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CORONARY ANGIOCARDIAC CATH

& Ablation ProceduresLecture # 3 A

Cardiac Anatomy & Circulation& Pathology Review # 3B

RT 255 (rev 2011/2014) Dawn Charman, M.Ed,R.TReference:

Frank. Merrill's Atlas of Radiographic Positioning and Procedures, 11th Ed. Mosby

2What 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

Check out procedure Video:http://www.youtube.com/watch?v=kY5gKdFWT3k&feature=related

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Cardiac Catheterizationalso 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*

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Indications & ProceduresIndications & 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 AblationsCardiac Ablations• Thrombolytic Therapy• Valvuloplasty • Pulmonary

Stenosis• Aortic Stenosis• Tricuspid Stenosis• Mitral Stenosis

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Who performs the procedure?

• The Interventional Radiologist / Cardiologist

• who specializes in the Angioplasty procedure.

• CIT Technologist

• Nursing

• Other support staff

6 Cardiac cath requires special equipment:

1. Angio supplies & equipment

2. Fluoro Imaging (w/ Cine – Digital)

3. & Ancillary equipment *

Type of catheter used will be dependant on the type Of Procedure performed

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8 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 B/P , pulse ox,

Improvements in digital storage & resolution has largely replaced cine Study can be stored on CD-R or DVD’s for review

9Basic 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.

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The left atrium forms the posterior border of the heart and receives blood from four pulmonary veins

Most of the cardiac veins drain into the coronary sinus on the posterior aspect of the heart, and this sinus drains into the right atrium

12Normal Rt & Lt Coronary Arteries

13Which area is demonstrated?

How are the vessels magnified ?

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Why Is A Cardiac Catheterization Done?

• Evaluate the patient's cardiac condition related to: • Partial or Complete blockage • Which coronary arteries are narrowed • The extent and degree of the narrowing • How well the heart muscle and valves are working • The extent of damage to the heart after a heart

attack • What treatment is required: medical management,

an angioplasty (PTCA) or surgery • Some cardiologists regularly treat patients

with cardiac catheterization

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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

17 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

18REASONS 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

19Indications 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 infarction3. Sudden cardiovascular death4. Valvular heart disease5. Congenital heart disease

– (before anticipated corrective surgery)6. Aortic dissection7. Pericardial constriction or tamponade8. Cardiomyopathy9. Initial and follow-up assessment for heart

transplant

20 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

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• 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 & Imaging

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• 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

23Cardiac catheterizationImaging

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

24Contrast Media

Iodinated non-ionic water-based contrastExamples of contrast used are: Visipaque Hypaque (PTCA only)

for balloon filling

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What Method is this?What Method is this?

26 Seldinger TechniqueSeldinger Technique

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Catherization: Selinger TechniqueCatherization: Selinger Technique

*Modified Seldinger only punctures one side of vessel – this Percutaneous method can be used for arteries or veins - describes the method of catheter introduction that is not a direct stick

*

28 • 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

• Radial, Subclavian & jugular may also be used depending on Physician choice and Pt condition

• Seldinger Tech is a percutaneous method for the femoral approach

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Transradial Catheterization Benefits Patients and Physicians

Using a transradial cardiac catheterization procedure: significantly reduces recovery time and improves patient outcomes instead of using femoral access.

less than 2 percent of cardiac cath in the United States use the transradial approach because only a small percentage of interventional cardiologists are trained in this specialized procedure

30Complications

• Minor:– Pain– Swelling– Bruising

• Major– Blood clots– Damage to heart or blood vessels– Normal electrical system damage– Death

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3131

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.

32 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.

Cardiac cath video: http://www.youtube.com/watch?v=yzxSrLa1d0g

A:Judkins RT B:Judkins LT C: Pigtail

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Enlarged coronary artery

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Cardiac Cath Normal vs Stenosis

35 Guidewires & Needles

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Swan-Ganz Catheters

Video of swan ganz procedure:http://www.youtube.com/watch?v=Lb1Z3bndmA8&NR=1

The catheter is introduced through a large vein—often the internal jugular, subclavian, or femoral veins. From this entry site, it is threaded, with the aid of fluoroscopy, through the right atrium of the heart, the right ventricle, and subsequently into the pulmonary artery.

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Percutaneous Transluminal Coronary Angioplasty

(PTCA) • Otherwise known as:

• Balloon Angioplasty

• Angioplasty

• PTCA

• Balloon Angioplasty is a technique used to dilate an area of arterial blockage with the help of a balloon catheter.

• It is a way of opening a blocked blood vessel.

38Balloon 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.

One Possible Complication:•Plaque material or blood clots dislodging and floating downstream, leading past the treated area

39 Balloon angioplasty and a stent are used to open up the stenotic left brachiocephalic vein. Excellent blood flow was restored in subsequent images.

40 Equipment Used During a Procedure:• Balloon Catheter• Metal mesh stent• Pump for balloon

• Usually a metal stent is placed in the opened artery to make sure restenosis does not reoccur

• Following the procedure, the balloon is deflated and additional x-rays are taken to determine how much blood flow has increased.

41 Prevention of Restenosis

• Lifestyle Change

• Healthy diet

• adequate exercise

• No Smoking

• Medicine coated stents

Although Balloon Angioplasty is a valuable tool it is not a cure for Artherosclerosis.

It is only a treatment,

Patients should try to lead a healthy life which will be the best treatment for their arteries.

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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.

43 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.

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Stenting is a procedure in which a physician inserts a

tiny, slender, expandable mesh tube(stent) that fits inside an artery has

been widened by Angioplasty.

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Stent PlacementStent Placement

• http://images.google.com/imgres?imgurl=http://www.nhlbi.nih.gov/health/dci/images/stent_restenosis.gif&imgrefurl=http://www.nhlbi.nih.gov/health/dci/Diseases/stents/stents_all.html&usg=__xDlbsaX9JhuYbpVojLcz19apr-I=&h=513&w=450&sz=59&hl=en&start=20&tbnid=vWwqaG-RNW7M-M:&tbnh=131&tbnw=115&prev=/images%3Fq%3Dabdominal%2Bstents%26gbv%3D2%26hl%3Den

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4646

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Abdominal Stent

48A stent graft or endograft used to repair aneurysm in the aorta and iliac region.

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AORTOGRAMReview exams &

anatomy

50 AORTOGRAMReview exams &

anatomy

51During 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

52After 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.

53Recovery

• 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

• INSTRUCT THE PATIENT TO:

• Drink plenty of fluids• Avoid driving, smoking

and bathing for 2 days• Avoid Walking for long

periods of time• Avoid Vigorous exercise

for at least 30 days

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Cardiac Ablation

CARDIAC

ABLATION

55RF ABLATION

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• 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

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

57Atrial flutter / ablation

58Cardiac Ablation

• Minimally invasive treatment for arrhythmias• Live fluoroscopy and angiography techniques

are used along with special electro physiologic equipment and catheters

• Performed by a doctor specializing in the hearts electrical system

• Pulse• ECG• Chest pain• Nausea• Syncope

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• Catheter positions for routine electrophysiologic study.

• Multipolar catheters • are positioned in the • high right atrium near• the sinus node, • in the area of the • atrioventricular apex, • and in the coronary • sinus.

60 Your Hearts Electrical System

• Sinoatrial node- – “Natural Pacemaker”– Upper Right Atrium– Produces electrical signal 60-100 times a min

• Atrioventricular node-– The bridge that connects Atriums to Ventricles– Special cells allow electrical signals to pass

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Arrhythmia

• When the heart beats too fast it is called tachycardia. Over 100 beats per minute.

• When the heart beats too slow it is called bradycardia. Under 60 beats per minute.

• Another type of arrhythmia is when the heart “skips” or doesn’t have a regular pattern.

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63CINE

• HIGHEST IN RADIATION DOSE • TO THE PATIENT / TECHNOLOGIST

• 1 MR/FRAME X 60 FRAMES/SEC FOR 30 MINUTES = ?

• HEAT LOADS?????

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1 MR/FRAME X 60 FRAMES/SEC FOR 30 MINUTES =

• 1 X 60 = 60 mR/sec• 60 mR/sec x 60 sec = 3600mR/min

• 3600mR/min x 30 min =• 108000 mr OR 10.8 R

CINE DOSE

65Imaging Considerations

• Magnetic resonance imaging (MRI)

– Recently gained in popularity for use in cardiac studies– Uses cine loop– May be ECG gated

• Magnetic resonance angiography (MRA)

66 Nuc Med / Pet scanningPerfusion Scanning

•Myocardial perfusion scan•Most widely used procedure

•Gated cardiac blood pool scans

•Used to evaluate ventricles

•Positron emission tomography (PET)

Nuclear cardiologyUsed to diagnose CAD, congenital heart disease, and cardiomyopathy

67Doppler Ultrasound

•Echocardiography•M-mode echocardiography•2-D echocardiography

•Real-time imaging•Transesophageal echocardiography (TEE)

•Spectral Doppler•Color Doppler

•Carotid stenosis, DVT•Stress echocardiography

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Heart CT 3D

• Computed tomography (CT)

• Cardiac scoring

• EBCT

• Spiral CT

• CT angiography (CTA)

Imaging Considerations

69Name of Exam?

70CHECK OUT THE LIVE ACTION!

• http://images.google.com/imgres?imgurl=http://www.heartsite.com/assets/images/cardiac_cath_man.jpg&imgrefurl=http://www.heartsite.com/html/cardiac_cath.html&h=350&w=269&sz=88&tbnid=KtrNOVmZWv3nhM:&tbnh=116&tbnw=89&hl=en&start=57&prev=/images%3Fq%3Dcardiac%2Bc