Post procedure

This chapter covers the actions required after the patient has undergone their procedure. It begins by explaining the role of the specialist nurse team, the checks that should be performed on the patient once they have returned to the ward, and the process for becoming ambulant. The chapter then goes on to explain how to review the results and data regarding the case. Communication of both results and potential follow-up procedures is then covered. The chapter ends by addressing discharge plans and guidance is given on completing a discharge summary.

Complications

Cardiac catheterization is an invasive study that involves real risks to the patient. The risks increase with patient age and co-morbidity. Though vascular complications (particularly haematoma formation) and vasovagal reactions are more common, the risk of serious complications from diagnostic cardiac catheterization and coronary angiography remains low. This chapter covers complications that may arise, including death, myocardial infarction, pulmonary oedema, stroke, hypotension, cardiac tamponade, contrast reactions, vasovagal reactions, arrhythmias, vascular complications, limb ischaemia, coronary dissection (including left main stem dissection and iatrogenic type A aortic dissection), air embolism, coronary perforation, renal failure, contrast nephropathy, and cholesterol embolization.

Cardiac catheterization

Cardiac catheterization allows the invasive acquisition of haemodynamic data using direct and indirect pressure measurements and oxygen saturations, and provides anatomical information using contrast angiography. Right heart catheterization used to be a routine part of an invasive cardiac study. The increased accessibility and accuracy of non-invasive imaging (in particular, echocardiography and Doppler techniques), however, has reduced the need to perform right heart catheterization. This chapter describes the principal uses of cardiac catheterization, the basics of pressure waveforms, equipment required, accessing the left and right heart, left and right heart pressures and waveforms, how to perform calculations, and the techniques of ventriculography and aortography.

Vascular access

This chapter discusses different types of vascular access in cardiac catheterization. It starts by describing the Seldinger technique, then goes on to explain which arterial access route to use, including difficulties and reasons for choosing an alternative approach and trends in vascular access. The ways of obtaining arterial access (both radial and femoral) are covered, and venous access is examined for the femoral, internal jugular, and subclavian veins. Anticoagulation issues including warfarin and direct oral anticoagulants are then discussed, and the chapter ends by describing compression devices and arterial closure devices.

Additional procedures

This chapter considers additional cardiac procedures that primary operators and team members in the cardiac catheterization laboratory will need an understanding of. This includes emergency interventions such as pericardiocentesis for pericardial tamponade, temporary pacemaker implantation for complete heart block, and cardioversion or defibrillation for cardiac arrhythmias. The chapter describes circulatory support with mechanical cardiopulmonary resuscitation, intra-aortic balloon pumps, and Impella® devices, and discusses the use of extracorporeal membrane oxygenation. Information is also included on how to perform endomyocardial biopsies. The chapter is fully illustrated with schematic diagrams as well as information on indications, contraindications, and methods for each procedure.

Coronary artery bypass graft angiography

Most patients undergoing coronary artery bypass grafting, or CABG, in the past decade will have had a combination of arterial grafts and saphenous vein grafts (or received total arterial revascularization), as conduit patency for mammary arterial grafts has been shown to be significantly higher than that of vein grafts. This chapter covers one of the most common operations performed on patients with three-vessel coronary disease. It describes the role of pre-angiography, choosing an appropriate catheter, and the location of various grafts. It is fully illustrated with clinical images throughout, annotated to aid understanding.

Specific conditions

This chapter covers cardiac catheterization for a number of different heart conditions, including detail on specific valve conditions such as aortic stenosis, transcatheter aortic valve implantation (TAVI) work-up for aortic stenosis, aortic regurgitation, mitral stenosis and regurgitation, and pulmonary and tricuspid valves. The chapter explores the application of cardiac catheterization for pulmonary conditions, pulmonary angiography, and specific findings and procedural detail for patients with atrial and ventricular septal defects, constrictive pericarditis, pericardial tamponade, as well as cardiomyopathies. The chapter concludes with a discussion of different causes of myocardial infarction with non-obstructed coronary arteries and the subsequent investigation of this group of patients.

The team

This chapter covers the different roles for the cardiologist, the nurse, the clinical physiologist, and the radiographer within the heart team. It describes the individuals’ responsibilities and functions from before the procedure starts to post-procedural care and patient discharge. This includes key aspects of periprocedural care such as World Health Organization checklists, sedation, patient monitoring with electrocardiograms and arterial pressure monitors, in addition to trigger points for escalation. The chapter also describes methods of training, annual requirements for procedural numbers, audit, logbooks, and record-keeping and explains some aspects of certification and recertification.

Introduction

This chapter introduces the subject of cardiac catheterization. It starts with background, basic definitions, and a history of the discipline. Indications for both cardiac catheterization and coronary angiography are explored, and the choice between cardiac computed tomography or invasive angiography is discussed. Radiology equipment is explained, along with fluoroscopy and acquisition in terms of optimizing the diagnostic picture with the lowest practicable dose. Following that, radiation safety and protective measures are defined, along with ALARA (‘as low as reasonably achievable’) and dose excess. Finally, preparation of both the patient and the catheter laboratory are covered.

Percutaneous coronary intervention

This chapter covers percutaneous coronary intervention. It starts with the history of the procedure, indications, and techniques for imaging the lesion, and describes different systems of lesion classification. The equipment required for percutaneous coronary intervention, including guiding catheters, angioplasty guide wires, angioplasty balloons, and intracoronary stents (drug-eluting stents, bioabsorbable scaffolds, etc.) are all covered. The percutaneous coronary intervention procedure is then explained. Intravascular ultrasound is compared and contrasted to optical coherence tomography. Antiplatelet and anticoagulant therapies are described in detail, and finally specific techniques in complex PCI are covered.