Shunt Detection and Quantification . Grossman’s cardiac catheterization, angiography, and intervention. Presenter : 蔣俊彥 Supervisor : 趙庭興 醫師. Outline. Oximetry Run Flow Ratio Early Recirculation of An indicator Angiography . Shunt suspection. Unexplained arterial desaturation
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Grossman’s cardiac catheterization, angiography, and intervention
Presenter : 蔣俊彥
Supervisor : 趙庭興 醫師
1. Left and or right pulmonary artery
2. Main pulmonary artery
3. Right Ventricle , outflow tract
4. Right ventricle , mid
5. Right ventricle , tricuspid valve or apex
6. Right atrium , low or near tricuspid valve
7. Right atrium , mild
8. Right atrium , high
9. Superior vena cava , low (near junction with
10. Superior vena cava , high (near junction with
11. Inferior vena cava , high (just at or below diaphragm)
12. Inferior vena cava , low L4-L5)
13. Left Ventricle
14. Aorta(distal to insertion of ductus )
a. Highest oxygen content in blood samples drawn from the right atrium exceeds the highest content in the venae cavae by 2vol %
b. a significant step-up at the ventricular level is present if the highest right ventricular sample is 1 vol % higher than the highest right atrial sample.
c. a significant step-up at the level of the pulmonary artery oxygen content is more than 0.5% vol% greater than the highest right ventricular sample.
1 vol% = 1ml O2/100ml blood or 10mlO2/l
is 12%-13% >8%
=0.96(14g Hgb /100ml blood) x (1.36 mlO2/g Hgb)
=18.3 mlO2/100ml blood
= 240ml O2/min /(183-152) mlO2/L = 7.74 L/min
Qs = 240ml O2/min/ Systemic arterial O2 content – Mixed
venous O2 content
= 240/(0.96-0.69)14(1.36)10=4.6 L/min
= 15 L/min
= 4.1 L/min
sign of the presence of irreversible pulmonary vascular disease.
PV O2 content -- MVO2 content
(MVO2 content-PV O2 content)
(SAO2 content –MV O2 content)x(MVO2 content-PVO2 content)
three main types: ostium secundum (68%) , stium primum
(18%) , sinus venosus defects (6%).
Secundum defects are located in the fossa ovalis below the
limbs band and usually single and central and often
amenable for device closure.
Sinus venosus defects occur in the posterior part of the interatrial
septum , near the superior vena cava , or rarely , the inferior vena
cava and are not amenable to device closure , largely because of
the proximity of nearby right pulmonary veins
The absence of transatrial gradient does not make the diagnosis of an ASD ,pericardial tamponade , restrictive physiology
angiography for pressure equalization across the atria , catheter course , and a step-up at the atrial level is important to make a diagnosis
Both angiography and balloon sizing of atrial defects are carried out to assess whether transcatheter closure is feasible
Suspect ostium primum ASD and perform LV angiogram in a so-called hepatoclavicular view (LAO cranial 40º )
About 50%-60% of patitents with secundum ASDs and those lesions is less than 24 mm diameter , balloon sizing of the defect with a soft , deformable balloon and angiography precede device placement .
Down syndrome .
Shunt direction are determined by the afterload that each ventricule faces.
increase LV afterload (e.g., hypertension, coarctation)
Decrease RV afterload ( pulmonary resistance occur in early infant )
Decrease LV afterload (vasodilator therapy)
Increase RV afterload ( the development of pulmonary stenosis or
pulmonary vascular disease)
Small VSDs have a large pressure gradient acrosss the interventricular septum. A large VSD is not to be a large defect. Small defects with associated pulmonary hypertension may mimic the pressure findings in a large defect.
interventricular septum are best seen in LAO veiw.
the right PA ; and a “mixed ” PA value cannot be defined accurately.
Most PDAs do not alter right- or left-side heart pressure unless they are large.
In the face of any left-side heart abnormalities (e.g., poor LV function, aortic stenosis ) , a PDA increases LV systolic pressure , LV diastolic pressure or both .
PDA is best done in a straight lateral view with contrast material injected distal to the PDA.
Most workers use coils in small PDAs and a modification of the double-umbrella technique of Rashkind or a Grifka coil and bag in larger ones.
undertake for balloon vavotomy , which cardiac dysfunction appears in the neonate or the peak-to-peak transvalvar gradient is higher than 50 mmhg , or associated with mild aortic regurgitation in older children,
bicommissural valve with leaflet fusion. The absence of the
intercoronary commissure is most common.
Progression of obstruction occurs in one third of those with valvar
aortic stenosis, making careful follow-up mandatory.
thin fibrous ridge or fibromuscular dysplasia of the LV outflow tract.
The clinical findings in all three lesions are similar in these patients with uncompromized LV function.
No oxygen saturation changes in the left or right heart blood
Multiple pigtail catheters are used to enter the LV ; a pullback tracing with these catheters may not localize the presence of subvalvar or supravalvar stenosis, making use of an end-hole catheter necessaryfor the purpose.
Balloon valvotomy has become the treatment of choice for valvar aortic stenosis at Boston Children Hospital. The results are roughly equivalent to those of surgical valvotomy.
The foramen ovale is usually open , allowing catheter access to the left side of the heart from a femoral venous approach. Arterial catheters usually are required only in ill neonetes and those with severe or more
obstruction. The opening in the pulmonary valve of an infant with severe pulmonary stenosis may be extremely small (less than 1 to 2 mm in diameter)
Do not routinely measure PA pressure directly in infants with critical valvar pulmonary stenosis, rather perform 4 F catheters and a 0.018 inch
torque wire to cross the valve , followed by rapid balloon dilation.
In mild pulmonary stenosis, the RV pressure is normal. As the degree of stenosis increases, the RA a wave increases. With severe pulmonary stenosis , RV systolic pressure approaches or exceeds LV pressure, main PA pressure falls, and the PA pulse pressure dampens. Marked hypertrophy of the RV may cause the infundibular os to close during late systole , resulting in further obstruction.
Right ventriculography in straight lateral view to outline pulmonary valve and subvalvar region.
A straight AP view with crainal angulation may outline the pulmonary valve, poststenotic dilation of the main PA often obscures the PA branch origin.
all forms of coarctation occur at or just distal to the left subclavian artery, at or near the level of the old ductus arteriosus
Coarctations have discrete “ curtains ” of tissue indepting the posterior wall of the aorta associated with hypoplasia of the transverse aortic arch.
The gradient across a coarctation is influenced not only by the degree of obstruction but also the degree of collateral flow around the obstruction
no abnormalities in their intracardiac oxygen saturation
The gradient measured by pullback in the catheterization laboatory is frequently smaller than the gradient measured by sphygmomanometer in clinic.
a straight lateral aortogram usually provides excellent visualization of the coarctation.
invaluable with or without stent placement.
(a) branch PA stenosis (5% to 10%)
(b) pulmonary atresia with PDA-dependent pulmpnary blood flow
(5% to 10%)
(c) additional muscular VSDs (5% to 10%)
(d) aortopulmonary collateral arteries supplying blood flow to the
lungs (5% to 10%)
(e) coronary arterial anomalies , especially the left anterior
descending arising from the right coronary artery (1% to 2%)
right-to-left shunt at the ventricular defect.The size of this shunt is
unrelated to the size of the VSD, which in TOF is almost always large
and unrestrictive. The right-to-left shunt and degree of cyanosis are
determined primarily by the degree of pulmonary obstruction and less
by the level of systemic vascular resistance.
desaturation , and unconsciousness. Hypercyanotic episodes may be
provoked by increased pulmonary obstruction or decreased systemic
resistance. They are best treated by sedation, intravenous volume
infusions , and increasing the systemic vascular resistance.
were created surgically to increase pulmonary blood flow . Currently , so-
called complete cardiac correction , relieving the pulmonary stenosis, and
closing the VSD, is usually undertaken in infancy , or early childhood.
the atrial level as well, across a PFO. The atrial shunts are signs of substanially decreased RV compliance and suggest long-
standing RV hypertension.
RV and LV pressures are equal in patients with TOF.
PA pressures are decreased in cyanotic patients without surgery.
In the presence of surgically created Waterston or Potts
aortopulmonary shunts , the PA is often distorted and pressures are
elevated but rarely after Blalock-Taussig shunts.
cardiac catheterization of patients with TOF.
establishes the diagnosis , defines the anatomy of the pulmonary valve
and subpulmonary region , and identifies the main PA and proximal PA
surgical correction in patients with uncomplicated TOF.
Pas, dilation of hypoplastic Pas and coil embolization of
aortopulmonary arteries make up an essential component of
right-sided and RV is left-sided with the LV giving rise to a right-
sided PA and the RV to a left-sided aorta. The type of
transposition is almost always accompanied by a VSD and
subpulmonary stenosis , is often by tricupid regurgitation and
atrioventricular conduction abnormalities, and is a very difficult
lesion to deal with
red blood coming back from the lungs returns to the lungs, and
blue blood coming back the body return to the body. Without a
defect in circulation (e.g., ASD, PDA, VSD) to allow mixing
between the two circuits, the patient would die a few minutes after
or between the great arteries (using prostaglandins to open the
echocardiography definition is so precise and the only reasons to catheterize such neonates are to do a BAS.
establishes the diagnosis, assess RV function , determines the presence
of a VSD, or a PDA, and assesses tricupid regurgitation.
an arterial switch operation is performed electively in the first 10 days of life and perform a BAS in the early neonatal period. Creation of an ASD remain the optimal method for stabilization of cyanotic infants.
hypoplastic left heart syndrome (HL-HS) , which is caused by
aortic or mitral atresia . LV is diminutive. HLHS died in the past
when PDA close. The pioneering efforts of Norwood et.al, to creat
a new aorta surgically , using the RV as a single ventricle , has
improved the survival.
splenia syndormes , also frequently have single ventricle .
an aortopulmonary shunt , usually a Blalock-Taussig shunt , and
the mandatory catheterization information consists of
measurement of PA pressure, resistance , intracardiac and aortic
pressures, and OA and systemic venous anatomic details. The
catheter is advanced from the descending aorta into the mouth of
the subclavian artery. Then the guidewire is passed from the tip of
the pigtail to the distal PA .
Because the SVC has been disconnected from the RA and anastomosed to the PA, another venous line from the left subclavian vein is required in the catheterization of these patients.
, in addition to femoral venous and arterial lines.
patients is increasingly recognized and is considered to be a
consequence of the hepatic venous blood from the pulmonary
circulation by the bidirectional Glenn procedure.
fenestration placed in the baffle at the time of surgery and who
are doing well are not electively catherized.
later come to have this communication electively closed with a
evidence of congestive heart failure /venous hypertension who
require catheterization for diagnostic and intervention purposes.
lead to ventricular failure and require coil occlusion.
require dilation and stenting even gradients are small.