ANAESTHESIA FOR CATHLAB PROCEDURES BASICS

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Cardiac Catheterization

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The history…. Werner Forssmann in 1929 – performed the 1st cardiac catheterization on himself!! He introduced catheter through his own left anticubital vein into the right atrium!!!! Forssmann, Cournard, and Richards – Nobel prize in Medicine for work in the field. Dr.Charles Dotter - Father of interventional cardiology pioneered concept of transluminal angioplasty known as dotter’s technique in1964. In 1967Juddkinn devloped femous transfemoral approach of cardiac catherization most commonly used now. Dr. Andres Gruntzig performed first succesful angioplasty in 1974.

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Indications of cardiac catheterization… Diagnostic :- Hemodynamics of heart ( chamber pressures, sizes, O2 saturations). Coronary angiography for CAD. Rheumatic heart diseases. Congenital heart diseases. Endovascular ultrasound. EPS (conduction studies) Interventional procedures :- Coronary interventions ( PTCA, Stents, atherectomy) . Coil embolization of BT shunts, APCs, aneurysms. Trans catheter device closure of PDA, VSD,ASD. Balloon dilatation of PS, MS, AS, TS, Atrial septostomy. Ablation of arrythmogenic foci. Pacemaker and ICD implantation. Elective cardioversion.

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4 Cardiac Catheterization O2 Sats Structure Pressure in Chamber Repair Defects Intra-arterial Balloon Coronary Intervent’ns

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Fetal Circulation… For the fetus the placenta is the oxygenator so the lungs do little work. RV & LV contribute equally to the systemic circulation and pump against similar resistance. Shunts are necessary for survival ductus venosus (bypasses liver). foramen ovale (R?L atrial level shunt). ductus arteriosus (R?L arterial level shunt).

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Transitional Circulation With first few breaths lungs expand and serve as the oxygenator (and the placenta is removed from the circuit). Foramen ovale functionally closes. Ductus arteriosus usually closes within first 1-2 days.

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Neonatal Circulation RV pumps to pulmonary circulation and LV pumps to systemic circulation. Pulmonary resistance (PVR) is high; so initially RV pressure ~ LV pressure. By 6 weeks pulmonary resistance drops and LV becomes dominant.

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Normal pediatric/adult circulation… LV pressure is 4-5 x RV pressure (this is feasible since RV pumps against lower resistance than LV) RV is more compliant chamber than LV

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Normal Heart No shunts. No pressure gradients. Normal AV valves. Normal semi lunar Valves. Normal coronaries. 75% 100% 20/ 90/ 20/8 90/ 60 100% 75%

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How Cath Lab looks…..? Patient care area A narrow, mobile operating table surrounded by an image intensifier and camera similar to a C-arm.

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How Cath Lab looks…..? Control station The control room houses a fully functional computer workstation that allows the interventionalist to control basic fluoroscopic maneuvers.

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Right Heart Catheterization procedure involves measurement of the pressures in the right side of the heart. Used in significant left and/or right ventricular dysfunction, valve disease, myopericardial disease, or where intracardiac shunting is suspected. balloon flotation catheter is inserted percutaneously into a suitable vein (femoral, brachial, subclavian, or internal jugular) . Catheter advanced to right atrium, right ventricle, pulmonary artery, and pulmonary artery wedge position. Pressure is recorded at each of these locations.balloon is deflated so that blood samples obtained for oxygen saturation measurement to screen for intracardiac shunts . Estimationof cardiac output :- Fick principle ,thermodilution method, using a thermistor on the catheter to analyze the temperature deviations in the pulmonary artery following a 10-mL bolus injection of room-temperature IV solution into the right atrium.

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Right heart pressures… Right atrium A catheter is guided into the right atrium. Example: Value: 18 mm Hg Mean: 15 mm Hg Heart rate: 89 bpm.

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Right ventricle A catheter is guided into the right ventricle passing through the tricuspid valve. Example: Systolic pressure: 42 mm Hg End diastolic pressure: 8 mm Hg Heart rate: 84 bpm.

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Pulmonary artery A catheter is pushed into the pulmonary artery passing through the pulmonary valve. Example: Systolic pressure: 29 mm Hg Diastolic pressure: 15 mm Hg Mean pressure: 21 mm Hg Heart rate: 130 bpm.

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Pulmonary capillary wedge pressure A catheter is guided into the left or right pulmonary capillary wedge position. Example: Value: 18 mm Hg Mean: 13 mm Hg Heart rate: 77 bpm.

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Left atrium pressure… A catheter may be pushed into the left atrium passing through the mitral valve.If there is a mitral stenosis it may not be possible to push the catheter into the left atrium. The Pulmonary Capillary Wedge pressure from the right heart catherisation may substitute the left atrium pressure. Example: Mean: 13 mm Hg Heart rate: 82 bpm Value: 18 mm Hg.

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Left heart catheterization and Normal pressure tracings…. Left ventricular (LV), radial artery, and pulmonary capillary wedge (PCW) pressures in a patient with normal cardiovascular function. Note the absence of a pressure gradient between the LV and radial artery in systole and between the LV and PCW in diastole. Pressure(mmHg) Time (sec) Left heart catheterization:- percutaneous femoral artery cannulation by sheldinger”s technique. Passing 6 F catheter in aorta & then in left ventricle in ventriculography, pulmonary trunk and pulmonary wedge for PCWP. An arterial transducer is attached to external end of catheter using a special bivalve,”MANIFOLD”.

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Left heart pressures… The following graphs give only an indication of the shape of the graph for each different measured pressure. The pressure gives only a rough indication of possible measured values.

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Aortic pressure A catheter is guided into the ascending part of the aorta. Example: Systolic pressure: 118 mm Hg Diastolic pressure: 57 mm Hg Mean pressure: 81 mm Hg Heart rate: 54 bpm.

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Left ventricle pressure A catheter is guided into the left ventricle passing through the aortic valve. Example: Systolic pressure: 166 mm Hg End diastolic pressure: 32 mm Hg Heart rate: 80 bpm.

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Normal cardiac catheterization data Pressure in mmHg Oxygen saturation Newborns Older children Right atrium (%) 60–80 a wave 3–8 5–10 v wave 2–6 4–8 Mean 0–4 2–6 Right ventricle (%) 65–75 Systolic 65–80 15–25 End-diastolic 2–7 3–8

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Normal cardiac catheterization data... Pressure in mmHg Oxygen saturation Newborns Older children Pulmonary artery ( %) 65–75 Systolic 65–80 15–25 Diastolic 35–50 8–12 Mean 40–70 10–16 PA wedge (%) 95–100 a wave 6–10 8–14 v wave 7–11 10–17 Mean 5–8 7–13

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Normal cardiac catheterization data... Pressure in mmHg Oxygen saturation Newborns Older children Left atrium (%)95–100 a wave 4–7 6–12 v wave 6–12 8–15 Mean 3–6 5–10 Left ventricle (%)95–100 Systolic 65–80 90–120 End-diastolic 3–7 2–5 Aorta (%)95–100 Systolic 65–80 90–120 Diastolic 45–60 60–75 Mean 55–65 70-90

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Normal flows & resistances newborns older children Flows L/min/BSA² Pulmonary 3.5–5.0 3.5–5.0 Systemic 3.5–5.0 3.5–5.0 Resistances Woods units × m2 BSA Pulmonary 8–10 1–3 Systemic 10–15 30

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Normal adult catheterization data SITE PRESSURE(mm Hg) O2 SATURATION (%) Inferior vena cava 0–8 80 ± 5 Superior vena cava 0–8 70 ± 5 Right atrium 0–8 75 ± 5 Right ventricle 15–30/0–8 75 ± 5 Pulmonary artery 15–30/4–12 75 ± 5 Pulmonary wedge 5–12 (mean) 75 ± 5 Left atrium 12 (mean) 95 ± 1 Left ventricle 100–140/4–12 95 ± 1 Aorta 100–140/60–90 95 ± 1

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Normal coronary anatomy…

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Coronary Artery Distribution ?LEFT CORONARY ARTERY Anterior descending branch Right bundle branch Left bundle branch Anterior and posterior papillary muscles (mitral) Anterolateral left ventricle ?CIRCUMFLEX BRANCH Lateral left ventricle ?RIGHT CORONARY ARTERY SA and AV nodes Right atrium and ventricle Posterior interventricular septum Posterior fascicle of left bundle branch Interatrial septum AV, atrioventricular; SA, sinoatrial.

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coronary anatomy relative to the interventricular and atrioventricular valve planes

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Procedure of coronary angiography… Femoral artery cannulation is performed by sheldinger’s technique. 6 F aortic catheter is passed . Through this a smaller size 1.5 Fpliable catheter is passed down aortic arch. coronary ostium is identified by hinging catheter in ostium. Radiocontrast dye is injected. Coronaries are visualised by fluroscopy.

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Normal coronary angiogram

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Left coronary arterty and Circumflex

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Right coronary artery

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Procedure of coronary angioplasty femoral artery cannulation with a sheath. coronary angiography. The target lesions for PCI are identified. Anticoagulation unfractionated heparin 50–70 IU/kg A guiding catheter 1.5 F placed in coronary artery ostium . steerable 0.4-mm guidewire is advanced across the target stenosis distal vessel beyond. advancement of a predilating balloon ~0.5 mm< caliber of target vessel, across the lesion. balloon is inflated to pressure of 6–16 atm. the stenosis is relived.

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CORONARY ANGIOPLASTY In this patient, there is a subocclusive filling defect in the left anterior descending artery (left). underlying lesion is treated by bifurcation stenting in the left anterior descending artery and the involved diagonal branch (right).

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Balloon mitral valvotomy… Right heart catheterisation done through rt femoral vain. transseptal puncture is done by guidewire. the deflated balloon catheter is advanced across the inter-atrial septum.

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Balloon mitral vulvotomy Deflated balloon catheter is advanced across the mitral valve into the left ventricle. The balloon is then inflated stepwise within the mitral orifice.

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Balloon mitral valvotomy… Pliable balloon tip is inflated & catheter is pulled so that it fits well in mitral orifice.

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balloon is directed across the valve and inflated in the valvular orifice. Balloon mitral valvotomy…

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WHY Are We Called…….? To anasthetize Pediatric patients for cardiac catherization. To give consious sedation for coronary intervention procedures. To anasthetize patients for ICD implantation. Cardiopulmonary ressuciatation. As a stand by anaesthesia for emergency coronary interventions… for intubation….!!!!!

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WHY Are We Called…….? High risk cases where major hemodynamic changes are expected. To sedate child during 2D ECHO. As a helping hand for rapid management of complications like pericardial tamponad etc. Other high risk cases as mentioned below...

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When the Risk is High….? Functional class- ? mortality for class IV. Severity of coronary obstruction- ? mortality for left main disease compared with one/ two vessel disease. Valvular heart disease- ?? risk with CAD. Left ventricular dysfunction- ? mortality with EF =30%. Severe noncardiac disease-renal insufficiency, IDDM, advanced peripheral and cerebral vascular disease, severe pulmonary insufficiency.

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When not to do….? Relative contraindications:- Uncontrolled ventricular irritability: ? risk of VF/VT. Uncorrected hypo K+ or digitalis toxicity. Uncontrolled hypertension- ? risk of MI/ CCF. Intercurrent febrile illness. Decompensated heart failure: acute pulmonary edema. Anticoagulation state : PT > 18 sec. Severe allergy to contrast agent. Severe renal insufficiency.

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THANK YOU ! ! !

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