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PELATIHAN

KARDIOLOGI INTERVENSI
TINGKAT DASAR

POKJA INTERVENSI KARDIOVASKULER


INDONESIA

LEARN by DOING
Endovascular procedures require a
combination of clinical knowledge and
technical skills.
To develope and intergrate the two
necessitates a realistic training
experience.
Patients safety will always be a number
one priority.
The use simulators allows trainees to
practice in a safe and realictic
environtment w/o putting pts at risk

Educational Purpose
A. Understand the indications, limitations, complications and
medical and surgical implications of the findings at
cardiac catheterization and angiography, as well as a
general understanding of related interventional
procedures.
B. Understand the pathophysiology of cardiovascular disease
and the ability to interpret hemodynamic and
angiographic data and to use these data to select cases
for surgical and catheterization-based therapeutic
procedures.
C. Obtain a basic understanding of radiation physics,
radiation safety, fluoroscopy and radiologic anatomy.
D. Understand the fundamental principles of shunt detection,
cardiac output determination and pressure waveform
recording and analysis.

Educational Purpose
E. Learn to perform pulmonary artery catheterization
with flow-directed catheters by the percutaneous
(subclavian, femoral and internal jugular) approach.
F. Learn the proper techniques of diagnostic left heart
catheterization and angiography by percutaneous
(brachial and femoral) approaches.
G. Learn to perform insertion and operation of
temporary right ventricular pacemakers. H. Learn to
perform and interpret the results of therapeutic
pericardiocentesis. Learn intra-aortic balloon
counterpulsation indications, insertion, and
management.

GOALS
They will have the knowledge and
skills necessary to safely and
competently perform these
procedures.
They will be versed in the
indications, contra-indications
and clinical judgment that is
associated with the
catheterizations procedures.

INDIKASI, KONTRA INDIKASI


SERTA KOMPLIKASI PROSEDUR
DIAGNOSTIK INVASIF

OVERVIEW
Right and left heart cath is a procedure where a
catheter is inserted into the cardiac chambers and
vessels percutanously.
Pressure and saturation of each chambers and
vessels were usually taken to obtain the diagnosis.
Angiography is frequently being done to visualize the
anatomical structure of the heart and vessels. It may
also be used to assess the cardiac function and
regurgitation severity.

Indications of Cardiac
Catheterization
To confirm the presence of clinically
suspected condition.
To define the anatomical and physiological
severity of the diseases.
To determine the presence of associated
condition or complication.
As a routine pre op assessment esp. for
elderly patient.

DIAGNOSIS
TMT
ECHO

CT scan

Cardiac
catheterization

NMR

Age and cardiac


catheterization
Patient age has a great influence on
feasibility, risk and clinical impact of
cardiac catheterization
Feasibility is mostly influenced by patient
size because of vascular approach and
catheter manipulation
Risks change according to patient size,
clinical stability, anatomic complexity

Neonates
Indications

Need of neonatal catheterization in


simple heart malformations is
exceptional, unless an
interventional procedure can be
anticipated (i.e. severe/critical
pulmonary/aortic valve stenosis)

Neonates
Indications
Any kind of duct dependance of
pulmonary circulation (pulmonary
atresia intact septum /+ VSD
MACPAs / other complex anomalies) is
the most common indication to cardiac
catheterization in neonates
Detailed knowledge of pulmonary
circulatory supply is infact essential to
plan any need and type of treatment in
these patients

Neonates
Indications
Patients with complex/uncommon
anomalies of the systemic circulatory
supply or with duct dependent circulation
are less commonly candidates to
diagnostic cardiac catheterization
Need to define some critical anatomic
details may lead to haemodynamic
assessment in complex heart
malformations

Neonates
Patients requiring diagnostic cardiac
catheterization in neonatal age are
often complex, critically ill and
candidates to interventional procedures
A further risk is rapresented by low
weight (SGA) and prematurity

NEONATES are the most


difficult and fragile patients

Neonates
Imaging
In neonates the fast injections of boluses of
contrast medium (1-2 ml/Kg) can cause
haemodynamic impairment because of the
acute volume overload
The minimum number of cineangiograms
necessary to accomplish the diagnosis
should be performed
Accurate choice of projections and amount
of contrast medium administered/ injection
is mandatory, particularly in the unstable
patient
The total amount of 10 ml/Kg/examination
should not be exceded

Infants & children


Planning the procedure
At least a rough presumptive diagnosis
is necessary for a correct procedure
Like for neonates, the
echocardiographic diagnosis is
nowadays quite accurate and cardiac
catheterization is usually necessary
only to clarify additional
anatomical/functional details,
necessary for the patient management

Infants & children


Imaging
Also in infants and small children the fast
injections of boluses of contrast medium (12 ml/Kg) can cause haemodynamic
impairment
The minimum number of cineangiograms
necessary to accomplish the diagnosis
should be performed
Accurate choice of projections and amount
of contrast medium administered/ injection
is mandatory, particularly in the unstable
patient
The total amount of 10 ml/Kg/examination
should not be exceded

Adolescents & adults


Planning the procedure
At least a rough presumptive diagnosis
is necessary for a correct procedure
Unless for neonates and infants, the
echocardiographic diagnosis can be
unaccurate in adults with congenital
heart disease, prticularly in
postoperative patients, and cardiac
catheterization is often necessary to
clarify additional anatomical/functional
details, necessary for the patient
management

Cardiac Catheterization / Coronary


Angiogram

Indications :
Unstable angina or Chest pain [uncontrolled
with medications or after a heart attack]
Heart attack
Before a bypass surgery
Abnormal treadmill test results
Determine the extent of coronary artery
disease
Disease of the heart valve causing symtpoms
(syncope, shortness of breath)
To monitor rejection in heart transplant patients
Syncope or loss of consiousness in patients with
aortic valve disease

Contraindications cardiac
catheterization
Absolut:
The refusal of mentally competent patients
to consent the prosedure
Incomplete equipment and cath facility

Contraindications cardiac
catheterization
Relative:

Uncontrolled CCF, hypertension, arrhytmias


Recent CVA < 1month
Infection/fever
Electrolyte inbalance
Acute GI bleeding or anemia
On anticoagulation
Pregnancy
Uncooperative patient
Medication intoxication ( e.g digitalis etc)
Renal failure

Cardiac Catheterization / Coronary


Angiogram
Relative contraindiciations :
Allergy to contrast (dye) medium
Uncontrolled Blood Pressure (Hypertension)
Problems with blood coagulation (Coagulopathy)
Kidney failure or dysfunction
Severe anemia
Electrolyte imbalance
Fever
Active systemic infection
Uncontrolled rhythm disturbances (arrhythmias)
Uncompensated heart failure
Transient Ischemic attack

Risks cardiac catheterization


Common risks of cardiac catheterization are:
Bruising
Infection
Rare risks include:
Heart attack
Stroke
Damage to the artery where the catheter was inserted
Irregular heart rhythms (arrhythmias)
Allergic reactions to the dye or medication
Tearing the tissue of your heart or artery
Kidney damage
Excessive bleeding
Infection
Blood clots
mayo clinic

Risk of complication
Listed below are the percentage of
complication of cardiac catheterization
in
current era (not including intervention)*
Death <0.2%
AMI <0.5%
Stroke <0.07%
Serious Ventricular Arrhythmias <0.5%
Morton J. Kern, The Cardiac Catheterization Handbook

Predisposing factor of higher risk


of complications

Known or suspected Left main coronary stenosis


Severe aortic stenosis
Severe CCF
LV dysfunction (EF<35%)
Diabetes
Advance age
Unstable angina
AMI
Aortic aneurysm
Prior CVA
Renal Impairment
Uncontrolled hypertension
Obesity
Newborn baby

COMPLICATIONS
Minor Complications of Cardiac

Catheterization:
Temporary pain
Minor infections
Nausea and vomiting
Bleeding
Reaction to medications or dye
Allergic skin reaction to tape, dressing, or latex
Abnormal heartbeats
Bruising or scarring at the catheter entry site.
Pyrogen reactions

COMPLICATIONS
Major Cardiac Catheterization
Complications:
death
Serious bleeding
Heart or lung problems, including irregular heart
rhythms and lung or heart failure
Stroke
Heart attack
Blood vessel, nerve, or organ damage
Blood clots in the legs, pelvis, or lungs
Failure of medical equipment
Reactions to medication or dye Kidney failure, with
possible dialysis needed
Other rare and unlikely events.

COMPLICATIONS
Major Cardiac Catheterization
Complications:

VT/VF
Cerbro vascular accident
Peripheral arterial occlusion
Pericardial tamponade
CHF
Cardiogenic shock

COMPLICATIONS
Cerebral Infarction

FOCAL ASYMPTOMATIC

(Radiology 2005;235:177-183.)

Vascular Complications decreased


coronary artery dissection
Chest 1976;70;551-553

stroke

COMPLICATIONS
vascular :

Bleeding:
Occlusion
Loss of distal pulse
Dissection
Pseudoaneurysm
AV fistula

Indication for cardiac catheterization


Indication
1. Suspected or known coronary
artery disease
a. New-onset angina
b. Unstable angina
c. Evaluation before a major surgical
procedure
d. Silent ischemia
e. Positive exercise tolerance test
f. Atapycal chest pain
2. Myocardial infarction
a. Unstable angina postinfarction
b. Failed thrombosis
c. Schock
d. Mechanical complications
(ventricular septal defect, rupture
of wall or papilary muscle)

Procedures
LV.COR
LV.COR
LV.COR
LV.COR,ERGO
LV.COR,ERGO
LV.COR,ERGO
LV,
LV,
LV,
LV,

COR
COR,RH
COR,RH
COR,RH

3. Sudden cardiovascular death


4. Valvular heart disease
5. Congenital heart disease (before
anticipated corrective surgery
6. Aortic dissction
7. Pericardial constriction or
tamponade
8. Cardiomyopathy
9. Initial and follow up assesment for
heart transplant

LV,COR, R+L
LV,COR, R+L, AO
LV,COR, R+L, AO
AO+ COR
LV,COR, R+L, AO
LV,COR, R+L, AO,
BX
LV,COR,R+L,AO,
BX

AO, Aortography; BX, endomyocardial biopsy; COR, coronary angiography; ERGO,


ergonovine provocation of coronary spasm; LV, left ventriculography; RH, Right heart
oxygen saturations and hemodynamics (e.g. placement of swanz-ganz catheter); R+L,
right and left heart hemodynamics

Contraindications to Cardiac
Catheterization

Absolute contraindications
Inadequate equipment or catheterization facility
Relative Contraindications
Acute gastrointestinal bleeding or anemia
Anticoagulation (or known, uncontrolled bleeding diathesis)
Electrolyte imbalance
Infection and fever
Medication intoxication (e.g. digitalis, phenothiazine)
Pregnancy
Recent cerebrovascular accident (<1 month)
Renal Failure
Uncontrolled congestive heart failure, high blood
pressure,arrhythmias
Uncooperative patient

Complication of cardiac
catheterization
Major
Cerebrovascular accident
Death
Myocardial infarction
Ventricular tchycardia, fibrilation, or serious arrhytmia
Other
Aortic dissection
Cardiac perforation, tamponade
Congestive heart failure
Contrast reaction (anaphylaxis, nephrotoxicity)
Heart block, asystole
Hemorrhage (local, retroperitoneal, pelvic)
Infection
Protamine reaction
Supraventicular tachyarrhythmia, atrial fibrilation
Thrombosis, embolus, air embolus
Vascular injury, pseudoaneurysm
Vasovagal reaction

Major Complications of Diagnostic


Catheterizations
Number

Death
Myocardial infarction
Neurologic
Arrhytmia
Vascular
Contrast
Hemodynamic
Perforation
Other
total (patients)

65
30
41
229

Percent

0.11
0.05
0.07
0.38
256
223

158
16
166
1184

0.43
0.37
0.26
0.03
0.28
1.98

Modified from Noto TJ, Johnson LW, Krone R, et al: Cardial


cathetirazion 1990: a report of the registry of the society for
cardiac angiography and interventions (SCA&I), Cathet
cardiosvascular 24:75-83; in uretzk BF; Weinert HH; Cardiac
catheterization: concepts, techniques and application, Walden,
Mass, 1997, Blackwell Science

Conditions of patients at higher risk


for compliactions of catheterization
Acute myocardial infarction
Advance age (>75 years)
Aortic aneurysm
Congestic heart failure
Diabetes
Extensive three-vessel coronary artery disease
Left ventricular dysfunction (left ventricular ejection fraction
<35%)
Obesity
Prior cerebrovascular accident
Renal insufficiency
Suspected or known left main coronary stenosis
Uncontrolled hypertension
Unstable angina

Conditions requiring special


Condition
Management
preparations
1. Allergy

1. Allergy

a. prior contrast studies

a. Contrast premedication

b. Iodine, fish

b. Contrast reaction algorithm

c. Lidocaine

c. Use Marcain (1mg/ml)

2. Patients receiving anticoagulation


(INR > 1.5)

2. Defer procedure
a. Vitamin K; 10 mEg/hr
b. Fresh frozen plasma
c. Hold heparin
d. Protamin for heparin

3. Diabetes
a. NPH Insulin (protamin reaction
b. Renal function (prone to contrastinduced renal failure)
c. Metformin usage

3. Hydration to increase urine output


>50ml/hr; metformin held 48 hours; if
renal insufficiency postpone
catheterization and consider urgency
and risks of lactic acidosis

Conditions requiring special


Condition
Management
preparations
4. Electrolyte imbalance (K+, Mg2)

5. Arrhytmias

4. Defer procedure, replenish or correct


electrolytes
5. Defer procedure, administer
antiarrhytmics
6. Defer procedure

6. Anemia

a. Control bleeding
b. Transfuse

7. Dehydration
8.Renal Failure

7. Hydration
8. Limit contrast
a. Maintain high urine output
b. Hydrate

Patient and clinical characteristics


associated with increased mortality from
cardiac catheterization
Age
Infants (<1 year old) and elderly (>65 years old)
Elderly women seem to be higher risk than elderly man
Functional class
Mortality in class IV patients is more than10 times greater
than in class I and II patients
Severity of coronary obstruction
Mortality for patients with left main coronary artery disease is
more than 10 times greater than for patients with one-or
two- vessel diseases
Valvular Heart disease
Severe valvular heart disease, especially severe aortic
stenosis, is associated with increased risk cardiac death

Patient and clinical characteristics


associated with increased mortality from
Left ventricular
dysfunction
cardiac
catheterization

Mortality for patients with left ventricular ejection fraction <30% is


more than 10 times greater than in patients with ejection fraction
50%
Severe noncardiac disease
Increased risk of adverse events associated with following conditions:
Diabetes
Severe pulmonary disease
Advanced cerebrovascular of peripheral vascular disease
Renal insufficiency

Modified from Grossman W: complication of cardiac catheterization: incidence, causes and


prevention. In Grossman W, Editor: Cardiac catheterization and angiography, ed 3,
Philadelphia, 1986, Lea & Febiger

Incidence of complication during diagnostic


cardiac catheterization for varios clinical and
angiographic variables
Death (%) MI(%) CVA(%) Arrhytmia (%)

Age
<60 0.07
>60 0.12

0.07
0.02

0.05
0.12

0.43
0.53

NYHA Class
I 0.02
II 0.02
III 0.05
IV 0.29

0.02
0.03
0.07
0.12

0.12
0.05
0.05
0.08

0.53
0.32
0.43
0.65

Incidence of complication during diagnostic


cardiac catheterization for varios clinical and
angiographic variables
Death (%) MI(%) CVA(%) Arrhytmia (%)
Ejection Fraction
>50% 0.03
0.04
30%-49%
0.12
<30% 0.30
0.12
Extent of CHD
1 Vessel
0.05
2 vessels
0.07
3 vessels
0.12
LM
0.55
0.17

0.05
0.35
0.06
0.08 0.55
0.09 0.94

0.06
0.08
0.08
0.13

0.04
0.08
0.09
0.66

0.42
0.45
0.53

Modified from Johnson LW, et al: Cathet cardiovasc diagn 17:5-10, 1989. CHD,
Coronary heart disease; CVA, cerebrovascular accident; LM,left main disease; MI,
myorcardial infarction; NYHA, New York Heart Association.

Conditions in which Nonionic, lowosmolality contrast agents should be


used preferentially during high-risk
cardiac
catheterization
Acute myocardial
infarction
Congestive heart failure
Ejection fraction 30%
Suspected left main or three-vessel coronary
artery disease
Severe aortic stenosis
Complex or multiple ventricular arrhytmias
Acute or chronic renal insufficiency
Anticipated use of large contrast agent
volume

Management of complications during


cardiac catheterization

Complications and precautions


Myocardial Infarction (0.2%)

Cerebrovascular accident (0.1%)


Systemic heparinization
Cleaning of guidewires before use
Limit guidewire-blood exposure (<2 min)
Use guidewire to cross aortic arch
(especially in atherosclerotic aortas, and
especially for amplatz or bypass graft
catheter)
Aspirate and flush catheters frequently
Remove air bubbles in any of tubing,
solutions, or injection syringe
Ensure all tubing and catheter
connections are tight

Treatment
Introcoronary nitroglycerin (rule out spasm)
Consider intracoronary
Thrombectomy or aspiration,
Coronary angioplasty, or emergency
Aortocoronary bypass

Management of complications during


cardiac catheterization

Complications and precautions


Dissestion (0.1%)
Never advanced guidewire orcatheter
againts resistance; catheter tip location
confirmed by gentle contrast injection.
Do not manipulate catheter in coronary
ostium, monitoring pressure of catheter
tip.
Do not inject with damped pressure.

Acute pulmonary edema


Treat preexisting CHF optimally
Limit contrast medium in high risk; avoid
LV angiography in severe aortic stenosis,
marked CHF, or pulmonary hypertension.
Use nonionic or low-osmolar contrast
media agents.
Avoid hypotension
Limit flush solution volume
Monitor LV filling pressure (PCW)

Treatment

No further coronary injections


If ischemia produced, stent or emergency
aortocoronary bypass.
If dissection associated with thrombus but
no ischemia, use heparin(controvential) and
consider coronary stenting.

Elevate patients trunk 30 to 45 degrees


Oxygen, morphine (2 to 5 mg IV), nitrates
(100 to 200 g IC), furosemide (20 to 100
mg IV); nitroprusside for afterload reduction;
inotropic support with dopamine or
dobutamine
Intraaortic ballon pumping

Management of complications during


cardiac catheterization

Complications and precautions


Cardiogenic schock
Careful patient selection: (1) left main
coronary artery stenosis, (2) aoric
stenosis at high risk, and (3) acute
infarction
Prophylactic IABP for high-risk left main
coronary artery angiography; minimize
number of injections; treat hypotension
Stop procedure if hypotension persist
Athopine, adequate volume expansion,
Aramine ([Metaraminol] intraaortic
injection of 0.125 to 0.250 mg) IABP
Rule out pericardial tamponade with RA
and RV pressures; consider urgent
echocardiogram
Monitor filling pressure

Treatment

If schock caused by coronary occlusion,


treat with emergency PTCA or CABG
surgery
Vasopressor supprot
IABP
Intubation and mechanical ventilation
Pacemaker as needed

CABG, Coronary bypass graft, CHf, congestive heart failure, IABP,inaaortic ballon pump; IC, intracoronary; IV,
intravenous; LV, left ventricular, PCW, pulmonary capilary wedge;PTCAM, percutaneous transluminal
coronary angioplasty, RA, right atrial, RV, right ventricular

Management of complications during


cardiac catheterization

Complications and precautions


Ventricular tachycardia, asystole or
fibrilations (0.6%)
Use nonionic agents in high risk patients
Do not wedge coronary artery catheter;
contrast material washout should be
brisk; ECG and BP should be normal
before next injection
Do not inject when catheter tip pressure
is damped
Use atropine, volume expansion, or
metaraminol (aramine for hypotension
Limit contrast medium injected into
coronary arteries; avoid prolonged
injections
Air Embolism
For prevention and treatment see p.454

Treatment

Cough for temporary increase in BP


Remove catheter from RV,LV or coronary
ostium
CPR followed by prompt defibrilation
Defiriblifation (200J)
Lidocaine (50 mg bolus, 2 to 4 mg/min IV)
Amiodarone (300 mg bolus) then infusion
Refractory VF ususally as a result of
extensive CAD; emergency percutaneous
should be considered

Same as cerebrovascular accident

Management of complications during


cardiac catheterization

Complications and precautions


Hematoma in femoral artery (0.1%
major, 1% major to 2 % Minor)
Puncture below inguinal ligament
Attention to compression
Prolonged compression if patient
coughing, aortic insuffisiency,
hypertension, or heparin not reserved
Vascular closure device

Retroperitoneal bleeding
Avoid high (above inguinal ligament)
femoral artery puncture
Watch for hypotension, low abdominal or
flank pain within 2-12 hous of procedure
Low hematrocrit, tachycardia (if not
receiving -blockers)

Treatment

Evacuation rarely required


Surgical cosult for enlarging hematoma,
compartment syndrome, or cool extrimity

Reserve anticoagulants
Volume replacemt
Trasfusion if hematocrit <25
Surgical consultation
CT scan

Management of complications during


cardiac catheterization

Complications and precautions

Cardiac Tamponade
Avoid stiff catheters in RA or RV; pacing
catheters handled gently
Avoid posterior LA wall during transseptal
catheterization

Contrast agent nephrotoxicity


Hydration and inonic contrast agents
Contrast agent reaction
vasovagal reaction

Treatment

Prompt pericardiocentesis with catheter


drainage
Cardiovascular surgery consultation
Surgical exploration and closure for
persistant bleeding

Generally self-limited; dialysis rarely needed

Modified from Tilkian AG, Daily EK; Cardiovascular procedurs: diagnostic techniques and therapeutic
procedures, St. Lois, 1986, Mosby

Premixing regimen used in the preparation


of norepinephrine (levophed) for bolus
therapy for blood support
1.

Dilute 1 mg norepineoherine in 9 ml normal


saline
= 1000g/10 ml
= 100g/ml
2. Take 1 ml of above mixture and further dilute in
another 9ml normal saline
= 100g/10 ml
= 10g/ml
3. Administer bolus doeses of 5g (0.5ml)
approximately every 5 minutes as needed.
Blood pressure usually responds within 3 to 5
minutes

Treatment of severe anaphylactoid


reactions: recommendations from society of
cardiac angiography and interventions
Initial pharmacological therapy
Ephinephrine 10g/min IV until desired blood pressure
response, then 1 to 4 g/min to maintain desired blood
pressure, given simultaneously with large volumes of
normal saline
Diphenhydramine (benadryl) 50 to 100 mg IV
Hydrocortisone 400mg IV
If unresponsive to initial therapy
H2 blocker therapy
Cimetidine 300 mg in 20 ml normal saline administred IV over
15 minutes
Ranitidine 50 mg in 20 ml normal saline administred IV over
15 minutes
Dopamine 2 to 15 g/kg/min IV infusion

MODUL ICI/IFI SCAI

http://www.scai.org/Courses/default.aspx

Table of Contents
Course 1: Basic Science Concepts for the Interventional Cardiologist
Course 2: Cath Lab Basics
Course 3: Valvular, Structural, and Congenital Heart Disease
Course 4: Intracoronary Imaging V Physiology
Course 5: Patient and Lesion-specific Approaches
Course 6: Acute Myocardial Infarction & Thrombus
Course 7: Anticoagulation in the Cath Lab
Course 8: Coronary Stenting (i)
Course 9: Coronary Stenting (ii): Drug-Eluting Stents
Course 10: Advanced PCI Techniques & Devices
Course 11: High Risk Groups and Complications
Course 12: Cardiac Imaging
Course 13: Peripheral Vascular Disease
Course 14: Carotid Artery Disease

ACC CathSAP4
www.cardiosourse.org
1: Fundamentals of Vascular Biology
2: Pathobiology of Vascular Disease
3: Cardiac Vascular Anatomy
4: Fundamentals of Cardiac Catheterization
5: Fundamentals of Cardiovascular Imaging
6: Interventional Pharmacotherapies
7: Coronary Interventional Equipment and Techniques
8: Patient-Specific Approaches and Guidelines
9: Lesion-Specific Approaches, Techniques, and Equipment
10: Procedure-Related Complications and Management
11: Valvular Heart Disease
12: Congenital Heart Disease
13: Structural Heart Disease
14: Peripheral Vascular Disease
15: Carotid and Cerebrovascular Disease
16: Post-Procedural Care
17: Miscellaneous Topics