Cardiac Catheterization

Older Equipment

Image intensifier

X-ray tube

Cine camera

Patient table

Videocameraor CCD

Cine film: Best spatial resolutionDynamic Digital: 60, 30, 15 frames/sVideo tape: Only as a back-up due to poor spatial resolution

Nonionic contrast: high iodine concentration (omnipaque 350)

Charge Coupled Device(CCD) replace vidicon, or plumbicon tubes and Image IntensifiersLightweightFast movements

Photoelectric detectors embedded in layers of silicon

Each pixel is 6 to 25 microns in size, and can store 10,000 to 50,000 electrons.

Modern equipment

Pixels ofa CCD arrangedin a matrix.

Each pixelcorrespondsto a pixel ona monitor

Software: Diagnostic reporting aid that replaces the hand drawings ofyesteryear.

Superior vena cavaPulmonary valve

Endocardium

Myocardium Pericardium

Interventricular septum

AV node

SA node Lt & Rt bundle branches(of HIS)

Selected injection of the left coronaryArtery: Cardiac Catheterization

Coronary Arteries

Left: Main CA Anterior descending: LAD (or anterior interventricular branch) Circumflex Diagonal branches

Right: Main Posterior descending: PDA (or posterior interventricular branch) Marginal branch

Perforating branches to myocardium

Coronary Arteriography

Rt coronary A

Rt Marginal Branch

Post. Descending A (PDA)(Post Interventricular A)

Rt coronary A

Rt Marginal Branch

Post. Descending A (PDA)(Post Interventricular A)

RAO view

LAO view

Lt coronary A

Circumflex Branch of LCA

Lt. Ant. Descending: LAD (Ant. interventricular branch)

Diagonal Branches of LAD

Lt coronary A

Circumflex Branch of LCA

Lt. Ant. Descending (LAD)

Diagonal Branch of LAD

LAO view

RAO view

Indications, Contraindications, and Risks for Cardiac Catheterization

Angina (vs indigestion)Poor exercise toleranceChest pain/pressure, left arm, jaw (or silent)MI from CAD

Contraindications

Cardiac or CADRecent CVASepsis

Risks

bradycardia & hypotensionPVCsV TachV Fib

Angiocardiography (Chambers and Valves)

* Septal defects (PDA)* Valvular disease (Pulmonary valve stenosis casues increased pressure in Rt. vent)* Transposition of great vessels (Dextra cardia) * Tetralogy of Fallot

6 f pig for chambers, 40-60 cc of contrast

Fetal Circulation

Demonstrating the origins of patent ductusarteriosis (PDA) andpatent foramen ovale

Left Ventriculogram

Calculating the ejection fraction of the left ventricle is accomplished by defining the edge of the ventricle wall during systole and diastole (top), by tracing the borders (bottom), and allowing the computer to do its work.

T TP

Q

R

S

Systole Diastole

Hemodynamics: Appendix B in Handbook of Radiologic Procedures

With the catheter in place,and the manifold connected,accurate pressures canbe taken within chambersor vessels through a device called a strain gauge

The Manifold and strain gauge transducer form a closed system

Hemodynamics: Appendix B in Handbook of Radiologic Procedures

Contrast HeperinizedSaline flush

Strain gaugetransducer

Systolic pressuremeasured throughthe catheter in the left ventricle.

Syringe for hand injections of contrast and flushing catheter

Manifold

Waste fluid

Pulmonary Wedge Pressures

The right heart is accessed viapuncture of the femoral vein. Following the normal blood flow, apartially inflated balloon aids in placement of the Swan-Ganz catheter tip in the pulmonary trunk, or pulmonary arteries.

With the balloon fully inflated andwedged in the pulmonary trunk thepressure is the same as in the leftatrium, (green arrows) which is otherwise difficult to access.

VenaCava

Aorta

Pulmonaryveins

Pulmonarytrunk

Pulmonary arterioles,capillaries, & venules

Pulmonary Wedge Pressure

In patient’s with nocardiac disease orpulmonary hypertensiona wedge mean pressure of > 25 mm Hgindicates thrombus

40 mm Hg indicates 60% - 70% obstruction.

Pressure in the rightor left pulmonaryarteries, though slightly higher, issimilar to that in the trunk vessel.

T TP

Q

R

S

Systole Diastole

Pulmonary wedge: mean < 12

mm Hg

10

5

a

cv

T TP

Q

R

S

Systole Diastole

Pulmonary artery: mean 9-17Systolic 15-30, Diastolic 4-14

mm Hg

10

5

20

15

Pressure wave formssuperimposed on ECG

T TP

Q

R

S

Systole Diastole

Right Atrium: Mean 0-8

mm Hg

10

5

a c

v

x

y

T TP

Q

R

S

Systole Diastole

Left Atrium: Mean 2-12Same as pulmonary wedge

mm Hg

10

5

a

c

v

Atrial Pressure Wave Formssuperimposed on ECG

T TP

Q

R

S

Systole Diastole

Right Atrium: Mean 0-8

mm Hg

10

5

a c

v

x

y T TP

Q

R

S

Systole Diastole

Pulmonary wedge: mean 2-12

mm Hg

10

5

a

cv

T TP

Q

R

S

Systole Diastole

Left Atrium: Mean 2-12

mm Hg

10

5

a

c

v

T TP

Q

R

S

Systole Diastole

Pulmonary artery: mean 9-17Systolic 15- 30, Diastolic 4-14

mm Hg

10

5

20

15

Summary of Measurements from the Atria and Pulmonary vessels

As a generality thecharacteristics ofthe atria and pulmonary vesselsare essentially thesame.

The most notable difference is the rightatrium’s mean of< 5 mm Hg, versus the pulmonary wedge and left artium pressures of < 12.

The wedge andleft atrium wave formsare differentiated bythe phasic delay.

T TP

Q

R

S

Systole Diastole

Left Ventricle: Systolic 100-140, Diastolic 3-12mm Hg

100

50

150

T TP

Q

R

S

Systole Diastole

Right Ventricle: Systolic 15-30, Diastolic 0-8mm Hg

100

50

150

Ventricular Pressure Wave FormsCharacteristics of the right and leftventricles are similar, except the left is five to six times that of the right.

T TP

Q

R

S

Systole Diastole

Left Ventricle: Systolic 100-140, Diastolic 3-12mm Hg

100

50

150

T TP

Q

R

S

Systole Diastole

Aorta: Systolic 100-140, Diastolic 60-90mm Hg

100

50

150

Left Ventricular Pressure Compared to the Aorta

During ejection the pressure in the left atrium and aorta are the same upto the closure of the aortic valve (dicrotic notch). The pressure drop inthe ventricle is dramatic after valve closure (<12), but remains high (<90)in the aorta.

Dicrotic notch

Coronary Artery Disease (CAD)

CAD - stenosis from atherosclerosis causing ischemia. Leads to myocardial infarction (MI) and necrosis of themyocardium. Previous MIs are demonstated by impaired wall motion on angiocardiography.

Most common form of heart disease and the leading causeof death in the United States.

Primarily effects the right coronary, left coronary, andcircumflex arteries. Typically the left coronary is dominant, which is why a high grade blockage of it has been dubbed the “widow maker.”

* Temporary chest pain (angina),

* SOB

* Nausea

* Weakness

* Diaphoresis

* Left arm, shoulder & upper abdomen pain

* Tightness and burning in chest

Signs and Symptoms of CAD

Atherosclerotic disease of the: Has the sign of: Which may results in:Coronary artery Angina myocardial infaction (MI)Carotid artery Transient ischemic attacks (TIA) Cerebrovascular accident (CVA, stroke)Lower extremities Intermittent claudication Arteriosclerosis Obliterans

Blood tests Electrocardiogram (EKG) Echocardiography Exercise stress test Coronary angiography Myocardial perfusion imaging (nuclear) Electron-beam computed tomography (EBCT)Telemetry monitoring

Diagnostic Tests for CAD

• Lifestyle changes • Statin drugs: Lipid (cholesterol) lowering• Calcium channel blockers: or nitrate drugs dilate arteries allowing more

oxygenated blood to reach the myocardium • Beta blockers: control symptoms of angina by reducing the workload

on the heart. • Coronary artery bypass graft (CABG), (not open heart) was first used

in 1964. Veins, harvested from the leg (or internal mammary artery) are reversed and grafted from the aorta to the distal side of the blockage.

Prevention and treatment of CAD