CORONARY ANGIOCARDIAC CATH& Ablation ProceduresLecture # 3 A
RT 255 (rev 2010) Dawn Charman, M.Ed,R.T
See notes page on powerpoint for additional information
Reference:
Frank. Merrill's Atlas of Radiographic Positioning and Procedures, 11th Ed. Mosby
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
History of Coronary Cath
•1844- Claude Bernard is the first one to insert a mercury thermometer into the carotid artery of a horse and advanced it through aortic valve into LT ventricle.
•1912- Frizt Bleichroeder - first one to insert catheter into vessels w/o radiograph.
•1929-Werner Frossman, a 25 y/o surgical resident - first one to place a catheter in his own heart (Rt side) using fluoroscopy, through his forearm – then documented it with a Chest radiograph
•1953-Seldinger developed percutanous approach to both RT and LT side of heart.
•1958 Mason Sones - Developed selective coronary procedure - method perfected in early 60’s
•1964- PTCA (percutaneous transluminal coronary angioplasty) invented by Swan and Ganz.
•1974 Dr. Andreas Gruentz -invented 1st PTCA Balloon
•1990’s – Cardiac Cath became the 2nd most frequently performed procedure in patients older than 65
•3,000,0000 procedures will be performed annually by 2010
Dr. Mason Sones
•In 1950’s, the credit for
•"inventing" coronary angiography
•Dr. Sones accidentally injected angiography contrast into the RT coronary arteries for the first time in a living patient during a routine aortography
•Aware of the significance of this observation, he went about designing equipment and techniques to routinely x-ray the various coronary arteries in human patients.
Coronary Angiography overview
•A diagnostic x-ray procedure designed to visualize the small nutrient arteries of the heart.
•These tiny blood vessels are only 1 to 3 millimeters in diameter.
•Thus it takes special x-ray equipment and techniques to obtain images of sufficient quality for diagnosis and surgical decision making
•Administered by a cardiologist with training in radiology or interventional radiologist
•The arterial puncture is typically given in the femoral artery
•The radiologist uses a guide wire and catheter to perform a contrast injection and x-ray series on the coronary arteries.
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*
Who performs the procedure?
•The Interventional Radiologist / Cardiologist
•who specializes in the Angioplasty procedure.
•CIT Technologist
•Nursing
•Other support staff
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
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.
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.
Normal Rt & Lt Coronary Arteries
Who has a Cardiac Cath?
•For most patients, the primary determining factor is whether a partial or complete blockage in the coronary arteries is present.
•The doctor and patient must decide whether these blockages should be treated with angioplasty or bypass surgery
•Some cardiologists regularly treat patients with cardiac catheterization
•Others treat patients with medications
Why Is A Cardiac Catheterization Done?
•Evaluate the patient's cardiac condition related to:
•How well the heart muscle and valves are working
•The extent of damage to the heart after a heart attack
•Which coronary arteries are narrowed
•The extent and degree of the narrowing
•What treatment is required: medical management, an angioplasty (PTCA) or surgery
Why is cardiac catheterization done?
•cardiac symptoms such as:
•chest pain
•shortness of breath
•dizziness
•fatigue
•a combination of any of these symptoms
•Disease of one or more of the heart valves causing symptoms such as shortness of breath
•Help diagnose and treat heart disease in patients of all ages
Indications/ Reasons for Cath:
Diagnostic Procedure
•Dx heart disease
•Assessment of heart function.
•Eval for congenital heart disease.
•Dx coronary artery disease.
•Demonstrates pumping ability
•Measures BP
Therapeutic
•Stent placement
•Artherectomy
•Closing arterial septic defects
•Coronary angioplasty
REASONS FOR CARDIAC CATH
•Angina pains (i.e., the discomfort from blocked coronary arteries)- not easily controlled with medication or that interfere daily life
•Chest pains of uncertain cause that repeatedly recur and defy diagnosis despite other tests
•Angina that occurs at rest despite medical therapy
•Recurrent angina after a heart attack
•Not everyone with angina needs a cardiac catheterization. (meds)
•Markedly abnormal stress test results
•Heart failure, when the suspected cause is coronary artery disease
Indications for Cardiac Catheterization
1.Suspected or known coronary artery disease
–Evaluation before a major surgical procedure
–Silent ischemia
–Atypical chest pain or coronary artery spasm
2.Myocardial infarction
3. Sudden cardiovascular death
4. Valvular heart disease
5. Congenital heart disease
–(before anticipated corrective surgery)
6. Aortic dissection
7. Pericardial constriction or tamponade
8. Cardiomyopathy
9. Initial and follow-up assessment for heart transplant
Patient Prep for Cath
Prior to exam
Patient History
Blood work
Electrocardiogram
Stress Test/ Echo
Chest x-ray
?Nuc Med Perfusion
Clear liquids only for kidney hydration - then NPO 4-6 hrs before procedure
Occur in cath lab
Hair shaved @ IV site
BP cuff placed
Oxygen administered
EKG leads placed
Local anesthesia administered by IV
Other meds for nausea
Cardiac catheterization & Imaging
•The angiogram catheter is maneuvered into position just above the outlet valve of the left ventricle
•(aortic valve or bulb).
•With careful maneuvering, the tip of the catheter can be positioned at the mouth of the main coronary arteries.
Cardiac Catheterization Procedure:
•Images with contrast of the (the coronary arteries) which supply blood to the heart muscle
•Left ventricle - the main pumping chamber of the heart
•Reveals if one or more of the coronary arteries is blocked
• or if the left ventricle
•is functioning properly
•and pumping blood throughout
the body
•Additional information can be
•obtained about pressure
•In the different chambers
•of the heart or
•If the heart valves are
•working normally
•or are leaky or stenotic
•The tip of the catheter
can be placed into various
parts of the heart to
measure the pressure
within the chambers.
•The catheter can be advanced into the coronary arteries and a contrast injected into the arteries (coronary angiography or arteriography).
•With the use of fluoroscopy the physician can tell where any blockages in the coronary arteries are.
•A small sample of heart tissue can be obtained for biopsy
Cardiac catheterization
Imaging
For the Rt Ventricle or
• tricuspid or pulmonic valves
•the catheter will be inserted through a large vein and guided into the right ventricle
•The catheter may also be placed in the left ventricle
•to examine the
•mitral and aortic
•valves of the heart
•& Coronary arteries
Indications & Procedures
•Abnormal heart size
•Angina (stable or unstable)
•Coronary Artery Disease
•Heart Attack
•Congenital Heart Disease
•Irregular heart disease (arrhythmias)
•Catheterization Procedures
•Cardiac Ventriculography
•Aortography
•Coronary Angiography
•Pulmonary Angiography
•PTCA
•Stents
•Cardiac Ablations
•Thrombolytic Therapy
•Valvuloplasty
• Pulmonary Stenosis
• Aortic Stenosis
• Tricuspid Stenosis
• Mitral Stenosis
Contrast Media
Iodinated non-ionic water-based contrast
Examples of contrast used are:
Visipaque
Oxilan
Hexabrix
Hypaque (PTCA only)
for balloon filling
Which area is demonstrated?
What Method is this?
Catherization: Selinger Technique
Seldinger Technique
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.
CARDIAC CATHETERS
•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.
•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
Guidewires & Needles
Swan-Ganz Catheters
Transradial Catheterization Benefits Patients and Physicians
stenosis
Enlarged coronary artery
Cardiac Cath
Normal vs Stenosis
During The Procedure
•Slight burning or stinging from the medicine (xylocaine) used to numb the catheter insertion site.
•Slight discomfort or pressure as the catheter is being inserted.
•Slight nausea, extra heartbeats, and/or a warm flushing throughout the body (10-20 seconds) as the contrast is being injected.
•Monitior patient’s vital signs
•Watch for signs of Contrast Media reaction
After the Procedure
•The patient will be observed for 6-8 hours before discharged home.
•The insertion site will be checked frequently for signs of bleeding.
•Blood pressure and the pulse in the leg (or arm) used will be checked frequently.
•A knot under the skin where the catheter was inserted may occur. This is only temporary.
•Bruising to the leg/groin area where the catheter was inserted may occur. The bruising may spread down the leg and is only temporary.
•Most patients are discharged in 8 hours with minimal activity restrictions.
Post care
•Catheter removed
•Small amount of bleeding, pressure placed for to the catheter site for approx 30min-60min.
•Patient might stay overnight
•Outpatient might be discharged after staying 4-8 hrs in recovery unit.
•Patient might have symptoms such as tenderness. Bruising, pain, and minor swelling for a few days after the procedure.
Complications
•Minor:
–Pain
–Swelling
–Bruising
•Major
–Blood clots
–Damage to heart or blood vessels
–Normal electrical system damage
–Death
Contraindications for cardiac catheterization pg 90
•Active gastrointestinal bleeding
•Acute or chronic renal failure
•Recent stroke
•Fever from infection or the presence of an active infection
•Severe electrolyte imbalance
•Severe anemia
•Short life expectancy because of other illness
•Digitalis intoxication
•Patient refusal of therapeutic treatment such as PTCA or bypass surgery
•Severe uncontrolled hypertension
•Coagulopathy and bleeding disorders
•Acute pulmonary edema
•Uncontrolled ventricular arrhythmias
•Aortic valve endocarditis
•Previous anaphylactic reaction to contrast media
Contraindications
Severe uncontrolled hypertension
Acute stroke
Acute GI bleeding
Allergic to iodinated contrast
Renal failure
Hypokalemia
Uncompensated congestive failure (pt who cannot lie flat)
Major Complications pg 90
•Some of these conditions may be temporary
•or they may be treated and reversed before cardiac catheterization is attempted.
•In more than 300,000 patients surveyed:
• major complication rate for the entire group was less than 2%
The risks of cardiac catheterization
vary according to the type of procedure
and the status of the patient undergoing the procedure
Patients with increased the risk of complications:
•Patient with poor response to life-threatening condition
•Cardiogenic shock
•Acute MI (within 24 hours)
•Renal insufficiency
•Cardiomyopathy
Risk (mild & severe)
Bleeding around IV site
Infection
Chest pain (muscle spasms)
Blood clot around IV site
Radiation Burns
Contrast Reaction
Extrensive bleeding
Stroke
Heart attack
Death
Kidney damage
Injury to blood vessel
Recovery
•Patient can’t move leg for a couple of hours
•A restraint may be placed on the patients leg to remind them
•A sand bag is placed on the angio site for pressure
•Patients are expected to walk after 3-4 hours
•Light activities for the next 48 hours
Procedures that may accompany coronary angiography pg 89
Common Diseases When Angioplasty & Stenting are Indicated:
•Atherosclerosis
•(hardening of the arteries)
•Coronary heart Disease
•Peripheral Vascular Disease
•Renal Vascular Hypertension
•Hemodialysis Access Maintenance
•Carotid Artery Disease
•Leg & arm artery disease
Other Procedures & Pathology
Percutaneous Transluminal Coronary Angioplasty (PTCA)
•Otherwise known as:
•Balloon Angioplasty
•Angioplasty
•PTCA
•CAD coronary artery disease
•is the narrowing of the arteries caused by a build up of fatty material within the walls of the arteries.
•This buildup causes the inside of the arteries to become rough and narrowed, limiting the supply of oxygen-rich blood to the heart muscle.
Percutaneous transluminal coronary angioplasty
Why is an PTCA Done?
•opens narrowed arteries to increase blood flow clears blockages in arteries to restore blood flow to the heart or extremities.
•In many cases, coronary stents are then inserted to support the tubular structure of the blood vessel and keep it open.
•done instead of coronary artery bypass surgery depending upon the type and location of the narrowing, the extent of the disease and the risk involved.
•The rate of restenosis (renarrowing) is 30% to 50% within the first six months.
Balloon Angioplasty
•Coronary Artery Bypass Grafting (CABG) is the mainstay of treatment for such patients.
•In patients with multiple high grade blockages, it is more effective to restore circulation throughout the heart with bypass surgery.
•Depending on lesion size, shape, length, location and other factors, some blockages can be treated without bypass surgery
•This procedure is nonsurgical
•may be done immediately following a cardiac catherization or sometime later.
•The patient is given a mild sedative but remains awake during the procedure to allow him to answer questions regarding his comfort level, any chest pain or shortness of breath.
The Procedure
• Inflatable balloon mounted on a catheter is threaded to the site of blockage usually through the femoral artery
•At the site, the balloon is inflated and deflated increasing the flow through the artery
•Next, contrast is injected into the catheter so the Interventional radiologist can view the stenosis
•Done in the Cardiac catheterization lab w/fluor
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.
Equipment Used During a Procedure:
•Balloon Catheter
•Metal mesh stent
•Pump for balloon
Prevention of Restenosis
•Lifestyle Change
•Healthy diet
•adequate exercise
•No Smoking
•Medicine coated stents
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.
Bypass Surgery
CABG
•The graft is attached above & below the blocked area so that blood actually flows around it and to the area of the heart below the blockage.
•Improves blood flow and thereby oxygen and nutrients to the heart muscle itself. Improved blood flow relieves symptoms of angina (chest pain), improves heart function and may prevent a heart attack. very effective in restoring circulation to heart tissue endangered by impeded blood flow.
CABG – Coronary Artery Bypass Graft
•Sometimes it is the only effective method to restore blood flow to a severely diseased heart.
•Balloon angioplasty is often used in emergency situations, especially when a person is experiencing a heart attack, as a lifesaving procedure to immediately restore blood flow to the heart.
Stent Implant
A catheter is used to deliver a small metal mesh tube (stent) to a blockage in an artery.
A stent, which helps keep the artery open, is often implanted after angioplasty
Abdominal Stent
stent placement video
Stent Placement
•
AAA
AORTOGRAM
Review exams &
anatomy
Cardiac Ablation
CARDIAC
ABLATION
RF ABLATION
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
ABLATION
UP CLOSE