1
CORONARY ANGIO
CARDIAC CATH
& Ablation Procedures
Lecture # 3 A
Cardiac Anatomy & Circulation
& Pathology Review # 3B
RT 255 (rev 2011/2014) Dawn Charman, M.Ed,R.T
Reference:
Frank. Merrill's Atlas of Radiographic Positioning and Procedures, 11th 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=kY5gKdFWT3k&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*
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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
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Aortography
Coronary Angiography
Pulmonary Angiography
PTCA
Stents
Cardiac Ablations
Thrombolytic Therapy
Valvuloplasty
Pulmonary Stenosis
Aortic Stenosis
Tricuspid Stenosis
Mitral Stenosis
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Who performs the procedure?
• The Interventional
Radiologist /
Cardiologist
• who specializes in
the Angioplasty
procedure.
• CIT Technologist
• Nursing
• Other support staff
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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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Done in a “Cath Lab”
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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
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Basic info about procedure
 IV sites in either arm, groin, or neck.
 Flexible catheter inserted to IV through the blood vessel.
 Then, cathether is threaded thorough the blood vessel to
the heart.
 Pressure measured at this point.
 Iodinated contrast injected through catheter once it
reaches the heart.
 Fluoroscopy guides the
cardiologist
with the catheter location.
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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
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Normal Rt & Lt Coronary Arteries
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Which area is demonstrated?
How are the vessels magnified ?
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Why Is A Cardiac Catheterization Done?
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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
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Why is cardiac catheterization done?
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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:
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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
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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
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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
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Patient Prep for Cath
Prior to exam
 Patient History
 Blood work
 Electrocardiogram
 Stress Test/ Echo
 Chest x-ray
 ?Nuc Med Perfusion
 Clear liquids only for
kidney hydration - then
NPO 4-6 hrs before
procedure
Occur in cath lab
 Hair shaved @ IV site
 BP cuff placed
 Oxygen administered
 EKG leads placed
 Local anesthesia
administered by IV
 Other meds for nausea
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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.
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• 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
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Cardiac catheterization
Imaging
For the Rt
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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
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Contrast Media
Iodinated non-ionic water-based contrast
Examples of contrast used are:
 Visipaque
 Hypaque (PTCA only)
for balloon filling
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What Method is this?
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Seldinger Technique
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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
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• 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
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•
Seldinger Tech is a percutaneous method for the femoral
approach
•
Radial, Subclavian & jugular may also be
used depending on Physician choice and
Pt condition
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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.
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Complications
• Minor:
– Pain
– Swelling
– Bruising
• Major
– Blood clots
– Damage to heart or blood vessels
– Normal electrical system damage
– Death
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What is this?
When is it used in
Cardiac Cath?
• used to inject a large amount
(25 to 50 mL) of contrast
material into either the right
or left ventricle the aortic root,
or the pulmonary vessels.
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CARDIAC CATHETERS
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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=yzxSrLa1d0g
A:Judkins RT
B:Judkins LT C:
Pigtail
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Enlarged coronary artery
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Cardiac Cath
Normal vs Stenosis
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Guidewires & Needles
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Swan-Ganz Catheters
Video of swan ganz procedure:
http://www.youtube.com/watch?v=Lb
1Z3bndmA8&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.
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•
Percutaneous Transluminal Coronary Angioplasty (PTCA)
Otherwise known as:
• Balloon Angioplasty
• 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.
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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
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Balloon angioplasty and a stent are used to open up
the stenotic left brachiocephalic vein. Excellent
blood flow was restored in subsequent images.
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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.
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Prevention of
Restenosis
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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.
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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.
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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.
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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.
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Stent Placement
• http://images.google.com/imgres?imgurl=http://www.nhlbi.nih.gov/he
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ov/health/dci/Diseases/stents/stents_all.html&usg=__xDlbsaX9JhuY
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AAA
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Abdominal Stent
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A stent graft or endograft used to repair aneurysm in the aorta and iliac region.
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AORTOGRAM
Review exams &
anatomy
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AORTOGRAM
Review exams &
anatomy
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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
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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.
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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
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CARDIAC
ABLATION
Cardiac Ablation
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RF ABLATION
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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
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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
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Atrial flutter / ablation
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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
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Pulse
ECG
Chest pain
Nausea
Syncope
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• 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.
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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
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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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CINE
• HIGHEST IN RADIATION DOSE
• TO THE PATIENT / TECHNOLOGIST
• 1 MR/FRAME X 60 FRAMES/SEC FOR 30
MINUTES = ?
• HEAT LOADS?????
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1 MR/FRAME X 60 FRAMES/SEC FOR
30 MINUTES =
• 1 X 60 = 60 mR/sec
• 60 mR/sec x 60 sec = 3600mR/min
• 3600mR/min x 30 min =
• 108000 mr OR 10.8 R
CINE DOSE
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Imaging Considerations
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Magnetic resonance imaging (MRI)
– Recently gained in popularity for use in cardiac studies
– Uses cine loop
– May be ECG gated
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Magnetic resonance angiography (MRA)
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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
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Doppler Ultrasound
•Echocardiography
•M-mode echocardiography
•2-D echocardiography
•Real-time imaging
•Transesophageal
echocardiography (TEE)
•Spectral Doppler
•Color Doppler
•Carotid stenosis, DVT
•Stress echocardiography
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Imaging Considerations
• Computed tomography (CT)
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•
Cardiac scoring
• EBCT
• Spiral CT
CT angiography (CTA)
Heart CT 3D
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Name of Exam?
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CHECK OUT THE LIVE ACTION!
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