1 CORONARY ANGIO CARDIAC CATH Ablation Procedures Lecture

1 CORONARY ANGIO CARDIAC CATH & Ablation Procedures Lecture # 3 A Cardiac Anatomy & Circulation & Pathology Review # 3 B RT 255 (rev 2011/2014) Dawn Charman, M. Ed, R. T Reference: Frank. Merrill's Atlas of Radiographic Positioning and Procedures, 11 th 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=k. Y 5 g. Kd. FWT 3 k&feature=related

3 Cardiac Catheterization also 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*

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

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: 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

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

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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 ?

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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 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

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 Patient Prep for Cath Prior to exam Ø Patient History Ø Blood work Ø Electrocardiogram Ø Stress Test/ Echo Ø Chest x-ray Ø ? Nuc Med Perfusion Ø Clear liquids only for kidney hydration - then NPO 4 -6 hrs before procedure Occur in cath lab Ø Hair shaved @ IV site Ø BP cuff placed Ø Oxygen administered Ø EKG leads placed Ø Local anesthesia administered by IV Ø Other meds for nausea

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 catheterization Imaging 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: ü Visipaque ü 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

• 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 28 • Seldinger Tech is a percutaneous method for the femoral approach • Radial, Subclavian & jugular may also be used depending on Physician choice and Pt condition

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 in Cardiac Cath? • used to inject a large amount (25 to 50 m. L) 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. Cardiac cath video: http: //www. youtube. com/watch? v=yzx. Sr. La 1 d 0 g A: Judkins RT B: Judkins LT C: Pigtail

33 Enlarged coronary artery

34 Cardiac Cath Normal vs Stenosis

35 Guidewires & Needles

36 Swan-Ganz Catheters Video of swan ganz procedure: http: //www. youtube. com/watch? v=Lb 1 Z 3 bndm. A 8&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. 36

37 • Percutaneous Transluminal Coronary Angioplasty (PTCA) Otherwise known as: • Balloon 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/he alth/dci/images/stent_restenosis. gif&imgrefurl=http: //www. nhlbi. nih. g ov/health/dci/Diseases/stents_all. html&usg=__x. Dlbsa. X 9 Jhu. Y bp. Voj. Lcz 19 apr. I=&h=513&w=450&sz=59&hl=en&start=20&tbnid=v. Wwqa. G-RNW 7 M M: &tbnh=131&tbnw=115&prev=/images%3 Fq%3 Dabdominal%2 Bst ents%26 gbv%3 D 2%26 hl%3 Den 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 AORTOGRAM Review exams & anatomy

50 AORTOGRAM Review exams & anatomy

51 During 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

52 After 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.

53 Recovery • 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

54 CARDIAC ABLATION Cardiac Ablation

55 RF ABLATION

56 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 • 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

57 Atrial flutter / ablation

58 Cardiac 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

59 • 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

61 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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63 CINE • HIGHEST IN RADIATION DOSE • TO THE PATIENT / TECHNOLOGIST • 1 MR/FRAME X 60 FRAMES/SEC FOR 30 MINUTES = ? • HEAT LOADS? ? ?

64 1 MR/FRAME X 60 FRAMES/SEC FOR 30 MINUTES = • 1 X 60 = 60 m. R/sec • 60 m. R/sec x 60 sec = 3600 m. R/min • 3600 m. R/min x 30 min = • 108000 mr OR 10. 8 R CINE DOSE

65 Imaging 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 scanning Perfusion Scanning • Myocardial perfusion scan • Most widely used procedure • Gated cardiac blood pool scans • Used to evaluate ventricles • Positron emission tomography (PET) Nuclear cardiology Used to diagnose CAD, congenital heart disease, and cardiomyopathy

67 Doppler Ultrasound • Echocardiography • M-mode echocardiography • 2 -D echocardiography • Real-time imaging • Transesophageal echocardiography (TEE) • Spectral Doppler • Color Doppler • Carotid stenosis, DVT • Stress echocardiography

68 Imaging Considerations • Computed tomography (CT) • • Cardiac scoring • EBCT • Spiral CT CT angiography (CTA) Heart CT 3 D

69 Name of Exam?

70 CHECK OUT THE LIVE ACTION! • http: //images. google. com/imgres? imgurl=http: //w ww. heartsite. com/assets/images/cardiac_cath_ man. jpg&imgrefurl=http: //www. heartsite. com/htm l/cardiac_cath. html&h=350&w=269&sz=88&tbnid =Ktr. NOVm. ZWv 3 nh. M: &tbnh=116&tbnw=89&hl=e n&start=57&prev=/images%3 Fq%3 Dcardiac%2 Bc