Thank you for joining us today. This is an introduction to the cardiac cath lab, a brief lecture, and of course you're going to be getting a lot more details from some of my colleagues on specifics in the cardiac catheterization laboratory, so this is really meant to be kind of an overview of what happens in the cardiac cath lab and why we do it. These are my disclosures. So the objective of this presentation is initially to go over indications and contraindications, what are the risks and complications that can happen in the cardiac catheterization laboratory, the treatment and what needs to happen pre and peri procedurally during a cardiac cath, what are some important equipment to keep in mind and to have available and familiar with, who are the team members that you will be working with, as I know some of you are nurses, some of you are CB techs, and some of you are other learners, and then what happens actually in the cardiac catheterization laboratory, and this is a very brief overview of some of the things that occur. So some of the indications for interventional cardiology and the referral to cardiac cath lab is whether one suspects or has known coronary artery disease and has symptoms thereof, and of course the most typical one is angina, subsonal chest pain, but that can also present itself as dyspneic exertion, as GERD-like symptoms with exertion, left arm tingling, left jaw pain, you know, angina is a very good masquerader, so there are a lot of things that can present as suspected coronary artery disease. Myocardial infarction, of course, is one of the most important things that we treat in the cardiac cath lab and one of the most important diseases, and that can be futile, and luckily the introduction of primary PCI for STEMI and STEMI has been very helpful, and this is one of the key symptoms that we treat and diagnoses. Sudden cardiac death, of course, is the next thing in mind, and that's kind of like a combination of a myocardial infarction that went the wrong way, and there's been a lot of good literature on treatment of that and reversal of sudden cardiac death with percutaneous coronary intervention and mechanical circulatory support. Valvular heart disease gets treated in the cardiac cath lab in tandem with our social care colleagues, and you may have heard of transcutaneous aortic valve replacement, TAVR, mitra clip for severe mitral regurgitation. There are really a lot of novel therapies that we're using currently for treatment of valvular heart disease. Congenital heart disease is also a very important component, and we'll go briefly over the hemodynamics and how that's important for congenital heart disease, but the key here is that there are a lot of patients who are born with congenital heart disease living longer, and those patients need treatment, and very often the treatment for that is percutaneous. Pulmonary hypertension is also important, and pulmonary hypertension, the same way that one has arterial hypertension, one can have it on the other side of the lungs, on the right side, and that's kind of an important diagnosis that can have a lot of complications. Pericardial constriction, cardiomyopathy, which is a broad term to just mean that the heart muscle is weak, and of course, the initial and follow-up assessment for heart transplant. There are other conditions like hypertrophic cardiomyopathy and more specific things that we treat as well for that cause of total ablation, but those are kind of more niche fields within the interventional cardiology procedure. So what are some of the contraindications and some relative contraindications? Most of these are relative. The ones that are with an asterisk are significant, so of course, an active GI bleed is a significant one. Digitalis intoxication is a significant one. Obviously, if a patient has capacity and is refusing the procedure, then that's an important one. Pulmonary edema. But some other ones with modification are renal failure and worsening thereof, recent stroke as that can convert to a hemorrhagic stroke, electrolyte imbalance, obviously the two that we care about the most are potassium and magnesium, anemia, short life expectancy, uncontrolled hypertension, and aortic valve endoparditis, for instance, as we're manipulating catheters very often close to the aortic valve. So those are things that we try to avoid having in a patient, but of course, if they have them, sometimes we have to deal with them, and the key is to mitigate the risks and minimize complications. So risks and complications from the procedures include death, which is pretty infrequent, luckily, and rare, especially as our technologies have evolved and our sheath sizes have decreased over time. Myocardial infarction, which is also pretty infrequent, but sometimes that can happen from a closure of a side branch during a procedure, a stroke, which is hard to predict, but can happen quite a bit, especially in patients who have a lot of plaque in their aorta and as manipulation is going on in the major arteries of the body, arrhythmias, that can happen since you're dealing with a key component of the body, the heart. Hemorrhage, it can happen at the axis site or at other places, so for femoral axis, RP, hemorrhage, retroperitoneal hemorrhage is one of the most common ones to look out for, but for radial axis, even, you can have axis site hematomas, which are important. Contrast-induced nephropathy, which in and of itself can be a whole lecture in whether or not this is a real entity, but clearly there is some literature saying that the best way to treat this is with hydration, pre- and post-procedure, if you're able to, allergic reaction and radiation exposure are also very important as we're using x-rays to treat patients in the cardiac athlete. We won't go over too much detail, but some of the things to keep in mind are the HMP, the blood work, the EKG, the cardiac testing that gets done, the echo, the exercise, sometimes nuclear and sometimes stress echo, the corner CTA that all have to be done prior to a visit to the cardiac cath lab, not necessarily all of them, but some patients will have some of them, but these are tests that are important to keep in mind and to be aware of when you treat these patients. So pericatheterization care includes getting a good IV that flows well, and in some cases getting two IVs if patients have a possible need for transfusion or a possible need for quick fluid resuscitation, sedation, treatment of anxiety and pain is very important. Very often anesthesia is not present, it's actually managed by the nurses and the physicians. It's very important to be familiar with sedatives and narcotics and how to reverse them, and benzodiazepines as well and how to reverse them. The key is not eating between four and six hours before a procedure, and that's kind of like a changing target as we're trying to shorten that time for patient satisfaction, but also in terms of safety a lot of the guidelines are actually much shorter than that. Keeping a record of the procedure hemodynamically, the fluoroscopic time and exposure, and obviously what gets administered during the procedure is key so that one is aware if there is a downward spiral or poor outcome. Which supplies are used, and that's very important since we use a lot of equipment in the cardiac catheterization laboratory, and of course other pertinent things such as expiration dates, need for follow-ups, and things like that. In terms of important equipment, you really got to be very familiar whether you're a tech or a nurse or a fellow or a PA or an NPA with a crash cart, knowing really where the basic meds are, where is your epi, where is your atropine, how do you treat the heart block, where do you put the pads, how do you treat refib or VTAC, and when to press the sync button and when not to press the sync button, when is atrial fibrillation appropriate for cardioversion, and so those are all things that you need to be very familiar with and I'm sure almost all of you are ACLS and DLS certified, but it's very, very important to be familiar with your crash cart on those days that are not that busy, but open up, have a cart that's open and obviously get trained to figure out where each medication lays in the crash cart. Oxygen and suction are very important, how to use defibrillator as we mentioned briefly, pulse oximetry and how to mitigate if you have trouble with getting a read, where to place the EKG leads, everyone should be able to do an EKG in the cardiac cath lab, the equipment to perform cardiac output studies such as thermodilution or being able to run an ABG for a fit cardiac output, running an activated clotting time, which is important for patients on attack regulation, and how to use a temper, these are all very, very important things to know. So who works in the cardiac cath lab? So team members include an international cardiologist typically, a physician with nurses who are taking care of the patients, and then the rest are actually depends on the institution, sometimes it will be a physician assistant or a nurse practitioner who are assisting the physician, and occasionally it will be a radiation technologist or a cardiovascular specialist, it could be an interventional cardiology fellow or a general cardiology fellow or an imaging specialist, plus or minus a lot of CBTs basically, cardiovascular technicians that also are very familiar with the equipment. Very often you'll also have industry reps who can come in and also help during new equipment or troubleshooting how to work devices, so there's really a very big group of people who you work with, and it's really a team sport, so that's very important to keep in mind that this is something that you work with as a team and take care of the patients as a team, which is important. So very briefly, this is what the right coronary artery looks like, the heart has three big arteries in general that feeds it, the right coronary artery goes to the right side and also perfuses the inferior wall, this is the left system, the left circumflex goes to the back of the heart and perfuses the lateral wall, and then the left anterior descending, which is the most important artery typically that feeds the anterior wall, the apex, the anterolateral wall, and the anterior septum, which is very important. So every anatomy is different, and of course this is like a typical, most common right dominant, which is about 70 to 80% of the population, however there are patients who are left dominant, so the circumflex would be really large and the right coronary artery would be pretty small, and there are a lot of variations of this, there is a dual LND system at times, there could be an anomalous right coronary artery coming from the left cusp, vice versa, so there are a lot of variations of the coronary artery, and you'll become more familiar with it the more you see of it of course. Another thing that we do in the cardiac catheter frequently besides of course taking a look at arteries and fixing those arteries, which we won't go over today because that's a separate talk, we are measuring hemodynamics, measuring pressures inside of the right side of the heart, the right atrium, the right ventricle, what the pressures look like, the pulmonary artery with the swan gans catheter, and wedge pressure, and how to recognize those pressures and these are the different positions of the swan gans catheter. Of course we talked about congenital heart disease and one of the important things that we do as well is measuring oxygen saturation during different parts of the cardiac cycle and different chambers and figuring out if a patient has shunting or not, but this is also important for pulmonary hypertension, for cardiac output, whether it's FIC, cardiac output or thermodilution, but these are all very important things. Hemodynamics are actually the way that the cardiac catheterization laboratory was predominantly focused on measuring hemodynamics and became more therapeutic with time over the last 30 years. Percutaneous mechanical circulatory support is very important, so these are patients who sometimes need blood pressure support and it's kind of a very quick overview of what a balloon pump would look like, an extracorporeal exchange catheter would look like, what a tandem heart would look like, and that's different because it doesn't have an oxygenator unlike the ECMO catheter and kind of pulls blood out of the left atrium and into the femoral artery, or an impella, which is an impeller device that sits in the left side of the heart and pumps blood out of it. Of course a lot of these patients don't need these support catheters and this is only for patients who have hemodynamic compromise, but these are some of the things that we also use in the cardiac cath lab in patients who are not doing well and need hemodynamic support. Again, this is kind of like a 10,000 feet view of what goes on in the cardiac cath lab. There's a lot more, but this is a very brief intro and I want to thank you for your attention.

cardiac cath lab

cardiac catheterization procedures

interventional cardiology

indications

contraindications