Exam 1- Intro to Invasive Cardiovascular Tech

What is right heart catheterization?

Delivery of medications directly to the circulatory system

What is right heart catheterization with hemodynamic [pressure] monitoring?

Diagnosis of congenital and acquired structural heart disease

What is peripheral vasculature?

Vascular imaging

What is left heart catheterization with hemodynamic [pressure] monitoring?

Left heart assessment

What is a presurgical procedure in cardiac catheterization?

• Non-selective coronary artery imaging

• Selective coronary artery imaging

What are some other progresses of the cardiac catheterization procedure?

• Peripheral vascular disease correction/intervention

• Coronary artery disease correction/intervention

• Structural heart repair/intervention

What did the Egyptians in 3000 B.C.E. use catheters for and what were they made of?

• Used catheters to drain the bladder and then remove

• Made out of bronze, reeds, or curled palm leaves

What is Stephen Hales known for?

• Contributed significantly to the knowledge of physiology by performing studies on animal subject

• Using a catheter made out of a brass pipe inserted into the carotid artery and jugular vein, he was able to measure the blood pressure of a horse

• First person to accurately measure blood pressure

• He was also able to describe the hemodynamic effects of hemorrhagic shock in animals

• Was one of the first to describe the pulsation action of arteries and cardiac valve function

What is Claude Bernard known for?

• Measured the blood temperature of a horse by inserting a mercurial thermometer into the carotid artery and advancing it into the left ventricle.

• He later described the process of “cardiac catheterization” in a published journal, creating the term we still use today

• Later, he used this same process to measure pressures created in the heart of animals.

• Defined role of pancreas, glycogenic function of the liver, regulation of blood supply by the vasomotor nerves.

What is Wilhelm Rontgen known for?

Discovered X-rays while researching physics of electrons in a cathode ray tube

What are Fritz Bleighroder, Ernst Unger, and W. Loeb known for?

• Conducted experiments attempting to inject drugs directly into diseased areas of the body by inserting catheters into blood vessels. Original research utilized dogs.

• Bleichroder eventually decided to become a test subject and had Unger perform three procedures on him through the basilic and femoral veins.

• Not clear if they ever accessed the heart, but Bleichroeder did experience “chest discomfort” during one of these tests.

What is Werner Forssman known for?

• German surgeon who performed the first documented human cardiac catheterization procedure

• The subject of the procedure was himself

• He was forbidden to perform the procedure, so he talked the surgical nurse to assist and the x-ray nurse to document it with a picture

What are Andre Cournand and Dickinson Richards known for?

• Developing several techniques and recording systems for measuring the pressures of the human heart (Right Heart Catheterizations) and calculating cardiac function (cardiac output and ejection fraction)

What is Henry Zimmerman known for?

• Is credited with the first person to perform a retrograde heart catheterization on a human subject

• Used the radial artery for access via a surgical or “cutdown” procedure.

What is Dr. Sven Ivar Seldinger known for?

• Developed the transluminal percutaneous left heart procedure via a femoral artery approach (Seldinger Approach)

• Prior to this, most heart catheterizations were performed via the “Sones” procedure (or brachial cutdown)

Who recieved the Nobel Prize in Philosophy or Medicine?

• Werner Forssman

• Andre Cournand

• Dickinson Richards

What is Mason Sones known for?

• Contributed for performing the first “selective” coronary angiogram (by accident)

• Prior to this, coronary arteries were imaged by occluding the ascending aorta, slowing down the heart, and injecting a lot of contrast into the aorta.

• It was believed that placing a catheter in the coronary and injecting contrast would kill the patient

What is Charles Dotter known for?

• Performed the first transluminal angioplasty (by accident)

• Accidently advanced a catheter through an occluded iliac artery on his way to image the abdominal aorta

• Created a method of angioplasty by inserting progressively larger catheters through an occlusion

• Surgeons were not impressed despite the outcomes he was able to prove and publish

• Problems: Dissections (tearing of a vessel wall) and embolism (breaking a plaque lose so it lodges lower in the vessel

What is Melvin Judkins known for?

• Dr. Melvin Judkins expanded on Dr. Seldinger’s percutaneous approach and created a procedure of accessing the heart via the femoral artery.

• Dr. Judkins was also one of the first physicians to design catheters specifically for the use of selective coronary angiography

• This procedure, which has been the gold standard for many decades, is known as the “Judkins Approach”

What is Andreas Gruentzig known for?

• Invented the balloon angioplasty catheter

• Developed the balloon angioplasty procedure

• Performed the first balloon angioplasty on a human (peripheral vessel) – 1974

• Presented research and outcomes of animal coronary angioplasty at an international conference (1976, AHA)

• Performed the first balloon coronary angioplasty on a human during an open heart surgery (1977)

• Performed first coronary balloon angioplasty on an awake patient (1977)

• From research to first human procedure – 2 years

What are Dr. Plamaz and Dr. Schatz known for?

Created the first coronary Stent approved by the FDA (Palmaz-Schatz)

For what purpose was angiography originally developed?

To visualize the coronary arteries and proximal proportions of the blood vessels by injecting contrast medium into the aortic root while filming an X-ray.

What are Swan-Ganz catheters used for?

To monitor right heart pressures and thermodilution cardiac outputs.

Were the first angioplasty balloons over-the-wire or fixed-wire devices?

Fixed-wire devices.

Explain why drug-eluting stents were developed.

Drug-eluting stents were developed to help prevent restenosis. This is an improvement of the Palmaz-Schatz stent, which still caused restenosis, but at lower rates compared to the balloon angioplasty. The drug-eluting stent was created to further help prevent the rate of restenosis.

What does the Monitor do in the cath lab?

• Observe and record the electrocardiogram (ECG)

• Measure hemodynamic waveforms

• Communicate to the medical staff of any changes observed

• Selecting a good cardiac roadmap image

• Documenting all events during the procedure

• Including inflation times, ischemic changes

• Equipment changes

• Calculating left ventricular ejection fractions

• Performing quantitative coronary analysis

In the past, X-ray systems did not automatically adjust the dose needed for every shot, so the monitor would adjust the kilovolt and milliampere before every shot.

What does the Circulator do in the cath lab?

• Record procedural events

• Administer medication

• Run blood samples on the oximeter

• Retrieve and open blood supplies

• Assist as needed if an emergency situation occurs

• Setting up

• Operating

• Interpreting results of intravascular ultrasound, Doppler flow, and fractional flow devices.

What does the Scrub Assistant do in the cath lab?

• Work at the table with the physician

• Helping exchange catheters

• Assisting with contrast medium injections

• Helping position catheters

• Advancing wires and balloons across lesions, and inflating and deflating balloons.

What is the advantage of using carbon ECG cables?

The use of other ECG cables can get in the way of a clear X-Ray picture. Carbon ECG cables, on the other hand, are radiolucent or can even be radiotransparent.

Why is it important to ensure that there are no air bubbles in the lines before injecting a bolus of contrast medium?

If air is injected into a patient, it may cause air embroli.

Give two reasons for a flat ECG signal.

1. Check if the patient is asystole and the hemodynamic pressure display should be checked immediately. If the pressure reading is continuing normally and the patient is responsive, then it can be assumed that there is an issue with the ECG machine. Most of the time, this will be caused by one or more ECG electrodes or leads has become disengaged.

2. Faulty connections or old cables can also be responsible for a break in the ECG signal.

Where should a circulator stand while an angiography run is being filmed?

The circulator should stand in a position where they are still able to effectively monitor the patient without entering the sterile field or in the way of the angiography.

Outline the process of donning a sterile gown.

The outside of the gown shouldn't ever be touched. The gown should be picked up by the inside of its collar. Then, each arm is slipped into a sleeve. This can be done both arms at once or one at a time. When using a disposable gown, scrub assistants will hand off the tie holder to the circulator and turn around, remove the tie from the holder, then tie themselves up. When using a cloth gown, assistants should allow for someone to hold the tie with a sterile clamp as they turn around. Assistants will then take the tie back and secure the gown.

How should the puncture site area be treated at the end of the procedure if the sheath is not to be removed immediately?

The puncture site area should be cleaned with saline and then dried. Non-vented sterile caps should be placed on the sheath's sidearm, and the area should be covered with a sterile dressing. Team members must inform the patient when the sheath will be removed, and which body parts can and cannot be moved. The patient should observe the area for any bleeding, such as wetness and stickiness.

Why are patients requested to drink a lot of fluids following an angiography or angioplasty procedure?

Patients are requested to drink lots of fluids following an angiography or angioplasty procedure to help flush out contrast medium from the body. Patients should also urinate as soon as they feel any pressure on the bladder.

Describe at least five tasks that are performed by a cath lab’s scrub assistant

1. Preps the patient’s access site(s) with an antiseptic solution.

2. Sets up the saline delivery lines (manifold or automated system) and the contrast medium.

3. Sets up and organizes the sterile instrumentation table.

4. Prepares the diagnostic catheters, guidewires, interventional devices, and other invasive equipment that may be used during the procedure according to manufacturer and hospital protocols.

5. Assists the physician with catheter and wire exchanges, and placement of interventional devices.

(MORE MARKED IN TEXT BOOK)

Describe at least five tasks that are performed by a cath lab’s circulator.

1. Assists other team members to transfer the patient to the procedure table.

2. Attaches the ECG electrodes.

3. Attaches a noninvasive blood pressure measurement cuff.

4. Inters a peripheral IV line, if the patient has not yet been cannulated.

5. Receives blood samples for point of care tests (activated blood clotting times, whole blood oximetry, etc.).

(MORE MARKED IN TEXT BOOK)

Describe at least five tasks that are performed by a cath lab’s monitor.

Cath lab monitors data from the lab database such as:

1. All hemodynamic data.

2. IV infusion volume.

3. All catheters and other equipment used.

4. All medications administered (which must also be documented on the appropriate medication sheets).

5. Any changes in patient status.

(ALL MARKED IN TEXT BOOK)

Oligo-

Few, scant

Para-

Beside, near, abdormal

Retro-

Backward, behind

Chrono-

Time

Xantho-

Yellow

Primi-

First

Nulli-

None

Pseudo-

False

Vaso-/ Vascul-

Vessel

Isch-

To hold back, restrict

How does the heart develop in babies?

Heart grows first → atria on bottom, ventricles on top, → Truncus arteriosus keeps growing → heart flips → atria on top, ventricles on bottom → heart continues to develop

What is the last to develop in babies?

Lungs — lungs push fluid before gases

• Right side of heart has less oxygen — in babies, however, it is the most oxygenated

What is the Pericardial Sac?

Sac around heart

• Connective tissue structure surrounding the heart and greater vessels

What are the layers of the Pericardial Sac?

1. Fibrous Pericardium — Tough outer layer

2. Serous Pericardium — Under layer

What are the layers of the Serous pericardium?

• Perietal layer: Connected to under side of Fibrous Pericardium

— Pericardial Space (Between these two layers) —

• Viceral layer: Connected to outer surface of the heart

What are the functions of the Pericardium?

1. Stabilzation of the heart within the thoracic cavity — limiting the heart’s motion

2. Protecting the heart from mechanical trauma and infection

3. The pericardial fluid functions as a lubricant and decreases friction of cardiac surface

4. Prevention of excessive dilation of heart (e.g. acute aortic or mitral regurgitation)

What does the Interventricular Groove/ Sulcus demarkate?

The left and right ventricle separation

What does the Atrioventricular Groove/ Sulcus demarkate?

The separation of atria and ventricles

What is it called when 2 grooves cross?

The Crux

What is the Interventricular Septum composed of?

Composed of both a muscular section and a smaller membranous section

What are the surface landmarks of the Interventricular Septum?

Margins of the septum can be traced on the heart’s exterior by following the anterior and posterior interventricular grooves

What causes a Pressure-Driven Bulge in the Interventricular Septum?

When the LV pressure greatly exceeds RV pressure, the muscular portion of the septum typically bulges into the RV cavity

What is the clinical relevance of the Interventricular Septum?

Defects in the membranous portion (VSD) are among the most common congenital heart defects, allowing left-to-right shunting

What vessels return to the Right Atrium?

• Superior vena cava - Head, arms, and thorax

• Inferior vena cava - Legs, pelvis, and abdomen

• Coronary sinus - Coronary veins drain to coronary sinus and the blood returns to the heart

Oxygen left over least to most: Coronary sinus, Superior vena cava, Inferior vena cava

What are the two sections of the Right Atrium?

1. Posterior (Sinus venosus)

2. Anterior (Atrial appendage, Atrial auricle)

What is the role of the Posterior section of the Right Atrium?

• Where greater veins drain into atrium

• Posterior septal wall of Right Atrium → smooth, thin wall, stretchy

What is the role of the Anterior section of the Right Atrium?

• Thick, muscular, cone shaped portion

• Collects blood for passive ventricular filling

— Includes Right Atrial Appendage and Tricuspid Valve ring

What are remnant valves on the Posterior section?

1. Eustachian Valve: Remnant valve that covered the IVC during fetal circulation

2. Thebsian Valve: Remnant of the coronary sinus ostium

3. Fossa Ovalis: Remnant of the Foramen Ovale after closure, located on the septum

What is the Terminal Crest (Crista Terminalis) in the Anterior section of the Right Atrium?

A muscle ridge extending from SVC to IVC

What is the Pectinate Muscle in the Anterior section of the Right Atrium?

Thin, trabeculated muscle specific to the atrium

What is the role of the Atria?

To fill and store blood as the ventricles contract

What is the filling process of the Atria?

When ventricles enter diastole, valve opens, blood rapidly and passively flows into the ventricle (passive filling)

— 75%-80% of blood that enters ventricle is through passive filling

• As passive filling ends, atria contracts, pushing blood from appendage into the filled ventricle

What are the names of the two Atrioventricular valves and where are they located?

1. Tricuspid valve: Between RA and RV → closed in ventricular systole, open in ventricular diastole

2. Mital (Bicuspid) valve: Between LA and LV

What are the names of the two Semilunar valves and where are the located?

1. Pulmonic valve: Between RV and pulmonary artery

2. Aortic valve: Between LV and aorta

What are Atrioventricular (AV) valves?

They separate the Atrium from the Ventricle

What are Semilunar valves?

They separate the ventricles from Great Arteries

In what direction does blood flow in the heart?

From high pressure to low pressure and the path of least resistance

What are the two sections of the Right Ventricle?

• Right Ventricular Inflow Tract (RVIT) — contracting

• Right Ventricular Outflow Tract (RVOT) — ejects blood to pulmonary artery

What consists of the RVIT?

1. Tricuspid Valve

2. Visible Trabeculae Carnae

3. Papillary Muscles

4. Chordae Tendinae

What are the 3 sets of Chordae Tendinae and what is it’s purpose?

1. Anterior set

2. Posterior set

3. Septal set

(Each connects to 1 Tricuspid Leaflet)

— Keeps Tricuspid Valve CLOSED

What consists of the RVOT?

It is smooth and consists of the Pulmonic Valve which gives rise to the pulmonary trunk

What separates the RVIT and RVOC?

The Crista Supraventricularis (Muscle ridge)

What are the names of the three papillary muscle groups that secure and align the AV valves?

I. Anterior Papillary Muscle

II. Septal Papillary Muscle (smallest)

III. Group of Posterior/Inferior Papillary Muscles

What are the key features of the Right Ventricle?

• Crista Supraventricularis: crossing point of three major muscle bands separating inflow and outflow tracts

• Walls are heavily trabeculated (ridged columns of muscle)

• Moderator Band: contains a portion of the Right Bundle Branch

What is the anatomy of the posterior wall of the Left Atrium?

Smooth and thin

What is the anatomy of the anterior wall of the Left Atrium?

• Anterior muscle wall (thick)

• Muscular portion contains the Left Atrial Appendage (LAA)

• Contains the connection of the mital valve annulus

• Left atrial septum contains the Fossa Ovalis (thinner upper remnant of the Foramen Ovale)

What is the Left Atrium stucture and function?

Exactly the same as the Right Atrium

What consists of the Inflow Tract of the Left Ventricle?

• Two Papillary Muscles (Anterior and Posterior)

• Chordae Tendinae

• Mitral Valve

What consists of the Outflow Tract of the Left Ventricle?

The Aortic Valve

Why is the left side of the heart thicker than the right?

Because it has to overcome the resistance of blood vessels. They constrict and dilate to control bloodflow throughout the rest of the body

(it accounts of 75% of the total cardiac muscle mass)

What is the Aortic Vestibule?

A smooth-walled region just below the aortic valve, distinct from the trabeculated body of the LV

Where does the aortic valve lie and what is its purpose?

The aortic valve lies between the left ventricle and the aorta. It pumps oxygenated blood through the aorta, which then delivers oxygenated blood to the rest of the body

What is the myocardium and what is it composed of?

The myocardium is the heart muscle. It is composed of linearly arranged myofibrils that are made up of sarcomeres. These sarcomeres are composed of myosin and actin myofilaments. When myosin pulls the actin towards the center of the sarcomere, the heart contracts.

Where is the SA node and what is its purpose?

The SA node is located in the high posterior right atrium wall, near the inflow track of the superior vena cava. The SA node normally initiates each cardiac cycle, leading to a wave of depolarization throughout both atria. It is the pacemaker of the heart. The impulse travels from the SA node to the AV node, through the anterior, medial, and posterior intranodal pathways, and to the left atria by the intra-atrial pathway (Bachmann’s bundle).

What is blood oxygen saturation?

Blood oxygen saturation is the percent of hemoglobin bound to oxygen. Mixed venous oxygen saturation analysis and monitoring is used to calculate the cardiac output, identifying left-to-right shunts, monitor patients, and assess cardiovascular response to treatments.

What is the Intimal Layer of a blood vessel?

Intimal layer endothelial cells modulate changes in vascular resistance in the systemic and pulmonic vascular beds. The endothelium secretes nitric oxide, which leads to vasodilation and endothelin-1, which leads to vasoconstriction which is done to maintain a normal vascular tone and regulate vascular tone in response to metabolic requirements. It also secretes chemicals to enhance or inhibit platelet aggregation and smooth-muscle cell proliferation and migration from the medial layer.

What is the Medial Layer of a blood vessel?

It is composed of smooth-muscle cells innervated by the nervous system and influenced by hormones and chemicals. The smooth-muscle cells have the ability to constrict and relax, which leads to vasoconstriction or dilatation, controlling blood distribution, blood pressure, and vascular resistance.

What is the Adventital Layer of a blood vessel?

It is composed of tough connective tissue that serves as the protective outer layer of the blood vessel.

Where does the circumflex artery lie and what part of the heart does it normally perfuse?

The circ. courses over the left AV groove and gives rise to obtuse marginals, arteries that perfuse the left ventricle’s lateral wall. The circ. also gives rise to the vessels that perfuse the left ventricle’s posterior wall.

What arteries branch off the aortic arch?

The brachiocephalic (innominate), left common carotid, and the left subclavian arteries branch off the aortic arch.

What is the ductus arteriosus and what purpose does it serve?

The ductus arteriosus is a part of the fetal circulation. It is a short vessel that connects the pulmonary artery to the aorta which allows fetal blood to bypass the lungs. It normally closes after birth because it is not required when the lungs are functional.

Describe the process of bloodflow through the heart.

Blood enters through the Inferior vena cava, Superior vena cava → Right Atrium → Tricuspid valve → Right Ventricle → Pulmonary Valve → Pulmonary Artery → Lungs → Pulmonary Veins → Left Atrium → Mitral Valve → Left Ventricle → Aortic Valve → Aorta → Rest of the body