Upload
alaina-little
View
223
Download
0
Tags:
Embed Size (px)
Citation preview
Cardiac Catheterization
Older Equipment
Image intensifier
X-ray tube
Cine camera
Patient table
Videocameraor CCD
Cine film: Best spatial resolutionDynamic Digital: 60, 30, 15 frames/sVideo tape: Only as a back-up due to poor spatial resolution
Nonionic contrast: high iodine concentration (omnipaque 350)
Charge Coupled Device(CCD) replace vidicon, or plumbicon tubes and Image IntensifiersLightweightFast movements
Photoelectric detectors embedded in layers of silicon
Each pixel is 6 to 25 microns in size, and can store 10,000 to 50,000 electrons.
Modern equipment
Pixels ofa CCD arrangedin a matrix.
Each pixelcorrespondsto a pixel ona monitor
Software: Diagnostic reporting aid that replaces the hand drawings ofyesteryear.
Superior vena cavaPulmonary valve
Endocardium
Myocardium Pericardium
Interventricular septum
AV node
SA node Lt & Rt bundle branches(of HIS)
Selected injection of the left coronaryArtery: Cardiac Catheterization
Coronary Arteries
Left: Main CA Anterior descending: LAD (or anterior interventricular branch) Circumflex Diagonal branches
Right: Main Posterior descending: PDA (or posterior interventricular branch) Marginal branch
Perforating branches to myocardium
Coronary Arteriography
Rt coronary A
Rt Marginal Branch
Post. Descending A (PDA)(Post Interventricular A)
Rt coronary A
Rt Marginal Branch
Post. Descending A (PDA)(Post Interventricular A)
RAO view
LAO view
Lt coronary A
Circumflex Branch of LCA
Lt. Ant. Descending: LAD (Ant. interventricular branch)
Diagonal Branches of LAD
Lt coronary A
Circumflex Branch of LCA
Lt. Ant. Descending (LAD)
Diagonal Branch of LAD
LAO view
RAO view
Indications, Contraindications, and Risks for Cardiac Catheterization
Angina (vs indigestion)Poor exercise toleranceChest pain/pressure, left arm, jaw (or silent)MI from CAD
Contraindications
Cardiac or CADRecent CVASepsis
Risks
bradycardia & hypotensionPVCsV TachV Fib
Angiocardiography (Chambers and Valves)
* Septal defects (PDA)* Valvular disease (Pulmonary valve stenosis casues increased pressure in Rt. vent)* Transposition of great vessels (Dextra cardia) * Tetralogy of Fallot
6 f pig for chambers, 40-60 cc of contrast
Fetal Circulation
Demonstrating the origins of patent ductusarteriosis (PDA) andpatent foramen ovale
Left Ventriculogram
Calculating the ejection fraction of the left ventricle is accomplished by defining the edge of the ventricle wall during systole and diastole (top), by tracing the borders (bottom), and allowing the computer to do its work.
T TP
Q
R
S
Systole Diastole
Hemodynamics: Appendix B in Handbook of Radiologic Procedures
With the catheter in place,and the manifold connected,accurate pressures canbe taken within chambersor vessels through a device called a strain gauge
The Manifold and strain gauge transducer form a closed system
Hemodynamics: Appendix B in Handbook of Radiologic Procedures
Contrast HeperinizedSaline flush
Strain gaugetransducer
Systolic pressuremeasured throughthe catheter in the left ventricle.
Syringe for hand injections of contrast and flushing catheter
Manifold
Waste fluid
Pulmonary Wedge Pressures
The right heart is accessed viapuncture of the femoral vein. Following the normal blood flow, apartially inflated balloon aids in placement of the Swan-Ganz catheter tip in the pulmonary trunk, or pulmonary arteries.
With the balloon fully inflated andwedged in the pulmonary trunk thepressure is the same as in the leftatrium, (green arrows) which is otherwise difficult to access.
VenaCava
Aorta
Pulmonaryveins
Pulmonarytrunk
Pulmonary arterioles,capillaries, & venules
Pulmonary Wedge Pressure
In patient’s with nocardiac disease orpulmonary hypertensiona wedge mean pressure of > 25 mm Hgindicates thrombus
40 mm Hg indicates 60% - 70% obstruction.
Pressure in the rightor left pulmonaryarteries, though slightly higher, issimilar to that in the trunk vessel.
T TP
Q
R
S
Systole Diastole
Pulmonary wedge: mean < 12
mm Hg
10
5
a
cv
T TP
Q
R
S
Systole Diastole
Pulmonary artery: mean 9-17Systolic 15-30, Diastolic 4-14
mm Hg
10
5
20
15
Pressure wave formssuperimposed on ECG
T TP
Q
R
S
Systole Diastole
Right Atrium: Mean 0-8
mm Hg
10
5
a c
v
x
y
T TP
Q
R
S
Systole Diastole
Left Atrium: Mean 2-12Same as pulmonary wedge
mm Hg
10
5
a
c
v
Atrial Pressure Wave Formssuperimposed on ECG
T TP
Q
R
S
Systole Diastole
Right Atrium: Mean 0-8
mm Hg
10
5
a c
v
x
y T TP
Q
R
S
Systole Diastole
Pulmonary wedge: mean 2-12
mm Hg
10
5
a
cv
T TP
Q
R
S
Systole Diastole
Left Atrium: Mean 2-12
mm Hg
10
5
a
c
v
T TP
Q
R
S
Systole Diastole
Pulmonary artery: mean 9-17Systolic 15- 30, Diastolic 4-14
mm Hg
10
5
20
15
Summary of Measurements from the Atria and Pulmonary vessels
As a generality thecharacteristics ofthe atria and pulmonary vesselsare essentially thesame.
The most notable difference is the rightatrium’s mean of< 5 mm Hg, versus the pulmonary wedge and left artium pressures of < 12.
The wedge andleft atrium wave formsare differentiated bythe phasic delay.
T TP
Q
R
S
Systole Diastole
Left Ventricle: Systolic 100-140, Diastolic 3-12mm Hg
100
50
150
T TP
Q
R
S
Systole Diastole
Right Ventricle: Systolic 15-30, Diastolic 0-8mm Hg
100
50
150
Ventricular Pressure Wave FormsCharacteristics of the right and leftventricles are similar, except the left is five to six times that of the right.
T TP
Q
R
S
Systole Diastole
Left Ventricle: Systolic 100-140, Diastolic 3-12mm Hg
100
50
150
T TP
Q
R
S
Systole Diastole
Aorta: Systolic 100-140, Diastolic 60-90mm Hg
100
50
150
Left Ventricular Pressure Compared to the Aorta
During ejection the pressure in the left atrium and aorta are the same upto the closure of the aortic valve (dicrotic notch). The pressure drop inthe ventricle is dramatic after valve closure (<12), but remains high (<90)in the aorta.
Dicrotic notch
Coronary Artery Disease (CAD)
CAD - stenosis from atherosclerosis causing ischemia. Leads to myocardial infarction (MI) and necrosis of themyocardium. Previous MIs are demonstated by impaired wall motion on angiocardiography.
Most common form of heart disease and the leading causeof death in the United States.
Primarily effects the right coronary, left coronary, andcircumflex arteries. Typically the left coronary is dominant, which is why a high grade blockage of it has been dubbed the “widow maker.”
* Temporary chest pain (angina),
* SOB
* Nausea
* Weakness
* Diaphoresis
* Left arm, shoulder & upper abdomen pain
* Tightness and burning in chest
Signs and Symptoms of CAD
Atherosclerotic disease of the: Has the sign of: Which may results in:Coronary artery Angina myocardial infaction (MI)Carotid artery Transient ischemic attacks (TIA) Cerebrovascular accident (CVA, stroke)Lower extremities Intermittent claudication Arteriosclerosis Obliterans
Blood tests Electrocardiogram (EKG) Echocardiography Exercise stress test Coronary angiography Myocardial perfusion imaging (nuclear) Electron-beam computed tomography (EBCT)Telemetry monitoring
Diagnostic Tests for CAD
• Lifestyle changes • Statin drugs: Lipid (cholesterol) lowering• Calcium channel blockers: or nitrate drugs dilate arteries allowing more
oxygenated blood to reach the myocardium • Beta blockers: control symptoms of angina by reducing the workload
on the heart. • Coronary artery bypass graft (CABG), (not open heart) was first used
in 1964. Veins, harvested from the leg (or internal mammary artery) are reversed and grafted from the aorta to the distal side of the blockage.
Prevention and treatment of CAD