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73 Cards in this Set

  • Front
  • Back
ANATOMY: What are the Layers of the Heart from the inside out?
Endocardium (inner)
Myocardium (middle) - muscle that helps contract the heart
Epicardium (Pericardium) - double walled sac
ANATOMY:What are the 4 Chambers of the Heart? And what divides them?
Left Atrium
Left Ventricle
Right Atrium
Right Ventricle
Divided by the Septum
ANATOMY:What is the route that Blood Travels in the body?
SVC/IVC Coronary Sinus
Right Atrium
Tricuspid Valve
Right Ventricle
Pulmonary Semi-lunar Valve
Pulmonary Trunk (artery w/deoxygenated blood)
Lungs
Pulmonary Vein
Left Atrium
Bicuspid/Mitral Valve
Left Ventricle
Semi-lunar/Aortic Valve
Aorta to Systems
ANATOMY:What do Valves do? What are the Valves of the Heart and their locations?
Valves permit blood to flow in one direction
Tricuspid valve - 3 leaflets between Rt atrium & Rt ventricle
Mitral/Bicuspid Valve - 2 leaflets between Left Atrium & Left Ventricle
Pulmonic Valve - between RV & PA (3 leaflets)
Aortic Valve - between LV & Aorta (usually 3 leaflets)
ANATOMY:Coronary Arteries:
Right Coronary Artery Branches
What section does it feed?
Rises from coronary cusp of Aortic Valve & travels down right AV groove/sulcus on heart's posterior side
Conus Branch - feeds RVOT (where arrythmias originate)
SA Nodul artery - feeds SA node and Right Atrium
Divides into Rt Circumflex artery & Posterior Desc Artery
ANATOMY:Coronary Arteries:
Left Coronary Artery Branches
Two Main Branches & their branches
Left Anterior Descending Artery -diagonals
Left Circumflex Artery - Obtuse Marginals (OMs)
ANATOMY:Coronary Arteries: LAD & CIRC
Where do they rise from & feed?
Arise from posterior sinus, runs in the AV groove between the left atrial appendage & the main trunk of the pulmonary artery
Indications for Coronary Angiography
CAD, new onset, unstable angina, pre-op, positive ETT
MI - post infarct, Cardiomyopathy, CHD, Heart transplant pre-op, Valvular Heart disease, Aortic Dissection
Contraindications for Coronary Angiography
Uncontrolled CHF, HTN, arrhythmia, Fever of unknown origin, electrolyte imbalance, CVA within last month, patient unwilling, Medication toxicity, Pregnancy, Renal insufficiency, Hemorrhages
Cardiac Image Acquisition:
Radiographic Image of Left Heart Failure
Cardiac enlargement
Enlarged superior pulmonary veins
Diminished inferior pulmonary veins
Pleural effusions
Interstitial & Alveolar Edema
Cardiac Image Acquisition:
Radiographic Image of Right Heart Failure
Dilated SVC
Dilated Right Ventricle & Right Atrium
Widening of the Mediastinum
Elevated Right Hemi-diaphragm
ANATOMY:Where do the coronary arteries arise from?
Sinus of Valsalva
ANATOMY:What are the layers in the arteries?
Intima (inner layer) made up of endothelial cells
Media (middle layer) smooth muscle & collagen
Adventia (outer layer) smooth muscle & vasovasorium; arteriole network
Access Methods for Angiogram & types of closure devices
Access through Femoral, Brachial, Radial (Allen's test)
Closure pads, angio seal (collagen plug) perclose, suture sheath
Contrast Administration during Angiogram
Ample enough to substitute blood contained in coronary vessels
Too low - streaming
Too high - risk of coronary dissection resulting in myocardial blushing
Too long - patient at risk of bradycardia or myocardial blockade
Complications during an angiogram
Bleeding at puncture site
MI or death
Vascular injury: CVA, Hemmorrhage, emboli, dissection
Protamine reaction
Vasovagal attacks
Contrast reaction
Infection, CHF,
Cardiac puncture, cardiac tamponade
Severe arrhythmias: V-tach, V-Fib, A-Fib, SVT, Heart Block, Asystole, during angiogram
ANATOMY:Internal Mammary Angiography: LIMA & RIMA
Origin? Catheter used? Projection?
LIMA: originates anteriorly from the caudal wall of the subclavian artery distal to vertebral artery. JR4 or IMA catheter for better flow characteristics, less susceptible to atherosclerosis than saphenous veins.
RIMA: less common, crosses mediastinum, right subclavian below vertebral
ANATOMY:Saphenous Vein Graft Angiography: Location of grafts, catheters used, helpful hints
RCA bypass - located few cm above and anterior to RCA orifice. JR4, RCB (vertical take-off) Amplatz
LAD & diags - somewhat higher & to left. JL4, LCB, Amplatz
Obtuse marginals - usually highest & furthest left. JL4, LCB
Helpful to find grafts: Metallic markers or do Aortic Root contrast injection
Ventriculography
Left Ventricle with cine to determine ventricular function (wall motion & ejection fraction)
Helps determine:
septal defects, mitral regurg
Pigtail or closed-end catheter, 30˚RAO free from spine
Right Ventricle rarely done except for R to L shunting, pulm stenosis & eval pulmonary outflow, tricuspid regurg & rt ventricle dysplasia
Biopsy:
Indications, Complications & Bioptome Catheter
Endomyocardial biopsy, bioptome tip catheter to right ventricle septal wall, under fluoro or echo US
Indications: used to monitor transplant for infections
viral myocarditis
secondary cardiomyopathy
endocardial fibrosis
cardiac malignancies
Cardiotoxicity
Contraindications: Anatomic abnormalities, anticoagulation
Bioptome complications: conduction block, leaflet damage, tamponade from RV perf
Percutaneous Transluminal Coronary Angioplasty:PTCA What is it? Dilemma during intervention & prevention
PTCA is revascularization of coronary arteries.
Spasm of the artery may result in total occlusion therefore Nitroglycerin is given
To improve outcome:
Use Laser catheters, Atherectomy catheters or intracardiac stents
Percutaneous Transluminal Coronary Angioplasty:PTCA
Pre-procedure Work-up
ECG, ETT (exercise treadmill test), coronary angiography
Meds: antiplatelet aggregation - antithrombotics
Sublingual nifedipine or continuous drip nitro for spasm
Calcium channel blocker to help dilate smooth muscle
In order: nifedipine, diltizem, verapamil
Percutaneous Transluminal Coronary Angioplasty:PTCA
Procedure
Transluminal pressure during procedure
:manifolds/transducers, pressure tubing w/'y' connector (toughy), hemodynamic monitoring & recording
Larger sheath to accomodate equipment
Percutaneous Transluminal Coronary Angioplasty:PTCA
Guiding Catheters
Thinner wall - larger lumen: accomodates contrast & balloons, etc
'Y' connector (toughy) for balloon catheter & wire thru 1 port and contrast/flush/meds through other port
Percutaneous Transluminal Coronary Angioplasty:PTCA
Wires
.014 Wires
Used once guide is in aortic root
Stiffer wire for difficult stenosis or total occlusions
Softer wire for tortuous vessels
Percutaneous Transluminal Coronary Angioplasty:PTCA
Manipulating Catheters
"Backing out"
Catheter is injected from coronary orifice to provide support needed to advance the balloon across the lesion
Percutaneous Transluminal Coronary Angioplasty:PTCA
Manipulating Catheters
"Deep Throat"
To provide additional support when crossing a very tight stenosis, catheter goes further into vessel, used only in extreme cases to so avoid dissection
Percutaneous Transluminal Coronary Angioplasty:PTCA
Balloon Catheters
Inflated with Contrast (30%)
Watch patient for cardiac hemodynamic compromise (decrease in pressures, angina, arrhythmia)
Percutaneous Transluminal Coronary Angioplasty:PTCA
Outcome
Positive results include:
Good angiographic flow
Reduced pressures
No evidence of thrombus or residual ischemia
Percutaneous Transluminal Coronary Angioplasty:PTCA
Debulking: Transluminal extraction catheters
Thrombus sucked out through catheter (Angiojet or Aspiration Catheter)
Laser angioplasty: catheter with laser tip, pulsating beam of light vaporizes plaque
Directional atherectomy: high speed device on tip of catheter, like a sander to remove plaque (Roto-blader)
Percutaneous Transluminal Coronary Angioplasty:PTCA
Stent Placement
Scaffolding the artery wall from inside the lumen
- anticoagulation managed
Implantation
- distal stent placed first for multiple stents
Percutaneous Transluminal Coronary Angioplasty:PTCA
Thrombolysis
Mechanical: Angiojet & Aspiration catheters
Pharmacologic:
-Streptokinase, tenectplase (TPA) alleplase, releplase, urokinase
-given 6-12 hours onset of MI
- complications: bleeding, contraindications: stroke, hemorrhage, CVA < 1 yr, intercranial neoplasm, active bleeding, suspected aortic dissection
Pericardiocentesis: What is it? Indications. Risks.
The use of a needle to remove fluid from the pericardial sac which may be evaluated for diagnostic purposes. To evaluate pericardial effusion or tamponade.
Supplies: Needle, Wire, Catheter (could be left in place for hours as a drain)
Indication: Pericarditis, CHF, Cancer, Cardiac trauma
Risks: Puncture of myocardium or coronary artery, pneumopericardium (air in pericardium sac), MI, infection, needle induce arrhythmia, puncture of lung, liver stomach
Intra-Aortic Balloon Counterpulsation (IABP)
Access point, Balloon prep
Body placement
Primary goal
Inflations & Deflations
Puncture 2 cm below inguinal line, negative vacuum on balloon
Placed in descending aorta with the tip distal to aortic arch (below origin of the left subclavian artery) and above renal arteries
Primary goal: to increase myocardial oxygen supply & decrease myocardial oxygen demand
Secondary goal: to improve CO, EF, increase coronary perfusion pressure & systemic perfusion, lower HR and PCWP
Inflation with onset of diastole (t-wave dicrotic notch), deflation just prior to onset of systole (r-wave)
Helium used due to low molecular weight (minimizes shuttle time & thus increases efficiency)
Intra-Aortic Balloon Counterpulsation (IABP)
Indications
Indications: Refractory unstable angina, cardiogenic shock, hemodynamic compromise, high risk PTCA, V-tach because of myocardial ischemia
Left Main or 3 vessel disease, going to surgery
Acute MI with mechanical impairment (mitral regurg)
Left Ventricular failure
Intra-Aortic Balloon Counterpulsation (IABP)
Contraindications
Aortic dissection or aneurysm
severe aortic valvular insufficiency
sepsis
bleeding diathesis
femoral-iliac abnormalities / bypass grafts
Removal of Foreign Bodies
Types of objects and devices
Dislodged stents, catheter breakage
Snare loop retrieval (safest)
Basket retrieval device
Forceps retrieval device
Goose neck snare (surgical)
Hemodynamics: Ejection Fraction
EF = SV (Stroke Volume) / EDV (End Diastolic Volume)

The % of the EDV that is ejected during systole

Above 55% is normal
40-55% is moderately impaired
30-40% seriously impaired
below 30% gravely impaired
*Averaging 65% as 'normal'
Hemodynamics: Stroke Volume
SV = EDV (End Diastolic Volume) - ESV (End Systole Volume)

Volume in mL ejected during contraction
Hemodynamics: Cardiac Output
Calculation, What is it? How is it measured? CI?
CO = SV (stroke volume) X HR (heart rate)
Normal range is 4-8 L/min
The amount of blood the left ventricle pumps into the aorta, an accurate indicator of cardiac function
CI (cardiac index) provides a comparison between individuals' cardiac function regardless of their body size.
Hemodynamics : Cardiac Output Measurements
Fick Method
Oxygen consumption method

CO = oxygen consumption/[10 (CaO2 - CvO2)]
CaO2 = arterial oxygen content
CvO2 = venous content
Percutaneous Equipment: Diagnostic Catheters
What do they do? Types of Catheters
Catheters deliver contrast, embolizing material, meds and instruments
Types include:
End Hole: stronger stream of contrast, selective
Side Hole: greater contrast delivery, less recoil, used for aorta, vena cava, LV
Balloon tip: angioplasty
Tapered or Nontapered
Percutaneous Equipment: Diagnostic Catheters
Sizes, Shapes
Sizes: measured in French (3-12F) outer diameter
-increments of .33 or 1/3 mm
Shapes: various shapes for various uses
Percutaneous Equipment: Diagnostic Catheters Materials
Radiolucent: to view bubbles
Radiopaque: to visualize with fluoro
Percutaneous Equipment: Interventional Guiding Catheters
Thinner wall and larger lumen to allow contrast injection with balloon in place
Percutaneous Equipment: Diagnostic Guidewires
What are they made of?
Stainless steel core with stainless steel wrapping, coated with Teflon. Has rigid proximal end with somewhat flexible distal tip to prevent vessel wall damage
Percutaneous Equipment: Diagnostic Guidewires
Types of coating on wires
Diameters
Types of cores:
Teflon, polyurethane, polyethylene, hydrophilic (glidewires)
Diameters: .014-.045"
Cores:
-Fixed: for sclerotic vessels
-Moveable: core moved with use of handle (madril) to length of tip (allows flexibility, increases maneuverability in vessel, 10-15cm moveable core tip)
Percutaneous Equipment: Diagnostic Guide wires
Sizing factors
inner diameter of catheter
vessel size
needle gauge
*Wire small enough to permit blood to flow in the vessel yet large enough to prevent back flow
*Keep wire taught & within sterile field!
Percutaneous Equipment: Interventional Guide wires
Types of Steerable Coronary Guide wires
Stiffer wire: crossing difficult stenosis, total occlusions
Softer wire: safer for tortuous vessels
Percutaneous Equipment: Needles
one-piece or single wall needle
2 piece or double wall (Seldinger, Modified Potts)
3 piece or sheath needles
-Cannula, Stylet, sheath (Amplatz, Potts-Courand, Becton Dickinson or translumbar needle)
Bevel up! - not to sheer wire!
Intravascular Devices: Intravascular Ultrasound (IVUS)
what does it do?
Measures lumen size & true vessel size & lesion length
Helps choose proper therapy & determine optimal revascularization
Give 2 dimensional eval of lumen, inside out, 360˚ view
Determines vessel size, superficial calcium deposits, small artery wall tears (dissections), guide for complete stent deployment
Intravascular Devices: Fractional Flow Reserve (FFR)
Pressure wires
What does it do?
How does it work?
maximum blood flow to the myocardium achieved in the presence of narrowing compared with the maximum blood flow possible in the theoretical absence of the narrowing
*Compares the coronary pressure prior to the lesion to the pressure distal to the lesion
Wire has microsensor 3cm from tip
Measures pressure as well as temperature
-injection of saline at tip of guiding cath for temp meas & IV injection of adenosine for pressure measures
Intravascular Devices: FFR Measurements
Pa = aortic pressure at guiding catheter
Pd = distal coronary pressure near tip of wire
FFR = ratio Pd/Pa at maximum hyperemia
Therapeutic Devices: Balloons
Over-the-wire
Central lumen for guidewire
Separate lumen for balloon inflation
Advantages: more flexible, trackable nature, distal wire position, multiple guide wires, distal port
Disadvantages: 2 people needed, larger profile
Therapeutic Devices: Balloons
Rapid Exchange (Singel Operator Exchange) Monorail
To improve the ease of exchanging, single operator, guidewire exiting about 30cm from the tip
Advantages: distal wire position, enhanced visualization, lower profile, single operator, stiffer for more pushability.
Disadvantages: need excellent guiding catheter support, poor tracking if not flushed
Therapeutic Devices: Balloons
Fixed Wire
serves as its own guide wire, balloon mounted on steerable wire
Advantages: enhanced visualization, single operator, flexible, best for access to distal lesions, use with small guiding catheter, low profile
Disadvantages: no through lumen, need to recross lesion with each removal
Therapeutic Devices: Balloons
Perfusion Balloons
enables blood to perfuse across a stenosed area into the distal coronary artery when the balloon is inflated.
'bail-out' balloon for spontaneous closure (not used commonly now due to modern thrombolytics & class IIb/IIIa agents
Therapeutic Devices: Balloons
Compliant
Early-generation made of polymers like polyester, were stiffer & larger than today's.
Then made polymer hybrid called polyolefin copolymer, which came to be called 'compliant' balloons.
They are responsive to balloon inflation pressures, increasing in diameter with each Atm applied.
They are soft flexibilty & trackability over high degree, tortuous coronary lesions. Shape to the artery as they are inflated. They may 'dog bone' which increases risk of dissection or intimal disruption
Therapeutic Devices: Balloons
Non-compliant (NC)
Polyethyleneterphthalate (PET) balloons suited for long-inflation angioplasty & coronary stenting.
Holds across the length of the balloon, minimizing 'dog bone' effect.
Ideal for unstable and calcified lesions
Used for post-stent placement
They are less able to pass through tortuous anatomy, but becoming less of an issue over time with lower profile
Therapeutic Devices: Balloons
Cutting Balloons
Razor-sharp microtome blades imbedded on a hard polymer inflation balloon
As the balloon is inflated, blades are exposed and pushed out , creating microsurgical incisions into both hard and softer plaque areas
Valuable for PTCA of smaller diameter vessels and bifurcation side branches.
In combination with brachytherapy, favored approach for the tx of in-stent restenosis.
Therapeutic Devices: Stents
History
March 28, 1986, in Toulouse France, the first coronary stent was placed in a human for the first time (first one experimented in dogs)
Wallstent; self-expanding mesh stent
Therapeutic Devices: Stents
Indications
**Reduce vascular recoil, tack up intimal dissections, and increase vessel lumen diameter.
PTCA for acute infarction
Restnotic lesions
CTO
Sub-optimal results after PTCA
Saphenous vein graft disease
Primary reduction in restenosis in non-restenotic focal lesions, in 3mm vessels
Tx of abrupt, & prevention of threatened, coronary occlusions after balloon angioplasty
Therapeutic Devices: Stents
Self-expanding
prototype is the Wallstent
Woven-wire mesh that is fused together to form a mesh tube of a specific size.
Gives very good coverage, but does tend to block off side-branches (so good for SVGs or RCA)
High rate of stent thrombosis & restenosis
Poor radial strength
Used currently more often in SVGs, peripheral vascular disease in the iliacs and femoral vessels & carotid stenting
Therapeutic Devices: Stents
Balloon-expandable
Mounted on a PTCA delivery balloon & deployed in the vessel at the recommended inflation pressure
2 design types: coiled wire and slotted tube
Made of surgical stainless steel, newer stents of cobalt chromium alloy, which allows struts to be made thinner, increasing flexibility
Therapeutic Devices: Stents
Balloon-expandable (Coiled Wire Design)
stainless steel into a coil pattern
flexibility and radial support
Some made up of a # of coils welded together
Not used today
Therapeutic Devices: Stents
Balloon-expandable (Slotted Tube Design)
Palmaz-Schatz stent first with a slotted tube design
Cut with a laser, made of stainless steel or cobalt chromium
Offers superior radial strength over other stent designs
Therapeutic Devices: Stents
Drug-Eluting Stents (DES)
-The 3 elements & original drug types
Made up of 3 elements:
the stent, the drug, and the polymer that binds the drug to the stent
'Sirolimus' a cytostatic agent stops cellular proliferation just prior to this checkpoint, allowing viable cells to return to a resting state. Another drug called 'Paclitaxel' used in Taxus
Therapeutic Devices: Stents
Drug-Eluting Stents (DES)
If pre-dilating, choose balloon shorter in length than the DES to be deployed to avoid trauma/dissection outside the stent
Stent reach from 'normal vessel to normal vessel'
Post-dilating should be NC, shorter than stent and .25-.5mm larger than deployed DES, to ensure complete apposition to the vessel wall
Therapeutic Devices: Stents
Other Stent Types: AMS
Bioabsorbable Stents (AMS) - gradually disappears within the vessel, yet the lumen area is consistently larger compared to vessels treated with conventional stents. First one done in 2003 in Belgium below the knee
Therapeutic Devices: Stents
Other Stent Types: Bioengineered Endothelialization
Stent has a biologically activated coating designed to attract endothelial progenitor cells (EPCs), they are captured by the coating and encapsulation begins within one hour after implantation.
This rapid endothelialization eliminates the risk of acute thrombosis & may reduce the need for antiplatelet therapies
Therapeutic Devices: Stents
Other Stent Types: Side-branch/Bifurcation Stents
Stents wherein the middle section has less struts or a larger open cell, to place over side-branches.
Bifurcation stents, 'y' shaped stent mounted on 2 balloons, which are expanded simultaneously.
Therapeutic Devices: Stents
Other Stent Types: Covered Stents (Stent Grafts)
Stents covered with a mesh that becomes semi-impermeable when it is exposed to blood, but porous enough to allow endothelialization.
Such as in AAA.
Therapeutic Devices: Atherectomy
Non-surgical procedure to remove plaque