LECTURE 10 - PEDIATRIC cardiology CATH LAB.pdf

pediatric cath lab

1. Pediatriccathlab: whatnursesneedto
knowto promoteexcellence in
pediatriccardiology
AdityaA. Sembiring
Division of Pediatric Cardiology and Congenital Heart Disease
Department of Cardiology and Vascular Medicine
Faculty of Medicine Universitas Indonesia

2. Congenital heart disease
•Abnormality in
cardio circulatory
structure or function
that is present on
birth, even if it is
discovered much
later
MossandAdam’sheartdiseaseininfants,children,and
adolescentsincludingthefetusandyoungadult.9thed.2016

3. How common are CHD?
Congenital heart disease àabout 0.8 % of all live births
Indonesia?
Approx. 43,200 cases of CHD per
year with 10,800severe CHD
MossandAdam’sheartdiseaseininfants,children,and
adolescentsincludingthefetusandyoungadult.9thed.2016

4. Trend in the prevalence of CHD
The reported prevalence of CHD globally
continues to increase, with evidence of severe
unmet diagnostic need
Globalbirthprevalenceofcongenitalheartdefects1970-2017:updatedsystematic
reviewandmetaanalysisof260studies.Intjepidemiol.2019Apr1;48(2):455-463.

5. Timeline: CHD treatment
PASTNOW
Diagnosis
Modality
Treatment
Catheterization
Laboratory
Operating Room
Imaging
Catheterization
Laboratory

6. PERKI pusat 2019
Banda Aceh
12 / 5
SumUt
57/ 13
Pekanbaru
15 / 5
SumBar
30/ 3
Jambi
8 / 1
Palembang
8 / 3
Bengkulu
4 / 1Banten
60 /13
Jawa Barat
134/ 24Jawa Tengah
68 /14Yogyakarta
36 /6Bali
37/ 5
Kep Riau
8 / 3
Jakarta
254/ 53
Balikpapan
4/ 3
Samarinda
7 / 3
Manado
18 / 4
Palu
4 / 1Banjarmasin
9 / 2
Makassar
29 / 6
Jawa Timur
179 /31
Bangka
5 / 0
Bandar Lampung
8/ 3
Palangkaraya
6 / 1
Pontianak
8/ 0Tarakan
2 / 0
Bontang
4/ 0
Gorontalo
4 / 0
Kendari
4 / 0Ambon
1 / 0
NTB
8 / 3
Jayapura
5 / 1
Papua Barat
1 / 0
Distribution of Cardiologist and Cath Lab in
Indonesia, 2018
Papua
4/ 0
Kupang
4 / 2
Mamuju
1/ 0
Ternate
1 / 0
TOTAL
Cardiologists: 1150
Pediatric Cardiologists (+Fellow): 80
Cath Lab: 201
Cardiac Surgical Center: 10
3+1*
1+1*
1
73+2*
7+4*
1
2
1+1*
2+1*24+3*
6+1*
2
2
Distribution of Pediatric Cardiologists
in Indonesia, 2019
1*1
1*
1*
CHD cases
Pediatric
Cardiologists

7. Importance of nurses in the cathlab
“We cannot offer the high level of care we strive
for today if we do not offer the best level of
education and opportunities to the nurses” –Jean
Fajedat
Acardiaccatheterizationlaboratorycorecurriculumforthecontinuingprofessional
developmentofnursesandalliedhealthprofessions(EAPCI)2016

8. What nurses needs to know in the
cathlab(1)
Cardiovascular anatomy and physiology
Pathophysiology
Cardiovascular patient assessment
Aseptic technique
Radiation protection and safety
Acardiaccatheterizationlaboratorycorecurriculumforthecontinuingprofessional
developmentofnursesandalliedhealthprofessions(EAPCI)2016

9. What nurses needs to know in the
cathlab(2)
Hemodynamic monitoring
Cardiovascular pharmacology
Procedures and protocols for diagnostic left and right heart cath
Interventional cardiovascular catheterization procedures
Cardiovascular cathlabcomplication
Acardiaccatheterizationlaboratorycorecurriculumforthecontinuingprofessional
developmentofnursesandalliedhealthprofessions(EAPCI)2016

10. Diagnosticcardiac
catheterization

11. Pre-procedural patient preparation
•Patient information and informed consent
•Planning the study: complete history, physical
examination, ECG, Xray, Lab (renal function,
electrolytes, CBC, blood typing), echo
•Premedication, sedation, anesthesia:
–No solid food for 8 hours
–No Milk/infant formula for 6 hours
–No breast milk for 4 hours
–No clear fluid for 2 hours
MossandAdam’sheartdiseaseininfants,children,and
adolescentsincludingthefetusandyoungadult.9thed.2016

12. Pre-procedural patient preparation•Iv line (preferably in an upper extremity) -> fluid maintenance!! Extremely important especially in neonates
•Local anesthesia: lidocaine (not exceed 6mg/kgBB), use small needle
•Sedation and analgesia: fentanyl, midazolam, ketamine, and propofol -> avoid propofol in low EF
•Use heating blankets -> children are prone to hypothermia!
•During general anesthesia/during procedure, monitor: HR, BP, SaO2, temp, ECG
MossandAdam’sheartdiseaseininfants,children,and
adolescentsincludingthefetusandyoungadult.9thed.2016

13. Vascular access
•Femoral artery &
vein
•Most commonly used
in all diagnostic
cardiac cath
•Internal jugular vein /
subclavian vein
•Used in patients with
BCPS/LA isomerism
•Radial artery
•Used in interrupted
aortic arch/severe
coarctatioao
MossandAdam’sheartdiseaseininfants,children,and
adolescentsincludingthefetusandyoungadult.9thed.2016

14. BCPSLA isomerismInterrupted Aoarch

15. Antibiotics and anticoagulants
Cardiac Catheterization for Congenital Heart Disease From Fetal
Life to Adulthood. 2015.

16. Catheters
•MPA2 catheter
•Sidehole, endhole
•Hemodynamic
measurements
•Blood gas
sampling
•Angiographic
injection
•FEVR
•Pigtail catheter
•Sidehole, endhole
•Hemodynamic
measurements
•Blood gas
sampling
•Angiographic
injection
•FEAR
•JR 3.5 or 4
catheter
•Endhole
•Hemodynamic
measurements
•Blood gas
sampling
•Contrast injection
by hand
•FEAR/FEVR

17. Wires
•J-wire 0,035”
•Direct pigtail
catheters from
FEAR -Ao-LV
•Less traumatic on
Aovalve
•Less maneuverable
•Hydrophilic wire
0,035”
•Direct MPA2 or JR
3.5/4 catheters
either from FEAR
or FEVR
•More
maneuverable

18. Hemodynamic Data
•Data accuracy affected by oxygenation,
ventilation, heart rate, and blood pressure
•Diagnostic:
Begins with assessment of initial arterial blood
pressure,venousfilling pressures, and measurement of O2
saturation in SVC and artery femoral
Detection of shunts and quantifying resistance
Saturation sampling (any step up?) and pressure data (assess
pulmonary and systemic flows, resistance, and flow ratio)
MossandAdam’sheartdiseaseininfants,children,and
adolescentsincludingthefetusandyoungadult.9thed.2016

19. Pressure Measurements
•Measured using fluid-filled catheters connected
to pressure-sensitive transducers
•Converted into electrical signal —> waveform
over time on monitor (peak = systolic; trough =
diastolic; mean = electronic damping of signal
over cardiac cycles)
MossandAdam’sheartdiseaseininfants,children,and
adolescentsincludingthefetusandyoungadult.9thed.2016

20. Potential Source of Pressure Tracing
Artefact
Loose connection
in the systemAir in the systemInaccurate calibration
or baseline drift
Partial catheter
obstructionCatheter “filling”End-hole artefact
Peripheral pulse wave
amplificationCatheter entrapment
MossandAdam’sheartdiseaseininfants,children,and
adolescentsincludingthefetusandyoungadult.9thed.2016

21. Right Heart Catheterisation
Right atriumRight ventricle
each horizontal line = 2 mmHg
MossandAdam’sheartdiseaseininfants,children,and
adolescentsincludingthefetusandyoungadult.9thed.2016

22. Right Heart Catheterisation
Pulmonary arteryPulmonary capillary wedge
each horizontal line = 2 mmHg
MossandAdam’sheartdiseaseininfants,children,and
adolescentsincludingthefetusandyoungadult.9thed.2016

23. Left Heart Catheterisation
Aorta
each horizontal line = 10 mmHg
MossandAdam’sheartdiseaseininfants,children,and
adolescentsincludingthefetusandyoungadult.9thed.2016

24. Left Heart Catheterisation
Left atriumLeft ventricle
each horizontal line = 2 mmHgeach horizontal line = 10 mmHg
MossandAdam’sheartdiseaseininfants,children,and
adolescentsincludingthefetusandyoungadult.9thed.2016

25. Normal Hemodynamic Pressure in
Children
MossandAdam’sheartdiseaseininfants,children,and
adolescentsincludingthefetusandyoungadult.9thed.2016

26. Hemodynamic data

27. Hemodynamic data
MossandAdam’sheartdiseaseininfants,children,and
adolescentsincludingthefetusandyoungadult.9thed.2016
•Vascular resistance unit = Wood unit
(WU) = mm Hg/L/min
•Indexed to BSA = Wood units·m2 =
mm Hg/L/min·m2
•Normal PVRI 1-3 WU.m2
•Normal SVRI 20-28 WU.m2

28. Angiography
•VSD: LAO 50oCra20o
•PDA: RAO 30oor LAO 110o
•PA: LAO 30oCra30o
•AoA&AoD: frontal lateral
•MAPCAs: frontal lateral
•Contrast volume (mL) 1-1,5 mL/kg in cardiac chamber
or Ao, 0,5-1 mL/kg in PA (max 30-40 mL)
•Flow rate (mL/s) as fast as possible (max 20-30 mL/s)
•Contrast delivered in 2 second in cardiac chambers and
1 second in great arteries

29. LAO 50oCra20o LAO 30oCra30o
RAO 30o LAO 110o

30. Frontal view

31. Interventioncardiac
catheterization

32. Types of intervention
Transcatheter closure of congenital cardiac
defects
Balloon dilatation of stenotic vessels and
valves (Baloonangioplasty and valvulopasty)
Atrial Septostomy Procedures
Others

33. PDA closure

34. ASD closure

35. VSD closure

36. Balloon Pulmonary Valvuloplasty
(BPV)

37. Balloon Aortic Valvuloplasty (BAV)

38. Balloon Atrial Septostomy (BAS)

39. Intraprocedural Monitoring
•ECG: bradycardia, tachyarrhythmia, ST
elevation/depression
•BP: hypotension/hypertension
•SaO2
•Ready for CPR & defibrillator at anytime

40. Post Procedural Monitoring
•Hemostasis: Manual compression, figure eight hecting-> don’t forget to open the hecting3 hour afterward, vascular closure device
•Monitor: BP, HR, SaO2, Temperature
•Assess for access complications:
–Hematoma
–Acute arterial occlusion
–Chronic arterial occlusion
–Retroperitoneal hemorrhage
–Pseudoaneurysm
–AV fistula

41. Thankyou