Peri-procedural Patient Management in theManagement in …Peri-procedural Patient Management in...
Transcript of Peri-procedural Patient Management in theManagement in …Peri-procedural Patient Management in...
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Peri-procedural Patient Management in the Cath Lab
Peri-procedural Patient Management in the Cath LabManagement in the Cath LabManagement in the Cath Lab
Young Hak Kim MD PhDYoung-Hak Kim, MD, PhD
Department of Cardiology University of Ulsan College ofDepartment of Cardiology, University of Ulsan College of Medicine, Heart Institute, Asan Medical Center, Seoul, Korea
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Cardiac CatheterizationCardiac Catheterization
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Activity in the Cath RoomActivity in the Cath Roomyy• Diagnosis of cardiac disease
C di bi- Cardiac biopsy- Cardiac catheterization
• C t di• Coronary artery disease : - Percutaneous coronary intervention
• Val lar heart disease• Valvular heart disease- Mitral stenosis, pulmonic stenosis, aortic stenosis
• Congenital heart disease• Congenital heart disease- ASD, PDA, VSD
• Arrhythmia• Arrhythmia- Electrophysiologic study
Pacemaker ICD implantation- Pacemaker, ICD implantation
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Coronary Artery DiseaseCoronary Artery Disease
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A h l iA h l iAtherosclerosisAtherosclerosis Myocardial Myocardial infarctioninfarctionAnginaAngina
AsymptomaticAsymptomaticstenosisstenosis Plaque rupturePlaque rupture
gg
DeathDeath
2020 3030 4040 5050 60 yrs60 yrs
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Coronary Arteryy y
Conductance vessel to s ppl blood floto supply blood flow to the myocardium
Supply of oxygen d t i tand nutrient
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Coronary AngiographyCoronary Angiography
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Percutaneous Coronary InterventionPercutaneous Coronary Interventionyy
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Percutaneous Mitral Balloon Valvuloplastyp yTo treat mitral stenosis
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Cardiac BiopsyCardiac Biopsyp yp y
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Electrophysiologic StudyTo detect and treat abnormal conductance
Electrophysiologic StudyTo detect and treat abnormal conductanceTo detect and treat abnormal conductanceTo detect and treat abnormal conductance
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Implantable Caroverter DefibrillatorI t l h k t t t t i l t h di
Implantable Caroverter DefibrillatorI t l h k t t t t i l t h diInternal shock to treat ventricular tachycardiaInternal shock to treat ventricular tachycardia
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Pacemaker InsertionPacemaker InsertionTo treat conduction delayTo treat conduction delay
B
Catheter to RA
Battery
Catheter to RA
C th t t RVCatheter to RV
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AtrialAtrial SeptalSeptal Defect ClosureDefect ClosureAtrialAtrial SeptalSeptal Defect ClosureDefect ClosureAtrialAtrial SeptalSeptal Defect ClosureDefect ClosureAtrialAtrial SeptalSeptal Defect ClosureDefect Closure
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Preprocedural ManagementPreprocedural Managementp gp g
• Physical and emotional status• Baseline lab test CBC Cr PT/aPTTBaseline lab test-CBC, Cr, PT/aPTT• NPO• Skin preparation• IV line – left side (antecubital vein for (
adenosine infusion) • MedicationMedication
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Medications before PCIMedications before PCI
• Aspirin for all coronary patients
• Cl id l (l di 300 600 )• Clopidogrel (loading 300-600 mg)
• Beta-blocker, nitrate, calcium channel blocker -, ,not necessary except MI
• IV nitrate – not necessary.
• Heparin – unstable patientsepa u stab e pat e ts
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Post-procedural ManagementPost-procedural Managementp gp g
• Close observation• Frequent symptom and sign (V/S) evaluation• Frequent symptom and sign (V/S) evaluation• Keep IV fluid• Recurrent chest pain or other symptom• EKG monitoringEKG monitoring• Neurological change
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Post-procedural acute complicationsPost procedural acute complications
• Local complication at puncture site• Pericardial tamponade due to perforationPericardial tamponade due to perforation• Abrupt closure• Renal failure• Renal failure• Atheroembolism, CNS problem• H iti it ti d l d• Hypersensitivity reaction – delayed• Fatal arrhythmia• Bleeding
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High Risk PatientsHigh Risk PatientsHigh Risk PatientsHigh Risk Patients
• Major complications in hospital mortality• Major complications in-hospital mortality• ST elevation MI
U t t b fti• Urgent coronary artery bypass grafting• Atheroembolism (Stroke)
• Minor complicationsp• Periprocedural cardiac enzyme elevation• Vascular access site problemsVascular access site problems
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Procedural ComplicationsProcedural Complicationspp
• Stent thrombosis • Intramural hematomaIntramural hematoma • Side branch occlusion • Di t l b li ti• Distal embolization • Coronary artery perforation • Emergency CABG for failed PCI
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Stent ThrombosisStent ThrombosisAbrupt persistent chest pain with ST
segment changesegment change
• Acute (<1 day)- due toIncomplete stent expansion,
uncovered dissection, intramural h thematoma
• S b t (1 30 d )• Subacute (1~30 days)
• Late (> 30 da s)• Late (> 30 days)- High in DES than BMS
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Endothelization vs. Stent ThrombosisEndothelization vs. Stent Thrombosis
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Stent ThrombosisStent ThrombosisPost-procedure 14 months after PCI
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StrokeStroke
• 0.07 to 0.4 % after PCI• Due to air atheroma or thrombus• Due to air, atheroma, or thrombus• In most cases, it appears to occur in the setting
f t i th i th ti h th tof extensive atheroma in the aortic arch that are disrupted during guiding catheter advancement i t th iinto the coronaries
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Acute Renal FailureAcute Renal Failure
• Hemodynamic instability• Radiocontrast toxicityRadiocontrast toxicity• Atheroembolism.
: most likely in patients with diabetes mellitus, chronic renal failure, shock or dehydrated patients
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Atheroemboli Induced ARFAtheroemboli Induced ARF
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AtheroemboliAtheroemboli
Th f tiffThe use of stiff, large-bore guiding
th t lt icatheters results in aortic trauma and the "scraping" ofthe scraping of atheromatous debris from thedebris from the aortic wall, providing aproviding a potential source of systemic embolism.y
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Arrhythmia Arrhythmia yy
• PVC• Ventricular tachycardia or fibrillation• Bradycardia• Bradycardia
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Ventricular tachycardia or fibrillation Ventricular tachycardia or fibrillation yy
• 0 4 percent of PCI0.4 percent of PCI
• D t• Due to- excess catheter manipulation - commonly from intracoronary contrast injection.
• The risk is greatest with injection of high osmolar contrast agents into RCA particularly in the settingcontrast agents into RCA, particularly in the setting of a prolonged injection or a damped pressure tracingtracing
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Defibrillation forDefibrillation forDefibrillation for fatal arrhythmiaDefibrillation for fatal arrhythmiafatal arrhythmiafatal arrhythmia
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200 J200 J
200 300 J200 - 300 J
360 J360 J
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Allergic ReactionsAllergic ReactionsAllergic ReactionsAllergic Reactions
• Local anesthetic• Iodinated contrast agentsIodinated contrast agents
- occurs in up to 1%. hi h t i ti t ith hi t f i t t- highest in patients with a history of prior contrast reactions.
- Other conditions, such as asthma and other atopic diseases.
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Pretreatment for patients withPretreatment for patients withPretreatment for patients with previous hypersensitivity
Pretreatment for patients with previous hypersensitivity
• Prednisone 50 mg orally 13,7, and 1 h g y , ,prior to procedure
• Diphenhydramine 50 mg PO/IM/ or IV 1 hDiphenhydramine 50 mg PO/IM/ or IV 1 h prior to procedure
• Lower / iso osmolar RCM should be• Lower / iso-osmolar RCM should be recommended
• Emergency therapy should be available• Emergency therapy should be available
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Puncture site complicationPuncture site complicationPuncture site complicationPuncture site complication
• Hematoma – inguinal retroperitonealHematoma inguinal, retroperitoneal
• PseudoaneurysmPseudoaneurysm
• A-V fistulaA V fistula
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Risk Factors for Vascular ComplicationRisk Factors for Vascular Complicationpp
• Periprocedural use of heparin or fibrinolytic therapy, especially if there is prolonged or excessive anticoagulation
• Repeat procedurep p• Peripheral vascular disease• ObesityObesity• Duration of time sheath remains in place,
particularly if >15 hoursparticularly if >15 hours• Use of intraaortic balloon pump
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Radial Artery PunctureRadial Artery PunctureRadial Artery PunctureRadial Artery Puncture
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Radial Artery PunctureRadial Artery PunctureRadial Artery PunctureRadial Artery Puncture
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Femoral Artery PunctureFemoral Artery PunctureFemoral Artery PunctureFemoral Artery Puncture
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Femoral Artery PunctureFemoral Artery PunctureFemoral Artery PunctureFemoral Artery Puncture
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Vascular Closure Vascular Closure Manual CompressionManual Compression
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Vascular Closure Vascular Closure Compressor CompressionCompressor Compression
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Vascular Closure Vascular Closure Bandage CompressionBandage Compression
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Device ClosureEff ti t d t it li ti
Device ClosureEff ti t d t it li tiEffective way to reduce puncture site complication
Angio-Seal DeviceEffective way to reduce puncture site complication
Angio-Seal Device
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Take Home MessageTake Home MessageTake Home MessageTake Home Message
•Check ital sign (HR / BP)•Check vital sign (HR / BP) •Ch k h t i (EKG /•Check chest pain (EKG /
Chest X ray)Chest X-ray)•Check puncture site•Check puncture site •Check patient’s complaints !!!!•Check patient s complaints !!!!