Cath Lab Basics - Cardiology

 

Mainly the clinical part of the catalog basics I would be discussing today all of my presentation will be the what are the indications of pediatric target, cat procedures? We would broadly classified as a diagnostic or interventional procedure. The aims and limitations of the diagnostic cardiac catheterization, the complications associated with it, the case selection and planning the basic calculations of cardiac output. Ps, the pulmonary and systemic muscular resistance and These are the things I would be covering in today's topic. So, first jumping with the indications Basically, we classify any cardiac categorization as a diagnostic cardiac catheterization or an interventional procedure. So, in a diagnostic cardiac catheterization, we are primarily aiming at defining the physiology or the hem of the cardiac anomaly with addition, We even try to define the anatomy of the congenital heart defect if in case it diagnostic cardiac catheterization and it is a gold standard for it. a second would be any interventional procedures like a device closures almond, or a maze. or Alas. Atlas. So, before we even think of any procedure of cardiac catheterization, we should understand that any cat made progress for a need to intervention. Hence, a plan, basic plan and basics should always be in place before we embark on it. Diagnostic cardiac, like for example, when we do a diagnostic cardiac, there's a good chance the having an arrhythmia. So, you'll have to have a cardio or defibrillator or medications to terminate the arrhythmia or it can go into complete Heart block. So, you should always have it. on the table before we embark on the diagnostic categorization. in the category of defining the physiology of the hems of the diagnostic categorization assessment of PH in CT forms the foremost and major chunk of where we assess the UPS, vascular resistance, and if the PBR is high, the ability for the either oxygen or in nitric oxide or Est, some of the almonds which we use to accessibility of the PBR in cases of pulmonary ratio with a defect and multiple pulmonary collateral, It is definitely better to delineate them. on categorization as compared to any Nafta. non invasive in cases of cardiac transplantation. It is more imperative that we get a pulmonary artery, vascular resistance. the fillings, and also a biopsy in the pre transplant evaluation and in prose transplant for development of a vascular and for a biopsy to assess if there is any rejection Those were the class one indications for diagnostic. Now, for Classes. two indications, most of the centers still do like in our center. we always do for assessing the suitability for into font and completion. We assess transparent ingredient and pressures and pulmonary vascular resistance in cases of cardiomyopathy to differentiate sometimes restrictive cardiomyopathy or cardiomyopathy. constitutes and also for taking a biopsy in cases of pediatrics. Coronation would be needed in Kawasaki disease in post transplant, vascular, and in any of the coronary anomalies. The Communist, especially a institute. we do a lot of post op immediate post-op diagnostic catheterization for any unexplained deterioration which cannot be explained by any other form of imaging. There are a few special categories like in combined lesions like a stenosis and I regurgitation where invasive tests generally do not clear some of the dots which is the dominant lesion which is the second lesion or in cases of obstruction say membrane with the or with aortic stenosis. We'd love it becomes difficult to assess the which level of is the dominant. And how much is the combined obstruction so that we we can form an indication for intervention has already discussed diagnostic in immediate post-op in the ICO is very important. 

Sometimes you do a theme post op and say there is a rescue lesion. your circumstances Titan says no, the we check the step up in the once we came off the bypass, it was not significant. So you have to give it So, we'll have to quantify a residual translation in the form of PPS. You may need a diagnostic to quantify any rest out. obstructions especially in the fall because they maybe left some ROT because when they're in dias, sometimes they may not see the all the threeds of right protract obstruction post and font to delineate almonds because immediate post-op, the patient may not be achieving the target saturation which we would have thought otherwise, Our presence of any collateral and in cases of penetrated Fontana where the deer is such that he may not be able to be excavated. So, we may test the closure of font by occlusion. if the the pressures are good, then probably we can go ahead and close the administration as well and to define out of pulmonary collateral when especially in cases of where we don't do routinely to the CT scan. Then maybe our next, the increased LA returns when the patient is on CPP, and in cases of be patient occlusion leading to the saturation may not be very well documented on echo cardiogram because of either open chest or any of the chest or because the patient is ventilated. the imaging may not be great and the second category would be the interventions. There is a myriad of device closures Alas angioplasty, and sting, and a estoy and interventions for Foundation. Either closure of the penetration or when there's a font and failure to pop off. you have to open the font and into the atrium or in recently. started the procedures which is which is bound to become very common after so many years of intra for that is the revolving plantation So, next, we'll have to understand what RR aims to do with categorization has already discussed to broadcast. Categories are diagnostic and and in the diagnostic category. It is first and foremost to define the physiology or the hems of the art lesion and secondly, if there are any caveats in the emerging, there any unanswered questions on the anatomy, we can even delete anatomy but physiology will be the gold standard for diagnostic cardiac catheterization in cases of anatomy, there are better non-invasive test like cardiac MRI which can give you a beautiful images so that you don't have an eye out for the anatomy. in cases of intervention. 

Our aim is to go in to the intervention where it is indicated and suitable and come out without any complications but however, we should never forget to define and the hemorrhoids before any intervention like in cases of a it doesn't mean you just go inside, put a and come out. No, you have to do the right cat. Do the Qbs. assess the pulmonary artery pressures and then do the procedure. The limitations of categorization are the first and foremost is it's an invasive procedure and it is laced with risk of complications and there is need for extensive inventory not just in inventory but also the knowledge, expertise, and experience to use the hardware which is presented at hand also improvise on that when there is a requirement because you cannot have all gets all which are available all over the world to be in your inventory. So, you have to have that expertise to improvise on the hardware which is already at hand and definitely radiation is one of the major limitations of cardiac. It is both to the patient which many for many of the patients say in cases of intervention, it becomes one time or for an operator is cumulative and lifelong difficult to maintain the hem steady state if we cannot maintain the state, the results after the procedure or the calculation will be all over the place. So, you should always try to maintain the immoral, steady state and if it's not possible, you should have the expertise to interpret with reference to the change in the state and one of the major limitations of delineate the anatomy diagnostic. it is, is it is to delineate only do you have we have images but that's still just adds some more information but you generally don't get complete threed orientation So, they are the limitations of catego rization. The advantages are to is the intervention is intervention. Second is the accurate and gold standard humor assessment. in the present era. There are combined emerging in the catalog which adds advantages of both the modalities thus negating the limitation of individual imaging. So, you can have a three DP floral overlay for any device closures or threed floral overlay for procedures like plantation where other ways you may have to use humongous amount of contrast to define the very much dilated and So, next, coming to the complications basically, first would be the anesthesia related. We are colleagues of the Anesthesia Department. Take care for us Particularly, it will be the vascular injury where there may be occlusion, loss of pulse or limb altogether, possibility of arrhythmias including Heart Block and Tachycardia which needs to be intervened immediately. So, again, you have to have a appropriate hardware to medicines to take care of them. We can trigger ay expelling cases of any physiology, babies, or stimulate pulmonary hypertension crisis in cases of ASD with pulmonary hypertension, that can be a chance of cardiac perforation injury while manipulating the cats of the virus especially the stiffness that may be Ism especially related to singles where the there is poly or there is in and a stroke and diffuse brain injury in cases of again, singles where there can be paradoxical embolism or a single men. There's no need for paradoxical. It can em bleeding which may require transfusion allergic reaction to contrast renal insufficiency which may be related to contrast because of that. and a stable hems due to any other complications like bleeding. also leading to hypertension that also adds to the renal insufficiency renal type of renal failure and last but not the least and the most dreaded being that all over the world probably, it's presently in less than .2 percent of cases where there is life risk there are few procedures specific complications which we always have to keep in mind and explain to the patients about their devices either immediate or lake and station like I especially where you may have to do a emergency surgical intervention in our institute, we generally use a lesion specific consent forms where we don't need to write anything. It's already written. We tell the patients to go through it read. we even show that you images of what I things looks like and then take a consent. So, lesions, specific consent forms should be the at least in India, we are trying to do it all in a lesion specific consent forms. So, that was for a device closures. This is for angioplasty. We have another for diagnostic and one more for strengthening procedures which lists of the colonist and most severe form of complications. So, come coming to the case and planning or two things should be the first things which should be part of when you are selecting a case for a one is indication for diagnostic intervention. We already have it. So you should not have any ambiguity there that if there is a soft indication you'll have done discuss with the patient party that there are other safer morals available but why we are doing this Kat is not limited to the answer like in ASD. we may be doing a study. So, that does not mean you just complete and come out. Everything should be complete and comprehensive sometimes in adult patients, we may say a window so we think it's AST with pulmonary hypertension. So, doing it more vigorously like do a LB to make sure there is no post in the event. We do. ionic injection to make There is no greater level chanting. So, the study should always be complete and comprehensive. and before the patient is plan for for a echocardiogram, other non-invasive should be done and only if the anatomy and physiology are not completely explained. that's when we plan for it. Diagnostic tests, the clinical status should always be examined and documented because a risk profile always depends on this. A stable patient to do a diagnostic is safer but in cases of when dysfunction or anatomy is like Congenital TJ where it's a higher chances of a complete Heart block or dysfunction where even a little change in in the So, clinical status should always be appropriately assessed to perform a study and also to bailout in cases of complications. So, always have the surgeons informed about the complex cases you're taking so that if there is any issue, there is always a chance for bailout They should be adequate. Heart in stock for any. For example, if we are doing a cot tent or Alas should always have a tent stop just in case if there is any need, if there is any need for covering the intimates or Avis and always have a pre cat investigations. well done before the and an informed consent has already explained. Specific consent form is always useful so that the questions from the patient and are minimal and it is safe medical legally as well. as much as possible and physiology should be defined by a with CT or MRI as required. investigations. It is generally a basic investigation. Complete blood to make sure there's no chance of any infection. All the other parameters are fine plotting, profile, renal function tests and see these are the basic S which needs to be done before we take any child for it. I've just listed ECG, a coin x Ray as a part of the basic work up before we take the patient in We should always plan the access when we see the child and start planning for the procedure. We should always pulpit all the pulses and check the locals especially in cases of any previous cat. So, the access which should be based on location of the heart you want to enter and the anatomy and the hardware available We should always have a contingency in place if the primary access fails to provide entry into the intended site. So, a brief checklist of the patient which we generally do or have to do a day before the procedure Patient identification is the first and foremost, correct. Correct. Correct diagnosis and correct procedure. So, a DC should be performed and confirmed that all the parameters are as the patient was seen before. the patient is admitted review. any CT MRI images just to make sure that you understand the threed orientation of the heart and how to go about further and review all the relevant investigations before planning for the procedure. Again, the second important after identification of the patient is the clinical status. Always examine and make sure the clinical status is same as when you plan the procedure. Sometimes, a newborn comes for a evaluation. You are saying that it's a stenosis but function was fine. He turns up 3 days and get admitted then the night before you see is dysfunctional. So, clinical status has changed a lot and this again, this is on the prognosis So, all these clinical status should be examined a day before and confirmed that it is at a steady state. Again, check the site, take a return informed consent, cross check that it's done. Always have a blood request at hand so that if there is any unwanted incident, we can always ask for blood and pay for the time being for the surgeon to help and or as per the list of the day IV fluids, this is the most most important and most neglected part of this checklist because in small If you keep it. for four to 6 hours, they going to get dehydrated. So, all your parameters you want us especially the pressures and EDP will vary based on if he's well hydrated or dehydrated. so IV fluids should be as part of the way and clinical status like in cases of cardiac failure. you definitely do not want to lower the patient with fluid. So, fluid restriction would be planned the type in the type of anesthesia with the team and it should be based on case to case basis in cases where there are dysfunction you want a safer procedure, then definitely having the patient anesthetist and incubated would be safer and another important, not important thing would be the to check medications like an anti ugliness or platelets or antibiotics if they have taken at the appropriate time and when it should be, stop like it stop depending on the medicine. forty-eight to 72 hours before the procedure. So, if in case the patient is still taking out and we try to do a PS, we may not get any results. So, this should be a game check access it again depends on the aim of the study, The standard access all over the world is artery and femoral vein just because it's become a part of the, it's almost like a ritual and it's easy to access and sometimes we may have to change the access as per case like for any ABC interrupted procedures, even if it is diagnostic, it's easier to go from a PC to AI, RB and PA or in that are commonly using in places of BP in units and infants because the entry into a RV will be easier from the jugular vein especially when the when the class sizes small or if the regurgitation is it's easier to cross from the artery. carotid artery puncture or surgical cut down. We use The surgical cuts for PDS tinting and in cases of anatomy in a small neon or or preemies auxiliary can be used radial artery for tinting where it is difficult to cross retrograde. in cases of IV ABC interruption for either a ASD closure or BST closures I mean, the device closure and last but not the least, of our surgical interventions are very commonly performed. of CPD, or perforation in cases of pulmonary rat intact. We have done both of these and it's easier to perform the perforation of the membrane and the baby is very small and getting the cat to the end holding it under the becomes difficult. So, next coming to the most interesting and confusing part is the calculations which are done especially in cases of operatives. So, cardiac by definition, it's the quantity of blood which is supplied to the systemic circulation per unit time that we measure per minute So, the standard principle which is used worldwide in cardiac catheterization, toes principle which take off a substance by any or is blood flow to the or multiplied by the arterial concentration difference between the substance but here we are taking oxygen substance. So, converting it to the cardiac output, it would be oxygen consumption by a difference Finally, it is curious. systemic cardiac output. So, oxygen consumption and I mixed Venus saturation difference If there is any absence of any QB is effectively equal to So, there are multiple processes which are available which were used previously but are cumbersome to be done in a setting of the cat for each procedure. So, initially, the pornographic are the metabolic rate meter was used. The Douglas was used to assess oxygen consumption and presently in in present respiratory a spectrum is used but comparatively, it is easier to use a La no gram because do the Douglas matter which is very cumbersome or we can get access to respiratory spectrum in the Cath lab in most of the art centers. Sonogram is well, applied and very well documented about the validity of the normal grass but a few caveats here again is it is not validated in children below 3 years and about 40 years adults. We can use the upper limit of the age oxygen consumption but less than 3 years, there are a few formula which are available which can be used for in case of children less than 3 years but it again becomes very cumbersome to use that formula In each case. So, simple equation which is standardized. So, if you do it across the spectrum, it becomes, you know, even if there is error, there is error across the spectrum of all the cases which finally negates the assumptions. So, simple equation, especially in adults, we can use this one to 25 ML plus or minus 25 ML per minute per meter square Sos which are used to assess cardiac output in a lab is dilution dilution method which I think is not a part of this discussion as of now. So, I'll skip it for now. the next time to the oxygen content. So, this is how because based on fixed principle, we are using the substance which is carried as the oxygen. So, oxygen content is the oxygen attached to the hemoglobin plus dissolved oxygen. So, depending on the partial pressure of oxygen, the more the the more dissolved oxygen it will have. So, we have to take into account both which is attached Tobin and dissolve in the plasma. So, 0 carrying capacity, oxygen content is oxygen carrying capacity into percentage saturation. This is attached to hemoglobin and .000 .003 ML perimeter of COtwo of dissolved oxygen in the plasma Please note that I've added a factor multiplied by ten to convert to this which is ML or Desk two liter. So, finally, it becomes .03 ML per eight millimeter. So, the oxygen carrying capacity is in a formal is one 1.36 ML of oxygen can be attached to one gram of hemoglobin and the amount of hemoglobin para Desk of plant and again, multiplying by a factor of ten because we need to convert this Desk into later. So again, here converting this to Desk two liter and here again, Desk to because we get a cardiac output as X amount liters minute per meter square. So, we need to convert everything to per minute. So, we're converting, adding a multiplying factor. Ten both places to convert from Desk to later the oxygen content Finally. the attached to hemoglobin. So, there are few errors in oximetry while sampling. one is dilution in the hepatitis syringe. If the amount of he is too much, say point to point ML and they're doing in a smaller child, you are trying to save more blood, trying to less that can get diluted and get filled up saturation. If there is a Un time in testing. So, ideally, all the samples for one run off, right? Heart should be oximetry should be around between two to 5 minutes. If it is there is a significant delay in testing or sampling that may be error. There may be no air in the syringe which will increase the Ps of the that be inappropriate. Mixed a sample or samples taken at a significant time which again is we'll have to understand that we need rabbits sampling within two to 5 minutes. So, easy ways to enter a chamber which is all difficult to enter. So, in case of a canal because of the BST Inlet EST and EST becomes very difficult for the to for us to maneuver into that field. So, it's always throug h. and from IBC to PA. then start the sampling so you can take a pier first then pull back. go to the SPCA BC, take the sample. So, in that case time delay will be avoided. the IVC sampling at a very low level like it below the hype lanes near the Renal Vein where the renal vein saturation will be very high SP MSPC sampling a very low level or into the RA where in cases of ASD or BST There may be a sampling and one of the most difficult to attain is attain and continue is a steady state in the chemo dynamics This is these are the standard formula. Which one of us are aware of. So, QP would be oxygen consumption by content or saturation. Difference between to pulmonary artery QS would be oxygen consumption by saturation or oxygen content difference between iodine mixed Venus pulmonary vascular resistance is the system that is a mixed Sorry. pulmonary vascular. that is same as with the systemic vascular resistance but there is a one more time we have to regularly use is the QE pulmonary blood flow. QP is the amount of blood which finally enters the pulmonary circulation. QEP effective That is the amount of blood from the systemic means which is destined to which should enter the pulmonary veins. So, he will be able to QP in case of absence of any direction in cases of leftovers. We can always negate the QP, QQEP will give you that left direction. to avoid all the fallacies of assumed that we can directly go into evaluating the UPS ratio by taking off the common oxygen consumption and saturation difference between a penis or pulmonary to pulmonary artery. This takes all the most of the fallacies and assumptions which we do well assessing the oxygen consumption like say So, next coming to the Shanti Valuation on oximetry. So, mixed Venus sample You have to understand that ABC most of the times approximate a saturation. IVC, Renal Vein has high saturation and in cases of coronary sinus because of cardiac, the saturation will be low Many of the fallacies which we generally don't idea is in cases of a very deeply selected child. The brain is, you know, completely deeply. There will be high SPC saturation in cases of postal status, The sax and the winds will be low and during exercise, the IBC saturation will be lower as peripheral extractions will be higher for a mixed saturation. We generally use the flame equation which gives more weight to the SPC That is three times the saturation plus a saturation divided by four. It averages three times SPC and one time IBC to get the mixed saturation in case many of the places we take the sample do it. do the procedure, and then assess sometimes the saturation will come up which may not be represented. Then again, you'll have to understand that we can still take AB Cs mixed in a saturation to be represented So, where do we sample? So, in cases of mixed veins, we already discussed taking ABC sample as the cleaners versus flame formula or already the SPC sampling should be done at the level where the, you know, veins join to form the SPC and make sure that an echocardiogram, there is no ABC like many of the ASD will have left. and joining me that if we have not diagnosed, it can lead to a false high BC saturation. So, in case we already know that it's coming to the left denominator, we can go into the right denominator or stop in to take the SEC in cases of IBC. we have to take sample at IBC. I just beyond the place where the hype joints so it's between he and I recently joined in the right atrium. It's the on the lateral one. pulmonary. You have to take on the resistance as mixing is incomplete especially in cases of arterial. That is PDA or a window. The mixing will not be incomplete by the time it reaches the so you'll have to try to take the sample beyond the highlights but we have to be very mindful of the fact that we have to avoid be sampling. Otherwise, the saturation will be very high and not representative again. the results will be all over the place which we may not be able to judge after that. So, we have to make sure to take the PM on Heart Vessels but not matching it. It's always advisable to take both pulmonary and average them in cases of pulmonary veins, direct sampling or if they're they're in a septum is intact bicep puncture as in when it is required. if there is no physiological in the lungs. then we can take a sample as indicating of pulmonary The x ray is fine. There is no Venus congestion or a plethora or pulmonary edema. No collapse of the lungs in such cases but the lungs are find his then probably you can take a sample as indicated on one and we have to choose the in case where there are x Ray findings of some collapse consolidation in some of the laws we have to plan and choose a way of a segment which is normal. coming to the A sample. Any art. Beyond Dita can be used to take a sample except in cases of ducts where there is a right to left or by directional chanting where ascending and descending a sample to be taken separately. and the has already discussed The sampling time should be short with me, Aorta and to avoid missing the physiological that means sometimes the we are working on taking sample. We may take the aortic sample first and then but also from and take it in between. If there is lots of time, delay and the anesthesia goes more deep, there may be some hyper ventilation. So, may come less than a sample. So, you'll have to The sampling time between those two should be minimal. A few lesions, specific fallacies, ABC in cases of PVC as we already discussed should be about the site of raining so we can take from the right denominator IBC in cases of so you'll have to define where the drainage is and take the sample below it. in the PBA. You can take from both dissolved oxygen. We have to understand that in room, air ventilation is very minimal and can generally be neglected. So, say for example, if I were to who is 21%, the PA partial pressure of atmospheric oxygen is generally 160 millimeters of mercury but once we breathe, there is mixing of the carbon dioxide and water vapor in the respiratory tract. So, the POD reduces 210 So, even with the best of ones, it can only transmit millimeters of mercury giving 100% saturation. So, when you calculate dissolved oxygen, at it will as indicated in the formula, it will be point .03 ML Hl it will come to three. Just consider a case where We have calculated exaggeration, ninety-nine, PO. 200 hemoglobin twelve The dissolved oxygen is only three but once we start giving supplemental oxygen the depending on the pressure, especially if it's ventilated, it can still reach up to 30400 also. so, you can see that in when the PO to radio increases from hundred to 300 the dissolved oxygen almost increased proportionately. So, in cases of dissolved oxygen, I mean, if you are giving supplemental oxygen post oxygen study. Always make sure you add the dissolved oxygen one note of caution here is in cases of high cardiac output, even a lower step up gives an indication to higher ups. so higher output generally leads to lower extractions. So, mixed saturation will be higher Take for example where the aortic the patient is fine. the arctic and saturation are equal in both settings. in a normal output generally between twenty to 25% extraction will happen. So, we have the saturation of seventy and there is a step up seven. 7% from Mixed Cleaners to pay consider the second example where there is high. So, lesser extraction. So, mixed saturation will be higher again. Consider step up when we put this into Qbs where I-0 and PV saturation the same compared to normal and cardiac output in cases of normal cardiac output. The UPS came to 1.26 even though the step up is only 7% in both and in cases of high output. the same 7%, they have a US 1.5. This is because the denominator, the PVP, reduces more as compared to the A mixed in a saturation. So, if the mixed saturation are higher and you know, it's already a high output, then chances of getting a higher cupid guesses So, what is the step up of saturation? How much is significant? And what does it all mean? So, this is the standard. This is mainly for a single sample. So, we call it 755. That is 7% step up at a three level or 5% at 2011 or 5% at three at eleven or combined anything more than equal to 7% is considered significant in cases of sampling which probably in the present era. we don't do it will be 533. So three four runs of oximetry is done and you are and you get 5% at a level 3%, 23%, and artery or more than equal to 5% at any level from SAP, it's considered significant but for practical issues for sampling which we regularly do, it's 755 the differential diagnosis at eight and are very well known. So, I will not go into details of that. So, main thing is to understand to keep this in mind. single sample 7855, great artery or four ulcer If it's simple, it's 533 and five instead of has already spoken. If we separately do the Q and QS calculation using the VA or two, then maybe added the fallacies of assumptions and other issues with the oxygen will and so direct PBS calculation the palaces of the assumption. So, already spoken about formula that is a mixed by me that give you the Qbs. Similarly, PBR ratio also negates the fallacies of assumption and Arabs but still the absolute is needed in, you know, publication and to define the prognosis and operable. So, it is still considered important. So, by definition, anything more than three would you need to PBR. I is considered PH three to five with you. would be borderline but if it is vastly active and again, you can advice closure of the chances in cases of PBR. more than five it needs testing and if it reduces below five on reactivity testing, it is noted as reactive or operable and with the view, discussion, the patient can be operated for closure options in case it's more than a more than eight 200 meters per then it is considered inoperable and generally in such high cases, the PBR even after reactivity testing comes down below five would be in cases hypertension. The APR may be super, super system where more than fifteen where it's a proof of immortality So profitability by diagnostic cardiac categorization should always be done with the backdrop of the clinical data. cat report or PBR ISIS by itself will not decide. It adds to already known clinical data. So, we should always have a clinical data before we embark on the operative care. like the features of CCF, failure to thrive and recurrent respiratory infection which indicates increased the left or right the age age Es. Probably. he is the large AST may not be may not become AM till fourth decade but compare that to a large BST where it can become a second or third decade. Compare that to a large PD or a window where it can become A and M with the first decade signs of hypertension like pre-recorded activity Vale from the should be noted Chest X-ray This is the standard guidelines. criteria we use for assessing and deciding whether it is operable or not. So, 20% for TBI 24% PBR PAPI less than six but in the recent European guidelines they have made it between three to five and less than 5 hours operable PBA PBR. A is a ratio of less than .3 and that me and pay less than .4. so far. cats which are not done for that is we have to define anatomy like in cases of traditional Vs collateral coronary anomalies, peer pressure where direct entry which can be taken especially in cases of and LV to Iota where MRI is not available. We can use this to show any rot and in cases of pre peer pressured, all your criteria can be assisted. So, coming to my last part is the fuse. So, you should always get a view to define any single structure. So, only one injection or one view will never give you a complete evaluation. So, you should always use it. If there is a plane which will which is very helpful and it will reduce the amount of contrast I think I'll show you a few images rather than going for reading through all of this. Okay. have a single me a PM. gives a good anatomic information. Additional views can be used for a collateral or collateral for pulmonary valve, ROOT. lateral view or you will be very useful for PI cases of NRA cranial is very good to assess for pulmonary. Again, lateral view can be helpful for the confluence. It is a thirty for aortic valve You should be used which would be a sixty and a thirty. corona fistula. We always need to be to individualize because the fistula has multiple turns and runs around all everywhere. So, it needs to be neutralized Special mention about Congenital corrected TGAPU gives you an posterior orientation of the vent if the heart is Meso. If the heart is I has a leopard then shallow and if it's to shallow, ROU can be helpful. So, just a few examples. So, this is standard review. A long oblique where the BST was well defined but in this case, the BST was not very clear. So, we went into a lateral view where this was an outlet defect where it was very well-defined So, PA is a standard audio and lateral. So, again, use for the same patient so that you don't miss the critical points in cases of ARBOT. It is RIO and lateral. So, it gives ROOT Pulmonary is not well defined in a as for the lateral view defines it well, for the aortic in you. Alas again are used. So that crossing becomes easier. So, REO and LA If you see this single listing, just forget this. You see this single lateral view. You don't seem to completely delineate. What is the issue here but once we take multiple views, you can see that there is a double chamber, right? Which could have been easily missed. if we had taken only the lateral. you obviously, we knew beforehand on the echocardiogram. so, we took multiple views to define it further. has already indicated. We took a diagram for coronary fistula. The huge. and it is RC. a fistula is running all over the place. Then we, once we snared and did a loop, we could go into the narrowest point and do injection and define it well. So, coronary fistula, there is no hard and fast depending on where how the aneurysm is running and how it is draining. You need to change it accordingly. So, again, it was a legal career though. We got it. beyond that. So, it was Leo. We went into shallow. We could define the last very well. So, this is one of the interesting cases which you get to do when you have a large follow up. This was a case of CC TJ which underwent double switch operation. So, you can see that the ABC is going into the systemic baffle going into the left side and the ventricle into the artery This is the retrograde entry into the left ventricle. right side. left, left. Giving you guys to iota. So, if you see here, you can see the appendage as well. So, this is the penis or systemic penis back to the right morphology, the right ventricle on the left side which gives rise to pulmonary artery after the pulmonary is to the atrium and threw the baffle into the left with the left ventricle is draining into the pumping into the pit. So, this is one of the other thing I want to discuss. So, if you see this single and diagram. You don't see anything is a mess but once we get there, APIs of two different patients but both patients have the same disease. So, it was an anatomically correct position. So, morphology which drains into the pulmonary artery which is on the right and posterior where normally related will be on the left and anterior. So subtle features are seeing here because If the pulmonary goes under the just behind the sternum and goes posterior here, it's more posterior as compared to normal related. So, I'll be giving rise to post So, it was a situation and RV was giving rise to. you can see the pier here through that small VST. There's a PST which is the artery and from there to the pier. So, this was one of the interesting things you get to do when you are working So, finally, take home points Indications should be always be strong and documented. If there is a soft indication, always discussed the alternatives with the parents. Consent should be returned, informed, already spoken about the specifics forms use non invasive tests to get as much information as possible before embarking on it. You should always try to get and maintain a steady state throughout the procedure. So, if cannot be maintained. Try to do all the single run of the saturation within that time frame. So, that heart rate wakefulness of the child is not changed between the time you take a Swiss and then it may not be representative of the whole study Always have the aim of the study that is what you want to achieve by doing this. So, start with the target always but never end with the only the target. Try to be complete and comprehensive. defying complete anatomy and physiology. Take all pressures and blood samples to whichever chamber or vessel you enter and make sure it's recorded in the system so that you can always come back and reassess and if you have any doubts, you can ask for help from it. More experienced per person and always make sure you do the post processing of the samples. immediately and completely. Thank you. and that's it. Is there any question? No, ma'am. There is no question in the Yes, please. with apparent. This is the A I expect you to be fine. Thank you, Justin. Can you tell about something about PCW and the LTB recording how to do accurately and how to do the record accurately. The pressure dressings just like highlight on this. Yeah. capillary So, main thing is you will have to have a so it's to get a pressure. by having it. balloon catheter. like a swan guns. So, once the balloon is inflated, it goes and wedges on the pulmonary veins and Generally, if the difference considering that on ecard, there is no to come. stenosis and it is representative of A and LBEDP. If the difference between a DP, and pulmonary veins capillary capillary, we pressure is anything more than three, it is considered There is a pre capillary or RTV spasm. Anything more than seven is definitely a cause of pre capillary or pulmonary artery. spasm causing hypertension. So, it will pulmonary capillary If you don't have a balloon catheter, you can use a multipurpose You to make sure that the pressure tracing are on the screen and there is variability when the patient is breathing in case of the trays. Generally, the trace which was there. we generally dissociate and goes towards zero. If the wedge pressure is correct, you will have both the AV waves with respiratory changes. So, that is a good expression if you have a balloon catheter, nothing better than that. As for the EDPE to, you know, get into event and take it and again, you have to have an understanding that we have to make sure the mitral valve is fine and as far as possible, try to interrogate and see if there is any vein obstruction Any more question from anybody. You know. Excuse me. Yes, sir. Yeah. Thank you. for your excellent and lucid presentation. Thank you. I'm doing a professional Lecture. in a big as if you were carrying on the side of the room just as a tutor was so impressive and so explaining, self explaining it really enjoyed. You cast everything. I think nothing is left for practical purpose. Yes. so II. really enjoy. Actually, this is the I think this will be very helpful for the for our students, for our juniors as well as for the senior colleagues for the capitulation of the tough things, particularly hemorrhoid study is an essential part of pediatric cardiology practice in our Day-to-day life. So, I have a simple question. Where do you like to do the right to left calculation? What are those cessation And how do you do it? Both of the fallacies. Right? Right. Right to left. Chanting one can be at the heart level of the which we call as anatomical, right? That is ASD. ASD. Bidi or or a level that is anatomical. Second would be the physiological right to left. That is malformation or any pulmonary artery to left it. fistula or any collapse Where of the where the blood does not enter the capillary. So, those two categories will have to II think II cannot recall the formula. So, there are formula two QEP would be there. Right to left. Yes. Yes. QSQUP will be the right to left. Anatomical Shanti but in case of severe border in case they're having AX Directional in case of a Bd In that case, PBR as well as CPS, and magnitude of and for assessment all, you have to do the right to left also So, it will if it will definitely be a better idea as to quantum of right to left But if we can get a reversible criteria to ask for the old, a vast criteria less than six units or as per the new European guidelines where they say less than five would be adequate, that would be the aim of the study but if we can calculate and get a quantum of right to left, then definitely it'll help us understand and prognostication that is better. Thank you very much. Okay. Thank you. Thank you. Bye. Now. I would like to thank Doctor Prakash for taking a heel pain to prepare this Lecture for our students. This was really an outstanding preparation of his Lecture and this will be recorded and this Lecture will be in record for our students for future reference. So, I just want to mention here that cardiac catheterization is maybe For some person who are very skillful, maybe it's simple for some simple diseases but catheterization should be may turn into a very nightmare procedure and any type of complication may happen in any simple procedure. even for a simple like a trilogy, you are doing it at Trilogy Pillowcase for seeing whether there is any additional PSD whether Corona is you, you if you suspect any coronary abnormalities or if you suspect any me. So, Hard work. You must be ready for putting a pacemaker temporary. So, everything should be ready in your we usually do the cardiac catheterization under sedation. So, everybody has their own sedation protocol. We have our own protocol but anytime patient may go through respiratory arrest, you know that all these drugs like me like, like like ketamine. these are respiratory inhibiting. So, at any in children. Respiratory is more common than that of the cardiac arrest. So, whenever you notice any deer please check whether the child is breathing or not. That is the first duty and the one the staff circulating or the one who is responsible for the anesthesia situation should look at the child constantly and the operators should keep one of his eye on the monitor looking the heart rate looking the situation is foot is always always keep an eye on the screen of the monitor. on your foot for pedaling on your eyes, on your ear, on your hand, and what is most important for the cardiac catheterization is collection of the simple and collection of the patient. So, what my consultant when I was in Saudi Arabia, he taught me a few basic things. He said, once you hear any obstruction, please don't proceed. So, Safety guard is when you feel any obstruction. don't push. If you push, then you will be in a complication. So, that take whether there is any obstruction, whether the catheter is in the wrong track, whether it's is part of something. So, whenever you face and do everything under Flores guide, don't do, don't push your catheter without clasp, Whatever you are, we are. we are now we I did maybe like 10 thousand capitalization but I don't feel that I so much to manipulate. Psp. I will be able to do that but I will never do that. So, this this is one of the precautions. So, don't push and always do it on the clasp. Don't do anything. Don't pass your catheter even through the femoral without philosophic and always take wire for the catheter because and may enter into any side branch or enter into anything may cause any complications especially in the children. So, always take wire when you cross a long way for the end. and it is very nice to use like Barb. these are very expensive catheter. for my case, I don't care about money. I care about the safety of my patients. So, for diagnostic categorization, I always use geographic catheter especially for the young child. So, if there will be no chance of puncture or perforation of the heart and whenever we entered into a chamber. please record the pressure and situation. Please take the situation immediately. because maybe you will not be able to go to that chamber again after hundreds of styles. If you want to miss it because some of the chamber are very difficult to enter. For example, pulmonary artery in the position of the letter to this. So, once you enter into pulmonary artery, in the position of the arteries, you please take the simple These are some tips. again. what precautions mentioned, repeatedly that you, when you are calculating QPQS ratio, or who are you calculating? PVR. All the records you should be done in simultaneous setting, a recording femoral. Now, in one sitting and you are measuring pulmonary artery in another city. So, cardiac output and oxygen consumption. These things So many conditions of the body for example. now, the heart rate of the child is hundred per minute. So, now, you are taking the situation. You are calculating QP, and then again, you are recording when the heart rate is 150. So, definitely there will be a lot of difference. There will be if the heart is into cardiac will be reduced and extra will be reduced. So, you will have a false cube. So, what you will do during your cardiac do the abilities test in our setup. We don't have any nitric oxide or so We do these things with as much oxygen as possible. Though we don't have any facilities. other than our high flux for 100% situation or the ventilator for 100% situation. we just give high flu season and 100% to and if you want to record this situations and again after minutes of this oxygen therapy. then, you'll have to record those things simultaneously. Not that you are taking. Now, pulmonary is simple and after 10 minutes, you are now taking femoral artery and then after 5 minutes, you are taking a sample. So, you'll have to record everything simultaneously. your hand for and your eyes and your ears should be coordinated is and you muscular 0 is for any kind of the to affect any kind of respiratory arrest, any kind of cardiac arrest and these are actually very normal thing in the the cardiac respiratory and you must be an expert in that before start doing catheterization individually, you have to know how to do the CC, how to incubate the way we have an aesthetic, they can do that but as a cardiologist, you must be an intensive. Also, every cardiologist must be an invisibility. So you now you is having some problem. You are calling anesthetist. He will take some time to come because for normal, diagnostic categorization, you don't need any anesthesia. We are the person who are doing these things alone. So, suddenly, something may happen. You have to be ready and even if you do not know how to incubate, you just do am begging by doing am begging. You can save a life for a whole day. until your help is available. So, these are some of the things which are important for the hem study but for the anatomy study purpose, there are some cases we have as I have mentioned like CTD like a normal TG is very important to enter into the chamber and most of the time, our main structure for which we are very concerned is the pulmonary artery. So measuring pulmonary artery pressure measuring, taking pulmonary artery, measuring pulmonary. These are challenging I just want to thank Doctor Prakash again for his outstanding presentation and all the students and the audience again for attending this academic session. Thank you. Juan can conclude the session now. next year Today, we all, all the audience and those who will see this lectures and all and very kindly, they will be benefited and they have to reference from Lecture What do you what? Who will be next? Yeah. next. doctors from Heart Foundation. I will check and I will let you know later but definitely there will be election next next Friday. again, Oh, Doctor Jamil Ata Lecture is Doctor Jamil Alta from Kingdom of Saudi Arabia. He will discuss about the Congenital adult with congenital heart disease, a Cd So, thank you again. Thank you very much for your nice Lecture. and hope for your health in this coronavirus situations. Thank you everybody who are attending these lectures. Thank you all.