Updated 7/2/2024

UW CARDIAC CATHETERIZATION

STEMI

The goal is door to balloon time < 90 minutes. The ER staff at HMC and UW may elect to activate the cath lab directly, without your involvement. If they do, just start driving as you should aim to be the first one there to do an initial assessment. Alternatively, they may call you first for your opinion. If it’s an obvious slam dunk you can activate the cath lab before you ever see the patient. If the case is probably appropriate for emergent cath, but not obvious, most of us would see the patient first and then activate the lab. Early discussion with the on-call attending is prudent. Also, the interventional fellow will be activated. Work to support them. Reviewing a faxed copy of the ECG may be useful; however this may also result in considerable delay in patient evaluation. When in doubt, evaluation of the patient and ECG in person is your best bet.

To Activate the Cath Lab at the UNIVERSITY

1.     First, page the cath attending on call to discuss the case

2.     Page the lead cath tech on call as soon as you’ve talked to the attending

Prep for Emergent Cath:

  •  Activate the Cath Lab

  •  Have a brief H&P done by the time the cath attending arrives if possible: history of bleeding, strokes, vascular surgery or stents, check lower extremity pulses

  •  Labs: CBC, Basic lytes and creatinine, Coags, Troponin (pending results should not delay catheterization)

  • ECG

  •  CXR (obtaining this in the ER should not delay transfer to the cath lab)

  • Treat: ASA and P2Y12.

    • Usually ticagrelor 180 mg (unless >75, hx of intracranial hemorrhage, active bleeding, severe hepatic impairment, high bleeding risk) vs prasugrel 60 mg po (unless>75, hx TIA/CVA, active bleeding, wt < 60 kg, high bleeding risk) vs clopidogrel 600 mg po. Unfractionated heparin can be started in the cath lab if not started in the ER.

  •  Consent the patient (including consent for angiography and intervention, consider consenting for MCS)

Rescue Angioplasty

“Failure of Thrombolytics” (This is ever changing, but generally speaking):

Persistent chest pain or ST segment elevation 2 hours after lytic therapy.

Consider emergent cath for failed thrombolysis, especially if:

1.     Killip class III or IV

2.     New left bundle or >2mm ST elevation in >4 leads

3.     Large inferior MI

4.     Anterior MI with less than 70% resolution of ST segments

5.     Poor cardiac reserve due to prior infarctions

General Fellows Expectations For STEMI

1. General fellow should be first call for all non-STEMI cath lab activation requests, complete the workup as needed and discuss with the on-call attending. 

2. General fellow should take part in all STEMI cases for triage, consenting, and working to get the patient to the lab. 

3. For TRUE STEMI/CRITICAL PATIENTS, the interventional fellow and attending may allow one attempt at access or may perform themselves, and typically will perform the diagnostic angiogram and intervention for speed and efficiency. This is at the discretion of the interventional attending. The general fellow will scrub in to learn management of these critical patients and be part of back table preparation of interventional tools. Especially at Harborview, these skills can be very helpful, so learning how to manage wires, balloons and stents is necessary.  

4. For stable patients, the general fellow should be expected to obtain access and perform diagnostic angiography (unless guide catheters are used). 

5. The general fellow should perform right heart catheterizations and IABP placements. 

6. If the general fellow is paged out during an intervention, they may scrub out and tend to other duties as necessary.

Care of the Post-PCI Patient

Sheath Removal 

When the ACT is below 170 sec (depending on the lab and the machine used to determine ACT), the sheath can be pulled. If no closure device is used, manual compression for at least 3 minutes per French size should be done for arterial punctures with additional time as needed until bleeding stops. Set up so you can visualize the entire leg as you’re holding pressure to check for color of the extremity. You may need to intermittently decrease the pressure slightly to allow adequate perfusion to the limb. We do not use C-clamp or a Femostop devices.

If bleeding recurs, hold manual pressure on the site again for 3 minutes per French size. Do not use sandbags. Again, visualize the entire limb and slightly relieve pressure intermittently to avoid completely occluding flow to the limb.

Guidelines for Ambulation After Sheath Removal Based on Type of Closure

  1. Manual Compression: 4 French: 2 hours; 6 French: 6 hours (2-4 hours total if at the VA)

  2. Angioseal or Perclose: May ambulate after 2 hours

  3. Radial approach: Reduce arm/wrist mobility for 2 hours. Follow band removal per protocol. If bleeding, reinflate and repeat the process. 

Anticoagulation After Elective PCI

1.     Bivalirudin (Angiomax) used when heparin allergy present. Lower bleeding risk compared to heparin + IIb/IIIa inhibitors but newer data indicates similar bleeding rates and inferior 30 day MACE to heparin (HEAT-PCI). It is given only immediately peri-procedure and does not need to be continued after the patient leaves the cath lab. 

2.     Heparin: used during the intervention to keep ACT > 200-250, but usually shut off in the cath lab. Does not need to be continued after intervention 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.

3.     IIb/IIIa inhibitors: May be started if intracoronary thrombus was identified during the procedure. Ask the interventional fellow or attending for recommendations on dosing and duration.

Post-PCI Chest Pain

Consider emergent repeat cath if:

1.     Hemodynamically unstable

2.     Dynamic ECG changes with pain

3.     A new episode of classic (recurrent) pain syndrome requiring escalating anti-anginal therapy

Hypotension

Hypotension may occur post-PCI. The most benign etiology is a vagal response to sheath removal. Patients may feel diaphoretic, lightheaded and complain of nausea. Bradycardia usually accompanies hypotension. The episode should temporally correlate with holding manual pressure at the groin site, etc. Treatment is supportive, with atropine and volume infusion. HOWEVER, this is largely a diagnosis of exclusion. Hypotension may represent life-threatening bleeding or tamponade. All patients with post-PCI hypotension need to be evaluated. Hematoma may develop at the puncture site, or may be retroperitoneal, which common presents with hypotension and back pain. An emergent non-contrast CT scan of the abdomen and pelvis is diagnostic. Tamponade may be excluded in post-PCI hypotension, although physical examination is usually sufficient. As above, an ECG should also be obtained to exclude peri-procedural myocardial infarction.

 

Intra-Aortic Balloon Pump (IABP)

INDICATIONS

  • Cardiogenic shock

  • Bridge to Revascularization

  • Bridge to tertiary center

  • Bridge to transplant or LVAD

  • Refractory unstable angina    

  • During and after high risk PCI (left main or proximal LAD)

  • Before induction for CABG in patients with high risk anatomy

  • Decompensated aortic stenosis, particularly if coronary disease present

  • Refractory ventricular tachycardia

  • Weaning from cardiopulmonary bypass

CONTRAINDICATIONS

1.     Aortic dissection

2.     Abdominal or thoracic aneurysm (repaired OK)

3.     Severe peripheral vascular disease

4.     Presence of descending aortic or iliac grafts (relative contraindication)

5.     Coagulopathy or contraindication to heparin

6.     More than moderate aortic insufficiency

7.     If severely obese, use a sheath instead of sheathless.

Management Issues:

1.     Check CXR immediately after placement and then daily for tip location. It should be located 1-2 cm below the top of the aortic arch and at or above the level of the carina.

2.     The patient should be on heparin unless the IABP is 1:1, then it is optional

3.     Daily CBC to check for bleeding, mechanical hemolysis and thrombocytopenia

4.     If femoral, patient must remain supine in bed with leg straight

5.     Monitor pulses hourly while balloon is in place.

Managing Complications - Always reach out to the interventional team if a complication is suspected

Superficial Bleeding: can usually be controlled with prolonged manual compression. Remember that the arterial entry site that should be compressed is several centimeters superior to the entry site at the skin. Progressive abdominal pain that radiates to the back should raise concern for a retroperitoneal hematoma.

Lower Extremity Ischemia: remove the balloon and sheath and consult vascular surgery

Balloon Rupture (rare): Blood or brown flecks may be seen in the gas drive line lumen or it may result in cessation of augmentation. Complications include helium embolism and balloon entrapment. Stop inflation immediately and remove the catheter within 30 minutes.

Balloon Entrapment (rare): This occurs when the balloon cannot be completely deflated for removal, usually as a result of balloon rupture and clot formation within the balloon itself. The patient should undergo emergent imaging with fluoroscopy to ascertain the position of the balloon. Surgical removal may be necessary. There are case reports of using thrombolytics through the gas drive line to successfully lyse the clot and remove the balloon normally. Try to remove the balloon, if it doesn’t come easily call vascular surgery.

Changing an IABP

1.     In emergencies, the sheath (if present) may be wired and a new balloon inserted through an old sheath but there is a high rate of infection with this technique.

2.     Whenever possible, use the contralateral femoral artery. Stop heparin. Put the old balloon on standby as the new guidewire is positioned in the aortic arch. Turn the old balloon back on as the new balloon is readied. When ready, deflate and quickly remove the old balloon and immediately insert the new balloon from the contralateral side.

3.     Ipsilateral approach: can be done surgically.

Placement in the cath lab. Let the attending teach you, but also watch this:

Pulling a Balloon Catheter

1.     If the hemodynamics look good on 1:3, stop the heparin 4 hours before you want to pull the balloon. If in doubt, check an ACT (< 150 is safe to pull the balloon). We’ll often put the balloon back on 1:1 once the heparin is stopped to help prevent clot formation.

2.     Get everything ready
- Suture removal kit
- Iodine or chlorhexadine
- A bucket of 4x4 gauze pads
- A chuck to put the balloon onto
- Gloves +/- gown for you
- Patient’s RN

3.     Uncover the patient’s leg fully so you can see the foot and feel distal pulses easily.

4.     Remove the sutures or stat lock

5.     Place two fingers above the puncture site and find the pulse. Place one finger below the puncture site and find the pulse. Keep your fingers on these spots.

6.     Have the nurse stop the balloon before you pull it!

7.     Pull the balloon and sheath out all at once as you hold pressure with your one finger distal to the puncture site. Let the site bleed freely for 2-3 cardiac cycles. Now hold pressure with all three fingers and get control of the bleeding. Wipe the pooled blood away with the 4x4s so you can see if it’s still oozing around your fingers. Hold pressure for 3 minutes per French size of the sheath. After 5 minutes of manual occlusive pressures, slightly relieve pressure to avoid completely occluding flow to the limb.

Emergent/Urgent Pericardiocentesis  

Indications:

1.     Tamponade

2.     To determine the etiology of an effusion if it is uncertain (urgent if purulence is suspected)

Contraindications:

1.     Skin infection at entry site

2.     Significant pulmonary disease

3.     Hemodynamic instability not from tamponade

4.     Anticoagulation: (INR > 1.8) or PTT > 2x normal

5.     Thrombocytopenia: platelets < 50 K/mm3 with bleeding or < 20 K/mm3 without bleeding.

6.     Trauma: acute traumatic hemopericardium requires immediate surgical exploration.

7.     Aortic dissection: tamponade due to dissection should be treated surgically

8.     Small or posteriorly located effusions

Relative Contraindications

1.     Loculated effusions: surgical drainage preferred

2.     Purulent effusions: surgical drainage preferred

3.     Malignant effusions: surgical drainage preferred

Logistical Issues:

These are done in the cath lab with echo assistance. You’ll need to arrange a time with the cath lab first and then schedule a sonographer to do the echo.

Complications (Elective)

1.     Overall 0.3-3% with echo guidance

2.     Infection

3.     Pneumothorax

4.     Cardiac laceration or puncture

5.     Acute pulmonary edema

6.     Artery laceration

7.     Peritoneal puncture

8.     Arrhythmias 

9. Death

Subxiphoid Technique:

1.     Use echo to find the effusion and determine the best approach, usually sub-xiphoid

2.     Prep the area (shave if there is time)

3.     Anesthetize the point where the xyphoid process and the left costal margin meet, but medial to the sterna-costal border. A small incision at the point of entry makes inserting the catheter easier. Anesthetize along the path from left of sub-xiphoid towards the left mid-scapula.

6.     Attach a long 18-ga Cook needle to a handheld syringe partially filled with lidocaine.

8.     From the sub-xiphoid area, direct the tip posteriorly and superiorly towards the left shoulder at approximately 30 degrees angulation. It helps to keep the need horizontal and use your left hand to push the whole needle, skin and syringe downward and underneath the ribs as you would on a subclavian line.

9.     Advance the needle, aspirating constantly.

10.  Inject lidocaine intermittently as the needle is advanced to ensure needle patency.

11.  Once in the pericardial space, one person grabs hold of the needle at the skin and does not let go, ever. The other person advances a floppy tip guidewire through the needle.

a.     There is no ONE way to confirm you are in the pericardial space, if the fluid is bloody you should use at least two of the following confirmatory measures before declaring success:

i.     Place a few drops of fluid on filter paper or gauze. If there’s a ring of clear liquid around a solitary drop of blood, it’s probably pericardial.

ii.     Fluoroscopically: Watch the wire on fluoro as you advance it upwards towards the left atrial silhouette and confirm that it appears to track in the pericardial space. You can inject some contrast if needed.

iii.     Echocardiographically: Inject agitated saline.

iv.     Fluid analysis (should be available in the cath lab):
- Check a blood gas of the pericardial fluid
- Check a hematocrit

v.     Pressure: Place the pigtail catheter and measure the pressure with the manifold. It should look like an atrial tracing with a lot of respiratory effect. If it looks atrial, then you are either in the pericardial space OR one of the atria. The main difference is that the pericardial pressure should decrease dramatically after only 100-200cc are drained. This is easy to check if you attach a pressure manifold to the end of the catheter by 3-way stopcock to the drainage catheter. It’s a good idea to use a piece of extensor tubing between the manifold and the needle or catheter, otherwise it’s awkward.

12.  Advance a 7 or 8 Fr catheter with side ports, a pigtail or preferably a pigtail with side ports into the pericardial space.

13.  Drain the fluid, send samples to the lab.

14.  If the catheter is to be left in place, it is usually attached to an accordion drain and flushed with 10cc normal saline qshift. This is done by either the CCU team or cardiology consult team.

15.  Generally speaking, the catheter is removed when it drains less than 50cc over a 24 hour period.