UW Cath – Creighton Don, MD

Learning Objectives:

1. Work-up—thorough knowledge of the indications and contraindications for coronary angiography, invasive hemodynamic monitoring, ventricular support devices, and percutaneous coronary, peripheral vascular, and valvular/structural heart interventions. 2. Coronary angiography—advanced knowledge of catheter selection and imaging optimization and radiation safety. The fellow should be able to perform all aspects of the procedure independently, including setting up shots and panning, without an attending scrubbed in the case. 3. Percutaneous coronary interventions—fellows should assist with PCI’s when possible, managing wires, balloons, and devices on the back table. Fellows interested in interventional cardiology should back-scrub on PCI cases and may get to perform PCI’s in the second month. 4. Right heart catheterizations—fellows should be able to perform RHCs safely and independently, demonstrating proper use of ultrasound guided techniques, ability to accurately interpret and troubleshoot hemodynamic data, and perform calculations of shunts, resistances, and valve areas. The fellow should be able to identify the hemodynamics associated with left and right heart failure, constriction, tamponade, valvular disease, and pulmonary disease. 5. Ventricular support devices—fellows should be able to place IABPs independently and be able to optimize and troubleshoot IABP function. They should understand the indications and contraindications for using other ventricular assist devices. 6. Structural heart disease—The fellow should understand optimal patient selection, pre- procedural planning, and the basic procedural approaces for patients for undergoing intracardiac defect closure, TAVR, valvuloplasty, paravalvular leak closure, alcohol septal ablation. 7. Vascular—understand basic screening and treatment for vascular disease, demonstrate techniques to avoid and manage vascular complications, and show basic ability to deploy vascular closure devices. 8. Patient care—demonstrate advanced knowledge of pre/post-procedural management. 9. Clinical trials—Learn about ongoing interventional clinical trials at UWMC and help identify patients for these studies.

Daily duties and expectations:

1. Review cases for the following day. 2. Determine the eligibility of scheduled patients for their procedures and determine if there are special circumstances that need to be addressed (e.g. anesthesia, prehydration, contrast allergy treatment etc.) 3. Perform history/physical, consent and moderate sedation workup by 7:30 for the first patient (8:30 start). Consent inpatients the night before. Evaluate the first patient before conference.

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4. Coordinate with the charge nurse (8-2009) and cath lab ARNP (8-1408) and triage patients on the schedule. Help to manage patient flow in the lab for the day. 5. Discuss procedures with attending prior to the procedure start. Write post-cath orders before the patient leaves the cath lab. Discuss relevant findings with the attending. Submit notes within 24 hours. 6. Sign out patients to the cath lab ARNP (8-1408) and provide back up for post-procedural patients in the ICRU and 4S. If the interventional fellow is not available, assist with management of patients post-PCI patients on 4S until sign-out to Cards I. You may be asked to help with patient discharges. 7. Participate in the weekly interventional cardiology conference and quarterly journal club.

Conferences:

Mondays: TAVR meeting, 7:00 to 8:30 AM, CT Surgery Conference Room. Entry #3370 (Opt)

Tuesdays: Interventional Cardiology Conference, 7:30 to 8:30 AM, SA5505

Wednesdays: Cardiology/CT Surgery Conference, 7:30 to 8:30 AM, RR134

Quarterly: Interventional Cardiology Journal Club (TBD).

You will be expected to present at least one interesting case illustrating complex decision making, an unexpected complication, or an unusual finding at the Tuesday conference.

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Introduction to the UW Cardiac Catheterization Laboratory for Cardiology Fellows July 2016

Your Role in Caring for Catheterization Patients In and Out Of the Lab

Every fellow has at least one embarrassing story of how they brought a patient to a procedure only to find that they had overlooked a simple lab value or piece of the history which invariably turns out to be an absolute contraindication to the procedure you’ve planned. How do you avoid this? Attitude.

Have the right attitude, that is. Nobody wants to be the slowest member of the team but, in the beginning, that is exactly what you will be. And while you should strive to become more efficient, it is acknowledged that you, the physician, may be the rate-limiting step in getting a patient to a procedure. Yet, it is this pre-procedure evaluation that is the most valuable of all: deciding whether the procedure is indicated, assessing what can be done to make the procedure as safe as possible for the patient and determining ahead of time what you will do with the results.

You must resist the temptation to simply “tee up” a patient for the lab instead of performing a thorough evaluation to decide for yourself and thinking about what can and should be done next and how best to do it safely.

During the procedure, remember that you are just learning, there is a lot to learn, and you can’t learn it all in a day, or a week, or even a few months; no matter how smart you are or where you trained before.

Each attending has a slightly different way of doing things and to really learn the most, you have to keep your mind open to new ideas no matter how advanced you think you’ve become. You will be judged not by how much you know or can do on day one, but by your openness to learning, accepting feedback, and striving to improve your skills.

Finally, these patients are your responsibility. When the case is over, they are still your responsibility, or at least everything having to do with the procedure you did will always belong to you. If you are called about a potential complication, see the patient. Work with their team of doctors to help resolve the issue. Make sure the patient understands the findings of the procedure, any recommendations and odds of future events.

Pre-Catheterization Care

The Often Overlooked, Essential H&P

Skipping a brief but thorough H&P will likely result in the delivery of suboptimal patient care. The perceived pressure to avoid appearing “slow” must not prevent adequate consideration of the patient’s case or safety. The ultimate question that must be answered and reported first to the

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attending is: Why are you doing this procedure and what will you do with the information you get from it?

A complete pre-catheterization history includes:

- Why is the patient here: (e.g. Angina or Dyspnea? If so, get a description.) - What were the results of any stress test? (e.g. duration of exercise, location of ischemia/infarcts?) - What are the results of prior echos, catheterizations, interventions or bypass surgeries? - History of diabetes, stroke, tobacco use, history of COPD or other significant comorbid conditions? - Any history of allergies to contrast agents? (e.g. with prior CT scans or caths) - Current medications and allergies - Is the patient able to lay flat for 7 hours? - Is the patient able to give consent? If not, who should? - Who will drive the patient home? - Will the patient need any (financial) assistance obtaining any post-catheterization drugs that might be prescribed (e.g. clopidigrel, statin, etc.) - Are they at risk for any of the specific complications? For example: o Bleeding: cough, uncontrolled hypertension (≥ 180/90 mmHg), inability to follow instructions, history of recent GI bleeding or bleeding diathesis o Vascular disease: dimished distal pulses, history of grafts or stents? o Renal insufficiency: if creatinine is >1.5, should they be pre-treated or counseled differently? o Medical noncompliance: if they get a stent, will they need help paying for Plavix? etc.

A complete pre-catheterization physical exam includes:

- Listen to the heart and lungs, check for edema and elevated JVP - Examine upper and lower extremity pulses bilaterally & listen for femoral and carotid bruits - Bilateral Allen’s or Barbeau’s test if radial access is needed - Any additional organ systems based on pertinent history (e.g. neurological exam)

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Essential Pre-Procedure Studies (if stable, OK if <30 days of procedure)

WBC If there is leukocytosis or leukopenia, should the catheterization be postponed?

HCT Any recent significant drops or severe anemia should be explained and probably dealt with prior to catheterization if possible.

Platelets In general, over 100K are desirable for arterial hemostasis and minimal bleeding risk. If less than 100K, are they also dysfunctional due to renal or liver disease? Is there HIT? Should anti-platelet agents be avoided?

Potassium Significant hyperkalemia (> 5.5) or hypokalemia (<3.3) should be corrected prior to catheterization

Creatinine If Cr > 1.5, strongly consider renal protective measures.

PT/INR INR should be ≤ 1.7 for elective arterial cases. Urgent cases could be performed with higher INRs with discussion. Are there coagulopathies anticoagulant use? PTT

ECG Are there old infarcts?

Informed Consent for Non-emergent Cases

Remember that this is your chance to answer the patient’s questions, not a time to perseverate on all the bad things that can happen. In particular, make sure they understand why we are doing the test and what the test will look for. They should also understand in advance what the options might be if a problem is found (e.g. for significant coronary disease: medical management, stenting or bypass surgery).

The known risks for cardiac catheterization are still essentially based on data from the 1980s and are all highly variable dependent on the patient’s comorbidities as well as the complexity and urgency of the procedure. The following numbers are simply guidelines or best guess for an otherwise healthy patient. Comorbidities such as diabetes, baseline renal insufficiency, history of stroke, aortic valve disease, severe pulmonary hypertension, vascular disease, prior bypass surgery, and recent surgeries or illnesses can significantly increase the risk of certain complications.

The following estimates for the risk of cardiac catheterization and coronary angiography (based on 59,792 patients) were obtained from UpToDate (5/2016)

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Percent Mortality 0.11 Myocardial infarction 0.05 Cerebrovascular accident 0.07 Arrhythmia 0.38 Vascular complications 0.43 Contrast reaction 0.37 Hemodynamic complications 0.26 Perforation of heart chamber 0.28 Other complications 0.28 Total of major complications 1.70

Noto, TJ Jr, Johnson, LW, Krone, R, et al. Cardiac catheterization 1990: A report of the Registry of the Society for Cardiac Angiography and Interventions (SCA&I). Cathet Cardiovasc Diagn 1991; 24:75.

Coronary Intervention (as above, with the following changes:)

Vascular Complications 2-5 Major Bleeding 1.0 MI/Stroke/Death 0.25 to 1 Perforation 0.2 to 0.6 Urgent CABG 0.01

It is often helpful to state these risks in terms of “minor vs. severe” complications rather than giving actual numbers, mentioning the extremely rare potential need for emergent open heart surgery. Ultimately it’s helpful to reassure them that the risk to catheterization is small compared to other invasive procedures and that you are just a part of a very experienced crew that will work very hard to make sure everything goes just as perfectly as planned.

Specific Issues in Pre-catheterization Care

Pre-Cath orders and Consent

At UW and HMC:

- Pre-cath orders must be entered in ORCA/CPOE at least the night before any elective outpatient caths are scheduled, but preferably earlier. - Coordinate this with the cath lab ARNP/ICRU lead every day to make sure the orders are done for the next day’s cases - Look for the PowerPlan called “CARD Pre-Procedure Cath Lab Multiphase” and fill out a “Document in Plan” for each patient, dated for the procedure day.

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- Consents and pre-sedation assessments are performed on all patients. Failure to do these in a timely fashion is the biggest roadblock for moving patients through the lab efficiently, and you will hear about this from the staff. - Try to consent inpatients ahead of time, even the night before if you can. Arrive at 7:30 AM on M, Tu, Th to consent the outpatients who should be in the ICRU at that time. Arrive at 7:00 AM on Wed, Fri so that you can consent the patients prior to conference. - Work with your colleagues on the inpatient cardiology services—the inpatient fellow ordering the procedure may be able to perform the consent as this greatly streamlines the process and insures that inpatient cases will be done. VA:

- The VA has their own system for pre-cath evaluation and orders, which is similar, but you will be oriented separately for this

Cath Lab Flow

At UW:

- Go over the schedule with the RN lead 206- 598-2009 first thing in the morning and throughout the day, triaging and optimizing the order of patients, and letting him/her know about your or other fellow availability through the day. - Stay ahead on consents/sedation assessment/orders - Touch base with the inpatient cardiology fellows about the priority of add-on cases and whether the consent/sedation orders have been signed

Preventing Contrast Nephropathy

All Patients:

- Minimize the amount of contrast used. A guideline of 2-3cc per injection of the RCA and 6-7 cc per injection of the LCA and bypass grafts is often sufficient. - Pre-hydration and post-hydration unless heart failure is present. A common dose is normal saline at 1 ml/kg/hr starting the morning of the procedure for a total volume of 500 to 1000 cc - Determine the thresholds for total contrast use. Doses > 3-5x the GFR are associated with dramatically increased contrast induced nephropathy

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Renal insufficiency

(arguably defined as: proteinuria, CrCl < 60 ml/min or serum Cr > 1.5 mg/dL):

- Given the poor data to support the use of Mucormyst/N-acetylcistine this is not routinely used. - Sodium Bicarbonate or saline: if bicarb, use 3 amps sodium bicarb in 1L D5W given as a 3 ml/kg bolus 1 hour before the procedure and continued at 1 ml/kg/hr for 6 more hours.

Diabetic Patients

- Metformin (Glucophage) should be held the day of the procedure and restarted 48 hours after the contrast load to avoid metabolic acidosis. - For insulin dependent patients with a stable serum glucose (e.g. between 70 and 250 mg/dL), have the patient continue their normal long-acting doses the day before, but give half the normal insulin dose on the morning of the procedure or while the patient is NPO. - Other oral hypoglycemics such as glyburide and glipizide rarely need to be held while the patient is NPO, but in those that use insulin ½ the normal morning dose is given the day of procedure. - Aggressive use of an insulin drip should be considered if the glucose > 200 mg/dL during the procedure. - Be sure to check glucose levels at the time of the procedure or if the patient has been NPO for a prolonged period

Patients on Anticoagulation Prior to Catheterization

- Coumadin should, in general, be held 3 nights before the catheterization and can be restarted in uncomplicated cases the night of the catheterization with a goal INR at the time of arterial puncture and sheath removal of ≤ 1.7. Bridge mechanical mitral valves heparin or enoxaparin. - The novel anticoagulants should be stopped 48 hours before the procedure, but potentially longer depending on creatinine clearance. The UW Anticoagulation Services gives recommendations on management of anticoagulation around invasive procedures on their website and they are happy to answer questions: https://depts.washington.edu/anticoag/home/content/anticoagulation-around- invasive-procedures-0 - Heparin should generally be stopped 1 hour before the procedure or “on-call to cath lab,” even in the setting of NSTEMI or if the patient is already on a IIb/IIIa inhibitor. It can usually be restarted without bolus 6 hours after the sheath is pulled if absolutely necessary and there are no other risk factors for bleeding. LMWH should be held at least 8-12 hours before the procedure. 42 | Page

- If for some reasonable medical indication these guidelines cannot be followed, radial access probably provides the best chance for hemostasis and the least likelihood of bleeding or vascular complications. - For right heart catheterizations, the bleeding risk is lower so can be performed safely on patients even with coagulation issues. In general for elective cases the INR ≤ 1.7 should be followed, but most attendings will consider performing the right heart cath with INRs up to 3.0, especially for patients with LVADs or mechanical valves who are not easily bridged.

Contrast Allergy

All patients with a history of contrast allergy should be pretreated. A shellfish allergy does not qualify as a contrast allergy. An example regimen is:

- Prednisone 60mg q12h x 3 doses so the last dose is about 1 hour before the procedure - Benadryl 25mg about 6 and 1 hour before the procedure - Ranitidine 150mg about 13 and 1 hour before the procedure.

Post-catheterization Care

First and foremost, your responsibilities to a patient definitely do not end as soon as they clear the threshold of the cath lab on their way to recovery. A follow up visit by you on your patients later in the day or early the next day is expected and appreciated by patients, who often forget what you told them in their whirlwind stay in the cath lab. And if there are any complications, there is no substitute for an evaluation by someone with experience in dealing with vascular access sites and other issues surrounding catheterization. As an extreme example, retroperitoneal bleeding has been known to cause death after catheterization, often due to a failure to diagnose. This unfortunate complication is not uncommon but should not be fatal. It emphasizes that attention must be paid to all symptoms after arterial catheterization. This can be confusing as a symptom such as back pain, which is consistent with a retroperitoneal bleed, are common in older people who are forced to lie flat for several hours. But if there are concerning symptoms, you should have a very low threshold to examine the patient yourself and involve your attending early if there are any questions.

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ACC-NCDR Data Entry

Basic demographic, clinical, and procedural information needs to be entered for each patient. The cath lab techs will be responsible for this, but will ask you for information as necessary. At the end of the case, you will need to inform the tech about the percent stenosis in each main vessel.

Hemostasis: Pulling sheaths and Balloon Pumps

- Sheaths can safely be removed when the ACT < 180 sec and platelets are > 100 K/mm3. This can be done while the patient is on IIb/IIIa inhibitors, though you may want to use a cutoff of ACT < 150 sec. If the patient was on bivalirudin during the procedure, the sheath can be pulled 2 hours after the infusion is stopped without checking an ACT, unless the patient has renal insufficiency, in which case ACTs are checked. - Remember not to hold pressure based on where the skin puncture is, but where the artery itself was actually punctured; usually about 1-2 cm above the skin entry site. - To pull a femoral sheath, start by exposing the entire leg including the toes. Feel the pulse about 2 cm above the skin entry site, where the sheath enters the vessel. Place two fingers at that site and one finger directly below the vessel entry site. Holding your hand in this position, occlude the artery distal to the skin entry site and pull the sheath. Allow 1-2 cardiac cycles to bleed out, theoretically forcing any clots out the skin instead of down the leg as you occlude the vessel distally. After 1-2 cardiac cycles, compress the vessel at and proximal to the puncture in the vessel wall and release your distal finger to allow the vessel to back bleed for 1-2 seconds. Then compress with all three fingers to achieve complete hemostasis. Hold pressure with all three fingers for the duration of the hold time. - Do not use gauze between your fingers and the skin. After a 1-2 minutes of complete hemostasis, continue to exert enough pressure to prevent any bleeding but still allow a palpable pulse in the foot when an assistant checks it for you. If a pulse cannot be felt without causing bleeding, intermittently let up on the compression just enough to allow a weak pulse to be felt in the foot for a few seconds every 2-3 minutes for the duration of the hold. Putting an oximetry probe on the distal extremity may help determine if optimal ‘patent hemostasis’ is being achieved. - In general, hold compression for a total of 3 minutes for every French size (6 Fr = 18 minutes). Compression devices such as C-clamps and Fem-o-stops should be used only by personnel experience in their placement and monitoring. If the patient is actively bleeding, though, manual compression is the only acceptable technique. - If a venous sheath is side-by-side an arterial sheath and both are to be pulled, pull the arterial sheath and ensure hemostasis. After 3 to 5 minutes of complete hemostasis, pull the venous sheath and compress both sites simultaneously for the remainder of the hold (at the point of vascular entry). - Instruct the patient to lie flat, HOB < 30 degrees, and keep their leg straight. They should not life their head during this time (increases bleeding risk) or bend their hip on that side for any reason. If a persistent benign cough is present, prescribe cough suppressants during this time. They should notify their nurse immediately if they experience any bleeding or pain.

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Adequate pain medications must be provided so they patient may remain comfortably flat and still. - To help avoid late vascular complications, the patient should not drive themselves home and avoid heavy lifting for 1-2 days afterwards. - For radial access sites, use a compression wrist band for at least 2 hours.

Guidelines for Ambulation After Sheath Removal

Femoral artery:

Manual only: May ambulate after 2 hrs for 5 Fr, 4 hrs for 6 Fr

Closure device: May ambulate after 2 hours

Brachial artery: Arm straight for 4-6 hours

Radial artery: Wrist compression for 2 hours.

General Issues Post-catheterization

If ReoPro is Used: check platelets 2 hours after procedure and the following morning. Stop ReoPro if there is a significant fall in platelets from the patient’s baseline (>40%?) and notify the attending. Watch for active bleeding and transfuse platelets if significant bleeding is present.

Orders: It is the fellow’s responsibility to ensure all orders are written for the patient after the cath, including post-cath care, sheath instructions, orders for antiplatelet agents, fluids and insulin drips if necessary. The PowerPlan in CPOE is under “Card Post-Procedure Cath Lab.”

Potential Vascular Complications from Arterial Access

Acute (minutes to hours of pulling the sheath)

- Re-bleeding: Manually obtain hemostasis by holding pressure as if it were never done at that site in the first place. Consider extending the hold time to 25 to 50% longer. Consider compression devices like a Fem-o-stop device only after hemostasis has been achieved using manual compression. Have a high index of suspicion for subcutaneous or retroperitoneal hematoma if suspicious symptoms develop. - Superficial hematoma: if expanding, compress at the site of vessel wall puncture and hold pressure as if bleeding externally. Additional analgesia with IV narcotics may be necessary. Superficial hematomas usually resolve spontaneously over 2-6 weeks and can be painful. Compression of the superficial femoral nerve can occur and should resolve over several weeks.

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- Retroperitoneal hematoma: symptoms include deep back, abdominal, or scrotal pain with signs of hypotension, falling hematocrit. Ecchymosis is usually not seen. Diagnosis with stat non-contrast abdominal and pelvic CT scan. Treat with immediate compression at the site of vascular access, stopping anticoagulation, transfuse as necessary and monitor closely. If conservative treatment is ineffective, consider angiography and embolization of the bleeding artery and vascular surgery evaluation. - Proximal arterial thrombosis/dissection: If causing critical leg ischemia, consult vascular surgery and obtain an urgent vascular ultrasound. - Distal emboli: heparin is often used. Ultrasound of the femoral artery may help exclude dissection and obtain vascular surgery consult. - Radial artery occlusion: This can occur in up to 5% of patients, but is often not diagnosed acutely because it is asymptomatic. Anticoagulation may be tried for symptomatic patients. - Brachial artery hematoma: Inadequate hemostasis can lead to a significant compartment syndrome which needs to be addressed urgently. Aggressive compression at the arteriotomy site is critical and vascular surgery should be consulted if a compartment syndrome is suspected.

Late (days to weeks after catheterization)

- Arterial pseudoaneursym: Within days after catheterization. This is a hematoma external to the vessel that seals of the vessel wall but continues to slowly expand over days to weeks. Its symptoms are of increasing or continued pain at the catheterization site or sometimes a palpable “lump” and a femoral bruit. It is diagnosed by vascular ultrasound and can be treated with ultrasound guided compression or by injections of thrombin. If undiagnosed or left untreated, it can lead to significant late bleeding complications or AV fistula formation. - Arteriovenous fistula: One to several weeks after catheterization. Usually occurs after an arterial pseudoaneurysm erodes into the adjacent femoral vein. Risk factors include a multiple arterial and venous punctures during an attempt to place a sheath, placing a venous and arterial sheath on the same side. Symptoms are few and include local pain. Diagnosis is made by hearing a continuous, predominately systolic murmur over the site and by vascular ultrasound. Treatment is typically surgical.

Other Severe Acute Complications

Stroke:

- All new neurologic or psychiatric symptoms after catheterization should be thoroughly evaluated. The known risk of stroke is 0.1%, but is higher in those with previous stroke, aortic stenosis, prior bypass surgery, calcified aortas, coronary interventions and diabetes. 46 | Page

MI:

- Consider emergent repeat cath for post-PCI chest pain if: 1. Hemodynamically unstable 2. Dynamic ECG changes with pain 3. A new episode of classic (recurrent) pain syndrome requiring escalating anti-anginal therapy.

Pharmacotherpay: Medications Commonly Given During and After Catheterization

In the Cath Lab:

Diagnostic Cases:

Heparin: Given by some operators at the beginning of the case, particularly for radial cases (typically 50-80 u/kg)

Nitroglycerin: Intra-coronary nitroglycerin in doses of 100-200 mcg up to 400 mcg can be given. This should be flushed through with 1-2 cc contrast under fluoroscopy to confirm intra-coronary delivery. Sublingual nitroglycerin tables are also commonly used.

Interventional Cases:

ASA: 325mg the day of the procedure.

Thienopyridine

• Clopidogrel: Loading dose 300 to 600mg, and 75 mg daily thereafter (up to 150 mg for ACS patients). • Prasugrel: 60 mg loading dose and 10 mg daily. Contraindicated in patients >75 years old and history of any CVA. Caution if weight ≤60 kg • Ticagrelor: 180 mg loading dose and 90 mg BID. Concomitant ASA dose <100. Bivaliridun (Angiomax): Direct thrombin inhibitor used in place of heparin and IIb/IIIa inhibitors. Usually stopped in the cath lab or allowed to finish 1-2 hours post PCI.

Heparin: Given to keep ACT > 250-350 sec at the time of stent deployment. Usually shut off in the cath lab after the procedure is done unless a coronary dissection is suspected, intra-coronary thrombus was seen during the procedure, or there was a suboptimal result of angioplasty in the setting of MI.

IIb/IIIa inhibitors: Rarely used routinely for elective cases. May be used for treating a large thrombus burden or ACS patients who cannot take a ADP antagonist.

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Immediately After Stent Placement

ASA: 325mg PO load (if not on chronic therapy) then then 81-325 mg PO daily indefinitely.

Plavix: Load with 300 to 600 mg then continue at 75mg daily for a minimum of 1 month for bare-metal stents and preferably 12 months for drug eluting stents. 150 BID may be used for 7 days post PCI in ACS patients.

Thienopyridine/ADP antagonist: minimum of 1 mo for bare-metal stents and 6-12 mo for drug eluting stents.

Heparin/Bivalirudin: usually discontinued in the cath lab after the procedure except for specific cases described above. If indicated for another reason (such as prosthetic valves, pulmonary embolism, etc.) full anti-coagulation in an uncomplicated case can usually be restarted without a bolus 6 hours after the sheath is pulled.

Low Molecular Weight Heparin: Do not give within 48 hours after catheterization due to late bleeding complications.

IIb/IIIa inhibitors:

Abciximab (ReoPro)

- Contraindications: active internal hemorrhage or significant GI/GU bleeding within 6 weeks; h/o CVA within 2 years or CVA with significant neurological deficit; clotting abnormalities; oral anticoagulant use within 7 days unless INR < 1.2; platelets < 100,000; major surgery or trauma within 6 weeks; intracranial tumor, AVM, aneurysm; severe uncontrolled hypertension; history vasculitis; concurrent use of dextran. - PCI Dose: 0.25 mg/kg bolus 10-60 minutes before the start of intervention followed by infusion of 0.125mcg/kg/min to a maximum of 10 mcg/min for 12 hours. - Not used in the setting of ACS without PCI. - Can cause an acute thrombocytopenia within hours after administration.

Eptifibatide (Integrilin)

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- Contraindications: active abnormal bleeding or h/o bleeding diathesis within previous 30 days; history of CVA within 30 days or history of hemorrhagic stroke; BP > 200/110; major surgery in previous 6 weeks; thrombocytopenia; creatinine > 4 mg/dL; dialysis. - ACS Dose: 180 mcg/kg bolus to maximum of 22.6 mg over 1-2 minutes. Maintenance 2 mcg/kg/min to a maximum of 15 mg/hour. All of benefit was seen in patients going to PCI, and the majority of that was seen in diabetics. - PCI Dose: same as ACS with the addition of an identical repeat bolus 10 minutes after 1st bolus. Start immediately before PCI and continue for 12-18 hours. - Renal failure: If Cr > 2mg/dL, use same bolus dose(s) but decrease maintenance to 1 mcg/kg/min with maximum of 7.5 mg/hour. - ACT goal (elevated ACT is due to Heparin): 200-300 sec during PCI; pull sheath when ACT < 150 sec - Heparin target: PTT 50-70 sec

Other outpatient medications not to lose track of:

o ASA and theinopyridine: as above o B-blockers: for all with a history of MI or LV dysfunction unless contraindicated. o ACE-I: All patients with atherosclerotic events or LV dysfunction and those at high risk for CV events. o Statins: for any with atherosclerotic events and, if none, based on risk factors o Sub-lingual Nitroglycerin: all post-PCI patients should be discharged with sublingual nitroglycerin unless contraindicated.

Reversing IIb/IIIa Inhibitors Stop the infusion. If bleeding, give at least two 6-packs of platelets. (Especially if ReoPro where the effects may last more than 24 hours. Integrillin effects will usually go completely away after 4 hours with simply stopping the infusion.)

The Patient with Acute MI: Goal door-to-balloon time < 90 minutes

Pre-catheterization Care for the Acute STEMI

THE Essential task to accomplish in the ER (assuming the patient isn’t in the lab already):

- Evaluate the patient enough to determine whether the cath lab is the correct immediate next step and, if so, do everything you can to make sure the patient makes it out of the ER to the cath lab alive and expediently. This is not a critique of the ER, but a reminder to the cardiologist that if the patient’s presentation is most consistent with acute MI, then all the prep can be done in the cath lab if absolutely necessary. So, if you can’t stabilize the patient with STEMI quickly and the cath lab is ready, just get them to the lab. 49 | Page

Nearly essential tasks to accomplish in the ER:

- Directed H&P, confirm no contraindications to femoral arterial approach, contrast or anticoagulation - ECG and draw labs - Treat acute heart failure aggressively with lasix and IV nitroglycerin as necessary - If not done already by the ER, activate the cath lab and discuss with cath attending - Make sure ASA 325mg was given by EMS or the ER, regardless of patient-reported history of aspirin use - Consent the patient - Facilitate getting the patient to the cath lab as soon as the cath lab is ready for them

Bonus tasks that should not delay going to the cath lab:

- Give thienopyridine, as discussed with the interventional attending. - Metoprolol 5mg IV if the patient is not bradycardic, in shock, having active failure. - If RV infarct is present and no evidence of pulmonary edema, give normal saline. - Starting heparin or bivalirudin. - Write your note

Informed Consent for Emergent Cases (STEMI)

Obtaining true informed consent in the emergent setting is almost as difficult as simply defining what that means. While there are still risks of complications due directly to an emergent catheterization (certainly higher than that for diagnostic cases), the risk of harm is actually greater if the procedure is not done. Often times, simply telling them that they are having a heart attack and that based on our best studies, they are likely to do better if they have the catheterization than if they have anything else done is enough to satisfy most patients that they are informed as they need or want to be.

However, it often goes unsaid, probably inappropriately, that there are other options to emergent catheterization; including thrombolytics, basic medical management or no treatment. All of these other options are associated with higher morbidity and mortality and, on hearing this, are almost never chosen by patients.

Fundamental Cardiac Catheterization: Femoral Arterial Access

Important General Principles:

• No matter which technique you use, the goal is the same: to place the arterial sheath in the common femoral artery, about 2 cm below the inguinal ligament and at the mid femoral head, at a 30 to 45 degree angle of entry while puncturing only the anterior-most wall of the artery.

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• If the angle of attack is too steep, the sheath bends excessively or even kinks, putting undue stress on the vessel wall and increasing the likelihood of bleeding and complications.

• If the sheath enters the artery above or through the inguinal ligament it is very difficult to get adequate hemostasis when it is removed since you can’t compress it against the femoral head and there is an increased risk of retroperitoneal hematoma.

• If the sheath enters either the profunda or superficial femoral (i.e. below inferior to the bifurcation of the common femoral artery) there is increased risk of thrombotic occlusion of the vessel. But better to be too low than too high.

• Last but not least, the attending must be in the room for vascular access if we are to bill for the procedure.

1) To begin, first palpate the landmarks:

• Anterior superior iliac spine • Pubis symphysis • The inguinal ligament between the two

The femoral artery is usually slightly more medial than the half-way point between the ASIS and the pubis symphysis and courses from this point superiorly directly towards the umbilicus.

Find the pulse 2 cm inferior to the inguinal ligament using the 2nd, 3rd, and 4th digit on your left hand to help define the path of the artery. This is where your needle should enter the artery, which means the needle should enter the skin about 2cm below that. Fluoroscopy can be used to correlate external landmarks with the ideal puncture site at the mid-femoral head (see Variation #2 below).

2) When you have identified both the pulse and the spot where your needle should enter the skin, place a skin wheal of 1% lidocaine at that spot using the 25 ga needle. Giving a total of about 10cc, anesthetize deeper and deeper towards the artery (an easy way to do this is to work downward towards either side of the artery, taking care not to hit the femoral nerve). Try not to puncture the artery with this needle if possible.

3) Allowing a few minutes for the lidocaine to set in, get everything else you’ll need ready. An 18 ga Cook needle or micropuncture kit, a 6 Fr sheath with introducer (both flushed with saline) and the short J tip wire that comes in the kit. Make sure fluoroscopy is enabled and the foot pedal is easily accessible so you can take a picture if necessary.

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4) Find your landmarks again, confirm the location that you want to enter the artery and that your anesthetic was given at the correct location. With the 2nd, 3rd and 4th digits of your left hand, palpate the femoral artery directly over where you plan to enter it with the needle. You can roll your fingers medial and lateral, back and forth to confirm the precise location and course of the vessel. At this point, fix the artery in position with these three fingers to prevent it from moving without occluding its flow. If you can’t visualize the artery well by placing your 2nd, 3rd, and 4th digits of your left hand all in-line with the artery, try just placing your index and middle finger on either side of the artery at the point that you plan to enter with the needle. In this way, your fingers will be lined up perpendicular to the path of the artery. Use these fingers to, as before, press firmly and fix the artery in position as you enter it with the needle to prevent it from rolling out beneath the pressure of the needle.

Aiming half-way between directly superiorly and towards the umbilicus, advance the Cook needle at a 30 to 45 degree angle to the skin through the skin and towards the femoral artery. As the needle gets close, you will likely feel the pulsations transmitted through the needle. Unless the patient is very young, you will likely feel a ‘pop’ as the needle goes through the anterior wall of the artery.

The blood flow returning should pulsate briskly or “squirt”. If it does not, the needle the tip has:

• Not been advanced far enough (the bore of the needle is mostly still obstructed by the near wall of the artery) or • Actually entered the femoral vein or • Entered a small more, superficial artery (this usually means your approach is too inferior) or • Entered a femoral artery with poor inflow (the common femoral, iliac or aorta is/are occluded) or • Been placed in an incredibly sick patient. 5) If there is good, bright pulsitile flow, release your left hand and use it to ‘lock’ the needle in place very firmly. With your right hand, advance the wire smoothly and carefully through the needle. If there is any resistance, stop.

Never advance a wire against resistance.

If you feel resistance early on but there is still good pulsitile flow, either the bore of the needle is not completely within the lumen of the vessel or the tip of the needle is too close to the far side of the lumen of the vessel, preventing the wire from turning out of the needle to head up the artery. You may also be in a small branch of the femoral artery. You can try advancing or withdrawing the needle or tipping the hub of the needle downward to cause the needle to align more parallel with the artery before retrying the wire.

If you feel resistance after the wire has already turned up the artery, the risk is that you will cause a retrograde dissection, arterial perforation, or embolic event by pushing the wire against resistance. 52 | Page

6) Advance the wire about 15 cm into the artery (so about 15 cm of wire are still out of the patient), remove the needle while holding pressure firmly on the arterial puncture site with your left hand. With your right hand, place the sheath on the end of the wire and advance the sheath into position using a slight ‘twisting’ or ‘screw’ motion to help get through the sub-cutaneous tissues. Flush the sheath by aspirating 5cc of blood then flush forward with 10 cc normal saline, taking care to make sure no bubbles are injected.

Variation #2: Using radiographic landmarks to locate the artery

To help you locate the correct location, you can use a very quick straight AP static image of the right pelvis. Using this image, the artery should course over the medial half of the femoral head towards the umbilicus. Your goal is puncture the artery directly over the middle of the femoral head. On a thin person, this means that the needle should enter the skin directly over the inferior border of the femoral head. Find this position on the skin by placing a scissors or hemostat on the patient so that the tip of the instrument is exactly over the inferior border of the femoral head, in-line with the medial half of the femoral head.

There are two important caveats with this technique:

1. This should be used to augment your ability to palpate landmarks and the pulse, not be used in place of it. 2. In anything but thin patients, this method can easily result in a high stick. In obese patients, the extra sub-cutaneous tissue you must traverse will require that you enter the skin well below the inferior border of the femoral head and in patients with even a moderate abdominal panus, the anatomical relationships between the femoral artery and the femoral head on an AP projection tend to break down. This can accounted for with experience, but early on this technique should be used as an aide to palpation and not an absolute guide.

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Sheath in external iliac artery.

Needle enters artery here Needle enters skin here

Variation #3: Ultrasound Guidance

This can be very effective to insure puncture of the common femoral artery, but can often lead to a high stick and sometimes puncture of the external iliac. Use this in conjunction with the other techniques described above.

Fundamental Cardiac Catheterization: Angiographic Views

The following projection angles are given only as a guideline as there are many variations and indivual patients vary somewhat in the orientation of the heart, which you may want to account for in the views you select. In general, the left coronary system is imaged to show the most important structures first: left main, proximal LAD, then the rest. A common sequence to accomplish this is to image ‘from the four corners’: left shoulder, right shoulder, right hip, left hip (LAO cranial, RAO cranial, RAO caudal, LAO caudal). Whether you start with the right or left coronary is usually a matter of preference unless dictated by known prior coronary anatomy.

Almost all arteries and grafts, including LIMAs, are best cannulated from a LAO 30o view.

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Views of the Right Coronary Artery

LAO 30-40 Cranial 10-20 Straight RAO

Right coronary artery Right coronary artery LAO30-40 RAO 20-40 Cranial 10-20

RCA

Posterior lateral branches Posterior lateral branch

PDA

Single best shot of the right coronary. Better visualizes the mid right coronary artery

If ostium not well seen try lateral view. The spine is on the right side

The spine is seen on the right side in LAO view and the No Diaphragm diaphragm is in most of the picture because of cranial.

AP Cranial

Right coronary artery RAO 10- LAO 10 Cranial 40

Posterior lateral branches Better visualizes PDA and posterior lateral branches.

Spine is in center

Diaphragm is in

PDA

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Common Views of the Left Coronary Artery

- Usually pictures are taken to see the left main first, then the proximal then mid-LAD, then the circumflex. - If you could only take two pictures because a patient is unstable, at least get an LAO cranial and an RAO caudal.

LAO 30-40 Cranial 10-20 RAO 30 Caudal 30 Left coronary artery Diagonal LAO 30-40 Left coronary artery Left Main Cranial 10-20 RAO 10- 25 LAD Caudal 25- 30

Best view of mid circumflex and obtuse Circumflex marginals. Left Main Spine on left Septal Good view of left main, proximal and mid LAD. Circumflex No diaphragm

Use in left dominant systems to visualize PDA.

LAD Obtuse Marginal

RAO 10 Cranial 40 LAO 50 Caudal 30

Left coronary artery Left coronary artery Left main LAO 10 – RAO 10 LAO 40-50 Cranial 40 Caudal 30-40 Circumflex (Spider)

LAD Best view of left main and bifurcation of the Obtuse marginal circumflex. Obtuse marginal Best view of entire LAD. LAD Septals Spine on right Variable spine. No diaphragm Circumflex Left main Septals

Lateral Left coronary artery LAO 90

LAD Good view of mid and distal LAD

Good view of true Circumflex circumflex and left dominant PDA

Excellent view for LIMA anastomosis and septals

Obtuse marginal Sternum on left 56 | Page

Spine on right

Left Ventriculography

RAO 20—30

Ventriculogram RAO 20-30

Aorta Minimum magnification

No panning needed

12 to 15 cc/sec are injected through a pigtail catheter for 3 seconds.

If lateral wall is of concern consider LV LAO 60 degree view.

Mitral regurgitation grading system:

1+: contrast clears with each beat and never opacifies entire atria 2+:Contrast does not clear with each beat and only faintly opacifies the aorta 3+: left atrium opacifies equal o the left ventricle 4+: Opacification of the left atria occurs in the first beat and contrast material refluxes into the pulmonary veins

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Finding and Imaging Bypass Grafts

Bypass grafts are generally cannulated easiest in at LAO 30, including the LIMA. In general, the grafts themselves are imaged at both LAO 30o and RAO 30o. If the graft appears patent and the focus is instead on the distal bed, use instead the standard projections above for the target artery as a starting point. The RCA graft will come off the lowest, the LAD/diagonal grafts next highest, and the circumflex/OM grafts come off the highest.

Ascending Aortography (e.g. to find bypass grafts or anomalous coronary arteries)

Ascending aortograms are often performed at LAO 30o, occasionally with some cranial angulation. In this view, grafts to the right coronary point to the left of the image and grafts to the left coronary point to the right of the image.

Sample Coronary Angiogram, Right and Left Heart Catheterization and PCI Report

Procedure:

1. Left heart catheterization 2. Coronary angiogram 3. Left ventriculogram 4. Right heart catheterization 5. Percutaneous intervention of the LAD.

Operators:

Patience U. Whish, MD, Cardiology Attending; Joe “Radiation Shield” Shmoe MD, Cardiology Fellow

Indications:

Mr. S is a 60 year-old man with dyspnea and a positive stress echocardiogram which was also suggestive of pulmonary hypertension who presents for further evaluation by cardiac catheterization and percutaneous intervention if indicated.

Access:

Right femoral artery

Left femoral vein

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Procedure:

After informed consent was obtained, the patient was brought to the cardiac catheterization laboratory and prepped and draped using sterile technique. The area of the right femoral artery and left femoral vein were infiltrated with 1% lidocaine. Using a modified Seldinger technique, an 8 Fr venous sheath was easily inserted into the left femoral vein. By the same technique, a 6 Fr arterial sheath was easily inserted in the right femoral artery under fluoroscopic guidance. The patient was then given 1,500 U of intra—arterial heparin.

A 7.5 Fr Swan-Ganz catheter was then inserted in the venous sheath and an 0.025” modified J tip wire was ultimately needed to float the catheter to wedge position under fluoroscopic guidance. Right atrial, right ventricular, pulmonary and pulmonary capillary wedge pressure were measured as the catheter along the way. Thermodilution cardiac outputs were and mixed venous oxygen saturation were measured before the catheter was removed.

A 6 Fr FR4 catheter was then inserted over a modified J tip guidewire and used to cannulate the right coronary artery. Multiple angiographic views of this artery were then obtained by selective injection before the catheter was removed. A 6 Fr FL4 catheter was then inserted over the wire and used to cannulate the left coronary artery. Multiple angiographic views of this artery were then obtained by selective injection, 200 mcg of IC nitroglycerin was given before final images were taken and the catheter was removed over a wire. A 6 Fr angled pigtail catheter was then inserted over a wire and placed in the left ventricle. After measuring pressure, a left ventriculogram was performed. After a pullback maneuver, the catheter was then removed.

Interventional procedure:

An ACT measured 160sec and the patient was given an additional 3000U of IA heparin. Reopro IV was started and dosed by weight. A 6Fr Voda guide catheter was inserted over a modified J tip guidewire. A BMW wire was advanced without difficulty into the distal LAD. A 3.5 x 15mm Taxus stent was advance over the wire and the position confirmed in multiple views before being deployed at 14 atm. ACT was 260 sec. After final angiographic views were obtained, the wire and the catheter were removed. The sheath was sutured in place and the case was ended.

The patient received a total of 2 mg of Versed and 75 mcg of Fentanyl during the procedure. There were no complications and the patient tolerated the procedure well.

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Findings:

Hemodynamic:

RA a-8, v-7, m-7 mmHg

RV 52/7 mmHg

PA 48/22 m31 mmHg

PAWP 12 mmHg

LV 136/10 mmHg

Ao 132/72, m87 mmHg

MVO2 73% (room air)

Distal Ao sat 95% (room air)

Thermo C.O. 4.8 L/min

Thermo C.I. 2.8 L/min m2

Fick C.O. 6.0 L/min

Fick C.I. 3.3 L/min m2

SVR 1416 dynes s/ cm5

PVR 3.9 Wood units

Angiographic:

Left Main:

The left main is a large, long vessel that divides into three branches. There is a 20% stenosis in the mid-left main.

LAD:

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The LAD is a medium-sized vessel that gives off two small to medium-sized diagonal branches. There is a focal 80% stenosis of the mid LAD just proximal to the first diagonal. There is mild atherosclerotic disease throughout the remainder of the LAD system. Post-intervention, the 80% mid-LAD stenosis was successful treated with 0% residual stenosis.

Ramus intermedius:

This is a 2 mm vessel with minimal luminal irregularities.

Left Circumflex:

This is a large vessel with several obtuse marginal vessels. There is no significant disease in the circumflex system.

Right Coronary Artery:

This is a medium-large, dominant vessel that gives rise to a small to medium-sized PDA and a single, small LV extension branch artery. There is 40% stenosis of the distal RCA just proximal to the origin of the PDA.

Left Ventriculogram:

The left ventricle is normal in size with no wall motion abnormalities. There is 1+ mitral regurgitaiton.

Summary:

1. Successful stenting of the 85% mid-LAD lesion using a 3.5x 15mm Taxus stent with 0% residual stenosis. Otherwise, mild diffuse coronary artery disease is noted. 2. Normal left ventricular size and function with mild mitral regurgitaiton. 3. Moderate pulmonary hypertension with only minimally elevated LVEDP and wedge pressure. A primary pulmonary process is suspected.

Recommendations:

1. Plavix 300mg x 1 load, then 75 mg PO daily for 1 year. This should not be electively stopped during this time without first consulting cardiology. 2. ASA 325mg daily for 6 months, then 81mg daily. 3. Aggressive risk factor modification 4. The patient will be admitted to the Cardiology N service overnight for observation and to complete 12 hours of Reopro. After discharge, we will see him back in clinic in 1 month.

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1st Year 2nd Year Sites of practice VA, HMC, UWMC (on call only) UWMC, HMC on call Clinical evaluation and management Pre-procedure eval, Advanced understanding of indications and pre- Intermediate/advanced understanding of indications and consents procedural evaluation for diagnostic studies and pre-procedural evaluation for complex PCI and basic basic interventions structural interventions Post-cath care Advanced ability to provide post-procedure care including management of medications and vascular complications Diagnostic studies Vascular access • Advanced ability to perform arterial • Intermediate/advanced ability to deploy closure and venous access. devices • Basic understanding/ability to use • Intermediate ability to perform radial access closure devices. Right heart caths • Intermediate practitioner. • Independent practitioner. • Advanced ability to interpret • Advanced understanding of hemodynamics of hemodynamic data in heart failure, pathologic states—e.g. constriction, tamponade, valvular disease. congenital heart disease.

Coronary angiograms • Intermediate practitioner • Independent for basic cases • Understanding of standard views and • Intermediate/advanced ability to pan, set anatomy, using standard catheters up/modify shots, select catheters for complex anatomy, managing complex PVD Interventions IABP, Intermediate practitioner Independent practitioner Pericardiocentesis, Temp wire Percutaneous • Basic familiarity with PCI equipment • Intermediate understanding of PCI equipment and Coronary interventions and devices procedures • Basic ability to support PCIs “back • Intermediate ability to support PCIs scrub” • Intermediate understanding of indications for • Familiarity with IVUS/FFR FFR/IVUS, basic familiarity with procedure Structural Basic familiarity with evaluation and Intermediate familiarity with evaluation and management interventions management of patients undergoing structural of patients undergoing structural heart procedures heart procedures Peripheral Intermediate practitioner basic angiography Independent: Closure devices, basic aniography (iliac- Basic familiarity with evaluation and femoral, subclavian, aortic) management of patients undergoing peripheral Familiarity with basic iliac interventions, non-invasive vascular procedures studies Interventional Cardiology pre-fellowship: 2-4 month rotation 3rd year Interventional Cardiology Fellowship: 1 year post-fellowship, Interviews Dec 2015 for July 2017 start Structural Interventional fellowship: 1 year post-IC fellowship. Interviews Dec 2015 for July 2016 start

UW CARDIAC CATHETERIZATION LAB CHECKLIST 62 | Page

1. PREPROCEDURE WORKUP a. Patient history History, indication, risks Plan—PCI? DES v BMS? Access? Coronary anatomy, echo, stress tests Labs: Creatinine, hgb, plts, lytes, INR/PTT Contraindications: contrast allergy, vascular disease, bleeding, acute CHF b. Exam Airway Lungs/heart/JVP Vascular c. Consent and sedation assessment Consent form ORCA: Moderate sedation orders ORCA: Moderate sedation evaluation d. Pre-cath orders (night before) CPOE—pre-cath orders on patients (except TAVR, CTO, structural heart patients) 2. LAB FLOW 7:00 AM Plan the day with “Doc of the Day” and Charge RN 598-2009 Triage patients and discuss fellow availability (vacation, sick leave, clinic, coverage) Stay ahead on consents/orders Communicate with Cards A/B (Add-ons, NPO, labs, vascular access) 3. PROCEDURE 4. POST-PROCEDURE CPOE Orders—(“Card post-cath” groin/sheath management, fluids, ASA/clopid, med rec) Cores for CARD-I patients Sign out to ARNP 598-1408 Groin check Notes within 24 hours (preferably as soon as possible after procedure)

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Day before Morning Pre-procedure Procedure Post-procedure Through the day

• 1. Review case • 7:00 AM daily • History, studies, exam, • Orders/Med Rec • Stay ahead of histories • Consent/Assess discuss with attending • Groin checks and consents/assessments 2. Pre-cath orders outpatients • Consent-Assesments discharge plan • Keep in touch with (CPOE) • Discuss with "Doc of signed • Notes within 24 hours CARD A/B 3. Inpatient day" and charge RN • Reassess patient flow consents/orders with charge RN 4. Touch base with ICRU

• Consents and ORCA sedation orders need to be done prior to AM conferences • IC fellows to cover consents/workups on general fellow clinic day and Friday morning • Card A/B fellows should make an effort to obtain consents on inpatients • Cath and Card A/B fellows need to discuss patients and keep the charge RN in the loop Key contacts: ICRU 598-7146 Charge RN 598-2009 ARNP 598-1408

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