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PRESENTED BY
GABRIEL K FERNANDES
CARDIOVASCULAR INTERVENTIONAL
TECHNOLOGIST
METROPOLITAN HEART INSTITUTE &
RESEARCH CENTRE INDIA LTD.
IN ASSOCIATION WITH RADIOGRAPHERS
ASSOCIATION OF MAHARASHTRA.
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
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
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.
ECG
Blood pressure
Pressure measurements
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
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 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.
Zero
Calibration
Cardiac
Output
Thermodilution
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
Coronary
arteries
The
The
Cardiac
procedures
Cardiac
catheterisation
Procedure
Projections
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 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 arteries
Left
Coronary arteries
Right
Coronary artery
Right
Coronary artery
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).
Left
ventricle angiogram
Optimize
quality
image
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.
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.
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.
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
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
Basic
heart
pathology of the
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 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
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