Cardiac Catheterization Flashcards
(179 cards)
1
Q
What are relative contraindications to cardiac catheterization?
A
- Pregnancy (1st and 2nd trimesters)
- Active systemic infection
- Decompensated CHF / Respiratory distress
- Uncontrolled HTN
- Uncontrolled coagulopathy or severe thrombocytopenia
- Inability to provide informed consent
- Inability to tolerate procedure or cooperate (cannot lie supine)
- Severe anaphylactic reaction to contrast medium (for patient’s receiving contrast)
- Acute or chronic renal failure (for patient’s receiving contrast)
- Diabetic patient’s on Metformin -> (hold metformin x 48 hours after the procedure to prevent possible lactic acidosis if renal failure develops)
- DNR status (consider periprocedural suspension of this status)
2
Q
What are the main vascular access points for cardiac catheterization?
A
- Femoral
- Radial
- Brachial
3
Q
What should “time out” include prior to cardiac catheterization?
A
- Patient name
- Procedure being performed
- Prepocedure antibiotic administration (if necessary)
- Verifying consent is signed
- Verification of the correct site and side being used
- Confirmation of any allergies
- Confirmation of site preparation
- Special equipment and/or imaging studies that may be required
4
Q
What are the sequence of angiographic views in evaluation of the RCA?
A
- LAO 40, CRA 20
- prox-mid RCA
- AP CRA 30-40
- distal RCA, PDA-PLB bifurcation
- RAO 90
- mid-RCA
Additional views:
- RAO 30, CRA 20
- prox-mid RCA
- LAO 50, CRA 30
- distal RCA
5
Q
What are the standard LV ventriculogram angiographic views?
A
- RAO 30 degrees
- visualizes the high lateral, anterior, apical, and inferior LV walls
- LAO 45-60, CRA 20
- identifies the lateral and septal LV walls
6
Q
Protocol to reduce the incidence of Contrast-Associated Nephropathy following cardiac catheterization?
A
Identify risks
- eGFR < 60 ml/min
- DM Manage medications
- hold nephrotoxic drugs (NSAIDS)
Manage intravascular volume
- hydrate with either normal saline or sodium bicarbonate (either acceptable)
- hydrate 1-1.5 ml/kg/min for 3-12 hours before and 6-12 hours post
Radiographic contrast
- minimize contrast volume
- use either low-osmolar or iso-osmolar contrast
Follow up data
- obtain 48-hour creatinine
7
Q
What are the major disadvantages to radial artery access?
A
- Smaller caliber of artery
- smaller sheath/catheter systems
- new “sheathless” catheters being developed
- Radial artery spasm
- may limit ability to manipulate catheters and can be very painful
- Radial artery occlusion
- 3-5% of patients
8
Q
Describe risk stratification using TIMI and GRACE
A
9
Q
Describe factors that dictate “Early Invasive” (within 24h) strategy in UA/NSTEMI?
A
- Grace score > 140 or TIMI ⇒ 5
- Temporal change in Troponin
- New or presumably new ST depression
10
Q
What should the cardiac catheterization preprocedural assessment include?
A
- History
- Indications (including symptom status, noninvasive studies)
- Medications and likelihood of adherence
- Metformin dose
- Anticoagulation
- Antiplatelet loading (if anticipated PCI)
- Allergies (including contrast)
- Bleeding risk / anticipated surgeries
- NPO status
- Code Status
- Focused Physical Examination
- Mental status
- Cardiac/Respiratory systems including fluid status
- Vascular examination keyed to access sites and perfusion distally
- Labs
- CBC, BMP, INR, PTT (selected patients)
- EKG
- Prior Catheterization data
- Access site, catheters
- Anatomy (anomalies, grafts) -
- Prior interventional procedures
- Complications and difficulties with the procedure
- Prior Surgical Data
- Number and types of conduits
11
Q
Describe factors that dictate “Delayed Invasive” (within 25-72h) strategy in UA/NSTEMI?
A
- DM and renal insuffiency (GFR < 60 mL/min/1.73m2)
- Reduced LV function (EF < 40%)
- Early postinfarction angina
- PCI within 6 months
- Prior CABG
- GRACE risk score 109-140; TIMI risk score ⇒ 2
12
Q
What are the four major statin benefit groups (from 2013 ACC/AHA update)?
A
- Clinical ASCVD
- LDL ⇒ 190 mg/dl
- DM (and the following)
- LDL 70-189 mg/dl
- Age 40-75 years
- Estimated 10 year ASCVD ⇒ 7.5% (every 4-6 years)
- if not DM + LDL 70-189 mg/dl + not receiving statin therapy
- 5-7.5% –> shared decision making + additional risk factors
13
Q
Describe factors that dictate “Immediate Invasive” strategy in UA/NSTEMI?
A
- Refractory Angina
- Hemodynamic instability
- Electrical instability (sustained VT or VF)
- Acute CHF or worsening MR
- Recurrent angina or ischemia at rest or with low-level activities despite intensive medical therapy
14
Q
What are treatment strategies for NSTEMI/UA?
A
- Immediate invasive (within 2h)
- Ischemia guided strategy
- Early Invasive (within 24h)
- Delayed Invasive (within 25-72h)
15
Q
What trials created the TIMI risk score?
What trials validated the TIMI risk score?
A
- TIMACS
- TIMI 11B and ESSENCE trials
16
Q
When should the following anticoagulants be discontinued prior to CABG?
- Heparin
- Enoxaparin
- Bivalirudin
- Fondaparinux
A
- Heparin –> zero or at time of surgery
- Enoxaparin –> 12 hours (T 1/2 = 4-6 hours)
- Bivalirudin –> 3 hours (continuance of UFH)
- Fondaparinux –> 24 hours
17
Q
What is the risk associated with each TIMI risk score?
A
- All-Cause Mortality, New or Recurrent MI, or Severe Recurrent Ischemia Requiring Urgent Revascularization within 14 days
- Also useful in predicting:
- 30 day mortality
- 1 year mortality
18
Q
When should enoxaparin be discontinued prior to surgery?
A
12 hours
- T 1/2 = 4-6 hours
- use of enoxaparin < 12 hours prior to CABG is associated with lower postoperative hemoglobin and a higher risk of blood tranfusion
19
Q
Describe the TIMI risk score for UA/NSTEMI
A
- Known CAD (stenosis ⇒ 50%)
- ⇒ 2 episodes of angina within 24 hours
- Presence of ⇒ 3 CAD risk factors
- DM, tobacco use, HTN, HLD, FH of CAD
- Positive cardiac biomarkers
- ST changes ⇒ 0.05 mV
- Age ⇒ 65 years
- ASA use in the past 7 days
20
Q
Describe pre-test probability
A
21
Q
Describe factors that dictate “Ischemia-guided” strategy in UA/NSTEMI?
A
- Low-risk score
- TIMI < 2
- GRACE < 109
- Low risk, troponin negative female patients
- Patient or clinician preference in the absence of high-risk features
22
Q
Diagnostic findings: Right heart catheterization
A
- Right sided cardiac pressures
- Pulmonary artery pressures
- PCWP
- CO
- Vasodilator challenges to evaluate transpulmonic gradients
23
Q
What is the set up for Image intensifier (II) and x-ray source (or flat-panel detector in fully digital laboratories)?
A
- II -> directly above patient
- X-ray source -> below the patient
24
Q
What medications are commonly used in radial artery catheterization?
Why are these medications used?
A
Antispasm “cocktail”
- Nitroglycerin (100-300 mcg)
- Verapamil (2.5-5.0 mg) or Diltiazem (5mg)
- Systemic anticoagulation (Unfractionated Heparin, weight based (50-100 U/kg)
- Helps to avoid radial artery occlusion
- Buffer or dilute meds throughout procedure -> reduces arterial spasm
- Back-bleed and flush sheath repeatedly throughout procedure
25
What are the sequence of angiographic views in evaluation of the LCA?
* LAO 15
* LM
* RAO 20 / CAU 20
* LCx, LAD
* AP CAU 30
* LCx
* LAO 40-60 / CAU 30
* "Spider"
* LAO 60
* LPL's, LPDA's
* LAO 40 / CRA 20
* LAD "Gutter"
* AP CRA 40
* LAD
* RAO 30
* LCx, LAD
26
Diagnostic findings: Endomyocardial biopsy
* transplant rejection
* primary myocardial disease
27
Diagnostic findings: Supravalvular aortography
* proximal aortic dissection
* aortic root disease
* aortic insufficiency
* anomalous anatomy
* saphenous vein graft origins
28
What is the optimal projection for visualizing:
* Mid-LAD
RAO Cranial
29
What is the optimal projection for visualizing:
-Distal RCA, PDA, PLB
LAO cranial
30
What is the optimal projection for visualizing:
-Proximal and Mid-LMCA
RAO Caudal (shallow) or AP Caudal
31
What is the optimal projection for visualizing:
-Ramus Intermedius (RI)
LAO Caudal
32
What is the optimal projection for visualizing:
-Proximal-RCA
LAO cranial
33
What is the optimal projection for visualizing:
-Proximal LAD
RAO Cranial\*\*
- overlap with the CFx may occur LAO Caudal and Cranial
- Foreshortening may occur
- Good view for visualizing entire LAD (septals - down and diagnoals up/away)
34
What is the optimal projection for visualizing:
-Proximal and Mid-Circumflex
AP Caudal
LAO Caudal
-Ostium and RI best visualized in this view
RAO Caudal (shallow)
-obtuse marginal branches best visualized in this view
35
What is the optimal projection for visualizing:
-Distal LMCA
LAO Caudal (spider view)
36
Definition and description:
-Third Diagonal branch
3rd branch from the LAD that travels over the anterolateral surface of the LV
37
What are two tests that can be utilized in determine patency of the ulnar artery prior to a radial artery approach?
What is the reasoning behind these tests?
* Barbeau (modified Allen's) test
* staging system using pulse oximetry and plethysmography on the thumb with alternating compression of radial and ulnar arteries
* Allen test
* compressing both arteries while pumping/releasing a fist -\> blanching of the palm -\> release of ulnar artery results in rapid capillary refill
\*\*\*\*\*Both tests assess ulnar flow into the palmar arch
38
What is required for imaging/visualization of aorta-to-native vessel bypass grafts?
- Aorta-graft proximal anastomosis
- Body of the Graft
- Distal graft-coronary arterial anastomosis
- Adequacy of perfusion of the bypassed native vessel
39
What should be considered when evaluating arterial (radial, femoral) access points in cardiac catheterization?
* Body habitus (obese patients avoid upper extremity)
* Ability to lie flat
* Pulse strength (avoid weak pulse or bruit)
* Pre-access assessment of distal pulses (helps to establish baseline for comparison pos-procedure)
* Presence of abdominal bruit or peripheral livedo reticularis (stigmata of abdominal aortic atheroma)
* Prior vascular surgery along access point
40
What is the optimal projection for visualizing:
-Proximal and Mid-PDA
RAO projection
41
What should be considered when evaluating venous access points in cardiac catheterization?
* Thrombotic or venous disease
* IVC filter (can be traversed with small catheter system)
* Prior unsuccessful attempts
42
What are the advantages of CFA access?
* relatively superficial, predictable location makes it reliable
* location overlying the femoral head provides solid support against which manual compression may be applied to achieve active hemostasis
43
What are key points regarding CFA access?
* Puncture CFA below the inguinal ligament, but above the bifurcation of the superficial femoral artery (SFA) and profundis femora artery
* "Target Zone" for arterial puncture = over inferomedial aspect of femoral head
* Inguinal ligament course can be identified by path between ASIS and symphisis pubis
* Inguinal skin crease is variable, frequently does not correspond with location of inguinal ligament (caudal to femoral bifurcation in 75% of patients, especially obese patients)
44
Explain the stepwise approach for obtaining femoral artery access via the modified Seldinger technique.
* Local anesthesia is given 1-2 cm distal to planned entry point
* Small skin incision is made, followed by gentle blunt dissection to establish channel for easy passage of the sheath (channel allows for blood to escape rather than to collect in deep thigh tissues)
* Palpate pulse with one hand and advance access needle to puncture (only) front wall of artery (45-60 degree angle)
* Insert guide wire through needle and advance (slow if any resistance) then remove needle
* Confirm wire placement in CFA (passes to the left of the spine) with fluoroscopy
* Advance sheath over wire and remove the wire
* Confirm sheath placement:
* aspirate 2-3 mL blood from side of sheath
* flush with heparinized-saline solution
* arterial pressure should be checked with connection of a pressure manifold to the side arm of the sheath
45
What did the FAUST trial demonstrate?
FAUST (Femoral Arterial Access With Ultrasound Trial)
* multicenter clinical trial (1,000 patients, 500 in each group) use of real-time ultrasound guidance in obtaining CFA access
* No difference in rate of successful cannulation
* Reduced:
* number of attempts
* time required to gain femoral artery access
* occurrence of vascular complications (from 3.4% to 1.4%).
46
What are the most common complications associated with CFA arterial access?
* Obstruction of vessel -\> limb ischemia
* Pseudoaneurysm
* AV fistula formation
* Urinary retention (decreased ambulation, opiates)
* Retroperitoneal hematoma
* Femoral neuropathy and infections (rare)
\*\*\*\*most problems occur due to inadequate identification of the anatomic landmarks
47
What must be checked before a femoral sheath can be successfully removed?
**Activated Clotting Time (ACT)**
* time taken for blood clot to form
* sheath not removed until \< 150s
* Normal = 70-120s
* Normal (with heparin) = 180-240s
48
How long should manual pressure be held at access point after sheath removal?
5 minutes per sheath size
* 5Fr = 25 minutes
* 6Fr = 30 minutes
49
What did the RIVAL trial demonstrate?
RIVAL (Radial Versus Femoral Access for Coronary Intervention) trial
* 7,021 patients undergoing cardiac catheterization and intervention for an acute coronary syndrome were randomized to radial or femoral access
* No significant difference in primary endpoint (death, MI, CVA, noncoronary artery bypass graft-related bleeding at 30 days) between the two groups (3.7% in radial group and 4.0% in femoral group)
* Major vascular complications were significantly lower in the radial group compared with the femoral group (1.4% vs. 3.7%; p \< 0.0001)
50
What are the types of invasive lesion assessment?
FFR Coronary flow reserve
Intracoronary imaging
- intravascular ultrasounds (IVUS)
- optical coherence tomography
51
Explain IVUS use and what it measures?
Identification of coronary artery lesions Quantification of plaque volume
* by tracing external elastic membrane (EEM) and lumen areas of the proximal reference, lesion and distal reference Types of arterial remodeling
52
What are the contents of informed consent?
Willingness to undergo the procedure
Acknowledgement that the performing physician has discussed and confirmed
* goals
* risks
* benefits
* alternatives
53
What procedure should be performed in a patient with RCA-CTO with ambiguous cap + 30 mm long + bridging collaterals?
Retrograde approach to CTO PCI \*occlusion \> 20 mm + ambiguous cap + bridging collaterals -\> lower success rate with anterograde PCI
54
What is GRACE?
Global Registry of Acute Coronary Events
55
What is the TIMI Risk Score?
- "Thrombolysis In Myocardial Infarction"
- Risk score utilized in NSTEMI / UA -Comprises seven equally weighted risk indicators which categorizes patient's risk of death and ischemic events and provides a basis for therapeutic decision making
- Risk of all-cause mortality, new or recurrent MI, or severe recurrent ischemia prompting urgent revascularization within 14 days showed a graded increase with increasing TIMI score
56
What are the components of the TIMI Risk Score?
"AMERICA"
- Age \> 65 years
- Markers (cardiac enzymes)
- EKG changes (ST changes \> 0.05mV)
- Risk factors for CAD ( \> 3 = Obesity, HTN, DM, Dyslipidemia, Cigarette smoking, FH premature CAD)
- Ischemic chest pain ( \> 2 episodes of chest pain within 24 hour period)
- Coronary (known) stenosis ( \> 50%)
- Aspirin (use within the past 7 days)
57
What are the breakdowns per point for the TIMI Risk Score?
Risk of all-cause mortality, new or recurrent MI, or severe recurrent ischemia prompting urgent revascularization within 14 days showed a graded increase with increasing TIMI score
* 0-1 - 4.7%
* 2 - 8.3%
* 3 - 13.2%
* 4 - 19.9%
* 5 - 26.2%
* 6-7 - 40.9%
58
What two trials validate the use of the TIMI-risk score?
-TIMI 11B -ESSENCE (Efficacy and Safety of Subcutaneous Enoxaparin in Unstable Angina and Non-Q Wave Myocardial Infarction)
59
Patients with TIMI-risk score \> 3, derive benefit from what interventions?
- Early invasive therapy\*\*
- LMWH
- Glycoprotein IIb/IIIa inhibitors
60
What did the RITA 3 trial show?
\*\*\*In low-moderate risk NSTE-ACS, a routinely invasive strategy is preferable to a provisionally invasive strategy (performed only for recurrent ischemia or positive stress test)
- Randomized patients presenting with low-moderate risk NSTE
- ACS to routine angiography vs. optimal medical therapy
- Routine angiography group -\> reduction in death, MI and refractory angina at 4 months
61
Class I recommendations derived from RITA 3 and TIMACS trials?
- Early invasive strategy is indicated in patients who have (refractory angina, hemodynamic instability, electrical instability) without serious comorbidities or contraindications to these procedures
- Early invasive strategy indicated in initially stabilized UA/NSTEMI patients who have an elevated risk for clinical events
62
What did the TIMACS trial demonstrate?
- Among NTEMI patients managed with routine invasive approach, angiography within 24 hours did not confer benefit when compared with angiography after 36 hours
- Except among the subgroup of patients with high-risk NSTEMI as defined by GRACE score \> 140
63
What are the antiplatelet recommendations for patients presenting with ACS and are treated with CABG?
DAPT x 12 months after ACS \*CLASS I RECOMMENDATION
64
What are the antiplatelet recommendations for DAPT in patients with previous coronary stent placement and subsequently undergo CABG?
Resume postoperatively to complete recommended duration of therapy (12 months)
\*CLASS I RECOMMENDATION
65
What are the antiplatelet recommendations for patients with SIHD who are treated with CABG?
DAPT x 12 months after CABG may be reasonable to improve graft patency
\*CLASS IIb recommendation
66
What are the antiplatelet recommendations for patients with SIHD after BMS placement?
DAPT x 1 month (minimum)
\*CLASS I RECOMMENDATION
67
What are the antiplatelet recommendations for patients with SIHD after DES placement?
DAPT x 6 months (minimum)
\*CLASS I RECOMMENDATION
68
Describe the Appropriate Use Criteria (AUC)?
- Consensus standard for the use of diagnostic catheterization and PCI in order to ensure proper and ethical use of these procedures
- AUC attempts to critically and systematically create, review, and categorize clinical situations where diagnostic and therapeutic procedures are utilized
- Establish consensus standards regarding whether the procedures potential benefit outweighs its possible risks -\> is that procedure reasonable to perform for the specific clinical situation?
- Not meant as a substitute for clinical judgement but a guide in decision making
69
What are examples of the Appropriate Use Criteria in regards to suspected CAD?
- focus on symptom status -estimate of global CAD risk
- presence and severity of abnormal noninvasive findings
- other clinical elements that inform patient risk
70
What are examples of the Appropriate Use Criteria in regards to Coronary Revascularization?
Evaluates clinical scenarios based on:
- procedure urgency
- angina class
- adequacy of antianginal theapy
- presence and severity of abnormal noninvasive findings
- disease burden and location
71
When was the first cardiac catheterization performed? And on who?
- 1929
- Dr. Werner Forssmann performed a right heart catheterization on himself
72
What does French (Fr) measure in regards to sheaths?
-labeled size refers to INNER diameter/lumen
73
What does French (Fr) measure in regards to catheters and guide catheters?
-labeled size refers to their OUTER diameter
74
What are French (Fr) sizes in relation to Inches and Millimeters?
Fr 0.3 = 0.039 inch = 1 mm
Fr 0.4 = 0.053 inch = 1.35 mm
Fr 0.5 = 0.066 inch = 1.67 mm
Fr 0.6 = 0.079 inch = 2 mm
Fr 0.7 = 0.092 inch = 2.3 mm
Fr 0.8 = 0.105 inch = 2.7 mm
Fr 0.9 = 0.118 inch = 3.0 mm
Fr 0.10 = 0.131 inch = 3.3 mm
75
Why should sheaths be flushed frequently during cardiac catheterization?
to prevent thrombus formation
76
What are sheath characteristics?
- diameter
- length
- guidewire capability
- construction
- flexibility
- presence of radiopaque tip
- presence of hydrophilic coating
77
What are the longest sheaths made?
100 cm
78
What are the largest diameter sheaths made?
24 Fr (for structural heart procedures)
79
What are several components of radial artery sheaths and there benefits?
hydrophilic sheath -\> reduces vasospasm 5 Fr in size -\> reduces complications
80
What are the most commonly used sheaths for femoral access?
Short in length
* 10/11 cm in legth
* 4-6 Fr in diameter
81
What femoral sheaths have the propensity for thrombus formation? What should be done to prevent this?
- Mesh braided sheaths
- Unfractionated Heparin (2000-3000u)
82
What is the downside of utilizing smaller diagnostic French catheters (in an attempt to reduce bleeding complications)?
- suboptimal angiography due to streaming
- catheter dislodgment during injection
- inadequate vessel opacification
83
What is often needed for diagnostic angiography with smaller "high flow" catheters?
Advanced injection system
84
What are the three components of a diagnostic catheter?
- distal angulated portion
- the hub
- the shaft
85
What is the suggested catheter type for RCA with: -normal origin and course
JR-4
86
What is the suggested catheter type for LCA with: -Normal origin and course
JL4
87
What is the suggested catheter type for Right-sided SVG with: -Routine
Multipurpose
88
What is the suggested catheter type for Left-sided SVG with:
-Routine
JR
89
What is the suggested catheter type for LIMA or RIMA with:
-Normal
IM
90
How are sizes identified in the Judkins and Amplatz diagnostic catheters?
length between the primary and secondary curves
91
What is the difference between dampening and ventriculization of arterial pressure?
- ventriculization -\> fall of diastolic arterial pressure
- dampening (over) -\> fall of both systolic/diastolic arterial pressure
92
What is the most common cause of a ventricularized pressure measurement?
obstructive lesion in the ostium of the vessel cannulated
93
What are causes of dampening of arterial pressure?
- loose connections
- mismatch between catheters and vessel
- non-coaxial intubation of the vessel
- obstructive lesions
- vasospasm
- Air bubbles
- Kinks
94
What is the most appropriate treatment for 2-vessel disease involving the proximal LAD + DM or abnormal LV function?
What study supports this finding?
What tools can be utilized to support this treatment?
- CABG
- STICH (Surgical Treatment for Ischemic Heart Failure) trial --\> mortality benefit over optimal medical therapy in 10-year follow up
- Several calculations (SYNTAX, STS, EuroSCORE, SYNTAX II)
95
What is a complication that may occur in patients with LBBB undergoing RHC? What is the treatment?
RBBB --\> Complete heart block Withdrawal or repositioning of the heart cath (if hemodynamically stable)
\*Atropine will not help as block is infranodal
\*\*temporary pacemaker if RBBB does not resolve after withdrawal
96
Describe the course, branches and supply of the LAD?
most frequent direct continuation of the Left Main Artery courses along the anterior interventricular groove Gives rise to:
- anterior septal perforating arteries --\> supply septum
- diagonal branches --\> supply anterolateral free wall
97
Describe the course, branches and supply of the LCX?
- Normally arises from the Left Main Artery at its bifurcation
- Courses posteriorly under the left atrial appendage in order to reach the left AV groove
- Gives rise to one or more Obtuse Marginal Branches Variable distribution over the posterior and inferior walls
98
Describe the course, branches and supply of the RCA?
Courses in the R AV Groove Circumscribes the TV annulus
Essential dependent myocardium is the free wall of the RV
99
What determines the dominant coronary artery?
artery from which the posterior descending artery arises RCA is dominant in 85-90% of patients
100
Define Coronary Anomaly?
any patter that is not observed in \> 1% of a general population
101
How are coronary arteries named?
By their nature --\> indicated by the distal myocardial territory they feed Not by site of origination
102
Define the aortic sinus (of Valsalva)?
anatomic dilation of the ascending aorta located just above the aortic valve cusps Three aortic sinuses (1 anterior, 2 posterior)
- left posterior --\> LCA
- anterior -\> RCA
- right posterior -\> no vessels (aka "non-coronary sinus)
103
What makes anomalous coronary arteries lethal?
ischemia caused by the specific route they take to go from the "incorrect" to the "correct" side of the heart
104
What is the incidence of (only) congenital artery anomalies?
1% of patients undergoing coronary angiography 0.3% of patients at autopsy
105
What anomalous coronary artery features are associated with sudden cardiac death (SCD)?
* Intramural course
* Slit-like ostium (compared with round)
* Torsion
* Exercise-induced compression, vasospasm, ischemia or scar-induced ventricular arrhythmia
106
What are the current ACC/AHA guidelines criteria for intervention in R- or L-ACAOS?
- Symptoms of abnormal chest pain, dyspnea on exertion, syncope, or aborted SCD (Class I, Level B)
- Positive treadmill stress test, ideally nuclear, in the correct dependent myocardial territory, in the presence of: Intramural course (Class I, Level B) (High risk course = intramural course)
- Imaging with IVUS (can yield definitive quantification of stenosis severity in individual cases)
- Elite athletes who desire to continue strenuous physical exertion, in spite of ACAOS-IM --\> can electively proceed with intervention
107
What are the indications for surgical revascularization in patients with ACAOS?
Class I
* Anomalous left main coursing between the aorta and pulmonary artery
* Anomalous coronary between the aorta and pulmonary artery and documented ischemia
Class IIa
* beneficial with established vascular wall hypoplasia, coronary compression or obstruction to coronary blood flow; irrespective of documented ischemia
Class IIb
* may be reasonable when LAD courses between the arota and pulmonary artery
108
What are the surgical options for ACAOS-IM?
Unroofing or denuding the inner-side aortic media at the IM segment, to eliminate the stenosing channel (most popular choice)
CABG
* -has become obsolete in recent years
* -high incidence of graft failure (due to competitive flow)
Translocation of the anomalous arteries
* -generally is not indicated
* -meant to solve stenosis by compression between aorta and pulmonary artery
* -never the mechanism of dysfunction in IM cases
109
What are causes of (under) dampening?
- Catheter artifact
- Stiff non-compliant tubing
- Hypothermia
- Tachycardia or dysrhythmia
110
What is damping or dampening of arterial pressure?
-pressure line system which acts as a shock absorber
111
What are the recommendations for complete revascularization of noninfarct arteries at the time of PCI or STEMI?
HDS STEMI patients may be performed
- at time of procedure or
- planned as a staged procedure
112
When does the risk for contrast induced nephropathy increased during cardiac catheterization?
Volume of contrast is \> 3.7 x eGFR
113
What is "Rescue" PCI?
mechanical perfusion with PCI in the context of failed thrombolysis
114
What two studies demonstrated the benefit of Rescue PCI in the setting of failed thrombolysis?
MERLIN (Middlesborough Early Revascularization to Limit Infarction) study
* reduction in 30-day death, reinfarction, stroke, subsequent revascularization, heart failure
* higher bleeding events (groin hematoma)
REACT (Rescue Angioplasty versus Conservative Treatment or Repeat Thrombolysis) trial
115
Why should Fondaparinux not be used as the sole anticoagulant to support PCI in patients with NSTE-ACS?
Increased risk of catheter thrombosis
116
What trial demonstrated superior ischemic outcomes when compared to Clopidogrel in STEMI? What was shown to have better outcomes?
TRITON-TIMI 38
- Reduction in death from CV causes, MI, or stroke at 15 months
- Increased bleeding risk Prasugrel (Effient)
- more potent and rapid platelet inhibition with less variability
117
Optimal imaging of the coronary arteries requires in depth knowledge of all of the following?
- Coronary arterial anatomy
- Catheters available for angiography
- Limitations of XR systems used for coronary arterial imaging
- Angles of the gantry with which each coronary arterial segment is best visualized
118
What is the best approach to angiography in cardiac catheterization?
Systematic approach:
- standard initial gantry angles (at least two orthogonal views of each artery)
- thorough review of images
- subsequent tailored views (as needed)
119
What are major pitfalls of angiography?
Evaluation of 3D structures in 2D views
Vessel Overlap
Vessel segment Foreshortening
Vessel Curvature
Bifurcation Angle
Eccentric Stenoses
120
What is vessel segment foreshortening?
- occurs when a segment of vessel is not imaged perpendicularly to the X-ray beam
- resultant oblique view --\> difficulty in assessing length of segment or severity of stenosis
- problematic when attempting to estimate appropriate balloon or stent length in preparation for intervention
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Definition and description:
-Proximal RCA
- segment from the right sinus of Valsalva origin to the first major acute marginal branch
- lies between RA and PA
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Definition and description:
-mid-RCA
segment continuing from the proximal RCA/AMB
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Definition and description:
-distal-RCA
- segment from the end of the mid RCA --\> PDA and right posterior AV segment bifurcation
- usually at the crux of the heart
- gives rise to PDA (in 85-90% of cases)
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Definition and description:
-Right posterior AV segment
- Continuation of distal RCA in the AV groove past the crux of the heart
- Gives rise to right posterolateral branches (PLB)
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What is the crux of the heart?
- latin meaning "cross"
- back part of the heart where coronary sulcus and posterior inerventricular sulcus intersect
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Definition and description:
-1st-3rd right posterolateral branches
-arise from the right posterior AV segment -travel over the LV posterolateral surface
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Definition and description:
-Posterior descending septal perforators
branches from the PDA that enter into the inferior interventricular system
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Definition and description:
-Acute marginal segment(s)
segments arising form the RCA (proximal-mid) that course over the (anterior-medial) surface of the RV toward the apex
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Definition and description:
-Left main coronary artery
segment from the left sinus of Valsalva to the bifurcation of the LAD and LCx usually several cm in length
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Definition and description:
-Proximal LAD
segment of the LAD from the left main to the origin of the 1st septal perforator courses the interventricular sulcus
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Definition and description:
-Mid-LAD
segment from the 1st septal perforator to the next large diagonal branch
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Definition and description:
-Distal-LAD
segment from the end of the mid-LAD to the end of the LAD Two variations of LAD
- Type I --\> smaller LAD, does not reach the apex
- Type II --\> larger LAD that rounds the apex and may extends along the posterior interventricular septum giving rise to more septal perforating branches. Often referred to as "wrap-around LAD"
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Definition and description:
-First diagonal branch
1st branch from the LAD that travels over the anterolateral surface of the LV
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Definition and description:
-Lateral first diagonal branch
inferior branch of the first diagonal branch
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Definition and description:
-Second diagonal branch
2nd branch from the LAD that travels over the anterolateral surface of the LV
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Definition and description:
-lateral second diagonal branch
inferior branch of the 2nd diagonal branch
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Definition and description:
-LAD septal perforator
- Branches from the LAD that enter into the interventricular system
- Emerge from the LAD as branches below the level of the membranous septum
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Definition and description:
-Proximal Circumflex
- segment from the left main to the origin of the 1st OM branch
- arises from the left main at a variable angle
- travels beneath the left atrial appendage --\> courses posteriorly in the AV groove/sulcus
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Definition and description:
-Mid Circumflex artery
segment in the AV groove from the 1st --\> 2nd OM branch
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Definition and description:
-Distal Circumflex artery
segment in the AV groove from the 2nd --\> 3rd OM branch
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Definition and description:
-First Obtuse Marginal (OM) branch
- branch from the proximal CFx
- travels over the anterolateral surface of the LV toward the apex
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Definition and description:
-Lateral first obtuse marginal branch
Inferior branch of the 1st OM
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Definition and description:
-Second obtuse marginal branch
branch from CFx that travels over the anterolateral surface of the LV toward the apex
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Definition and description:
-Circumflex artery AV groove continuation segment
Continuation of the distal CFx that remains in the AV groove past the acute margin of the LV Gives rise to posterolateral branches
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Definition and description:
-First left posterolateral branch
1st branch from the CFx AV continuation that travels over the posterolateral surface of the LV after the acute margin
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Definition and description:
-Left posterolateral descending artery
- Seen in Left dominant systems (16% of patients)
- Arises from the CFx continuation
- Courses toward the apex
- Gives rise to septal perforating arteries
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Definition and description:
-Ramus Intermedius (RI)
Branch from the Left Main artery when it trifurcates --\> LAD, CFx, RI Travels over the anterolateral surface of the LV toward the apex
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Definition and description:
-Lateral ramus intermedius
Inferior branch of the RI
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What are options for high-risk patients with severe AS, who meet indications for AVR before noncardiac surgery?
- Proceed with noncardiac surgery with invasive hemodynamic monitoring and optimization of loading conditions
- Percutaneous aortic balloon dilation --\> bridging strategy
- transcatheter aortic valve replacement (TAVR)
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What did the CURE trial show?
- Patients presenting with UA/NSTEMI managed with a conservative approach, adding daily Clopidogrel within 24 hours reduced long-term ischemic complications.
- First trial to show that long-term clopidogrel, when added to aspirin, decreased the rate of recurrent ischemic events after UA/NSTEMI -PCI-CURE Study --\> also supported use of "upstream" clopidogrel use
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Percutaneous retrieval of foreign bodies in the vascular tree is successful in what percentage of cases?
70-90%
-varies depending on type of device and its location
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When do the majority of stent losses occur?
retracting a stent into the guiding catheter when the equipment is not coaxial, causing the guide to strip the stent off the delivery balloon/catheter
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What are options if a stent cannot be safely removed?
- Deployment in a safer area of the vascular system
- Stabilization in the current location --\> crushing it into the vessel wall with another stent
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What are tools that can be utilized for embolized stents?
- Balloon Catheters
- Guidewires
- Vascular snares
- Vascular forceps
- Vascular Baskets
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What is the first step after embolization of a foreign body during catheterization?
move the device to a position in which it will cause the least harm most commonly --\> IVC below the hepatic veins
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In the setting of foreign body embolilization during PCI: -what should be done if the device migrates to the ventricles?
it should be pushed to the aorta or pulmonary artery before retrieval is attempted minimizes trauma to the valves and entanglement in the subvalvular apparatus
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What is the rate of vascular access site complication associated with PCI?
1.5%
\*\*\*National Cardiovascular Data Registry (NCDR) Cath PCI Registry data from 2009-2013
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What is the most common complication following femoral arterial access for cardiac catheterization?
Bleeding
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What are the risk factors associated with femoral access bleeding and complications?
Patient related -female gender, elderly, lower body weight/body surface area, obesity, HTN, CKD, PVD, CHF, acute MI Procedure related
- large sheath size, venous sheath, high/low puncture, posterior wall puncture, prolonged sheath dwell time, IABP (or other HD support device), +/- vascular closure device Pharmacotherapy related
- Over anticoagulation with Heparin, post-procedural Heparin, GPIIb/IIIa inhibitors, Use of Heparin rather than Bivalrudin
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What is the most common complication from femoral arterial puncture?
Groin hematoma
\*\*Retroperitoneal hemorrhage (RPH) --\> high mortality
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What are the major complications of catheterization with femoral access?
- Bleeding
- Groin hematoma
- AVF
- Pseudoaneurysm
- Perforation
- Dissection
- Infection
- Embolization
- Thrombosis
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What can reduce vascular complications with arterial puncture?
US guidance
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What is an angiographic marker for the inguinal ligament and retroperitoneum?
inferior epigastric artery
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What benefits does US-guidance of femoral access offer?
Reduced:
- number of attempts
- time to access
- vascular complications
- unintended venous punctures
Improved first-pass success rate
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Anticoagulant that when combined with GPIIB/IIIa inhibitors and compared against Heparin reduces hemorrhagic complications related to PCI?
Bivalrudin (Angiomax)
\*\*defined by TIMI and GUSTO criterion
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What are immediate recommendations for access site bleeds?
Depends on severity of bleed and HDS
- manual or mechanical compression
- reversal of anticoagulation (if possible)
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What is the diagnosis and management of bleeding around an indwelling sheath?
Arterial laceration Insertion of a larger sheath
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What is the next step in a groin hematoma if conservative measures fail or patient becomes hemodynamically unstable?
contralateral groin access with angiography and possible intervention
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What is the recommended time to remain in recumbent with the affected leg straight after groin hematoma?
1 hour per Fr sheath size --\> monitor for signs of bleeding
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What size pseudoaneurysm (post-CFA access) can be observed?
\< 2 cm (will likely close spontaneously)
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What are the indications for vascular surgery consult in a patient with a CFA-pseudoaneurysm?
- at site of vascular graft anastomoses
- mycotic aneurysms
- Pseudoaneurysms associated with skin necrosis or causing femoral nerve compression
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What are the first steps in treatment of coronary perforation?
Balloon inflation
-occlude the vessel proximal to the perforation to minimize extravasation of blood in the pericardium and prevent or delay development of tamponade
Covered stent
-utilized if ballon inflation fails
\*\*If tamponade develops --\> emergent pericardiocentesis (consider autotransfusion of withdrawn blood)
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What are findings of hypocalcemia on EKG?
Shortened QT interval May prolong PR
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LAO Caudal (spider view)
-best for visualizing LCx ostium and RI
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RAO Caudal
-best for visualizing obtuse marginal branches
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What is Bland-Garland-White Syndrome?
anomalous left coronary artery from the pulmonary artery
* usually presents in infancy as CHF but may be diagnosed in adult patients with significant collaterals from the RCA to the LAD and LCx
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What is the treatment for Bland-Garland-White syndrome?
* Surgical restoration of dual coronary circulation (Class I)
* Noninvasive stress testing is recommended every 3-5 years after correction of ALCAPA. (Class I)
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