Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
1929: Werner Forssmann - chest X-ray and document the first right heart
catheterization study
1941: André Cournand - more detailed right heart studies
1947: Zimmerman - the first simultaneous left and right heart
catheterization study.
1953: Sven-Ivar Seldinger - the eponymous technique for percutaneous
vascular access.
1956: Forssmann, Cournand, and co-worker Dickinson Richards were
awarded the Nobel Prize
1959: Mason Sones - new technique for selective coronary angiography
1977: Andreas Grüntzig - the first coronary angioplasty
The first coronary artery stents were implanted in 1986. Since the early 1990s
there has been a rapid and successful development of PCI procedures and
devices.
KATETERISASI JANTUNG
Cardiac catheterization is the passage of a catheter
into the left and/or right heart to provide diagnostic
information about the heart and/or blood vessels.
ANGIOGRAFI KORONER
Coronary angiography is a procedure where contrast
material is injected into the coronary arteries under
X-ray guidance in order to define the coronary anatomy
and determine the degree of luminal obstruction.
It remains the standard investigation for patients
with known or suspected coronary artery disease.
CATHETERIZATION LABORATORY FACILITIES
•Dokter
Adalah seorang kardiolog yang telah mendapat
pendidikan khusus bidang intervensi. Dalam
pelaksanaannya dapat dibantu dokter/residen
kardiologi.
•Perawat
Perawat yang terlibat adalah yang sudah mendapat
latihan khusus bidang kateterisasi diagnostik
maupun intervensi.
•Radiografer
Tenaga yang mampu mengoperasikan mesin
kateterisasi dan telah mengikuti latihan khusus
CATH LAB PERSONNEL
• Medical director
• Physicians
• Nurses
• Cardiology trainees (fellows)
• Physician extenders, including nurse practitioners
and physician assistants
• Radiological technologists
• radiographic system
• sterile supplies
• emergency cart
1. Informed Concent :
Sebelum ditandatangani, dokter operator/asisten harus:
a. menjelaskan tindakan dan prosedur yang akan dilakukan.
b. menjelaskan risiko tindakan kateterisasi, yaitu:
* risiko mayor: kematian, stroke, infark miokard
* risiko minor: perlukaan vaskuler, reaksi alergi, perdarahan, hematoma.
c. memberikan gambaran data risiko tindakan, misalnya; risiko emboli
< 1:500, risiko perforasi < 1:500
2. Meningkatkan rasa percaya diri penderita
a. Dengarkan keluhan penderita
b. Menjelaskan secara gamblang tujuan tindakan
c. Tim tidak boleh ragu-ragu (meyakinkan), bersikap sopan dan profesional
d. Menjelaskan kepada keluarga tentang tujuan kateterisasi sebelum
tindakan
3. Evaluasi EKG ulang
4. Evaluasi Vital sign: nadi, tekanan darah, suara nafas, suara jantung
5. Catheterization's orders: sehari sebelum kateterisasi (malam harinya)
perintah persiapan ditulis pada status penderita misalnya; obat yang
diteruskan, obat yang dihentikan, pemberian premedikasi bila diperlukan,
cukur rambut pubis, tidak perlu puasa, pasang infus tangan kanan.
B. Persiapan di Lab. Kateterisasi
Absolute contraindications
Inadequate equipment or catheterization facility
Relative contraindications
Acute gastrointestinal bleeding or anemia
Anticoagulation (or known uncontrolled bleeding diathesis)
Electrolyte imbalance
Infection/fever
Medication intoxication (e.g., digitalis, phenothiazine)
Pregnancy
Recent cerebral vascular accident (>1 mo)
Renal failure
Uncontrolled congestive heart failure, high blood pressure,
arrhythmias
Uncooperative patient
ACC/AHA guidelines for coronary
angiography
The Complications During Angiography
Conditions of Patients at Higher Risk for
Complications of Catheterization
Acute myocardial infarction
Advanced age (> 75 y)
Aortic aneurysm
Aortic stenosis
Congestive heart failure
Diabetes
Extensive three-vessel coronary artery disease
Left ventricular dysfunction (left ventricular ejection fraction
<35%)
Obesity
Prior cerebral vascular accident
Renal insufficiency
Suspected or known left main coronary stenosis
Uncontrolled hypertension
Unstable angina
Estimated The Risk(Mayo Score)
2% patients
with total score
over 14
expected
procedural
mortality 25%!
Conditions Requiring Special Preparations for Cardiac Catheterization
Condition Management
Allergy Treat potential hypersensitivity
Prior contrast studies Contrast premedication
Iodine, fish Contrast reaction algorithm
Premedication allergy Hold premedication
Lidocaine Use Marcaine (1 mg/mL)
Patients receiving anticoagulation Defer procedure
(INR >1.5) Vitamin K
Fresh frozen plasma
Hold heparin
Protamine for heparin
Diabetes Hydration, urine output >50 mL/h
NPH insulin (protamine reaction) Glucophage held 48 h
Renal function If renal insufficiency postpone catheterization
Glucophage usage (prone to CIN) Consider urgency and risks of lactic acidosis
Electrolyte imbalance (K or Mg) Defer procedure, replenish/correct electrolytes
Arrhythmias Defer procedure, administer antiarrhythmics
Anemia Defer procedure
Control bleeding
Transfuse
Dehydration Hydration
Renal failure Limit contrast
Maintain high urine output
Hydrate
Right Coronary Artery Left Coronary Artery
SA = Sino-Atrial Node branch LAD = Left Anterior Descending
RV = Right Ventricular branch Dx = Diagonal
AM = Acute Marginal branch SP = Septal Perforator
AV = Atrio-Ventricular branch; Cx = Circumflex
OM = Obtuse Marginal
RPLA = Right Postero-Lateral branch
RPDA = Right Posterior Descending Artery PLA = Postero-Lateral branch
PDA = Posterior Descending Artery
Coronary Artery
LCA RCA
The Catheters
Overview
- Amplatz Right
- Judkins Right
- Sones
- Judkins Left
- Amplatz Left
Judkins Left (JL) Catheter
3.5 4.0
5.0
Judkins Left (JL) Catheter
H
E
M
O
D
Y
N
A
M
I
C
S
Normal morphology and timing of left ventricular (LV), right ventricular
(RV), left atrial (LA), and aortic pressure waveforms in relationship to
each other, ECG intervals, and heart sounds.
INTRACARDIAC PRESSURES
Indications for POBA
Clinical indications Morphologic indications
Stent materials
Stents are generally manufactured from 316L stainless steel, with
increasing use of cobalt/chromium, cobalt/nickel alloys, and other
metals.
Work is currently being undertaken evaluating prototype metallic
and polymer-based bioabsorbable stent designs.
STENTS
Palmaz Stent
Percutaneous Transluminal Coronary Angioplasty ( PTCA )
Drug-eluting stents
With virtual elimination of immediate elastic recoil and late negative
remodelling by routine use of intracoronary stents, intimal proliferation's
role in restenosis became the focus of much research work. Similarities
between the rapid proliferation of smooth muscle cells in the nascent
neointima and the proliferation of malignant neoplastic cells in tumours
sparked interest in anti-cancer and immunomodulatory agents.
Antiproliferative agents
Currently available DES deliver either cytotoxic (paclitaxel) or cytostatic
(sirolimus and analogues) agents to either kill proliferating cells or arrest
PCI – Bifurcation stenosis
CHRONIC TOTAL OCCLUTION
Stenting
LEFT MAIN SEGMEN (LMS)
DISSECTING POST-STENTING
PCI – Saphenous Vein Graft
PRIMARY PCI
PEMASANGAN STENT PADA Px LAKI-LAKI, 64 THN, PURN TNI-AL
STENOSIS
MS Pressure Gradient
AORTA VALVULOPLASTY
STENTING pada COARCTATIO AORTA
MITRAL REGURGITATION
Pacu jantung temporer
Indikasi
1. Bradikardia simtomatik.
a. Blok a-v komplit
b. Blok a-v derajat 11 (Mobitz tipe 1 atau tipe 11)
c. Sick Sinus Syndrome
2. Pemasangan pacu jantung untuk profilaksis .
a. Kateterisasi jantung kanan pada penderita dengan LBBB
b. Kardioversi pada penderita dengan Sick Sinus Syndrome
c. Penderita Infark Miokard Akut yang disertai :
1) Bifascicular Bundle Branch Block yang baru
2) BBB yang baru disertai Blok A-V komplit transien
3) Blok A-V derajad II Mobitz tipe II.
4) Blok A-V komplit
3. Penanganan takikardia.
a. Torsade de pointes yang disebabkan "long QT syndrome”
b. Overdrive Pacing pada takikardi re-entrant yang resisten
pengobatan medikamentosa (SVT,VT,Atrial flutter)
Indikasi Pacu Jantung Permanen
1. Blok A-V yang di dapat
a. Blok A-V komplit permanen atau intermiten disertai salah satu keadaan
di bawah ini :
1) bradikardi simtomatik, simtom harus dianggap disebabkan oleh
blok a-v kecuali jika terbukti sebaliknya.
2) Payah jantung kongestif
3) Ritme ektopik atau kondisi lain dimana pengobatan dengan obat
anti aritmia menyebabkan terjadinya bradikardi simtomatik.
4) Periode asistol ‡ 3,0 detik atau irama lolos < 40 kali permenit
walaupun tanpa keluhan.
5) Delirium yang membaik dengan pemasangan pacu jantung
temporer.
6) Setelah ablasi a-v junction, myotonic dystrophy.
b. Blok a-v derajat II, permanen atau intermiten disertai bradikardi yang
simtomatik.
c. Atrial fibrilasi, atrial flutter, atau supraventrikuler takikardi disertai total
AV blok atau AV blok derajat tinggi , bradikardi dan salah satu kondisi
seperti yang disebutkan di atas pada Blok AV yang didapat. Bradikardi tidak
disebabkan oleh digitalis atau obat-obat yang mempengaruhi konduksi AV.
2. Pasca Infark miokard
a. Blok a-v derajat II atau blok a-v total yang persisten pasca infark
disertai blok pada tingkat His Purkinye (bilateral bundle branch block)
b. Penderita dengan blok a-v derajat tinggi yang transien disertai dengan
Bundle Branch Block.
Indikasi
1. Tamponade jantung
2. Pericardial effusion
post cardiotomy
3. Hemopericardium
post transeptal
puncture
PEMASANGAN POMPA BALON AORTA (IAB)
Indikasi
•Refractory ventricular failure.
•Syok kardiogenik.
•Unstable refractory angina
•Impending infarction
•Komplikasi mekanik karena IMA, misalnya : VSD, Mitral regurgitasi, ruptura
musculus papilaris
•Ischemia related intractable ventricular arrhythmia.
•Cardiac support pada operasi non cardiac dengan risiko tinggi.
•Septik syok.
•Weaning dari Cardiopulmonary bypass.
•Support dan stabilisasi selama angiografi koroner atau PTCA.
•Intra-operative pulsative flow generation.
Kontra infikasi
1. Aorta Insufisiensi berat.
2. Aneurisma aorta abdominalis.
3. Penyakit aorta-iliaka yang berat/kalsifikasi atau penyakit arteri perifer.
4. Irreversible brain damage.
5. End stage heart disease.
PEMASANGAN KATETER SWAN-GANZ
Pengertian
Memasukan kateter intra vena yang ujung kateternya berada di
dalam arteri pulmonalis untuk mengukur tekanan pengisian ventrikel
kiri, tekanan arteri pulmonalis, tekanan ventrikel kanan, tekanan
pengisian ventrikel kanan, curah jantung dan saturasi oksigen.
Kateter dapat dimasukkan melalui vena basilika, subclavia, mediana
cubiti atau jugularis
Indikasi
1. Payah jantung berat atau progresif.
2. Shock kardiogenik atau hipotensi progresif.
3. Komplikasi mekanik : defek septum ventrikel atau ruptur otot
papilaris
Kontraindikasi
Gangguan faal hemostasis / pembekuan darah.
KATETER SWAN-GANZ
Komplikasi Pemasangan Kateter Swan-Ganz
1. Hematoma.
2. Arteri tertusuk.
3. Emboli udara.
4. Kateter menekuk atau melilit.
5. Tidak mencapai wedge.
6. Pneumothoraks
7. Aritmia.
8. Perforasi atrium kanan / ventrikel kanan.
9. Infeksi.
10. Infark paru.
Electrophysiology Study (EPS)
The high success rates and low complication rates of catheter ablation
have revolutionized treatment of such conditions as Wolff-Parkinson-
White syndrome and atrioventricular (AV) nodal re-entrant tachycardia
More recently, the first-line therapy for treatment of patients with atrial
flutter and focal or re-entry atrial tachycardia / incisional atrial tachycardia
is mediated by macro-re-entry around the scar of a prior surgical
atriotomy
Transoesophageal echo-
cardiography of a device (25
mm Amplatzer PFO occluder
shown in the insert) 6 months
after implantation. LA: left
atrium; RA: right atrium; SVC:
superior vena cava.
PERCUTANEOUS MITRAL ANNULOPLASTY
CATH LAB - INSTALASI DIAGNOSTIK & INTERVENSI KARDIOVASKULAR (IDIK) RSUD DR.SOETOMO
Indications for PCI
Gruentzig's original selection criteria for angioplasty demanded that the patient
have:
• Stable angina
• Documented ischaemia on functional testing
• Single vessel disease (preferably proximal, non-occluded, and non-calcified
lesion)
• No features precluding CABG (if required as bailout) for example malignancy,
severe LV dysfunction, pulmonary disease etc.