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Cardiac Catheterization and Coronary Angiography Andre Tritansa Faizal Nurnajmia Curie Proklamatina Resource Person: dr. Doni Firman, SpJP (K)

Cardiac Catheterization and Angiography

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Page 1: Cardiac Catheterization and Angiography

Cardiac Catheterization

andCoronary Angiography

Andre Tritansa FaizalNurnajmia Curie Proklamatina

Resource Person: dr. Doni Firman, SpJP (K)

Page 2: Cardiac Catheterization and Angiography

History

Eric J. Topol (ed). Textbook of Cardiovascular Medicine, 3rd ed. 2007www.heartviews.org

Page 3: Cardiac Catheterization and Angiography

Definition

Cardiac Catheterization• A procedure use catheter that inserted to measure

pressures in the heart chambers, to determine cardiac output and vascular resistances and to inject radiopaque material to examine heart structures and blood flow

Pathophysiology of Heart Lily 6th Ed 2015

Page 4: Cardiac Catheterization and Angiography

Indication of Diagnostic Cardiac Catheterization

to confirm or exclude the presence of a condition already suspected from the history, physical examination, or noninvasive evaluation;

to clarify a confusing or obscure clinical picture in a patient whose clinical findings and noninvasive data are inconclusive;

to confirm the suspected abnormality and to exclude associated abnormalities that may require a surgeon's attention in patients for whom corrective surgery is contemplated

Eric J. Topol (ed). Textbook of Cardiovascular Medicine, 3rd ed. 2007

Page 5: Cardiac Catheterization and Angiography

Relative Contraindication to Diagnostic Cardiac Catheterization

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Page 6: Cardiac Catheterization and Angiography

50%→ outpatient procedure Indication for postprocedural hospitalization:

Hematoma formationDiagnosis post procedure eg. Severe LM, proximal 3VDUncompensated HF, unstable ischemic symptoms, severe

AS with LV dysfunction, renal insufficiency, continuous anticoagulation

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Technical Aspect of Cardiac Catheterization

Page 7: Cardiac Catheterization and Angiography

Preparation of the Patient

• Explain the procedure, risk and benefit• Pre-cath evaluation:history, physical exam, ECG, CBC,

electrolyte, creatinin, blood glucose, PT with INR• Fasting for 6 hours• Premedication: sedation, antihistamine• Discontinue oral anticouagulant 3 days before, INR < 1.8• Discontinue metformin until stable renal function for 48 hrs• Hydration pre and post procedure

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Page 8: Cardiac Catheterization and Angiography

Right Heart Catetherization

• Measurement and analysis of: Right atrium Right ventricle Pulmonary artery, pulmonary capillary wedge

pressure Cardiac output screening of intracardiac shunts

• Performed antegrade through IVC or SVC• Entry via femoral, internal jugular, subclavian, antecubital

vein

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Page 9: Cardiac Catheterization and Angiography

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Page 10: Cardiac Catheterization and Angiography

From Baim DS, Grossman W: Percutaneous approach, including transseptal and apical puncture. In Baim DS, Grossman W : Cardiac Catheterization, Angiography, and Intervention. 7th ed. Philadelphia, Lea & Febiger, 2006, p 86.)

Balloon Flotation Catetherization

Page 11: Cardiac Catheterization and Angiography

Left Heart Catetherization

The Judkins Technique

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Page 12: Cardiac Catheterization and Angiography

Left Heart Catetherization

Modified Seldinger Technique

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Page 13: Cardiac Catheterization and Angiography

Hemodynamic Data

• Pressure measurement• Measurement of Flow• Determination of vascular resistance

Ohm’s Law:

Q= ΔP/R

Page 14: Cardiac Catheterization and Angiography

Normal Right and Left Heart Pressure Recorded from Fluid Filled Catheter in Human

Pepine C,Hill JA, Lambert CR (eds). Diagnostic and Therapeutics Cardiac Catheterization.3rd ed. 1998

Page 15: Cardiac Catheterization and Angiography

Normal Pressure

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Page 16: Cardiac Catheterization and Angiography

Method Most reliable Least reliableFick Low cardiac output High cardiac output

Thermodilution High cardiac output Pulmonic regurgitation

Tricuspid regurgitation

Intracardiac shunting

Angiographic Normal-shaped ventricle

Extensive segmental wall motion abnormalities

arrhytmia

Aortic regurgitation

Mitral regurgitation

Eric J. Topol (ed). Textbook of Cardiovascular Medicine, 3rd ed. 2007

Cardiac Output Measurement

Page 17: Cardiac Catheterization and Angiography

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.Thermodilutio

n

Fick method

Page 18: Cardiac Catheterization and Angiography

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Shunt Quantification

Flamm formula

Flow ratio

Page 19: Cardiac Catheterization and Angiography

Systemic Vascular Resistance

Pulmonal Vascular Resistance

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Page 20: Cardiac Catheterization and Angiography

Physiologic & Pharmacologic Maneuvers

Dynamic exercise Pacing Tachycardia Physiologic stress → The Valsalva maneuver, Kussmaul sign Dobutamine infusion→ indicated in low flow, low gradient

AS Inhaled NO→ pulmonary hypertension Sodium nitroprusside→predict good clinical outcome in

dilated cardiomyopathy and MR

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Page 21: Cardiac Catheterization and Angiography

Adjunctive Diagnostic Technique

LV Electromechanical MappingDistinguish viable and non viable myocardium, ischemic

and non ischemic myocardiumPredict recovery of function after revascularizationGuiding stem cell injection

Intracardiac Echocardiography (ICE)Provide imaging of interatrial or interventricular septum

and left heart structuresGuidance of percutaneous ASD and PVO closureLocalization of fossa ovalis for transseptal puncture

Page 22: Cardiac Catheterization and Angiography

Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.

Page 23: Cardiac Catheterization and Angiography

Coronary Angiography

Page 24: Cardiac Catheterization and Angiography

Outline

• Overview• Indications and Contraindications• Complications• Technique• Pitfalls

Page 25: Cardiac Catheterization and Angiography

Overview

• Coronary angiography: imaging technique that uses X-rays to take coronary vessels pictures

• Remains standard to identify presence/absence of arterial narrowings related to CAD

• Most reliable anatomic information for determining appropriateness of medical therapy

• 1st performed by Mason Sones (1959), methods have improved substantially since then

Page 26: Cardiac Catheterization and Angiography

How is Coronary Angiography Done?

http://patient.info/health/coronary-angiography

Page 27: Cardiac Catheterization and Angiography

Coronary Angiography Principle• Radiation from x-ray tube is

attenuated as passes through body, detected by image intensifier

• Contrast injected to coronaries enhances x-rays absorption sharp contrast with tissues

• X-ray shadow converted to visible light image, displayed on fluoroscopic monitors, stored on digital storage system

• Flat-panel detectors replace image intensifiers (reduce radiation exposure, enhance image quality)

Bonow RO, et al. Braunwald Heart Disease. 9th Edition, 2012.

Page 28: Cardiac Catheterization and Angiography

Radiation Exposure (1)• 2 forms of radiation injury:

• Deterministic injury result in cell death and organ dysfunction (dose-dependent, most commonly result in skin injury)

• Stochastic injury result in genetic mutations (not dose-dependent)

• Radiation dose is measured as:• Total radiation exposure,

determined from x-ray tube output, expressed as dose-area product (DAP)

• Interventional reference point (IRP) dose, est. radiation dose to patient’s skin

Kern M. Do You Know Your Radiation Dose During Your Cath? Cath Lab Digest. Volume 19 - Issue 6 - June 2011

Page 29: Cardiac Catheterization and Angiography

Radiation Exposure (2)

Kern M. Do You Know Your Radiation Dose During Your Cath? Cath Lab Digest. Volume 19 - Issue 6 - June 2011

Page 30: Cardiac Catheterization and Angiography

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 31: Cardiac Catheterization and Angiography

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 32: Cardiac Catheterization and Angiography

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 33: Cardiac Catheterization and Angiography

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 34: Cardiac Catheterization and Angiography

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 35: Cardiac Catheterization and Angiography

Contraindications

• No absolute contraindications• Relative contraindications:

• unexplained fever• untreated infection• severe anemia or active bleeding• critical electrolyte imbalance• uncontrolled systemic hypertension• digitalis toxicity• ongoing stroke• acute renal failure• decompensated heart failure• severe intrinsic or iatrogenic coagulopathy (elevated INR)• active endocarditis

Page 36: Cardiac Catheterization and Angiography

Complications

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 37: Cardiac Catheterization and Angiography

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 38: Cardiac Catheterization and Angiography

Technique of Coronary Angiography

Page 39: Cardiac Catheterization and Angiography

Patient Preparation

• Lab exam <2 weeks prior: Hb, platelet, electrolyte, creatinine, PT (warfarin, liver disease, coagulopathy)

• Continue aspirin, UFH, LMWH, GP IIb/IIIa inhibitor• Discontinue warfarin (3 days prior), target INR ≤1.8 (femoral), ≤2.2

(radial), may treat with UFH/LMWH • Discontinue dabigatran 24 hrs prior (GFR >50 mL/min), 48 hrs prior

(GFR 30-50 mL/min)• Discontinue metformin prior until renal function normalized post

procedure

Page 40: Cardiac Catheterization and Angiography

Vascular Access (1)• Depends on operator-patient preferences,

anticoagulation status, peripheral vascular disease

• Femoral artery approach• Most commonly used• Puncture site distal to inguinal ligament, prox to

bifurcation of superficial & profunda femoral artery

• Bed rest for 1-2 hours after removal of 4-5F sheath and 2-4 hours of 6-8F sheath, longer if there is higher risk of bleeding

• Brachial artery approach• Preferred to femoral in presence of severe

peripheral vascular disease and morbid obesity• Easily accommodates 8F (1F = 0.33-mm

diameter) sheath • Risk of blood supply compromise to forearm

and hand in event of a vascular complication

http://www.myheart.com.pk/angiography/

Davidson CJ, Bonow RO. Cardiac catheterization. In: Braunwald’s Heart Disease 10th edition. 2015

Page 41: Cardiac Catheterization and Angiography

Vascular Access (2)• Radial artery approach• Preferred to brachial due to ease of

catheter entry & removal; dual blood supply to hand

• UFH (up to 5000 U)/bivalirudin for brachial & radial artery approaches

• Hydrophilic sheath and I.A. verapamil & NTG reduce spasm

• Factors assoc. with unsuccessfulness: high-bifurcation radial origin, full radial loop, extreme radial artery tortuosity

• Immediate ambulation; compared to femoral: lower cost, improve coronary visualization, reduce bleeding complications

• Generally accommodate 4-6F catheters

Allen test prior to procedure (ulnar arterial flow adequacy)

http://www.premierhealthspecialists.org/

Watson S, Gorski KA. Invasive Cardiology: A Manual for Cath Lab Personnel. 3rd Edition. 2011.

Page 42: Cardiac Catheterization and Angiography

Catheters• Polyethylene/polyurethane with fine wire braid within wall to allow

advancement and directional control and prevent kinking• Outer diameter size 4-8F (5-6F most common for diagnostic

arteriography)

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 43: Cardiac Catheterization and Angiography

• JL catheter is preshaped to allow entry into LCA from femoral with minimal manipulation (JL 4.0); for left/right brachial/radial artery 0.5 cm less curvature than for femoral is better suited

• JR catheter is preshaped to permit entry into RCA with small amount of rotational (clock-wise) manipulation from any vascular approach

• Catheter selection is based on habitus and aortic root size

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Judkins Catheters

Page 44: Cardiac Catheterization and Angiography

• Femoral or brachial approach• Excellent alternative in cases in

which Judkins catheter is not appropriately shaped to enter coronary arteries

• Amplatz L-1 or L-2 may be used from right brachial or radial approach

• Modified Amplatz right catheter (AR-1 or AR-2) can be used for engagement of a horizontal or upward takeoff RCA or SVG

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Amplatz Catheters

Page 45: Cardiac Catheterization and Angiography

Other Catheters

• IMA left catheter with angulated tip allows engagement of IMA or upward takeoff RCA

• Catheter shapes that permit engagement of SVGs include multipurpose catheter and Judkins right, modified Amplatz right, and hockey stick catheters

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 46: Cardiac Catheterization and Angiography

Drug Used (1)• Analgesics

• Conscious sedation (respond to verbal commands; maintain patent airway)• Diazepam 2.5-10 mg orally, diphenhydramine, 25-50 mg orally, 1 hour prior• I.V. midazolam 0.5-2 mg, fentanyl 25-50 μg for sedation during procedure

• Anticoagulants• IV UFH no longer routinely required• Increased thromboembolic risk (severe AS, critical PAD, arterial

atheroembolism, undergoing >1-2 min use of guidewires in central circulation) may be given I.V. UFH 2000-5000 U

• Brachial/radial artery catheterization should receive systemic UFH/bivalirudin

• Frequent catheters heparinized saline flush prevent microthrombi formation within catheter tip

• Continuous flush through arterial access sheath may lower distal thromboembolism

• Anticoagulant effect of UFH can be reversed with protamine 1 mg for every 100 U of heparin

Page 47: Cardiac Catheterization and Angiography

Drug Used (2)

• Treatment of Periprocedural Ischemia• Angina induced by tachycardia, hypertension, contrast agents,

microembolization, coronary spasm/enhanced vasomotor tone, or dynamic platelet aggregation

• NTG SL (0.3 mg), I.C. (50-200 μg), or I.V. (10-25 μg/min) in SBP >100 mm Hg• No contraindication to BB: I.V. metoprolol 2.5-5.0 mg/propranolol 1-4 mg• IAB counterpulsation as adjunctive in coronary ischemia and left main CAD,

cardiogenic shock, or refractory pulmonary edema

Page 48: Cardiac Catheterization and Angiography

• May produce adverse hemodynamic, electrophysiologic, renal effects• Side effects frequency varies depends on ionic content, osmolality,

viscosity• Ionic agents:

• Dissociate into cations & iodine-containing anions• High serum osm (>1500 mOsm) hypertonic• SB, heart block, QT & QRS prolongation, ST depression, giant T inv,

decreased LV contractility, decreased SBP, increased LVEDP; calcium-chelating properties also contribute to cardiac effects

• Non ionic agents:• Do not ionize in solution, more iodine-containing particles per milliliter of

contrast material• Lower osmolality (<850 mOsm), do not chelate calcium, fewer side

effects • Side effects relate in part to hyperosmolality hot flush, nausea, vomit,

arrhythmia

Contrast Agent (1)

Page 49: Cardiac Catheterization and Angiography

Contrast-Induced Nephropathy Contrast Reaction Prophylaxis

• Worsening renal fx (10-20%), esp. previous renal insuff, DM, dehydration, HF, large contrast volume, ≤48 hrs exposure to contrast highest risk: DM, eGFR <60 mL/min

• Fluid administration I.V. saline/sodium bicarbonate 1-1.5 mL/kg/min for 3-12 hours before procedure and 6-12 hours after procedure

• Rx to contrast agents:1. Mild (9%)—grade I: single episode of

emesis/nausea/sneezing/vertigo2. Moderate (9%)— grade II: hives or multiple

episodes of emesis/fevers/chills3. Severe (0.2-1.6%)— grade III: shock,

bronchospasm, laryngospasm/edema, unconscious, hypotension, hypertension, arrhythmia, angioedema, pulmonary edema

• Prophylactic H1 & H2 receptor–blocker (diphenhydramine 50 mg, cimetidine 300 mg) and aspirin

• Severe previous rx: prednisone 60 mg night before & 2 hours prior

Contrast Agent (2)

Page 50: Cardiac Catheterization and Angiography

Anatomy and Variations of Coronary Arteries

• Major epicardial and 2nd-3rd order branches can be visualized by coronary arteriography

• Smaller intramyocardial branches are not seen due to their size, cardiac motion, limitations in angiographic systems resolution

• Smaller vessels perfusion quantitatively assessed by myocardial blush score prognostic in STEMI and those undergoing PCI

Page 51: Cardiac Catheterization and Angiography

Smithuis R, Willems T. Coronary anatomy and anomalies. RadiologyDepartment of the Rijnland Hospitaland the University Medical Center Groningen. http://www.radiologyassistant.nl/

Page 52: Cardiac Catheterization and Angiography

Arterial Nomenclature and Extent of Disease

• Major coronary arteries : LAD, LCx, RCA (dominance defined by presence of posterior descending and adjacent posterolateral branch)

• CAD is defined as ≥ 50% diameter stenosis in ≥1 of these vessels• Subcritical stenoses <50% are characterized as nonobstructive CAD• Obstructive CAD is classified as one-, two-, or three-vessel disease

Page 53: Cardiac Catheterization and Angiography

BARI-CASS Coronary Artery Nomenclature

Alderman, et al. Native coronary disease progression exceeds failed revascularization as cause of angina after five years in the bypass angioplasty revascularization investigation (BARI). J Am Coll Cardiol. 2004;44(4):766-774.

Major determinants of 6-year outcome: number of diseased vessels, number of diseased proximal segments, and global LV function accounted for 80% of the prognostic information

Page 54: Cardiac Catheterization and Angiography

Syntax Score

http://www.medscape.com/

Page 55: Cardiac Catheterization and Angiography

Angiographic Projections• Heart is oriented obliquely in thoracic cavity RAO and LAO

projections to furnish true posteroanterior and lateral views of heart, limited by vessel foreshortening & branches superimposition

• Simultaneous x-ray beam rotation in sagittal plane provides better view:• Cranial view: image detector is tilted toward patient’s head• Caudal view : image detector is tilted down toward patient’s feet

• Optimal angiographic projection depends on body habitus, variation in coronary anatomy, location of lesion

• Recommendation:• Both LAO and RAO projections with both cranial and caudal angulation• At least two views of LCA and RCA

Page 56: Cardiac Catheterization and Angiography

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 57: Cardiac Catheterization and Angiography

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 58: Cardiac Catheterization and Angiography

Left Coronary Artery (1)

• LMCA• Arises from superior portion of left

aortic sinus, just below sinotubular ridge of aorta

• Diameter 3-6 mm, length 10-15 mm

• Courses behind RVOT and bifurcates into LAD and LCx

• Rarely absent LAD and LCx have separate ostia

• Best visualized: AP projection 0-20°caudal angulation

• Should view several projections with vessel off the spine to exclude LMCA stenosis

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10th edition. 2015

Page 59: Cardiac Catheterization and Angiography

Left Coronary Artery (2)• LAD

• Courses along epicardial surface of anterior IV groove toward apex

• RAO projection: extends along heart anterior aspect

• LAO projection: passes down cardiac midline, between RV & LV

• Major branches:• Septal branches arise at

approximately 90° angles and pass into IVS, varying in size, number, and distribution

• Diagonal branches pass over anterolateral aspect of heart

- Best angiographic projections for LAD :

• LAO cranial: midportion of LAD and separates diagonal and septal branches

• RAO cranial: proximal, middle, distal segments of LAD and separates diagonal branches superiorly and septal branches inferiorly

• AP cranial (20-40°): midportion of LAD, separating it from diagonal and septal branches

Page 60: Cardiac Catheterization and Angiography

Left Coronary Artery (3)

•LCx• Courses within posterior (left) AV groove toward inferior IV groove• Supplying left PDA from distal continuation of LCx (15%)• Remaining patients, distal LCx varies in size and length, depending on

number of posterolateral branches supplied by distal RCA• Gives off 1-3 large obtuse marginal branches as it passes down AV groove

principal branches of LCx, supply LV lateral free wall• Gives rise to 1-2 LA Cx branches supply lateral and posterior LA • RAO and LAO caudal: prox & mid LCx and obtuse marginal branches• AP or 5-15° RAO caudal: origins of obtuse marginal branches• LAO cranial: left PDA if LCA is dominant

Page 61: Cardiac Catheterization and Angiography

Right Coronary Artery (1)• Originates from right anterior aortic sinus, inferior to origin of LCA,

passes along right AV groove toward crux • First branch conus artery, arises at RCA ostium or within first few mm

of RCA (50% of patients). Remaining patients, arises from separate ostium in right aortic sinus just above RCA ostium

• Second branch sinoatrial node artery, arises from RCA in <60% patients, LCx artery <40%, and both arteries with a dual blood supply in remaining cases

• Midportion of RCA usually gives rise to one /several medium-sized acute marginal branches supply anterior wall of RV and may provide collateral circulation in LAD occlusion

Page 62: Cardiac Catheterization and Angiography

Right Coronary Artery (2)• RCA terminates in PDA and one/more RPL branches• RCA traverses both AV and IV grooves multiple projections are

needed to visualize each segment• LAO ± cranial/caudal angulation: ostium of RCA• Left lateral view: ostium of RCA in difficult cases, identified by reflux

of contrast material from RCA, which also delineates aortic root with swirling of contrast in ostium region

• LAO cranial/caudal: proximal RCA, but markedly foreshortened in RAO projections

• LAO cranial, RAO, and left lateral projections: mid- portion of RCA• LAO cranial or AP cranial: Origin of PDA, posterolateral branches• AP cranial or RAO projection: midportion of PDA

Page 63: Cardiac Catheterization and Angiography

RCA Dominance• Dominant (85%)

• Supply PDA and at least one posterolateral branch (right dominant)

• PDA courses in inferior IV groove, gives rise to small inferior septal branches, which pass upward to supply lower portion of IVS and interdigitate with superior septal branches passing down from LAD

• After giving rise to PDA, RCA continues beyond crux cordis as right posterior AV branch along distal portion of posterior (left) AV groove, terminating in one or several posterolateral branches supplying LV diaphragmatic surface

• Nondominant/Left dominant (15%)• One half have left PDA and left posterolateral

branches that are provided by distal LCx• RCA is very small, terminates before reaching

crux, does not supply LV• Codominant/Balanced (remaining)

• RCA gives rise to PDA, LCx provide all of posterolateral branches

http://www.syntaxscore.com/

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Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 65: Cardiac Catheterization and Angiography

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 66: Cardiac Catheterization and Angiography

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 67: Cardiac Catheterization and Angiography

Standardized Projection Acquisition• Each coronary artery should be visualized using different projections that

minimize vessel foreshortening and overlap• AP view + shallow caudal angulation often obtained first to evaluate LMCA • Other important views:

• LAO cranial (middle and distal LAD), leftward positioning of image intensifier should be sufficient to allow separation of LAD, diagonal, and septal branch

• LAO caudal (LMCA, origin of LAD, and proximal LCx)• RAO caudal (LCx and marginal branches)• Shallow RAO/AP cranial (mid and distal LAD)

• RCA at least two views (LAO & RAO):• LAO cranial (RCA and origin of PDA and posterolateral branches)• RAO (mid-RCA and proximal, middle, and distal termination of PDA)• AP cranial may be useful (distal termination of RCA)• Left lateral (ostium of RCA and midportion of RCA with separation of RCA and its

RV branches)

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Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 69: Cardiac Catheterization and Angiography

Congenital Abnormalities of Coronary Circulation• Divided into those that cause

and do not cause myocardial ischemia

• Malignant features of anomalous coronaries: slitlike ostium, acute angle of takeoff, intramural course, significant compression between aorta and pulmonary trunk

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 70: Cardiac Catheterization and Angiography

Myocardial Bridging• 3 major coronary arteries course

along epicardial surface• Occasionally, short segments

descend into myocardium for variable distance myocardial bridging (5-12%), usually LAD

• “Bridge” of myofibers passes over involved segment of LAD each systolic contraction cause narrowing of artery

• Angiography: bridged segment is of normal caliber during diastole, abruptly narrows with each systole

• No hemodynamic significance in most cases, may be associated with angina, arrhythmia, depressed LV function, myocardial stunning, early death after cardiac transplantation, SCD

Smithuis R, Willems T. Coronary anatomy and anomalies. Radiology Department of the Rijnland Hospitaland the University Medical Center Groningen. http://www.radiologyassistant.nl/

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Assessing Lesion Complexity

• Heterogeneity of composition, distribution, and location of plaque results in unique patterns of stenosis morphology

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

Page 72: Cardiac Catheterization and Angiography

Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwald’s Heart Disease 10 th edition. 2015

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Quantitative Angiography

• Quantitative analysis of digital angiograms:• Image calibration:

• Using contrast-filled diagnostic or guiding catheter as a scaling device, yielding a calibration factor in millimeters per pixel

• Arterial contour detection (mapping):• Drawing center line through segment of interest• Linear density profiles are constructed perpendicular to center line, and weighted

average of 1st and 2nd derivative functions is used to define catheter or arterial edges• Individual edge points are connected using automated algorithm, and outliers are

discarded and edges are smoothed• The automated algorithm is applied to selected segment, absolute coronary dimensions

& percent diameter stenosis are obtained

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Pitfalls of Coronary Angiongraphy• Coronary angiography limitations:

• substantial interobserver variability• lack of correlation with functional measures with intermediate (40% to 70%)

stenoses• inability to identify vulnerable plaque lesions that may be predisposed to

rupture

• Technical factors can be mitigated at time of image acquisition to improve interpretations:

• Inadequate vessel opacification• Eccentric stenoses• Superimposition of branches• Microchannel recanalization

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Inadequate Vessel Opacification

• Causes:• Increased native coronary flow in LVH, aortic insufficiency, or

anemia• Competitive filling from collateral branches or bypass graft

conduits• Catheter positioning that is not “in line” with coronary ostium• Use of a smaller (4F) injection catheter• Dislodgment of diagnostic catheter during injection of contrast

agent• Overcome by:

• Forceful injection of contrast agent so long as catheter tip position and pressure recording confirm safety of such a maneuver

• Switching to angioplasty-guiding catheter (soft, short tip, larger lumen than diagnostic catheter)

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Eccentric Stenoses• Hemodynamic significance is dependent on percentage area

stenosis, not “worst” percentage diameter stenosis • Difficulty in ascertaining hemodynamic significance of eccentric and

bandlike lesions measurement of fractional flow reserve (FFR) with micromanometer-tip guidewire across abnormal region during I.V. adenosine

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Superimposition of Branches

• Common LAD & parallel diagonal branches• May occur ostium of obtuse marginal branch of LCx & origin of RV

branch of RCA• Obtain sufficient angulation to identify exact anatomy at origin of

side branch• Cranial projections for LAD• Caudal projections for LCx• Left lateral projection for RCA

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Microchannel Recanalization

• Angiography lacks resolution to differentiate 90% stenoses from recanalized total occlusions with microchannels & bridging collaterals

• Recanalization development of multiple tortuous channels small, close to one another, impression of single, slightly irregular channel

• Wire crossing may not be possible in some cases unless advanced wire techniques are used

Page 80: Cardiac Catheterization and Angiography

Thank You