Cardiac catheterization at a glance (including instruments, view, dye)

ROLE OF
CARDIAC CATHETERIZATION
IN CONGENITAL HEART DEFECTS
AT A GLANCE
Dr. Md. Mostafizur Rahman Bhuiyan
Medical officer
Paediatric cardiology

History
• First Cardiac catheterization –
▫ According to Andre Cournand, it was first performed by Claude Bernard in
1844, in a horse, both rt and lt ventrilces were entered by retrograde
approach from the jugular vein and carotid artery
▫ Werner Forssmann is credited with performing the first
cardiac catheterization of a living person himself, at the
age of 25 yrs
• Forssmann for his contribution and foresight shared the
Nobel Prize in Medicine with Andre Cournand and Dickinson
Richards in 1956

Cardiac catheterization implies the insertion of
flexible tube into one or more heart
chambers usually under fluoroscopic guide
for diagnostic or therapeutic purpose
Definition:

Indication of
cardiac catheterization :
1. Diagnostic indication -Collects data to
evaluate PT’s condition
2. Therapeutic indication
3. Prognostic indication

1. Diagnostic catheterization is no longer indicated in the routine preoperative
evaluation of most congenital defects, such as VSDs, ASD, TOF, DORV, CoA,
HLHS and other complex CHD.
2. Before interventional catheterization
1. Assessment of patient hemodynamics and anatomy
2. to confirm congenital or acquired heart disease in infants and children
3. When the anatomy of a CHD is inadequately defined by noninvasive mean
4. in very complex lesions  specific details about the anatomy or
hemodynamics
5. High-flow or low-flow physiology associated with semilunar valve stenosis
1. Combined aortic stenosis (AS) and insufficiency
2. Combined Pulmonary stenosis and insufficiency
6. In cavopulmonary anastomosis and after Fontan completion  Diagnostic
catheterization is useful in the evaluation for proceeding with completion of
Fontan, revision of Fontan, or transplantation
1.Diagnostic indication-

1. Diagnostic indication-
7. EP study
1. His bundle electrocardiography in 1st degree, 2nd
degree & CHB
2. Endocardial mapping inWPW syndrome
8. Endocardial biopsy
1. DCM
2. HCM
3. Amyloidosis
4. sarcoidosis

 Angiocardiography –
a) Rt and lt ventriculography
–
a) Chamber size
b) Wall thickness
c) Wall motion
d) Aneurysm
e) Volume
f) Dimension
g) Fractional shortening and
h) Ejection fraction
b) Aortography –
a) AR
b) AS
c) Co of Aorta
d) PDA
e) Aortic arch
syndrome
c) CAG – determine
coronary artery
anatomy

 Pressure study –
a) it means measurement of pressure and recording of its wave form.
b) High RV pressure in catheterization found in the following condition –
a) VSD
b) PS
c) PH in MS, COPD
d) Ruptured sinus of valsalva into RV
c) Trans-valvular pressure difference can grade the severity of –
a) AS
b) PS
c) MS
d) PCW help to find out LVEDP
 Oxymetry –
a) Shunt calculation
b) To determine Cardiac output

1. Closure of the following defects –
1. ASD
2. VSD
3. PDA
4. MAPCA
2. PTMC
3. Thrombolytic therapy – intracoronary, systemic
4. PTCA
5. PTA – for peripheral artery stenosis
6. Valvuloplasty – PS, MS,AS
7. Dilatation of coarctation of aorta

9. Introduction of ‘’UMBRELLA’’ in to IVC for recurrent
pulmonary emboli from DVT
10. Rushkind procedure inTGA, for balloon rupture of
interatrial septum by brockenbergh needle
11. Cardiac pacing
12. Peripheral arterial balloon dilatation
13. Hemodynamic monitoring and treatment of pt with
cardiogenic shock by swan gauze catheter

3. Prognostic indication
1. Post CABG catheter for assessment of –
1. cardiac function and
2. coronary perfusion
2. Post PTCA
3. After thrombolytic therapy
4. After repair ofVSD
5. After valve replacement
6. Prior to any cardiac operation to estimate the prognosis
of operation

Contraindication of
cardiac catheterization :
 Absolute contraindication – In expert hand none
is contraindicated
1. Patient refusal
2. IE

1. RecentAMI usually within 3 week  in case of adult pt
2. Intercurrent febrile illness
2. CCF
3. Severe or malignant hypertension  predispose to
myocardial ischaemia and/or heart failure during
angiography
4. Life threatening arrhythmia, but it is indicated in-
1. While myocardial mapping and subsequent
electrotherapy
2. Surgery is contemplated for treatment of arrhythmia
Relative contraindication –

5. Severe renal failure
6. Allergy to dye
7. Severe hypokalaemia
8. Anticoagulant state  PT > 18 s
9. Moribund pt
10. Primary pulmonary hypertension
11. Presence of LBBB
12. Digitalis toxicity
13. Severe anaemia
14. Severe PS
Relative contraindication –

MEDICATIONS USED
 Premadication –
 Inj Pethidine
 Inj Phenargoan
 Saline infusion
 Heparin -
 For Pt
 flushing all tubing, catheters, sheaths
 Lidocaine for tissue numbing
 Anaesthetic medication for relaxing the pt
 Water soluble contrast

EQUIPMENT NEEDED
 Procedure tray should include:
1. sterile –
1. gowns and gloves
2. sterile towels and drapes for procedure
3. equipment covers
4. Sterile gauze
5. scalpel, needles, scissors, hemostats
6. syringes for heparin/saline flush, lidocaine,
and blood oximetry
1. labels with marking pen for any item filled with a solution
2. basin for heparin/saline mixture & waste fluids,
3. skin prep solution
4. connection tubing

18
 Anaesthesia machine
 Oxygen supply
 Suction apparatus
 Defibrillator
 Temporary pacemaker
 Pulse oximeter
 NIBP
 Equipment to perform cardiac output studies
 Activated clotting time (ACT) equipment
EQUIPMENT NEEDED

EQUIPMENT NEEDED
1. Needle
2. Sheath
3. Wires
4. Catheters
5. Fluroscopic machine
6. Power injector

Vascular access:
Venous Access Arterial Access
Femoral vein
Median basalic vein
Subclavian vein
Internal jugular vein
Umbilical vein
Transhepatic route
Femoral artery
Radial artery
Umbilical artery
Carotid artery

Needles for percutaneous puncture
 Angiographic needle – designed for single wall puncture
 small in diameter,
 thin walled,
 short beveled
 very sharp.
 Hub  clear
 True Seldinger needle
 Chiba™ needle percutaneous transhepatic access

Angiographic Needle with Protector, Seldinger Hub, Thin Wall
True Seldinger Needle
Chiba Needle

Needle size chosen:
Age Diameter Length Wire
Infants and small
children
21 G 3 cm 0.018
Larger children and
young adults
19 G 5 cm 0.025’’
Adult and obese pt 18 G 7 / 8 cm 0.035’’

Technique for vascular access:
 The true “Seldinger™ technique” is not used for
percutaneous puncture into vessels.

Technique for vascular access:
 Modified Seldinger technique for vascular access
with single wall puncture into vessels.

Vascular Sheath
 Percutaneous introduction and then the use of an
indwelling vascular sheath in vessels is the standard
technique for catheterization of pediatric and congenital
heart patients.
 Ideal sheath should have:
1. Dilator 
1. long, fine and smoothly tapered tip.
2. inner lumen of the dilator tip should tightly fit over the guide wire
3. tip of the dilator should have a smooth, fine transitional taper onto
the surface of the wire.
2. female Lure™ lock connecting hub at the proximal end
3. back-bleed valve
4. Lateral tube / flush port

Vascular Sheath
When introduced from the inguinal area, the sheath should be long
enough to extend into the common iliac vein.
In small infants a sheath into the femoral vein should extend
proximal to the formation of the inferior vena cava.

Vascular Sheath
 Ideal short sheath (7.5 cm long) for venous site –
 5 Fr for an infant or child (<15– 20 Kg) and
 7 Fr for a larger child or adult
 Extra long sheaths (45 to 90 cm ) are used to –
1. guide catheters directly and repeatedly to an area
within the heart itself (biopsies, blade catheters),
2. for trans septal procedures,
3. to deliver special devices within the heart or great
vessels (stents, occlusion devices), and
4. for the withdrawal of foreign bodies from the vascular
system.

GUIDE WIRES
 Characteristics of wire:
 Flexibility: the ability of the wire to bend
 Trackability:
 Torque transmission: to the distal tip at 1:1 ratio
 Support: to deliver equipment (balloons, stents, atherectomy
devices, intravascular ultrasound probe, etc.)
 Stiffness, including wire tip stiffness, is dependent primarily on the
core material
 Diameter: Depends on vessels of different diameters.
 0.014 inches, or as thick as 0.065 inches
 Length: 45 cm to 400 cm.
 Short guide wire 45 – 80 cm
 Standard guide wire - 145 cm
 Exchange guide wire – 260 and above

GUIDE WIRES
 Components considered to select a guide wire:
1. core – determines stiffness and
1. Fixed
2. Movable core.
2. Outer coil
3. Coating,
4. Polymer jacket (optional)  terumo wire
5. wire tip-
1. Straight
1. soft, flexible
2. Special “extra” or “very” floppy tip
2. J”-tipped

GUIDE WIRES
 Guidewire Materials :
 Different materials used for the outer coil and core areas.
Outer coils may be plated with radio-opaque materials (like
Gold or Platinum) to aid visibility during a procedure.
1. Gold (Au) Radio-opaque properties
2. Platinum (Pt) Radio-opaque properties
3. Nitinol (NiTi) -Terumo
4. Stainless Steel – tiger wire
5. Stainless Steel with Nickel
6. Titanium Core
7. Tungsten (W)
o

GUIDE WIRES
1. Coating
2. Hydrophilic coating - polyethylene oxide (PEO) and polyvinylpyrrolidone
(PVP)
3. Anti-thrombogenic/Heparin coating Inhibits clotting
4. Hydrophobic coating - PTFE (polytetrafluoroethylene ),Teflon®)
5. Silicone coating Reduces friction
 Special coatings (heparin or teflon) –
1. less thrombogenic
2. slide more easily through catheters.
3. keep the wire and catheter from binding together within any of
the extruded plastic catheters
4. coated wires are slightly stiffer than the comparable size and
type of non-coated wire

GUIDE WIRES
 General usage guide wires
1. Percutaneous entry into vessels soft straight tipped and J-tipped wires
2. Support catheters (small and large) during various catheter manipulations,
3. Wires with long, soft tips  to enter into more distal vessels or through valves
4. Super stiff wire 
1. delivery of stiffer catheters and sheaths
2. support for balloon catheters during dilation procedures
5. Special, stiffer wires of smaller sizes (0.014)used to
1. support small balloon dilation catheters in coronary arteries
2. cardiac catheterizations of infants and small children.
6. Torque wire can be directed into very specific locations, into particular vessels, branches
or orifices
7. Terumo™ or theGlide™ wire is very effective for entering difficult locations even small
tortuous channels and to make acute turns
8. DEFLOCTOR wire - deflects the tips of catheters

CATHETER
 The exact choice of catheter should be -
 primarily the choice of an experienced individual catheterizing physician,
 specific characteristics, availability and, often, price
 Specific Catheter according to location and function
 Diameter
 Lumen
 Length
 Guide wire
 Flow
 Radio-opaque / Radio-translucent

CATHETER
 Catheters may be –
1. Guiding catheter
2. Diagnostic catheter
 Diagnostic catheter May be –
1. guidable or torque-controlled catheters and
2. flow-directed (“floating”) balloon catheters.
 Each of these two types of catheter are
subdivided into –
1. “end-hole”, diagnostic catheters and
2. Blind -ended, angiographic catheters.

1. End-hole catheters with/without side holes close to the tip.
1. Utilized in diagnostic catheterization procedures when wedge pressures
or wedge angiograms are desired.
2. to advance a guide wire out of and beyond the tip of the catheter either
for special manipulations into specific areas or
3. to exchange catheter
2. Blind-ended (Angiographic ) catheters – have a closed distal
end with several side holes close to the distal tip.
1. The closed end prevent recoil of the catheter during rapid, high volume or high-
pressure injections of contrast through the catheter.
2. can be used equally well for blood sampling and pressure recordings except in the
“wedge” positions.
3. There now is “hybrid” catheter,which combines advantages of
the both – Multi-track™ catheter –
1. For angiography simultaneously the passage of an additional wire
through the true lumen of the catheter

Various commonly used catheters:
 PulmonaryWedge Catheter 
 4 Fr-60 cm, 5-60, 5-110, 6-110, 7-110
 This is a flow-directed end-hole catheter
 Function: right-sided hemodynamics, including the
pulmonary capillary wedge pressure
 Berman Catheter –
 4 Fr-50 cm,5-50,5-80,6-90,7-90
 Blind end flow directed catheter,
 Proximal to the balloon there are several holes
 Function –
 sample blood
 is used primarily for angiography in the ventricles

:
 Thermodilution Catheter
 5 Fr, 6 Fr, 7 Fr catheters
 end-hole catheter with an additional lumen
terminating in a proximal side port.
 Thermistor (temperature monitor) at the tip
 Function - cardiac index assessment

 Multipurpose catheter –
 Relatively stiff, end-hole catheter
with a terminal bend.
 two side-holes near the tip
 Function:
 Right heart catheterization
 Probing the atrial septum,
 Pressure measurements over a wire,
 Angiography by hand,
 Angiogram  Useful for RCA or
SVG to RCA or LCA with inferior origin

Pigtail Catheters
• PigtailCatheters
• 3–7 Fr with lengths of 40–110 cm
 These are generally considered angiographic catheter
 Function 
 angiography of LV and the ascending aorta
 pressure measurements
 Marker pigtails –
 have radiographic markers of distance and size
 Funciton - used to determine angiogram magnification accurately

Diameter
(French)
Length
(cm)
Guide wire
(inch)
Max. Flow
(ml/sec
psi)
Type
5 110/100 .038 17/1000 3.5 small
5 110/100 .038 19/1000 4.0 standard
JR Judkins right Right coronary artery and SVG
interventions; may not provide coaxial
alignment for vein grafts to the
RCA

JL Judkins left Left coronary artery interventions

AL Amplatz left Useful for difficult anatomy of the left coronary
artery (especially left circumflex), SVG, Shepherd’s
Crook or high anterior RCA
AR Amplatz right RCA interventions or SVG to RCA with inferior
origin

XB or
EBU
Extra Backup Useful for difficult anatomy in LCA;
offers backup support from opposite
wall of aorta
IMA Internal
mammary
LIMA, RIMA, or native vessel beyond
anastomosis lesions. Sometimes fits
well for RCA interventions

SON Sones Sones Useful for RCA or
SVG to RCA or LCA with
inferior origin

LCB Left coronary
bypass
Useful for SVG to LCA with horizontal or
slightly superior origin
RCB Right coronary
bypass
Useful for SVG to RCA

Snare Catheter
 The Amplatz™ Goose-Neck Snare
 En Snare™
 has three separate interlaced loops that are
extended and withdrawn as a single unit
 Medi-tech™ snare
 made of memory spring-wire material.
 The snare loops are an elongated hexagon in
shape

Frontal/ Straight PA View (0o):
1. Systemic venous anatomy (RSVC, LSVC,
IVC).
2. Pulmonary venous anatomy.
3. RV anatomy and distal PA anatomy.
4. Descending aortography, aortopulmonary
collaterals.
5. Single ventricular morphology (especially
initial imaging).

Right Anterior Oblique / RAO
(-200 – 300)
 Good delineation of outlet/anterior muscular
VSD’s and the infundibulum.
 LV outflow tract imaging for sub-AS
(including AV canal gooseneck).
 LV function and quantification of MR and AR.
 An alternative view for measuring PDAs.
 Aortic valve annulus measurements.

O0 Frontal
+ 20-30o cranial
 Sitting Up  Based on the old practice of
moving the patient’s position rather than
cameras
 Best used for:
1. Improved imaging of MPA and branch PAs,
with less superimposition.
2. Pulmonary stenosis, for annulus
measurements.
3. Seeing full length of RPA (especially with
RAO 20–30o).

O0 Frontal
+ 30o caudal
 ‘‘Laid Back’’ view in old terminology
 Best used for:
1. Alternate view to image proximal branch PAs.
2. PAs arising from conduits (up to 60o caudal).
3. Coronary arteries from Ao, e.g., D-TGA.

Lateral / straight lateral
(90o)
 Best used for:
1. Excellent view of RV outflow tract/pulmonary
valve/MPA.
2. Good imaging of PDA and coarctation.
3. Coronary artery origin and course.
4. Distal PA anatomy.

Left Anterior Oblique (LAO –
20-70O)
 This is not to be confused with long axial
oblique. Generally refers to the rotation along
the lateral plane, and does not denote use of
cranial or caudal angulation.
 Best used for:
1. Elongating aortic arch, which may help for PDA or
coarctation,
2. Lengthening LPA (caudal angulation may help),
3. Truncal valve anatomy,
4. Proximal LPA anatomy.

Long Axial Oblique
(70OLateral 30Ocranial)
 Gives LV image similar to that found in
parasternal long axis view by echo.
 Best used for:
1. LV function and MR.
2. Sub AS, AS, and supra-AS.
3. Annulus measurement for aortic valve dilation.
4. VSD imaging ( membranous / conoventricular /
anterior and mid-muscular).

Hepatoclavicular /4-Chamber/
(45OLateral 45Ocranial)
 Gives image analogous to that found on
apical 4-chamber echo view. Looks at the
crux of the heart.
 Best used for:
1. ASDs (especially with catheter in RUPV).
2. Endocardial Cushion Defects (ECD).
3. Inlet/posterior muscularVSDs.
4. AV valve anatomy and regurgitation.
5. LV to RA shunt.
6. The origin of the LPA

Aortic Orifice View (100-120OLateral +20-
30Ocaudal)
 Similar to parasternal short axis echo view.
 Best used for:
1. Looking at coronary artery origins, especially with
antegrade ascending aorta injection with an
inflated Berman catheter.
2. Gives nice view of aortic valve cusps.

Power injector
•Contrast:
•Iopamidol
•Non ionic
•Low osmolar
•Dose: Maximal acceptable contrast dose
•(MACD) is calculated as 5 milliliters of
contrast per kilogram of body weight
divided by the baseline serum creatinine
level in milligrams per deciliter.
•Rule of thumb:
•1ml /kg for each angiographic view

Contrast:
 Variables determining the amount of contrast to be
used:
 General rule:
 low contrast volume with high flow rate
 High volume with low flow rate is ineffective
 Volume overload lesion likeVSD
 Pt size: low volume of contrast given at high flow in a chamber
 Catheter location –
 Low volume –
 low flow location (vein)
 Branching vessel ( Pulmonary artery)
 High volume – ventricles

Contrast:
 States of high flow:
 VSD
 Tachycardic patients may clear contrast more quickly,
 in patients with slow heart rates, slow injection times
 Layering – decrease the amount of contrast used in hand
injections by using layered injections
 in low-flow regions, or
 when balloon occluding the vessel proximally.
 Levophase  while doing Angiogram of RV or PA the
contrast returns from the pulmonary veins and opacifies
the left heart called levophase.
 decide before starting the angiogram how long you want to
image to get information from levophase.

BEFORE THE PROCEDURE
 Routine investigation
 Baseline vital signs
 Informed written consent
 NPO for 6 - 8 hours before the test.
 Patient should be wear a hospital gown.
 Remove any necklaces, bracelets, rings, or other
jewelry. You should also remove nail polish from
your fingernails and toenails.
 Bladder should be completely emptied just
before the test

PATIENT PREPARATION
 Patient Positioning for Cardiac Catheterization
 so that need not to be moved during procedure
 Puncture area must be surgically cleaned –
 Umbilicus to mid thigh
 The patient is then draped from neck down with
sterile drapes
 All equipment (radiation shields, image intensifier,
equipment used to manipulate machine) must be
prepared with sterile covers

PROCEDURE
 Local anaesthetic injected
 into the skin to numb the area
Vascular access
Groin sheath placement
Heparinize the pt
Flush the lateral tubing

 Catheters are inserted over a guidewire and
moved towards the heart.
 Oximetry done
 Haemodynamics recorded
 Once in position radio-opaque contrast
agents is injected to see cardiac anatomy on
fluoroscopy image.
 all the necessary angiographic views
recorded.
 The catheter can be removed and manual
pressure must be applied to entry site for 15
minutes & closed using pressure bandage,
stitches, or a special seal

Post Procedure follow-up:
 Verify the dressing
 0.9% NS IV infusion
 Monitor  at 10 minutes, 30 minutes and then hourly after
sheath removal.
1. HR
2. B/P
3. O2 saturation
4. Temperature
5. Assess circulation, motion and sensation to both feet

Post care
 Maintain bed rest while pressure is in place.
 No bending of groin is permitted. May turn side to
side for back care.
 May resume diet, per doctor order.
Notify your consultant for:
a. Absent or diminished pulse in affected limb.
b. Presence of a hematoma.
c. Symptomatic bradycardia or other arrhythmia.
d. Bleeding at insertion site.

INTERPRETATIONS
 Test results will be reviewed by a cardiologist
and will be available after the procedure.

Risks/Complications Of Cardiac
catheterizations
Cardiac catheterizations are not without risk to the patient.The following is a
listing of the more common complications.
1. Exposure to ionized radiation
2. Risk of general anesthesia (when
used)
3. Hypothermia (especially in small
infants)
4. Aggravation of hypoxia
5. Arrhythmias (temporary instability or
even permanent, as in heart block)
6. Vascular injury –
1. perforations/tears
2. Dissection
3. Thrombus formation
7. Cardiac perforation
8. Cardiac valve injury
9. Blood loss that requires transfusion
10. Allergic reactions to contrast, drugs,
or anesthetics
11. Renal insufficiency caused by
contrast material
12. Diffuse central nervous system injury
13. Stroke
14. Death

Toxicities Associated with Radiocontrast Agents
Allergic (anaphylactoid) reactions
1. Grade I: Single episode of emesis, nausea, sneezing, or vertigo
2. Grade II: Hives, multiple episodes of emesis, fevers, or chills
3. Grade III: Clinical shock, bronchospasm, laryngospasm or edema, loss of
consciousness, hypotension, hypertension, cardiac arrhythmia, angioedema, or
pulmonary edema
Cardiovascular toxicity
1. Electrophysiologic
1. Bradycardia (asystole, heart block)
2. Tachycardia (sinus, ventricular)
3. Ventricular fibrillation
2. Hemodynamic
1. Hypotension (cardiac depression,
vasodilation)
2. Heart failure (cardiac depression,
increased intravascular volume)
1. Nephrotoxicity
2. Discomfort
1. Nausea, vomiting
2. Heat and flushing
3. Hyperthyroidism

Complications of equipment :
 When the major or capital equipment fails  results in the interruption
or cancellation of the case
 failure of the X-ray/imaging equipment at the precise instant or a critical
point in an interventional procedure may result in a displaced device or
the dilation of the wrong area/structure.
 Both angiographic and physiologic recorders fail,
 Flaws in disposable/expendable equipment which result in –
 breaks or fractures and the loss of catheter tips or pieces of spring guide wire do result in the
embolization of a solid particle
 Catheter hubs coming loose during high-pressure injection result in a
failed angiogram,
 Leaks in stopcocks or connecting tubing result in poor pressure
transmission and inaccurate pressures being recorded,
 An unrecognized leak in a stopcock adjacent to the catheter can allow air
to be drawn into the system and being injected into the patient.

Cardiac catheterization at a glance (including instruments, view, dye)

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