1

1
1 Proximal RCA 2 Mid RCA 3 Distal RCA 4 RDP 16 RPL

INTRACORONARY PARAMETERS OF STENOSIS SEVERITY LAD While coronary angiography is used as the gold standard for documentation of the presence and extent of coronary artery disease, it has its limitations in assessing the funcLAD tional significance of coronary stenoses and particularly in intermediate coronary lesions i.e. lesions with diameter stenosis 40-70%. Therefore, intracoronary derived pressure, flow CX SENSE! and intravascular ultrasound (IVUS) parameters have been validated for clinical decision AV node His EFFICIENT CAG AV node making in the cathlab (see Table below). Ischemia and defer values for IVUS are: Lumen His RBB RBB 2 Systemic evaluation of the coronary tree: do not miss any occluded vessel or AV node cross sectional area of >4.0 mm in a coronary artery and >6,0 mm2 for the mainstem (MS). AF His RBB LAD LBB any anomaly. LBB AF Coronary lesions have often an eccentric appearance make several orthogonal CX LBB AF PF projections to be sure you do not miss an eccentric stenosis. PF FFR CFR RCFR HSR PF Be sensitive to catheter wedging, ostial lesions, catheter induced coronary artery Normal Value 1.0 > 3.0 1 0 AV node spasm and over projection of tortuous vessels. His RBB Ischemia detection < 0.75 < 2.0 < 0.65 > 0.80 Assess projections with a meaning: Defer PCI > 0.75 > 2.0 na na LBB AF LAD na Defer PCI ACS > 0.80 na na RCA PF RCA: Proximal: L 45 (15-50), Cranial 0RCA (0-35) RCA > 0.75 Defer PCI MS na na na CX Mid: L 45, R30 (0-45) FFR: fractional flow reserve; CFR: coronary flow (velocity) reserve; RCFR: relative CFR; Crux: L 25 (15-50), Cranial 25 (0-35) AV node HSR: hyperemic stenosis resistance (mmHg cm-1 s-1). His RBB LCA: Left main: LAD: proximal LAD: mid / distal RCx: proximal RCx: OM mid -distal R0 (0-10), Cranial 0 (-40 to +40) R5 (5-45), Cranial 35 (Caudal -40 to +40) R 30 (-50-30), Cranial 30 (0-40) L45 (-5-50), Caudal 30 (20-40) L45 (-5-50), Caudal 35 (-30-40) R 30-0, L45-0 R 20-0, L45-0
CX AV node
left main
RCA
LBB PF AF

11

1 11
12

13

13

PCI

3 4 4

16

16
15

2 14 15

2 16 3 4

5 Left main 5 6 Proximal LAD 6 9 7 Mid LAD 11 9 8 Distal LAD 12 7 9 D1 7 5 10 D2 13 6 11 10Proximal RCX 14 10 12 Intermediate / M1 11 13 Mid RCX 14 12 9 16 12 MO1 15 8 14 MO2 3 13 8 7 15 MO3
12

sinus

conus branch conus branch

9 7 10

RV

RV

sinus

RPL

RPL
RV

conus branch RPL

conus branch

8
6

14

RV

RV

RV

14 15 8

10

RV

RDP RDPsinus
conus branch

RPL

RDP

11 12 13 7 14 15 9

RIGHT CORONARY ARTERY (RCA): 2 Left Anterior Oblique View (L45-0) sinus node sinus node sinus node Use: Catheter intubation, Optimal visualisation: 16 3 RCA- proximal, -mid and -distal conus branch 4 conus branch
sinus node

RV : RIGHT CORONARY ARTERY (RCA) 10 Right Anterior Oblique View (R30-0) Optimal visualisation: RCA-mid collateral vessels to LAD (if present)
8

sinus branch sinus branch

RV

conus branch conus branch

sinus branch

conus branch RDP RPL

conus branch

sinus branch

RV branches RV branches RV

conus branch

RV branches
RDP

RCA CONDUCTION SYSTEM BLOOD SUPPLY CARDIAC

1 av nodal av nodal
conus branch
av nodal

5 6 11

LV angio: Aorta angio:

LAD

RIGHT CARDIAC CATHETERIZATION (NORMAL VALUES) Location RA RV PAP PCWP Cardiac Output (CO) Cardiac Index CI=CO/BSA Pulmonary Vascular Resistance PVR=(PAP-PCWP)/CO Systemic Vascular Resistance SVR= (Paorta-RAP)/CO Pressure (mmHg) a (2-10), v (2-10) 0-30 3-30 a (3-15), v (3-12) 3-6 l/min 2.5-3.5 l/min/m2 20-130 dynes sec cm-5 700-1600 dynes sec cm
-5

Saturation (%) 75 75 75 left97 main left main

RV branch RV branch RDP

RBB AF
RCX LAD

RV branch

RPL

RPL

RPL
12 9 7 14

RDP

sinus RDP branch

RV branches

RPL

RPL
conusRDP branch

RPL sinus

For educational purposes only. May contain errors. Read PCIpedia.org for fuller explanation. PCIpedia.org is part of the Cardionetworks Foundation. Version: 3/2010, meuwissen@cardionetworks.org

INDICATIONS FOR CORONARY ANGIOGRAPHY (CAG) Class I: STEMI: Acute, NSTEMI: < 72 hours (timing based on risk stratification). Class I: Disabling stable angina pectoris (CCS III-IV) despite medical therapy or high-risk criteria on clinical assessment / noninvasive testing or unexplained heart failure or survivors of cardiac arrest or severe ventricular arrhythmias or angina in conjunction with signs of heart failure or unexplained heart failure or early recurrence of angina after PCI/ CABG or pre cardiac valve surgery ( : >35 yrs, : >50 yrs.). Class IIa: Inconclusive or conflicting results after noninvasive stress testing or unable to undergo noninvasive testing (disability, illness, or morbid obesity) or reevaluLAD ation of performed procedures (main stem PCI, high restenosis risk). CX Class III: Risk of CAG outweighs the benefit (significant comorbidity) or CXmild angina (CCS class I or II) responding well to medical therapy. ALWAYS USE COMMON

(RELATIVE) CONTRA-INDICATIONS FOR CAG Symptomatic heart failure or uncontrolled hypertension or refractory arrhythmia or severe contrast medium allergy or inability for patient cooperation or pregnancy or active infection or severe renal failure or coagulopathy / anticoagulant state ( high INR / PT) or severe hemorrhage or intoxication (digitalis) or electrolyte disturbance (hypokaliema).

NOMENCLATURE PCI SEGMENTS

RIGHT CORONARY ARTERY (RCA): Left Anterior Oblique and Cranial View (L20-C25) Optimal visualisation: RCA-proximal, -distal, -crux, RDP, RPL sinus sinus

sinus node
13branch RDP conus

RPL

conus branc

av nodal

RDP2
left main

RPL

RAO 30

RDP

RV branches

His

SA node: RCA in 55-60 % AV node: RCA in 90 % His bundle : RCA / LAD Right bundle (RBB): LAD (S1) RCX Left bundle (LBB): left main RCX Anticus (AF): LAD Posticus (PF): LAD/ RCALAD RCA RCX

LBB PF

LAD

LAD IM
LAD

left main IM left main

RV branch

16

RAO 30 10main RAO 30 left

RPL
OM D D SN

LAO 60
sn RCA

LAO 60 OM LAO 60 D
CX S

RV
RPL left main

3 RDP
left main

15 left main av nodal left main LAD

SN CB RV CB CX

OM

IM
RCX
LAD

8
S
OM

LAD

LAD

4
RV branch

SN

CX S S left main

CB D 30 RAO D

sn RCA
OM

RCA

LAO 60
CB S LAD D

D main sn D left left main LAD

RDP
CX
S D CX
left main

CX

CB S

CXRV OM
AcM

LAD D

RV

OM

RV D

diagonal

LAD

LAD diagonal diagonal

LAD marginal marginal diagonal
septal

left main

marginal

main stem main stem

RCX

RCX

RCX

IM main stem

LAD RCX
IM

RDP RV SN
PL

left main
ACM

OM OM CX S CB
RV ACM

LAD

LAD
PL

ACM

CB RV DRV D S
LAD AcM
CX

OM snLADleft main D

S
RCA OM
SN left main

RCX main stem

RCX

RCX

ACM PL

S S PD AcM D OM

RAO RCA 30
CB
D

LAO 60
LAD
D

LAD
RCA RCA sinus node

PD
PL

PD

D
S OM

RV D S S AcM

OM sn
RCA 0M RV

0M
CX

CB

0Mplane Sinterventricular D D PL PL LAD D

D sinus
CB S PD S 0M

branch
LAD OM

PL

con

atrioventricular plane

RCX

RCA

interventricular atrioventricular plane plane interventricular plane

PD RV

D atrioventricular plane AcM atrioventricular plane D PL

conus branch
sinus node
RCA

conus branch

conus branch conus branch

RV branches
RV branches

RPL RDP sinus branch RPL RDP

RVRV branches branches

conus branch

av nodal conus branch

RPL

av nodal av nodal

RPL
RPL

RPL RDP
RV branches

sinus node

RPL

LEFT CORONARY ARTERY (LCA): Left Anterior Oblique and Cranial View (L50-C20) Optimal visualisation: Mainstem ostium, LAD-mid-distal, Diagonals, RCX-mid-distal
left main

LEFT CORONARY ARTERY (LCA): Left Anterior Oblique and Caudal View (Spider; L50-C25) Optimal visualisation: Mainstem ostium-body-bifurcation, LAD-proximal, RCx-proximal-mid
LAD
left main

RV branch

RPL

av nodal

av nodal

RDP RPL

LEFT CORONARY ARTERY (LCA): av nodal

RDP

conus branch

branch RV branchOptimal visualisation: MainstemRV body, LAD-mid-distal, MO RDP RV branch RDP RDP RV branch left main left main
RDP

RV branch

Right Anterior Oblique View (R30-0) RPL

RPL

RPL

RDP

RDP

RAO 30
D RAO

MODEL OF CORONARY ARTERIES IN ATRIOVENTRICULAR LAO 60 AND INTERVENTRICULAR PLANES

RPL
sn LAO 60 left main RAO

left main left main

left main

RCX

LAD LAD
LAD

IM
LAD

main left left main

left main

LAD
LAD LAD
LAD

left main

SN left main

RAO 30 RDP av nodal D RAO 30 RPL OM left main D LAO 60

OM

OM

30

LAO 60

left main
RCX
RCX

IM IM
IM

LAD
RCX

IM

left main left main RV branch

SN

RCX RCX
LAD diagonal

IM
LAD

RCX
LAD

left main

main stem
main stem stem RCX main main stem

RCX RCX
RCX

RCX
RCX

RCX IM

LAD LAD
septal

LAD

marginal diagonal diagonal diagonal LAD

marginal marginal marginal
septal

main stem

diagonal

RCXRCX

main stem
RCX main stem diagonal marginal

diagonal
septal marginal

marginal
LAD

sn left main CX S CX S S D S OM D CB S S CB CX D RCA CX D CB CB RCA SN OM S LAD SN LAD OM D OM LAD CX LAO 60 CX RV RAO 30 S LAD S CBLAD LAD LAD CB S S S RV RV S CB CB AcM S OM LAD OM DOM LAD ACMRV PL OM LAD OM RV OM S D sn S mainRV S LAD left leftRV main left main RV S D D D OM S PD RV 0M OM S D D D AcM AcM RV AcM CX RCA S D D ACM SN D D ACM ACM PL PL AcM RCA PL LAD D CB CX S S PL CB ACM PL PD D PD AcM PD 0M OM LAD 0M 0M RCX D ACM PD LAD PL 0M RV S interventricular plane atrioventricular plane PL OM RCA PD PL RCA PL RV RCA 0M PL S RCX RCA D D D D D PD AcM plane PL interventricular RCA atrioventricular plane D ACM interventricular plane atrioventricular plane PL plane interventricular plane interventricular plane atrioventricular plane atrioventricular D SN
D

CB

CXOM

S D

D RCA left main sn

CX CX LAD RDP S CB CB RV

snD left Dmain left main D LAD RCA SN

OM left main CB

sn

left main D
LAD D

RAO 30
OM D CX

30

RDP 60 LAO
CX

LAO 60
sn left main

RCA RV

OM

CX

RCA

septal septal

RCX

atrioventricular plane

PD

septal

atrioventricular atrioventricular plane plane plane atrioventricular

atrioventricular plane

PD RCA

PD

PD

interventricular plane
D

PD

0M

PL

atrioventricular plane

LEFT CORONARY ARTERY (LCA): Left lateral view (L90-0) Optimal visualisation: LAD-mid-distal, LIMA anastomosis (if present), RCx-mid-distal
left main LAD
LAD LAD left main left main RCX
left main

CORONARY ARTERY (LCA): Right Cranial View (R5-C40) Optimal visualisation: LAD-proximal-mid-distal, LIMA anastomosis (if present), Diagonals
left main
left main LAD left main
LAD left main

LEFT septal

left main

LEFT CORONARY ARTERY (LCA): Right Caudal View (R5-C40) LAD left mainOptimal visualisation: MS-bifurcation, LAD-proximal, RCx-proximal-mid-distal, MO-bifurcation LAD
LAD

atrioventricular plane OVERVIEW CORONARY VESSELS INCLUDING LEFT AND RIGHT DOMINANCE
PD

interventricular plane

atrioventricular plane

PD

RCX
RCX
RCX

left main

left main

left main

left main
RCX

LAD

left main

LAD

Right dominance in 85% of patients: RCA crux RPL and RDP. Left dominance in 10% of patients: RCA RPL and no RDP (LCA). Balanced in 5% of patients:RCA RDP and no RPL (LCA). ELECTROCARDIOGRAPHIC CULPRIT PREDICTION ECG in RCA occlusion: ST depression in aVL > I, ST elevation III > II, V4R isoelectric or elevated, S:R in aVL>3. ECG in RCX occlusion: ST elevation II > III, V4R negative T, S:R in aVL < 3. ECG in Anterior infarction: (table below) Main stem
marginal
marginal

atrioventricular plane

left main

left main

left main
RCX
RCX

LAD

LAD
LAD

RCX left main

left main RCX LAD

left main

LAD

LAD

RCX

RCX RCX

RCX

LAD septal septal

septal

LAD

RCX

RCX
LAD

RCX

RCX RCX
marginal marginal
RCX

LAD

RCX
diagonal

RCX

LAD septal septal

septal

diagonal septal diagonal septal

diagonal septal

diagonal

septal

marginal marginal
marginal
septal

marginal

marginal diagonal
septal marginal

marginal
diagonal

septal

marginal septal

diagonal marginal

diagonal
diagonal
diagonal

marginal

diagonal

1) ST vector -90 2) ST in aVR > V1 3) ST in V1-2 4) ST V1 2,5 mm 5) RBBB, Left axis 6) ST II 1,0 mm 7) ST maximal in V5-6

LAD, proximal to S1 / D1: 1) See mainstem nr. 2-7 2) ST vector -90 and -30 3) ST V1-6 4) ST II, III, aVF

LAD, distal to S1 / D1: 1) ST vector: 0 - 90 2) ST V1-6, II - aVL 3) No ST III 4) ST II, III, aVF

diagonal diagonal