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CATHLAB BASICS PRESENTED BY

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Title: CATHLAB BASICS PRESENTED BY


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

5
  • 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.

6
  • Introduction
  • Blood circulation
  • There are two distinct systems in the body for
    the blood circulation
  • 1.Pulmonary blood circulation
  • 2. Systemic blood circulation

7
  • 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.

8
  • 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.

13
  • 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.

16
  • 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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22
  • 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)

23
  • 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.

24
  • 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

33
  • 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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41
  • 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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43
  • 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.

46
  • 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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48
  • 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

49
  • 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.

52
  • 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.

53
  • 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.

54
  • 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.

55
  • 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.

58
  • 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

59
  • 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.

62
  • 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.

65
Left Coronary artery R.A.O. 30o
66
  • 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.

67
Left Coronary artery L.A.O. 55/60o
68
  • 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.

69
Left Coronary artery L.A.0. 55/60o 20o cranial
70
  • 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.

71
Left Coronary artery in Left Lateral
72
  • 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)

73
Right Coronary artery in Left lateral
74
  • 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.

75
Right Coronary artery in L.A.O. 45o 15o caudal
76
  • 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).

77
Right Coronary artery in R.A.O. 45o
78
  • 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.

83
  • Wegde filters
  • To prevent distracting highlights in the region
    of interest (lung tissue) that will affect image
    quality, wedge filters can be used.

84
  • 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.

86
  • Patient communication
  • A good patient communication will reduce patient
    physical or respiratory movement during image
    acquisition.

87
  • 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

89
  • 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

90
Left coronary arterty and Circumflex
91
Left coronary arterty and Circumflex
92
Right coronary artery
93
  • 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.

96
  • Other ways of reducing a coronary blockage
  • Instead of using a balloon there are other
    devices to increase the lumen of the coronary
    arteries

97
  • 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.

98
  • 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.

99
  • 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.

100
  • Electrophysiology (EP)
  • Reason for an Electrophysiology study (EP) is
    arrhythmia, or abnormal heart rhythm

101
  • 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.

102
  • 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.

104
  • 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

108
  • 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.

109
  • 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.

112
  • 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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