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Catheterization
and
Coronary Angiography
Andre Tritansa Faizal
Nurnajmia Curie Proklamatina
History
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
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
Relative Contraindication to
Diagnostic Cardiac
Catheterization
Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th
Edition, 2015.
Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.
Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.
Balloon
Flotation
Catetherizatio
n
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.)
Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.
Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.
Hemodynamic Data
Pressure measurement
Measurement of Flow
Determination of vascular resistance
Ohms Law:
Q= P/R
Pepine C,Hill JA, Lambert CR (eds). Diagnostic and Therapeutics Cardiac Catheterization.3rd ed. 1998
Normal
Pressure
Most reliable
Low cardiac
output
High cardiac
output
Least reliable
High cardiac output
Pulmonic regurgitation
Tricuspid regurgitation
Intracardiac shunting
Angiographic
Normal-shaped
ventricle
Extensive segmental
wall motion
abnormalities
arrhytmia
Aortic regurgitation
Mitral regurgitation
Fick method
Thermodilutio
n
Shunt
Quantification
Flamm formula
Flow ratio
Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.
Systemic Vascular
Resistance
Pulmonal Vascular
Resistance
Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.
Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.
Bonow RO, et al (eds). Braunwald Heart Disease: A Textbook of Cardiovascular medicine. 10th Edition, 2015.
Coronary Angiography
Outline
Overview
Indications and Contraindications
Complications
Technique
Pitfalls
Overview
Coronary angiography: imaging technique that uses Xrays 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
http://patient.info/health/coronary-angiography
Kern M. Do You Know Your Radiation Dose During Your Cath? Cath Lab Digest. Volume 19 - Issue 6 - June 2011
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015
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
Complications
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015
Technique of Coronary
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
http://www.premierhealthspecialists.or
g/
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: Braunwalds Heart Disease 10 th edition. 2015
Judkins Catheters
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: Braunwalds Heart Disease 10 th edition. 2015
Amplatz Catheters
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: Braunwalds Heart Disease 10 th edition. 2015
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: Braunwalds Heart Disease 10 th edition. 2015
Anticoagulants
Rx to contrast agents:
1. Mild (9%)grade I: single episode of
emesis/nausea/sneezing/vertigo
2. Moderate (9%) grade II: hives or
multiple episodes of
emesis/fevers/chills
3. 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
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.
Syntax Score
http://www.medscape.com/
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 patients head
Caudal view : image detector is tilted down toward patients feet
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015
- Best angiographic
projections for LAD :
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
RCA Dominance
Dominant (85%)
Codominant/Balanced (remaining)
http://www.syntaxscore.com/
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015
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: Braunwalds Heart Disease 10 th edition. 2015
Myocardial Bridging
3 major coronary arteries
No hemodynamic significance
in most cases, may be
associated with angina,
arrhythmia, depressed LV
function, myocardial stunning,
early death after cardiac
transplantation, SCD
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: Braunwalds Heart Disease 10 th edition. 2015
Popma JJ, et al. Coronoary ateriography and intracoronary imaging. In: Braunwalds Heart Disease 10 th edition. 2015
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
Overcome by:
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
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
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
Thank You