BVCCT-501 Cardiac Catheterization Laboratory Basics

CARDIAC CATHETERIZATION LABORATORY BASICS BVCCT-501
UNIT-1
Learning Objective:
 Type of catheters
 Catheter cleaning and packing
 Techniques of sterilization-advantages and disadvantages of each
 Setting up the cardiac catheterization laboratory for a diagnostic study
 Table movement
 Image intensifier movement
 Image play back
What is cardiac catheterization?

Cardiac catheterization (cardiac cath or heart cath) is a procedure to examine how well your heart is working.
A thin, hollow tube called a catheter is inserted into a large blood vessel that leads to your heart.
Not all heart problems require open-heart surgery. Our patients may benefit from minimally invasive
procedures like cardiac catheterization. In the Cath Lab, we can diagnose and treat a whole host of issues.
list of procedures performed in the Cath Lab:

 Balloon angioplasty
 Coronary and left ventricular digital angiography
 Coronary intravascular ultrasound
 Right and left heart catheterization
 Rotational artherectomy
 Stent implantation
 Thrombectomy
Cardiac catheterization is used to:
 Evaluate or confirm the presence of coronary artery disease, valve disease or disease of the aorta
 Evaluate heart muscle function
 Determine the need for further treatment (such as an interventional procedure or coronary
artery bypass graft, or CABG, surgery)
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Indwelling catheter:
An indwelling catheter is a catheter that stays inside the body for a longer period, and there are two types. A
urethral indwelling catheter is a catheter inserted through the urethra into the bladder, while a suprapubic
indwelling catheter is inserted through the stomach directly into the bladder. Indwelling catheters are inserted
by healthcare professionals and left inside the body for as long as they are needed. For long-term use they are
often changed every or every second month.
Intermittent catheters:
An intermittent catheter is inserted into the urethra on demand to empty the bladder, and then removed again
as soon as the bladder is empty. Users are taught how to catheterize themselves, and it is a straightforward
technique that can be performed by most people.
Even children as young as seven or eight years old can be taught how to catheterize, and by using aids,
people with reduced hand function can practice it as well.
Catheterization is undertaken roughly at the same intervals as you would normally go to the toilet, about 4-6
times a day.
Non-hydrophilic catheters vs hydrophilic catheters:

There are two major types of intermittent urinary catheters: Non-hydrophilic catheters, which are uncoated
catheters, and hydrophilic intermittent catheters which are coated with a slippery surface to make insertion
and withdrawal easy.
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Catheter Cleaning And Packing:

Many medical devices exist worldwide to be used for detection, diagnosis & treatment of medical conditions.
Such devices are available in both reusable & single use versions. Reusable devices are designed to be able to
be thoroughly cleaned & to withstand appropriate disinfection or sterilization between use in different
patients; although adequacy of these processes even under normal circumstances has been questioned. Single
use medical devices (SUDs) are designed by the manufacturer to be used once only. In fact, some experts
have argued that many SUDs are identical to the reusable version & the single use designation is a marketing
choice.
Cleaning is done manually in use areas without mechanical units (e.g., ultrasonic cleaners or washer-
disinfectors) or for fragile or difficult-to-clean instruments. With manual cleaning, the two essential
components are friction and fluidics. Friction (e.g., rubbing/scrubbing the soiled area with a brush) is an old
and dependable method. Fluidics (i.e., fluids under pressure) is used to remove soil and debris from internal
channels after brushing and when the design does not allow passage of a brush through a channel.
When a washer-disinfector is used, care should be taken in loading instruments: hinged instruments should
be opened fully to allow adequate contact with the detergent solution; stacking of instruments in washers
should be avoided; and instruments should be disassembled as much as possible.
Specimen Collection :
Catheters were randomly selected from devices used for first time; after ruling out catheters according to the
following Exclusion criteria:
 Cardiac catheters used for patients positive for hepatitis B (HBsAg positive), Hepatitis C ((HCV
antibody positive) & or HIV antibody positive).They are destructed as per department policy.
 Catheters showing change in size or shape, corrosion, surface cracking or pitting, swelling, increased
brittleness, rigidity, flattening or blunting of the tip, presence of weak spots, wear between moving
parts & resistance to insertion of guide wire or to the flow of liquid medium (Spanton, 1997).
Prewash step:
Immediately after cardiac catheter was used, 2-3 ml of saline or water was injected inside its lumen then
immersed in water or saline in leak proof container & transported to the cleaning room.
Cleaning step :
Two to three ml of air was injected inside each catheter using blower gun to avoid dilution of cleansing
solution.
Manual cleaning :
One hundred catheters (group 1) were completely immersed in diluted enzymatic cleanser (Aniosyme 50 ml/
1 litre water) (Anios, France) for 20-60 minutes & the outer surface was cleaned with soft brush then the
inside was cleansed by repeated injection of enzymatic cleanser with insertion of guidewire to assure
complete clearance of any debris or blood clots then catheters were washed using water by immersion &
injection several times.
Ultrasonic irrigator cleaning :
One hundred cardiac catheters (group 2) were cleaned inside US irrigator PC plus system with cannulated
pulse enhancement (CPE) (Medisafe, UK). The ultrasonicator ensures that the insides were scrubbed &
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flushed as well as the outside. By connecting the catheter to the irrigation flush port, the sonically charged jet
of fluid was directed along the inside of the catheter lumen &dislodged all organic matter thus providing an
efficient cleaning process (Alex, 2010). The US irrigator used 3 E- ZYME (a combination of three high
performance enzymes; which digested all residues & deposits normally found on invasive instruments &
devices including proteins, lipids, carbohydrates &mucopolysaccharides at temperature 40- 60°C). Quality
control: Cycle number, time, washing temperature, washing/ flush status & sonic status were monitored &
recorded. The washed catheter was then subjected to rinsing by filtered water several times by repeated
injection & suction to ensure complete removal of the detergent.
Washer-Disinfector Cleaning :
cardiac catheters were inserted into the ports of washer disinfector (Laoken, China) a complete automated
washer, rinsing and drying system.
Drying step:
Using air compressor gun, for catheters of
Inspection step :
All catheters were subjected to check for feasibility of its reuse regarding changes in properties of each
catheter to rule out & dispose catheters according to exclusion criteria mentioned above.
Check for cleaning procedure Assurance of complete cleaning was done using test for residual blood
detection: Diaquick FOB cassette (Dia-Lab production & chemicals, Wiener Neudorf, Austaria): A rapid,
visual sandwich immunochromatographic test for qualitative detection of human blood hemoglobin with the
aid of extraction buffer.
Packaging:
Using sealing machine; Speedy-seal 12 (Unident Co, Anios laboratories, France), temperature (50-200°C)
was used to ensure complete sealing.
Microbiological examination and endotoxin detection:
When catheters were introduced into a patient, endotoxin was eluted from the liquid passing through the
lumen as well as from direct contact of the outside of the catheter with blood. Precisely the dose of endotoxin
causing pyrogenic reaction is unknown but approximately levels>50 EU/ ml can cause reaction however
severity is not only limited to dose but to patient susceptibility as well (Kundsin& Walter, 2001). Endotoxin
was detected using LAL (Limulus Amebocyte Lysate test (Charles RiverEndosafe, USA). Endotoxin
produced opacity & gelation of LAL reagent; while bacteria& fungi were detected using conventional culture
media (blood, MacConkey s & Sabaroud s dextrose agar media)
Suggested protocols for Catheter reuse in India:
For solid catheters (non-luminal)
Based on number of reuses defined (maximum 5 times), verify that the catheter can still be reused.
 Soak the catheter in an enzymatic detergent (neutral or alkaline)/enzymatic cleaning agent.
 Meticulously clean the entire surface of the catheter. Use flush and brush if required. Discard the used
enzymatic detergent.
 Rinse well in potable tap water/sterile distill water.
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 Immerse in any high level disinfectant, which has material compatibility such as 3% hydrogen peroxide
solution for 3 hours.
 Rinse with clean water thoroughly, multiple times and wipe dry. Use alcohol flush to facilitate drying.
The device should be completely dry for the ethylene oxide sterilization to be effective and avoid
producing toxic residues.
 Inspect for any blood stains or dirt and discard if present
 Check for integrity and functionality
 Re-package in double layers
 Sterilize with ethylene oxide
 Label the date of re-sterilization
 Note the reuse number (different color code for 1st, 2nd, 3rd, 4th & 5th final reuse)
For hollow (luminal) equipment:
○ Based on number of reuses defined (maximum 3 times), verify that the catheter can still be reused.
 Soak the catheter in an enzymatic detergent (neutral or alkaline)/enzymatic cleaning agent. Ensure that
the lumens are completely filled with enzymatic detergent and disinfectant.
 Meticulously clean the entire surface of the catheter. Use flush and brush if required. Discard the used
enzymatic detergent.
 Rinse with pressurized potable tap water/sterile distill water for 10 min.
 Immerse in any high level disinfectant, which has material compatibility such as 3% hydrogen peroxide
solution for 3 h.
 Rinse with clean water thoroughly, multiple times and wipe dry.
 Drying to be performed by using compressed air jets free of oil, dust and moisture.
 Inspect for any blood stains or dirt and discard if present.
 Check for integrity and functionality of the catheter.
 Re-package in double layers
 Sterilize with ethylene oxide
 Note the reuse number (different color code for 1st, 2nd and 3rd reuse)
 For pulse generators/defibrillators
 Inspect for integrity and clean outer surface with tap water
 Unscrew lead and clean inner lumen with syringe and needle followed by flushing
 Cleanse the device with an enzymatic detergent (neutral or alkaline)/enzymatic cleaning agent.
 Dry at room temperature for 24 h or use compressed air
 Check parameters
 Immerse in any high level disinfectant which has material compatibility such as povidone-iodine for 4 h
 Clean with sterile distilled water
 Wipe with 70% ethanol
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 Air-drying
 Repackage in double layers
 Sterilize using ethylene oxide
 Consider resterilizing with ethylene oxide 2–3 days prior to implant
For all ethylene oxide re-sterilization:
Aerate for 24 h before use
 Check for sterility indicator
 Use only within expiry date of resterilization
 Check for mechanical integrity, functunality & device testing before reuse
Setting up the cardiac catheterization laboratory for a diagnostic study:
Facility Design for Efficient and Effective Care :
While facility design is often limited by available space (square footage) and its location, there are some
design features that are critical to the efficient use of space. It is essential for the procedure room and control
room to be adjacent to each other, with storage space as well as the clean and soiled utility areas located
within the immediate cardiac catheterization suite area. However, if there are space limitations, additional
storage, patient holding areas, the family waiting area, staff locker/lounge area, offices, image archival
storage and physician changing areas may be located nearby. The ideal situation is to allow for all areas to be
located in one centralized suite.
Procedure Room:
The catheterization laboratory procedure room should provide ample space for the equipment, in-room
storage and movement of the patient into and out of the room via stretcher or patient bed. The American
College of Cardiology recommends 500-600 square feet for the procedure area and 150-200 square feet
allotted to the control room.
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These recommendations allow for adequate space, but are overridden by any state regulations that define
space allocation.
Items for consideration in the procedure room include in-room storage cabinetry, standing-height counter
space, a clinical sink, and positioning of computer drops for hospital information system terminals. Multiple
computer drops should be installed at the time of construction or renovation, even if there is not an
immediate plan to install terminals. Likewise, at least one phone line into the procedure room itself is
recommended. If your lab is performing permanent pacemaker insertions or some of the more advanced
percutaneous aortic repair procedures in this setting, ventilation and airflow must meet operating room
standards.
Equipment Storage Space:
If two procedure rooms are being designed, a side-by-side configuration with a shared equipment storage
space between the two rooms provides for equipment ease of access and allows for streamlined inventory
management. The equipment storage space should be lined with an electrical power strip to allow for
multiple plug access to keep any battery powered/charging equipment accessible. The equipment storage area
should also be configured with cabinetry to hold catheters, guiders, balloons, stents and guidewires.
Many laboratories prefer to use movable wire shelving that allows for changes in configuration as a result of
changing inventory and/or changes in supplies.
Control Room:
The control room is another critical space, the room should be of adequate size to allow staff movement and
required equipment (such as imaging control panels and hemodynamic monitors), but an overly large control
room invites visitors (vendors, other staff, other physicians) who can be a distraction during a case. While
procedure rooms may be side-by-side or back-to-back, it is not advisable to have a single control room that
supports multiple procedure rooms. Again, this can be a distraction when the activity in one of the rooms is
of an urgent or high-risk nature. Some state regulations prohibit a shared control room. The control room
floor should also be elevated by one or two steps to allow for full visualization of the field.
Patient Holding:
Additional space for patient holding to provide pre-procedure assessment and immediate post procedure care
is essential and can be designed in several ways. Many cardiac catheterization laboratories provide only
Stage I recovery (immediate post-procedure vital sign and anesthesia recovery monitoring) in the holding
area.
If that is the case, a minimum of two beds or stretchers per procedure room is needed to facilitate patient flow
in and out of the lab. Some facilities admit outpatients directly to the cath lab area and recover Stage I and
Stage II (ongoing monitoring for the remainder of the recovery period) patients as well as discharge
outpatients from this area.
In the latter case, the number of beds required should be based on average daily case volumes and should
allow for efficient patient flow, eliminating waiting for a bed situations. (Space constraints often limit the
ability of a facility to use the holding area in this manner.) The holding area should contain a small nurses
station area to allow for documentation, computer terminals, a scheduling secretary, etc. Patient bays should
preferably be walled cubicles with breakaway doors.
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This will allow for increased patient privacy in light of the newest HIPAA regulations. The patient bays
should also be equipped with gases, call light, monitors (including EKG, NIBP and SaO2), stretchers and a
small storage cart or cabinet. Multiple computer drops and phone lines should also be installed at the nurses
station area.
Consideration should also be given to providing for computer drops in each patient bay to allow for bedside
terminals, if not currently, then in the future. Many cardiac catheterization holding areas have added
televisions and tranquility lighting to create a more patient-friendly and soothing environment.
Equipment Selection for the Cardiac Angiography Suite:
The major pieces of equipment for the cardiac catheterization laboratory can carry a price tag of more than a
million dollars and have numerous options and configurations. Making an informed decision on these items
is critical to the usefulness of the room as well as the satisfaction of the users, physicians as well as staff.
While there are several pieces of equipment to be placed in the procedure room, this article will concentrate
on the imaging equipment, hemodynamic monitoring equipment, and data/imaging archival. These pieces of
equipment should be reviewed through an RFP (Request for Proposal) process that will allow the equipment
to be compared on an apples-to-apples basis as much as possible.
The RFP pricing should be followed by individual vendor presentations and site visits to see the equipment in
use. Included in the RFP process should be a request for a list of contact names and phone numbers of
hospitals currently using the equipment under consideration.
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Imaging Equipment:
Imaging equipment is the core of the cardiac catheterization laboratory. An early decision regarding this
equipment and its features is essential to allow the architects to best utilize its specifications in the procedure
room layout. The specifications are also needed to determine power supply needs as well as air cooling
considerations. The facility should select equipment based on program needs (current and long term) and
physician/staff preferences, while still keeping in mind the hospital’s financial constraints.
Image Intensifier (I-I) Size:

Cardiac imaging systems typically have a smaller I-I size to provide a more concentrated area of focus. If the
procedure room will also be used for peripheral studies, consider a dual I-I system that will allow for larger
areas of focus (as in peripheral run-off studies) or purchase of the larger single I-I that will allow for
magnification. Likewise, if peripheral work is to be done in this setting, the C-arm/table should allow for full
table panning to include the legs. Optional bolus-chasing features should be considered.
Flat panel technology:
While conventional digital imaging is the standard today, flat panel technology is now available and may be
evaluated. Conventional digital imaging uses a fluoroscopic imaging chain including an analog image
intensifier, while flat panel imaging converts the x-ray signals into digital images. The point of acquisition
eliminates the artifact and distortion associated with the image intensifier chain. Flat panel technology also
reduces the radiation dose required for imaging. This technology is not available from all vendors at this
time, and it may be more useful to those performing peripheral work (due to panel size) at present. However,
this technology will most likely become mainstream in the next 3“5 years. It is certainly worth discussing
with vendors, as well as taking a site visit to discuss any pros and cons with the end-user.
Rotational angiography:
which allows for 3-D imaging of the arteries, is another equipment option offered by most of the major
vendors. Again, most of the initial use for this option has been in peripheral angiography, but the technology
is now being applied to coronary diagnostic and interventional work as well.
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Table options:
Make sure that the table weight capacity is as high as possible. Previous tables accommodated 325“350
pounds, which created some limitations for patient imaging. Most vendors will offer a table with a capacity
of up to 450 pounds. To allow for stretcher positioning, the table should also be able to rotate laterally a
minimum of ninety degrees. Tables may be floor or ceiling-mounted and are generally selected as to what is
available from a particular vendor (not all offer ceiling-mounted tables) and what is required by the room’s
physical limitations.
There are situations in which the ceiling height, amount of support and weight bearing will not permit the use
of a ceiling-mounted table. Standard equipment options that should be packaged with the imaging equipment
include: Table accessories such as armboards and extenders; Overhead and table lead shielding; Overhead
surgical light; The power injector. While most of these items can be purchased from other vendors, having a
single vendor responsible for the installation of all equipment helps ensure everything will be mounted and
interact properly.
Hemodynamic Monitoring Equipment:
Hemodynamic monitoring equipment is essential to the cardiac angiography suite and several products are
available for consideration. Several imaging equipment vendors also offer hemodynamic monitoring systems.
There are some advantages to having a single provider for both major pieces of procedure room equipment.
However, if the vendor’s hemodynamic equipment is not user-friendly, does not have database capabilities
and is not upgradeable, a separate vendor may be preferable. While every hemodynamic system records
waveforms, calculates shunts, gradients and other required parameters, there is a wide spectrum of
capabilities among products for data entry, report generation, databasing and integration with hospital
information systems.
Some monitoring systems will also archive images from the x-ray system. When comparing these systems, it
is essential to know what you want the system to be able to do today as well as in the next five years. For
example: Perhaps there is no immediate plan to interface the hospital information system with the cath lab
system, but is the system capable of future system integration? Perhaps the hospital is not currently
participating in the American College of Cardiology database, but is the monitoring system approved for and
capable of handling the database should the hospital decide to participate during the next several years?
When considering the hemodynamic system, also consider if the procedures to be performed in the cath lab
include electrophysiology (EP) studies, since additional software and equipment will be required and may
require interfacing or additions to the system’s current software. Finally, consider documentation and report
generation from the system.
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Table Movement:
The Numbers:
Each number represents how many unique movements the table can perform .Most fluoroscopy table
manufacturers follow this same code when identifying their tables. Each number upward has all the same
movements as the previous number, plus one additional movement. For example, a 4-move table can do
everything a 3-move table can AND one more unique movement
1-Move: Height Adjustment

This moves the table straight up and down. Height range varies between manufacturers and models.
2-Move: Lateral Tilt
This allows the table to tilt from side to side. The degree of tilt also varies by manufacture and model.
3-Move: Trendelenburg Tilt
This tilts the table from head to foot. The degree of tilt also varies by manufacture and model.
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4-Move: Longitudinal Travel

Longitudinal Travel (or head to foot travel) moves the c-arm table top head to foot over the central column.
The range of movement represented in inches varies between manufacturers and models.
Here's a helpful graphic, courtesy of Streamline C-Arm Tables, that visualizes movements 1-4:
5-Move: Lateral Travel

Lateral Travel (or side to side travel) moves the c-arm table top side to side over the central column. The
range of movement represented in inches varies between manufacture and models
Float-Top
A float-top table adds diagonal movements to the 5-move configuration. These tops unlock, glide in all
directions for maximum flexibility, and then lock back into place.
Image Intensifier:
Image intensifiers (II) are utilized to convert low energy x-radiation into visible light images. Frequently the
detector portion of an x-ray C-arm used in operating theaters, the image intensifier has a low scatter input
portion made of low absorption substances such as titanium or aluminum. Image intensifiers are several
thousand times more sensitive compared to standard 400-speed screen-film combinations, and in practice can
produce images using several thousand times less radiation.
The biggest advantage of image intensifiers in medical imaging is the synergy of high detector efficiency and
high conversion efficiency to effectively utilize fluoroscopy while adhering to the radiation
protection principle of dose optimization.
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After the x-ray beam emerges from the patient, it enters the image intensifier tube through the input window
and is partially absorbed by the fluorescent input screen (entrance phosphor) creating a number of light
photons.
The light photons strike the photocathode of the input screen and are absorbed by photoelectric interactions,
causing it to emit photoelectrons (via the photoelectric effect).
The electrons are accelerated towards the output fluorescent screen by an electric field produced between the
photocathode and anode. Focusing and distortion minimization is accomplished by the focusing electrodes.
The electrons hit the output phosphor and cause large numbers of light photons to be produced, which
subsequently may be captured by various imaging devices
Clinical Applications of An Image Intensifier:
An image intensifier or II is used in two ways:
• As a fixed piece of equipment in a dedicated screening room
• Mobile Equipment for use in theatre A Fixed Screening Room: Philips MultiDiagnost Eleva
Components of an Image Intensifier System:
• C-Arm (encompasses the actual X-ray source and Image intensifier)
• Table
• Radiographic exposure and program controls
• Post processing software
• Viewing monitors Fixed Image Intensifiers These are used in most x-ray departments as 'screening
rooms'. The types of investigations for which this machine can be used for is vast.
Examples include:
• Barium Studies (Swallows, Meals, Enemas)
• Endoscopy Studies (ERCP)
• Fertility Studies (HSG)
• Angiography Studies (Peripheral, Central and Cerebral)
• Therapeutic Studies (Line placements i.e. Permacath / Hickman, Transjugular Biopsies, TIPS Stent,
Embolisations)
• Cardiac Studies (PTCA)
• Orthopedic procedures (ORIF, DHS, MUA, Spinal work)
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Mobile Image Intensifiers :

General Configuration and range of movements A mobile image intensifier generally consists of two units,
the intensifier unit and the television or workstation unit. The intensifier unit consists of a C-arm with a
variety of movements that allows for use in a variety of surgical procedures such as cardiology, orthopedics
and urology. The C-arm has an image intensifier and an x-ray tube positioned directly opposite from each
other.
The c-arm is capable of many movements:
• Horizontal travel: about 200 mm
• Orbital travel: about 115 degrees
• Motorized vertical travel: 460 mm
• Wig-wag about +/-12 cm (entire C-Arm and Image Intensifier)
• C-arm rotation about the horizontal axis +/- 210 degrees The c-arm must be compact and lightweight
to allow easy positioning with adequate space to work around and a wide range of motion.
Radiation safety features:
• Last image hold, "freezing" the screen and availing for examining the screen without exposing the
patient to unnecessary radiation.
• Pulsed fluroscopy
• Single pulse fluroscopy mode
• Manual mode in order to reduce dose (ALARA)
• Fluoroscopy timer warning
• Movements of II allow distance between patient and image detector low, so therefore reducing dose
to patient.
• Beam limitation devices to minimize beam area Special features
• Real time viewing
• Remote control keypad
• Removable cassette holder, for both fluroscopy and plain film images
• Contrast correction
• Zoom
• Edge enhancement
• Digital subtraction
• Wheels fitted with cable deflectors
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UNIT-2
Learning Objective:
 Intra cardiac pressures
 Pressure recording systems
 Fluid filled catheters versus catheter tipped
 manometers Artifacts, damping, ventricularization
 Pressure gradient recording – pullback, peak – to peak
 Cardiac output determination
Intra Cardiac Pressures:

A pressure wave is the cyclical force generated by cardiac muscle contraction. Its amplitude and duration are
influenced by various mechanical and physiological parameters. The pressure waveform of a cardiac
chamber is influenced by the following factors:
1) Force of contraction of the contracting chamber
2) Its surrounding structures
3) Contiguous chambers of the heart
4) The pericardium
5) The lungs
6) The vasculature
7) The heart rate
8) The respiratory cycle
For the assessment of intracardiac pressures, two systems are currently in use:
1) Fluid filled systems
2) Micromanometer catheters
Atrial Pressure:
The RA pressure wave form has three positive deflections — “a”, “c”, and “v” waves. The “a” wave is due to
atrial systole and follows the P-wave on surface ECG. The “x” descent follows the “a” wave and represents
atrial relaxation and downward pulling of the tricuspid annulus by RV contraction. The “x” descent is
interrupted by the “c” wave, which is a small positive deflection caused by protrusion of the closed tricuspid
valve into the RA. The pressure in the RA rises after the “x” descent due to passive atrial filling. The atrial
pressure then peaks as the “v” which represents ventricular systole.
The LA pressure waveform is similar to that of the RA although normal LA pressure is higher representing
the high pressure system of the left side of the heart. In LA pressures, unlike RA pressures, the “v” wave is
generally higher than the “a” wave.
Pulmonary Capillary Wedge Pressure:
The PCW waveform is similar to LA pressure waveform except that it is damped and delayed due to
transmission through the lungs. The “c” waves may not be seen. Normally the PA diastolic pressure is similar
to the mean PCW pressure as the pulmonary circulation has a low resistance.
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Ventricular Pressure:
RV and LV waveforms are similar in morphology but different in magnitude. The duration of systole and
isovolumic contraction and relaxation are longer and the ejection period shorter in the LV than in the RV.
End diastolic pressure in generally measured at the “C” point which is the rise in ventricular pressure at the
onset of isovolumic contraction.
Great Vessel Pressures:
The contour of the central aortic pressure and PA pressure tracing consists of a systolic wave, the incisura
(indicative of closure of the semilunar valves) and a gradual decline in pressure until the following systole.
The pulse pressure reflects the volume and compliance of the arterial system.The mean aortic pressure more
accurately reflects the peripheral resistance.
Pressure Recording System:
The most common method of measuring pressures in the cardiac catheterization laboratory is to use fluid-
filled catheter systems that convey the pressure wave from the site of interest through a catheter, manifold,
and a pressure transducer that converts the pressure waveform to an electrical signal. A catheter with a
pressure transducer at the tip provides a more accurate pressure recording, but these catheters are too
expensive for routine clinical use.
Fluid-filled catheters commonly produce several types of artifacts in recorded waveforms:

1. Low-frequency response
2. Overshoot
3. Zero level
Low-frequency response and overshoot are common to all types of fluid-filled pressure-transmitting devices.
The natural resonant frequency of a catheter–manometer system is the frequency at which the system
oscillates when stimulated. The desirable frequency response for measuring intracardiac pressures in an adult
with a fluid filled catheter system is about 20 Hz or more. When the natural resonant frequency response of a
catheter system is below about 12 Hz, low-frequency catheter oscillation waves will obscure high-frequency
cardiac waveforms. The operator should try to minimize the following factors that lower the frequency
response of a catheter–manometer system:
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1. Air bubbles in the catheter system

2. High-viscosity fluid in the catheter (e.g., contrast material instead of saline)
3. Long fluid-filled tubing between the catheter and the pressure transducer
4. A long catheter
5. A narrow-bore catheter
6. A catheter made of soft, compliant material
Overshoot is produced by reflected waves within the catheter–manometer system. The magnitude of
overshoot can be reduced by mechanical or electrical damping. Overdamping eliminates overshoot, but it
reduces frequency response. Optimal damping reduces overshoot without producing a major drop in
frequency response (Fig.below).
Fig: A:Underdamped. B: Optimally damped. C: Overdamped.
The pressure transducer in a fluid-filled catheter system must be placed in a position equal to the mid-height
atrial level to achieve the “zero level.” This is approximately one-half the distance between the front and the
back of the chest in a supine patient. If the transducer is placed at the level of the anterior chest surface of a
supine patient, the recorded pressures will be falsely low.
Respiration produces cyclical changes in the absolute pressure of all intrathoracic cardiovascular structures.
Pressure measurement should be measured during end expiration. The ultimate goal of setting up a fluid-
filled catheter pressure measurement system is to achieve the highest frequency response possible, optimally
damp the system to eliminate overshoot, and locate the pressure transducer at the zero level.
BASIC INTRACARDIAC WAVEFORMS:
The basic configuration of normal waveforms is similar for the right and left atria. The V-wave amplitude is
generally greater than the A wave in the left atrium, whereas the A wave predominates in the right atrium
(RA). Electromechanical delay is about 40 to 80 milliseconds.
The basic intra-atrial waveforms and the events to which they correspond are as follows:
A: atrial contraction
C: ventricular contraction
V: rising atrial pressures during ventricular systole; occurs during the T wave
C-V, or systolic: rapidly rising atrial pressure due to severe atrioventricular valve regurgitation
X descent: atrial relaxation; occurs after the A-wave peak, before the C wave
X′ descent: atrial relaxation; occurs after the C wave and before the V wave
17
Y descent: opening of the atrioventricular valve; occurs after the peak of the V wave (Fig. below).
Fig:Timing of the interatrial waveform with the electrocardiogram.
Arrhythmias may produce a variety of changes in intracardiac pressures:

1. Atrial fibrillation will eliminate A waves.
2. Junctional rhythm will displace A waves closer to the C wave.
3. Premature ventricular contractions (PVCs) and ventricular pacemaker rhythm may produce cannon A
waves in the atrium as a result of atrial contraction against a closed atrioventricular valve.
Table:Normal Values for Intracardiac Pressure
Fluid filled catheters versus catheter tipped manometers:

Fluid filled catheter :
• fluid-filled catheter attached to a pressure transducer
• pressure wave is transmitted by the fluid column within the catheter
• Pressure measurement system should have the highest possible natural frequency and optimal
damping
• Data should be collected ,with the patient in steady state before introduction of radiographic contrast.
• Accurate ‘zero’ reference is essential
• Transducers must be calibrated frequently (before each recording)
• The pressure transducer -calibrated against a known pressure and the establishment of a zero
reference undertaken at the start of the catheterization procedure
• To “zero” the transducer, the transducer is placed at the level of the atria, which is approximately
midchest
18
• If the transducer is attached to the manifold and is therefore at variable positions during the
procedure, a second fluid-filled catheter system should be attached to the transducer and positioned at
the level of the midchest
Micromanometer Tipped Catheter:

• Fluid filled system-distortion of wave forms- artifacts, amplification of systolic pressure in periphery,
damping or augmentation of frequency response system.
• For precise,undistorted ,high fidelity pressure recordings
• Micromamometer chips at the end of catheters
• Interposing fluid column is eliminated
• Have higher natural frequencies and more optimal damping characteristics
• To assess pressure waveform contours in a tachycardia situation, rate of ventricular pressure
rise(dp/dt) etc
• Limitation- additional cost, fragility , time needed for properly calibrating and using the system
19
Left ventricular (LV) pressure signals as recorded with a micro manometer and with a system using long.
Fluid-filled tubing and several interposed stopcocks between the pressure transducer and the 7F NIH
catheter. The micro manometer tracing is labeled A, and the fluid-filled catheter tracing is labeled B. Note
both the early diastolic and the early ejection phase overshoots recorded with the fluid-filled catheter,
indicating a poor frequency response, especially in the graph on the left.
Artifacts:
Movement artifact (WHIP Artifact)
• Motion of tip of the catheter within the measured chamber
→ Enhance the fluid oscillations of the transducer system
• May produce superimposed waves of ±10 mm Hg
• Particularly common in PA
 Render systolic and to a lesser extent diastolic pressures unreliable.
 No way to fix it internally.
 Stabilize externally.
 If whip noted -consider using mean pressures. (usually not affected)
End pressure artifact
 An end-hole catheter measures an artificially elevated pressure because of streaming or high
velocity of the pressure wave
 Flowing blood- sudden halt- K E is converted to pressure
 This added pressure may range from 2-10 mm Hg
Catheter impact artifact
 When the catheter is struck by the walls or valves of the cardiac chambers.
 Common with the pigtail catheter in the LV, where the MV hits the catheter as they open in
early diastole
Damping:
Dissipation of the energy of oscillation of a pressure management system due to friction:
Damping α= viscosity of fluid / radius of catheter
Reflected waves:
Both pressure and flow at any given location are the geometric sum of the forward and backward waves.
20
Physiological Characteristics of Reflected wave;

• Augmented pressure wave reflections
– Vasoconstriction
– Heart failure
– Hypertension
– Aortic / iliofemoral obstruction
– Post-valsalva release
• Diminished pressure wave reflections
– Vasodilation (physiologic / pharmacologic)
– Hypovolemia
– Hypotension
Valsalva maneuver strain phase
Ventriculization:
Ventricularization of pressure during coronary angiography has been said to identify the presence of left
main coronary artery disease,ventricularization is seen when the catheter tip is advanced into an ostial
stenosis, partially obstructing flow, and is characterized by a steep decline of pressure in diastole with large
pulse pressure, absence of the dicrotic notch, and appearance of presystolic positive deflection. A
ventricularized pressure waveform can be considered a hybrid between coronary arterial pressure and
coronary wedge pressure.
Pressure gradient recording – pullback, peak – to peak
Aortic stenosis is one of the most common valvular problems in the developed world. 1 Along with an aging
population, the prevalence of aortic stenosis is expected to increase in the future. Although patients can be
asymptomatic in early stages of the disease, symptoms that may be present, especially in patients with a
severe aortic stenosis, include shortness of breath; chest pain (angina), pressure, or tightness; and fainting.
Once symptoms are present, the prognosis is poor unless aortic valve replacement is performed promptly.
Before undergoing treatment, these patients can be examined with the Langston Dual Lumen Catheter from
Teleflex, which measures simultaneous pressures across the aortic valve to help clinicians determine the
21
pressure gradient and effective orifice area (EOA)
Fig: Placement of Langston Dual Lumen Catheter for simultaneous measurement of differential pressures
DIAGNOSTIC OPTIONS FOR AORTIC STENOSIS:
Noninvasive Tests:
Abnormal patterns on an electrocardiogram can reflect a thickened heart muscle and suggest the diagnosis of
aortic stenosis. A transesophageal echocardiogram, due to the relative proximity to the heart, is more
accurate than a standard external echocardiogram, but it requires esophageal anesthetic, conscious sedation,
and a brief outpatient stay.
A chest x-ray can show whether the heart shadow is normal or enlarged. Careful inspection of a chest x-ray
sometimes reveals calcification of the aortic valve, but not the extent of the stenosis.
An echocardiogram (ultrasound) can show a thickened, calcified aortic valve that opens poorly. Doppler flow
can be used to determine the pressure difference on either side of the aortic valve and to estimate the EOA,
but it is not always accurate, depending on the skill of the operator and the anatomy of the patient.
Cardiac Catheterization:
Cardiac catheterization assists in determining the severity of a valvular stenosis by directly measuring the
pressure gradient and flow across the valve. In patients with aortic stenosis, a true transvalvular pressure
gradient is strongly recommended before valve replacement.
Any catheter designed for ventricular entry can obtain a left ventriculogram and measure the pressure within
the left ventricle (LV). However, the Langston Dual Lumen Catheter can simultaneously measure the
pressure in the aorta and the LV.
There are several ways that a pressure gradient may be measured across the aortic valve in a
catheterization procedure:
Pullback method:
A single-lumen pigtail catheter first measures the LV pressure before a “pullback” of the catheter into the
aorta to measure the pressure in the aorta. Measurement is not simultaneous because each is taken during
different cardiac beats, which can change the pressures.
22
Double stick method:

Puncturing both groins or radial arteries and placing two pigtail catheters—one in the LV and one in the
aorta. This technique produces accurate simultaneous aorta and LV pressures, but requires bilateral femoral
or radial artery punctures, plus the additional introducer sheath, guidewire, and pigtail catheter.
Sidearm of a short sheath:
Using a single-lumen pigtail catheter to measure the LV pressure while using the sidearm of the introducer
sheath to measure the aortic pressure. This method may be subject to mistaken readings if there is any iliac or
aortic stenosis, which would affect the sidearm pressure reading. Although measuring the gradient between
the LV and the femoral artery is convenient, downstream augmentation of the pressure signal and delay in
pressure transmission between the proximal aorta and femoral artery may alter the pressure waveform and
introduce errors.
Sidearm of a long sheat:
Using a single lumen pigtail to measure the LV pressure while using the sidearm of a long introducer sheath
to measure the aortic pressure.
While this technique can yield positive results it can be difficult and dangerous to run a long sheath through
the aorta.
Transseptal Approach:
This technique involves a venous approach via a puncture of the ventricular septum with a needle followed
by advancement of a catheter into the LV. An additional catheter is placed in the aorta and measures
simultaneous pressures at the aortic root. This invasive technique is better suited for patients with mechanical
aortic valves due to the desire to avoid placing anything across the mechanical valve.
Peak to Peak Pressure gradient:
The peak-to-peak gradient is the difference between the peak left ventricular and peak aortic pressures, which
is a nonphysiological measurement because the peak pressures occur at different points in time.
23
Cardiac output determination:

Definition:
Quantity of blood delivered to the systemic circulation per unit time expressed in L/min
Techniques of measurement:
– Fick-Oxygen Method
– Indicator-Dilution Methods
• Indocyanine Green
• Thermodilution
Extraction reserve and CO:
• The extraction of a particular nutrient expressed as A-V difference across that tissue.
• The factor by which the arteriovenous difference can increase at constant cardiac output, owing to
changes in metabolic demand, termed as extraction reserve.
• Normal extraction reserve for O₂- 3. ie, under extreme metabolic demand, tissues can extract upto
120ml of O₂(40×3) from each liter of blood delivered.
• As the cardiac output falls, extraction of O₂ by the tissues increases. Upto 1/3 fall in C.O can be
compensated by 3 times increase in extraction reserve.
• C.O below one third of normal- incompatible with life (CI ≤ 1.0 L/min/m²).
• Upper limit of C.O in trained athletes- 600% of resting output.
• under extreme exercise, total body O₂ requirement increases to 18 times, which is met by 6 fold rise
in C.O and 3 fold rise in extraction reserve
• As the cardiac output falls, extraction of O₂ by the tissues increases. Upto 1/3 fall in C.O can be
compensated by 3 times increase in extraction reserve.
• C.O below one third of normal- incompatible with life (CI ≤ 1.0 L/min/m²).
• Upper limit of C.O in trained athletes- 600% of resting output.
• under extreme exercise, total body O₂ requirement increases to 18 times, which is met by 6 fold rise
in C.O and 3 fold rise in extraction reserve
24
Relationship of arteriovenous oxygen difference and cardiac index:
Cardiac Output Measurement:

Fick Oxygen Method
• Fick Principle: The total uptake or release of any substance by an organ is the product of blood flow
to the organ and the arteriovenous concentration difference of the substance.
• As applied to lungs, the substance released to the blood is oxygen, oxygen consumption is the product
of arteriovenous difference of oxygen across the lungs and pulmonary blood flow.
Q= Oxygen Consumption /Arteriovenous O2 difference
In the absence of a shunt, systemic blood flow (Qs) is estimated by pulmonary blood flow (Qp).
Oxygen Consumption:
• Uptake of oxygen from room air by the lungs is measured.
• Douglas bag method
• The polarographic method
• The paramagnetic method
Douglas bag method:
• Older
• A timed sample of patients expired air is collected in a Douglas bag & analyzed for O2 content and
( Beckman oxygen analyzer) and volume
• O2 content of room air is also measured
• Oxygen consumption per l per minute is calculated
Polarographic method:
• Metabolic rate meter by Waters instruments
• Parts: oxygen hood /mask
• Polarographic oxygen sensor cell
25
• V o2=O2 content in the room air – O2 content in the air flowing past the polarographic cell
• Respiratory quotient is assumed
Paramagnetic method:
• Paramagnetic sensor for measuring O2
• Adjusts for temperature and partial pressure of water vapour
• Calculates respiratory Q for each patient
Fick Oxygen Method: O2 Consumption
• Douglas Bag Method;
– Volumetric technique for measuring O2
– Analyzes the collection of expired air
– Utilizes a special mouthpiece and nose clip so that patient breathes only through mouth
– A 2-way valve permits entry of room air while causing all expired air to be collected in the
Douglas bag
– Volume of air expired in a timed sample (3 min) is measured with a Tissot spirometer
Douglas Bag Method:
Step 1: Calculate oxygen difference
O2 content room air = pO2 room air x 100 /Corrected barometric pressure
O2 content expired air = pO2 expired air x 100 / Corrected barometric pressure
Oxygen difference = O2 room air - O2 expired air = ______ mL O2 consumed / L air
Step 2: Calculate minute ventilation
Tissot difference = Tissot initial – Tissot final = _____ cm
Tissot volume = Tissot difference x correction factor = _____ L
Total volume = Tissot volume + sample volume = _____ L
Ventilation volume =
Total volume expired air x correction factor = _____ L
Minute ventilation = Ventilation volume/ Collection time
Step 3: Calculate oxygen consumption:
O2 consumption = O2 difference x minute ventilation
O2 consumption index = O2 consumption/ Body surface area
Polarographic O2 Method:
– Metabolic rate meter
– Device contains a polarographic oxygen sensor cell, a hood and a blower of variable speed
connected to the oxygen sensor.
– The MRM adjusts the variable-speed blower to maintain a unidirectional flow of air from the
room through the hood and via a connecting hose to the polarographic oxygen-sensing cell.
26
VM = VR + VE - VI
– VM = Blower Discharge Rate
– VR = Room Air Entry Rate
– VI = Patient Inhalation Rate
– VE = Patient Exhalation Rate
VO2 = (FRO2 x VR) - (FMO2 x VM)

FRO2 = Fractional room air O2 content = 0.209
FMO2 = Fractional content of O2 flowing past polarographic cell
Polarographic O2 Method:
VO2 = (FRO2 x VR) - (FMO2 x VM)
VO2 = VM (0.209 - FMO2) + 0.209 (VI - VE)
Servocontrolled system adjusts VM to keep fractional O2 content of air moving past polarographic sensor
(FMO2) at 0.199 (Constant if steady state)
VO2 = 0.01 (VM) + 0.209 (VI - VE)
VO2 = 0.01 (VM) + 0.209 (VI - VE)
VO2 = 0.01 (VM) (Respiratory quotient RQ = VI / VE = 1.0)
Sampling technique:
– Mixed venous sample
• Collect from pulmonary artery
• Collection from more proximal site may result in error with left-right shunting
– Arterial sample
• Ideal source: pulmonary vein
• Alternative sites: LV, peripheral arterial
– If arterial desaturation (SaO2 < 95%) present, right-to-left shunt must be
excluded
Measurement:
– Reflectance (spectophotometric analysis ) oximetry
27

Indicator Dilution Method- ‘Stewart’
• Requirements
1. Bolus of indicator substance(non toxic) which mixes completely with blood and whose
concentration can be measured
2. Indicator is neither added nor subtracted from blood during passage between injection and
sampling sites
3. Most of sample must pass the sampling site before recirculation occurs
4. Indicator must go through a portion of circulation where all the blood of the body becomes
mixed
Stewart-Hamilton Equation:
CO = Indicator amount (mg) x 60 sec/ mean indicator concentration (mg/mL) x curve duration
• Indicators
– Indocyanine Green
– Thermodilution (Indicator = Cold)
28
UNIT-3
Learning Objective:
 Thermo dilution method

 Oxygen dilution method
 Principles of oximetry
 Shunt detection and calculations.
 Coronary angiography
Thermodilution Method:
The Stewart-Hamilton equation shows the relationship between blood flow, the indicator, and its blood
concentration. However, an adjustment is necessary if the equation is used for thermodilution because
temperature changes, rather than indicator concentrations, are measured. The change in temperature
represents an unknown mass of blood losing heat to a known mass of cold indicator, and it is therefore
possible to calculate blood volume by using temperature change measurements to calculate the blood mass
(in grams) and convert that value into blood volume. This is done by incorporating 2 important variables for
each of the 2 fluids—specific heat and specific gravity—to the equation. The specific heat represents the
energy needed to change the temperature of 1 g of a substance by 1°C, and the specific gravity is the density
of a substance in relation to the density of water. The units for specific heat and specific gravity are cal/°C·g
and mg/mL, respectively.
• Fegler 1954 (CONSERVATION OF ENERGY)

• cold saline or 5% D
• balloon-tipped flow-directed pvc catheter
• thermistor at tip
• opening 25 to 30 cm proximal to the tip
• Via vein to PA (proximal opening –SVC or RA, thermistor –PA)
• 5 to 10 mL to proximal port
• change in temperature at the thermistor recorded
29
VI = volume of injectate
SI, SB = specific gravity of injectate and blood
CI, CB = specific heat of injectate and blood
TI = temperature of injectate
D TB = change in temperature measured downstream
0.825-correction factor for warming of injectate from the syringe or by catheter
Advantages over indocyanine green dye method:
– Withdrawal of blood not necessary
– Arterial puncture not required
– Indicator (saline or D5W)- inert and inexpensive.
– Virtually no recirculation, simplifying computer analysis of primary curve sample
Sources of Error (± 15%)
– Unreliable in tricuspid regurgitation
– Baseline temperature of blood in pulmonary artery may fluctuate with respiratory and cardiac
cycles
– Loss of injectate with low cardiac output states (CO < 3.5 L/min) due to warming of blood
by walls of cardiac chambers and surrounding tissues. The reduction in D TB at pulmonary
arterial sampling site will result in overestimation of cardiac output
– Empirical correction factor (0.825) corrects for catheter warming but will not account for
warming of injectate in syringe by the hand
LIMITATIONS TO THERMODILUTION CARDIAC OUTPUT:

• Thermodilution CO measurements are affected by various disease states and anatomic defects. When
CO is low, thermodilution becomes less reliable because of the small temperature change induced as
the indicator warms up in the diminished circulation.
• The smaller area under the curve causes an overestimated CO. A similar effect is seen in the setting
of severe tricuspid regurgitation where thermodilution yields lower accuracy compared with the Fick
method.Underestimation of CO can also result from high flow states that
cause thermodilution variability that is potentially related to rapid PA temperature variation and
limited thermistor sensitivity to rapid temperature change. Pulmonary valve insufficiency has been
shown to affect the appearance of the thermodilution curve, but it does not affect its overall value.
• Although CO extremes cause thermodilution measurement variability, values within a certain range
are useful. Thermodilution-measured CO values between 3.4 and 15.8 L/min have a correlation
coefficient of 0.98 compared with dye dilution methods. Comparable results between Fick
and thermodilution are observed in CO from 3.2 to 17.5 L/min. Only in values >15 L/min does
minimal variability appear, and thermodilution begins to underestimate CO.
30
Thermodilution Curves:
The blood temperature changes measured by thermodilution are graphed on a temperature-time curve. The
original curve shows a sharp negative deflection followed by a rise to an apex and gradual return to baseline
values. This trend represents the initial drop in blood temperature followed by the increase observed as the
blood dilutes and carries out the cold indicator. For easier representation, the thermodilution curves are
placed as upright deflections (Fig. below), and the area under the curve, which represents the indicator
concentration as a function of time, is inversely proportional to CO
Fig: Thermodilution (TD) curve. Representation of cardiac output (CO)curve variations. A, Normal TD CO
curve, with sharp initial upstroke followed by a deflection that slowly returns near to baseline. B, Low CO
curve that takes longer to reach the baseline and possesses a much larger area under the curve compared with
the normal curve. C, Representation of high CO with its small curve and correspondingly smaller area under
the curve.
Principles of oximetry:
Pulse oximetry is a simple, relatively cheap and non-invasive technique to monitor oxygenation. It monitors
the percentage of haemoglobin that is oxygen-saturated. Oxygen saturation should always be above 95%,
although in those with long-standing respiratory disease or cyanotic congenital heart disease, it may be lower,
corresponding to disease severity.
The oxyhaemoglobin dissociation curve becomes sharply steep below about 90%, reflecting the more rapid
desaturation that occurs with diminishing oxygen partial pressure (PaO 2).On most machines the default low
oxygen saturation alarm setting is 90%.
Principles of pulse oximetry:
Oximeters work by the principles of spectrophotometry: the relative absorption of red (absorbed by
deoxygenated blood) and infrared (absorbed by oxygenated blood) light of the systolic component of the
absorption waveform correlates to arterial blood oxygen saturations. Measurements of relative light
absorption are made multiple times every
31
econd and these are processed by the machine to give a new reading every 0.5-1 second that averages out the
readings over the last three seconds.
Two light-emitting diodes, red and infrared, are positioned so that they are opposite their respective detectors
through 5-10 mm of tissue. Probes are usually positioned on the fingertip, although earlobes and forehead are
sometimes used as alternatives. One study has suggested that the ear lobe is not a reliable site to measure
oxygen saturations.Probes tend to use 'wrap' or 'clip' style sensors.
Uses:
Central cyanosis, the traditional clinical sign of hypoxaemia, is an insensitive marker occurring only at 75-
80% saturation. Consequently, pulse oximetry has a wide range of applications including:
 Individual pulse oximetry readings - can be invaluable in clinical situations where hypoxaemia may be a
factor - for example, in a confused elderly person.
 Continuous recording - can be used during anaesthesia or sedation, or to assess hypoxaemia during sleep
studies to diagnose obstructive sleep apnoea. Peri-operative monitoring has not, however, been shown to
improve surgical outcomes.
 Pulse oximetry can replace blood gas analysis in many clinical situations unless PaCO 2 or acid-base state
is needed. It is cheaper, easier to perform, less painful and can be more accurate where the patient is
conscious (hyperventilation at the prospect of pain raises PaO2).
 Pulse oximetry allows accurate use of O2 and avoids wastage. For example, in patients with respiratory
failure, rather than limit the use of O2 to maintain hypoxic ventilatory drive, it can be adjusted to a
saturation of ~90% which is clinically acceptable.
 Neonatal care - the safety limits for oxygen saturations are higher and narrower (95-97%) compared to
those for adults.Pulse oximetry is not yet a standard of care in the screening of neonates for asymptomatic
congenital heart disease but may become so.It appears to be significantly more reliable than clinical
methods alone, as shown by recent studies.
 Intrapartum fetal monitoring - there has been some interest in the use of fetal pulse oximetry in
combination with routine cardiotocography (CTG) monitoring, although its use does not reduce the
operative delivery rate.
Pulse oximeters are now used routinely in critical care, anaesthesiology, and A&E departments, and are often
found in ambulances. They are an increasingly common part of a GP's kit.
Pulse oximetry's role in primary care may include:
 Diagnosing and managing a severe exacerbation of chronic obstructive pulmonary disease (COPD) in the
community.
 Grading the severity of an asthma attack. Where oxygen saturations are less than 92% in air, consider the
attack potentially life-threatening.
 Assessing severity and oxygen requirements for patients with community-acquired pneumonia.
 Assessing severity and determining management in infants with bronchiolitis.
32
General pointers to the management of hypoxaemia

Oxyhaemoglobin
Management
saturation
Measure regularly and especially at night. Review trends. Where value is
90-95%
unexpected, check signal quality and probe.
As above, continuous monitoring and give oxygen until saturations above
80-90%
90%.
<80% As above and consider ventilatory support
Using an oximeter:
 Resting readings should be taken for at least five minutes.
 Poor perfusion (due to cold or hypotension) is the main cause of an inadequate pulse wave. A sharp
waveform with a dicrotic notch indicates good perfusion whilst a sine wave-like waveform suggests poor
perfusion.
 If a finger probe is used, the hand should be rested on the chest at the level of the heart rather than the
affixed digit held in the air (as patients commonly do) in order to minimise motion artefact.
 Checking that the displayed heart rate correlates to a manually checked heart rate (within 5 beats per
minute) generally rules out significant motion artefact.
 Emitters and detectors must oppose one another and light should not reach the detector except through the
tissue. Ensure the digit is inserted fully into the probe and that flexible probes are attached correctly.
Appropriately sized probes should be used for children and infants.
 Oximeter accuracy should be checked by obtaining at least one simultaneous blood gas, although this
rarely happens. Oximeters may correct average oximeter bias based on pooled data but this does not
eliminate the possibility of larger individual biases.
Sources of error:
 Pulse oximetry cannot differentiate between different forms of haemoglobin. Carboxyhaemoglobin is
registered as 90% oxygenated haemoglobin and 10% desaturated haemoglobin, thereby causing an
overestimation of true saturation levels.
 Significant venous pulsation such as occurs in tricuspid incompetence and venous congestion.
 Environmental interference: vibration at 0.5-3.5 Hz, excessive movement and perhaps high level of
ambient light, including infrared heat lamps.
 Cold hands - warm extremity if local poor perfusion.
 Nail polish should be removed, as it may cause false readings.
 Intravascular dyes, such as methylthioninium chloride, may also temporarily falsely reduce saturation
readings.
Improving an oximeter signal:
 Warm and rub skin
 Apply a topical vasodilator - eg, glyceryl trinitrate (GTN) cream
33
 Try an alternative probe site

 Try a different probe
 Try a different machine
Shunt detection and calculations:

Oximetry is the most convenient and commonly used method for detecting and calculating left-to-right
shunts in the cardiac catheterization laboratory. To document the presence of the shunt and calculate its size,
venous and arterial access should be obtained. Oxygen saturation is measured in SVC, IVC, RA, RV, and PA
and compared with normal oxygen saturation values. If femoral vein access is used for right heart
catheterization, the small-diameter, 4-Fr short entry sheath is placed in the common femoral artery. The
peripheral arterial line can be utilized for systemic arterial oxygen saturation measurement when jugular or
subclavian veins are used as access sites for right heart catheterization. A “step-up” of mean O 2 blood
saturation from SVC to PA > 7% suggests presence of an intracardiac shunt. If a steady and consistent rise >
5% in mean oxygen saturation is noted at any point while moving the PA catheter from one cardiac chamber
to another, the presence of a shunt is highly suspected
Shunt detection:
A cardiac shunt is an abnormal blood flow in the circulatory system. Normally, pulmonary blood flow equals
systemic blood flow. A shunt can be right to left (from pulmonary circulation to systemic circulation), left to
right or bidirectional.
A intracardiac shunt can be detected and localized by using blood samples with measurement of the oxygen
saturation at different sites within and close to the heart, the so-called “oximetry run”. This run obtains blood
samples from all right-sided locations, including the SVC, IVC, right atrium, right ventricle, and pulmonary
artery. Figure below show an example of an oximetry run in patients with atrial en ventricular septal defects.
Figure:'Oximetry run' in a patient Figure: Oximetry run' in a patient with

with atrial septal defect. The 'step-up' ventricular septal defect. The 'step-up'
detected in the right atrium (RA) detected in the right ventricle (RV)
identifies a left-to-right shunt at this identifies a left-to-right shunt at this
location. location
34
A shunt can also be quantified. This is based on measurement of pulmonary (Qp in L/min) and systemic
cardiac output (Qs in L/min).
Qp (L/min) = oxygen consumption (mL/min) / pulmonary venous oxygen content ‒ pulmonary arterial
oxygen content (mL/L)
Qs (L/min) = oxygen consumption (mL/min)/ systemic arterial oxygen content ‒ mixed venous oxygen
content mL/L)
The shunt is then measured by the flow ratio Qp/Qs. A ratio < 1.5 indicates a small left to right shunt, and a
ratio of 1.5-2.0 a moderate-size shunt. A ratio of 2.0 or more indicates a large left to right shunt and generally
requires percutaneous or surgical repair to prevent pulmonary or RV complications. A flow ratio of less than
1.0 indicates a net right to left shunt
Formulae Flow calculations are based on the Fick principle as follows:
Flow = oxygen consumption (VO2 ) (proximal oxygen content) – (distal oxygen content) Oxygen content is
O2 carrying capacity multiplied by O2 saturation.
1. Calculate O2 carrying capacity as follows: O2capacity = Hgb × 1.36 × 10
2. Blood flow (Q) in L/min:
(a) Qpulmonic = VO2 /[O2capacity × (PVsat – PAsat)/100]
(b) Qsystemic = VO2 /[O2capacity × (Aosat – MVsat)/100]
(c) Effective fl ow is the amount of non-shunted fl ow carried from systemic to pulmonic capillary beds:
Qeffective = VO2 /[O2capacity × (PVsat – MVsat)/100]
3. Shunt volumes in L/min:
(a) Right-to-left shunt = Qsystemic – Qeffective
(b) Left-to-right shunt = Qpulmonic – Qeffective
4. Flow/shunt fractions:
(a) Qpulmonic/Qsystemic (Qp/Qs) = Aosat – MVsat PVsat – PAsat
Coronary angiography:
Angiography is an imaging test that uses X-rays to view your body’s blood vessels. The X-rays provided by
an angiography are called angiograms. This test is used to study narrow, blocked, enlarged, or malformed
arteries or veins in many parts of your body, including your brain, heart, abdomen, and legs.
A coronary angiogram is an X-ray of the arteries in the heart. This shows the extent and severity of any heart
disease, and can help you to figure out how well your heart is working.
35
What happens during coronary angiography?

To create the X-ray images, doctor will inject a liquid dye through a thin, flexible tube, called a catheter. The
doctor threads the catheter into the desired artery from an access point. The access point is usually in the arm
but it can also be in the groin.
The dye makes the blood flowing inside the blood vessels visible on an X-ray and shows any narrowed or
blocked area in the blood vessel. The dye is later eliminated from the body through kidneys and urine.
Risks involved with angiography and angioplasty
As with all medical procedures, there are both risks and benefits associated with having a coronary
angiography and angioplasty.
Minor complications may include:
 Bleeding under the skin at the wound site – this should improve after a few days,
 Bruising – it is common to have a bruise from the catheter for a few weeks
 Allergy to the contrast dye used, causing symptoms such as a rash.
More serious complications are uncommon, but may include:
 Damage to the artery in the arm or groin from the catheter, possibly affecting blood supply to the limb
 Heart attack
 Stroke
 Damage to the kidneys caused by the contrast dye
 Tissue damage caused by X-ray radiation if the procedure is prolonged
 Serious bleeding
 Death.
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UNIT-4
Learning Objective:
 Coronary angiographic catheters

 Use of the manifold
 Angiographic views in coronary angiography
 Laboratory preparation for coronary angiography
 Left Ventriculography – catheters, views, use of the injector
Coronary angiographic catheters

The angiographic catheter is a plastic tube which functions as a conduit for contrast, fluids, and pressure
measurement during cardiac catheterization of coronary arteries and the left ventricle.
Diagnostic Catheters:
1.Angiography
2.Pressure Monitoring
3.Oxygen saturation monitoring
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Ideal characteristics of a catheter:

Better torque control:
Increase outer diameter
Reinforced construction
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Pushability:
Increase outer diameter
Stiffer material
Decreasing overall part length
Flexibility:
Decrease outer diameter
Material with less modulus elasticity
Increasing overall part length
Trackability
Radio-opacity
Atraumatic-tip
Low-surface frictional resistance
Kink resistance
Parts:
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Wall thickness:
Thick Walled:
 Better pushability & torque transmission
 Accentuates pressure waveform-systolic overshoot & diastolic dips
Thin Walled:
 Improves monitoring,blood sampling and flushing abilities ,decrease thrombogenicity
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Disadvantage:
less torque control
Not suitable for high pressure injection
Catheter Materials:
Angiographic catheters made from synthetic & semi-synthetic polymers:
 Dacron
 Nylon
 PVC
 Ployethylene
 Fluropolymers(Teflon)
 Polyurethane
 Silicon
Radioopacity by incorporating Ba, Bi,Ir
Characteristics:
 Flexibility and Stifness
 Friction coefficient-Vascular trauma
 Thrombogenecity
 Tensile strength
 Moisture & drug absorption
 Mouldability
41
Tip & Hub:

Tapering Tip for diagnostic catheters
Hub:
Metal or plastic ,larger than catheter, tapered hubs easier insertion of guide wire.
Catheters for native coronaries:
42
43
Amplatz Catheter:
Use of the manifold:

It most frequently occurs as a result of improper flushing or aspiration of catheters used for vascular
procedures and the removal of the injection syringe attached to manifold for intracoronary medication
administration. Intracoronary nitroglycerin is commonly administered during a diagnostic cardiac
catheterization.
Angiographic views in coronary angiography:
Coronary Angiography is utilised to assess the level of stenosis that may be present within the coronary
arteries. By using catheter-injected dye and x-rays, the coronaries, collateral branches and foreign bodies
within them can be viewed in detail, and can allow practitioners to make a decision on how best to proceed
down a treatment pathway.
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In order to view the arteries sufficiently and assess the level of stenosis in greater detail, the x-ray images are
taken from a multitude of different angles.
In order to view the arteries sufficiently and assess the level of stenosis in greater detail, the x-ray images are
taken from a multitude of different angles.
Left Heart
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46
Right Heart
47
Camera Positioning
AP – The image intensifier sits over the patient, with the beam travelling from back to front
RAO – The image intensifier sits on the right of the patient
LAO – The image intensifier sits on the left of the patient

Laboratory preparation for coronary angiography:
A coronary angiography is a test to find out if you have a blockage in a coronary artery. Your doctor will be
concerned that you’re at risk of a heart attack if you have unstable angina, atypical chest pain, aortic stenosis,
or unexplained heart failure.
During the coronary angiography, a contrast dye will be injected into your arteries through a catheter (thin,
plastic tube), while your doctor watches how blood flows through your heart on an X-ray screen.
Preparing for a coronary angiography:
Doctors often use an MRI or a CT scan before a coronary angiography test, in an effort to pinpoint problems
with heart.
Patient should not eat or drink anything for eight hours before the angiography. Patients should also have
someone stay with them at night after the test because patients may feel dizzy or light-headed for the first 24
hours after the cardiac angiography.
48
At the hospital, patients will be asked to wear a hospital gown and to sign consent forms. The nurses will
take blood pressure, start an intravenous line and, if patient have diabetes, check blood sugar.
Left Ventriculography – catheters, views, use of the injector:
With the advancement of noninvasive imaging methods such as echocardiography, less emphasis has
recently been placed on the ventriculogram as part of a cardiac catheterization. However, entry into the left
ventricle with hemodynamic measurement and visualization of the left ventricle using contrast
ventriculography remains an important aspect of a complete angiographic study.
In patients presenting acutely with ST elevation myocardial infarction, assessment of myocardial and
valvular function with ventriculography may provide important prognostic information and may guide in part
the management of the patient. In obese patients with difficult echocardiographic windows, ventriculography
may provide diagnostic information that cannot be obtained from the echocardiogram.
Indications:
 Assessment of left ventricular function including left ventricular ejection fraction, wall motion
abnormalities, ventricular size and mass
 Identification and assessment of mitral regurgitation
 Identification and assessment of ventricular septal defects
Contraindications:
 Decompensated heart failure
 Extreme elevation of LVEDP
 Critical aortic stenosis
 Left ventricular thrombus
 Iodinated contrast allergy
Complication:
 Ventricular arrythmias
 Embolization of air or thrombus
 Contrast related complications
 Decompensated heart failure
 Myocardial staining
Technique:
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Crossing the Aortic Valve

 Crossing the aortic valve in patients without significant aortic stenosis is fairly straight-forward.
 Ventriculography is best performed with an angled pigtail catheter which avoids some of the pitfalls such
as myocardial staining and catheter movement which can occur with an end hole catheter.
 The angled pigtail catheter does not allow the measurement of precise pressure gradients (part of the
catheter may lie proximal and the other part distal to the stenosis or obstruction).
 The aortic valve may be difficult to cross with an angled pigtail catheter in patients with aortic stenosis.
Ventriculography in patients without aortic stenosis:
 To cross the valve in patients without stenosis, the 0.35 wire is left in the catheter slightly back from the
tip and the pigtail catheter is placed above the valve forming a ‘6’ above the valve and advanced until it
prolapses above the valve. Once a loop is formed above the valve with the prolapsed catheter, it is pulled
back and rotated slightly clockwise. As the catheter falls into the aortic root it is advanced. This
maneuver will usually facilitate entry into the left ventricle. Sometimes, the body of the catheter will
prolapse across the valve. If this happens, advancement of the 0.35 wire will usually prolapse the catheter
into the ventricle. Having the patient take a breath advancement of the pigtail into the ventricle during
systole will sometimes facilitate ventricular entry.
Ventriculography in patients with aortic stenosis:
 In patients with aortic stenosis crossing the aortic valve may be more difficult due to the profile of the
pigtail. Also, the 0.035 J-tipped wire often will not engage the stenosed orifice.
 In cases of suspected severe stenosis, crossing the aortic valve is best accomplished using a catheter able
to be directed toward the ostium such as an Amplatz Left-1 or an Amplatz Right-2. In this situation the
catheter is advances into the aortic root and an 0.035 or 0.038 wire with either a tight curve or straight
wire is advanced through the aortic orifice.
 Setting up to cross the valve is almost as important as crossing the valve itself. Before attempting to cross
with this system, cinematography of the calcified valve in both the RAO and LAO tomographic
projections will often give the operator clues in the direction and angulation of the orifice.
 Once proceeding, the catheter is placed in the root and the wire is advanced forward. As the catheter
rotates through the orifice the wire will prolapse in one of the cusp. Quarter turns of the catheter and
close attention to the direction of the wire will often allow the wire to cross the valve. Once the valve is
crossed, the catheter is advanced into the ventricle and hemodynamic measurements can be made.
 Crossing a stenosed aortic valve carries risk of embolization from both the valve and also from thrombus
organization on the wire while attempts are made. Due to this fact, crossing the valve should be reserved
for cases where noninvasive imaging of the valve has provided inconclusive results. Also, the patient
should be administered heparin (5000 U) and attempts to cross the valve should be limited to 3 minutes
before flushing the catheter.
Optimal Ventriculography:
 Unfortunately, unless biplane angiography is available, ventriculography only provides a 2-dimensional
projection of the ventricle and each image will not include all of the left ventricular segments.
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 The 2 standard views for ventriculography are the RAO (30°) which demonstrates the Anterior, Apical
and Inferior ventricular walls.
 A LAO 60°LAO 20° Cranial view allows for better imaging of the lateral and septal ventricular walls.
 The latter views are particular useful in patients with lateral ischemia (especially circumflex ischemia),
suspected VSD and mitral regurgitation.
 Once advanced into the left ventricle, the pigtail should be located in the mid ventricular cavity.
 Too superior or apical positioning of the catheter may lead to excessive ectopy. Ectopy may interfere
with interpretation of wall motion abnormalities.
 Too inferior of a position may interfere with the mitral apparatus leading to an overestimation of mitral
regurgitation.
 Difficult manipulation or visual tanglement of the catheter may indicate involvement with the apparatus.
 Reposition of the catheter usually requires countering and pulling the catheter then advancing once the
tip is free. A test injection of 5 cc of contrast medium may help to confirm correct positioning of the
catheter and prevent wasted contrast from a poor ventriculogram.
 All hemodynamic measurements should be performed prior to ventriculography.
 Also, ventriculography should be avoided in patients with decompensated heart failure, severe aortic
stenosis and ventricular thrombus.
 * If digital subtraction is available, a hand injection may be attempted with the patient holding their
breath. This should only be used as a quick estimation as important pathology such as a VSD may be
missed due to incomplete opacification with this method.
Settings
 Optimal ventriculography is performed using a power injector to fill the left ventricular cavity.
 Adjustable settings on the power injector include pressure and flow rates, volume, rate of pressure rise.
 Each patient will have slight variation in settings based on ventricular size, sex, and catheter type and
size.
 Generally, 10-15 ml/sec for 30-40 cc will be sufficient to image a normal ventricle and heart rate.
 A rate of rise of 0.4 cc/sec in order to prevent lunging of the catheter leading to increased ectopy.
 The pressure rate settings is typically 600 psi for a 6 Fr, 900 psi for a 5 Fr system and 1200 psi for a 4Fr
system.
 Careful attention is required to remove air from the injector system prior to use to prevent catastrophic
embolism during ventriculography.
Manipulation Technique:
The operator should keep the left hand on the catheter during injection to change the position as required
during the procedure. If the catheter is too far in the apex, pullback of 1-2 cm will usually reposition the
catheter for several beats to obtain useful information.
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CARDIAC CATHETERIZATION LABORATORY BASICS BVCCT-501

What is cardiac catheterization?

list of procedures performed in the Cath Lab:

Non-hydrophilic catheters vs hydrophilic catheters:

Catheter Cleaning And Packing:

Image Intensifier (I-I) Size:

1-Move: Height Adjustment

4-Move: Longitudinal Travel

5-Move: Lateral Travel

Mobile Image Intensifiers :

Intra Cardiac Pressures:

Fluid-filled catheters commonly produce several types of artifacts in recorded waveforms:

1. Air bubbles in the catheter system

Fig: A:Underdamped. B: Optimally damped. C: Overdamped.

Fig:Timing of the interatrial waveform with the electrocardiogram.

Arrhythmias may produce a variety of changes in intracardiac pressures:

Table:Normal Values for Intracardiac Pressure

Fluid filled catheters versus catheter tipped manometers:

Micromanometer Tipped Catheter:

Physiological Characteristics of Reflected wave;

pressure gradient and effective orifice area (EOA)

Double stick method:

Cardiac output determination:

Relationship of arteriovenous oxygen difference and cardiac index:

Cardiac Output Measurement:

VO2 = (FRO2 x VR) - (FMO2 x VM)

Cardiac Output Measurement:

 Thermo dilution method

• Fegler 1954 (CONSERVATION OF ENERGY)

LIMITATIONS TO THERMODILUTION CARDIAC OUTPUT:

General pointers to the management of hypoxaemia

 Try an alternative probe site

Shunt detection and calculations:

Figure:'Oximetry run' in a patient Figure: Oximetry run' in a patient with

What happens during coronary angiography?

 Coronary angiographic catheters

Coronary angiographic catheters

Ideal characteristics of a catheter:

Tip & Hub:

Catheters for native coronaries:

Use of the manifold:

RAO – The image intensifier sits on the right of the patient

LAO – The image intensifier sits on the left of the patient

Preparing for a coronary angiography:

Left Ventriculography – catheters, views, use of the injector:

Crossing the Aortic Valve

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