Cardiovascular X-ray

Cathlab
Basics
 Contents

Contents

2 PREFACE 3 6 CORONARY ARTERIES 14

6.1 The Left Anterior
3 INTRODUCTION 4 Descending Artery (LAD) 14
3.1 Blood circulation 4 6.2 The Circumflex Artery (CX) 14
6.3 The Right Coronary Artery (RCA) 15
4 THE HEART 5 6.4 Other important coronary
4.1 The four chambers of the heart 5 artery branches 15
4.2 The cardiac cycle 6
4.3 ECG 6 7 CARDIAC PROCEDURES 16
7.1 Cardiac catheterisation 16
5 BLOOD PRESSURE 8 7.1.1 Projections 17
5.1 Pressure measurements 8 7.2 Optimize image quality 19
5.2 Left heart pressures 8 7.3 Interventions 21
5.2.1 Aortic pressure 9 7.3.1 PTCA 21
5.2.2 Left ventricle pressure 9 7.3.2 Stent placement 21
5.2.3 Left atrium pressure 9 7.3.3 Other ways of reducing a
5.2.4 Pullback pressure 10 coronary blockage 21
5.3 Right heart pressures 10 7.3.4 The four chambers of the heart 22
5.3.1 Right atrium 10 7.3.5 IABP 23
5.3.2 Right ventricle 11
5.3.3 Pulmonary artery 11 8 BASIC PATHOLOGY OF THE HEART 24
5.3.4 Pulmonary capillary wedge pressure 11 8.1 Arteriosclerotic coronary disease 25
5.4 Zero Calibration 12 8.2 Valvular diseases 25
5.5 Cardiac Output 12 8.2.1 Aortic valve stenosis 25
5.5.1 Thermodilution 12 8.2.2 Aortic regurgitation 25
5.5.2 Fick 13 8.2.3 Mitral stenosis 25
5.5.3 Ventriculography 13 8.2.4 Mitral regurgitation 26
8.3 Congenital diseases 26
8.3.1 Left-to-right shunt 26
8.3.2 Patent ductus Botalli 26
8.3.3 Coarctation of the aorta 26

2 Contents C ARDIAC BASICS

 2 Preface
This book "Cardiac catherisation Basics" is aimed for technicians
working in the cardiac catheterisation room who quickly like to refresh their
knowledge.
The purpose of this book is to give a basic overview of the anatomy,
physiology and pathology of the heart as a guidance for the catheterisation
procedure and to help to realize a good image quality.
Since this book only provides limited information, It has to be considered
only as an extra guidance tool and will not replace the application training
provided by the local organisation.

C ARDIAC BASICS Preface 3

3.1 Blood circulation

3 Introduction

3.1 Blood circulation

There are two distinct systems in the body for the blood circulation:
1.Pulmonary blood circulation
2. Systemic blood circulation

Pulmonary circulation
The pulmonary arteries and veins carry blood from the heart to the lungs and
return it to the heart. Blood which returns from the body to the heart is
pumped into the lungs via the pulmonary artery to the lungs. With
breathing, the air passes into the lungs through progessively smaller airways
called bronchioles. The lungs contain millions of bronchioles, all leading to
alveoli, microscopic sacs where oxygen and carbon dioxide are exchanged.
The oxygen rich blood is collected into the pulmonary veins of each lung and
is returned via the heart into the systemic circulation.

Systemic circulation
The systemic arteries carry blood via the aorta from the heart to all other
parts of the body and return it to the heart via the vena cava inferior and
superior. This oxygen rich blood supplies all organs and tissue of the body via
the capillaries. There it exchanges the oxygen with carbon dioxide and waste
blood circulation products.

4 Introduction C ARDIAC BASICS

 The four chambers of the heart 4.1

4 The Heart

R. Pulmonary The human heart is a muscular pump. The muscle layer

artery
Aorta
that takes care of the contraction of the heart to decrease
Sup. Vena L. Pulmonary the size and forces the blood out of its chambers is called
Cava artery
L. Pulmonary myocardium.
veins Normally the size of the heart is a little bit larger than a
Left human fist. It pumps about 8000 litres of blood each day.
Atrium Reaching the age of 70 years, the number of heart beats
Right
Atrium
Mitral valve will be over 2.5 billion.
Aortic The heart is divided into two halves, the right and left, by a
valve
Tricuspid Pulmonary
Valve
main septum which extends from the base to the apex.
Valve Left
Ventricle There is no communication between these halves after
birth.
Inf. Vena Right The right side pumps the blood to the lungs and is less
Cava Ventricle powerful than the left side which is the pump for the
systemic circulation that has to drive the oxygen saturated
blood to the organs.
blood circulation within the heart

4.1 The four chambers of the heart

Each half of the heart consists of the two chambers which communicate
through a valve. The upper chambers are called atria, the lower chambers are
called ventricles.

In total the heart has four valves:

Aortic
Valve - The mitral valve is between the left atrium and ventricle
Pulmonary - The tricuspid valve is between the right atrium and ventricle
Valve
- The pulmonary or pulmonic valve is between the right ventricle and the
Mitral T ricusp id pulmonary artery.
Valve Valve
- The aortic valve is between the left ventricle and the aorta.
cross section of the heart

C ARDIAC BASICS The Heart 5

4.2 The cardiac cycle

4.2 The cardiac cycle

The heart beats automatically although it is under the control of the nervous
Sin u s N o de
system for it receives innervation from the vagus nerve and the sympathetic
A V N ode
nervous system. The pumping action of the heart consists of a contraction or
systole and a relaxation or diastole. Both atria contract simultaneously,
R igh t H IS B u n d le
driving their contents into the relaxed ventricles during ventricular diastole.
A triu m The ventricles then simultaneously go into systole whereas the atria go into
R igh t B u n d le
Le ft B u n d le
the diastole and blood flows into the atria from the vena cava to be
discharged into the ventricles during the next atrial systole. The usual adult
rate of the heart is about 70 BPM (beats per minute) but it increases during
Pu rk in je exercise or excitement and in various abnormal conditions.
F ib ers The rhythm of the cardiac cycle results from the coordination of the
myocardial contractions achieved by special areas in the myocardium. The
cardiac impulse starts in the sino-atrial node situated in the wall of the right
electrical circuit of the heart atrium, it spreads to the atrio-ventricular node and is conducted from this
point by the Bundle of His that divides into several bundle branches to all
parts of the ventricles. The cardiac cycle is accompanied by electrical changes
that can be detected by the electrocardiograph (ECG).

4.3 ECG
PQ ST
A normal ECG has the following features:
P T U Wave
QRS
Wave W ave non constant
Complex

Calibration • P Wave: depolarisation. Atrial contraction begins (Atrial depolarisation)

1 mV R
• PR interval: Atrial contraction
• QRS complex: Ventricular contraction begins (Ventricular depolarisation)
T • ST segment: rapid systolic ejection
+ P (U)
• T Wave: due to ventricular repolarisation (relaxation of ventricular
0
-
muscle)
Q
S

ECG

6 The Heart C ARDIAC BASICS

 ECG 4.3

With a normal sinus rhythm, one would expect the following:

Atrial Systole
0.1 s
Complete
cardiac
diastole Ventricular
0.4 s systole
0.3 s

heart cycle

The total duration of one cycle is approximately 0.8 seconds

activity of the heart compared with the ECG

C ARDIAC BASICS The Heart 7

5.1 Pressure measurements

5 Blood pressure
Pressure (mm Hg)
closing of The pulse is the dilatation of an artery caused by the blood
120 Aortic Valve pressure increase due to the contraction of the heart. Blood
Aortic
100 pressure opening pressure is the pressure exerted by the blood against the vessel
80
of
Aortic
wall. The systolic pressure is determined primarily by the rate
Valve L. Ventricular and volume of ventricular ejection in relation to the arterial
pressure
60 elasticity.
40
L. Atrial opening of Systolic pressure is the pressure during contraction of the heart,
AV Valves
20
pressure normally between 100 to 120 mm Mercury (approximately 16 k
0 closing of AV Valves Pascal).
0.2 0.4 0.6 T im e (s)
The diastolic pressure is determined by the rate of diastolic
ECG = 72 bpm pressure drop and the heart rate as it effects the duration of the
P
R
T
diastole. Diastolic pressure is the pressure during relaxation of
P
the heart, normally between 65 and 80 mm Mercury
Q S
(approximately 11 k Pascal)
blood pressure

5.1 Pressure measurements

The three principal attributes of circulating blood are flow, volume and
pressure. Various methods for measuring cardiac output provide information
concerning total blood flow through the heart, but of these three important
variables, only blood pressure is routinely measured in patients. Direct
pressure measurements have intrinsic value in determining certain conditions
under which the circulatory system is functioning.
During a coronary angiography several pressures at different catheter
positions are measured.

5.2 Left heart pressures

The following graphs give only an indication of the shape of the graph for
each different measured pressure. The pressure gives only a rough indication
of possible measured values.

8 Blood pressure C ARDIAC BASICS

 Left heart pressures 5.2

5.2.1 Aortic pressure

200
A catheter is guided into the
ascending part of the aorta. 160

Example: 120
Systolic pressure: 118 mm Hg AO
80
Diastolic pressure: 57 mm Hg
Mean pressure: 81 mm Hg 40

Heart rate: 54 bpm P1

5.2.2 Left ventricle pressure

A catheter is guided into the left ventricle 200

passing through the aortic valve. 160

Example: 120
Systolic pressure: 166 mm Hg
80
End diastolic pressure: 32 mm Hg
Heart rate: 80 bpm 40 LV

P1

5.2.3 Left atrium pressure

A catheter may be pushed into the left
atrium passing through the mitral valve.
If there is a mitral stenosis it may not 100

be possible to push the catheter into 80

the left atrium. The Pulmonary 60

Capillary Wedge pressure from the LA

right heart catherisation may 40

substitute the left atrium pressure. 20

P2

Example:
Value: 18 mm Hg
Mean: 13 mm Hg
Heart rate: 82 bpm

C ARDIAC BASICS Blood pressure 9

5.3 Right heart pressures

5.2.4 Pullback pressure

A Catheter is pulled back from the left
ventricle into the aorta. 200
Example:
left ventricle 160

Systolic pressure: 188 mm Hg 120

End diastolic pressure: 151mm Hg 80

AO

Heart rate: 167 bpm

aorta 40 LV

Systolic pressure: 190 mm Hg P1

Diastolic pressure:135 mm Hg
Mean pressure: 125 mm Hg
Heart rate:158 bpm

This pullback method is to make an assessment of the aortic valve and very
common during a cardiac procedure. the two pressures are used for the
pressure gradient that plays a role in the assessment of valvular stenosis.

5.3 Right heart pressures

5.3.1 Right atrium
100
A catheter is guided into the right
atrium. 80

Example: 60

Value: 18 mm Hg
40
Mean: 15 mm Hg
Heart rate: 89 bpm 20 RA

P2

10 Blood pressure C ARDIAC BASICS

 Right heart pressures 5.3

5.3.2 Right ventricle

A catheter is guided into the right 100

ventricle passing through the 80

tricuspid valve. 60
Example:
Systolic pressure: 42 mm Hg 40

End diastolic pressure: 8 mm Hg 20

Heart rate: 84 bpm
P1 RV

5.3.3 Pulmonary artery

A catheter is pushed into the
pulmonary artery passing 80
through the pulmonary valve.
Example: 60

Systolic pressure: 29 mm Hg 40

Diastolic pressure: 15 mm Hg PA
20
Mean pressure: 21 mm Hg
Heart rate: 130 bpm P1

5.3.4 Pulmonary capillary wedge pressure

A catheter is guided into the left 80 RCW

or right pulmonary capillary
wedge position. 60

Example: 40

Value: 18 mm Hg 20
Mean: 13 mm Hg
Heart rate: 77 bpm P1

C ARDIAC BASICS Blood pressure 11

5.4 Zero Calibration

5.4 Zero Calibration

(For pressure measurements)
Zero point determination with the thorax gauge according Burri
Before starting a cardiac procedure, a zero calibration is done for
each patient. According to an international agreement, the
reference level for the pressure measurement system is the
pressure on the surface of the right atrium. It can be assumed
that the pressure there is identical to atmospheric pressure at the
end of expiration. It is therefore crucial before each examination
that the membrane of the pressure transducer (Dome) is
adjusted to the level of the patient’s right atrium before setting
the zero balance of the pre-amplifier.
This reference point is measured using a special tool that divides
the patient’s chest height into 2/5 and 3/5.

5.5 Cardiac Output

The cardiac output is mainly influenced by changes in the stroke volume and
the heart rate. (CO = SV x bpm)
The cardiac output in healthy adults is between 5 and 8 litres per minute.
During a cardiac procedure, the Cardiac Output (CO) is measured using
different techniques.

5.5.1 Thermodilution
Right Atrium Proximal lumen The Cardiac Output is measured using a special
Pulmonary Artery
Distal lumen
thermodilution device. A special Pulmonary artery balloon
catheter (Swan-Ganz) is used with a thermistor at the tip.
The catheter is positioned in the Pulmonary artery. A cold
T CO Thermistor fluid ( usually 10 ml saline for adults) is injected. This cold
Cardiac output saline mixes with the blood causing a decrease in blood
device
temperature. This is sensed by the thermistor.
Proximal
The cardiac output is measured by the change in temperature
Balloon RA over time.
Injectate
Distal PA

Thermodilution with a Swan-Ganz catheter

12 Blood pressure C ARDIAC BASICS

 Cardiac Output 5.5

5.5.2 Fick
Applied to the lungs, the Fick principle is used to calculate the volume of
blood required to transport the oxygen taken up from the alveoli per unit
time.
This calculation can be done using special hemodynamic software that
requires the following input:
- Haemoglobin (Hb)
- Venous oxygen saturation (VO2)
- Oxygen saturation taken from aorta
- Oxygen saturation from pulmonary artery
- Body surface area (BSA)
- Weight
- Height
- Sex

5.5.3 Ventriculography
With the help of X-ray images and special software of the system (Ejection
Fraction program), the cardiac output can be measured.

EF calculation of the left ventricle

C ARDIAC BASICS Blood pressure 13

6.1 The Left Anterior Descending Artery (LAD)

6 Coronary arteries

There are two main coronary arteries - the left and right.
Sup. Vena Cava
The left coronary artery begins as a main stem called the Left Main
Coronary Artery (LMCA) which varies between 1 and 15 mm in
Aortic Arch
length. This artery divides in two major branches, the Left Anterior
L. Main
R. Coronary Coronary Descending artery (LAD) and the Circumflex artery (CX).
Artery Artery
Circumfllex The Right Coronary Artery (RCA) is a single long vessel with
L. Coronary
Artery
smaller side branches.
The LAD and CX each supply large areas of heart muscle with
blood. The coronary artery tree is categorized into three systems
based on the mass of heart muscle which are supplied with oxygen.

Inf. Vena Cava branch of

R. Coronary Artery
Coronary arteries

6.1 The Left Anterior Descending Artery (LAD)

The LAD is a branch that runs on the front of the heart in the groove that
demarcates the left and right ventricles. This artery supplies oxygen and
nutrients to a large part of the inter-ventricular septum and the front wall of
the left ventricle. Obstruction of this artery causes infarction of a large
muscular area in the left ventricle and may be fatal.

6.2 The Circumflex Artery (CX)

The CX is the other major branch of the LMCA and turns backwards to run
along the groove between the left atrium and ventricle. This artery has
multiple smaller side branches that supply blood to the left margin of the
ventricle. Since this margin is obtusely angled, these branches are also called
obtuse marginal (OM) branches, of which there may be a varying number
(1-7). These OM branches also supply a considerable area of ventricle
muscle, and may cause serious damage if diseased.

14 Coronary arteries C ARDIAC BASICS

 The Right Coronary Artery (RCA) 6.3

6.3 The Right Coronary Artery (RCA)

The RCA is the other main coronary artery branch arising from the aorta and
running in the groove between the right atrium and ventricle. This artery is
usually smaller than the LMCA, and supplies a smaller area of heart muscle,
mainly the right ventricle. As it curves behind the heart, the RCA has two
side branches - the Posterior Descending Artery (PDA) and the Posterior Left
Ventricular Branches (PLB). The PDA supplies blood to the posterior
portion of the interventricular septum and the PLB supplies a part of the
back wall of the left ventricle.

6.4 Other important coronary artery branches

While the "big three" are the major branches, some smaller ones may be
quite important as well. The sino-atrial node artery supplies the S-A node
which is the pacemaker of the heart and sets its rhythm.
This branch comes off the RCA in 55% and off the LCA in the other 45%.
The atrio-ventricular node artery supplies the A-V node, which is located
between the atria and ventricles and controls spread of electrical impulses
from the atrium to the ventricle. While in 90% of cases this branch
originates from the RCA, in the other 10% it may be a branch of the CX.
Damage or blockage of this branch may result in a serious arrhythmia called
"heart block".

C ARDIAC BASICS Coronary arteries 15

7.1 Cardiac catheterisation

7 Cardiac procedures
The cath-lab is used for several procedures, the following will give an
overview of the most common diagnostic and intervention procedures.

7.1 Cardiac catheterisation

Cardiac catheterisation may be indicated for:
1.Unstable angina
2.Abnormal treadmill test
3.Valvular disease
4.Acute myocardial infarction (heart attack)
5.Cardiomyopathy and/or heart failure
The following information can be obtained from a cardiac catheterisation:
1 Determination of presence of stenoses (narrowing) in the coronary
arteries or coronary artery bypass grafts
2 Determination of how well the heart muscle squeezes (contractibility)
3 Evaluation of the heart valves
4 Measurement of various pressures inside the chambers of the heart
5 Determination of presence of any birth defects or shunts
Procedure
Catheters are pushed up in the aorta, usually via the femoral or brachial
artery and then into the coronary arteries. Contrast medium is injected to
assess blood flow through the artery while various exposures are taken from
different angles. Then another catheter, pigtail shaped, is placed into the
aorta where pressure measurements are made. This catheter is then advanced
across the aortic valve and pressures within the left ventricle are obtained.
The catheter is then attached to an injector and contrast medium is injected.
Pressure measurements are again taken after injection of contrast medium
and as the catheter is withdrawn back across the aortic valve and then
removed.

16 Cardiac procedures C ARDIAC BASICS

 Cardiac catheterisation 7.1

7.1.1 Projections
To visualise the coronary arteries several projections are necessary. When
mentioning the various projections, remember that L.A.O. rotation indicates
that the Image Intensifier is rotated to the left side of the patient. R.A.O.
rotation indicates that the Image Intensifier is rotated to the right side of the
patient. Using cranial angulation the Image Intensifier angulates to the
patient’s head while using the caudal angulation the Image Intensifier
angulates towards the patient’s feet.

LAO rotation RAO rotation

To recognize the different vessels one can think of the following hints:
• - The Circumflex lies closest to the spine
• - Only the LAD (Left Artery Descendens) reaches the apex
• - In L.A.O. position, the apex points to the left
• - In L.A.O. position, the LAD lies to the left
• - In L.A.O. position, the spine is on the right
• - In R.A.O. position, the spine is on the left

cranial angulation caudal angulation

• - In R.A.O. position, the apex points to the right.
• - In L.A.O. position, the RCA (Right Coronary Artery) resembles a “C”.

Left Coronary arteries

R.A.O. 30o
The Right Anterior Oblique R.A.O. projection at 30o permits the entire
circumflex system to be studies as well as the first centimetres of the anterior
inter ventricular artery.
L.A.O. 55/60o
The Left Anterior Oblique (L.A.O.) projection at 55/60o mainly studies the
diagonal arteries and the mid and distal parts of the LAD. On the other hand
the circumflex is not well defined.
L.A.0. 55/60o + 20o cranial projection
The cranial angulation of 20o combined with the L.A.O. projection at 55/60o
is especially useful to study the left main coronary artery.
Left Lateral projection
The left lateral projection, allows the study of the different segments of the
anterior inter ventricular artery, the first diagonal artery and the left marginal
artery.

C ARDIAC BASICS Cardiac procedures 17

7.1 Cardiac catheterisation

Right Coronary artery

Left lateral projection
This projection permits the study of the second (vertical segment of the right
coronay artery and the collateral branches (conus branch, right ventricular
artery, right marginal artery)
L.A.O. 45o + 15o caudal angulation
This projection allow the whole study of the R.C.A. and clearly defines the
region of the crux of the heart.
R.A.O. at 45o
The Right Anterior Oblique (R.A.O.) projection at 45o permits the survey of
the second (vertical) segment of the right coronary artery, the posterior inter
ventricular artery and the collateral branches (right ventricular and right
marginal arteries).

The projections described above are just some of the views used by physicians
to image the arteries of the heart. These projections may be altered,
depending on a patient’s vessel anatomy, or may be omitted if the physician
does not find them useful to the study.

Left ventricle angiogram

To measure various pressures and to visualize how well the
Antero-basal left ventricle contracts, a pigtail shaped catheter is used. This
anterior
R1 catheter has several side holes to make it possible to inject
R2 contrast using a high flow rate.
postero
basal R6

R5
R3 The left ventricle can be divided into several areas to
R4
determine which part of the ventricle muscle is not
L functioning properly.
inferior
Apical
LV angiogram The projection most used to visualise the left ventricle is
Example of area division in the left ventricle LAO 30o

18 Cardiac procedures C ARDIAC BASICS

 Optimize image quality 7.2

7.2 Optimize image quality

The patient’s treatment depends on the diagnosis. Therefore the image
quality plays a major role. To obtain the best image quality, the following
factors have to be taken into account.
Shutters
Shutters are built in the system to adjust the field of view and to avoid
showing white margins at the edges of the image that might interfere with
the perception of image detail. Be aware that if the field of view is set too
small, there is a risk to miss some of the anatomy.
Wegde filters
To prevent distracting highlights in the region of interest (lung tissue) that
will affect image quality, wedge filters can be used.
Protocol
Image quality is also determined by the protocol selected. Within each
protocol several parameters are optimised for a certain exposure technique or
projection. It is therefore of utmost importance to select the correct protocol
before starting a diagnostic exposure run.
Image Intensifier position
The image intensifier is moved away from the patient in preparation of the
next projection using a different rotation and or angulation. To avoid air gaps
that deteriorate image quality, the distance between the image intensifier and
the patient should be minimized every time again after change in projection
view.
Patient communication
A good patient communication will reduce patient physical or respiratory
movement during image acquisition.
Catheterposition

When starting an image acquisition, the best image quality is achieved when
the whole anatomy of the coronary arteries is visible without having to move
the table.
This is possible when having the catheter tip positioned correctly within a
certain area of the field of view on the monitor.

C ARDIAC BASICS Cardiac procedures 19

7.2 Optimize image quality

To give an indication of the position of the catheter tip for each projection,
the field of view is divided into 9 zones.
1 2 3
If the tip is within the zone 1,2,3 or 5, then in most of the acquired runs the
4 5 6 whole anatomy of the coronary arteries will be within the field of view
7 8 9 without having to move the table. Examples:
Left coronary arterty and Circumflex

1 1 1

RAO 30o RAO 30o Caudal 25o RAO 30o Cranial 25o

2 2/3
5

LAO 60o Cranial 25o LAO 50o Caudal 30o (Spider View) Lateral

Right coronary artery

2 1 2

LAO 60o RAO 30o LAO 60o Cranial 25o

20 Cardiac procedures C ARDIAC BASICS

 Interventions 7.3

7.3 Interventions
7.3.1 PTCA
Percutaneous Transluminal Coronary Angioplasty (PTCA) is a procedure to
attempt to open up a narrowed artery by using a catheter that has a balloon
at the tip of it. When the balloon is inflated, the pressure flattens the plaque
against the walls of the artery which will then improve the blood flow to the
heart.

Procedure

The balloon catheter has a radiopaque marker in the middle portion of the
balloon. Note that there are also balloon catheters with proximal and distal
markers. The central marker is placed in the middle of the coronary artery
stenosis. The balloon is then slowly inflated with a small hand-held pump
that is filled with contrast. The balloon is inflated until there is no dent in the
balloon. The balloon is left inflated anywhere from one to two minutes
depending on the individual case and watched under fluoroscopy. Several
inflations may be necessary to achieve the desired reduction of the stenosis.

7.3.2 Stent placement

Stent placement is a procedure that often follows the PTCA. Once the
narrowed artery is opened, a stent reduces the likelihood that the artery will
narrow again. Coronary stents are stainless steel frames attached to a special
designed balloon catheter. The stent is expanded by inflating the balloon.
Once the stent is expanded succesfully the balloon is deflated. The stent itself
is designed in such a way that it remains it shape after deflating the balloon.
Drug eluting stents reduce the risk of re-stenosis.

7.3.3 Other ways of reducing a coronary blockage

Instead of using a balloon there are other devices to increase the lumen of the
coronary arteries:

Angiojet
An angiojet can be used to widen a coronary artery that is narrowed due to a
fresh thrombus. This high pressure jet creates a low pressure region within
the blood vessel and the whole system acts like a vacuum cleaner and sucks
up the fresh thrombus.

C ARDIAC BASICS Cardiac procedures 21

7.3 Interventions

Atherectomy
Used on hard plaque which a balloon is unable to compress. A special
atherectomy catheter has a small knife to shave off the plaque. The catheter
consists of a shaft on which a balloon is mounted on one side, on the side
opposite the balloon there is an opening in the shaft, which allows the blade
to protrude. The catheter is positioned with the opening over the plaque and
the balloon inflated to hold the catheter in place. The blade is then moved
back and forth across the plaque, the shavings are sucked back via the
catheter. Once the plaque has been de-bulked, the normal PTCA procedure
or stent placement will follow.

Rotablator
The rotablator is primarily used for concentric hard plaque and calcified
lesions. It uses a diamond powder coated tip on a catheter at high speed
(80.000 to 150.000 rpm) to de-bulk the lesion prior to PTCA procedure and
stent placement.

7.3.4 Electrophysiology (EP)

Reason for an Electrophysiology study (EP) is arrhythmia, or abnormal heart
rhythm
EP mapping procedure.

Pacing wires are positioned in various areas in the heart. These wires are
connected to a large computer, which allows specific measurements of all
parts of the hearts electrical system. This test takes approximately 1 to 3
hours to complete. If the arrhythmia is reproduced the arrhythmia may
terminate itself, or an electrical shock, delivered through adhesive patches on
the chest and back may return the rhythm to normal.
Ablation

Catheter ablation is a technique to eliminate alternate pathways present in

the heart causing arrhythmias (abnormal heartbeats) that interfere with the
normal conduction.

22 Cardiac procedures C ARDIAC BASICS

 Interventions 7.3

Procedure
Once the area of the heart has been defined through catheter mapping, a
special ablation catheter is placed at the site of the abnormal pathway. Radio-
frequency waves are delivered through this catheter. The heat formed by this
catheter causes scar tissue on this pathway of cells so that the abnormal
conduction cannot pass through.
Pacemaker

Pacemaker implantation is done on patients with severe heart rhythm

disturbances. If the SA node sends impulses out too slowly, it results in a
rhythm that is too slow. This is called "Sick Sinus Syndrome". Another
situation may result from impulses being blocked at some point along the
electrical pathway in the heart. This is called heart block, and can also result
in a rhythm which is too slow.
Procedure
An incision is made, and the pacemaker lead is placed through the subclavian
vein which leads directly to the right side of the heart. A small pocket is then
made in the upper chest area and the pacemaker generator is placed. The lead
will be connected to the generator, checked and programmed. The incision is
then closed.

7.3.5 IABP
The Intra-Aortic Balloon Pump (IABP) is a mechanical device to reduce the
workload of the heart and to improve blood flow to the coronary arteries.
The pump consists of a balloon attached to the end of a catheter. The
balloon sits in the aorta and opens and closes in response to the hearts
contractions. After the heart contracts and propels oxygen-rich blood into
the aorta, the balloon rapidly opens up and propels some of the oxygen-rich
blood back toward the coronary arteries. Just before the hearts next
contraction, the balloon rapidly deflates creating a lower pressure in the aorta
so the heart does not have to work as hard to pump the blood out.

C ARDIAC BASICS Cardiac procedures 23

8.1 Arteriosclerotic coronary disease

8 Basic pathology of the heart

8.1 Arteriosclerotic coronary disease

In all blood vessels of all people some fatty material starts to build up on the
inside of the blood vessel walls. In some people the rate of deposit of fatty
material is faster than in others resulting in atherosclerose or arteriosclerosis.
Although the terms are used interchangeably, atherosclerose is a type of
arteriosclerosis that is characterised by deposits of plaque.
Arteriosclerosis is particularly dangerous when the vessel that is involved is a
coronary artery and the lumen is narrowed by 50 to 70% of its normal
diameter.
Arteriosclerosis can lead to angina pectoris, heart attack or myocardial
infarction.

8.2 Valvular diseases

The heart has four valves. Any of these valves may fail to function properly,
but most commonly the valves on the left side of the heart are affected. The
valves may narrow, called stenosis, or may close incorrectly, called prolapse.

8.2.1 Aortic valve stenosis

Aortic valve stenosis results in having the left ventricle to work harder to push
out the blood. As this occurs the muscular walls of the ventricle thicken.

8.2.2 Aortic regurgitation

When the aortic valve fails to close completely after the heart has pumped
out the blood into the aorta, blood leaks back into the left ventricle. This
may be the result of an endocarditis (infection) or heart attack. It may leave
the valve scarred resulting in improper functioning of the valve.

8.2.3 Mitral stenosis

A mitral stenosis results in an increase of pressure in the left atrium leading to
an elevation of the pressure in the lungs.

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 Congenital diseases 8.3

8.2.4 Mitral regurgitation

Improper closure of the mitral valve causes blood to leak from the left
ventricle back into the left atrium. This may be the result of an endocarditis
(infection) or heart attack. It may leave the valve scarred resulting in
improper functioning of the valve.

8.3 Congenital diseases

Valve damage is not the only congenital condition that can damage the heart.
Other forms of congenital heart disease include holes in the septum that
allow the blood to leak or flow directly from one chamber into another,
rather than flowing in the proper direction through the valves.

8.3.1 Left-to-right shunt

Part of the blood flow goes directly from the left side of the heart
to the right side of the heart. The hole can either be between the
atria or between the ventricles.
ASD The patent hole (foramen ovale) between the atria is called the
VSD Atrial-Septal-defect.
The hole between the ventricles is called the Ventricular-Septal -
Left-to-right shunt defect

8.3.2 Patent ductus Botalli

d. Botalli If the communication between the aorta and the pulmonary
veins remains after birth, de-oxygenated blood mixes with the
systemic circulation.

ductus Botalli

8.3.3 Coarctation of the aorta

This is a narrowing (stenosis) in the proximal descending part of
the aorta. The aortic valves are usually narrower than normal.

Coarctation

C ARDIAC BASICS Basic pathology of the heart 25

8.3 Congenital diseases

26 Basic pathology of the heart C ARDIAC BASICS