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

1. CORONARY ANGIOCARDIAC CATH& Ablation ProceduresLecture # 3 ACardiac Anatomy & Circulation& Pathology Review # 3B RT 255 (rev 2011/2014) Dawn Charman, M.Ed,R.T Reference: Frank. Merrill's Atlas of Radiographic Positioning and Procedures, 11th Ed. Mosby

2. What is cardiac cath? • Procedure which involves placement of a catheter into RT or LT side of heart. • Invasive • Coronary angiography is often included together with cardiac cath • Diagnostic procedure and/or • a therapeutic procedure • Adults & Children Check out procedure Video: http://www.youtube.com/watch?v=kY5gKdFWT3k&feature=related

3. 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* Cardiac Catheterizationalso known as a heart cath or coronary angiogram

4. Abnormal heart size Angina (stable or unstable) Coronary Artery Disease Heart Attack Congenital Heart Disease Irregular heart disease (arrhythmias) Catheterization Procedures Cardiac Ventriculography Aortography Coronary Angiography Pulmonary Angiography PTCA Stents Cardiac Ablations Thrombolytic Therapy Valvuloplasty Pulmonary Stenosis Aortic Stenosis Tricuspid Stenosis Mitral Stenosis Indications & Procedures

5. 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: • Angio supplies & equipment • Fluoro Imaging (w/ Cine – Digital) • & Ancillary equipment * Type of catheter used will be dependant on the type Of Procedure performed

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

9. Basic info about procedure • IV sites in either arm, groin, or neck. • Flexible catheter inserted to IV through the blood vessel. • Then, cathether is threaded thorough the blood vessel to the heart. • Pressure measured at this point. • Iodinated contrast injected through catheter once it reaches the heart. • Fluoroscopy guides the cardiologist with the catheter location.

11. 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

12. Normal Rt & Lt Coronary Arteries

13. Which area is demonstrated? How are the vessels magnified ?

15. 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

16. 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. 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 Indications/ Reasons for Cath:

18. REASONS FOR CARDIAC CATH • Angina pains (i.e., the discomfort from blocked coronary arteries)- not easily controlled with medication or that interfere daily life • Chest pains of uncertain cause that repeatedly recur and defy diagnosis despite other tests • Angina that occurs at rest despite medical therapy • Recurrent angina after a heart attack • Not everyone with angina needs a cardiac catheterization. (meds) • Markedly abnormal stress test results • Heart failure, when the suspected cause is coronary artery disease

19. Indications for Cardiac Catheterization 1.Suspected or known coronary artery disease • Evaluation before a major surgical procedure • Silent ischemia • Atypical chest pain or coronary artery spasm 2.Myocardial infarction 3. Sudden cardiovascular death 4. Valvular heart disease 5. Congenital heart disease • (before anticipated corrective surgery) 6. Aortic dissection 7. Pericardial constriction or tamponade 8. Cardiomyopathy 9. Initial and follow-up assessment for heart transplant

20. 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 Patient Prep for Cath

21. Cardiac catheterization & Imaging • The angiogram catheter is maneuvered into position just above the outlet valve of the left ventricle • (aortic valve or bulb). • With careful maneuvering, the tip of the catheter can be positioned at the mouth of the main coronary arteries.

22. 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

23. Cardiac 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

24. Contrast Media Iodinated non-ionic water-based contrast Examples of contrast used are: • Visipaque • Hypaque (PTCA only) for balloon filling

25. What Method is this? 25

26. Seldinger Technique

27. Catherization: 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 27

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

29. Transradial Catheterization Benefits Patients and Physicians 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 Using a transradial cardiac catheterization procedure: significantly reduces recovery time and improves patient outcomes instead of using femoral access.

30. Complications • Minor: • Pain • Swelling • Bruising • Major • Blood clots • Damage to heart or blood vessels • Normal electrical system damage • Death

31. What is this?When is it used inCardiac 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. 31

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. • A:Judkins RT B:Judkins LT C: Pigtail Cardiac cath video: http://www.youtube.com/watch?v=yzxSrLa1d0g

33. Enlarged coronary artery

34. Cardiac Cath Normal vs Stenosis

35. Guidewires & Needles

36. Swan-Ganz Catheters 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. Video of swan ganz procedure: http://www.youtube.com/watch?v=Lb1Z3bndmA8&NR=1 36

37. 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.

38. Balloon Angioplasty • A small area of the groin or arm is shaved and cleaned where the catheter is inserted. • Medication is used to anesthetize the area so a small incision can be made where the catheter will be inserted. • A catheter with a deflated balloon on the tip is inserted through the artery in the groin or arm. • X-ray is used to guide the catheter up into the heart. • 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.

42. 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.

44. 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.

45. Stent 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 45

46. AAA 46

47. Abdominal Stent 47

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

49. AORTOGRAMReview exams &anatomy

50. AORTOGRAMReview exams &anatomy