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Coronary anatomy (view source)

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Patients with older age, diabetes mellitus, chronic renal insufficiency, multivessel disease, low ejection fraction have a higher risk of complications.
Patients with older age, diabetes mellitus, chronic renal insufficiency, multivessel disease, low ejection fraction have a higher risk of complications.


=Time-out procedure=
In surgery, the use of a pre-operative checklist has improved the outcome. Implementation of a 19-item surgical safety checklist improved team communication and reduced rates of death and complications in patients undergoing noncardiac surgery<cite>Haynes</cite>. Implementation of a comprehensive preoperative checklist targeting the entire surgical pathway (including items such as medication, marking of operative side and the use of postoperatieve instructions) was associated with a reduction in surgical complications and mortality in hospitals with a high standard of care<cite>deVries</cite>.
Although the goal of most procedures in interventional cardiology is to access the heart and its associated vasculature (making wrong site procedures less of a concern), a preprocedure checklist is also recommended in the catheterization laboratory<cite>Naidu</cite>. Information obtained preprocedural should include procedural indication, patients history, informed consent, a review of medication (in particular antiplatelet therapies and metformin) and a risk of bleeding assessment. Renal function should be less than 90 days old. If the patient is using VKA an INR is obtained < 24 preprocedural.  Images of prior catheterizations are obtained and procedural reports of any coronary or peripheral bypass surgery reviewed. The history should be reviewed for previous heparin-induced thrombocytopenia (HIT). Allergies should be checked, especially contrast allergies or allergies to medication used periprocedural (p.e. heparin). Each laboratory has a protocol for preventing contrast allergic reaction (using p.e. Prednison and an antihistaminic).
Before procedure a time-out procedure is performed by all team members before vascular access is obtained. Patient identification should be checked and confirmed and agreement on the right procedure obtained. Figure 1 shows a sample of a time-out checklist.
Figure 1
<br/>
Sample ‘‘Time Out’’ Preprocedure Checklist
The physician taking ultimate responsibility for the procedure should lead the Time Out and ensure each of the following items is announced:
#Patient’s name and medical record number
#Procedure to be performed (e.g., left heart catheterization, coronary angiography, right heart catheterization)
#Route to be used (e.g., right femoral artery)
#Confirm that the equipment needed is available or alternatives are available including intended stent type for PCI or cath-possible patients
#Patient’s allergies and premedication if appropriate (e.g., heparin-induced thrombocytopenia, contrast allergy)
#Special laboratory or medical conditions (e.g., elevated INR, chronic kidney disease)
=Vascular Access Site=
=Vascular Access Site=
Before Judkins developed the percutaneous transfemoral approach in the late sixties, brachial arteriotomy was performed to introduce the catheter. This is seldomly used nowadays. In the majority of cases arterial catheters are introduced via the femoral artery or radial artery using the Seldinger technique.
Before Judkins developed the percutaneous transfemoral approach in the late sixties, brachial arteriotomy was performed to introduce the catheter. This is seldomly used nowadays. In the majority of cases arterial catheters are introduced via the femoral artery or radial artery using the Seldinger technique.
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*LAO 20 cranial 25                      Crux, RDP and RPL
*LAO 20 cranial 25                      Crux, RDP and RPL


[[File:RecommendedRadiographicProjections.png]]
[[File:RecommendedRadiographicProjections_03072014.png]]
LAO 45
LAO 45


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For collateral connections, it is necessary to make longer angiographic projections. In a RCA obstruction, intercoronary collaterals can form between the septal branches of the LAD and the RDP through the interventricular septum. Collaterals connecting distal portions of two arteries are frequently observed, p.e. connections between the distal RCx and RCA in the interventricular groove and between diagonal branches of the LAD. A collateral between the conus branch of the RCA to the proximal LAD is called a ring of Vieussens. Atrial branches from the RCA or the Kugel’s artery (mostly an small artery arising from proximal RCA anastomosing with branches of sinus node artery) can form connections between the proximal and distal RCA.
For collateral connections, it is necessary to make longer angiographic projections. In a RCA obstruction, intercoronary collaterals can form between the septal branches of the LAD and the RDP through the interventricular septum. Collaterals connecting distal portions of two arteries are frequently observed, p.e. connections between the distal RCx and RCA in the interventricular groove and between diagonal branches of the LAD. A collateral between the conus branch of the RCA to the proximal LAD is called a ring of Vieussens. Atrial branches from the RCA or the Kugel’s artery (mostly an small artery arising from proximal RCA anastomosing with branches of sinus node artery) can form connections between the proximal and distal RCA.
=Time-out procedure=
In surgery, the use of a pre-operative checklist has improved the outcome. Implementation of a 19-item surgical safety checklist improved team communication and reduced rates of death and complications in patients undergoing noncardiac surgery<cite>Haynes</cite>. Implementation of a comprehensive preoperative checklist targeting the entire surgical pathway (including items such as medication, marking of operative side and the use of postoperatieve instructions) was associated with a reduction in surgical complications and mortality in hospitals with a high standard of care<cite>deVries</cite>.
Although the goal of most procedures in interventional cardiology is to access the heart and its associated vasculature (making wrong site procedures less of a concern), a preprocedure checklist is also recommended in the catheterization laboratory<cite>Naidu</cite>. Information obtained preprocedural should include procedural indication, patients history, informed consent, a review of medication (in particular antiplatelet therapies and metformin) and a risk of bleeding assessment. Renal function should be less than 90 days old. If the patient is using VKA an INR is obtained < 24 preprocedural.  Images of prior catheterizations are obtained and procedural reports of any coronary or peripheral bypass surgery reviewed. The history should be reviewed for previous heparin-induced thrombocytopenia (HIT). Allergies should be checked, especially contrast allergies or allergies to medication used periprocedural (p.e. heparin). Each laboratory has a protocol for preventing contrast allergic reaction (using p.e. Prednison and an antihistaminic).
Before procedure a time-out procedure is performed by all team members before vascular access is obtained. Patient identification should be checked and confirmed and agreement on the right procedure obtained. Figure 1 shows a sample of a time-out checklist.
Figure 1
<br/>
Sample ‘‘Time Out’’ Preprocedure Checklist
The physician taking ultimate responsibility for the procedure should lead the Time Out and ensure each of the following items is announced:
#Patient’s name and medical record number
#Procedure to be performed (e.g., left heart catheterization, coronary angiography, right heart catheterization)
#Route to be used (e.g., right femoral artery)
#Confirm that the equipment needed is available or alternatives are available including intended stent type for PCI or cath-possible patients
#Patient’s allergies and premedication if appropriate (e.g., heparin-induced thrombocytopenia, contrast allergy)
#Special laboratory or medical conditions (e.g., elevated INR, chronic kidney disease)


=Left ventriculography=
=Left ventriculography=
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[[File:IntraAortic_figure1.jpg]]
[[File:IntraAortic_figure1.jpg]]
<br/>
Figure 1: intra-aortic location of IABP
Figure 1: intra-aortic location of IABP


[[File:IntraAortic_figure2.jpg]]
[[File:IntraAortic_figure2.jpg]]
<br/>
Figure 2: balloon pressure curve.  
Figure 2: balloon pressure curve.  


''Technique''
''Technique''
<br/>
<br/>
The balloon pump system consists of a balloon-tipped catheter (polyurethane, 10cm, 40ml, dual lumen) that is positioned in the descending aorta 1 to 2 cm beyond the origin of the left subclavian artery and is inserted percuteaneously through a 8-9 French sheath. The balloon is inflated in with helium after aortic valve closure (triggered on the R wave of surface ECG), and maintained until just before the beginning of systolic ejection when the helium is abruptly withdrawn. When appropriately timed, the effect of the IABP is to reduce ventricular afterload and increase cardiac output.
The balloon pump system consists of a balloon-tipped catheter (polyurethane, 10cm, 40ml, dual lumen) that is positioned in the descending aorta 1 to 2 cm beyond the origin of the left subclavian artery and is inserted percuteaneously through a 8-9 French sheath. The balloon is inflated in with helium after aortic valve closure (triggered on the R wave of surface ECG), and maintained until just before the beginning of systolic ejection when the helium is abruptly withdrawn. When appropriately timed, the effect of the IABP is to reduce ventricular afterload and increase cardiac output.


''Indication''
''Indication''
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*Severe arrhythmia owing to refractory ischemia
*Severe arrhythmia owing to refractory ischemia
*Prophylactic high risk intervention (high risk PCI due to LV dysfunction or large territory at risk, severe multivessel disease, left main disease)
*Prophylactic high risk intervention (high risk PCI due to LV dysfunction or large territory at risk, severe multivessel disease, left main disease)


Contra-indications are:
Contra-indications are:
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*High risk of bleeding
*High risk of bleeding
*Bilateral femoral-popliteal bypass grafts
*Bilateral femoral-popliteal bypass grafts


''Precautions''
''Precautions''
<br/>
<br/>
The level of anticoagulation should be monitored daily, with aPTT maintained 50-70 seconds to prevent thrombotic or embolic complications. Evalutions of the limbs and peripheral circulation should be checked regularly. Before removal, patients are weaned by decreasing the counterpulsation (to 1:2/1:3). The incidence of major complications is 2.8%. Common complications are limb ischemia, access site bleeding and balloon leak. Risk factors for complications are female sex, older age (>75 years), BSA < 1.65m2 and peripheral vascular disease.
The level of anticoagulation should be monitored daily, with aPTT maintained 50-70 seconds to prevent thrombotic or embolic complications. Evalutions of the limbs and peripheral circulation should be checked regularly. Before removal, patients are weaned by decreasing the counterpulsation (to 1:2/1:3). The incidence of major complications is 2.8%. Common complications are limb ischemia, access site bleeding and balloon leak. Risk factors for complications are female sex, older age (>75 years), BSA < 1.65m2 and peripheral vascular disease.


''Clinical results''
''Clinical results''
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= Other circulatory assist devices: Impella =
The Impella device is an axial flow pump on a catheter.  The system has an electromagnetic motor directy coupled to a helical impeller located near the tip of a catheter. When the “snorkel” at the tip of the catheter is placed across the aortic valve and into the left ventricular chamber, the motor rotates the impeller at 50.000 rpm, drawing ventricular blood into the distal end of the catheter and discharging it non-pulsatile into the ascending aorta. The device can be placed via the femoral artery in a 9 Fr sheath. There are 2 versions: a 2.5 and a 5L (33.000 rpm), with maximal outputs of respectively 2.5 and 5.0L/min. Before placement an echocardiography should rule out LV thrombus<cite>Engstrom</cite>.
Possible indications for Impella placement are high risk PCI and cardiogenic shock.
In 2012, the PROTECT II trial randomized 452 patients with 3-vessel of left main coronary artery disease and severely depressed left ventricular function to an Impella (2.5L) or an IABP. The Impella provided superior hemodynamic support, but with no difference in the 30 days endpoint of major adverse events<cite>Cardiol</cite>.
In 2008, a multicenter registry showed the Impella 2.5 to be safe and potentially useful in hemodynamic support in high-risk PCI (multivessel, left main, last remaining vessel, low LV function) with rates of myocardial infarction, stroke, bleeding and vascular complications at 30 days of 6.2%<cite>Oneill</cite>.
[[File:Impella.jpg|thumb|400px|Example of a 2.5L Impella system<cite>McCulloch</cite>]]
<br/>


= References =
= References =
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#EurHeart2 pmid=19168529
#EurHeart2 pmid=19168529
#Thiele pmid=22920912
#Thiele pmid=22920912
#Engstrom pmid=21118589
#Cardiol pmid=20082934
#Oneill pmid=22935569
#McCulloch  pmid=21285459
</biblio>
</biblio>
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