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CATHLAB BASICS

PRESENTED BY
GABRIEL K FERNANDES
CARDIOVASCULAR INTERVENTIONAL
TECHNOLOGIST
METROPOLITAN HEART INSTITUTE &
RESEARCH CENTRE INDIA LTD.
IN ASSOCIATION WITH RADIOGRAPHERS
ASSOCIATION OF MAHARASHTRA.

November, 1998 Council on Clinical


Cardiology, American Heart Associa

CARDIAC CATHETERIZATION LABORATORY

CONTENTS
1 PREFACE
2 INTRODUCTION
3 THE HEART
4 BLOOD PRESSURE
5 CORONARY ARTERIES
6 CARDIAC PROCEDURES
7 BASIC PATHOLOGY OF THE

HEART

Preface
This book "Cardiac catheterization Basics"
is aimed for technicians working in the
cardiac catheterization room who quickly
like to refresh their knowledge.
The purpose of this book is to give a basic
overview of the anatomy,physiology and
pathology of the heart as a guidance for
the catheterization procedure and to help
to realize a good image quality.Since this
book only provides limited information, It
has to be considered only as an extra
guidance tool.

Introduction
Blood circulation
There are two distinct systems in
the body for the blood circulation:
1.Pulmonary blood circulation
2. Systemic blood circulation

Pulmonary circulation

The pulmonary arteries and veins carry blood


from the heart to the lungs and return it to the
heart. Blood which returns from the body to the
heart is pumped into the lungs via the
pulmonary artery to the lungs. With breathing,
the air passes into the lungs through
progessively smaller airways called bronchioles.
The lungs contain millions of bronchioles, all
leading to alveoli, microscopic sacs where
oxygen and carbon dioxide are exchanged.The
oxygen rich blood is collected into the
pulmonary veins of each lung and is returned
via the heart into the systemic circulation.

Systemic circulation
The systemic arteries carry blood
via the aorta from the heart to all
other parts of the body and return
it to the heart via the vena cava
inferior and superior. This oxygen
rich blood supplies all organs and
tissue of the body via the
capillaries. There it exchanges the
oxygen with carbon dioxide and
waste products.

The Heart

The human heart is a muscular pump. The muscle


layer that takes care of the contraction of the
heart to decrease the size and forces the blood
out of its chambers is called myocardium.
Normally the size of the heart is a little bit larger
than a human fist. It pumps about 8000 litres of
blood each day.Reaching the age of 70 years, the
number of heart beats will be over 2.5 billion.The
heart is divided into two halves, the right and
left, by a main septum which extends from the
base to the apex.There is no communication
between these halves after birth.
The right side pumps the blood to the lungs and
is less powerful than the left side which is the
pump for the systemic circulation that has to
drive the oxygen saturated blood to the organs.

The

four chambers of the


heart

RA ( RIGHT ATRIUM )
RV ( RIGHT VENTRICLE )
LA ( LEFT ATRIUM )
LV ( LEFT VENTRICLE )
Each half of the heart consists of the two
chambers which communicate through a
valve.The upper chambers are called
atria, the lower chambers are called
ventricles.

In total the heart has four valves:


The mitral valve is between the left
atrium and ventricle
The tricuspid valve is between the
right atrium and ventricle
The pulmonary or pulmonic valve
is between the right ventricle and
the pulmonary artery.
The aortic valve is between the left
ventricle and the aorta.

The cardiac cycle

The heart beats automatically although it is under


the control of the nervous system for it receives
innervation from the vagus nerve and the
sympathetic nervous system.The pumping action
of the heart consists of a contraction or systole and
a relaxation or diastole. Both atria contract
simultaneously,driving their contents into the
relaxed ventricles during ventricular diastole.The
ventricles then simultaneously go into systole
whereas the atria go into the diastole and blood
flows into the atria from the vena cava to be
discharged into the ventricles during the next atrial
systole.The usual adult rate of the heart is about
70 BPM (beats per minute) but it increases during
exercise or excitement and in various abnormal conditions.

The rhythm of the cardiac cycle results


from the coordination of the myocardial
contractions achieved by special areas in
the myocardium. The cardiac impulse
starts in the sino-atrial node situated in
the wall of the right atrium,it spreads to
the atrio-ventricular node and is
conducted from this point by the Bundle
of His that divides into several bundle
branches to all parts of the ventricles.The
cardiac cycle is accompanied by electrical
changes that can be detected by the
electrocardiograph (ECG).

ECG

A normal ECG has the following features:


P Wave: depolarisation.Atrial contraction
begins (Atrial depolarisation)
PR interval: Atrial contraction
QRS complex: Ventricular contraction
begins (Ventricular depolarisation)
ST segment: rapid systolic ejection
T Wave: due to ventricular repolarisation
(relaxation of ventricular muscle)

Blood pressure

The pulse is the dilatation of an artery caused by


the blood pressure increase due to the contraction
of the heart. Blood pressure is the pressure exerted
by the blood against the vessel wall.The systolic
pressure is determined primarily by the rate and
volume of ventricular ejection in relation to the
arterial elasticity.

Systolic pressure is the pressure during contraction of the


heart,normally between 100 to 120 mm Mercury
(approximately 16 k Pascal).

The diastolic pressure is determined by the rate of


diastolic pressure drop and the heart rate as it
effects the duration of the diastole.Diastolic
pressure is the pressure during relaxation of the
heart, normally between 65 and 80 mm
Mercury(approximately 11 k Pascal)

Pressure measurements

The three principal attributes of circulating blood


are flow, volume and pressure. Various methods
for measuring cardiac output provide information
concerning total blood flow through the heart,
but of these three important variables, only
blood pressure is routinely measured in patients.
Direct pressure measurements have intrinsic
value in determining certain conditions under
which the circulatory system is functioning.
During a coronary angiography several pressures
at different catheter positions are measured.

Left heart pressures

The following graphs give only an


indication of the shape of the
graph for each different
measured pressure. The pressure
gives only a rough indication of
possible measured values.

Aortic pressure
A catheter is guided into the
ascending part of the aorta.
Example:
Systolic pressure: 118 mm Hg
Diastolic pressure: 57 mm Hg
Mean pressure: 81 mm Hg
Heart rate: 54 bpm.

Left

ventricle pressure

A catheter is guided into the left


ventricle passing through the
aortic valve.
Example:
Systolic pressure: 166 mm Hg
End diastolic pressure: 32 mm Hg
Heart rate: 80 bpm.

Left atrium pressure

A catheter may be pushed into the left


atrium passing through the mitral valve.If
there is a mitral stenosis it may not be
possible to push the catheter into the left
atrium. The Pulmonary Capillary Wedge
pressure from the right heart catherisation
may substitute the left atrium pressure.
Example:
Mean: 13 mm Hg
Heart rate: 82 bpm
Value: 18 mm Hg.

Pullback pressure
A Catheter is pulled back from the left ventricle
into the aorta.
Example:
left ventricle
Systolic pressure: 188 mm Hg
End diastolic pressure: 151mm Hg
Heart rate: 167 bpm
aorta
Systolic pressure: 190 mm Hg
Diastolic pressure:135 mm Hg
Mean pressure: 125 mm Hg
Heart rate:158 bpm

This

pullback method is to
make an assessment of
the aortic valve and very
common during a cardiac
procedure. the two
pressures are used for the
pressure gradient that
plays a role in the
assessment of valvular
stenosis.

Right heart pressures


Right atrium
A catheter is guided into the right
atrium.
Example:
Value: 18 mm Hg
Mean: 15 mm Hg
Heart rate: 89 bpm.

Right ventricle
A catheter is guided into the right
ventricle passing through the
tricuspid valve.
Example:
Systolic pressure: 42 mm Hg
End diastolic pressure: 8 mm Hg
Heart rate: 84 bpm.

Pulmonary artery
A catheter is pushed into the
pulmonary artery passing through
the pulmonary valve.
Example:
Systolic pressure: 29 mm Hg
Diastolic pressure: 15 mm Hg
Mean pressure: 21 mm Hg
Heart rate: 130 bpm.

Pulmonary capillary wedge


pressure
A catheter is guided into the
left or right pulmonary
capillary wedge position.
Example:
Value: 18 mm Hg
Mean: 13 mm Hg
Heart rate: 77 bpm.

Zero

Calibration

(For pressure measurements)


Before starting a cardiac procedure, a zero
calibration is done for each patient. According to an
international agreement, the reference level for the
pressure measurement system is the pressure on
the surface of the right atrium. It can be assumed
that the pressure there is identical to atmospheric
pressure at the end of expiration. It is therefore
crucial before each examination that the membrane
of the pressure transducer (Dome) is adjusted to the
level of the patients right atrium before setting the
zero balance of the pre-amplifier.
This reference point is measured using a special tool
that divides the patients chest height into 2/5 and
3/5.

Cardiac

Output

The cardiac output is mainly


influenced by changes in the stroke
volume and the heart rate. (CO = SV
x bpm)
The cardiac output in healthy adults
is between 5 and 8 litres per
minute.During a cardiac procedure,
the Cardiac Output (CO) is measured
using different techniques.

Thermodilution

The Cardiac Output is measured using a


special thermodilution device. A special
Pulmonary artery balloon catheter (SwanGanz) is used with a thermistor at the
tip.The catheter is positioned in the
Pulmonary artery. A cold fluid ( usually 10
ml saline for adults) is injected. This cold
saline mixes with the blood causing a
decrease in blood temperature. This is
sensed by the thermistor.
The cardiac output is measured by the
change in temperature over time.

Fick
Applied to the lungs, the Fick principle is used to
calculate the volume of blood required to transport
the oxygen taken up from the alveoli per unit time.
This calculation can be done using special
hemodynamic software that requires the following
input:
Haemoglobin (Hb)
Venous oxygen saturation (VO2)
Oxygen saturation taken from aorta
Oxygen saturation from pulmonary artery
Body surface area (BSA)
Weight
Height
Sex

Ventriculography

With the help of X-ray images and


special software of the system
(Ejection Fraction program), the
cardiac output can be measured.

Coronary

arteries

There are two main coronary arteries - the left


and right.The left coronary artery begins as a
main stem called the Left Main Coronary Artery
(LMCA) which varies between 1 and 15 mm in
length. This artery divides in two major
branches, the Left Anterior Descending artery
(LAD) and the Circumflex artery (CX).
The Right Coronary Artery (RCA) is a single long
vessel with smaller side branches.
The LAD and CX each supply large areas of heart
muscle with blood. The coronary artery tree is
categorized into three systems based on the
mass of heart muscle which are supplied with
oxygen.

The Left Anterior Descending Artery


(LAD)

The LAD is a branch that runs on the front of


the heart in the groove that demarcates the
left and right ventricles. This artery supplies
oxygen and nutrients to a large part of the
inter-ventricular septum and the front wall of
the left ventricle. Obstruction of this artery
causes infarction of a large muscular area in
the left ventricle and may be fatal.

The

Circumflex Artery (CX)

The CX is the other major branch of the


LMCA and turns backwards to run along the
groove between the left atrium and
ventricle.This artery has multiple smaller
side branches that supply blood to the left
margin of the ventricle. Since this margin is
obtusely angled, these branches are also
called obtuse marginal (OM) branches, of
which there may be a varying number (1-7).
These OM branches also supply a
considerable area of ventricle muscle, and
may cause serious damage if diseased.

The

Right Coronary Artery (RCA)

The RCA is the other main coronary artery


branch arising from the aorta and running
in the groove between the right atrium and
ventricle. This artery is usually smaller than
the LMCA, and supplies a smaller area of
heart muscle,mainly the right ventricle. As
it curves behind the heart, the RCA has two
side branches - the Posterior Descending
Artery (PDA) and the Posterior Left
Ventricular Branches (PLB). The PDA supplies
blood to the posterior portion of the
interventricular septum and the PLB supplies a
part of the back wall of the left ventricle.

Other important coronary artery


branches

While the "big three" are the major branches, some


smaller ones may be quite important as well. The
sino-atrial node artery supplies the S-A node which is
the pacemaker of the heart and sets its rhythm.
This branch comes off the RCA in 55% and off the LCA
in the other 45%.The atrio-ventricular node artery
supplies the A-V node, which is located between the
atria and ventricles and controls spread of electrical
impulses from the atrium to the ventricle. While in
90% of cases this branch originates from the RCA, in
the other 10% it may be a branch of the CX.Damage
or blockage of this branch may result in a serious
arrhythmia called heart block".

Cardiac

procedures

The cath-lab is used for several


procedures, the following will give
an overview of the most common
diagnostic and intervention
procedures.

Cardiac

catheterisation

Cardiac catheterisation may be


indicated for:
1.Unstable angina
2.Abnormal treadmill test
3.Valvular disease
4.Acute myocardial infarction
(heart attack)
5.Cardiomyopathy and/or heart
failure

The following information can be


obtained from a cardiac
catheterisation:
1 Determination of presence of stenoses
(narrowing) in
the coronary arteries or
coronary artery bypass grafts
2 Determination of how well the heart
muscle
squeezes (contractibility)
3 Evaluation of the heart valves
4 Measurement of various pressures inside
the chambers of the heart
5 Determination of presence of any birth
defects or shunts

Procedure

Catheters are pushed up in the aorta, usually via


the femoral or brachial artery and then into the
coronary arteries. Contrast medium is injected to
assess blood flow through the artery while various
exposures are taken from different angles. Then
another catheter,pigtail shaped, is placed into the
aorta where pressure measurements are made.
This catheter is then advanced across the aortic
valve and pressures within the left ventricle are
obtained.The catheter is then attached to an
injector and contrast medium is injected.Pressure
measurements are again taken after injection of
contrast medium and as the catheter is withdrawn
back across the aortic valve and then removed.

Projections

To visualise the coronary arteries several


projections are necessary. When mentioning
the various projections, remember that
L.A.O. rotation indicates that the Image
Intensifier is rotated to the left side of the
patient. R.A.O. rotation indicates that the
Image Intensifier is rotated to the right side
of the patient. Using cranial angulation the
Image Intensifier angulates to the patients
head while using the caudal angulation the
Image Intensifier angulates towards the
patients feet.

To recognize the different vessels one can


think of the following hints:
- The Circumflex lies closest to the spine
- Only the LAD (Left Artery Descendens)
reaches the apex
- In L.A.O. position, the apex points to the left
- In L.A.O. position, the LAD lies to the left
- In L.A.O. position, the spine is on the right
- In R.A.O. position, the spine is on the left
- In R.A.O. position, the apex points to the
right.
- In L.A.O. position, the RCA (Right Coronary
Artery) resembles a C.

Left

Coronary arteries

R.A.O. 30o
The Right Anterior Oblique R.A.O.
projection at 30o permits the
entire circumflex system to be
studies as well as the first
centimetres of the anterior inter
ventricular artery.

Left Coronary artery

Left

Coronary arteries

L.A.O. 55/60o
The Left Anterior Oblique (L.A.O.)
projection at 55/60o mainly studies
the diagonal arteries and the mid
and distal parts of the LAD. On the
other hand the circumflex is not
well defined.

Left Coronary artery

Left

Coronary arteries

L.A.0. 55/60o + 20o cranial


projection
The cranial angulation of 20o
combined with the L.A.O.
projection at 55/60o is especially
useful to study the left main
coronary artery.

Left Coronary artery L.A.0. 55/60o +


20o cranial

Left

Coronary arteries

Left Lateral projection


The left lateral projection, allows
the study of the different segments
of the anterior inter ventricular
artery, the first diagonal artery and
the left marginal artery.

Left Coronary artery in Left


Lateral

Right

Coronary artery

Left lateral projection


This projection permits the study of
the second (vertical segment of
the right coronay artery and the
collateral branches (conus branch,
right ventricular artery, right
marginal artery)

Right Coronary artery in


Left lateral

Right

Coronary artery

L.A.O. 45o + 15o caudal


angulation
This projection allow the whole
study of the R.C.A. and clearly
defines the region of the crux of
the heart.

Right Coronary artery in L.A.O. 45o +


15o caudal

Right

Coronary artery

R.A.O. at 45o
The Right Anterior Oblique (R.A.O.)
projection at 45o permits the
survey of the second (vertical)
segment of the right coronary
artery, the posterior inter
ventricular artery and the
collateral branches (right
ventricular and right marginal
arteries).

Right Coronary artery in R.A.O


45o

Left

ventricle angiogram

To measure various pressures and to


visualize how well the left ventricle
contracts, a pigtail shaped catheter is
used. This catheter has several side holes
to make it possible to inject contrast using
a high flow rate.
The left ventricle can be divided into
several areas to determine which part of
the ventricle muscle is not functioning
properly.
The projection most used to visualise the
left ventricle is RAO 30o

Optimize

quality

image

The patients treatment depends


on the diagnosis. Therefore the
image quality plays a major role.
To obtain the best image quality,
the following factors have to be
taken into account.

Shutters
Shutters are built in the system to
adjust the field of view and to
avoid showing white margins at
the edges of the image that might
interfere with the perception of
image detail. Be aware that if the
field of view is set too small, there
is a risk to miss some of the
anatomy.

Wegde filters
To prevent distracting highlights in
the region of interest (lung tissue)
that will affect image quality,
wedge filters can be used.

Protocol
Image quality is also determined
by the protocol selected. Within
each protocol several parameters
are optimised for a certain
exposure technique or projection.
It is therefore of utmost
importance to select the correct
protocol before starting a
diagnostic exposure run.

Image Intensifier position


The image intensifier is moved
away from the patient in
preparation of the next projection
using a different rotation and or
angulation. To avoid air gaps that
deteriorate image quality, the
distance between the image
intensifier and the patient should
be minimized every time again
after change in projection view.

Patient communication
A good patient communication will
reduce patient physical or
respiratory movement during
image acquisition.

Catheter position
When starting an image
acquisition, the best image quality
is achieved when the whole
anatomy of the coronary arteries is
visible without having to move the
table.
This is possible when having the
catheter tip positioned correctly
within a certain area of the field of
view on the monitor.

To give an indication of the position


of the catheter tip for each
projection, the field of view is
divided into 9 zones.
If the tip is within the zone 1,2,3 or
5, then in most of the acquired
runs the whole anatomy of the
coronary arteries will be within the
field of view without having to
move the table.
Examples:

To give an indication of the position


of the catheter tip for each
projection, the field of view is
divided into 9 zones.
If the tip is within the zone 1,2,3 or
5, then in most of the acquired
runs the whole anatomy of the
coronary arteries will be within the
field of view without having to
move the table.
Examples:

Left coronary arterty and


Circumflex

Left coronary arterty and


Circumflex

Right coronary
artery

Interventions
PTCA
Percutaneous Transluminal Coronary
Angioplasty (PTCA) is a procedure to
attempt to open up a narrowed
artery by using a catheter that has
a balloon at the tip of it. When the
balloon is inflated, the pressure
flattens the plaque against the walls
of the artery which will then
improve the blood flow to the heart.

Procedure
The balloon catheter has a radiopaque marker
in the middle portion of the balloon. Note that
there are also balloon catheters with proximal
and distal markers.The central marker is
placed in the middle of the coronary artery
stenosis. The balloon is then slowly inflated
with a small hand-held pump that is filled with
contrast. The balloon is inflated until there is
no dent in the balloon. The balloon is left
inflated anywhere from one to two minutes
depending on the individual case and watched
under fluoroscopy. Several inflations may be
necessary to achieve the desired reduction of
the stenosis.

Stent placement
Stent placement is a procedure that often
follows the PTCA. Once the narrowed artery
is opened, a stent reduces the likelihood
that the artery will narrow again. Coronary
stents are stainless steel frames attached
to a special designed balloon catheter. The
stent is expanded by inflating the balloon.
Once the stent is expanded succesfully the
balloon is deflated. The stent itself is
designed in such a way that it remains it
shape after deflating the balloon.

Drug eluting stents reduce the risk of re-stenosis.

Other ways of reducing a coronary


blockage

Instead of using a balloon there are


other devices to increase the
lumen of the coronary arteries:

Angiojet
An angiojet can be used to widen a
coronary artery that is narrowed
due to a fresh thrombus. This high
pressure jet creates a low pressure
region within the blood vessel and
the whole system acts like a
vacuum cleaner and sucks up the
fresh thrombus.

Atherectomy

Used on hard plaque which a balloon is unable to


compress. A special atherectomy catheter has a
small knife to shave off the plaque. The catheter
consists of a shaft on which a balloon is mounted
on one side, on the side opposite the balloon
there is an opening in the shaft, which allows the
blade to protrude. The catheter is positioned
with the opening over the plaque and the
balloon inflated to hold the catheter in place.
The blade is then moved back and forth across
the plaque, the shavings are sucked back via the
catheter. Once the plaque has been de-bulked,
the normal PTCA procedure or stent placement

Rotablator
The rotablator is primarily used for
concentric hard plaque and
calcified lesions. It uses a diamond
powder coated tip on a catheter at
high speed 80.000 to 150.000
rpm) to de-bulk the lesion prior to
PTCA procedure and stent
placement.

Electrophysiology (EP)
Reason for an Electrophysiology
study (EP) is arrhythmia, or
abnormal heart rhythm

EP mapping procedure.
Pacing wires are positioned in various
areas in the heart. These wires are
connected to a large computer, which
allows specific measurements of all parts
of the hearts electrical system. This test
takes approximately 1 to 3 hours to
complete. If the arrhythmia is reproduced
the arrhythmia may terminate itself, or an
electrical shock, delivered through
adhesive patches on the chest and back
may return the rhythm to normal.

Ablation
Catheter ablation is a technique to
eliminate alternate pathways
present in the heart causing
arrhythmias (abnormal heartbeats)
that interfere with the normal
conduction.

Procedure
Once the area of the heart has been
defined through catheter mapping,
a special ablation catheter is placed
at the site of the abnormal
pathway.Radiofrequency waves are
delivered through this catheter. The
heat formed by this catheter causes
scar tissue on this pathway of cells
so that the abnormal conduction
cannot pass through.

Pacemaker
Pacemaker implantation is done on
patients with severe heart rhythm
disturbances. If the SA node sends
impulses out too slowly, it results in a
rhythm that is too slow. This is called
"Sick Sinus Syndrome". Another situation
may result from impulses being blocked
at some point along the electrical
pathway in the heart. This is called heart
block, and can also result in a rhythm
which is too slow.

Procedure
An incision is made, and the
pacemaker lead is placed through
the subclavian vein which leads
directly to the right side of the
heart. A small pocket is then made
in the upper chest area and the
pacemaker generator is placed. The
lead will be connected to the
generator, checked and
programmed. The incision is then
closed.

IABP

The Intra-Aortic Balloon Pump (IABP) is a


mechanical device to reduce the workload of the
heart and to improve blood flow to the coronary
arteries.The pump consists of a balloon attached
to the end of a catheter. The balloon sits in the
aorta and opens and closes in response to the
hearts contractions. After the heart contracts
and propels oxygen-rich blood into the aorta, the
balloon rapidly opens up and propels some of
the oxygen-rich blood back toward the coronary
arteries. Just before the hearts next contraction,
the balloon rapidly deflates creating a lower
pressure in the aorta so the heart does not have
to work as hard to pump the blood out.

Basic

heart

pathology of the

Arteriosclerotic coronary disease

In all blood vessels of all people some fatty


material starts to build up on the inside of the
blood vessel walls. In some people the rate of
deposit of fatty material is faster than in others
resulting in atherosclerose or arteriosclerosis.
Although the terms are used interchangeably,
atherosclerose is a type of arteriosclerosis that is
characterised by deposits of plaque.
Arteriosclerosis is particularly dangerous when
the vessel that is involved is a coronary artery
and the lumen is narrowed by 50 to 70% of its
normal diameter.
Arteriosclerosis can lead to angina pectoris,
heart attack or myocardial infarction.

Valvular diseases
The heart has four valves. Any of
these valves may fail to function
properly,but most commonly the
valves on the left side of the heart
are affected. The valves may
narrow, called stenosis, or may
close incorrectly, called prolapse.

Aortic valve stenosis


Aortic valve stenosis results in
having the left ventricle to work
harder to push out the blood. As
this occurs the muscular walls of
the ventricle thicken.

Aortic regurgitation
When the aortic valve fails to close
completely after the heart has
pumped out the blood into the
aorta, blood leaks back into the left
ventricle. This may be the result of
an endocarditis (infection) or heart
attack. It may leave the valve
scarred resulting in improper
functioning of the valve.

Mitral stenosis
A mitral stenosis results in an
increase of pressure in the left
atrium leading to an elevation of
the pressure in the lungs.

Mitral regurgitation
Improper closure of the mitral
valve causes blood to leak from
the left ventricle back into the left
atrium. This may be the result of
an endocarditis (infection) or heart
attack. It may leave the valve
scarred resulting in improper
functioning of the valve.

Congenital diseases
Valve damage is not the only
congenital condition that can
damage the heart.Other forms of
congenital heart disease include
holes in the septum that allow the
blood to leak or flow directly from
one chamber into another,rather
than flowing in the proper direction
through the valves.

Left-to-right shunt
Part of the blood flow goes directly from
the left side of the heart to the right side
of the heart. The hole can either be
between the atria or between the
ventricles.
The patent hole (foramen ovale) between
the atria is called the Atrial-Septal-defect.
The hole between the ventricles is called
the Ventricular-Septal -defect

Patent ductus Botalli


If the communication between the
aorta and the pulmonary veins
remains after birth, de-oxygenated
blood mixes with the systemic
circulation.

Coarctation of the aorta


This is a narrowing (stenosis) in the
proximal descending part of the
aorta. The aortic valves are usually
narrower than normal.

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