Cardiac Cath Lab Basics

Continue Continue Continue Continue Continue Continue Continue Continue Continue Continue Continue Continue Continue Cath Lab Basics Objective One Objective Two Identify the two primary components of a cardiac catheterization lab Identify key cardiac pathologies seen in cath lab cases Summarize radial and femoral artery access techniques Outline cath lab workflow steps 1 4 3 2 Cardiac Cath Lab Basics Online Training Objectives Welcome to Cardiac Cath lab basics online training.... The following four objectives will be covered in this training.... Identify the two primary components, of a cardiac catheterization laboratory....., Explain the role of the recording system, in providing real-time patient data, during cardiac catheterization procedures....., Describe the workflow, and interaction between cath lab staff, and the recording system..... Recognize the importance, of accurate data recording, and monitoring in the cath lab, for effective diagnosis and intervention.... ? Cath lab components A medical equipment with a monitor AI-generated content may be incorrect. A few doctors looking at a computer screen AI-generated content may be incorrect. Components There are two components that make up the cath lab. They are the x-ray system and the recording system. The x-ray system is used to document the cardiac catheterization study by acquiring images of the coronary arteries. The recording system documents the case for medical records and reporting. The recording system provides real time patient data such as EKG waveforms, heart rate, oxygen levels, and blood pressure. ? Cath lab types Adult Cath lab Diagnostic Interventional Electrophysiology (EP)lab Cardiac electrical pathways Cardiac conduction system Pediatric Cath lab Diagnostic > Heart function & structures Interventional Adult Cath lab There are several different cath lab types. In the adult cath lab, diagnostic and interventional angiography studies are done. In the pediatric cath lab, diagnostic procedure to evaluate heart function and structures along with interventional angiography studies are done. The other type of cardiac lab is an EP or electrophysiology lab. In the EP lab, the hearts electrical pathways and conduction system are studied ? Cath lab types Adult Cath lab Diagnostic Interventional Electrophysiology (EP)lab Cardiac electrical pathways Cardiac conduction system Pediatric Cath lab Diagnostic > Heart function & structures Interventional Pediatric cath lab There are several different cath lab types. In the adult cath lab, diagnostic and interventional angiography studies are done. In the pediatric cath lab, diagnostic procedure to evaluate heart function and structures along with interventional angiography studies are done. The other type of cardiac lab is an EP or electrophysiology lab. In the EP lab, the hearts electrical pathways and conduction system are studied ? Cath lab types Adult Cath lab Diagnostic Interventional Electrophysiology (EP)lab Cardiac electrical pathways Cardiac conduction system Pediatric Cath lab Diagnostic > Heart function & structures Interventional EP Lab There are several different cath lab types. In the adult cath lab, diagnostic and interventional angiography studies are done. In the pediatric cath lab, diagnostic procedure to evaluate heart function and structures along with interventional angiography studies are done. The other type of cardiac lab is an EP or electrophysiology lab. In the EP lab, the hearts electrical pathways and conduction system are studied ? Adult cath lab Reasons for investigation Acquired heart defects Investigated Objects Coronaries (stenosis) Chambers (wall motion) Valves (stenosis, insufficiency) Big arteries (aneurysm) Adult Cath Lab In the adult cath lab, the patient is being investigated for acquired heart defects. Blood flow in the coronary arteries is checked and blood flow and blood pressure in the chambers of the heart is evaluated. The heart is investigated to determine if there are defects in the way that the wall of the heart moves. Heart valve function is checked for stenosis or insufficiency. Aneurysms can also be seen in a heart cath study.In the adult cath lab, the patient is being investigated for acquired heart defects. Blood flow in the coronary arteries is checked and blood flow and blood pressure in the chambers of the heart is evaluated. The heart is investigated to determine if there are defects in the way that the wall of the heart moves. Heart valve function is checked for stenosis or insufficiency. Aneurysms can also be seen in a heart cath study. ? Pediatric cath lab Reasons for investigation Congenital heart defects Investigated Objects Septal defects - ASD/VSD Valves - Stenosis, insufficiency Big arteries – Transposition Lung vessels - Stenosis Pediatric Cath Lab The pediatric cath lab patient is being evaluated for congenital heart abnormalities. The heart’s septum is being examined for possible defects like atrial septal defect or ventricular septal defect. Additionally, the function of the valves is assessed for insufficiency or stenosis. The procedure may also investigate abnormal connections between the major arteries or narrowing of the pulmonary vessels. ? Electrophysiology study (EP) Reasons for investigation Arrhythmias Investigated Objects Tachycardia Bradycardia Electrophysiology study (EP) In the EP or electrophysiology lab the patient is being evaluated for an arrythmia, commonly know as an abnormal heart rhythm. Tachycardia is a heart rhythm that is too rapid and interferes with the flow of oxygenated blood throughout the body. Bradycardia is a heart rhythm that is too slow. Pacemaker and ICD implants are also completed in the EP lab. ? Right Heart Angiography Reasons for investigation Heart problems Investigated Objects Cardiac output Right heart Right-heart angiography is performed to detect abnormalities in blood flow through the right side of the heart. Right heart vetriculography is a study of the right chambers (atrium and ventricle) of the heart. This test is used to obtain measurements of pressure, oxygen, and cardiac output through a catheter. The cardiac output of the heart is evaluated to determine the effectiveness of the heart function ? Pathology, anatomy, & physiology There are several congenital heart defects that are evaluated in the cath lab. Select the circles on the left to learn more about these defects. Pathology, anatomy, physiology There are several congenital heart defects that are evaluated in the cath lab.Hover over each marker to learn more about these… The first congenital defect is called Atrial Septal Defect (ASD). In this condition, there is a hole between the two upper chambers of the heart. Although blood from the left atrium flows into the right atrium through this defect, there may be few, if any, symptoms of this condition in infants and children, except for a possible heart murmur, which is an abnormal sound heard through the stethoscope when listening to the heart. The second congenital defect is called Ventricular Septal Defect (VSD). In this condition, a hole occurs between the two lower chambers of the heart. Because of this hole, blood from the left ventricle flows back into the right ventricle, due to higher pressure in the left ventricle. This causes an extra volume of blood to be pumped into the lungs by the right ventricle, which can create congestion in the lungs. Transposition is another congenital heart defect where the heart is on the right side, instead of the normal left side.Transposition of the great vessels: In this condition, the outflow tracts of the aorta and the pulmonary artery are switched during fetal development. This means that deoxygenated blood flows out to the body through the pulmonary artery and oxygenated blood flows back into the lungs through the aorta. By itself, this condition cannot sustain life after birth. However, there are usually accompanying defects that permit some oxygenated blood to get out to the body tissues. Patent ductus arteriosus (PDA) is the last congenital defect we will discuss. In the fetus, a connection occurs naturally between the pulmonary artery and the aorta. However, shortly after birth, this connection closes on its own. Sometimes, the hole does not close, which means that oxygenated blood from the aorta returns back to the lungs through the pulmonary artery, causing congestion in the lungs, increased workload on the heart, and may lead to an enlarged heart. Patent Ductus Arteriosus (PDA) In the fetus with PDA, a connection occurs between the pulmonary artery and the aorta which does not close shortly after birth. This can lead to pulmonary congestion and an increased workload for the heart. Transposition The outflow tracts of the aorta and the pulmonary artery are switched during fetal development. Oxygenated blood flows out to the body through the pulmonary artery and oxygenated blood flows back into the lungs through the aorta. Ventricular septal defect (VSD) An ventricular septal defect (VSD) is a hole between the heart’s lower chambers. The heart problem is present at birth. It is a type of congential heart defect. Atrial septal defect (ASD) An atrial septal defect (ASD) is a hole between the heart’s upper chambers. The heart problem is present at birth. It is a type of congential heart defect. ? Circulatory system anatomy Arteries High pressure vessels Veins Low pressure vessels Circulatory system The circulatory system is made up of the arteries and veins. The arteries are high pressure vessels that carry blood away from the heart. Veins are low pressure vessels that return blood to the heart. ? Heart anatomy Heart Anatomy, Function, and Blood Circulation https://www.webmd.com/heart-disease/high-cholesterol-healthy-heart Heart anatomy This is a diagram of the right side of the heart. The superior vena cava or SVC is shown here, where it empties into the right atrium. The Tricuspid valve is shown here between the right ventricle and right atrium. The left side of the heart is displayed here. Notice that the pulmonary veins are emptying into the left atrium. The mitral valve is displayed separating the left atrium and the left ventricle. The thick wall of the left ventricle is evident in this image as well. ? Atrio-ventricular valves Select the markers to learn more about the valves of the heart. Mitral valve The mitral valve separates the left atrium and the left ventricle. Tricuspid valve The tricuspid valve separates the right atrium and the right ventricle. Pulmonary valve The pulmonary valve separates the right ventricle and the pulmonary arteries. Aortic valve The aortic valve separates the left ventricle and the aorta. The blood flowing from here is oxygenated. Markers Select the markers on the left to learn more about the valves of the heart. The atrio-ventricular valves are displayed here. The tricuspid valve separates the right atrium and the right ventricle. The mitral valve separates the left atrium and the left ventricle Aortic valve disease examples Aortic valve disease examples Here are some examples of aortic valve disease. A normal valve is displayed in lower portions of the diagram. In diastole, the valve is completely closed and in systole the valve is fully opened. The upper left example is a stenotic valve. In systole, the valve does not open entirely. Aortic regurgitation is displayed in the upper right example. The leaflets do not close properly, allowing blood to leak back into the left ventricle. ? Components of the heart How the Normal Heart Works | Children's Hospital of Philadelphia https://www.chop.edu/centers-programs/cardiac-center/how-normal-heart-works Components of the heart The four chambers of the heart are the right atrium, right ventricle, left atrium, and left ventricle, separated by a muscular wall called the septum. The septum is further divided into the interatrial septum between the atria and the interventricular septum between the ventricles. The right atrium (RA) and right ventricle (RV) belong to the low pressure part of the heart, the right heart. The left atrium (LA and left ventricle (LV) make the left heart. The wall around the atriums is thin, as is the inner wall between the two chambers. As a congenital disease you find holes in this septum called atrial septum defect or ASD for short. The wall between the ventricles is thicker, especially around the left ventricle, because ventricles must generate higher pressure to pump blood throughout the body. The right ventricle wall is is about 1/3 thinner than the left ventricle wall because it operates under lower pressure, supplying the pulmonary system. Typical pressure values for the chamber are RA is 4m mHG, RV during pressure phase is 25 -30 mmHG, LA is approximately 10 mmHG, and LV during pressure phase is up to 140 mmHG. ? Surface anatomy of the heart Inferior Vena Cava (IVC) Superior Vena Cava (SVC) Aorta Right Coronary Artery Left Coronary Artery Surface anatomy of the heart Now we have a look on the surface of the heart, and the big vessels we see are the Superior and Inferior Vena Cava which lead blood with poor oxygen saturation from the upper and lower part of the body first to the right atrium, then to the right ventricle. The other big vessel we see is the Aorta, which originates from the left ventricle, where a two cusped valve takes care that during the resting phase of the left ventricle no blood may flow back. The two coronary vessels arise from the aorta. These coronaries supply the heart and its muscle cells with nourishment. Due to the direction they run they are called right and left coronary artery - RCA and LCA. The left coronary artery splits into two main branches. One, the LAD, the left anterior descending, runs along the intraventricular wall. The circumflex, or CX, runs to the rear side. ? Coronary stenosis & thrombus Coronary stenosis can be caused by atherosclerosis or thrombus. Atherosclerosis can be caused by: Poor nutrition Smoking Physical inactivity Obesity Family history Disease Thrombus can be caused by: Atrial fibrillation Heart Valve Replacement Heart attack Coronary stenosis & thrombus Coronary stenosis can be caused by atherosclerosis or thrombus. Atherosclerosis is the buildup of plaque (fat, cholesterol, and other substances) in the coronary arteries. Atherosclerosis can be caused by poor nutrition, smoking, physical inactivity, obesity, family history, or disease. Thrombus are blood clots that accumulate inside the vessel lumen. In a small vessel, blood flow may be completely blocked by thrombus. Thrombus can be caused by Atrial fibrillations, heart valve replacement or a heart attack. ? Cardiac conduction pathways A diagram of a heart AI-generated content may be incorrect. c Cardiac conduction pathways Inside the heart at certain points and along certain pathways, the electrical stimulation for the contraction of the muscle cells is guided. We see the Sinus node here, which, stimulated by itself, sends the first impulse for the rest of the heart. It does this normally, very regularly, about 70 times a minute. This electrical signal is led along the wall of the atria, which is what causes them to contract. Later on when all the physiological mechanisms have taken place, everything is set back to its normal state, and the atrial muscle cells are in the so-called refractory time. At this time the electrical stimulation has pathed the atrial level through one special gate, the HIS bundle, to the ventricular level. It runs along special fibres at the intraventricular wall until it has reached the apex. From here the ventricular muscle cells are stimulated, thus the ventricle contracts. During the refractory time of the ventricles the next electrical impulse is generated in the sinus node and the game goes on. Due to malfohrmation during the fetal phase or due to infarction, inflammation, operation, or stress the regular creation of electrical stimuli or the regular contraction of the heart cells is out of order. The patient suffers from arrythmias, which may be harmless like single extrasystoles, or be as severe as a condition causing death. ? Workflow Cath lab workflow Patient Data Registration Patient Positioning Electrode placement Cleaning of puncture site with antiseptic solution Adjustment and balancing of pressure transducer Sheath placement Catheter introduction and positioning Coronary angiograms LV angiogram Oxygen measurement Pressure measurement Image review, archiving and reporting Cath lab workflow The typical workflow in the cath lab is outlined as follows. The first step is to register the patient. The patient is positioned on the table in the head first supine position. Next, the electrodes are placed. The puncture site is cleaned with an antiseptic solution. The pressure transducer is adjusted and balanced. A sheath is placed for access. The appropriate catheter is introduced and positioned. Angiograms of coronaries is completed. If needed a left ventricular angiogram is done to evaluate the pumping function of the left ventricle. Oxygen and pressure measurements are obtained. After image review, a report is generated and the images are archived. The workflow for an interventional cardiac catheterization is similar to the diagnostic study with only a couple of minor differences. After the coronary angiogram, quantitative analysis is done. The vessel is evaluated and if stenosis is detected, the vessel is stretched with a balloon catheter. This is also called percutaneous transluminal coronary angioplasty. After the PTCA, a stent is placed to stabilize the vessel wall. Workflow Interventional cardiac cath workflow Patient Data Registration Patient Positioning Electrode placement Cleaning of puncture site with antiseptic solution Adjustment and balancing of pressure transducer Sheath placement Catheter introduction and positioning Coronary angiograms Quantitative Coronary Analysis Percutaneous Transluminal Coronary Angioplasty (PTCA) Stent placement Image review, archiving and reporting Interventional workflow Patient registration & positioning Registration Via HIS/RIS Via Sensis Manual registration Patient Positioning Isocentric Manually Via preprogrammed positions Patient registration & positioning There are several ways to register a patient. The patient can be registered from the scheduler or HIS/RIS. HIS is a hospital information system that handles patient care management across the healthcare system. RIS is a Radiology information system that handles the patient care management of the imaging department. The patient can also be registered via Sensis, the hemodynamic monitoring and recording system. Manual. Registration can also be completed on the x-ray system. Once the patient is registered, they will be positioned for the procedure. The patient will be positioned with the heart in the isocenter or positioned during the procedure manually. There are pre-programmed positions that can be used to position the patient also. ? Positioning for hemodynamic signals Positioning for hemodynamic signals Now let's focus on how the patient has to be prepared to get hemodynamic signals. First of all the ECG electrodes are fixed onto the patient's body. The signal received is a so-called surface ECG, which is an accumulation of the intracardiac electrical signals as they run through the heart's muscle cells over time. Typical fixing points for these electrodes are the extremities, with the right leg as neutral conductor. According to the different combinations, e.g. right arm to left arm, right arm to left leg, left arm to left leg, you get the first three leads, called Einthoven's leads. Another method for extremity ECG was introduced by Goldberger. On a six leads ECG protocol these leads are always displayed as the next following three, called aVR, aVL, and aVF, what stands for augmented voltage right, augmented voltage left, augmented voltage foot. In contrast to Einthoven always one electrode is measured in comparison to the combination of the other two. The third method, measuring the surface ECG along the thorax, can not be used during catheterization, due to overlay of relevant structures by the electrodes. There are also radiolucent electrodes, which tend to be more expensive, and because a catheterization is more of a survey, the extremity leads are sufficient. Pressure measurement system To prepare the pressure measurement system a special device which transforms a pressure wave into electrical signals has to be positioned to a certain level and balanced, i.e., normalized to atmospheric pressure. Pressure measurement system To prepare the pressure measurement system a special device which transforms a pressure wave into electrical signals has to be positioned to a certain level and balanced, i.e. normalized to atmospheric pressure. The level is that of the patient's right atrium, because here the circulatory pressure is almost 0. Then a three valve manifold which is connected to the pressure membrane of that measurement device is opened to let the air pressure of the lab come to the membrane. In this situation the whole system is balanced, the display must show the zero line now. Later on the measurement device is connected to the catheter, and the three valve manifold is opened to only let the pressure wave of the blood come through. The display will then show the up and down of pressure curves according to where the catheter tip is lying. ? Accessing the coronary system There are different ways to access the coronary system. The earliest one used was the Sones Technique. Select the colored zones on the left to learn more about the types of access used in today's cath lab. Brachial Radial Right & Left Femoral Accessing the coronary system There are different ways to access the coronary system. The earliest one used was the Sones technique. The brachial vein, artery, sometimes both - depending on what side of the heart being examined- is opened surgically, and the catheter is introduced. As the vessels here are rather small, big catheters with a diameter of almost 3 mm - 8French- which were used at that time, caused many problems. Radial artery access is a common access method for cardiac catheterization that involves inserting a catheter through the radial artery in the wrist. This technique is favored over traditional femoral access because it is associated with lower rates of bleeding and vascular complications, easier patient recovery, and less discomfort. Prior to accessing the radial artery, Allen's test can be helpful for evaluating patency of ulnar artery circulation. To perform this test, the patient's radial and ulnar arteries are compressed and then the patient is asked to make a tight fist with that hand. This compresses the blood from the hand and blanches the palm. The ulnar artery is then released, and the time it takes for the hand to return to a normal color is measured. Typically, the test is considered “positive” or “normal” when the time to return of normal color is 5 or 6 seconds. The femoral artery can be accessed percutaneously, without a surgical cutdown. Due to the size of the femoral artery and the pressure which is palpable, this puncture method is a favorable access method. The common femoral artery is the most direct continuation of the aorta, making it large enough to accommodate the catheters used for cardiac artery and Left Ventricular cannulization. Femoral access Another common access site is via the femoral artery. The femoral artery provides an access site with larger vessels that can usually be palpable. Radial access Radial artery access is a common access method for cardiac catheterization that involves inserting a catheter through the radial artery in the wrist. ? Seldinger access technique Skin puncture until bloodflow. Threading of a guidewire into the vessel. Removal of the needle. Tracking of arterial sheath. Tracking of internal dilator. Removal of guidewire and dilator. Seldinger access technique To facilitate this procedure, a special puncture method came in use. After needle puncture of the vessel, at first introduces a wire, which then keeps the access to the vessel for the coming device. The needle is torn back. A device called a sheath is pushed over the wire, and now when the wire is torn back, the sheath retains easy access when a catheter has to be exchanged. Seldinger Technique & Modified Seldinger Technique; https://www.youtube.com/watch?v=aXOtUv4BnpM ? Judkins catheters A blue and green curved object with red arrows AI-generated content may be incorrect. A chart of different types of curved objects AI-generated content may be incorrect. v Judkins catheters The Judkins catheters are reshaped for easy access of the right or left coronary ostium. The Judkins catheters are composed of a primary and secondary curve. The primary curve enables the catheter to engage in the coronary ostium. The secondary curve is designed to maintain the catheter stability by reaching the opposite side of the aorta. This distance and whether it is used for the right or left coronary specifies the label of the catheter, for example JL3.5 or JR4. The number represents the length from the primary to the secondary curve. The catheter used for LV angiograms is called a pigtail catheter, due to its shaped tip. A straight catheter with only one end hole could cause harm to the inner wall of the ventricle with the contrast media is injected. With the pigtail shape, injury is avoided and all over distribution of the contrast media is increased. ? Oxygen measurements & saturation Oxygen measurements are done during the procedure to determine a shunt and to check the cardiac output. The consequence of a shunt may be overload of the ventricular muscle or undernourishment of the body. Oxygen methods & saturation Oxygen measurements are done during the procedure to determine a shunt and to check the cardiac output. The cardiac output can be estimated by dividing oxygen consumption by the difference in oxygen content between arterial and venous blood. The difference between the arterial and mixed venous blood oxygen concentration correlates with oxygen uptake per unit of blood as it flows through the lungs, the Fick Principle. If oxygen saturation in the pulmonary veins minus oxygen saturation in the Aorta is greater than 2%, a right to left shunt is assumed. If a septum defect is present, normally part of the blood flows from left to right due to the higher pressure on the left side. Under certain circumstances this flow can switch to a right to left shunt. If oxygen saturation in the pulmonary arteries minus the oxygen saturation in the Vena Cava is greater than 2% a Left to right Shunt is assumed. The consequence of a shunt may be overload of the ventricular muscle or malnourishment of the body. ? Pressure curves & norm values A diagram of a heart rate AI-generated content may be incorrect. A screenshot of a medical report AI-generated content may be incorrect. Image comes from Wiggers diagram - Wikipedia Table: Normal Pressures in the Heart and Great Vessels-Merck Manual Professional Edition Presure curves This diagram gives you an overview on the shape of the different curves. As the right heart supplies the lungs "only", the pressure curve looks much smaller in amplitude than that for the left heart, which supplies the complete body from head to toe. Corresponding to the constriction of the heart the curves move more or less along the baseline and then raise up to peaks. The highest peak shows the left ventricular pressure curve since it is the left ventricle that must supply the blood bolus with enough energy to be pressed through the body, for example through the heart muscle. The same maximum pressure is reached by the aortic curve normally. At certain times within the pressure curve pressure values are taken. For ventricle curves that is the time when the maximum and the minimum pressure are reached, and the pressure before constriction of the muscle cells. Here you see a list of some hemodynamic norm values. The measured points in a ventricle curve are the systolic, diastolic and end-diastolic value. For the big vessels it is the systolic, diastolic and mean value. For the atria it is the mean pressure and, as this curve is influenced when the ventricles constrict, values of the so-called a-wave and v-wave are of importance. Gradients Gradient Gradients equate pressure differences at both sides of a valve. For example, in systole maximum pressure of the Left Ventricle (LV) and the Aorta are the same. Due to malformation of the Aortic Valve, the pressure in the LV may be higher than in the Aorta. The Aortic Valve shows a gradient. Pre - Transcatheter Aortic Valve Implantation Workup in the Cardiac Catheterisation Laboratory - ScienceDirect LV - AO Pullback - AORTIC STENOSIS Pressure & no pressure Gradients This image illustrates the comparison of a pressure and no pressure gradient. Gradients If the measured pressure values, for example, in the LV and the Aorta show differences in the maximum = systolic value, cardiologists talk of a „gradient". If a pressure measurement is performed in the LV and the Aorta a hemodynamic measurement system can calculate a gradient, just by comparing the systolic values. A normal LV to Aorta pullback pressure curve is shown in the upper part. The peak pressure in the LV and Aorta is the same. The curve below shows a gradient with normal LV but reduced systolic aortic pressure due to dilatation of the Aorta ascendant.In the "Pullback" Method, One catheter is used to perform the gradient measurement. The catheter tip is placed first in the LV then tears it back across the aortic valve into the aorta ascendent under permanent pressure registration Gradients Gradient Gradients equate pressure differences at both sides of a valve. For example, in systole maximum pressure of the Left Ventricle (LV) and the Aorta are the same. Due to malformation of the Aortic Valve, the pressure in the LV may be higher than in the Aorta. The Aortic Valve shows a gradient. Pre - Transcatheter Aortic Valve Implantation Workup in the Cardiac Catheterisation Laboratory - ScienceDirect LV - AO Pullback - AORTIC STENOSIS; https://www.youtube.com/shorts/A7nu-0UfeDE Pressure & no pressure Gradients This image illustrates the comparison of a pressure and no pressure gradient. Pressure & no pressure gradients If the measured pressure values, for example, in the LV and the Aorta show differences in the maximum = systolic value, cardiologists talk of a „gradient". If a pressure measurement is performed in the LV and the Aorta a hemodynamic measurement system can calculate a gradient, just by comparing the systolic values. A normal LV to Aorta pullback pressure curve is shown in the upper part. The peak pressure in the LV and Aorta is the same. The curve below shows a gradient with normal LV but reduced systolic aortic pressure due to dilatation of the Aorta ascendant.In the "Pullback" Method, One catheter is used to perform the gradient measurement. The catheter tip is placed first in the LV then tears it back across the aortic valve into the aorta ascendent under permanent pressure registration Angiogram projections Select each of the projections to the right to learn more. Angiogram projections Just to give you an idea how an LV study looks like on the monitor; here is a typical end diastolic 30° RAO view. The reason for this angulation, is that the spine does not overlie the heart, which otherwise would cause higher kV, hence decreased image quality. Another reason is that in the 30° RAO view the LV is seen almost in its full length, which is important for the typical 'Area-length' analysis method, which is used for ejection fraction and volume calculation. The 60° LAO view is the orthogonal view, which fits biplane analysis best. The spine does not overly the heart in this angulation which is important for image quality Here we have the orthogonal views for the RCA. The coronary can be judged from two sides. The advantage is evident: What looks like an occlusion in the RAO view comes out as a mild stenosis in the LAO view. 300 RAO and 600 LAO views Here are the orthogonal views for the RCA. 300 RAO and 600 LAO views Positioning is of key importance so that the spine does not overlie vessels. 600 LAO view The orthogonal view fits biplane analysis best. 300 RAO view The left ventricle is seen almost in its full length which is important for the Typical Area Length Analysis method. ? Course Review Congratulations. You have completed the Cath Lab Basics course. Select the numbered buttons below to review the material before proceeding to the final assessment. Objective Four Objective Three Objective Two Objective One 1 1 2 2 2 3 3 3 4 4 4 Course Review Objective 4 Identify key cardiac pathologies seen in cath lab cases. Arrhythmias Cardiac output Tachycardia Bradycardia Coronaries (stenosis) Chambers (wall motion) Valves (stenosis, insufficiency) Big arteries (aneurysm Septal defects - ASD/VSD Valves - Stenosis, insufficiency Big arteries – Transposition Lung vessels - Stenosis Objective 3 Summarize radial and femoral artery access techniques. Radial access Radial artery access is a common access method for cardiac catheterization that involves inserting a catheter through the radial artery in the wrist. Femoral access Another common access site is via the femoral artery. The femoral artery provides an access site with larger vessels that can usually be palpable. Objective 2 Outline cath lab workflow steps. Patient Data Registration Patient Positioning Electrode placement Cleaning of puncture site with antiseptic solution Adjustment and balancing of pressure transducer Sheath placement Catheter introduction and positioning Coronary angiograms Quantitative Coronary Analysis Percutaneous Transluminal Coronary Angioplasty (PTCA) Stent placement Image review, archiving and reporting Objective 1 Identify the two primary components of a cardiac catheterization lab. There are two components that make up the cath lab. They are the x-ray system and the recording system. The x-ray system is used to document the cardiac catheterization study by acquiring images of the coronary arteries. The recording system documents the case for medical records and reporting. The recording system provides real time patient data such as EKG waveforms, heart rate, oxygen levels, and blood pressure. Disclaimer Please note that the learning material is for training purposes only. 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Next Video Slide Some images have a magnifier icon in the bottom-left corner. Select these image to see an enlarged view of the image. Select the image again to return to the normal view. Select Submit to record your response. Click the X in the upper right corner to exit the navigation help. Assessment Slide Assessment Assessment Welcome to the assessment. For each question, select the button to the left of your answer, and then select Submit. You will have 3 attempts to take this assessment and to successfully pass this course, you must receive a score of 80% or higher. You will receive your score when you have completed the assessment. Note: If you close the learning activity at any time before you have finished the quiz, your answers will not be saved. Select Start to begin. Start Assessment Select the best answer. ? Catheter introduction Image review Question 1 of 6 Which step is typically performed first in the cardiac cath lab workflow? Patient data registration Oxygen measurement Multiple Choice Select the best answer. ? Larger vessel size Faster imaging Question 2 of 6 What is a primary advantage of radial artery access over femoral artery access in cardiac catheterization? Lower risk of bleeding and complications Easier catheter manipulation Multiple Choice Select the best answer. ? Adult cath lab Interventional cath lab Question 3 of 6 Which type of cath lab focuses on studying the heart’s electrical pathways and conduction system? Pediatric cath lab Electrophysiology (EP) lab Multiple Choice Select the best answer. ? Ventricular Septal Defect (VSD) Aortic Stenosis Question 4 of 6 What cardiac pathology is characterized by a hole between the two upper chambers of the heart? Patent Ductus Arteriosus (PDA) Atrial Septal Defect (ASD) Multiple Choice Select the best answer. ? The right ventricle pumps blood to the systemic circulation, requiring higher pressure. Both ventricles operate under similar pressure due to equal wall thickness. Question 5 of 6 Which statement best explains the difference in pressure values between the right and left ventricles? The left ventricle wall is thinner, resulting in lower pressure. The left ventricle must generate higher pressure to supply the entire body. Multiple Choice ? Select three (3) answers. Question 6 of 6 Blood pressure Blood pressure Blood pressure Which of the following are commonly monitored by the recording system in the cardiac cath lab? EKG waveforms Heart rate Bone density Oxygen levels Multiple Answer Retry Assessment Results %Quiz1.ScorePercent%% %Quiz1.PassPercent%% Continue YOUR SCORE: PASSING SCORE: Results Slide You have exceeded your number of assessment attempts. Exit You did not pass the course. Select Retry to continue. Congratulations. You passed the course. Exit To access your Certificate of Completion, select the Certificates tab from the learning activity overview page. You can also access the certificate from your transcript. ? You have completed the Cath Lab Basics Online Training. Completion details, certificates tab Cath Lab Basics Siemens Healthineers Here are some useful links and documents: 1 Cath Lab Basics 1.1 Objectives 1.2 Components 1.3 Adult Cath lab 1.4 Pediatric cath lab 1.5 EP Lab 1.6 Adult Cath Lab 1.7 Pediatric Cath Lab 1.8 Electrophysiology study (EP) 1.9 Right heart 1.10 Pathology, anatomy, physiology 1.11 Circulatory system 1.12 Heart anatomy 1.13 Markers 1.14 Aortic valve disease examples 1.15 Components of the heart 1.16 Surface anatomy of the heart 1.17 Coronary stenosis & thrombus 1.18 Cardiac conduction pathways 1.19 Cath lab workflow 1.20 Interventional workflow 1.21 Patient registration & positioning 1.22 Positioning for hemodynamic signals 1.23 Pressure measurement system 1.24 Accessing the coronary system 1.25 Seldinger access technique 1.26 Judkins catheters 1.27 Oxygen methods & saturation 1.28 Presure curves 1.29 Gradients 1.30 Pressure & no pressure gradients 1.31 Angiogram projections 1.32 Course Review 1.33 Disclaimer 3 Assessment 3.1 Assessment