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High-Risk Cardiac Catheterization
disease in the aorta or
PAD
coagulopathy
More than moderate AI, PAD,
Requires stable rhythm More than moderate AI,
personnel
more than moderate AS
VSD, PAD, RV failure
trans -septal puncture
Large cannulas,
Aortic stenosis LV thrombus, VSD, HOCM,
ventricle
Length of
Suppor t Advantages Limitations Contraindications
Up to 14 days Unloads lef t
1.0 L/min
Augment from 0.5 to
dissection
prolonged
ventricle
Augment up to 3.5 L/min Up to 14 days Full support,
Complete support Up to 6 hours Full support Limited duration,
Augment up to 2.5 L/min Up to 5 days Unloads left
embolus
ischemia
Comparison of Cardiocirculatory Support Devices
Table 8 -6
Insertion
Technique Major Complications Effect on Circulation
Type
IABP P or S Limb ischemia, aortic
CPS (ECMO) P or S Bleeding, hemolysis, stroke,
pVAD (TandemHeart) P Tamponade, limb ischemia
tVAD (Impella) P or S Aor tic valve damage, limb
device; VSD, ventricular septal defect.
pump; LV, left ventricular; P, percutaneous; PAD, peripheral arterial disease; pVAD, percutaneous ventricular assist device; RV, right vent ricular; S, surgical; tVAD, transvalvular ventricular assist
AI, Aortic insuf ficien cy; AS, ao rtic stenosis; CPS, cardiopulmonar y support; ECMO, extracorporeal membrane oxygenation; HOC M, hypertrophic obstr uctive cardiomyopathy; IABP, intraaor tic b alloon
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High-Risk Cardiac Catheterization 383
up to 4.0 L/min of blood flow. It has the benefit of unloading the left
atrium and thereby improving filling pressures, workload, and oxygen
demand. Major drawbacks to this system include vascular access size
(22-F venous and 15- to 17-F arterial); need for trans-septal access to
the left atrium, which requires a proficiency that not all interventionalists possess; and increased procedure time, which may not be possible
in a hemodynamically unstable patient. In contrast to extracorporeal
membrane oxygenation (ECMO), patients with right ventricular failure
are not candidates for the TandemHeart, which also somewhat limits
its use.
More prolonged support may require ECMO, which removes
carbon dioxide and adds oxygen to blood via an artificial membrane.
It is available as venovenous (for patients with respiratory failure) or
venoarterial, which adds an extracorporeal pump to provide hemodynamic support. ECMO has high complication rates including bleeding
due to continuous heparin administration and platelet dysfunction,
thromboembolism, and vascular damage during catheter insertion.
The major benefit of ECMO is that it provides total circulatory support
as needed. ECMO use declined when studies showed that prophylactic
IABP for high-risk cases was similar in efficacy and produced significantly fewer complications, such as bleeding/vascular access. ECMO
does not increase coronary perfusion pressure and may actually
increase afterload to a small degree, thereby decreasing the emptying
capabilities of the left ventricle and potentially requiring implantation
of an IABP for further support.
The IABP, Impella, and TandemHeart have provided significant
support to catheterization laboratory operators, who have achieved
positive outcomes after performing very high-risk percutaneous
procedures with the use of these devices. Table 8-6 lists the general
features of each of these devices, their hemodynamic effects, complications unique to each device, and potential limitations. As operators
become more adept at using these tools, many more advances can be
expected through the coming years.
Suggested Readings
Barrett BJ: Contrast nephrotoxicity. J Am Soc Nephrology 5(2):125, 1994.
Bashore TM, et al: American College of Cardiology Foundation/Societ y for Cardiovascu-
lar Angiography and Interventions Expert Consensus Document on Cardiac Catheterization Laboratory Standards Update. J Am Coll Cardiol 59(24):2221, 2012.
Boehrer JD, Lange RA, Willard JE, et al: Markedly increased periprocedure mor tality of
cardiac catheterization in patient s with s evere narrowing of the left main coronary
arter y. Am J Cardiol 70:1388–1390, 1992.
BRIDGE Study Investigators: Bridging anticoagulation: is it needed when warfarin is inter-
rupted around the time of a surger y or procedure? Circulation 125:e496–e498, 2012.
Briguori C, Airoldi F, D’Andrea D, et al: Renal Insufficiency Following Contrast Media
Administration Trial (REMEDIAL): a randomized comparison of three preventive
strategies. Circulation 115:1211–1217, 2007.
Cigarroa RG, Lange RA, Williams RH, et al: Dosing of contrast material to prevent contrast
nephropathy in patients with renal disea se. A m J Med 86(6, Pt 1):649, 1989.
Colyer WR, Jr, Moore JA, Burket MW, et al: Intraaortic balloon pump insertion after per-
cutaneous revascularization in patients with severe peripheral vascular disease.
Cathet Cardiovasc Diagn 42:1–6, 1997.
Davidson CJ, Hlatky M, Morris KG, et al: Cardiovascular and renal toxicity of a nonionic
radiographic contra st agent after cardiac catheterization. A prospective trial. Ann
Intern Med 110(2):119, 1989.
Ferguson JJ, Cohen M, Freedman RJ, et al: The current practice of intra-aortic balloon
counterpulsation: results from the Benchmark Registr y. J Am Coll Cardiol 38:1456–
1462, 2001.
Field JM, Hazinski MF, Sayre MR, et al: Part 1: Executive Summar y: 2010 American Heart
Association Guidelines for Cardiopulmonar y Resuscitation and Emergency Cardiovascular Care. Circulation 122:S6 40, 2010.
Folland ED, Oprian C, Giacomini J, et al: Complications of cardiac catheterization and
angiography in patients with valvular heart disease. Cathet Cardiovasc Diagn 17:15–
21, 1989.
Gurm HS, Smith DE, Ber wanger O, et al: Contemporary use and effect iveness of
N-actet ylcysteine in preventing contrast-induced nephropathy among patients undergoing percutaneous coronary intervention. J A m Coll Cardiol Intv 5:98–104, 2012.
384 8 —
https://t.me/med1917
Heupler FA: Guidelines for performing angiography in patients taking metformin. Cathet
Cardiovasc Diagn 43:121–123, 1998.
International Consensus on Science: Guidelines 2000 for cardiopulmonar y resuscitation
and emergency cardiovascular care. Circulation 102(suppl I):1–370, 2001.
Joshi GP, Chung F, Vann MA, et al: Society for Ambulatory Anesthesia consensus state-
ment on per ioperative blood glucose management in diabetic patients undergoing
ambulatory surgery. Ane sth Analg 111(6):1378, 2010.
Jurmann MJ, Siniawski H, Erb M, et al: Initial experience with miniature axial flow ven-
tricular assist devices for postcardiotomy heart failure. Ann Thorac Surg 77:1642,
2004.
Kahn JK, Rutherford BD, McConahay DR, et al: Supported “high risk” coronary angio-
plasty using intraaor tic balloon pump counterpuls ation. J Am Coll Cardiol 15:1151–
1155, 1990.
Kern M J, Aguirre F, Bach R, et al: Augmentation of coronary blood flow by intra-
aortic balloon pumping in patients after coronary angioplasty. Circulation 87:500–
511, 1993.
Kern MJ, Aguirre FV, Tatineni S, et al: Enhanced coronar y blood flow velocity during
intraaortic balloon counter pulsation in critically ill patients. J Am Coll C ardiol
21:359–368, 1993.
Klein LW, Sheldon MW, Brinker J, et al: The use of radiogr aphic contrast media during
PCI: a focused review. A position statement of the Society of Cardiovascular Angiography and Inter ventions. Catheter Cardiovasc Interv 74:728, 2009.
Landau C, Lange RA, Glamann DB, et al: Vasova gal reactions in the cardiac catheteriza-
tion laboratory. Am J Cardiol 73:95–97, 1994.
Majumdar SR, Kjellstrand CM, Tymchak WJ, et al: Forced euvolemic dieresis with man-
nitol and furosemide for prevention of contrast induced nephropathy in patient s with
CKD undergoing coronary angiography: a randomized controlled trial. Am J Kidney
Dis 54(4):602, 2009.
Millereau M: Dilution of potent dr ugs. Am J Cardiol 68:418, 1991.
Ohman EM, Califf RM, George DS, et al: The use of intraaortic balloon pumping as an
adjunct to reperfusion therapy in acute myocardial infarction: the thrombolyse s and
angiopla sty in myocardial infarction (TAMI) study group. Am Heart J 1218:895–901,
1991.
O’Neill WW, Kleiman NS, Moses J, et al: A prospective, randomized clinical trail of hemo-
dynamic support with Impella 2.5 versus intra-aortic balloon pump in patient s under-
going high-risk percutaneous coronary intervention: the PROTECT II Study.
Circulation 126:1717, 2012.
Rihal CS, Textor SC, Grill DE, et al: Incidence and prognostic importance of acute renal
failure after percutaneous coronary intervent ion. Circulation 105:2259 –2264, 2002.
Sankaranarayanan R, Msair i A, Davis GK: Stroke complicating cardiac catheterization—a
preventable and treatable complication. J Inva sive Cardiol 19(1):40–45, 2007.
Siegenthaler MP, Brehm K, Strecker T, et al: The Impella Recover microaxial left ventricu-
lar assist device reduces mortality for postcardiotomy failure: a three -center experi-
ence. J Thorac Cardiovasc Surg 127:812, 2004.
Seyfarth M, Sibbing D, Bauer I, et al: A randomized clinical trial to evaluate the safety
and efficacy of a percutaneous left ventricular assist device versus intra-aortic
balloon pumping for treatment of cardiogenic shock caused by myocardial infarc -
tion. J Am Coll Cardiol 52(19):1584–1588, 2008.
Sirtori CR, Pa sik C: Re-evaluation of a biguanide, metformin: mechanism of action and
tolerabilit y. Pharmacol Res 30(3):187, 1994.
Solomon R, Werner C, Mann D, et al: Effects of saline, mannitol, and furosemide to
prevent acute decreases in renal function induced by radiocontrast agents. N Engl J
Med 331(21):1416, 1994.
Tepel M, van der Giet M, Schwar zfeld C, et al: Prevention of radiographic-contrast-agent-
induced reduction s in renal function by acetylcysteine. N Engl J Med 343:180 –184,
2000.
Tommaso CL, Johnson RA, Stafford JL, et al: Supported coronary angiopla sty and
standby coronary angioplasty for high-risk coronar y artery disease. Am J Cardiol
66:1255–1257, 1990.
Vogel RA: Femoral-femoral cardiopulmonary bypas s a ssisted coronary angioplasty.
Cardiac Surg 78:213–220, 1993.
Voudris V, Marco J, Morice MC, et al: “High-risk” percutaneous transluminal coronar y
angiopla sty with preventive intra-aortic balloon counterpulsation. Cathet Cardiovasc
Diagn 19(3):160–164, 1990.
Weisberg LS, Kurnik PB, Kurnik BR: Risk of radiocontrast nephropathy in patients with
and without diabetes mellitus. Kidney Int 45(1):259, 1994.
Zwicker JC, Sila CA: MRI Findings in a case of transient cortical blindness after cardiac
catheter ization. Catheter Cardiovasc Interv 57(1):47–49, 2002.
High-Risk Cardiac Catheterization
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Research Techniques
BARRY A. BORLAUG • JOERG HERRMANN •
MORTON J. KERN
Research techniques have been and continue to be of great value for
understanding common problems in cardiology. Moreover, many of
these techniques, once solely limited to the research arena, have been
incorporated into routine diagnostic cardiac catheterization, such as
fractional flow reserve (FFR) and intravascular ultrasound (IVUS).
This chapter is an overview of commonly used research procedures
in the cardiac catheterization laboratory (Tables 9-1 and 9-2).
Attitude Toward Research in the
Catheterization Lab
The support staff in the cardiac catheterization laboratory may view
research studies as unnecessar y, unimportant, or dangerous to the
patient. These commonly held misconceptions should be dispelled
and the use and safety of the procedure advocated. It is to be emphasized, however, that only skilled physicians, with directed goals and
institutional research board approval, should apply these research
techniques. Discoveries that are to be made are invaluable in identifying new therapies and advancing the frontiers of treatment for cardiac
disease. It is most helpful for nurses and catheterization laboratory
physicians to appreciate these aspects and convey a sense of confidence and enthusiasm to the patient in reaching a common goal, that
is, to improve the care and outcome of patients with heart disease.
Quantitative Coronary and Left
Ventricular Angiography
Although visual estimation is universally used during angiography in
the clinical setting, significant observer variability is the rule. Quantitative coronar y angiography (QCA) and ventriculography are used to
help overcome the subjective limitations of angiographic interpretation. Because of time constraints, these methods are typically performed off-line after data acquisition.
Quantitative Coronary Angiography
QCA can be performed using digital (or hand-held) calipers or, more
commonly, computer-generated automated edge detection systems.
For exact measurements, image calibration is required from an object
with known dimensions, most commonly a contrast-filled coronary
catheter. The catheter image is enlarged for measurement of its diameter to generate a calibration factor (millimeters/pixel) that is used to
calculate vessel lumen size. QCA software then examines brightness
values in the area of interest and uses digital algorithms to calculate
vessel diameter from automatic border detection from operatorselected centerlines.
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Table 9 -1
Research Techniques
Research Techniques
Objective Method
I. Ventricular Function
1. Systolic function Ventricular P-V relationship
2. Diastolic function Ventricular P-V relationship (as above)
3. Exercise studies
4. Combined hemodynamic and
echocardiogr aphic studies
II. Myocardial Blood Flow (Coronary Vasodilatory Reserve, Effects of
Drugs)
III. Endothelial Function
1. QCA
2. Doppler flow
3. QCA
IV. Electrical Function (Abnormal Conduction, Excitation)
dP/dt, Derivative of pressure (dP) with respect to time (dt); LV, left ventricular; P-V,
pressure-volume; QCA, quantitative coronary angiography.
(simultaneous LV pressure with LV
volume by echocardiogram, contrast
angiogram, nuclear angiogram, or
impedance catheter)
Variables derived: end-systolic P-V
slope, intercept; contractility (+dP/dt)
Variables derived: end- diastolic P-V
slope, intercept; relaxation (−dP/dt,
τ, K)
Indicator dilution; inert gas (xenon,
nitrogen); thermodilution
Doppler flow velocity
Digital radiographic studies
Electrophysiologic studies
His bundle
Atrial and ventricular refractory periods
Conduction abnormalities
Inducible ventricular ectopy
Bypass tracts
Commonly measured parameters from QCA are minimal lumen
diameter (MLD), reference vessel diameter, acute lumen gain (final
MLD–baseline MLD) after percutaneous coronary intervention (PCI),
late lumen loss (follow-up MLD–final MLD) after PCI, and percent
diameter stenosis (Fig. 9-1).
Limitations of QCA, which can lead to data variability, include
inconsistencies in image acquisition (e.g., vessel foreshortening, different imaging planes or magnification) and frame selection and differences in vessel tone among measurements. Significant discrepancy in
distances from x-ray generator to calibration device (i.e., catheter) and
to coronary vessel also leads to underestimation or overestimation of
measurements. Precision can be improved with use of intracoronary
(IC) vasodilators for maximal vasodilatation, complete contrast filling
of the artery, and identical imaging equipment and planes among
measurements.
Quantitative Ventriculography
Quantitative ventriculography is best performed with biplane imaging
using a 60-degree straight left anterior oblique (LAO) projection and
a 30-degree right anterior oblique (RAO) projection. End-diastolic and
end-systolic frames of a completely opacified ventricle during a normal
sinus rhythm beat are examined using the centerline chord method.
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Research Techniques 387
Table 9 -2
Additional Research Techniques in the Catheterization
Laboratory
Left Ventricular Function Methods
Pressure-Volume Relationship s
End systole High-fidelity pressure
End diastole
Wall Stress
LV mass Quantitative ventriculography
Diastolic function High-fidelity pressure
Ventricular interaction RV/LV high -fidelity pressures
Aortic imp edance Aortic flow velocity, high-fidelity pressure
Coronary Physiology
Coronary blood flow, coronary
reser ve, coronary vasodilation
(response to drugs)
Ischemia Testing
Induced tachycardia Electrophysiologic study
Isoproterenol, dopamine Pharmacologic infusion
Transient coronary occlusion Coronary angioplasty
2D, Two -dimensional; LV, left ventricular; RV, rig ht ventricular.
LV volume
LV gram (cineangiographic, digital)
RV gram
2D echocardiogram
Impedance catheter
Doppler mitral inflow
Pharmacologic studies with papaverine,
adenosine, acetylcholine
Physiologic flow responses during
interventional procedures, such as
angioplasty or hemodynamic studies
Figure 9-1 Frame from quantitative coronary angiographic analysis. Auto-
matic edge and center line are performed and dimensions calibrated against
object (guide catheter) of known size.
In this method, chords perpendicular to a centerline in a frame halfway
between end-systolic and end-diastolic images are created and then
normalized to the end-diastolic perimeter. Regional wall motion is
quantified based on the degree of local chord shortening (positive
values = hyperkinesis; negative values = hypokinesis) (Fig. 9-2).
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Research Techniques
Quantitative Coronary Flow
Doppler Coronary Flow Velocities
Coronary flow reserve (CFR; maximal coronary blood flow/resting
coronary blood flow) is a global measure of coronary vasodilator
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Figure 9-2 Quantitative left ventriculographic wall motion analysis. Normal
left ventricular (LV) wall motion shows concentric inward motion of all LV
wall segments. Bottom, Chords and deviation from midline. The centerline
method of regional wall motion analysis uses end- diastolic and end-systolic
LV endocardial contours. Bottom, lower panel, A centerline is constructed by
the computer midway between the two contours. Motion is measured along
100 chords constructed perpendicular to the centerline. Motion at each
chord is normalized by the end-diastolic perimeter to yield a shor tening
fraction. Motion along each chord is plotted for the patient (single red arrow).
Mean motion in the normal ventriculogram group (double red arrow) and one
standard deviation (STD. DEV.) above and below the mean (dotted line) are
shown for comparison. Wall motion also is plot ted as the dif ference in units
of standard deviations from the normal mean (right panel). The normal ventriculogram group mean is represented by the horizontal zero line (below
left). EDV, End -diastolic volume; EF, ejection fraction; ESV, end -systolic
volume; SV, stroke volume.
Anatomy Physiology
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Research Techniques 389
Normal
Epicardial artery
Epicardial stenosis
Microvascular
disease
Figure 9-3
coronary vasodilatory reserve (CVR) responses. When both components are
normal, CVR is normal. CVR can be abnormal due to epicardial artery narrowing or microvascular disease. (From Wilson RF: Assessment of the
human coronary circulation using a Doppler catheter. Am J Cardiol 67:44D–
56D, 1991.)
Normal epicardial coronary artery and microvascular bed and
4 x
Flow
x
Arteriolar vasodilation (papaverine)
4 x
Flow
x
Arteriolar vasodilation (papaverine)
4 x
Flow
x
Arteriolar vasodilation (papaverine)
Time
Time
Time
circulatory capacity and is affected by epicardial and microvascular
circulatory abnormalities (Fig. 9-3). It was historically measured by
coronary sinus (CS) blood flow with the use of a continuous thermodilution technique. Currently, coronary flow is determined from IC
arterial flow velocity using 0.014-inch Doppler-tipped sensor guidewires. In the Doppler technique, quantitative measurement of coronary flow is obtained from the use of pulsed sound waves (12 to
15 mHz) and measurement of the returning signal reflecting off moving
red blood cells. The Doppler guidewire can also be coupled with a
pressure sensor (Fig. 9-4) to measure simultaneous poststenotic coronary pressure and flow.
A pressure-temperature sensor-tipped guidewire also can be used
to simultaneously measure FFR (by coronary pressure) and CFR
(by coronary thermodilution) with calculation of the index of microvascular resistance (IMR). Measurement of physiologic response of
coronary circulation to various drugs, maneuvers, and interventions,
as well as assessment of the significance of coronary obstructive
lesions before and after revascularization, are examples of useful applications (Box 9-1). Measurement of volumetric changes in coronary
ComboWire 1.5 cm offset
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Doppler transducer
Pressure sensor
A
B
Figure 9 -4 A, Combination pressure and flow sensor guidewire. The pres-
sure sensor is located at the junction between the soft radiopaque por tion
and the stiff portion of the guidewire. The Doppler cr ystal is at the distal
tip of the wire. B, Panel from display for simultaneous coronary pressure
flow recordings. APV, Average peak velocity; APV-B, average peak velocity
base; APV-P, average peak velocity peak; CFR, coronary flow reserve; FFR,
fractional flow reser ve; HMR, hyperemic microvascular resistance; HR, heart
rate; HSR, hyperemic stenosis resistance; Pa, aor tic pressure; Pd, distal
coronary pressure; Pd/Pa, pressure ratio. (Courtesy of Volcano Corporation,
Rancho Cordova, CA.)
Box 9 -1 Uses of the Doppler FloWire*
CVR assessment
Syndrome X
Transplant coronary arteriopathy
Collater al flow studies
Coronary flow research studies
Pharmacologic and endothelial function studies
Intraaortic balloon pumping
Coronary physiology of vascular disease
Ischemic test correlation
CVR, Coronary vasodilatory reser ve.
*FloWire Dopp ler Guide W ire ( Volcano Corporation, Rancho Co rdova, CA)
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Research Techniques 391
blood flow can be combined with measurement of myocardial oxygen
consumption (arterial and CS blood) to identify whether increases in
blood flow are caused by increased myocardial oxygen demand (i.e.,
metabolic regulation) or pharmacologic changes independent of myocardial demand (e.g., primary artery vasodilation or constriction).
Doppler Methodology and Setup
Setting up the Doppler wire system usually takes less than 10 minutes.
Timing of the reflected sound waves is used to measure blood flow
velocities from moving red blood cells in a sample area that is 5 mm
from the tip of the wire (and 2 mm across)—far enough away so that
blood velocity is not affected by the wake of the wire. The returning
signal is transmitted in real time to the display console. A gray-scale
spectral scrolling display shows velocities of all red blood cells within
the sample volume. Key parameters are derived from automatically
tracked peak blood velocities, making them less sensitive to position
(Fig. 9-5).
ECG
Ao
Figure 9 -5 Normal coronary flow velocity spectra showing small systolic
and large diastolic velocity components. Bottom, Diagram of measurements
shows a darkly hatched diastolic velocity integral (Dvi), lightly hatched systolic velocity integral (Svi), and peak systolic and diastolic velocities (PVs
and PVd, respectively). The means of diastole and systole and total cycle
variables can be computed. Ao, Aortic pressure; APV, average peak velocit y
(mean); DSVR, diastolic-to-systolic velocity ratio; ECG, electrocardiogram.
(From Ofili EO, Kern MJ, Labovitz AJ, et al: Analysis of coronary blood flow
velocity dynamics in angiographically normal and stenosed arteries before
and after endolumen enlargement by angioplasty. J Am Coll Cardiol 21:308–
316, 1993.)
PVd
Dvi
PVs
Svi
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