3. Cardiac Catheterization also known as a heart cath or coronary angiogram
This procedures provides the doctor with a "road map" of the arteries in the heart
To find any areas of blockage in the arteries that supply the heart with blood.
May also look at the valves, chambers & heart muscle
Can help in making decisions about the treatment of heart disease.
It is a usually performed by a cardiologist with assistance by RT,(CIT), nursing & support staff*
Diagnostic studies of the adult heart also aid in evaluating the patient who has confusing or obscure symptoms (e.g., chest pain of undetermined cause).
These studies are also used to assess diseases of the heart not requiring surgical intervention, such as certain cardiomyopathies.

4. Who performs the procedure?
The Interventional Radiologist / Cardiologist
who specializes in the Angioplasty procedure.
CIT Technologist
Nursing
Other support staff

5. Type of catheter used will be dependant on the type
Cardiac cath requires special equipment:
Angio supplies & equipment
Fluoro Imaging (w/ Cine – Digital)
& Ancillary equipment *
Type of catheter used will
be dependant on the type
Of Procedure performed
Patient Positioning for Cardiac Catheterization
Procedures such as selective coronary arteriography and certain pediatric catheterizations require imaging equipment to be positioned to reduce the superimposition created by the cardiac vasculature.
Moving the patient during the catheterization is not desirable, particularly when catheters have been carefully positioned to demonstrate specific anatomic structures or to record certain data.
In most catheterization laboratories, the image intensifier and fluoroscopic tube are mechanically suspended in a C-arm configuration to allow for equipment rotation around the patient and to provide cranial or caudal angulation.
The image intensifier is above the plane of the table, and the fluoroscopic tube is beneath the table.
During catheterization procedures, the patient is placed on the examination table in a supine position.
For optimal images, the imaging equipment should be rotated around the patient.
In some interventional procedures, biplane C-arms are advantageous because they allow simultaneous imaging of cardiac structures in two different planes
What are the advantages of bi-plane radiography?

6. In most catheterization laboratories, the image intensifier and fluoroscopic tube are mechanically suspended in a C-arm configuration to allow for equipment rotation around the patient and to provide cranial or caudal angulation.
What are the advantages of bi-plane radiography?
Faster exam time (AP & LAT taken alternately during thye same run)
Less Contrast Used - same reason as above
Less Heat load to tube (uses 2 tubes)
Does not necessarily reduce the RADIATION EXPOSURE to the patient

7. Done in a “Cath Lab” Cath lab includes a special table,
x-ray tube &monitor,
supplies (catheter, guidewire)
automatic injector pressure
Cardiac monitors
Vitals monitors
Other equipment*
Because of the nature of the patient's condition, the inherent risks of cardiac catheterization, and the types of procedures performed, each catheterization room should have the following equipment available:
• A fully equipped emergency cart. The cart typically contains emergency medications, cardiopulmonary resuscitation equipment, intubation equipment, and other related supplies.
• Oxygen and suction.
• Whole blood oximeters used to determine the oxygen saturation of the blood samples obtained during adult and pediatric catheterizations
• Defibrillator, used to treat life-threatening arrhythmias. Ideally, the defibrillator would also have external pacemaking capabilities.
• Temporary pacemaker to treat potential asystole or symptomatic bradycardia.
• Pulse oximeter to noninvasively monitor and assess level of oxygenation during sedation.
• Noninvasive blood pressure cuff.
• Equipment to perform cardiac output studies.
• Intraaortic balloon pump console and catheters to treat cardiogenic shock.
• ACT (activated clotting time) machine to measure levels of heparinization during interventional procedures.
B/P , pulse ox,
Improvements in digital storage & resolution has largely replaced cine Study can be stored on CD-R or DVD’s for review

8. Cardiac catheterization
The oxygen concentration can be measured across the valves and walls (septa) of the heart
Pressures within each chamber of the heart and across the valves can be measured.
The technique can even be performed in small, newborn infants.
The catheter also serves the purpose of monitoring blood pressures in these different locations inside the heart.
The angiogram procedure takes several hours, depending on the complexity of the procedure.
Computer-based physiologic monitor used to monitor patient ECG and hemodynamic pressures during cardiac catheterization.
The physiologic monitor is essential to cardiac catheterization procedures.
It is used to monitor and record vital patient functions, including electrical activity (ECG)* within the heart and blood pressure (hemodynamic) within the various intracardiac chambers
The patient's ECG and hemodynamic pressures are continuously displayed throughout the various types of procedures. (Selective samplings of ECG and hemodynamic pressures are recorded for permanent documentation.) (

9. Basic info about procedure
IV sites in either arm, groin, or neck.
Flexible catheter inserted to IV through the blood vessel.
Then, cathether is threaded thorough the blood vessel to the heart.
Pressure measured at this point.
Iodinated contrast injected through catheter once it reaches the heart.
Fluoroscopy guides the
cardiologist
with the catheter location.
A special device that is attached to the catheter called a pressure transducer to measure various chamber of the heart.
--- The amount of h2o is measured at the same time by withdrawing blood samples. Level of oxygen in the blood is significant to indicator to diagnosing congenital heart defect and evaluating myocaidal infarction or otherwise known as heart attack.
--- The injection of contrast helps visualize how the chambers of the heart and arteries are working,
A blockage of the coronary arteries re usually found once the contrast is injected.
-Cardiologist is able to find the exact location of the catheter placement only with the guidance of the fluoroscopy.
The tube is biplane.

10. The coronary arteries are vital because they supply oxygen and nutrients to the heart muscle.
Without blood flow, the muscle would sustain permanent damage in the form of a heart attack or myocardial infarction
Blood is supplied to the myocardium by the right and left coronary arteries. These vessels arise in the aortic sinus immediately superior to the aortic valve
Following a catheter exchange, selective angiography of the right coronary artery and left coronary artery is performed, with different projections used for each coronary artery to prevent superimposition with overlapping structures.
Coronary angiography allows the extent of intracoronary stenosis to be evaluated
Because of the complexity of the anatomy involved, the variations in patient body habitus, and the presence of anomalies, a comprehensive guide for angiographic projections is difficult to establish.
The physician determines the projections that best demonstrate the artery of interest. Coronary arteriograms are obtained in nearly all catheterizations of the left side of the heart.

11. Normal Rt & Lt Coronary Arteries

12. What Method is this?
Seldinger announced a percutaneous method of catheter introduction. The Seldinger technique eliminated the surgical risk, which exposed the vessel and tissues 12

13. Catherization: Selinger Technique*
However, the modified Seldinger technique allows for puncture of the anterior wall only. The steps of the technique are described in Fig The procedure is performed under sterile conditions. The catheterization site is suitably cleaned and then surgically draped. The patient is given local anesthesia at the catheterization site. With this percutaneous technique, the arteriotomy or venotomy is no larger than the catheter itself. Therefore hemorrhage is minimized. Patients can usually resume normal activity within 24 hours after the examination. In some diagnostic angiograms, the procedure can be performed in the early morning and the patient may be discharged later that same day. Most often an uncomplicated interventional procedure may be performed and the patient will recover in an ambulatory care area and then be discharged home, usually within 24 hours. The risk of infection is lower than in surgical procedures because the vessel and tissues are not exposed.
*Modified Seldinger only punctures one side of vessel – this Percutaneous method can be used for arteries or veins - describes the method of catheter introduction that is not a direct stick 13

14. Seldinger Technique
After a catheter is introduced into the blood-vascular system, it can be maneuvered by pushing, pulling, and turning the part of the catheter still outside the patient so that the part of the catheter inside the patient travels to a specific location.
A wire is sometimes positioned inside the catheter to help manipulate and guide the catheter to the desired location. When the wire is removed from the catheter, the catheter is infused with sterile solution, most commonly heparinized saline, to help prevent clot formation. Infusing the catheter and assisting the physician in the catheterization process may be the CIT's responsibility.
When the examination is complete, the catheter is removed. Pressure is applied to the site until complete hemostasis is achieved, but blood flow through the vessel is maintained. The patient is placed on complete bedrest and observed for the development of bleeding or hematoma. Newer closure devices, which close the vessel percutaneously, can also be used to close the puncture site.

15. What is this? When is it used in Cardiac Cath?
used to inject a large amount (25 to 50 mL) of contrast material into either the right or left ventricle the aortic root, or the pulmonary vessels.
Because the coronary arteries are of small caliber and of low flow rate, administration of contrast medium into these structures generally does not require a high-pressure injector.
Pressure injector
The pressure injector for the administration of radiographic contrast medium
May also used during cardiac catheterization.
In the catheterization laboratory, the pressure injector is used to inject a large amount (25 to 50 mL) of contrast material into either the right or left ventricle (the main pumping chambers of the heart), the aortic root, or the pulmonary vessels.
Because the coronary arteries are of small caliber and of low flow rate, administration of contrast medium into these structures generally does not require a high-pressure injector.
Instead, most physicians opt for manual injection using an angiographic control syringe 15

16. CARDIAC CATHETERS The advantages of catheterization are as follows:
May be inserted in an artery or vein
information is collected on the valves, chambers, and arteries, as well as the structure and function of the heart
A cardiac cath can show a cardiologist the precise location of a blockage or defect
The advantages of catheterization are as follows:
1. The risk of extravasation is reduced.
2. Most body parts can be reached for selective injection.
3. The patient can be positioned as needed.
4. The catheter can be safely left in the body while radiographs are being examined.
A:Judkins RT B:Judkins LT C: Pigtail
CATHETERIZATION
Catheterization for filling vessels with contrast media is a technique that is preferred to needle injection of the media. The advantages of catheterization are as follows:
1. The risk of extravasation is reduced.
2. Most body parts can be reached for selective injection.
3. The patient can be positioned as needed.
4. The catheter can be safely left in the body while radiographs are being examined.
The femoral, axillary, and brachial arteries are the most commonly punctured vessels. The transfemoral site is preferred because it is associated with the fewest risks.
The most widely used catheterization method is the Seldinger technique.
Catheters
The catheters used for left heart cardiac catheterization are similar to those angiographic catheters previously described, except that cardiac catheters are preformed for the cardiac vasculature
Specialized catheters are used for right heart catheterization procedures. Unlike angiographic catheters whose main purpose is as a conduit for contrast media, right heart catheters are typically flow-directed catheters that use an inflated balloon on the tip of the catheter to ease passage through the various chambers of the heart.
Depending on the type of procedure to be performed, the physician will decide which catheter to use.
Cardiac cath video:

17. It may be advanced to the left heart to look at the LT ventricle
Catheter can be introduced through femoral, brachial or carotid artery to the knob of the aorta for coronary arteries
It may be advanced to the left heart to look at the LT ventricle
Seldinger is a percutaneous method of catheter introduction. The Seldinger technique eliminated the surgical risk, which exposed the vessel and tissues as compared to the Direct Stick method for the carotid artery
Radial, Subclavian & jugular may also be used depending on Physician choice and Pt condition
Seldinger Tech is a percutaneous method for the femoral approach

18. Guidewires & Needles Needles
Vascular access needles are necessary when performing percutaneous procedures. Needle size is based on the external diameter of the needle and is assigned a gauge size. However, to allow for appropriate guidewire matching, the internal diameter of the needle must be known.
Vascular access needles come in different types, sizes, and lengths. The most commonly used access needle for adult cardiovascular procedures is an 18-gauge needle that is 2.75 inches long. This particular needle is compatible with a guidewire, which is the most frequently used guidewire in cardiovascular procedures. Appropriate needle size is predicated on the type or size of guidewire needed, the size of the patient, and the targeted entry vessel. To decrease the chances of vascular complications, the smallest gauge needle that meets the above criteria is used for vascular access. Access needles for the pediatric patient come in smaller gauge sizes with shorter lengths
Guidewires
Guidewires, also commonly referred to as a spring guide or wire guide, are used in angiography and other special procedures as a platform over which the catheter is to be advanced. To decrease the possibilities of complications, the guidewire should be advanced into the vasculature ahead of the catheter. Once positioned in the area of interest, the position of the guidewire is fixed and the catheter advanced until it meets the tip of the guidewire. Similar to needles, guidewires come in a variety of sizes, shapes, and lengths, and care must be taken to match the proper guidewire to the selected access needle and catheter.
The majority of guidewires are constructed of stainless steel
Guidewires allows the user a high degree of torque and maneuverability. It is offered in various lengths and has various shaped tips.

19. Percutaneous Transluminal Coronary Angioplasty (PTCA)
Otherwise known as:
Balloon Angioplasty
Angioplasty
PTCA
Balloon Angioplasty is a technique used to dilate an area of arterial blockage with the help of a balloon catheter.
It is a way of opening a blocked blood vessel.

20. Balloon Angioplasty
A small area of the groin or arm is shaved and cleaned where the catheter is inserted.
Medication is used to anesthetize the area so a small incision can be made where the catheter will be inserted.
A catheter with a deflated balloon on the tip is inserted through the artery in the groin or arm.
X-ray is used to guide the catheter up into the heart.
One Possible Complication:
Plaque material or blood clots dislodging and floating downstream, leading past the treated area
During PTCA, a specially designed guiding catheter is placed into the orifice of the stenotic coronary artery as determined by coronary angiography.
A steerable guidewire is inserted into the balloon catheter and advanced within the guiding catheter
The guidewire is advanced across the stenotic area; it serves as a support platform so that the balloon catheter can be advanced and centered across the stenosis.
Controlled and precise inflation of the balloon fractures and compresses the fatty deposits into the muscular wall of the artery. This compression, in conjunction with the stretching of the external vessel diameter, is necessary for successful angioplasty.
The balloon is deflated to allow rapid reperfusion of blood to the heart muscle. The inflation procedure, followed by arteriography, may be repeated several times until a satisfactory degree of patency is observed.
The limiting factor of PTCA is restenosis, which occurs in approximately 30% to 50% of the patients who undergo the procedure.

21. Balloon angioplasty and a stent are used to open up the stenotic left brachiocephalic vein. Excellent blood flow was restored in subsequent images.

22. Equipment Used During a Procedure:
Balloon Catheter
Metal mesh stent
Pump for balloon
Usually a metal stent is placed in the opened artery to make sure restenosis does not reoccur
Following the procedure, the balloon is deflated and additional x-rays are taken to determine how much blood flow has increased.

23. Prevention of Restenosis
Lifestyle Change
Healthy diet
adequate exercise
No Smoking
Medicine coated stents
Although Balloon Angioplasty is a valuable tool it is not a cure for Artherosclerosis.
It is only a treatment,
Patients should try to lead a healthy life which will be the best treatment for their arteries.

24. Coronary Artery Bypass Graft Surgery
is a surgical procedure to treat severe coronary artery disease (heart disease).
Part of a vein or artery (called a graft) from another part of the body is used to bypass a blockage in one or more of the coronary arteries.
The type of graft used,
a vein* from the leg,
or an artery from the chest,
depends on the number
and location of the blockage.

25. Stent Placement 25

26. AAA
Open repair of abdominal aortic aneurysms is a major operation, and you would need to be in hospital for approx. 7 to 10 days. Under a general anesthetic, an incision (cut) is made in the abdomen. Then the abdominal aorta above and below the aneurysm is controlled and clamped to stop blood flow, which enables the aneurysm to be opened up and a new artificial artery sewn in to replace the dilated segment. The clamps are then removed to restore the blood flow, and the abdomen is sewn up.
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Risks and complications of an 'open' operation with a graft
The major complications of the open operation are the risk of either bleeding or problems with the heart, which is put under some strain when the clamps are placed on the abdominal aorta. There can be problems resulting from a reduction in blood flow to the legs and kidneys during or after the operation. Overall, the incidence of serious complications is 5 to 7%.
What alternatives are there to having an open operation?
A relatively new technique that is being tested in hospitals is to use a 'stent' to help repair abdominal aortic aneurysms (see the diagram below). The aim of this technique is to perform a less major operation, which can be tolerated better by more patients. Depending on the shape and size of the arteries around the aneurysm, the abdominal aortic aneurysm can be repaired from the groin. This operation usually involves making small cuts on each side of the groin under general anesthetic. A graft is then inserted into the abdominal aortic aneurysm through an artery in the groin. Special stents are used to hold the graft in place. 26 26

27. A stent graft or endograft used to repair aneurysm in the aorta and iliac region.
Abdominal Aortic Aneurysm Endografts
An interventional therapy started in the late 1990s is treating abdominal aortic aneurysms (AAAs) with a transcatheter approach and stenting.
AAAs have been historically treated with an open repair of the aneurysm by a vascular surgeon.
This approach has its risks associated with abdominal surgery and a long hospital stay for recovery of the incision. The stent graft or endograft is a nitinol-covered stent that comes in pieces or one intact device depending on the manufacturer
Patients must have an aneurysm that is infrarenal or occurring below the renal arteries. The stent is a covered device and would occlude the renals.
This procedure is done either in the catheterization laboratory or in the operating room depending on the hospital. If done in the operating room, a portable C-arm is needed with DSA capabilities to reproduce the function of the catheterization laboratory DSA.

28. CARDIAC
ABLATION
Cardiac Ablation

29. RF ABLATION

30. AV Nodal Reentrant Tachycardia AV Reentrant Tachycardia
In cardiac ablation, a form of energy renders a small section of damaged tissue inactive. This puts an end to arrhythmias that originated at the problematic site
Most often, cardiac ablation is used to treat rapid heartbeats that begin in the upper chambers, or atria, of the heart. As a group, these are know as supraventricular tachycardias, or SVTs. Types of SVTs are:
INDICATIONS
Atrial Fibrillation
Atrial Flutter
AV Nodal Reentrant Tachycardia
AV Reentrant Tachycardia
Atrial Tachycardia

31. Cardiac Ablation Minimally invasive treatment for arrhythmias
Live fluoroscopy and angiography techniques are used along with special electro physiologic equipment and catheters
Performed by a doctor specializing in the hearts electrical system
Pulse
ECG
Chest pain
Nausea
Syncope

32. Catheter positions for routine electrophysiologic study.
Multipolar catheters
are positioned in the
high right atrium near
the sinus node,
in the area of the
atrioventricular apex,
and in the coronary
sinus.

33. Your Hearts Electrical System
Sinoatrial node-
“Natural Pacemaker”
Upper Right Atrium
Produces electrical signal times a min
Atrioventricular node-
The bridge that connects Atriums to Ventricles
Special cells allow electrical signals to pass

34. CINE HIGHEST IN RADIATION DOSE TO THE PATIENT / TECHNOLOGIST
1 MR/FRAME X 60 FRAMES/SEC FOR 30 MINUTES = ?
HEAT LOADS?????
Angiographic x-ray tubes must be capable of producing ionizing radiation for the long periods of time necessary for fluoroscopy and therefore must be designed to withstand greater heat loading. Ideally angiographic tubes should have a heat load capacity of 1.5 million heat units or greater. For most cardiac imaging, multifocal-spot, high-speed rotating fluoroscopic tubes are desirable. Extremely short exposure times are required to accommodate the rapid-exposure sequencing of the various recording systems.
(Frank, Eugene D.. Merrill's Atlas of Radiographic Positioning and Procedures, 11th Edition. Mosby, ).
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35. 1 MR/FRAME X 60 FRAMES/SEC FOR 30 MINUTES =
1 X 60 = 60 mR/sec
60 mR/sec x 60 sec = mR/min
3600mR/min x 30 min =
mr OR R
CINE DOSE

36. Imaging Considerations
Magnetic resonance imaging (MRI)
Recently gained in popularity for use in cardiac studies
Uses cine loop
May be ECG gated
Magnetic resonance angiography (MRA)

37. Nuc Med / Pet scanning Perfusion Scanning
Myocardial perfusion scan
Most widely used procedure
Gated cardiac blood pool scans
Used to evaluate ventricles
Positron emission tomography (PET)
Nuclear cardiology
Used to diagnose CAD, congenital heart disease, and cardiomyopathy
Myocardial perfusion scan
Most widely used procedure
Gated cardiac blood pool scans
Used to evaluate ventricles
Positron emission tomography (PET)
Nuclear Cardiology
Nuclear medicine procedures used in the assessment of cardiovascular disease include myocardial perfusion scans, gated cardiac blood pool scans, and positron emission tomography (PET). They are useful in assessing CAD, congenital heart disease, and cardiomyopathy.
A myocardial perfusion scan is the most widely used procedure in nuclear cardiology. It may be performed on patients with chest pain of an unknown origin, to evaluate coronary artery stenosis, and as a follow-up to bypass surgery, angioplasty, or thrombolysis. It is especially useful in detecting regions of myocardial ischemia and scarring (Figs and 8-16). In this study, a special agent is used to dilate the coronary arteries, and then a radionuclide, usually radioactive technetium sestamibi or thallium, is injected. It concentrates in the areas of the heart that have the best blood flow. Those areas lacking blood flow demonstrate filling defects, visualized between images taken at rest and under stress. Patients may be stressed by exercise using a treadmill or by the use of pharmaceuticals such as dipyridamole. Myocardial perfusion scanning is performed using a single photon emission computed tomographic (SPECT) camera, allowing the camera to rotate around the patient to obtain tomographic images of the heart parallel to the short and long axis of the left ventricle. SPECT myocardial perfusion scans can detect significant CAD in 90% of patients presenting with CAD.
Nuclear cardiology
Used to diagnose CAD, congenital heart disease, and cardiomyopathy

38. Doppler Ultrasound Echocardiography M-mode echocardiography
Real-time imaging
Transesophageal echocardiography (TEE)
Spectral Doppler
Color Doppler
Carotid stenosis, DVT
Stress echocardiography
Atherosclerosis as seen in Doppler sonography of the internal carotid artery in a 75-year-old man. Arrows point to the "hilly" plaque deposit on the lower surface of the artery; the lack of echo signal beneath them indicates calcium contained within the plaque

39. Imaging Considerations
Computed tomography (CT)
Cardiac scoring
EBCT
Spiral CT
CT angiography (CTA)
Heart CT 3D

40. Name of Exam?
Aortogram demonstrating patent ductus arteriosus. Notice filling of the pulmonary vessels as well as the aorta.

41. CHECK OUT THE LIVE ACTION!
Go to Review of Cardiac Anatomy, Pathology & Circulation - Lect # 3b