ROLE OF CARDIAC CATHETERIZATION IN CONGENITAL HEART DEFECTS AT A GLANCEDr. Md. Mostafizur Rahman

BhuiyanMedical officerPaediatric cardiology

History

History•First Cardiac catheterization –

▫ According to Andre Cournand, it was first performed by Claude Bernard in 1844, in a horse, both rt and lt ventrilces were entered by retrograde approach from the jugular vein and carotid artery

▫Werner Forssmann is credited with performing the first cardiac catheterization of a living person himself, at the age of 25 yrs

• Forssmann for his contribution and foresight shared the Nobel Prize in Medicine with Andre Cournand and Dickinson Richards in 1956

Cardiac catheterization implies the insertion of flexible tube into one or more heart chambers usually under fluoroscopic guide for diagnostic or therapeutic purpose

Definition:

Indication of cardiac catheterization :

1. Diagnostic indication -Collects data to evaluate PT’s condition

2. Therapeutic indication

3. Prognostic indication

1. Diagnostic catheterization is no longer indicated in the routine preoperative evaluation of most congenital defects, such as VSDs, ASD, TOF, DORV, CoA, HLHS and other complex CHD.

2. Before interventional catheterization 1. Assessment of patient hemodynamics and anatomy2. to confirm congenital or acquired heart disease in infants and children

3. When the anatomy of a CHD is inadequately defined by noninvasive mean

4. in very complex lesions specific details about the anatomy or hemodynamics

5. High-flow or low-flow physiology associated with semilunar valve stenosis

1. Combined aortic stenosis (AS) and insufficiency 2. Combined Pulmonary stenosis and insufficiency

6. In cavopulmonary anastomosis and after Fontan completion Diagnostic catheterization is useful in the evaluation for proceeding with completion of Fontan, revision of Fontan, or transplantation

1.Diagnostic indication-

1. Diagnostic indication-

7. EP study1. His bundle electrocardiography in 1st

degree, 2nd degree & CHB2. Endocardial mapping in WPW syndrome

8. Endocardial biopsy1. DCM2. HCM3. Amyloidosis4. sarcoidosis

1. Diagnostic indication-

Angiocardiography –a) Rt and lt

ventriculography –a) Chamber sizeb) Wall thicknessc) Wall motiond) Aneurysme) Volumef) Dimensiong) Fractional shortening

and h) Ejection fraction

b) Aortography – a) ARb) ASc) Co of Aortad) PDAe) Aortic arch

syndrome

c) CAG – determine coronary artery anatomy

1. Diagnostic indication- Pressure study – a) it means measurement of pressure and recording of its

wave form.b) High RV pressure in catheterization found in the following

condition –a) VSDb) PSc) PH in MS, COPDd) Ruptured sinus of valsalva into RV

c) Trans-valvular pressure difference can grade the severity of –a) ASb) PSc) MS

d) PCW help to find out LVEDP

Oxymetry – a) Shunt calculationb) To determine Cardiac output

2. Therapeutic indication

1. Closure of the following defects –1. ASD2. VSD3. PDA4. MAPCA

2. PTMC3. Thrombolytic therapy – intracoronary, systemic4. PTCA5. PTA – for peripheral artery stenosis6. Valvuloplasty – PS, MS, AS7. Dilatation of coarctation of aorta

2. Therapeutic indication

9. Introduction of ‘’UMBRELLA’’ in to IVC for recurrent pulmonary emboli from DVT

10. Rushkind procedure in TGA, for balloon rupture of interatrial septum by brockenbergh needle

11. Cardiac pacing

12. Peripheral arterial balloon dilatation

13. Hemodynamic monitoring and treatment of pt with cardiogenic shock by swan gauze catheter

3. Prognostic indication

1. Post CABG catheter for assessment of – 1. cardiac function and 2. coronary perfusion

2. Post PTCA

3. After thrombolytic therapy

4. After repair of VSD

5. After valve replacement

6. Prior to any cardiac operation to estimate the prognosis of operation

Contraindication of cardiac catheterization :

Absolute contraindication – In expert hand none is contraindicated

1. Patient refusal 2. IE

1. Recent AMI usually within 3 week in case of adult pt

2. Intercurrent febrile illness 2. CCF3. Severe or malignant hypertension

predispose to myocardial ischaemia and/or heart failure during angiography

4. Life threatening arrhythmia, but it is indicated in-1. While myocardial mapping and subsequent

electrotherapy2. Surgery is contemplated for treatment of

arrhythmia

Relative contraindication –

5. Severe renal failure 6. Allergy to dye7. Severe hypokalaemia8. Anticoagulant state PT > 18 s9. Moribund pt10.Primary pulmonary hypertension11.Presence of LBBB12.Digitalis toxicity13.Severe anaemia14.Severe PS

Relative contraindication –

MEDICATIONS USED

Premadication – Inj Pethidine Inj Phenargoan

Saline infusion Heparin -

For Pt flushing all tubing, catheters, sheaths

Lidocaine for tissue numbing Anaesthetic medication for relaxing the pt Water soluble contrast

EQUIPMENT NEEDED Procedure tray should include:

1. sterile –1. gowns and gloves 2. sterile towels and drapes for procedure3. equipment covers4. Sterile gauze5. scalpel, needles, scissors, hemostats6. syringes for heparin/saline flush, lidocaine,

and blood oximetry2. labels with marking pen for any item filled with a solution3. basin for heparin/saline mixture & waste fluids, 4. skin prep solution5. connection tubing

18

Anaesthesia machine Oxygen supply Suction apparatus Defibrillator Temporary pacemaker Pulse oximeter NIBP Equipment to perform cardiac output

studies Activated clotting time (ACT) equipment

EQUIPMENT NEEDED

EQUIPMENT NEEDED

1. Needle2. Sheath3. Wires4. Catheters 5. Fluroscopic machine6. Power injector

Vascular access:

Venous Access Arterial AccessFemoral veinMedian basalic veinSubclavian veinInternal jugular veinUmbilical veinTranshepatic route

Femoral arteryRadial arteryUmbilical arteryCarotid artery

Needles for percutaneous puncture

 Angiographic needle – designed for single wall puncture

small in diameter, thin walled, short beveled very sharp. Hub clear

True Seldinger needle Chiba™ needle percutaneous transhepatic

access

Angiographic Needle with Protector, Seldinger Hub, Thin Wall

True Seldinger Needle

Chiba Needle

Needle size chosen:

Age Diameter

Length Wire

Infants and small children

21 G 3 cm 0.018

Larger children and young adults

19 G 5 cm 0.025’’

Adult and obese pt

18 G 7 / 8 cm

0.035’’

Technique for vascular access: The true “Seldinger™ technique” is not used

for percutaneous puncture into vessels.

Technique for vascular access:

Modified Seldinger technique for vascular access with single wall puncture into vessels.

Vascular Sheath Percutaneous introduction and then the use of an

indwelling vascular sheath in vessels is the standard technique for catheterization of pediatric and congenital heart patients.

Ideal sheath should have:1. Dilator

1. long, fine and smoothly tapered tip. 2. inner lumen of the dilator tip should tightly fit over the guide

wire 3. tip of the dilator should have a smooth, fine transitional taper

onto the surface of the wire.

2. female Lure™ lock connecting hub at the proximal end 3. back-bleed valve4. Lateral tube / flush port

Vascular Sheath

When introduced from the inguinal area, the sheath should be long enough to extend into the common iliac vein.

In small infants a sheath into the femoral vein should extend proximal to the formation of the inferior vena cava.

Vascular Sheath

Ideal short sheath (7.5 cm long) for venous site – 5 Fr for an infant or child (<15– 20 Kg) and 7 Fr for a larger child or adult

Extra long sheaths (45 to 90 cm ) are used to –1. guide catheters directly and repeatedly to an area

within the heart itself (biopsies, blade catheters), 2. for trans septal procedures, 3. to deliver special devices within the heart or great

vessels (stents, occlusion devices), and 4. for the withdrawal of foreign bodies from the

vascular system.

GUIDE WIRES

GUIDE WIRES

Characteristics of wire: Flexibility: the ability of the wire to bend Trackability: Torque transmission: to the distal tip at 1:1 ratio Support: to deliver equipment (balloons, stents,

atherectomy devices, intravascular ultrasound probe, etc.) Stiffness, including wire tip stiffness, is dependent primarily

on the core material Diameter: Depends on vessels of different diameters.

0.014 inches, or as thick as 0.065 inches Length: 45 cm to 400 cm.

Short guide wire 45 – 80 cm Standard guide wire - 145 cm Exchange guide wire – 260 and above

GUIDE WIRESComponents considered to select a guide

wire: 1. core – determines stiffness and

1. Fixed 2. Movable core.

2. Outer coil

3. Coating,

4. Polymer jacket (optional) terumo wire

5. wire tip-1. Straight

1. soft, flexible 2. Special “extra” or “very” floppy tip

2. J”-tipped

GUIDE WIRES

GUIDE WIRES

Guidewire Materials : Different materials used for the outer coil and core

areas. Outer coils may be plated with radio-opaque materials (like Gold or Platinum) to aid visibility during a procedure.

1. Gold (Au) Radio-opaque properties2. Platinum (Pt) Radio-opaque properties3. Nitinol (NiTi) - Terumo4. Stainless Steel – tiger wire5. Stainless Steel with Nickel6. Titanium Core7. Tungsten (W)

o

GUIDE WIRES

1. Coating 2. Hydrophilic coating - polyethylene oxide (PEO) and

polyvinylpyrrolidone (PVP)

3. Anti-thrombogenic/Heparin coating Inhibits clotting

4. Hydrophobic coating - PTFE (polytetrafluoroethylene ), Teflon®)

5. Silicone coating Reduces friction

Special coatings (heparin or teflon) –1. less thrombogenic 2. slide more easily through catheters. 3. keep the wire and catheter from binding together within

any of the extruded plastic catheters4. coated wires are slightly stiffer than the comparable

size and type of non-coated wire

GUIDE WIRES

General usage guide wires

1. Percutaneous entry into vessels soft straight tipped and J-tipped wires

2. Support catheters (small and large) during various catheter manipulations,

3. Wires with long, soft tips to enter into more distal vessels or through valves

4. Super stiff wire 1. delivery of stiffer catheters and sheaths 2. support for balloon catheters during dilation procedures

5. Special, stiffer wires of smaller sizes (0.014)used to1. support small balloon dilation catheters in coronary arteries2. cardiac catheterizations of infants and small children.

6. Torque wire can be directed into very specific locations, into particular vessels, branches or orifices

7. Terumo™ or the Glide™ wire is very effective for entering difficult locations even small tortuous channels and to make acute turns

8. DEFLOCTOR wire - deflects the tips of catheters

GUIDE WIRES

CATHETER

CATHETER    The exact choice of catheter should be -

primarily the choice of an experienced individual catheterizing physician,

specific characteristics, availability and, often, price

Specific Catheter according to location and function

Diameter Lumen Length Guide wire Flow Radio-opaque / Radio-translucent

CATHETER

Catheters may be –1. Guiding catheter2. Diagnostic catheter

Diagnostic catheter May be –1. guidable or torque-controlled catheters and2. flow-directed (“floating”) balloon catheters.

 Each of these two types of catheter are subdivided into –

1. “end-hole”, diagnostic catheters and 2. Blind -ended, angiographic catheters.

1. End-hole catheters with/without side holes close to the tip.

1. Utilized in diagnostic catheterization procedures when wedge pressures or wedge angiograms are desired.

2. to advance a guide wire out of and beyond the tip of the catheter either for special manipulations into specific areas or

3. to exchange catheter

2.  Blind-ended (Angiographic ) catheters – have a closed distal end with several side holes close to the distal tip.

1. The closed end prevent recoil of the catheter during rapid, high volume or high-pressure injections of contrast through the catheter.

2. can be used equally well for blood sampling and pressure recordings except in the “wedge” positions.

3. There now is “hybrid” catheter,which combines advantages of the both – Multi-track™ catheter –

1. For angiography simultaneously the passage of an additional wire through the true lumen of the catheter

Various commonly used catheters:

Pulmonary Wedge Catheter 4 Fr-60 cm, 5-60, 5-110, 6-110, 7-110 This is a flow-directed end-hole catheter Function: right-sided hemodynamics, including the

pulmonary capillary wedge pressure Berman Catheter –

4 Fr-50 cm,5-50,5-80,6-90,7-90 Blind end flow directed catheter, Proximal to the balloon there are several holes Function –

sample blood is used primarily for angiography in the ventricles

Various commonly used catheters:

:

Thermodilution Catheter 5 Fr, 6 Fr, 7 Fr catheters end-hole catheter with an additional

lumen terminating in a proximal side port.

Thermistor (temperature monitor) at the tip

Function - cardiac index assessment

Various commonly used catheters:

Multipurpose catheter – Relatively stiff, end-hole catheter with a terminal bend. two side-holes near the tip

Function: Right heart catheterization Probing the atrial septum, Pressure measurements over a wire, Angiography by hand, Angiogram Useful for RCA or SVG to RCA or LCA with inferior origin

Various commonly used catheters:

Pigtail Catheters • Pigtail Catheters

• 3–7 Fr with lengths of 40–110 cm These are generally considered angiographic catheter Function

angiography of LV and the ascending aorta pressure measurements

Marker pigtails – have radiographic markers of distance and size Funciton - used to determine angiogram magnification

accurately

Diameter (French)

Length(cm)

Guide wire(inch)

Max. Flow(ml/sec

psi)

Type

5 110/100 .038 17/1000 3.5 small

5 110/100 .038 19/1000 4.0 standard

JR Judkins right

Right coronary artery and SVG interventions; may not provide coaxial alignment for vein grafts to the RCA  

JL Judkins left Left coronary artery interventions  

AL Amplatz left Useful for difficult anatomy of the left coronary artery (especially left circumflex), SVG, Shepherd’s Crook or high anterior RCA  

AR Amplatz right RCA interventions or SVG to RCA with inferior origin

XB or EBU

Extra Backup

Useful for difficult anatomy in LCA; offers backup support from opposite wall of aorta

IMA Internal mammary

LIMA, RIMA, or native vessel beyond anastomosis lesions. Sometimes fits well for RCA interventions  

SON Sones  

Sones Useful for RCA or SVG to RCA or LCA with inferior origin  

LCB Left coronary bypass

Useful for SVG to LCA with horizontal or slightly superior origin  

RCB Right coronary bypass

Useful for SVG to RCA  

Balloon Catheter

Snare Catheter

The Amplatz™ Goose-Neck Snare En Snare™

has three separate interlaced loops that are extended and withdrawn as a single unit

Medi-tech™ snare made of memory spring-wire material. The snare loops are an elongated

hexagon in shape

FLUOROSCOPIC MACHINE

Frontal/ Straight PA View (0o):

1. Systemic venous anatomy (RSVC, LSVC, IVC).

2. Pulmonary venous anatomy.3. RV anatomy and distal PA anatomy.4. Descending aortography,

aortopulmonary collaterals.5. Single ventricular morphology

(especially initial imaging).

Right Anterior Oblique / RAO (-200 – 300) Good delineation of outlet/anterior

muscular VSD’s and the infundibulum.

LV outflow tract imaging for sub-AS (including AV canal gooseneck).

LV function and quantification of MR and AR.

An alternative view for measuring PDAs.

Aortic valve annulus measurements.

O0 Frontal + 20-30o cranial

Sitting Up Based on the old practice of moving the patient’s position rather than cameras

Best used for:1. Improved imaging of MPA and branch

PAs, with less superimposition.2. Pulmonary stenosis, for annulus

measurements.3. Seeing full length of RPA (especially with

RAO 20–30o).

O0 Frontal + 30o caudal

‘‘Laid Back’’ view in old terminology Best used for:

1. Alternate view to image proximal branch PAs.

2. PAs arising from conduits (up to 60o caudal).

3. Coronary arteries from Ao, e.g., D-TGA.

Lateral / straight lateral (90o) Best used for:

1. Excellent view of RV outflow tract/pulmonary valve/MPA.

2. Good imaging of PDA and coarctation.3. Coronary artery origin and course.4. Distal PA anatomy.

Left Anterior Oblique (LAO – 20-70O) This is not to be confused with long axial

oblique. Generally refers to the rotation along the lateral plane, and does not denote use of cranial or caudal angulation.

Best used for:1. Elongating aortic arch, which may help for PDA

or coarctation,2. Lengthening LPA (caudal angulation may help),3. Truncal valve anatomy,4. Proximal LPA anatomy.

Long Axial Oblique (70OLateral 30Ocranial) Gives LV image similar to that found

in parasternal long axis view by echo.

Best used for:1. LV function and MR.2. Sub AS, AS, and supra-AS.3. Annulus measurement for aortic valve

dilation.4. VSD imaging ( membranous /

conoventricular / anterior and mid-muscular).

Hepatoclavicular /4-Chamber/ (45OLateral 45Ocranial)

Gives image analogous to that found on apical 4-chamber echo view. Looks at the crux of the heart.

Best used for:1. ASDs (especially with catheter in RUPV).2. Endocardial Cushion Defects (ECD).3. Inlet/posterior muscular VSDs.4. AV valve anatomy and regurgitation.5. LV to RA shunt.6. The origin of the LPA

Aortic Orifice View (100-120OLateral +20-30Ocaudal)

Similar to parasternal short axis echo view.

Best used for:1. Looking at coronary artery origins,

especially with antegrade ascending aorta injection with an inflated Berman catheter.

2. Gives nice view of aortic valve cusps.

Power injector

• Contrast: • Iopamidol

• Non ionic• Low osmolar

• Dose: Maximal acceptable contrast dose • (MACD) is calculated as 5 milliliters of

contrast per kilogram of body weight divided by the baseline serum creatinine level in milligrams per deciliter.

• Rule of thumb: • 1ml /kg for each angiographic view

Contrast: Variables determining the amount of contrast to

be used: General rule:

low contrast volume with high flow rate High volume with low flow rate is ineffective

Volume overload lesion like VSDPt size: low volume of contrast given at high flow in a

chamber Catheter location –

Low volume – low flow location (vein) Branching vessel ( Pulmonary artery)

High volume – ventricles

Contrast: States of high flow:

VSD Tachycardic patients may clear contrast more quickly, in patients with slow heart rates, slow injection times

Layering – decrease the amount of contrast used in hand injections by using layered injections in low-flow regions, or when balloon occluding the vessel proximally.

Levophase while doing Angiogram of RV or PA the contrast returns from the pulmonary veins and opacifies the left heart called levophase. decide before starting the angiogram how long you want

to image to get information from levophase.

Procedure:

BEFORE THE PROCEDURE

Routine investigation Baseline vital signs Informed written consent NPO for 6 - 8 hours before the test. Patient should be wear a hospital gown. Remove any necklaces, bracelets, rings, or

other jewelry. You should also remove nail polish from your fingernails and toenails.

Bladder should be completely emptied just before the test

PATIENT PREPARATION

Patient Positioning for Cardiac Catheterization so that need not to be moved during procedure

Puncture area must be surgically cleaned – Umbilicus to mid thigh

The patient is then draped from neck down with sterile drapes

All equipment (radiation shields, image intensifier, equipment used to manipulate machine) must be prepared with sterile covers

PROCEDURE Local anaesthetic injected into the skin to numb the area

Vascular access

Groin sheath placementHeparinize the pt

Flush the lateral tubing

Catheters are inserted over a guidewire and moved towards the heart.

Oximetry done Haemodynamics recorded Once in position radio-opaque contrast

agents is injected to see cardiac anatomy on fluoroscopy image.

all the necessary angiographic views recorded.

The catheter can be removed and manual pressure must be applied to entry site for 15 minutes & closed using pressure bandage, stitches, or a special seal

Post Procedure follow-up: Verify the dressing 0.9% NS IV infusion

Monitor at 10 minutes, 30 minutes and then hourly after sheath removal.

1. HR

2. B/P

3. O2 saturation

4. Temperature

5. Assess circulation, motion and sensation to both feet

Post care

Maintain bed rest while pressure is in place. No bending of groin is permitted. May turn side to

side for back care. May resume diet, per doctor order.

Notify your consultant for: a. Absent or diminished pulse in affected limb. b. Presence of a hematoma. c. Symptomatic bradycardia or other arrhythmia. d. Bleeding at insertion site.

INTERPRETATIONS

Test results will be reviewed by a cardiologist and will be available after the procedure.

Risks/Complications Of Cardiac catheterizations Cardiac catheterizations are not without risk to the patient. The following is a listing of the more common complications.1. Exposure to ionized

radiation

2. Risk of general anesthesia (when used)

3. Hypothermia (especially in small infants)

4. Aggravation of hypoxia

5. Arrhythmias (temporary instability or even permanent, as in heart block)

6. Vascular injury –1. perforations/tears2. Dissection3. Thrombus formation

7. Cardiac perforation

8. Cardiac valve injury

9. Blood loss that requires transfusion

10. Allergic reactions to contrast, drugs, or anesthetics

11.Renal insufficiency caused by contrast material

12.Diffuse central nervous system injury

13.Stroke

14.Death

Toxicities Associated with Radiocontrast Agents

Allergic (anaphylactoid) reactions1. Grade I: Single episode of emesis, nausea, sneezing, or

vertigo 2. Grade II: Hives, multiple episodes of emesis, fevers, or chills 3. Grade III: Clinical shock, bronchospasm, laryngospasm or

edema, loss of consciousness, hypotension, hypertension, cardiac arrhythmia, angioedema, or pulmonary edema

Cardiovascular toxicity1. Electrophysiologic

1. Bradycardia (asystole, heart block)

2. Tachycardia (sinus, ventricular)

3. Ventricular fibrillation 2. Hemodynamic

1. Hypotension (cardiac depression, vasodilation)

2. Heart failure (cardiac depression, increased intravascular volume)

1. Nephrotoxicity2. Discomfort

1. Nausea, vomiting 2. Heat and flushing

3. Hyperthyroidism

Complications of equipment : When the major or capital equipment fails results in the

interruption or cancellation of the case  failure of the X-ray/imaging equipment at the precise instant or a

critical point in an interventional procedure may result in a displaced device or the dilation of the wrong area/structure.

 Both angiographic and physiologic recorders fail,  Flaws in disposable/expendable equipment which result in –

breaks or fractures and the loss of catheter tips or pieces of spring guide wire do result in the embolization of a solid particle

 Catheter hubs coming loose during high-pressure injection result in a failed angiogram,

 Leaks in stopcocks or connecting tubing result in poor pressure transmission and inaccurate pressures being recorded,

An unrecognized leak in a stopcock adjacent to the catheter can allow air to be drawn into the system and being injected into the patient.

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