1
Q
State the contraindications to the femoral approach
A
- Patients with peripheral vascular disease (femoral bruits or diminished peripheral pulses)
- Abdominal aortic aneurysm
- Marked iliac tortuosity
- Prior femoral arterial graft surgery
- Gross obesity
2
Q
State the indications to the brachial approach
A
- Severe peripheral vascular disease, making upper extremity vascular access preferable.
- A need for early ambulation or mobility (severe back pain, outpatient procedures)
- Urgent or emergent catheterization with an increased risk for bleeding (anticoagulant or thrombolytic therapy)
3
Q
State the contraindications to the brachial approach
A
- Should not be used by an inexperienced operator unless backed up by a vascular surgeon or a cardiologist with expertise in this technique.
- Absence of brachial pulse
- Presence of an arteriovenous fistula
- Overlying soft tissue infection
- Severe ipsilateral axillary or subclavian vascular disease
- Inability to extend the arm at the elbow or supinate the hand.
4
Q
Select the side effects of contrast agents
A
- Transient hemodynamic depression with arterial hypotension.
- Electrophysiologic changes. T wave inversion
- Sinus bradycardia and hypotension.
- Prolonged PR, QRS, QT intervals
- Significant arrhythmia (asystole or v-tach/v-fib).
- Myocardial Ischemia owing to interruption of oxygen delivery or inappropriate arteriolar vasodilation.
- Allergic reaction.
- Cumulative Renal toxicity
- Hot flashes due to powerful vasodilation.
- Transient nausea and vomiting
5
Q
List the factors influencing the choice of approach in the cath lab
A
- Patient issues (aortic occlusion, morbid obesity)
- Procedural issues (need for use of larger bore catheters)
- Patient/operator preference
6
Q
Name the most common local complication with using the brachial approach for catheterization
A
Thrombotic events
7
Q
definition and method of prevention for the formation of a hematoma
A
- a collection of blood within the soft tissues.
- Accurate puncture and puncture site compression or closure technique to minimize hematoma formation are essential parts of good catheterization technique.
8
Q
definition and methog of prevention for the formation of a pseudoaneurysm
A
- Develops if a hematoma remains in continuity with the arterial lumen after dissolution of the clot clogging the arterial puncture site. Blood flowing in and out of the arterial puncture expands the hematoma cavity during systole.
- The keys to avoiding pseudoaneurysm formation are accurate puncture of the common femoral artery and effective initial control of bleeding after sheath removal
9
Q
definition and method of prevention for the formation of an arteriovenous fistula
A
- Ongoing bleeding from the femoral puncture site that decompresses into an adjacent venous puncture site to form an arteriovenous fistula.
- The most common findings at surgery are a low puncture (the superficial femoral or profunda, transecting a small venous branch), emphasizing the importance of careful puncture technique.
10
Q
- State the most common complication after cardiac catheterization by the femoral approach
A
•Poorly controlled bleeding from the arterial puncture site
11
Q
Cite the mechanism of a vasovagal reaction
A
- Inappropriate systemic arteriolar vasodilation.
* Triggered by pain and anxiety, particularly in the setting of hypovolemia.
12
Q
State which patients are more likely to have an allergic reaction to protamine sulfate
A
Patients on NPH insulin.
13
Q
State four materials that cardiac catheterization may precipitate allergic reactions
A
- Iodinated contrast agent
- Local anesthetic
- Protamine sulfate
- Heparin (HIT)
14
Q
State the catheters used for right heart catheterization
A
•Lehman,Goodale Lubin, Swan Ganz, Cournand,(pg 7), Eppendorf, Grollman Pigtail, Berman Angiographic, Gensini, Bynum Wilson, NIH (National Institutes of Health)
15
Q
State the catheters used for right-sided ventriculography
A
•Grollman Pigtail, Eppendorf, NIH (National Institutes of Health)
16
Q
Discuss the J-loop technique when performing a right heart catheterization with a balloon tipped catheter when approaching from the SVC
A
Femoral-
•Bend the tip of the catheter against the lateral right atrial wall or engage the ostium of the hepatic vein forming a large “J”.
•Rotate the loop clockwise so that the catheter tip sweeps the anterior and anteromedial Right Atrial walls to cross the tricuspid valve into the RV.
•Advance the catheter to PA through the RVOT by rotating clockwise causing the tip of the catheter to point upward into the RVOT.
17
Q
Discuss the J-loop technique when performing a right heart catheterization with a balloon tipped catheter when approaching from the IVC
A
- The catheter should be advanced so the tip catches on the lateral right atrial wall and the catheter looks like the letter J on fluoroscopy.
- Next, the catheter is rotated counterclockwise so that the tip of the J sweeps the anterior right atrial wall (avoiding the coronary sinus) and jumps across the tricuspid valve into the RV.
- Because the catheter usually retains it’s J curve its tip will be pointing toward the RVOT and can easily be advanced into the PA.
18
Q
Choose and identify the anatomical landmarks used in the selection of a puncture site for catheterization via the femoral approach
A
- 1 or 2 cm below the inguinal ligament for FA.
- Visualize the inferior border of the femoral head via fluoroscopy.
- Femoral vein will lie approximately one fingerbreadth medial to the artery, along a parallel course.
- The inguinal ligament runs from the anterior superior iliac spine to the pubic tubercle.
19
Q
- Select the reasons for performing a transseptal left heart catheterization
A
- Direct LA pressures recording due to pulmonary venous disease.
- Distinguish between IHSS and catheter entrapment.
- Failure to get retrograde LH cath due to AS or Peripheral vascular disease.
- Danger of damaging prosthetic valves.
- Percutaneous mitral or aortic valvuloplasty
20
Q
- Choose the basic features and construction of a balloon-tipped flow-directed catheter
A
- Made of PVC
- Soft pliable shaft
- Balloon located 1- 2 mm from tip and sticks out past the end of the catheter to prevent damage to the endocardium.
- 110 cm long and color coded for sheath size.
- Requires ½ French size larger sheath.
- Heparin coated for prolonged insertion.
- 3 or 4 lumen catheter for RA, PA, PCW pressure and medication port.
- Proximal port 20 – 30 cm from tip
- Radiopaque
21
Q
State which two areas are used to draw oxygen saturations in order to determine if there is a possible left-to-right shunt
A
SVC and PA
22
Q
- Select the oxygen percent step-up used to determine if there is a left-to-right shunt
A
If the saturation between the SVC and PA is > 8%, a left to right shunt may be present.
23
Q
Select the percentage of patients that have a right-dominant, left-dominant, and co-dominant coronary artery circulation
A
Right Dominant – 85%
Left Dominant – 8%
Co-dominant – 7%
24
Q
Select the criteria used to determine if a patient has a right-dominant
A
Right dominant
•RCA gives rise to PDA and the posterolateral LV branches which supply the inferior aspect of the LV and IVS.
•Supplies one or more posterior LV branches after the origin of the PDA.
•The LAD has septal branches that curve down into the IVS and diagonals over the anterolateral free wall.
25
20. Select the criteria used to determine if a patient has a left-dominant
Left Dominant
•Posterolateral branch, PDA and AV nodal arteries are supplied by terminal portion of the left circumflex.
•RCA supplies only the RA and the RV
26
Select the criteria used to determine if a patient is co-dominant/balanced coronary artery circulation
Co-Dominant
•RCA gives rise to the PDA and then terminates.
• Circumflex gives rise to all the Posterior LV branches and perhaps a parallel PDA that supplies the IVS
27
List the mistakes that may lead to an incomplete, uninterpretable or misinterpreted study
* Inadequate number of projections
* Inadequate injection of contrast
* Superselective injection
* Catheter induced coronary spasm.
* Congenital variants of coronary origin/distribution
* Myocardial bridges
* Total Occlusion
28
Choose the optimal location for the catheter while performing left ventriculography
Midcavity of the Left Ventricle, without ectopy, not interfering with mitral valve function.
29
Select the complications of cardiac ventriculography
* Arrhythmia
* Intramyocardial Staining
* Embolism
* Fasicular Block
* Hot Flash
* Depressed arterial pressures due to vasodilation
* Increased heart rate
* Depressed LV contraction
* Transient nausea and vomiting
30
Choose the anatomical features that should be located when trying to gain access into the right internal jugular vein
* Head to left, have patient raise head
* Identify sternal notch, clavicle, and the sternal and clavicular heads of the sternocleidomastoid muscle.
* Skin nick should be made between the two heads of muscle, two fingerbreadths above the top of the clavicle.
31
25. State the main hazard of endomyocardial biopsy, as well as the steps that should be taken in order to detect for it
•Ventricular perforation
32
Five-position code for pacemakers
```
Position I Chamber Paced
Position II Chamber Sensed
Position II Modes of Response
Position IV Programmable Functions
Position V Anti tachyarrythmia fcn
```
33
Position I Chamber Paced
V - Ventricle
A - Atrium
D – Atrium and Ventricle
34
Position II Chamber Sensed
V – Ventricle
A – Atrium
D – Atrium and Ventricle
O – None
35
Position III Modes of Response
```
T – Trigger
I – Inhibited
D – Double
O – None
T – Trigger
I – Inhibited
D – Double
O – None
```
36
Position IV Programmable Functions
```
P – Programmable rate and/or Output
M – Multi-programmable
C – Communicating
R – Rate Modulation
O – None
```
37
Position V Anti tachyarrythmia fcn
B – Bursts
N – Normal rate competition
S – Scanning
E – External
38
Choose the contraindications for intra-aortic balloon counterpulsation
```
Contraindications
•Significant Aortic regurgitation
•Uncontrolled bleeding diathesis.
•Abdominal aortic aneurysm
•Aortic dissection
•Uncontrolled septicemia
•Severe bilateral peripheral vascular disease uncorrectable by peripheral angioplasty or cross-femoral surgery
•Bilateral femoral-popliteal bypass grafts for severe peripheral vascular disease
```
39
28. Select the correct reason why intra-aortic balloon counterpulsation timing is adjusted when the console is set at 1:2 pumping
•Counterpulsations are begun at 1:2 ratio so that preliminary timing adjustments can be made so that arterial pressure tracings with or without counterpulsation can be compared.
40
Name the correct part of the central aortic wave form and the EKG waveform that is used to time the inflation and deflation of the intra-aortic balloon
Inflate at the dicrotic notch (T wave on EKG)
| Deflate before systole (at or before the “R” wave)
41
Select the characteristics of cardiac tamponade
```
Cardiac Tamponade is characterized by:
Pulsus paradoxus.(Pg 726)
Identical elevation of left and right-sided diastolic pressures with the loss of y descent.
Jugular venous distension
Compression of cardiac chambers
Increase in ventricular interdependence
```
42
Select the advantages of endotracheal intubation
* Keeps the airway patent
* Enables delivery of a high concentration of oxygen
* Facilitates delivery of a selected tidal volume to maintain adequate lung inflation
* May protect the airway from aspiration of stomach contents or other substances in the mouth, throat, or upper airway
* Permits effective suctioning of the trachea
* Provides an alternative route for administration of resuscitation medications when intravenous (IV) or intraosseous (IO) access cannot be obtained. These medications are atropine, vasopressin, epinephrine, and lidocaine. Note however that drug delivery and drug effects following endotracheal administration are less predictable than those delivered by the IV/IO route
43
Choose the possible complications associated with delivering too many breaths
• Hyperventilation (too many breaths per minute or too large a volume per breath) can be harmful because it increases intrathoracic pressure, decreases venous return to the heart, and diminishes cardiac output. It may also increase gastric inflation and predispose the patient to vomiting and aspiration of gastric contents.
44
hypokinesia
•Hypokinesia – a diminished, but not absent, motion of one part of the LV wall (weak or poor contraction).
45
akinesia
•Akinesia – total lack of motion of a portion of the LV wall (no contraction).
46
dyskinesia
•Dyskinesia – paradoxical systolic motion or expansion of one part of the LV wall (abnormal bulging out during systole).
47
Given a coronary artery bypass graft, match that graft to its most common origin from the aortic wall
* Grafts to the LCA arise form the left anterior surface of the aorta, with graft to the circumflex somewhat higher on the aorta than those to the LAD or diagonal branches.
* Grafts to the RCA or distal portions of a dominant Circumflex usually originate from the right anterior surface of the aorta somewhat behind the plane of the native right coronary ostium
48
Define profile as it applies to coronary dilation catheters
•The diameter of the smallest opening through which the deflated balloon may pass
49
indications to cardiac catheterization and angiography
Indications
•Diagnosis of obscure or confusing problems, such as chest pain of unknown cause.
•Consideration for heart surgery, as it can provide a precise and complete roadmap.
•Research.
•Acute coronary ischemic syndrome
•Incapacitating or progressive angina
•Patients with high-risk non-invasive test.
•Patients who have survived sudden cardiac death
•Patients with angina and symptoms and signs of CHF
50
contraindications to cardiac catheterization and angiography
Contraindications
•The only absolute contraindication is patient refusal.
•Uncontrolled ventricular irritability.
•Uncorrected Hyperkalemia or Digitalis toxicity.
•Uncorrected hypertension.
•Intercurrent febrile illness.
•Decompensated heart failure (pulmonary edema).
•Anticoagulated state (PT >18sec).
•Severe allergy to radiographic contrast agents.
•Severe renal insufficiency or anuria.
51
Choose the areas on a gown that are considered sterile once it has been put on by the operator
* Gowns are sterile in the front, from waist to axillary line(70)
* Sleeves are sterile, except the axillary area.
* Only portions easily observed are sterile.
* Hands are kept in sight and above waist.
* Hands are arms are never folded.
52
Select the times when the catheterization lab should be cleaned
* Prior to first case
* During surgical procedure – spot clean
* Between cases
* After cases are over
RCIS
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Decks in class (4)
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