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CATHLAB BASICS PRESENTED BYGABRIEL K FERNANDESCARDIOVASCULAR
INTERVENTIONAL TECHNOLOGISTMETROPOLITAN HEART INSTITUTE &
RESEARCH CENTRE INDIA LTD.IN ASSOCIATION WITH RADIOGRAPHERS
ASSOCIATION OF MAHARASHTRA.
November, 1998 Council on Clinical Cardiology, American Heart
Association
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CARDIAC CATHETERIZATION LABORATORY
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CONTENTS1 PREFACE2 INTRODUCTION3 THE HEART4 BLOOD PRESSURE5
CORONARY ARTERIES6 CARDIAC PROCEDURES7 BASIC PATHOLOGY OF THE
HEART
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PrefaceThis book "Cardiac catheterization Basics" is aimed for
technicians working in the cardiac catheterization 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 catheterization 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.
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IntroductionBlood circulationThere are two distinct systems in
the body for the blood circulation:1.Pulmonary blood circulation2.
Systemic blood circulation
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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.
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Systemic circulationThe 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 products.
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The HeartThe human heart is a muscular pump. The muscle layer
that takes care of the contraction of the heart to decrease the
size and forces the blood out of its chambers is called
myocardium.Normally the size of the heart is a little bit larger
than a human fist. It pumps about 8000 litres of blood each
day.Reaching the age of 70 years, the number of heart beats will be
over 2.5 billion.The heart is divided into two halves, the right
and left, by a main septum which extends from the base to the
apex.There is no communication between these halves after birth.The
right side pumps the blood to the lungs and is less powerful than
the left side which is the pump for the systemic circulation that
has to drive the oxygen saturated blood to the organs.
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The four chambers of the heartRA ( RIGHT ATRIUM )RV ( RIGHT
VENTRICLE )LA ( LEFT ATRIUM )LV ( LEFT VENTRICLE )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.
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In total the heart has four valves:The mitral valve is between
the left atrium and ventricleThe tricuspid valve is between the
right atrium and ventricleThe pulmonary or pulmonic valve is
between the right ventricle and the pulmonary artery.The aortic
valve is between the left ventricle and the aorta.
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The cardiac cycleThe heart beats automatically although it is
under the control of the nervous system for it receives innervation
from the vagus nerve and the sympathetic nervous system.The pumping
action of the heart consists of a contraction or systole and a
relaxation or diastole. Both atria contract simultaneously,driving
their contents into the relaxed ventricles during ventricular
diastole.The ventricles then simultaneously go into systole whereas
the atria go into 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 exercise or excitement
and in various abnormal conditions.
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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 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).
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ECGA normal ECG has the following features:P Wave:
depolarisation.Atrial contraction begins (Atrial depolarisation)PR
interval: Atrial contraction
QRS complex: Ventricular contraction begins (Ventricular
depolarisation) ST segment: rapid systolic ejection T Wave: due to
ventricular repolarisation (relaxation of ventricular muscle)
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Blood pressureThe pulse is the dilatation of an artery caused by
the blood pressure increase due to the contraction of the heart.
Blood pressure is the pressure exerted by the blood against the
vessel wall.The systolic pressure is determined primarily by the
rate and volume of ventricular ejection in relation to the arterial
elasticity.Systolic pressure is the pressure during contraction of
the heart,normally between 100 to 120 mm Mercury (approximately 16
k Pascal).The diastolic pressure is determined by the rate of
diastolic pressure drop and the heart rate as it effects the
duration of the diastole.Diastolic pressure is the pressure during
relaxation of the heart, normally between 65 and 80 mm
Mercury(approximately 11 k Pascal)
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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.
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Left heart pressuresThe 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.
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Aortic pressureA catheter is guided into the ascending part of
the aorta.Example:Systolic pressure: 118 mm HgDiastolic pressure:
57 mm HgMean pressure: 81 mm HgHeart rate: 54 bpm.
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Left ventricle pressureA catheter is guided into the left
ventricle passing through the aortic valve.Example:Systolic
pressure: 166 mm HgEnd diastolic pressure: 32 mm HgHeart rate: 80
bpm.
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Left atrium pressureA catheter may be pushed into the left
atrium passing through the mitral valve.If there is a mitral
stenosis it may not be possible to push the catheter into the left
atrium. The Pulmonary Capillary Wedge pressure from the right heart
catherisation may substitute the left atrium pressure.Example:Mean:
13 mm HgHeart rate: 82 bpmValue: 18 mm Hg.
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Pullback pressureA Catheter is pulled back from the left
ventricle into the aorta.Example:left ventricleSystolic pressure:
188 mm HgEnd diastolic pressure: 151mm HgHeart rate: 167
bpmaortaSystolic pressure: 190 mm HgDiastolic pressure:135 mm
HgMean pressure: 125 mm HgHeart rate:158 bpm
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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.
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Right heart pressuresRight atriumA catheter is guided into the
right atrium.Example:Value: 18 mm HgMean: 15 mm HgHeart rate: 89
bpm.
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Right ventricleA catheter is guided into the right ventricle
passing through the tricuspid valve.Example:Systolic pressure: 42
mm HgEnd diastolic pressure: 8 mm HgHeart rate: 84 bpm.
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Pulmonary arteryA catheter is pushed into the pulmonary artery
passing through the pulmonary valve.Example:Systolic pressure: 29
mm HgDiastolic pressure: 15 mm HgMean pressure: 21 mm HgHeart rate:
130 bpm.
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Pulmonary capillary wedge pressureA catheter is guided into the
left or right pulmonary capillary wedge position.Example:Value: 18
mm HgMean: 13 mm HgHeart rate: 77 bpm.
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Zero Calibration(For pressure measurements)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 patients
right atrium before setting the zero balance of the
pre-amplifier.This reference point is measured using a special tool
that divides the patients chest height into 2/5 and 3/5.
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Cardiac OutputThe 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.
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ThermodilutionThe Cardiac Output is measured using a special
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 fluid ( usually 10 ml
saline for adults) is injected. This cold saline mixes with the
blood causing a decrease in blood temperature. This is sensed by
the thermistor.The cardiac output is measured by the change in
temperature over time.
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FickApplied 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 aortaOxygen saturation from pulmonary
arteryBody surface area (BSA)WeightHeightSex
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Ventriculography
With the help of X-ray images and special software of the system
(Ejection Fraction program), the cardiac output can be
measured.
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Coronary arteriesThere are two main coronary arteries - the left
and right.The left coronary artery begins as a main stem called the
Left Main Coronary Artery (LMCA) which varies between 1 and 15 mm
in length. This artery divides in two major branches, the Left
Anterior Descending artery (LAD) and the Circumflex artery (CX).The
Right Coronary Artery (RCA) is a single long vessel with 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.
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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.
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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.
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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.
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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".
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Cardiac procedures
The cath-lab is used for several procedures, the following will
give an overview of the most common diagnostic and intervention
procedures.
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Cardiac catheterisationCardiac 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
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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
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ProcedureCatheters 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.
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ProjectionsTo 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 patients head while using the caudal angulation
the Image Intensifier angulates towards the patients feet.
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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- In R.A.O. position, the apex points to
the right.- In L.A.O. position, the RCA (Right Coronary Artery)
resembles a C.
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Left Coronary arteriesR.A.O. 30oThe 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.
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Left Coronary artery R.A.O. 30o
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Left Coronary arteriesL.A.O. 55/60oThe 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.
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Left Coronary artery L.A.O. 55/60o
Left Coronary artery L.A.O. 55/60o
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Left Coronary arteriesL.A.0. 55/60o + 20o cranial projectionThe
cranial angulation of 20o combined with the L.A.O. projection at
55/60o is especially useful to study the left main coronary
artery.
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Left Coronary artery L.A.0. 55/60o + 20o cranial
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Left Coronary arteriesLeft Lateral projectionThe 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.
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Left Coronary artery in Left Lateral
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Right Coronary arteryLeft lateral projectionThis 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)
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Right Coronary artery in Left lateral
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Right Coronary arteryL.A.O. 45o + 15o caudal angulationThis
projection allow the whole study of the R.C.A. and clearly defines
the region of the crux of the heart.
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Right Coronary artery in L.A.O. 45o + 15o caudal
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Right Coronary arteryR.A.O. at 45oThe 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).
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Right Coronary artery in R.A.O. 45o
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Left ventricle angiogramTo measure various pressures and to
visualize how well the left ventricle contracts, a pigtail shaped
catheter is used. This catheter has several side holes to make it
possible to inject contrast using a high flow rate.The left
ventricle can be divided into several areas to determine which part
of the ventricle muscle is not functioning properly.The projection
most used to visualise the left ventricle is RAO 30o
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Optimize image quality
The patients 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.
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ShuttersShutters 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.
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Wegde filtersTo prevent distracting highlights in the region of
interest (lung tissue) that will affect image quality, wedge
filters can be used.
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ProtocolImage 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.
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Image Intensifier positionThe 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.
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Patient communicationA good patient communication will reduce
patient physical or respiratory movement during image
acquisition.
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Catheter positionWhen 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.
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To give an indication of the position of the catheter tip for
each projection, the field of view is divided into 9 zones.If the
tip is within the zone 1,2,3 or 5, then in most of the acquired
runs the whole anatomy of the coronary arteries will be within the
field of view without having to move the table. Examples:
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To give an indication of the position of the catheter tip for
each projection, the field of view is divided into 9 zones.If the
tip is within the zone 1,2,3 or 5, then in most of the acquired
runs the whole anatomy of the coronary arteries will be within the
field of view without having to move the table. Examples:
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Left coronary arterty and Circumflex
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Left coronary arterty and Circumflex
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Right coronary artery
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InterventionsPTCAPercutaneous 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.
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ProcedureThe 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.
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Stent placementStent 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.
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Other ways of reducing a coronary blockage
Instead of using a balloon there are other devices to increase
the lumen of the coronary arteries:
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AngiojetAn 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.
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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.
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RotablatorThe 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.
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Electrophysiology (EP)Reason for an Electrophysiology study (EP)
is arrhythmia, or abnormal heart rhythm
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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.
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AblationCatheter ablation is a technique to eliminate alternate
pathways present in the heart causing arrhythmias (abnormal
heartbeats) that interfere with the normal conduction.
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ProcedureOnce the area of the heart has been defined through
catheter mapping, a special ablation catheter is placed at the site
of the abnormal pathway.Radiofrequency 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.
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PacemakerPacemaker 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.
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ProcedureAn 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.
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IABPThe 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.
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Basic pathology of the heart
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Arteriosclerotic coronary diseaseIn 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.
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Valvular diseasesThe 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.
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Aortic valve stenosisAortic 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.
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Aortic regurgitationWhen 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.
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Mitral stenosisA 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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Mitral regurgitationImproper 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.
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Congenital diseasesValve 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.
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Left-to-right shuntPart 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.The patent
hole (foramen ovale) between the atria is called the
Atrial-Septal-defect.The hole between the ventricles is called the
Ventricular-Septal -defect
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Patent ductus BotalliIf the communication between the aorta and
the pulmonary veins remains after birth, de-oxygenated blood mixes
with the systemic circulation.
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Coarctation of the aortaThis is a narrowing (stenosis) in the
proximal descending part of the aorta. The aortic valves are
usually narrower than normal.
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THANK YOU
Left Coronary artery L.A.O. 55/60o