CARDIAC CATHETERIZATION

Question 1

What constitutes cardiac catheterization?

Answer 1

Cardiac catheterization typically includes:
* Coronary angiogram
* Left heart catheterization
* Left ventricular (LV) angiogram
* Right heart catheterization

Coronary angiogram involves opacification of coronary arteries with iodinated contrast after selective cannulation.

Question 2

What is a coronary angiogram?

Answer 2

Opacification of coronary arteries with iodinated contrast after selective cannulation using specialized end-hole catheters

Catheters are inserted via peripheral arterial access, usually femoral or radial.

Question 3

What is the purpose of left heart catheterization?

Answer 3

To place a catheter within the LV to record LV systolic and end-diastolic pressures.

Question 4

Why are most operators shying away from routinely performing LV angiogram?

Answer 4

To minimize contrast use and radiation exposure, especially when the same information can be obtained from an echocardiogram.

Question 5

What are the indications for coronary angiogram?

Answer 5

Indications include:
* Candidates for coronary revascularization
* Unacceptable ischemic symptoms despite optimum medical therapy
* Suspected symptomatic CAD with indeterminate stress test results
* Unexplained left ventricular systolic dysfunction
* Stress testing suggesting multivessel disease.

Question 6

What are the major complications of cardiac catheterization?

Answer 6

Major complications include:
* Death
* Periprocedure stroke
* Myocardial infarction
* Mechanical ventilation
* Major vascular complications
* Other risks include radiation exposure, contrast-induced nephropathy.

Question 7

What percentage risk is there for any major complication during cardiac catheterization?

Answer 7

< 1%

Question 8

What is the risk of procedural mortality during cardiac catheterization?

Answer 8

Approximately 1 in 1000.

Question 9

Which patients should be premedicated to prevent allergic reactions to iodine-based contrast?

Answer 9

Patients with a history of true allergic reactions to iodine-based contrast.

Question 10

What is the common premedication regimen for allergic patients?

Answer 10

50 mg prednisone orally at 13, 7, and 1 hour prior to the procedure, and 50 mg diphenhydramine an hour prior.

Question 11

What are the major risk factors for contrast-induced nephropathy (CIN)?

Answer 11

Major risk factors include:
* Preexisting renal disease
* Diabetes.

Question 12

What is the most important method to reduce the risk of contrast nephropathy?

Answer 12

Periprocedure hydration.

Question 13

How are coronary angiographic projections named?

Answer 13

Named according to the position of the image intensifier and degree of angulation.

Question 14

What does LAO stand for in angiographic projections?

Answer 14

Left anterior oblique.

Question 15

What is considered a significant stenosis for the left main coronary artery (LMCA)?

Answer 15

≥ 50% diameter stenosis.

Question 16

What is considered a significant stenosis for other coronary arteries?

Answer 16

≥ 70% diameter stenosis.

Question 17

What does fractional flow reserve (FFR) measure?

Answer 17

The ratio of distal coronary pressure to proximal aortic pressure after maximal hyperemia.

Question 18

What FFR value indicates a physiologically significant stenosis?

Answer 18

A ratio less than 0.75 to 0.80.

Question 19

What is the significance of a coronary flow reserve decrease?

Answer 19

Begins to decrease when a coronary artery stenosis is 50% or more of the luminal diameter.

Question 20

What is the role of quantitative coronary angiography (QCA)?

Answer 20

More objectively assesses lesion severity than ocular judgment.

Question 21

What are the standard angiographic views to image the left coronary system?

Answer 21

Best visualized in AP projection with slight caudal angulation.

Question 22

What is the initial imaging view for the right coronary artery (RCA)?

Answer 22

LAO 30-degree view.

Question 23

What access is increasingly used over femoral access for cardiac catheterization?

Answer 23

Radial access.

Question 24

What are the benefits of radial access for cardiac catheterization?

Answer 24

Lower incidence of vascular complications such as bleeding.

Question 25

What does FFR stand for?

Answer 25

Fractional flow reserve

FFR is a measure used to assess the physiological significance of coronary artery stenosis.

Question 26

What is the normal value range for FFR?

Answer 26

Close to 1

A ratio less than 0.75 to 0.80 indicates a physiologically significant stenosis.

Question 27

What is considered a physiologically significant stenosis based on FFR values?

Answer 27

Less than 0.75 to 0.80

Question 28

What is the relationship between the size of the myocardium supplied by a vessel and FFR significance?

Answer 28

The larger the myocardium, the more likely it will be found functionally significant by FFR.

Question 29

What is the effect of an FFR-guided revascularization approach?

Answer 29

It significantly reduces overall costs, the number of stents placed, and the need for urgent revascularization.

Question 30

What does iFR stand for?

Answer 30

Instantaneous wave-free ratio

iFR is a method to assess coronary artery lesions without the use of adenosine.

Question 31

How does iFR differ from FFR?

Answer 31

iFR measures pressures during a specific diastolic interval, while FFR measures during maximal hyperemia induced by adenosine.

Question 32

What is the cutoff ratio for significant stenosis in iFR?

Answer 32

Less than 0.90

Question 33

What is the purpose of intravascular ultrasound (IVUS)?

Answer 33

To provide direct assessment of coronary arterial vasculature

IVUS utilizes a flexible catheter with a miniature ultrasound probe.

Question 34

What can IVUS accurately assess regarding plaque morphology?

Answer 34

Plaque types ranging from fatty to fibrotic to calcific.

Question 35

What is a key advantage of using IVUS in percutaneous coronary intervention?

Answer 35

It helps ensure optimal stent expansion and apposition, leading to decreased stent failure.

Question 36

What imaging technique uses near-infrared light to assess arterial anatomy?

Answer 36

Optical coherence tomography (OCT)

OCT provides higher resolution images compared to IVUS.

Question 37

What is a disadvantage of OCT compared to IVUS?

Answer 37

OCT requires the absence of blood in the visualized portion of the artery for image acquisition.

Question 38

How is aortic regurgitation assessed during cardiac catheterization?

Answer 38

By performing an aortogram and noting the amount of contrast regurgitating into the left ventricle.

Question 39

What is the grading scale used for regurgitation assessment?

Answer 39

1 to 4 system

1 indicates little if any regurgitation, while 4 indicates profound or severe regurgitation.

Question 40

What are the three methods used to describe the aortic transvalvular gradient?

Answer 40

• Peak instantaneous gradient
• Peak-to-peak gradient
• Mean gradient

Question 41

What are vascular closure devices (VCDs)?

Answer 41

Hemostatic devices that reduce the need for prolonged compression at the femoral access site.

Question 42

What is intracardiac echo (ICE)?

Answer 42

Direct imaging of cardiac structures via transvenous insertion of a miniaturized echo probe.

Question 43

What are some key tips for performing cardiac catheterization?

Answer 43

• Advance catheters only with a wire ahead
• Remove catheters with the wire ahead
• Do not advance equipment if resistance is felt
• Ensure catheters are suctioned and flushed before angiograms
• Visualize pressure tracings to check for dampening

Question 44

What is the role of adenosine in FFR measurement?

Answer 44

To achieve maximal hyperemia in the coronary microcirculation.

Question 45

What is a potential drawback of adenosine administration during FFR?

Answer 45

It can have side effects in certain patients and increases procedure duration.