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CARDIAC CATHETERIZATION - Previous anaphylactoid reaction to contrast media

- Insertion and passage of small plastic tubes
(catheters) into arteries and veins to the heart to
obtain x-ray pictures (ANGIOGRAPHY) of coronary
arteries & cardiac chambers to measure pressures in
the heart (HEMODYNAMICS)
Procedures that may Accompany Coronary Angiography
- Central venous access
- Left ventricular angiography
- Aortography
- Cardiac pacing and Electrophysiologic Studies
- Intra-aortic Balloon Counterpulsation
Coronary Angiography
- Radiographic visualization of the coronary vessels
after the injection of radiopaque contrast media
- Gold standard for identifying the presence or
absence of arterial narrowing related to
atherosclerotic coronary artery disease
- Provides the most reliable anatomical information for
determining the appropriateness of medical therapy,
percutaneous coronary intervention, or coronary
artery bypass graft surgery in patients with ischemic
CAD
- Acute stroke
- Acute renal failure or severe chronic non—dialysis –
dependent kidney disease
- Unexplained fever or untreated active infection
- Severe anemia
- Uncooperative patient
Information Obtained from Coronary Angiography
- Identification of the location, length, diameter, and
contour of the coronary arteries
- Presence and severity of coronary luminal
obstructions
- Characterization of the nature of the obstruction
- Presence and extent of coronary collateral vessels
Catheterization of the Coronary Artery
 Femoral
o Combination of physical and radiographic
landmarks is used
o Usually located 1 – 2 cm below the inguinal
crease, 1 – 2 second fluoroscopy to visualize
the course of the common femoral artery
 Brachial
 Radial

INDICATIONS PROCEDURES Patients at Increased Risk for Complications after

1. Suspected or CAD Coronary Angiography
- New onset angina LV, COR
- Unstable angina LV, COR  Increased GENERAL MEDICAL risk
- Evaluation before a major LV, COR o Age >70
surgical procedure o Complex congenital heart disease
- Silent ischemia LV, COR o Morbid obesity
- (+) exercise tolerance LV, COR o General debility or cachexia
test o Uncontrolled glucose intolerance
- Atypical chest pain or LV, COR o Arterial O2 desaturation
coronary spasm o Severe COPD
2. Myocardial Infarction o Renal insufficiency with creatinine >1.5mg/dl
- Unstable angina LV, COR
postinfarction  Increased CARDIAC risk
- Failed thrombolysis LV, COR o Three vessel CAD
- Shock LV, COR, RH o Left main CAD
- Mechanical complications LV, COR, R + L o Functional class IV
(VSD, rupture of wall or o Significant mitral or aortic valve disease on
papillary muscle) mechanical prosthesis
3. Sudden cardiovascular death LV, COR, R + L o Ejection fraction < 35%
4. Valvular heart disease LV, COR, R + L, AO o High risk exercise treadmill testing
5. Congenital heart disease LV, COR, R + L, AO o Pulmonary hypertension
(before anticipated corrective o Pulmonary artery wedge pressure >
surgery or ASD/PFO closure) 25mmHg
6. Aortic dissection AO, COR
 Increased VASCULAR risk
7. Pericardial constriction or LV, COR, R + L
o Anticoagulation or bleeding diathesis
tamponade
o Uncontrolled systemic hypertension
8. Cardiomyopathy LV, COR, R + L
o Severe peripheral vascular disease
9. Initial and follow up LV, COR, R + L o Recent stroke
assessment for heart o Severe aortic insufficiency
transplant
Risks of Cardiac Catheterization and Coronary
Contraindications for Cardiac Catheterization Angiography
There is no true absolute contraindication to cardiac Vascular complications – 0.43
catheterization other than the refusal of the competent patient. Arrhythmia – 0.38
Contrast reaction – 0.37
Relative contraindications: Mortality – 0.11
- Acute GI bleeding Cerebrovascular accident – 0.07
- Severe hypokalemia Myocardial infarction – 0.05
- Uncorrected digitalis toxicity Hemodynamic complications
- Anticoagulation with INR >1.8 or severe coagulopathy Perforation of heart chamber

Historical Perspectives
 Dr. Charles Dotter & Dr. Melvin Judkins
o Introduced transluminal angiography (1964)
o Used multiple catheters of increasing
diameter to open blocked arteries and
improve blood flow in px with arteriosclerosis
in peripheral (leg) arteries
 Dr. Andres Gruentzig
o First performed percutaneous transluminal
coronary angioplasty (PTCA)
o Used a prototype, fluid – wire balloon
catheter
Mechanism
 Most luminal improvement following PTCA seems to
result from plaque redistribution
o Longitudinal displacement of plaque and
downstream from the lesion
o Results from “controlled overstretching” of
the vessel by the PTCA balloons which leads
to fracture of the intimal plaque, partial
disruption of the media & adventitia and
enlargement of both the lumen and the
overall outer diameter of the vessel
PERCUTANEOUS CORONARY INTERVENTION
 Includes other techniques capable of relieving
coronary narrowing
o Rotational atherectomy
o Directional atherectomy
o Extraction atherectomy
o Laser angioplasty
o Implantation of intracoronary stents
INTRACORONARY STENTS
- The concept of a temporary endoluminal splint to
scaffold an occluded peripheral vessel was introduced
by Charles Dotter nearly 40 yrs ago but was not
practical until the first human coronary implantation
was performed in 1986.
 Drug Eluting Stents
o A normal metal stent that has been coated
with pharmacologic agent (drug) that is
known to interfere with the process of
restenosis (reblocking)
o Extremely successful in reducing restenosis
from the 20 – 30% range to simple digits
o Sirolimus, paclitaxel, everolimus,
zotarolimus, tacrolimus, pimecrolimus,
supralimus
3 major components to a drug-eluting stent:
a. Type of stent that carries the drug coating
b. Method by which the drug is delivered (eluted) by
the coating to the arterial wall (polymeric or other)
c. The drug itself – how does it act in the body to
prevent restenosis?
 Bare Metal Stents
LALALA-LALAϋ
ANTIPLATELET & ANTITHROMBOTIC THERAPIES
 ASA
o Empiric dose: 80 – 325mg given at least 2h
before PCI is recommended
 Clopidogrel
o 600mg loading dose followed by 75mg daily
 Prasugrel (Effient)
o 60mg loading dose and 10mg/day for the
maintenance dose
 GP IIb/IIIa inhibitors
o Inhibits the binding of fibrinogen and other
adhesive proteins to adjacent platelets by
means of the GPIIb/IIIa receptor w/c serves
as the “final common pathway” of platelet
thrombus formation
 Heparin
o Higher levels of anticoagulatioin with heparin
are roughly correlated with therapeutic
efficacy in the reduction of complications
during coronary angioplasty
o Should achieve an ACT of 250 – 300s with
Hemotec device and 300 – 350s with the
Hemochron device
CORONARY ARTERY BYPASS SURGERY
 Venous conduits
o Saphenous vein: used mainly for distal
branches of the right and circumflex
coronary arteries
 Also used for sequential grafts to
these vessels and diagonal
branches
 Internal mammary artery bypass grafts
o Also known as the internal thoracic artery
o Usually remarkably free of atheroma,
especially in patients < 65 y/o
Symptomatic Results
- Coronary bypass surgery: highly effective in the relief
of angina and results in improved quality of life
- Approximately 80% of px are free of angina at 5 yrs
and 63% at 10 yrs
o By 15 yrs, only 15% are alive and free of an
ischemic event
- Acceleration in adverse events after 5 – 15 yrs is due
to gradual occlusion of vein grafts in addition to
progressive disease in the native coronary vessels
Coronary Artery Bypass Surgery – INDICATIONS
- Significant left main coronary artery stenosis
- Left main equivalent: significant (70%) stenosis of the
proximal left anterior descending (LAD) and proximal
left circumflex arteries
- Three – vessel disease
- Two – vessel disease with significant proximal LAD
stenosis and either ejection fraction <0.50 or
demonstrable ischemia on noninvasive testing
- One or two – vessel disease without significant
proximal LAD stenosis, but with a large area of viable
myocardium and high – risk criteria on noninvasive
testing
- Disabling angina despite maximal noninvasive
therapy, when surgery can be performed with
acceptable risk
Source: Dr. Tan de Guzman’s lec