CATHLAB BASICS PRESENTED BY

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CATHLAB BASICS PRESENTED BY

• GABRIEL K FERNANDES
• CARDIOVASCULAR INTERVENTIONAL TECHNOLOGIST
• METROPOLITAN HEART INSTITUTE RESEARCH CENTRE
  INDIA LTD.
• IN ASSOCIATION WITH RADIOGRAPHERS ASSOCIATION OF
  MAHARASHTRA.

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CARDIAC CATHETERIZATION LABORATORY
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• CONTENTS
• 1 PREFACE
• 2 INTRODUCTION
• 3 THE HEART
• 4 BLOOD PRESSURE
• 5 CORONARY ARTERIES
• 6 CARDIAC PROCEDURES
• 7 BASIC PATHOLOGY OF THE
• HEART

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• Preface
• This book "Cardiac catheterization Basics" is
  aimed for technicians working in the cardiac
  catheterization room who quickly like to refresh
  their knowledge.
• The purpose of this book is to give a basic
  overview of the anatomy,physiology and pathology
  of the heart as a guidance for the
  catheterization procedure and to help to realize
  a good image quality.Since this book only
  provides limited information, It has to be
  considered only as an extra guidance tool.

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• Introduction
• Blood circulation
• There are two distinct systems in the body for
  the blood circulation
• 1.Pulmonary blood circulation
• 2. Systemic blood circulation

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• Pulmonary circulation
• The pulmonary arteries and veins carry blood from
  the heart to the lungs and return it to the
  heart. Blood which returns from the body to the
  heart is pumped into the lungs via the pulmonary
  artery to the lungs. With breathing, the air
  passes into the lungs through progessively
  smaller airways called bronchioles. The lungs
  contain millions of bronchioles, all leading to
  alveoli, microscopic sacs where oxygen and carbon
  dioxide are exchanged.The oxygen rich blood is
  collected into the pulmonary veins of each lung
  and is returned via the heart into the systemic
  circulation.

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• Systemic circulation
• The systemic arteries carry blood via the aorta
  from the heart to all other parts of the body and
  return it to the heart via the vena cava inferior
  and superior. This oxygen rich blood supplies all
  organs and tissue of the body via the
  capillaries. There it exchanges the oxygen with
  carbon dioxide and waste products.

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• The Heart
• The human heart is a muscular pump. The muscle
  layer that takes care of the contraction of the
  heart to decrease the size and forces the blood
  out of its chambers is called myocardium.
• Normally the size of the heart is a little bit
  larger than a human fist. It pumps about 8000
  litres of blood each day.Reaching the age of 70
  years, the number of heart beats will be over 2.5
  billion.The heart is divided into two halves, the
  right and left, by a main septum which extends
  from the base to the apex.There is no
  communication between these halves after birth.
• The right side pumps the blood to the lungs and
  is less powerful than the left side which is the
  pump for the systemic circulation that has to
  drive the oxygen saturated blood to the organs.

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• The four chambers of the heart
• RA ( RIGHT ATRIUM )
• RV ( RIGHT VENTRICLE )
• LA ( LEFT ATRIUM )
• LV ( LEFT VENTRICLE )
• Each half of the heart consists of the two
  chambers which communicate through a valve.The
  upper chambers are called atria, the lower
  chambers are called ventricles.

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• In total the heart has four valves
• The mitral valve is between the left atrium and
  ventricle
• The tricuspid valve is between the right atrium
  and ventricle
• The pulmonary or pulmonic valve is between the
  right ventricle and the pulmonary artery.
• The aortic valve is between the left ventricle
  and the aorta.

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• The cardiac cycle
• The heart beats automatically although it is
  under the control of the nervous system for it
  receives innervation from the vagus nerve and the
  sympathetic nervous system.The pumping action of
  the heart consists of a contraction or systole
  and a relaxation or diastole. Both atria contract
  simultaneously,driving their contents into the
  relaxed ventricles during ventricular
  diastole.The ventricles then simultaneously go
  into systole whereas the atria go into the
  diastole and blood flows into the atria from the
  vena cava to be discharged into the ventricles
  during the next atrial systole.The usual adult
  rate of the heart is about 70 BPM (beats per
  minute) but it increases during exercise or
  excitement and in various abnormal conditions.

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• The rhythm of the cardiac cycle results from the
  coordination of the myocardial contractions
  achieved by special areas in the myocardium. The
  cardiac impulse starts in the sino-atrial node
  situated in the wall of the right atrium,it
  spreads to the atrio-ventricular node and is
  conducted from this point by the Bundle of His
  that divides into several bundle branches to all
  parts of the ventricles.The cardiac cycle is
  accompanied by electrical changes that can be
  detected by the electrocardiograph (ECG).

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• ECG
• A normal ECG has the following features
• P Wave depolarisation.Atrial contraction begins
  (Atrial depolarisation)
• PR interval Atrial contraction
• QRS complex Ventricular contraction begins
  (Ventricular depolarisation)
• ST segment rapid systolic ejection
• T Wave due to ventricular repolarisation
  (relaxation of ventricular muscle)

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• Blood pressure
• The pulse is the dilatation of an artery caused
  by the blood pressure increase due to the
  contraction of the heart. Blood pressure is the
  pressure exerted by the blood against the vessel
  wall.The systolic pressure is determined
  primarily by the rate and volume of ventricular
  ejection in relation to the arterial elasticity.
• Systolic pressure is the pressure during
  contraction of the heart,normally between 100 to
  120 mm Mercury (approximately 16 k Pascal).
• The diastolic pressure is determined by the rate
  of diastolic pressure drop and the heart rate as
  it effects the duration of the diastole.Diastolic
  pressure is the pressure during relaxation of the
  heart, normally between 65 and 80 mm
  Mercury(approximately 11 k Pascal)

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• Pressure measurements
• The three principal attributes of circulating
  blood are flow, volume and pressure. Various
  methods for measuring cardiac output provide
  information concerning total blood flow through
  the heart, but of these three important
  variables, only blood pressure is routinely
  measured in patients. Direct pressure
  measurements have intrinsic value in determining
  certain conditions under which the circulatory
  system is functioning.
• During a coronary angiography several pressures
  at different catheter positions are measured.

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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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• 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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• Pullback pressure
• A Catheter is pulled back from the left ventricle
  into the aorta.
• Example
• left ventricle
• Systolic pressure 188 mm Hg
• End diastolic pressure 151mm Hg
• Heart rate 167 bpm
• aorta
• Systolic pressure 190 mm Hg
• Diastolic pressure135 mm Hg
• Mean pressure 125 mm Hg
• Heart rate158 bpm

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• This pullback method is to make an assessment of
  the aortic valve and very common during a cardiac
  procedure. the two pressures are used for the
  pressure gradient that plays a role in the
  assessment of valvular stenosis.

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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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• Zero Calibration
• (For pressure measurements)
• Before starting a cardiac procedure, a zero
  calibration is done for each patient. According
  to an international agreement, the reference
  level for the pressure measurement system is the
  pressure on the surface of the right atrium. It
  can be assumed that the pressure there is
  identical to atmospheric pressure at the end of
  expiration. It is therefore crucial before each
  examination that the membrane of the pressure
  transducer (Dome) is adjusted to the level of the
  patients right atrium before setting the zero
  balance of the pre-amplifier.
• This reference point is measured using a special
  tool that divides the patients chest height into
  2/5 and 3/5.

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• Cardiac Output
• The cardiac output is mainly influenced by
  changes in the stroke volume and the heart rate.
  (CO SV x bpm)
• The cardiac output in healthy adults is between 5
  and 8 litres per minute.During a cardiac
  procedure, the Cardiac Output (CO) is measured
  using different techniques.

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• Thermodilution
• The Cardiac Output is measured using a special
  thermodilution device. A special Pulmonary artery
  balloon catheter (Swan-Ganz) is used with a
  thermistor at the tip.The catheter is positioned
  in the Pulmonary artery. A cold fluid ( usually
  10 ml saline for adults) is injected. This cold
  saline mixes with the blood causing a decrease in
  blood temperature. This is sensed by the
  thermistor.
• The cardiac output is measured by the change in
  temperature over time.

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• Fick
• Applied to the lungs, the Fick principle is used
  to calculate the volume of blood required to
  transport the oxygen taken up from the alveoli
  per unit time.
• This calculation can be done using special
  hemodynamic software that requires the following
  input
• Haemoglobin (Hb)
• Venous oxygen saturation (VO2)
• Oxygen saturation taken from aorta
• Oxygen saturation from pulmonary artery
• Body surface area (BSA)
• Weight
• Height
• Sex

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• Ventriculography
• With the help of X-ray images and special
  software of the system (Ejection Fraction
  program), the cardiac output can be measured.

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• Coronary arteries
• There are two main coronary arteries - the left
  and right.The left coronary artery begins as a
  main stem called the Left Main Coronary Artery
  (LMCA) which varies between 1 and 15 mm in
  length. This artery divides in two major
  branches, the Left Anterior Descending artery
  (LAD) and the Circumflex artery (CX).
• The Right Coronary Artery (RCA) is a single long
  vessel with smaller side branches.
• The LAD and CX each supply large areas of heart
  muscle with blood. The coronary artery tree is
  categorized into three systems based on the mass
  of heart muscle which are supplied with oxygen.

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• The Left Anterior Descending Artery (LAD)
• The LAD is a branch that runs on the front of the
  heart in the groove that demarcates the left and
  right ventricles. This artery supplies oxygen and
  nutrients to a large part of the
  inter-ventricular septum and the front wall of
  the left ventricle. Obstruction of this artery
  causes infarction of a large muscular area in the
  left ventricle and may be fatal.

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• The Circumflex Artery (CX)
• The CX is the other major branch of the LMCA and
  turns backwards to run along the groove between
  the left atrium and ventricle.This artery has
  multiple smaller side branches that supply blood
  to the left margin of the ventricle. Since this
  margin is obtusely angled, these branches are
  also called obtuse marginal (OM) branches, of
  which there may be a varying number (1-7). These
  OM branches also supply a considerable area of
  ventricle muscle, and may cause serious damage if
  diseased.

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• The Right Coronary Artery (RCA)
• The RCA is the other main coronary artery branch
  arising from the aorta and running in the groove
  between the right atrium and ventricle. This
  artery is usually smaller than the LMCA, and
  supplies a smaller area of heart muscle,mainly
  the right ventricle. As it curves behind the
  heart, the RCA has two side branches - the
  Posterior Descending Artery (PDA) and the
  Posterior Left Ventricular Branches (PLB). The
  PDA supplies blood to the posterior portion of
  the interventricular septum and the PLB supplies
  a part of the back wall of the left ventricle.

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• Other important coronary artery branches
• While the "big three" are the major branches,
  some smaller ones may be quite important as well.
  The sino-atrial node artery supplies the S-A node
  which is the pacemaker of the heart and sets its
  rhythm.
• This branch comes off the RCA in 55 and off the
  LCA in the other 45.The atrio-ventricular node
  artery supplies the A-V node, which is located
  between the atria and ventricles and controls
  spread of electrical impulses from the atrium to
  the ventricle. While in 90 of cases this branch
  originates from the RCA, in the other 10 it may
  be a branch of the CX.Damage or blockage of this
  branch may result in a serious arrhythmia called
  heart block".

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• Cardiac procedures
• The cath-lab is used for several procedures, the
  following will give an overview of the most
  common diagnostic and intervention procedures.

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• Cardiac catheterisation
• Cardiac catheterisation may be indicated for
• 1.Unstable angina
• 2.Abnormal treadmill test
• 3.Valvular disease
• 4.Acute myocardial infarction (heart attack)
• 5.Cardiomyopathy and/or heart failure

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• The following information can be obtained from a
  cardiac catheterisation
• 1 Determination of presence of stenoses
  (narrowing) in the coronary arteries or
  coronary artery bypass grafts
• 2 Determination of how well the heart muscle
  squeezes (contractibility)
• 3 Evaluation of the heart valves
• 4 Measurement of various pressures inside the
  chambers of the heart
• 5 Determination of presence of any birth defects
  or shunts

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• Procedure
• Catheters are pushed up in the aorta, usually via
  the femoral or brachial artery and then into the
  coronary arteries. Contrast medium is injected to
  assess blood flow through the artery while
  various exposures are taken from different
  angles. Then another catheter,pigtail shaped, is
  placed into the aorta where pressure measurements
  are made. This catheter is then advanced across
  the aortic valve and pressures within the left
  ventricle are obtained.The catheter is then
  attached to an injector and contrast medium is
  injected.Pressure measurements are again taken
  after injection of contrast medium and as the
  catheter is withdrawn back across the aortic
  valve and then removed.

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• Projections
• To visualise the coronary arteries several
  projections are necessary. When mentioning the
  various projections, remember that L.A.O.
  rotation indicates that the Image Intensifier is
  rotated to the left side of the patient. R.A.O.
  rotation indicates that the Image Intensifier is
  rotated to the right side of the patient. Using
  cranial angulation the Image Intensifier
  angulates to the patients head while using the
  caudal angulation the Image Intensifier angulates
  towards the patients feet.

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• To recognize the different vessels one can think
  of the following hints
• - The Circumflex lies closest to the spine
• - Only the LAD (Left Artery Descendens) reaches
  the apex
• - In L.A.O. position, the apex points to the left
• - In L.A.O. position, the LAD lies to the left
• - In L.A.O. position, the spine is on the right
• - In R.A.O. position, the spine is on the left
• - In R.A.O. position, the apex points to the
  right.
• - In L.A.O. position, the RCA (Right Coronary
  Artery) resembles a C.

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• Left Coronary arteries
• R.A.O. 30o
• The Right Anterior Oblique R.A.O. projection at
  30o permits the entire circumflex system to be
  studies as well as the first centimetres of the
  anterior inter ventricular artery.

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Left Coronary artery R.A.O. 30o
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• Left Coronary arteries
• L.A.O. 55/60o
• The Left Anterior Oblique (L.A.O.) projection at
  55/60o mainly studies the diagonal arteries and
  the mid and distal parts of the LAD. On the other
  hand the circumflex is not well defined.

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Left Coronary artery L.A.O. 55/60o
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• Left Coronary arteries
• L.A.0. 55/60o 20o cranial projection
• The cranial angulation of 20o combined with the
  L.A.O. projection at 55/60o is especially useful
  to study the left main coronary artery.

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Left Coronary artery L.A.0. 55/60o 20o cranial
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• Left Coronary arteries
• Left Lateral projection
• The left lateral projection, allows the study of
  the different segments of the anterior inter
  ventricular artery, the first diagonal artery and
  the left marginal artery.

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Left Coronary artery in Left Lateral
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• Right Coronary artery
• Left lateral projection
• This projection permits the study of the second
  (vertical segment of the right coronay artery and
  the collateral branches (conus branch, right
  ventricular artery, right marginal artery)

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Right Coronary artery in Left lateral
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• Right Coronary artery
• L.A.O. 45o 15o caudal angulation
• This projection allow the whole study of the
  R.C.A. and clearly defines the region of the crux
  of the heart.

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Right Coronary artery in L.A.O. 45o 15o caudal
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• Right Coronary artery
• R.A.O. at 45o
• The Right Anterior Oblique (R.A.O.) projection at
  45o permits the survey of the second (vertical)
  segment of the right coronary artery, the
  posterior inter ventricular artery and the
  collateral branches (right ventricular and right
  marginal arteries).

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Right Coronary artery in R.A.O. 45o
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• Left ventricle angiogram
• To measure various pressures and to visualize how
  well the left ventricle contracts, a pigtail
  shaped catheter is used. This catheter has
  several side holes to make it possible to inject
  contrast using a high flow rate.
• The left ventricle can be divided into several
  areas to determine which part of the ventricle
  muscle is not functioning properly.
• The projection most used to visualise the left
  ventricle is RAO 30o

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• Optimize image quality
• The patients treatment depends on the diagnosis.
  Therefore the image quality plays a major role.
  To obtain the best image quality, the following
  factors have to be taken into account.

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• Shutters
• Shutters are built in the system to adjust the
  field of view and to avoid showing white margins
  at the edges of the image that might interfere
  with the perception of image detail. Be aware
  that if the field of view is set too small, there
  is a risk to miss some of the anatomy.

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• Wegde filters
• To prevent distracting highlights in the region
  of interest (lung tissue) that will affect image
  quality, wedge filters can be used.

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• Protocol
• Image quality is also determined by the protocol
  selected. Within each protocol several parameters
  are optimised for a certain exposure technique or
  projection. It is therefore of utmost importance
  to select the correct protocol before starting a
  diagnostic exposure run.

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• Image Intensifier position
• The image intensifier is moved away from the
  patient in preparation of the next projection
  using a different rotation and or angulation. To
  avoid air gaps that deteriorate image quality,
  the distance between the image intensifier and
  the patient should be minimized every time again
  after change in projection view.

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• Patient communication
• A good patient communication will reduce patient
  physical or respiratory movement during image
  acquisition.

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• Catheter position
• When starting an image acquisition, the best
  image quality is achieved when the whole anatomy
  of the coronary arteries is visible without
  having to move the table.
• This is possible when having the catheter tip
  positioned correctly within a certain area of the
  field of view on the monitor.

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• To give an indication of the position of the
  catheter tip for each projection, the field of
  view is divided into 9 zones.
• If the tip is within the zone 1,2,3 or 5, then in
  most of the acquired runs the whole anatomy of
  the coronary arteries will be within the field of
  view without having to move the table.
• Examples

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• To give an indication of the position of the
  catheter tip for each projection, the field of
  view is divided into 9 zones.
• If the tip is within the zone 1,2,3 or 5, then in
  most of the acquired runs the whole anatomy of
  the coronary arteries will be within the field of
  view without having to move the table.
• Examples

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Left coronary arterty and Circumflex
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Left coronary arterty and Circumflex
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Right coronary artery
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• Interventions
• PTCA
• Percutaneous Transluminal Coronary Angioplasty
  (PTCA) is a procedure to attempt to open up a
  narrowed artery by using a catheter that has a
  balloon at the tip of it. When the balloon is
  inflated, the pressure flattens the plaque
  against the walls of the artery which will then
  improve the blood flow to the heart.

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• Procedure
• The balloon catheter has a radiopaque marker in
  the middle portion of the balloon. Note that
  there are also balloon catheters with proximal
  and distal markers.The central marker is placed
  in the middle of the coronary artery stenosis.
  The balloon is then slowly inflated with a small
  hand-held pump that is filled with contrast. The
  balloon is inflated until there is no dent in the
  balloon. The balloon is left inflated anywhere
  from one to two minutes depending on the
  individual case and watched under fluoroscopy.
  Several inflations may be necessary to achieve
  the desired reduction of the stenosis.

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• Stent placement
• Stent placement is a procedure that often follows
  the PTCA. Once the narrowed artery is opened, a
  stent reduces the likelihood that the artery will
  narrow again. Coronary stents are stainless steel
  frames attached to a special designed balloon
  catheter. The stent is expanded by inflating the
  balloon. Once the stent is expanded succesfully
  the balloon is deflated. The stent itself is
  designed in such a way that it remains it shape
  after deflating the balloon.
• Drug eluting stents reduce the risk of
  re-stenosis.

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• Other ways of reducing a coronary blockage
• Instead of using a balloon there are other
  devices to increase the lumen of the coronary
  arteries

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• Angiojet
• An angiojet can be used to widen a coronary
  artery that is narrowed due to a fresh thrombus.
  This high pressure jet creates a low pressure
  region within the blood vessel and the whole
  system acts like a vacuum cleaner and sucks up
  the fresh thrombus.

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• Atherectomy
• Used on hard plaque which a balloon is unable to
  compress. A special atherectomy catheter has a
  small knife to shave off the plaque. The catheter
  consists of a shaft on which a balloon is mounted
  on one side, on the side opposite the balloon
  there is an opening in the shaft, which allows
  the blade to protrude. The catheter is positioned
  with the opening over the plaque and the balloon
  inflated to hold the catheter in place. The blade
  is then moved back and forth across the plaque,
  the shavings are sucked back via the catheter.
  Once the plaque has been de-bulked, the normal
  PTCA procedure or stent placement will follow.

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• Rotablator
• The rotablator is primarily used for concentric
  hard plaque and calcified lesions. It uses a
  diamond powder coated tip on a catheter at high
  speed 80.000 to 150.000 rpm) to de-bulk the
  lesion prior to PTCA procedure and stent
  placement.

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• Electrophysiology (EP)
• Reason for an Electrophysiology study (EP) is
  arrhythmia, or abnormal heart rhythm

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• EP mapping procedure.
• Pacing wires are positioned in various areas in
  the heart. These wires are connected to a large
  computer, which allows specific measurements of
  all parts of the hearts electrical system. This
  test takes approximately 1 to 3 hours to
  complete. If the arrhythmia is reproduced the
  arrhythmia may terminate itself, or an electrical
  shock, delivered through adhesive patches on the
  chest and back may return the rhythm to normal.

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• Ablation
• Catheter ablation is a technique to eliminate
  alternate pathways present in the heart causing
  arrhythmias (abnormal heartbeats) that interfere
  with the normal conduction.

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• Procedure
• Once the area of the heart has been defined
  through catheter mapping, a special ablation
  catheter is placed at the site of the abnormal
  pathway.Radiofrequency waves are delivered
  through this catheter. The heat formed by this
  catheter causes scar tissue on this pathway of
  cells so that the abnormal conduction cannot pass
  through.

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• Pacemaker
• Pacemaker implantation is done on patients with
  severe heart rhythm disturbances. If the SA node
  sends impulses out too slowly, it results in a
  rhythm that is too slow. This is called "Sick
  Sinus Syndrome". Another situation may result
  from impulses being blocked at some point along
  the electrical pathway in the heart. This is
  called heart block, and can also result in a
  rhythm which is too slow.

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• Procedure
• An incision is made, and the pacemaker lead is
  placed through the subclavian vein which leads
  directly to the right side of the heart. A small
  pocket is then made in the upper chest area and
  the pacemaker generator is placed. The lead will
  be connected to the generator, checked and
  programmed. The incision is then closed.

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• IABP
• The Intra-Aortic Balloon Pump (IABP) is a
  mechanical device to reduce the workload of the
  heart and to improve blood flow to the coronary
  arteries.The pump consists of a balloon attached
  to the end of a catheter. The balloon sits in the
  aorta and opens and closes in response to the
  hearts contractions. After the heart contracts
  and propels oxygen-rich blood into the aorta, the
  balloon rapidly opens up and propels some of the
  oxygen-rich blood back toward the coronary
  arteries. Just before the hearts next
  contraction, the balloon rapidly deflates
  creating a lower pressure in the aorta so the
  heart does not have to work as hard to pump the
  blood out.

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• Basic pathology of the heart

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• Arteriosclerotic coronary disease
• In all blood vessels of all people some fatty
  material starts to build up on the inside of the
  blood vessel walls. In some people the rate of
  deposit of fatty material is faster than in
  others resulting in atherosclerose or
  arteriosclerosis.
• Although the terms are used interchangeably,
  atherosclerose is a type of arteriosclerosis that
  is characterised by deposits of plaque.
• Arteriosclerosis is particularly dangerous when
  the vessel that is involved is a coronary artery
  and the lumen is narrowed by 50 to 70 of its
  normal diameter.
• Arteriosclerosis can lead to angina pectoris,
  heart attack or myocardial infarction.

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• Valvular diseases
• The heart has four valves. Any of these valves
  may fail to function properly,but most commonly
  the valves on the left side of the heart are
  affected. The valves may narrow, called stenosis,
  or may close incorrectly, called prolapse.

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• Aortic valve stenosis
• Aortic valve stenosis results in having the left
  ventricle to work harder to push out the blood.
  As this occurs the muscular walls of the
  ventricle thicken.

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• Aortic regurgitation
• When the aortic valve fails to close completely
  after the heart has pumped out the blood into the
  aorta, blood leaks back into the left ventricle.
  This may be the result of an endocarditis
  (infection) or heart attack. It may leave the
  valve scarred resulting in improper functioning
  of the valve.

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• Mitral stenosis
• A mitral stenosis results in an increase of
  pressure in the left atrium leading to an
  elevation of the pressure in the lungs.

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• Mitral regurgitation
• Improper closure of the mitral valve causes blood
  to leak from the left ventricle back into the
  left atrium. This may be the result of an
  endocarditis (infection) or heart attack. It may
  leave the valve scarred resulting in improper
  functioning of the valve.

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• Congenital diseases
• Valve damage is not the only congenital condition
  that can damage the heart.Other forms of
  congenital heart disease include holes in the
  septum that allow the blood to leak or flow
  directly from one chamber into another,rather
  than flowing in the proper direction through the
  valves.

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• Left-to-right shunt
• Part of the blood flow goes directly from the
  left side of the heart to the right side of the
  heart. The hole can either be between the atria
  or between the ventricles.
• The patent hole (foramen ovale) between the atria
  is called the Atrial-Septal-defect.
• The hole between the ventricles is called the
  Ventricular-Septal -defect

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• Patent ductus Botalli
• If the communication between the aorta and the
  pulmonary veins remains after birth,
  de-oxygenated blood mixes with the systemic
  circulation.

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• Coarctation of the aorta
• This is a narrowing (stenosis) in the proximal
  descending part of the aorta. The aortic valves
  are usually narrower than normal.

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