Coronary catheter
An invasive catheter-based procedure that gives detailed hemodynamic and anatomic information about the heart and the coronary arteries.
Left heart catheter
- catheter is inserted into radial* or femoral artery
- Flexible sheath inserted into the vessel over a
guidewire - Diagnostic catheter then advances under
fluoroscopic guidance into left ventricle
à Get direct measurement of LV
pressure, hemodynamics (AS, HCM)
Coronary angiography
An invasive catheter-based procedure
that uses radiopaque contrast dye to
define the coronary anatomy and help
determine extent of coronary disease
Coronary Cath and Coronary angiography indications
1) evaluate severity of cardiac disease in symptomatic pts and
2) determine if medical, surgical or catheter-based interventions are warranted
Relative contraindications for cardiac cath:
- decompensated diastolic HF
- Acute renal failure
- Chronic renal failure (unless dialysis is planned)
- Bacteremia
- Acute stroke
- active GI bleeding
- Anticoagulation or recent thrombolytics
- severe, uncorrected electrolyte abnormalities
- contrast allergy, aspirin allergy
Cardiac cath risks
- Risks are low:
<0.1% MI, 0.01% for stroke, 0.05% for
death - In-hospital mortality is 1.4% -
increased if done emergently during
AMI, hemodynamically unstable - Other risks: arrhythmias, acute renal
failure (dye or poor perfusion),
contrast allergy dye allergic reaction,
vascular complications/perforation,
Most common complications =
access site bleeding, 1.5-2.0%
Cardiac cath post procedure guidelines
- Bed rest ~2h, can often be discharged same day
- Observe high-risk patients overnight
- Pressure dressing on access site
- Monitor for hypotension
- Increased fluid intake (contrast à osmostic diuresis)
Percutaneous coronary intervention - what is it?
Invasive catheter-based interventions on
a plaque or stenosis in the coronary
arteries.
- Balloon Angioplasty
- Stent Angioplasty
- Atherectomy
- Thrombectomy
PCI - indications
ACS/STEMI
NSTEMI
UNSTABLE ANGINA
STABLE ANGINA
ANGINAL EQUIVALENT
HIGH-RISK STRESS TEST FINDINGS
CRITICAL CORONARY ARTERY STENOSIS
THAT DOES NOT QUALIFY FOR CABG
PCI - risks and complications
- DISSECTION OR RUPTURE
(CORONARY OR AORTA) - BLEEDING (ACCESS SITE MOST
COMMON) - INFECTION
- RENAL FAILURE
- STROKE
- MI
When is CABG preferred over PCI?
2 or 3-vessel disease + high SYNTAX score
left main disease pts with DM and multivessel disease
When is PCI preferred over CABG?
severe symptoms
failed medical therapy
High-risk coronary anatomy
Worsening LV function
CABG - What is it?
Coronary artery bypass graft: Revascularization procedure using a grafted
vessel to go around the stenotic/diseased
coronary
Vessels commonly used for bypass grafting
1) Left internal mammary artery (LIMA)
2) Saphenous vein graft (SVG) harvested
from either leg.
3) Right internal mammary artery (RIMA)
4) Radial artery from either arm
Usual “Life” of a bypass:
1) LIMA, RIMA, radial artery - 10-12 years
2) SVG - 7-10 years
CABG - Indications
● Left main coronary artery stenosis >50%
● 3-vessel disease >70% with/without proximal LAD involvement
● 2-vessel disease: LAD + one other major artery
● Patients with significant anginal symptoms despite adequate medical
therapy and 1+ significant stenosis >70%
● 1-vessel disease >70% in a survivor of sudden cardiac death, with ischemia
related V-tac
CABG contraindications
- Patient refusal
- High Mortality Risk/Not a surgical
candidate - Coronary arteries incompatible with
grafting - No viable myocardium to graft
- <70% blockage, single lesion (left
circumflex or right coronary)
Clinical significance of a CABG
Appropriately selected patients have
improved outcomes and increased
survival benefits compared to PCI or
medical therapy alone
STEMI stands for vs. NSTEMI
ST Elevation myocardial infarction
Non - ST Elevation myocardial infarction
CABG - Risks and Complications
- Post-op arrythmias - 20-50%
- Death: 1-2% and varies according to co-
morbidities, urgency of surgery, case-
volume - Graft failure: SVG most common w/in 1st
month can be up to 25%; 1st year (10-
20%), 5th year (~2%).
1) LIMA has better success, 90%
patency rates at 10 years
Right heart catheterization - what is it?
A catheter-based procedure used to determine
right heart and pulmonary artery pressures
Under fluoroscopic guidance, a catheter is
floated sequentially through the right atrium,
right ventricle, pulmonary artery, and into the
pulmonary wedge position (as a surrogate
for left atrial pressure)
Indications for Right heart catheterization
OLD STANDARD TEST to establish PH
diagnosis and choice of treatments
unexplained dyspnea, pulmonary hypertension,
valvular heart disease, pericardial disease, right
and/or left ventricular dysfunction, congenital
heart disease, and suspected intracardiac
shunts
Electrophysiology Studies (EPS) - What is it?
To assess, detect, and/or discover the origin of an arrhythmia. Often
used to assess success of current pharmacologic therapy
Indications for EPS studies
Arrhythmia: Bradycardia, sick sinus, high-grade AV blocks, a-fib, v-
fib, v-tach, re-entry tachycardias; preparatory to pacemaker and/or
defibrillator placement
