Cardiac Catheterization
Older Equipment
Video
camera
or CCD
Image intensifier
Cine
camera
Cine film: Best spatial resolution
Dynamic Digital: 60, 30, 15 frames/s
Video tape: Only as a back-up due to poor
spatial resolution
Nonionic contrast: high iodine concentration
(omnipaque 350)
Patient table
X-ray
tube
Modern equipment
Charge Coupled Device
(CCD) replace vidicon, or plumbicon
tubes and Image Intensifiers
Lightweight
Fast 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.
Pixels of
a CCD
arranged
in a
matrix.
Each pixel
corresponds
to a pixel on
a monitor
Software: Diagnostic
reporting aid that
replaces the
hand drawings of
yesteryear.
Superior vena cava
Pulmonary valve
AV node
SA node
Lt & Rt bundle branches
(of HIS)
Endocardium
Myocardium
Interventricular septum
Pericardium
Selected injection of the left coronary
Artery: 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
RAO view
Rt Marginal
Branch
Post. Descending A (PDA)
(Post Interventricular A)
LAO view
Rt coronary A
Rt Marginal
Branch
Post. Descending A (PDA)
(Post Interventricular A)
LAO view
Lt coronary A
Circumflex
Branch of LCA
Lt. Ant. Descending: LAD (Ant. interventricular branch)
Diagonal Branches of LAD
Lt coronary A
Lt. Ant. Descending (LAD)
RAO view
Circumflex
Branch of LCA
Diagonal Branch of LAD
Indications, Contraindications, and Risks for Cardiac Catheterization
Angina (vs indigestion)
Poor exercise tolerance
Chest pain/pressure, left arm, jaw (or silent)
MI from CAD
Contraindications
Cardiac or CAD
Recent CVA
Sepsis
Risks
bradycardia & hypotension
PVCs
V Tach
V 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 ductus
arteriosis (PDA) and
patent 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.
Hemodynamics: Appendix B in Handbook of Radiologic Procedures
With the catheter in place,
and the manifold connected,
accurate pressures can
be taken within chambers
or vessels through a
device called a strain
gauge
R
T
P
T
QS
Systole
Diastole
Hemodynamics: Appendix B in Handbook of Radiologic Procedures
The Manifold and
strain gauge
transducer form a
closed system
Strain gauge
transducer
Contrast
Heperinized
Saline flush
Waste fluid
Systolic pressure
measured through
the catheter in the
left ventricle.
Manifold
Syringe for hand injections of
contrast and flushing catheter
Pulmonary Wedge Pressures
The right heart is accessed via
puncture of the femoral vein.
Following the normal blood flow, a
partially inflated balloon aids in
placement of the Swan-Ganz
catheter tip in the pulmonary trunk,
or pulmonary arteries.
With the balloon fully inflated and
wedged in the pulmonary trunk the
pressure is the same as in the left
atrium, (green arrows) which is
otherwise difficult to access.
Aorta
Pulmonary
arterioles,
capillaries,
& venules
Vena
Cava
Pulmonary
veins
Pulmonary
trunk
Pulmonary Wedge Pressure
In patient’s with no
cardiac disease or
pulmonary hypertension
a wedge mean pressure
of > 25 mm Hg
indicates thrombus
40 mm Hg
indicates
60% - 70%
obstruction.
Pressure wave forms
superimposed on ECG
Pulmonary wedge: mean < 12
mm
Hg
a
R
10
c
v
5
T
P
T
QS
Systole
Diastole
Pulmonary artery: mean 9-17
Systolic 15-30, Diastolic 4-14
20
Pressure in the right
or left pulmonary
arteries, though
slightly higher, is
similar to that in
the trunk vessel.
R
15
10
5
T
mm Hg
Systole
P
T
QS
Diastole
Atrial Pressure Wave Forms
superimposed on ECG
Left Atrium: Mean 2-12
Same as pulmonary wedge
Right Atrium: Mean 0-8
mm Hg
10
mm Hg
R
T
c
v
5
T
P
x
Systole
Diastole
P
T
QS
Ty
QS
Systole
v
c
5
10
a
R
a
Diastole
Summary of Measurements from the Atria and Pulmonary vessels
Right Atrium: Mean 0-8
mm Hg
Pulmonary wedge: mean 2-12
mm Hg
R
a
10
R
10
a
v
P
T
y
x
5
T
QS
Systole
Diastole
mm Hg
T
Systole
Diastole
Pulmonary artery: mean 9-17
Systolic 15- 30, Diastolic 4-14
20
R
a
P
QS
Left Atrium: Mean 2-12
10
v
c
5
T
c
v
10
5
P
T
QS
Systole
5
T
mm Hg
Diastole
The most notable
difference is the right
atrium’s mean of
< 5 mm Hg, versus
the pulmonary wedge
and left artium
pressures of < 12.
R
15
c
T
As a generality the
characteristics of
the atria and
pulmonary vessels
are essentially the
same.
Systole
P
T
QS
Diastole
The wedge and
left atrium wave forms
are differentiated by
the phasic delay.
Ventricular Pressure Wave Forms
Characteristics of the right and left
ventricles are similar, except the left
is five to six times that of the right.
Right Ventricle:
Systolic 15-30, Diastolic 0-8
mm Hg
150
R
Left Ventricle:
Systolic 100-140, Diastolic 3-12
mm Hg
150
R
100
100
50
50
T
P
T
QS
Systole
Diastole
T
P
T
QS
Systole
Diastole
Left Ventricular Pressure
Compared to the Aorta
Left Ventricle:
Systolic 100-140, Diastolic 3-12
Aorta:
Systolic 100-140, Diastolic 60-90
mm Hg
150
mm Hg
150
R
100
100
50
50
T
P
T
T
QS
Systole
R
P
Dicrotic notch
T
QS
Diastole
Systole
Diastole
During ejection the pressure in the left atrium and aorta are the same up
to the closure of the aortic valve (dicrotic notch). The pressure drop in
the ventricle is dramatic after valve closure (<12), but remains high (<90)
in the aorta.
Coronary Artery Disease (CAD)
CAD - stenosis from atherosclerosis causing ischemia.
Leads to myocardial infarction (MI) and necrosis of the
myocardium. Previous MIs are demonstated by impaired
wall motion on angiocardiography.
Most common form of heart disease and the leading cause
of death in the United States.
Primarily effects the right coronary, left coronary, and
circumflex arteries. Typically the left coronary is dominant, which is
why a high grade blockage of it has been dubbed the “widow maker.”
Signs and Symptoms of CAD
*
*
*
*
*
*
*
Temporary chest pain (angina),
SOB
Nausea
Weakness
Diaphoresis
Left arm, shoulder & upper abdomen pain
Tightness and burning in chest
Atherosclerotic
disease of the:
Has the sign of:
Which may results in:
Coronary artery
Carotid artery
Lower extremities
Angina
Transient ischemic attacks (TIA)
Intermittent claudication
myocardial infaction (MI)
Cerebrovascular accident (CVA, stroke)
Arteriosclerosis Obliterans
Diagnostic Tests for CAD
Blood tests
Electrocardiogram (EKG)
Echocardiography
Exercise stress test
Coronary angiography
Myocardial perfusion imaging (nuclear)
Electron-beam computed tomography (EBCT)
Telemetry monitoring
Prevention and treatment of 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.