an overview of the cardiac catheterization lab€¦ · discuss procedures performed in cardiac...

51RADIOLOGIC TECHNOLOGY, September/October 2019, Volume 91, Number 1

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An Overview of the Cardiac Catheterization LabJonathan B Havrda, MPH, R.T.(R)(CT)(BD)Elizabeth Paterson, BS, R.T.(R)(CT)(M)

All radiologic technologists spend time during their edu-cation learning heart and large vessel anatomy.

However, after graduation and passing the registry exam, only a few technolo-gists consistently use this knowledge in their daily work. Thus, periodic review of this information can be helpful.

Heart AnatomyAnatomically, the heart is a dynamic

organ that includes complex tissues working in unison to sustain life.1 Knowledge of the heart, pericardium, and large vessel anatomy, and how they interact, is key to identifying and treat-ing pathologies.

The central portion of the chest is called the mediastinum; this structure lies between the thoracic vertebrae and the lungs.2 In addition to the heart, the mediastinum houses the thymus gland, great vessels, trachea, and esophagus.2 Within the mediastinum is the pericardial sac—a double-walled

sac that contains and supports the heart and great vessels.2 The inner and outer walls of the pericardial sac are called the epicardium and endocardium, respectively. Between these 2 walls sits a thin f luid-filled space called the peri-cardial cavity.3

In most people, most of the basic structures of the heart lie on the left side of the chest, obliquely, behind the sternum, and anterior to the spine at the level of the fifth through eighth thoracic vertebrae.2 The heart is the primary organ of the circulatory system and acts as a pump to move blood through arteries and veins (see Figure 1).3 Typically, a heart is shaped like a cone that is 12 cm long, 9 cm wide, and approximately 6 cm deep.3 The heart has a base and an apex, with the base of the heart aimed superiorly, to the right side of the mid-sagittal plane, and posteriorly; the apex of the heart points to the left and cau-dally, resting against the anterior wall of the chest.3

After completing this article, the reader should be able to:�� Describe the anatomy and physiology typically imaged and treated in the cardiac catheterization lab.�� Explain the most common pathologies treated in the cardiac catheterization lab.�� Discuss procedures performed in cardiac catheterization labs.�� List methods for minimizing radiation exposure and contrast reaction during cardiac catheterization procedures.�� Summarize the role of the radiologic technologist in the cardiac catheterization lab.

The role of the cardiac catheterization lab technologist differs from other radiologic technologist roles. This article demystifies the cardiac catheterization lab by explaining commonly performed procedures. The anatomy and pathology that might require treatment in the catheterization lab also are discussed.

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An Overview of the Cardiac Catheterization Lab

ventricle control the deoxygenated venous blood, and the left chambers of the heart pump the oxygenated blood into the circulatory system.3 This cycle is accom-plished by a series of electrical signals that initiate contraction and relaxation.

The Atria and Associated ValvesThe right side of the heart’s lateral border is formed

by the right atrium.5 In this chamber, the inferior vena cava (IVC) and superior vena cava (SVC) drain deoxy-genated blood from the circulatory system into the heart.5 The valve separating the IVC and the right atri-um is called the eustachian valve.5 Between the SVC and IVC is a vertical smooth ridge of muscle called the crista terminalis. This structure sometimes is diagnosed mis-takenly as a tumor or thrombus; such abnormalities can lead to atrial arrhythmias (irregular rapid heart rate).5,6 Along the interarterial septum is a circular indenta-tion known as the fossa ovalis.6 If patent, the fossa ovalis might result in an abnormal connection between the sides of the heart, or a right-to-left shunt, which can be seen using contrast-enhanced echocardiography.6 This condition is associated with an increased risk for post-surgical atrial fibrillation, emboli, cryptogenic stroke, and other pathologies.6

Another important part of the right atrium is the triangle of Koch, which consists of the sinoatrial node, the atrioventricular node, and the tendon of Todaro.6 The sinoatrial node is located between the SVC and the crista terminalis and acts as the primary pacemaker of the heart.6 The tendon of Todaro is a fibrous band that attaches the eustachian and thebesian valves.6

The atrioventricular node plays an important role in treating ventricular nodal reentrant tachycardia and often needs modification.6 The right atrium joins with the right ventricle through the right atrioventricular, or tricuspid, valve.3

Of the 4 heart chambers, the left atrium is located most superiorly and furthest posteriorly.5 In this chamber, the right and left pulmonary veins transport oxygenated blood from the lungs, where it begins its journey into systemic circulation.3 The 4 parts of the left atrium are the appendage, septum, vestibule, and vascular components.7 The appendage of the left atrium is the area containing the pectinate muscles;

The heart consists of muscular tissue called myocar-dium and is separated into right and left halves.3 The arterial (left) side of the heart’s myocardium typically is 3 times thicker than the venous (right) side because of the force required to push blood through the circulatory system.3 The left and right halves are further separated into chambers. The superior atria sit above the lower chambers, which are called ventricles.3

Myocytes are the cells that produce contractions and comprise most of the myocardium.4 A fibrocol-lagenous connective tissue known as the endomysium surrounds each myocyte and provides a framework of support for the myocardium.4 An additional group of connective tissues known as the perimysium provides added support and prevents changes in alignment of the myocytes.4

Heart Chambers and the Cardiac CycleThe atria function as receiving chambers, whereas

the ventricles are the distributing chambers of the cir-culatory system.3 Systole and diastole are the 2 phases of the cardiac cycle that pump and carry blood to every part of the body; systole is contraction responsible for pumping blood, and diastole is relaxation during receipt of blood.3 One complete contraction (systole) and relaxation (diastole) is 1 cycle, which lasts 0.8 seconds in an average adult.3 The right atrium and

Figure 1. Anatomy of the human heart and primary associated blood vessels. © 2019 ASRT.

Semilunar valves

Arch of aorta

Left subclavian artery

Left common carotid artery

Right pulmonary veins

Right ventricle

Chordae tendineae

RIGHTATRIUM

Left ventricle

LEFT ATRIUM

Superior vena cava

Right pulmonaryarteries

Brachiocephalic artery

Inferior vena cava

Atrioventricular(tricuspid) valve

Left pulmonary artery

Left pulmonary veins

Atrioventricular(mitral) valve

Interventricular septum

Trabeculae carnae

Interatrial septum


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Havrda, Paterson

VasculatureThe right and left coronary arteries arise after the

aortic valve. Newly oxygenated blood moves through the coronary arteries and supplies the myocardium.3 After oxygen is delivered to the myocardium, blood f lows into the cardiac veins and the coronary sinus.3 This deoxygenated blood drains into the right atrium and starts the process again. Pericardiophrenic arteries and veins are located on the sides of the peri-cardium; the pericardiophrenic veins branch off the brachiocephalic veins and lead to the phrenic veins.5 Enlargement of these vessels can signal blockage of the SVC or IVC.5

The pulmonary circuit consists of the pulmonary veins and arteries that are responsible for transporting blood into and out of the lungs to receive and deliver oxygen to the rest of the body12; this circuit is the pri-mary purpose of the 2 right-sided heart chambers.11 The blood returning from the body that reaches the heart through the SVC and IVC is low in oxygen and high in carbon dioxide.11 The low-oxygen blood enters the right atrium and moves to the right ventricle to be pumped to the lungs via the pulmonary trunk.11 The pulmonary arteries deliver the low-oxygen blood to the lungs for gas exchange; carbon dioxide is expelled and oxygen is taken in.11 The pulmonary veins bring the freshly oxy-genated blood back to the heart through the pulmonary veins, which drain into the left atrium.11 This anatomy is unique to the pulmonary circuit—the veins carry oxygenated blood and the arteries transport deoxygen-ated blood.11

Great VesselsThe largest blood vessel in the human body is

the aorta. This artery serves as the first blood vessel responsible for systemic circulation, delivering blood to all body tissues.11 In an average adult, the aorta has a diameter of 2.5 cm, which decreases slightly as it moves inferiorly to its bifurcation near the pelvis.11 The first part of this vessel is the aortic root, a complex structure allowing for the movement of high volumes of blood with minimal resistance and tissue stress under con-stantly changing demands.13 The aortic root comprises 6 anatomic parts working in unison to complete a high-demand job13:

the smooth circumferential surface surrounding the mitral valve is the vestibular component.7 The most important part of the left atrium is the venous com-ponent, which is the receiving area for the pulmonary veins.7 The left atrium joins with the left ventricle through the left atrioventricular or mitral valve.3

Ventricles and Associated ValvesIn a patient with a healthy heart, the right ventricle

sits directly behind the sternum and is the most ante-rior chamber.8 The right ventricle inlet consists of the tricuspid valve, chordae tendineae, and the papillary muscles.8 The chordae tendineae are fibrous cords that connect the papillary muscles to the tricuspid valve and prevent prolapse of the valve into the atrium by providing tension.9 Heart valve degenerative diseases, 1 of the most frequent causes of cardiovascular mortality, typically are associated with lengthening or rupturing of the chordae tendinae.10 Three papillary muscles in the right ventricle contract and prevent inversion or prolapse of the tricuspid valve via attachment to the chordae tendineae.11

Deoxygenated blood is pumped through the right ventricle into the pulmonary arteries via the pulmo-nary valve.3 The blood enters the pulmonary trunk and moves into pulmonary circulation to become oxygen-ated.3 A separation in the right ventricle between the tricuspid valve and the pulmonary valve is called the ventriculofundibular fold.8

The left ventricle is the last chamber in the cardiac cycle. The 3 primary portions of the left ventricle are the inlet portion, which contains the mitral valve; the outlet portion, including the connection with the aorta; and the apical portion.4 The left ventricle receives oxygenated blood from the right atrium and pumps it into the circulatory system via the aortic valve.3 This chamber forms the left border of the heart and includes chordae tendineae and papillary muscles responsible for maintaining mitral valve function.5 The aortic valve is located obliquely on the axial plane and typically is seen on contrast-enhanced computed tomography (CT) scans.5 The ventricular septum convexes into the right ventricular chamber and is muscular except for a small fibrous portion as it nears the aortic valve.4


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approximately the level of the 5th thoracic vertebra to the 12th thoracic vertebra before moving through the diaphragm and becoming the abdominal aorta.11 This pathway supplies blood to the thorax, abdomen, and lower extremities.

Just as large vessels supply oxygenated blood to the entire body, a series of large veins brings the low-oxygen blood back to the heart and pulmonary circuit to restart the process. The SVC carries all deoxygenated blood from systemic circulation above the diaphragm, and catheters can be routed into the pulmonary circuit (see Figure 2).11 On each side, the subclavian veins and internal jugular veins join to form the right and left bra-chiocephalic veins, which then join to form the SVC.11

The IVC is the final point in blood return for all vessels and anatomy below the diaphragm; it is located left of the abdominal aorta and bifurcates around the level of the fifth lumbar vertebra into the common iliac veins.11 After traveling through the diaphragm, the IVC enters the heart in the inferior right atrium.11

� annulus � interleaflet trigones � leaflet attachments � sinuses of Valsalva � sinotubular junction � valve leaflets

Three aortic valve leaflets create the boundary between the heart and the circulatory system and cre-ate a hemodynamic junction.13 The leaflet attachments form a thick, fibrous structure at the aortic root and provide stability.13 The attachments are crown-shaped, and the points of the crown, which aim toward the ascending aorta, are known as commissures.13

The next structure is 3 protrusions known as the sinuses of Valsalva. Two of these bulges are the starting points of the left and right coronary arteries and are known as the left and right coronary sinuses.13 Precise functions of the sinuses of Valsalva are unknown, but they might affect stress reduction on the aortic leaflets.13

Sitting below the commissures are 3 interleaflet tri-angles, which are thinned areas of aortic wall. A section of this structure contains the bundle of His that plays a role in heart muscle conduction and pacemaking.13

The distal portion of the sinuses and the commis-sures form the sinotubular junction, a tubular structure that separates the aortic root from the ascending aorta.13 Dilation of this area can lead to aortic insufficiency and require surgical repair.13 The annulus is an area with a small diameter that often is used to determine the size of prosthetic heart valves.13

Blood travels through the aortic root into the ascend-ing aorta. The ascending aorta typically is about 5 cm long and travels superiorly and sits posteriorly and to the right of the pulmonary trunk before curving left at the aortic arch.11 The arch is situated behind the ster-num at the level of the sternal angle and has 3 branches: the brachiocephalic trunk, the left common carotid artery, and the left subclavian artery.11 The brachioce-phalic trunk travels superiorly and passes behind the right clavicle, branching into the right common carotid artery and the right subclavian artery.11 The 3 branches of the aortic arch provide oxygenated blood to the head, neck, upper limbs, and sections of the thorax.11

The descending aorta is located after the arch of the aorta, which travels through the chest from

Figure 2. Access from the superior vena cava into the pulmonary vessels. © 2019 ASRT.


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Havrda, Paterson

The most suitable site for access depends on the patient’s condition, the type of pathology and target anatomy, and provider preferences. In addition, com-plications or anatomical variations might require the provider to change access points to find a more suit-able route to the desired final target anatomy. The proper selection and management of the vascular access point is vital to procedural success. Improper care of the access site can lead to substantial bleed-ing; excessive bleeding occurring after a procedure is associated with recurrence of cardiac events and can increase the risk of death.15

PathologyThe complexity of the heart and surrounding vessels

can cause a wide range of pathology. The cardiac cath-eterization lab can be used for diagnostic testing and therapeutic procedures. Comprehending the anatomy and pathology types can help technologists and clini-cians successfully provide care.

Congenital Heart DefectsCongenital or hereditary heart defects or disease

cover a wide range of pathologies that affect a varied population. Many of these defects are diagnosed and treated in infancy, resulting in adults living with con-

ditions that require care and in some cases further treatment.16

An atrial septal defect is a congenital heart defect present at birth but commonly diagnosed in adults because of the presenta-tion of symptoms that accompany nearly a third of atrial septal defect cases.16 Many anatomical changes can cause an atrial septal defect, but they all lead to shunting of blood between the atria.16 Patients with atrial septal defects might suffer from fatigue and dyspnea on exertion.16 These symptoms might be signs of supraventricular arrhyth-mias, right heart failure, embolisms or recurrent infections caused by atrial septal defects, which prompt the patient to seek medical treatment.16

A ventricular septal defect is the most common congenital heart defect in infants

Heart and Vessel Access PointsTo successfully perform procedures to diagnose or

correct cardiac pathology, vascular access points are needed. These access points are chosen to provide the safest access and most direct route while limiting the possibility of complications.

The femoral artery is a vascular access point com-monly used for cardiac catheterization lab procedures (see Figure 3). These arteries are located bilaterally on the anterior medial portions of each upper leg.11 They provide a fairly direct route as they join with the common iliac arteries, which provide access to the abdominal aorta and the heart.11 Other factors that make this a favorable site are patient and provider ergonom-ics—the patient can lie supine comfortably, allowing the provider to stand or sit at the procedure table’s side.14

Another possible access point is the radial artery, which provides access to the heart via a superficial and readily compressible site.15 This site, typically used for taking a radial pulse, is located between the medial por-tion of the elbow to the lateral distal forearm.11

The brachial artery also can be used as an access point. This vessel is located at the medial portion of the humerus and often provides an easily palpated pulse location.11 Other potential access points are the internal jugular vein and the subclavian vein or arteries.

Figure 3. Femoral catheter access to the heart via the aorta. © 2019 ASRT.

Catheter entrance

Catheter

Right coronary artery

Aorta

Left coronary artery

Aorta


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collagen fibers in the valve leaflets rupture and the chordae tendineae lengthen.10

Severe stenosis involving the aortic valve is associ-ated with high mortality when untreated.17 Another issue that might occur with the aortic valve is regur-gitation because of a bicuspid valve.18 When this happens, blood f lows backward into the heart from the aorta, requiring the heart to work harder to meet the body’s oxygen needs.

Multiple other issues can affect the pulmonary valves. For example, pulmonary valve stenosis can obstruct f low in the pulmonary circuit, and pulmonic regurgitation limits the ability of the pulmonary circuit to oxygenate the blood supply successfully.19 Patients with congenital heart disease also might have severe pulmonic regurgitation or stenosis after surgical repair.19

Myocardial Infarction and Coronary Artery DiseaseWorldwide, myocardial infarction is a common

cause of mortality and morbidity. Myocardial infarction occurs because of unstable coronary atherosclerosis (see Figure 4).20 When atherosclerotic instability occurs, inflammation of the coronary vessel walls causes insufficient blood f low and myocardial ischemia. These events can lead to sudden death or damage to the myocardium. A myocardial infarction might be the first indication of coronary artery disease, or might occur chronically in patients with known disease.20

The cell death caused by myocardial infarction might cause symptoms including pain in the chest, upper extremity, jaw, or epigastric area. This pain typi-cally lasts more than 20 minutes, is not localized, and is not affected by changes in position or by moving.20

Stenosis of the coronary arteries also can lead to angina pectoris. When blood f low is affected and oxygenated blood is not supplied sufficiently to the myocardium, the patient might experience chest dis-comfort and symptoms of dyspnea.21

Heart FailureIn the United States, approximately 5.8 million

people are affected negatively by heart failure, and each year approximately 550 000 cases are diagnosed.22 In addition, nearly 300 000 deaths are attributed to heart

and children. Depending on size and location, this defect can cause blood to be pumped simultaneously into the aorta, pulmonary artery, and right ventricle during left ventricle contraction.16 Adults with a small defect might have no symptoms or only mild symptoms but can be at greater risk for infective endocarditis.16 A large defect can cause left or right ventricular failure and usually requires treatment.16

Aortic stenosis typically is caused by a deformed aortic valve, which can become thickened and calcified from abnormal hemodynamic stress.16 The most com-mon symptoms of aortic stenosis are angina pectoris, syncope, and heart failure.16 Once symptoms are pres-ent, life expectancy is diminished without treatment; the most common type of treatment is a valve replacement.16

Pulmonary stenosis accounts for more than 10% of congenital heart defects in adults.16 With mild stenosis, no symptoms might occur other than a loud systolic murmur.16 More severe stenosis leads to dyspnea on exertion, fatigue, and, in some cases, chest pain and syn-cope.16 In symptomatic cases, some treatment options are associated with excellent prognosis, with the most severe cases requiring valve replacement.16

Coarctation of the aorta is a congenital narrowing of the descending aorta distal to the left subclavian artery.16 This condition causes higher systolic blood pressure in the arms compared with the lower extremi-ties and diminished or absent femoral arterial pulses.16 Typically there are no symptoms, but when symptoms are present they include headache, nosebleed, dizziness, and palpations.16 Pregnant women with coarctation are at high risk for aortic dissection.16 When left untreated, nearly 75% of patients die by age 50 years and 90% die by age 60 years.16

Cardiac Valve PathologyDegenerative disease of the mitral valve affects

almost 2.5% of the population of developed countries and frequently leads to cardiac mortality.10 There are 2 primary types of degenerative mitral valve disease. Barlow disease, a chronic disease that affects middle-aged individuals involves thickened valve leaflets and excess tissue.10 Fibroelastic deficiency, a pathology that occurs in elderly populations, is indicated by valves that become thin and more transparent.10 In both types,


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Havrda, Paterson

metallic or plastic elements on the balloon surface. These rigid portions enhance the balloon’s interaction with the plaque by limiting balloon slippage during dilation or helping control the plaque dissections. Two types of catheters used for coronary balloon angioplasty procedures are cutting balloons, which have micro-blades that run parallel to the longitudinal axis of the balloon, and scoring balloons which have helical or par-allel nylon elements.23

The addition of stent application during coronary balloon angioplasty provides structure to the newly recanalized vessel and limits the possibility of the vessels recoiling to their preballoon shape.23 This reduction in recoil increases the benefit of the dilation, and the stent also acts as a wall to keep the plaque and tissue in place.23

Two main types of stents are used for coronary balloon angioplasty: self-expanding and balloon-expanding. Self-expanding coronary stents enter the vessel collapsed in a sheath. When the sheath is removed, the stent springs into shape and provides sup-port for the vessel.23 Balloon-expandable stents enter the vessel over a balloon. When the balloon is inflated, it expands the stent and attaches it to the vessel wall. Balloon-expandable stents are used for most coronary stent procedures.23

Stents typically are a series of interconnected cobalt or platinum–chromium alloy hoops.23 In certain pathologies, including coronary perforations, a covered stent might be used. Covered stents have a barrier layer of polytetrafluoroethylene or micromesh and prevent poststent embolization.23

Historically, some patients experience recurrent vessel narrowing because of neointimal hyperplasia (ie, thickening of vessel walls) after stent placement.23 To prevent this issue, stents were designed that slowly release drugs that limit the proliferation of vascular wall tissues and prevent further narrowing. Commonly used drug-eluting stents contain a drug called sirolimus that limits vascular smooth muscle cell production.23

Coronary balloon angioplasty is the most commonly used intervention for myocardial revascularization, but it is not the best option for all patients.24 Patients with advanced or chronic obstruction of their coronary arteries might require surgical options including coro-nary artery bypass graft.23,24 Studies show that patients

failure per year. Heart failure is a final stage of many heart diseases and involves a combination of criteria including elevated jugular venous pressure, pulmonary rales, peripheral edema, or hepatomegaly.22

ProceduresIn 1950, 400 out of every 100 000 people died from

cardiovascular pathology. By 2010 that number had dropped to approximately 100.23 In the cardiac catheter-ization lab, multiple procedures can be used to diagnose and treat cardiac pathology. The work of cardiologists, researchers, medical equipment developers, radiologists, and technologists has helped to improve treatment.

Coronary Balloon AngioplastyThe first coronary angioplasty procedure was per-

formed more than 40 years ago by a Swiss cardiologist named Grüntzig.23 In this successful surgery the vessel in question remained patent for 37 years. Since that time, the technology and techniques have improved, allowing for f lexibility and the ability to treat hard-to-access or highly obstructed vessels.23

Studies have shown that recanalization of the coro-nary arteries using angioplasty can help prevent the need for future surgery, including coronary artery bypass graft, and can improve long-term survival.24,25

Balloon angioplasty can treat coronary stenosis by compressing and dissecting atherosclerotic plaque that is blocking blood f low through the vessel.23 Catheters used in angioplasty include modifications such as rigid

Healthy blood vessel

Blood vessel wall

Partial blockage ggee

Figure 4. The interior of a healthy and diseased coronary artery. © 2019 ASRT.


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Catheter AblationCatheter ablation is a common treatment for

arrhythmia caused by atrial fibrillation. Atrial fibrilla-tion is the most common heart arrhythmia worldwide and is responsible for a high number of hospitalizations and deaths.29 This procedure is designed to eliminate tissue and signal pathways that cause the arrhythmia and return the heart to normal sinus rhythm.29 To eliminate the pathology-causing tissues, radiofrequen-cy energy is targeted to the pathology-causing tissue using a catheter under f luoroscopic guidance or a 3-D mapping system.30

Other Diagnostic and Therapeutic ProceduresBalloon dilation of heart valves is a valid treatment

option for patients with valve stenosis.31 This procedure commonly includes implantation of a stent to prevent collapse of the valve after the balloon is removed.31 Similar to other procedures performed in the cardiac catheterization lab, the stent is guided toward the valve from a distant entry point using f luoroscopy.

Replacement of the aortic valve also is possible using a procedure performed in the cardiac catheterization lab. When patients have severe stenosis of the aortic valve, a transcatheter aortic valve implantation might be performed.32 This is a preferred option for patients for whom open-heart surgery is high risk because of other morbidities.32 Compared with other options, a transfemoral transcatheter aortic valve implantation is associated with a shorter hospital stay, lower costs, and lower risk to the patient.17

Conventional angiography and cardioangiography are diagnostic tests that might be performed in the cardiac catheterization lab. During these procedures, radiopaque contrast media is directed into the heart and associated vessels to target specific locations based on the patient’s symptoms.33

Angiography has high spatial resolution and provides high-quality diagnostic images of the cardiovascular system (see Figure 5). Another benefit includes observ-ing vessel movement using f luoroscopic exposures during conventional angiography. Limited vessel move-ment might indicate rigidity and calcification of the blood vessel.32 The use of digital subtraction angiogra-phy, which removes overlying structures including the

with advanced disease who undergo coronary artery bypass graft instead of percutaneous coronary interven-tions have improved outcomes.24 Conversely, in acute situations, including ST-elevation myocardial infarc-tion, revascularization using stents placed after balloon angioplasty is the best option and results in a reduction in mortality.23

Balloon SeptostomyBalloon atrial septostomy is another procedure

performed in the cardiac catheterization lab designed to treat pulmonary arterial hypertension. A recent study showed that patients with pulmonary arterial hypertension, which can lead to right heart failure, organ dysfunction, and premature mortality, have a 5-year survival rate of 57% if they remain untreated.26 In balloon atrial septostomy, a balloon catheter is used to dilate the atrial septum, producing atrial commu-nication.27 The communication between the left and right atria leads to decompression of the right heart, improved hemodynamics, and increased survival.26 The procedure often is used in conjunction with pharma-cologic interventions. This combination is superior to balloon atrial septostomy alone, and in many cases is used as a bridge for patients awaiting a lung transplant or to relieve symptoms created by right heart failure.26,27

Electrophysiology StudyTo check for pathology involving the heart’s elec-

troconduction system and associated pathways, an electrophysiology test might be performed in the cardiac catheterization lab. To perform this test, cath-eters are guided into the heart. The catheters contain electrodes that measure and pace the heart’s rhythm and conduction system.28 The electrodes are guided through the heart using f luoroscopy, and 2 large magnets are placed on both sides of the patient. The electrodes are guided through the conduction pathway and used to pace each heart chamber and to look for potential sites of pathology.28

Next, the electrophysiologist attempts to reproduce the patient’s pathology using electric current pulses at specific conduction locations. In addition, drugs might be used to induce arrhythmia to further locate the source of abnormal electrical activities.28


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Havrda, Paterson

training and demonstrated clinical competence specific to the field. The technologist assists in sterile technique and operates patient monitoring and emergency equip-ment in addition to imaging equipment.3

Best PracticesA common configuration for a cardiac catheter-

ization lab, where elective, urgent, and emergent procedures are performed, is shown in Figure 7.36 This unique setting can pose challenges to maintain-ing and prioritizing high-quality patient care and safety for patients and staff.36 Excellent preprocedural communication, clinical management, documenta-tion, and universal protocol can improve outcomes for all patients.36 The catheterization team should be

skeleton, provides even higher spatial resolution imag-es.32 Limitations of conventional angiography include that the anatomy is shown in a 2-D plane, which might limit the team’s ability to visualize stenosis or pathology that is seen only when viewed in 3-D.32

Embolization of fistulas or certain types of aneu-rysms also is performed in the catheterization lab. Many agents are used to occlude the pathology, includ-ing coils, ethanol, and polymers.34 After diagnostic angiography is used to identify and localize the mal-formation, the occluding agent is administered to the fistula or aneurysm via a catheter.34,35 Figure 6 shows an aneurysm and subsequent coil embolization.

The Radiologic Technologist’s RoleThe cardiac angiography team includes a physician

(typically an interventional radiologist), a cardiac inter-ventional technologist, and other specialists such as an anesthetist and a nurse.3 The cardiac interventional technologist is a radiologic technologist with additional

Figure 5. Coronary artery stenosis. Reprinted with permission under the Creative Commons Attribution 2.0 Generic license. Pantaleo MA, Mandrioli A, Saponara M, Nannini M, Erente G, Lolli C, and Biasco G. Development of coronary artery stenosis in a patient with metastatic renal cell carcinoma treated with sorafenib. BMC Cancer. 2012;12:231. https://creativecommons.org/licenses/by/2.0.

Figure 6. Coil embolization off of the internal common carotid artery at the bifurcation of the anterior and middle cerebral arteries. Reprinted with permission from Rogerio Cisi under the Creative Commons Attribution-ShareAlike 4.0 International license. https://creativecommons.org/licenses/by-sa/4.0/deed.en.


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issues, and circumstances that allow for exceptions to obtaining consent.36 Specific mention should be made for do not resuscitate status and whether it has been revoked for the duration of the procedure.36 The con-sent should be discussed in terminology that allows a lay person to understand what the procedure entails, and the risks, benefits, and alternatives, including no treatment.36 The potential outcomes and possible com-plications during and after the procedure should be explained in detail.36

Cardiac catheterization procedures are performed under conscious sedation. If a certified registered nurse anesthetist or anesthesiologist is not directly involved with the procedure, the physicians and allied health staff involved should demonstrate proficiency in sedation pharmacology, patient monitoring, airway management, sedation management, and recovery.36 An anesthesia assessment should be included in the patient’s preprocedural examination to identify any potential complications or allergies.

All team members should be briefed in advance about the intended procedure and the planned sequence.36 A time out should be performed with all team members present before vascular access is obtained.36 Patient identification should be checked and confirmed, there should be unanimous agree-ment on the procedure to be performed, and patient allergies should be specified.36 In general, because the

properly credentialed and in compliance with all con-tinuing medical education requirements of the state where they practice.36

PreprocedureBefore the procedure, a physician or midlevel provid-

er (eg, a physician assistant or advanced practice nurse) must perform a patient’s physical examination and cap-ture their history.36 If the procedure is emergent, then a history and limited physical examination is reasonable. The history and physical examination should describe the patient’s present illness, comorbidities, and indica-tions for the catheterization procedure. Any history of contrast reactions should be documented, including the clinical reaction. If the patient has a contrast reaction history, the cardiologist and radiologist should weigh the risks and benefits of the catheterization procedure and proceed accordingly. The physical examination should focus on the patient’s heart and vascular system, including peripheral pulses. A therapeutic plan detailing the expected outcomes of the cardiac catheterization should be considered, to assist in overall clinical care.36

Informed consent is required before every cardiac catheterization because of its invasive nature and significant medical risks. The hospital should have a preprocedure checklist and written policy on informed consent that describes the process to obtain consent, including documentation, surrogate decision-maker

Figure 7. A typical cardiac catheterization lab with digital ceiling-mounted C-arm and sterile field. Reprinted with permission from Hmhedp under the Creative Commons Attribution-Share Alike 3.0 Unported license. https://creativecommons.org /licenses/by-sa/3.0.


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Havrda, Paterson

common method to obtain percutaneous access, is con-ducted by the interventional radiologist.3

Once vascular access is established, controlled access is available with little blood loss. The catheter is con-nected to the manifold and can be advanced toward the heart to begin the coronary angiogram.3

If the percutaneous approach cannot be used, the cutdown technique is employed.3 This technique requires a small incision in the skin to allow direct

intended site of intervention is the heart and its associ-ated vasculature, wrong-site procedures do not occur.36 In addition, because coronary arteries can be accessed via several vessels (eg, the radial, brachial, and femoral arteries), site marking typically is not indicated.36

ImagingIn most cardiac catheterization laboratories, the

image intensifier and f luoroscopic tube are mechani-cally suspended in a C-arm configuration to allow for rotation around the patient and to make cranial and caudal angulation available.3 The f luoroscopic tube is below the table and the image intensifier is above the table and patient. During procedures, the patient is placed supine on the table and the imaging equipment rotates around the patient. Moving the patient during a catheterization procedure is not desirable because catheters have been introduced and positioned to demonstrate specific anatomy or record certain data. Therefore, imaging equipment must accommodate the patient’s position and move around a stationary patient. In some cases, biplane C-arms are beneficial because they allow simultaneous imaging of the heart in 2 planes.3

ProcedureThe patient is transported to the catheterization

suite and cardiac monitoring is initiated, including electrocardiography, noninvasive blood pressure moni-toring, and pulse oximetry.3 The appropriate site for catheter introduction is disinfected using aseptic tech-nique to minimize postprocedural infection risk. The site of catheter introduction varies according to body habitus, the procedure, and physician preference. The most common sites are3:

� axillary � brachial � femoral � jugular � radial � subclavian

Venous access is achieved using either a percutane-ous or venous cutdown approach. For catheterization of the femoral vein or artery, the percutaneous approach is used. The Seldinger technique (see Figure 8), a

Figure 8. The common steps associated with the Seldinger technique for catheter access to the circulatory system. A. A beveled compound needle containing an inner cannula pierces the artery. B. The needle’s inner cannula is removed and a flexible guidewire is inserted. C. The needle is removed; pressure fixes the wire and reduces hemorrhage. D. The catheter is slipped over the wire and into the artery. E. The guide-wire is removed, leaving the catheter in the artery. Reprinted with per-mission from Cupr78up under the Creative Commons Attribution-Share Alike 3.0 Unported license.

A

B

C

D

E


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radiologists have become increasingly complex as technology and medical devices continue to develop.37 These changes can lead to increased procedural times and volumes, which result in increased radiation exposure and more time wearing protective shield-ing. Technologists and nursing staff spend long hours on their feet, wearing heavy lead aprons. One study of Mayo Clinic employees showed musculoskeletal pain to be more common among health care workers who participated in interventional procedures and highest among nonphysician employees.37 Time per week par-ticipating in radiation procedures, increasing use of the lead apron, and women were associated with a higher prevalence of musculoskeletal pain. The cause of these findings was not identified in this study, but it might relate to a more constant exposure to physical stressors. Unlike physicians working in this department who regularly rotate out of the interventional lab, technolo-gists and nursing staff typically do not. Technologists and nurses also typically are involved in more physi-cally taxing tasks, such as patient transfers on and off the interventional table and applying compression after sheath removal.37

More attention and effort should be directed toward reducing the physical stresses that interventional employees endure.37 Limiting procedure times, regular ergonomic evaluations with associated training, and ancillary staff rotations out of the interventional suite would be beneficial. Improvements to lead shielding (eg, lighter, nonlead-based radioprotective material for aprons) are ongoing and can reduce occupational strain when applied consistently in clinical practice.37

The link between occupational exposure to radiation and subsequent development of malignancy or cataracts has long been debated.37 Research has established that occupational radiation doses from fluoroscopically guided interventional procedures are the highest doses registered among medical staff using x-rays.38 One study evaluated the order of magnitude of cancer risk caused by professional radiation exposure in modern invasive cardiology practice.38 The study examined dosimetric data from men and women employed in a cardiovascu-lar catheterization lab with effective doses greater than 2 mSv, and lifetime attributable risk of cancer was esti-mated.38 Of 26 workers with recorded exposures greater

visualization of the vein or artery, which is dissected bluntly and exposed. The cutdown technique fre-quently is used to obtain access to the basilic or brachial artery in the antecubital fossa.3

PostprocedureWhen the procedure is completed, all catheters are

removed from the body. If the cutdown approach was used for venous access, the arteriotomy or venotomy is repaired as necessary.3 If a percutaneous approach was used, direct pressure is placed on the puncture site until the bleeding is controlled. Wound sites are cleaned and bandaged as appropriate to minimize infection risk, and elastic dressings often are used to encourage hemostasis. Postprocedural medications and orders are prescribed by the physician. The puncture site must be observed for hemorrhage or hematoma for a period of time based on facility protocols. The distal pulse rate, strength, and regularity should be noted in the patient’s record before the patient leaves the catheterization lab.3 The patient’s vital signs should be monitored for 4 hours to 8 hours in a recovery unit before discharge. Instructions for home care and recovery procedures are given to the patient or family member before the patient leaves the recovery area.3 Catheterization laboratories should track and record f luoroscopy times and total radiation dose per patient and inform attending physi-cians when thresholds indicative of potential radiation damage are reached.36 When a patient receives a radia-tion dose exceeding 6 Gy, he or she should be educated about potential radiation skin burns, and a followup appointment should be scheduled in 1 to 2 months to assess skin damage and other effects.36

Occupational HazardsThe cardiac catheterization lab should be treated as

an active patient care area, with special attention to the fact that ionizing radiation is used.36 All personnel in the room should wear personal protective equipment including lead aprons and thyroid shields.36 For staff working closest to the radiation source, lead glasses should be considered.36

Working in the cardiac catheterization lab can be physically demanding. Fluoroscopically guided inter-ventional procedures performed by cardiologists and


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Havrda, Paterson

Elizabeth Paterson, BS, R.T.(R)(CT)(M), is the radiology floor supervisor, lead mammographer, and associate PACS administrator at Cottage Hospital in Woodsville, New Hampshire. She attended the Lebanon College School of Radiography in Lebanon, New Hampshire and received a bachelor’s degree in health care administration at New England College in Henniker, New Hampshire. Elizabeth serves as the correspondence secretary for the New Hampshire Society of Radiologic Technologists.

Reprint requests may be mailed to the American Society of Radiologic Technologists, Publications Department, 15000 Central Ave. SE, Albuquerque, NM 87123-3909, or emailed to [email protected].

© 2019 American Society of Radiologic Technologists.

References1. Sheth PJ, Danton GH, Siegel Y, et al. Cardiac physiology

for radiologists: review of relevant physiology for inter-pretation of cardiac MR imaging and CT. Radiographics. 2015;35(5):1335-1351. doi:10.1148/rg.2015140234

2. Bontrager KL, Lampignano JP. Textbook of Radiographic Positioning and Related Anatomy. 8th ed. St Louis, MO: Mosby.

3. Long BW, Smith BJ, Merrill V. Merrill’s Atlas of Radiographic Positioning & Procedures. 12th ed. St Louis, MO: Elsevier Mosby; 2012.

4. Ho SY. Anatomy and myoarchitecture of the left ven-tricular wall in normal and in disease. Eur J Echocardiogr. 2009;10(1):iii3-iii7. doi:10.1093/ejechocard/jep159

5. Broderick LS, Brooks GN, Kuhlman JE. Anatomic pitfalls of the heart and pericardium. 2005:441-453. doi:10.1148 /rg.252045075

6. Malik SB, Kwan D, Shah AB, Hsu JY. The right atrium: gateway to the heart--anatomic and pathologic imaging findings. Radiographics. 2015;35(1):14-31. doi:10.1148 /rg.351130010

7. Ho SY, Sanchez-Quintana D, Cabrera JA, Anderson RH. Anatomy of the left atrium: implications for radiofrequency ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 1999;10(11):1525-1533. doi:10.1111/j.1540-8167.1999.tb00211.x

8. Haddad F, Hunt SA, Rosenthal DN, Murphy DJ. Right ven-tricular function in cardiovascular disease, part I: anatomy, physiology, aging, and functional assessment of the right ventricle. Circulation. 2008;117(11):1436-1448. doi:10.1161 /CIRCULATIONAHA.107.653576

than 2 mSv, 15 had complete records of at least 10 years to 25 years. For those 15 subjects with more complete lifetime dosimetric histories, the median individual effective dose was 46 mSv; this was the cumulative life-time dose.38 Based on this data, the median risk of fatal or nonfatal cancer was 1 in 192. This study concluded that the cumulative professional radiological exposure was associated with non-negligible lifetime attributed risk of cancer for the most-exposed contemporary car-diac catheterization lab staff.38 Although radiation is a significant contributor to lifetime cancer risk in cardiac catheterization lab staff, it might not be the biggest fac-tor. Other possible risk factors include those that are potentially avoidable such as obesity, diet and alcohol consumption, and those that are uncontrollable, such as age and family history.

ConclusionCardiac catheterizations are dynamic procedures

that rely heavily on radiography imaging. Current trends indicate that the number and variety of outpa-tient cardiac catheterization procedures will continue to increase.3 Experts believe that the greatest area for growth in the field of cardiac catheterization is in inter-ventional procedures. Existing and new interventional procedures will provide patients with practical, relative-ly low-risk, and cost-effective alternatives to open-heart surgery.3 With evolving technology and medical research, cardiac catheterization labs will continue to provide valuable services to diagnose and treat a wide variety of cardiovascular diseases and conditions.

Jonathan B Havrda, MPH, R.T.(R)(CT)(BD), is the director of radiology and laboratory services at Cottage Hospital in Woodsville, New Hampshire. He received his radiography education at the Mercy Medical Center School of Radiography in Rockville Centre, New York, and a master of public health from the Dartmouth Institute at Dartmouth College in Hanover, New Hampshire. He is a member of the Radiologic Technology Editorial Review Board and represents the Radiography Chapter in the American Society of Radiologic Technologists House of Delegates. He also is the membership secretary of the New Hampshire Society of Radiologic Technologists.


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21. Kern MJ, Lerman A, Bech JW, et al; American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology. Physiological assessment of coronary artery disease in the cardiac catheterization laboratory: a scientific statement from the American Heart Association Committee on Diagnostic and Interventional Cardiac Catheterization, Council on Clinical Cardiology. Circulation. 2006;114(12): 1321-1341. doi:10.1161/CIRCULATIONAHA.106.177276

22. Bui AL, Horwich TB, Fonarow GC. Epidemiology and risk profile of heart failure. Nat Rev Cardiol. 2011;8(1):30-41. doi:10.1038/nrcardio.2010.165

23. Byrne RA, Stone GW, Ormiston J, Kastrati A. Coronary balloon angioplasty, stents, and scaffolds. Lancet. 2017;390(10096):781-792. doi:10.1016/S0140-6736(17) 31927-X

24. Mäkikallio T, Holm NR, Lindsay M, et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet. 2016;388(10061):2743-2752. doi:10.1016/S0140 -6736(16)32052-9

25. Saito S. Different strategies of retrograde approach in coronary angioplasty for chronic total occlusion. Catheter Cardiovasc Interv. 2008;71(1):8-19. doi:10.1002/ccd.21316

26. Chiu JS, Zuckerman WA, Turner ME, et al. Balloon atrial septostomy in pulmonary arterial hypertension: effect on survival and associated outcomes. J Heart Lung Transplant. 2015;34(3):376-380. doi:10.1016/j.healun.2015.01.004

27. Sandoval J, Gaspar J, Peña H, et al. Effect of atrial septos-tomy on the survival of patients with severe pulmonary arterial hypertension. Eur Respir J. 2011;38(6):1343-1348. doi:10.1183/09031936.00072210

28. Thomas KE, Zimetbaum PJ. Electrophysiology study: indications and interpretations. In: Management of Cardiac Arrhythmias. Totowa, NJ: Humana Press; 2011:123-138.

29. Narayan SM, Krummen DE, Shivkumar K, Clopton P, Rappel WJ, Miller JM. Treatment of atrial fibrillation by the ablation of localized sources: CONFIRM (Conventional Ablation for Atrial Fibrillation With or Without Focal Impulse and Rotor Modulation) trial. J Am Coll Cardiol. 2012;60(7):628-636. doi:10.1016/j.jacc.2012.05.022

30. Verma A, Jiang CY, Betts TR, et al; STAR AF II Investigators. Approaches to catheter ablation for persistent atrial fibrillation. N Engl J Med. 2015;372(19):1812-1822. doi:10.1056/NEJMoa1408288

31. Deanfield J, Thaulow E, Warnes C, et al; Task Force on the Management of Grown Up Congenital Heart Disease, European Society of Cardiology, ESC Committee for

9. Karas S Jr, Elkins RC. Mechanism of function of the mitral valve leaflets, chordae tendineae and left ventricular papillary muscles in dogs. Circ Res. 1970;26(6):689-696. doi:10.1161/01.RES.26.6.689

10. Icardo JM, Colvee E, Revuelta JM. Structural analysis of chordae tendineae in degenerative disease of the mitral valve. Int J Cardiol. 2013;167(4):1603-1609. doi:10.1016 /j.ijcard.2012.04.092

11. Marieb EN, Wilhelm PB, Mallatt J. Human Anatomy and Physiology. Pearson. 10th ed. 2015;784.

12. Hassani C, Saremi F. Comprehensive cross-sectional imag-ing of the pulmonary veins. Radiographics. 2017;37(7):1928 -1954. doi:10.1148/rg.2017170050

13. Charitos EI, Sievers H-H. Anatomy of the aortic root: impli-cations for valve-sparing surgery. Ann Cardiothorac Surg. 2013;2(1):53-56. doi:10.3978/j.issn.2225-319X.2012.11.18

14. Alvarez-Tostado JA, Moise MA, Bena JF, et al. The brachial artery: a critical access for endovascular procedures. J Vasc Surg. 2009;49(2):378-385. doi:10.1016/j.jvs.2008.09.017

15. Jolly SS, Yusuf S, Cairns J, et al; RIVAL trial group. Radial versus femoral access for coronary angiography and intervention in patients with acute coronary syndromes (RIVAL): a randomised, parallel group, multicentre trial. Lancet. 2011;377(9775):1409-1420. doi:10.1016/S0140 -6736(11)60404-2

16. Brickner ME, Hillis LD, Lange RA. Congenital heart disease in adults. First of two parts. N Engl J Med. 2000;342(4):256-263. doi:10.1056/NEJM20000 1273420407

17. Babaliaros V, Devireddy C, Lerakis S, et al. Comparison of transfemoral transcatheter aortic valve replacement performed in the catheterization laboratory (minimal-ist approach) versus hybrid operating room (standard approach): outcomes and cost analysis. JACC Cardiovasc Interv. 2014;7(8):898-904. doi:10.1016/j.jcin.2014.04.005

18. Schäfers HJ, Aicher D, Langer F, Lausberg HF. Preservation of the bicuspid aortic valve. Ann Thorac Surg. 2007;83(2):S740-S745. doi:10.1016/j.athoracsur.2006 .11.017.

19. Sigakis CJG, Mathai SK, Suby-Long TD, et al. Radiographic review of current therapeutic and monitoring devices in the chest. Radiographics. 2018;38(4):1027-1045. doi:10.1148 /rg.2018170096

20. Thygesen K, Alpert JS, White HD; Joint ESC/ACCF /AHA/WHF Task Force for the Redefinition of Myocardial Infarction. Universal definition of myocardial infarction. Eur Heart J. 2007;28(20):2525-2538. doi:10.1093/eurheartj /ehm355


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Havrda, Paterson

Practice Guidelines, Pascal Vouhe Task Force members. Management of grown up congenital heart disease. Eur Heart J. 2003;24(11):1035-1084. doi:10.1016/S0195-668X(03)00131-3

32. Toggweiler S, Leipsic J, Binder RK, et al. Management of vascular access in transcatheter aortic valve replace-ment: part 1: basic anatomy, imaging, sheaths, wires, and access routes. JACC Cardiovasc Interv. 2013;6(7):643-653. doi:10.1016/j.jcin.2013.04.003

33. de Roos A, Higgins CB. Cardiac radiology: centenary review. Radiology. 2014;273(2s)(suppl):S142-S159. doi:10.1148/radiol.14140432

34. Müller-Wille R, Wildgruber M, Sadick M, Wohlgemuth WA. Vascular anomalies (part II): interventional therapy of peripheral vascular malformations. RoFo Fortschr Geb Rontgenstr Nuklearmed. 2018;190(10):927-937. doi:10.1055/s-0044-101266

35. Sadick M, Müller-Wille R, Wildgruber M, Wohlgemuth WA. Vascular anomalies (part I): classification and diagnostics of vascular anomalies. RoFo Fortschr Geb Rontgenstr Nuklearmed. 2018;190(09):825-835. doi:10.1055/a-0620-8925

36. Naidu SS, Rao SV, Blankenship J, et al; Society for Cardiovascular Angiography and Interventions. Clinical expert consensus statement on best practices in the cardiac catheterization laboratory: Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv. 2012;80(3):456-464. doi:10.1002/ccd.24311

37. Orme NM, Rihal CS, Gulati R, et al. Occupational health hazards of working in the interventional laboratory: a multisite case control study of physicians and allied staff. J Am Coll Cardiol. 2015;65(8):820-826. doi:10.1016/j.jacc.2014.11.056

38. Venneri L, Rossi F, Botto N, et al. Cancer risk from profes-sional exposure in staff working in cardiac catheterization laboratory: insights from the National Research Council’s biological effects of ionizing radiation VII report. Am Heart J. 2009;157(1):118-124. doi:10.1016/j.ahj.2008.08.009


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Read the preceding Directed Reading and choose the answer that is most correct based on the article.

3. The left ventricle receives oxygenated blood from the:a. right atrium.b. right ventricle.c. left atrium.d. superior vena cava.

4. What is the most common congenital heart defect in infants and children?a. atrial septal defectb. ventricular septal defectc. pulmonary stenosisd. coarctation of the aorta

5. Barlow disease, a chronic disease that affects indi-viduals who are ______, involves thickened valve leaflets and excess tissue.a. infantsb. teensc. middle-agedd. elderly

1. Most of the basic structures of the heart lie at the level of the _____ through the _____ thoracic vertebra.a. third; sixthb. fourth; seventhc. fifth; eighthd. sixth; ninth

2. The left atrium consists of the:1. appendage. 2. vestibule.3. vascular components.

a. 1 and 2b. 1 and 3c. 2 and 3d. 1, 2, and 3

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6. A balloon angioplasty successfully can treat a coronary stenosis by compressing and dissecting _____ that are blocking blood flow through the vessel. a. valvesb. leaflet attachementsc. atrial septal defectsd. atherosclerotic plaques

7. In addition to operating imaging equipment, a technologist assists also in:

1. diagnosis.2. sterile technique.3. patient monitoring and emergency

equipment.

a. 1 and 2b. 1 and 3c. 2 and 3d. 1, 2, and 3

8. Based on study data, the medial risk of fatal or nonfatal cancer was 1 in _____.a. 162b. 172c. 182d. 192

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