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Cardiac Catheterization

and Percutaneous Coronary


Intervention
BY:
Jobelyn Delena Tunay, RN
Percutaneous Coronary
Intervention
Percutaneous coronary intervention (PCI) is a non-surgical
procedure used to treat narrowing (stenosis) of the coronary arteries
of the heart found in coronary artery disease. After accessing the
blood stream through the femoral or radial artery, the procedure
uses coronary catheterization to visualise the blood vessels on X-
ray imaging.
After this, an interventional cardiologist can perform a coronary
angioplasty, using a balloon catheter in which a deflated balloon is
advanced into the obstructed artery and inflated to relieve the
narrowing; certain devices such as stents can be deployed to keep
the blood vessel open. Various other procedures can also be
performed.
■PCI is used primarily to open a blocked coronary artery and
restore arterial blood flow to heart tissue, without requiring open-
heart surgery. In patients with a restricted or blocked coronary
artery, PCI may be the best option to re-establish blood flow as
well as prevent angina (chest pain), myocardial infarctions (heart
attacks) and death.
■Today, PCI usually includes the insertion of stents, such as
bare-metal stents, drug-eluting stents, and fully resorbable
vascular scaffolds (or naturally dissolving stents).
■The use of stents has been shown to be important during the
first three months after PCI; after that the artery can remain open
on its own. This is the premise for developing bioresorbable stents
that naturally dissolve after they are no longer needed.
Clinical indications for PCI include the following:

• Acute ST-elevation myocardial infarction (STEMI)


• Non–ST-elevation acute coronary syndrome (NSTE-ACS)
• Unstable angina.
• Stable angina.
• Anginal equivalent (eg, dyspnea, arrhythmia, or dizziness
or syncope)
• High risk stress test findings.
Why is it done?

• Frequent or severe chest pain (angina) that is not


responding to medication.
• Evidence of severely reduced blood flow (ischemia) to an
area of heart muscle caused by one or more narrowed
coronary arteries.
• An artery that is likely to be treated successfully with
angioplasty whether or not stenting is also used.
Stent
• is a metal or plastic tube inserted into the lumen of an
anatomic vessel or duct to keep the passageway open,
and stenting is the placement of a stent.
• There is a wide variety of stents used for different
purposes, from expandable coronary, vascular and biliary
stents, to simple plastic stents used to allow the flow of
urine between kidney and bladder.
• "Stent" is also used as a verb to describe the placement
of such a device, particularly when a disease such as
atherosclerosis has pathologically narrowed a structure
such as an artery.
Stenting should:

• Open up the artery and press the plaque against the


artery's walls, thereby improving blood flow.
• Keep the artery open after the balloon is deflated and
removed.
• Seal any tears in the artery wall.
• Prevent the artery wall from collapsing or closing off again
(restenosis).
• Prevent small pieces of plaque from breaking off, which
might cause a heart attack.
Coronary Angioplasty
Coronary Angioplasty

■ is a procedure used to widen blocked or narrowed


coronary arteries (the main blood vessels supplying the
heart). The term "angioplasty" means using a balloon to
stretch open a narrowed or blocked artery.
The most common angioplasty risks include:
• Re-narrowing of artery (restenosis). With angioplasty alone —
without stent placement — restenosis happens in about 30
percent of cases. Stents were developed to reduce
restenosis. Bare-metal stents reduce the chance of restenosis
to about 15 percent, and the use of drug-eluting stents
reduces the risk to less than 10 percent.
• Blood clots. Blood clots can form within stents even after the
procedure. These clots can close the artery, causing a heart
attack. It's important to take aspirin, clopidogrel (Plavix),
prasugrel (Effient) or another medication that helps reduce
the risk of blood clots exactly as prescribed to decrease the
chance of clots forming in your stent.
• Talk to your doctor about how long you'll need to take
these medications. Never discontinue these medications
without discussing it with your doctor.

• Bleeding. You may have bleeding in your leg or arm


where a catheter was inserted. Usually this simply results
in a bruise, but sometimes serious bleeding occurs and
may require a blood transfusion or surgical procedures.
Other rare risks of angioplasty include:
• Heart attack. Though rare, the pt may have a heart attack
during the procedure.
• Coronary artery damage. The coronary artery may be torn or
ruptured (dissected) during the procedure. These
complications may require emergency bypass surgery.
• Kidney problems. The dye used during angioplasty and stent
placement can cause kidney damage, especially in people
who already have kidney problems. If at increased risk, the
doctor may take steps to try to protect the kidneys, such as
limiting the amount of contrast dye and making sure that the
pt is well-hydrated during the procedure.
• Stroke. During angioplasty, a stroke can occur if plaques
break loose when the catheters are being threaded
through the aorta. Blood clots also can form in catheters
and travel to the brain if they break loose. A stroke is an
extremely rare complication of coronary angioplasty, and
blood thinners are used during the procedure to reduce
the risk.
• Abnormal heart rhythms. During the procedure, the heart
may beat too quickly or too slowly. These heart rhythm
problems are usually short-lived, but sometimes
medications or a temporary pacemaker is needed.
Preparation:

• Before a scheduled angioplasty, the doctor will review the


medical history and do a physical exam. The pt will have
have an imaging test called a coronary angiogram to see
if blockages can be treated with angioplasty.

• A coronary angiogram helps doctors determine if the


arteries to your heart are narrowed or blocked.
History
Include the following when taking the history of a child post
cardiac catheterisation:

• Identify whether the patient had a diagnostic or interventional


cardiac catheter.
Note: Interventional catheters have a significantly higher rate of
complications compared to diagnostic cardiac catheters.
• Identify access site (position and whether arterial or venous).
• Age of patient.
Note: there is a higher risk of complications in children less than
1 year of age.
• Identify “normal” cardiac rhythm for the patient by
referring to pre-procedure ECG’s
• Note: Sinus rhythm (attach SR-Link here) is normal
cardiac rhythm, but children born with extra conduction
pathways are likely to show abnormal ECG patterns
which for them is essentially the ‘norm’.
• Is the patient on any anticoagulants?

• Note: if anticoagulants have been administered pre


catheterisation the patient is at higher risk of bleeding.
• Note: All patients will have received heparin during the
procedure.
• Identify if the patient had any complications during theatre
or in recovery. If bleeding occurred what intervention was
implemented to achieve haemostasis.
• Ask for the findings of the catheter procedure.
• Ascertain what medications have been administered or
ordered.
During the procedure
The test itself lasts 30 minutes to 1 hour, but the entire
procedure, including precatheterization and
postcatheterization care, may take up to 4 hours. Tell the
patient what to expect, including the following points:

• He'll receive I.V. medication for anxiety and pain as needed


throughout the procedure.
• The testing takes place in a cool, darkened room. He'll lie on
a special procedure table where X-rays can be taken, either
by repositioning the table or by moving the X-ray machine
around him. He'll be attached to equipment for continuous
cardiac, BP, and pulse oximetry monitoring.
• He'll be awake throughout the procedure and may be asked
to cough or take a deep breath at certain times. Tell him to
immediately report any unusual symptoms, such as chest
discomfort or trouble breathing.
• When contrast media is injected into the left ventricle, he may
feel warm or flushed for up to a minute.
• After the test, the catheters are removed and bleeding is
controlled with direct pressure or with a vascular closure
device. He'll be continuously assessed and monitored in a
postcardiac catheterization recovery area. Depending on his
condition and the method used to stop bleeding, he'll spend
some time on bed rest with the affected extremity
immobilized.
Puncture site assessment:

Assess puncture site for:

• Bleeding- check pressure dressing for any oozing or bleeding


from puncture site and mark the size of bleed if possible
Note: check for bleeding immediately after vomiting or vigorous
coughing.
• Haematoma- assess site for swelling, redness and pain and
mark the size of haematoma if possible

Note: A haematoma can indicate internal bleeding into the thigh,


pelvis or retroperitoneal space.
• Infection- assess site for heat, pain and redness. Also
assess for other signs of infection including an increase in
temperature, tachycardia, and rigors.

• Ecchymosis- assess skin around site for purple


discoloration.
Assessment of Potential
Complications
Assess for retroperitoneal bleeding

• Assess vital signs- fluctuating BP response, bradycardia and


hypotension are signs of retroperitoneal bleeding.
• Assess for abdominal pain, groin pain and back pain.
• Note: Retroperitoneal haematomas are ipsilateral to the
puncture site so pain on the same side of the access site
needs further investigations.
• Assess for diaphoresis.
• Assess for signs of bleeding - tachycardia, hypotension,
decreased peripheral perfusion, widening pulse pressure,
agitation, decreased haemoglobin level
Assess for arrhythmias

• Assess patient’s ECG rhythm on the cardiac


monitor. Ensure patient is in sinus rhythm
(Link- Sinus rhythm)or is in a rhythm deemed
normal for the patient
Assess for thrombus
• Neurovascular observations: assess limb for colour, warmth,
CRT, pulse strength, sensation, movement and pain.
• In the presence of venous access site clot, the affected limb
will appear red, swollen, the patient will have an increase in
pain levels and delayed CRT due to pooling of blood.
• In the presence of an arterial access site clot, the affected
limb will appear pale, cool, have diminished or absent pulses
distal to the insertion site, have decreased sensation and
delayed CRT due to lack of supply of arterial blood.
• Note: If you notice a limb with decreased perfusion
assess pressure dressing to ensure it is not too tight.
• Note: For accurate assessment of the pulse, mark the
pulse position on the patient’s foot. A doppler can be
utilised if a pulse is not palpable.

• *Assess and document intake and output


Routine Management
On arrival to the ward assess and record patient
observations - these should include:

• Behaviour - alert, lethargic, irritable


• HR
• RR
• BP
• SpO2
• Oxygen requirements
• Temperature
• Neurovascular observation
• Continue observations as per RPAO clinical guideline (Link).
Neurovascular observations should be performed with every set of
observations.
• Assess puncture site 30 minutely for 4 hours than hourly until
ambulation. Reassess site after first ambulation and then a minimum
of 4 hourly prior to discharge.
• Note: the puncture site assessment commences from the time the
patient enters the PACU, not when they are transferred to the inpatient
unit.
• Patient is required to remain on bed rest for:
*4 hours for a diagnostic catheterisation.
*6 hours for an interventional catheterisation.
Note: patient is permitted to move side to side while on
bed rest to increase comfort.
• Ensure head of bed is no higher than 30 degree for duration
of bed rest.
• Do not remove dressing prematurely unless ordered to by
RMO.
• Dressing is to be removed prior to discharge for cardiac RMO
to assess.
• Note: if a patient remains in hospital for longer than 24 hours,
the dressing should be removed 24 hours post procedure.
• Provide regular analgesia as ordered.
• Aspirin may be ordered for device closures - be aware if
medical team has requested such medications and when it
should be commenced.
Management of Complication
Haematoma
• Apply manual compression over the haematoma to prevent
further bleeding.
• If patient has a heparin infusion, stop infusion.
• Assess for signs of intravascular volume depletion-
tachycardia, widening pulse pressure, hypotension,
decreased peripheral perfusion, delayed CRT, agitation. If
insufficient cardiac output seek urgent medical assistance.
• Auscultate haematoma for presence of pulse and a systolic
bruit which indicates a pseudoaneurysm.
• Notify physician
• Bleeding at site
• Apply pressure above insertion site with gauze to achieve
haemostasis. Haemostasis should occur within 5-10
minuets.
• If patient has a heparin infusion, stop infusion.
• Reinforce pressure bandage.
• Notify physician
Arrhythmia
• Assess if this is a new arrhythmia for the patient. If new Notify
physician
• Assess patient’s cardiac output- BP, peripheral perfusion,
colour and alertness. If insufficient cardiac output seek urgent
medical assistance
• Note: regardless if the arrhythmia is new or deemed a normal
occurance for the patient, if cardiac output is insufficient you
must seek urgent medical assistance.
• Print rhythm strip or complete an ECG if patient is stable.
• Continuous cardiac monitoring.
Thrombus

• Notify physician if any changes in neurovascular


observations .
• Ultrasound to confirm clot.
• Antithrombotic agent as ordered by the medical team.
First line of treatment for an occluded vessel is a heparin
infusion. Thrombolysis may be used in rare
circumstances.
Retroperitoneal bleeding

• Notify physician if suspected


• Assess for signs of intravascular volume depletion.
• Bloods - FBE and Blood group and antibody screen.
• Continuous monitoring.
• CT scan.
• Blood product transfusion.
Cardiac Catheterization
Cardiac Catheterization
■ Is one of the invasive procedures used to
visualize the heart’s chambers, valves and great
vessels in order to diagnose and treat disease
related to abnormalities of the coronary arteries.

■ The procedure involves inserting a long,


flexible, radiopaque catheter into a peripheral vein
peripheral artery and guiding it under fluoroscopy
(x-ray observation) or angiography.
Purpose:

Chamber pressure
Oxygen Saturation
Ventricular Function
Valvular Insufficiencies and stenosis
Septal defects
Congenital abnormalities
Myocardial Function
Indications:
The indications for cardiac catheterization are to:
■ Confirm suspected heart disease, including coronary artery
disease, myocardial disease, valvular disease and valvular
dysfunction
■ To determine the location and extent of the disease process.
■ To assess the following:
• Stable, severe angina unresponsive to medical management
• Unstable angina pectoris
• Uncontrolled heart failure, ventricular dysrhythmias, or
cardiogenic shock associated with acute myocardial infarction,
papillary muscle dysfunction, ventricular aneurysm, or septal
perforation.
■ To determine best therapeutic option (percutaneous
transluminal coronary angioplasty, stents, coronary artery
bypass graft, valvulotomy versus valve replacement)

■ To evaluate effects of medical or invasive treatment on


cardiovascular function, percutaneous transluminal
coronary angioplasty, or coronary artery bypass graft
patency.
Contraindications:
• Allergy to the contrast medium used in the study
• Pregnancy, unless the benefits of performing the study greatly
outweigh the risk to the fetus. It is a relative but not absolutely
contraindicated.
• Clients who will not allow cardiac surgery to be performed to
correct pathology diagnosed by the study.
• Medical conditions such as severe infection, irreversible brain
damage, or congestive heart failure (CHF), which are
considered relative to their extent emergency status, and
potential benefit as opposed to the risk.
•Coagulopathy, impaired renal function, and debilitation
usually contraindicate catheterization of both sides of the
heart. Unless a temporary pacemaker is inserted to
counteract induced ventricular asystole, left bundle-branch
block contraindicates catheterization of the right side of the
heart.

•Digitalis toxicity, anemia and electrolyte disturbance


Normal findings/ Normal Values
•Pressures
Left ventricular systolic 90-140mm Hg
Left ventricular end diastolic 4-12mm Hg
Central venous Pressure (CVP) 2-14cm H2O
Left atrium 2-12mm Hg
Pulmonary artery systolic/end-diastolic 17-32/4-13mm Hg
Pulmonary wedge pressure 6-13 mm Hg
•Cardiac Output 3-6 L/min
•Ejection Fraction 60-70%
Oxygen Saturation Values for the Heart
and it's Surrounding Vessels

Superior vena cava 70%


Inferior vena cava 80%
Coronary sinus 20%
Right chambers 75%
Pulmonary artery 75%
Left chambers 95%
Nursing assessment before the
procedure:
1. measuring the client’s vital signs
2. auscultate the heart and the lungs
3. evaluating the peripheral pulses
4. Asking the client about any history of allergy to iodine-
based contrast agents
5. asking if the client normally takes a digitalis preparation
or diuretic
Assessment After The Study:

1. monitoring vital signs every 15 minutes for 1 hour, every


30 minutes for the next hour and every hour if stable
2. taking peripheral pulses. The radial pulse should be
palpable and as strong as it was prior to the catheterization.
3. assessing the skin color and temperature on both
extremities of the site and comparing for circulatory
alterations
4. assess site blood leaks and apply pressure.
Procedure:

Catheters most frequently used for right and left-heart


catheterization are:

1. Sones
2. Judkins
3. Amplatz
Coronary Arteriography

1. Pigtail
2. Eppendorf
3. NIH
4. Lehman
5. Sones
6. Judkins
7. Amplatz
Procedure:
1. The client is placed in a supine position on the x-ray table,
and securely strapped into the table
2. An infusion of D5W
3. ECG leads are positioned and attached to the client as
well as a cardiac monitor
4. Blood pressure, pulse and respiration equipment is used
for continuous monitoring of the heart activity and vital signs.
5. The catheterization site is shaved if necessary, cleansed
and draped to establish a sterile field.
6. A local anesthetic is injected at the insertion or cutdown
site,
7. General anesthesia via gas or rectal suppository is
administered to young children under age 12
8. The vein or artery is punctured with a needle and a wire
inserted through the needle.The catheter is then passed
over the wire and into the vessel after the needle is
removed
9.The site is sutured if the cutdown was performed

10. a sterile pressure dressing is applied

11. patient is returned to a recovery area for further


observation
Right Heart Catheterization
• femoral and
antecubital vein
Left Heart Catheterization
• Brachial or
femoral artery
Coronary Arteriography
Transseptal Technique
Risks:

• Cardiac catheterization involves radiation


exposure for staff members as well as the
patient.
Before the Procedure:
Explain to the client:
•  That the procedure is performed in a special cardiac
laboratory equipped with monitors and supplies to
minimize the risk of complications.
•  That the procedure is performed by a physician
(cardiologist) and takes about 1-3 hours, depending on the
test to be performed.
•  That the food and fluids are withheld for at least 4-6
hours before the study
•  That some medications are withheld according to
physician’s instruction, especially anticoagulant therapy,
which is discontinued before the study.

•  That the site is shaved, cleansed, and anesthetized


with a local anesthetic and that the catheter is inserted
and that a sensation is experienced as the catheter is
advanced.
• That a sedative, analgesic, or other medication to allay
anxiety and promote comfort is given 1 hour before the study.
•  The ECG activity, pulse, and blood pressure are monitored
during the procedure because a temporary increase in pulse
or arrhythmias can occur during the advancement of the
catheter.
•  That the contrast medium can be injected into the heart
and vessels and cause a warm feeling or metallic taste but
that it lasts only a few minutes.
•  That the client can be requested to cough or breathe
deeply during the study to enhance the blood flow through the
heart.
Prepare for the Procedure:
■ Obtain informed consent
■ Obtain the client’s height and weight, which will be used to
determine dye administration.
■ Ensure that dietary and fluid restrictions have been
followed.
■ Ensure that routine medications are restricted or allowed
per physician order and that anticoagulants have been
discontinued.
■ Provide a hospital gown without metallic closures. Allow
the client to retain dentures, glasses, or hearing aids, as
they do not interfere with the study.

■ Ensure that medications to reduce allergic response to


the contrast medium are administered, that is, antihistamine
and corticosteroid.
■ Obtain baseline pulse, blood pressure, ECG, and peripheral
pulses, and mark the sites of peripheral pulses for comparison
after the study.
■ Administer a sedative or antianxiety agent such as diazepam
(Valium), or both types of medication, and an analgesic such as
meperidine (Demerol) as ordered before the procedure (30
minutes to 1 hour).
■ Initiate an intravenous (IV) line to administer fluids and
medications as needed during the procedure.
■ Have the client void before the procedure.
■ Obtain a history of suspected or known cardiac conditions,
cardiovascular status, cardiac medications, allergies to iodine,
and previous tests and procedures.
During the Procedure:
■ Place the patient in the supine position on a tilt- top
table and secured by restraints.
■ ECG leads in place for continuous monitoring.
■ The patient may be asked to cough or deep breathe.
■ Monitor patient’s heart rate and rhythm; respiratory and
pulse rates, and blood pressure frequently during the
procedure.
The following equipment and associated supplies be on
hand when performing cardiac catheterization to treat
ventricular arrythmias or other complications:
resuscitation bag ECG
oxygen defibrillator
Suction endotracheal tube
oximetric device
monitor for pulse and blood pressure
external temporary pacemaker
medications such as lidocaine, bretylium, epinephrine,
atropine, morphine, isoproterinol
After the Procedure:
• Monitoring vital signs every 15 minutes for 1 hour, every 30
minutes for the next hour, and every hour if stable
• Taking peripheral pulses and assessing skin for color and
temperature on both extremities of the site and comparing for
circulatory alterations.
• Maintain bed rest for 4 to 6 hours, depending on the
procedure
• Extend the extremity used and immobilize it with sand bags
• Encourage movement of the unaffected extremity.
• Schedule post procedure ECG and future suture removal
from the insertion site.
• Observe for complications of cardiac catheterization.
• Complaints of pain and discomfort at the insertion site, chest
pain, nausea, feelings of light-headedness should be
reported.
• Because the contrast medium acts as an osmotic diuretic,
monitor urine output and ensure that the client receives
sufficient oral and IV fluids for adequate excretion of the
medium.
• Pain medication for insertion site and back discomfort may be
given as prescribed.
• Neurologic changes such as visual disturbances, slurred
speech, swallowing difficulties, and extremity weakness
should also be reported
For the patient being discharged on the hospital on the same day as
the procedure, instrcutions are provided for self care:
• For the next 24 hours, do not bent at the waist (to lift
anything), strain, or lift heavy objects.
• Avoid tub baths, but shower as desired.
• Talk with physician about when to return to work, drive or
resume strenuous activities.
• Call physician if bleeding, swelling, bruising, pain from
procedure puncture site, temperature of 38.60C occurs.
• If test results showed coronary artery disease, talk with
physician about treatment and rehabilitation programs.
• Talk with physician or nurse about lifestyle changes to reduce
further or future heart problems
Complications:
• allergic reaction to contrast media
• dysrhythmias and bleeding from puncture site
• Arterial thrombosis
• Perforation of the heart or intratoracic great vessels
• Vagal reactions
• Myocardial infarction
• Pyrogen reaction Complications