General overview

• How to select guide?
  • Size of ascending aorta
  • Location of ostium
  • Tortuosity proximal to target
  • Calcification proximal to target
  • Lesion characteristics
• Guide support
  • Passive
    • Due to design of guide
    • Two components-
      • Backup from opposite aortic wall
      • Stiffness
  • Active
    • By operator manipulation
    • Two components
      • Making the guide conform to aortic root
      • Deep engagement
• JL guide
  • Curves
    • Primary- 90 deg
    • Secondary- 180 deg
    • Tertiary- 35 deg
  • Engages LM easily
  • Coaxial alignment is difficult due to 90 deg primary curve
  • Often, support for PCI is inadequate
• Amplatz guide
  • Secondary curve rests against
    • AL- non-coronary posterior cusp
    • AR- left cusp
  • Good support for PCI
  • Used for
    • Short LM
    • Superior takeoff
    • Downgoing LCx
    • Downgoing RCA
  • Chance of ostial dissection due to downward tip
• Multipurpose guide
  • Single minor bend at tip
  • Uses-
    • High LM takeoff
    • Downward RCA
• EBU-
  • Long secondary curve abuts opposite aortic wall- very good support
  • Long tip forms straight line with coronary

Guide manipulations

• Standard safety techniques
  • After putting Y adapter-
    • First bleed back generously
    • Then flush
    • Then look for bubbles
  • During procedure
    • Frequently flush
    • Always look for dampening
  • During injection    
    • Keep syringe pointed down, so air will not go in
    • Always look for reflux
  • When withdrawing balloon/ stent/ TEC
    • Watch tip, especially if proximal plaque
    • Look for dampening
• Tortuous iliac artery
  • If torque is not transmitting
    • Wait for torque to transmit
    • Gently move guide in and out for a very short distance
  • Put long sheath (23 cm)
  • Manipulate with 038 long J through Y adapter
• Dampening of arterial pressure
  • Ventricularization- diastolic BP drop
  • Dampening- systolic and diastolic BP drop
  • Causes-
    • Ostial lesion- most common
    • Coronary spasm
    • Guide is too big for artery
      • Downsize guide or
      • Put guide with side holes
    • Non- coaxial alignment
    • Guide is deep in
      • Make guide out or
      • Push in balloon/ stent/ TEC
  • Guide with side holes
    • Suboptimal opacification
    • More contrast needed
    • Decreased backup from aortic root (rare)
    • Kinking at sideholes (rare)
• Checking backup potential
  • Advance guide a bit
    • Further intubation- good backup
    • Prolapsing out- poor backup
• Active intubation
  • Other names- active support, power position
  • Do only if
    • Large artery
    • No proximal lesion
  • Do only if coaxial alignment is not possible
  • Chance of proximal dissection or thrombosis is high
  • Osteoproximal stent placement may not be possible

Judkins guide

• JL
  • Size is cm between primary and secondary curves
  • 3.5 cm for Asians, 4 cm for Caucasians
  • Enter by gentle counterclockwise rotation
  • Size is determined by
    • Size of aortic root- lower size for smaller root and vice versa
    • Direction of LAD- lower size for superiorly directed LAD
  • Smaller sized JL will point to superior wall and dissect here with injection, especially in elderly with unsuspected plaques
  • Tip should point up. If it points down, the guide is too large.
  • Small JL will double back
• JR
  • Rotate clockwise while withdrawing to engage
  • Check in RAO 30 deg- tip will be a head-on ring if coaxial

Amplatz guide

• Sizes
  • 1- small root
  • 2- normal root
  • 3- large root
• Relation between guide tip and ostium
  • Tip above ostium- larger than needed sized guide
  • Tip into ostium- correct size
  • Tip below ostium- lesser than needed size
  • If size is not correct, do not attempt forceful engagement
• If RCA ostium is very high, AL may be used
• Engaging-
  • Keep wire till guide reaches sinus
  • Advance guide to reach ostium level
  • For AL- rotate counter clockwise
  • Then retract to engage
• Optimal position- closed loop
• Undesirable position- open loop with tip pointing down inferior wall of ostium
• Disengagement
  • Be very careful
  • Simple withdrawal is never to be done- tip advances further- dissection
  • Advance guide to prolapsed out of ostium
  • Then rotate guide to go away from coronary area
  • Then withdraw
  • Less likely to cause damage if retracted over a wire
• Removing balloon
  • 1^st option- while pulling out balloon, simultaneously push the guide to prolapsed it out, all the time watching fluoro
  • 2^nd option- push balloon- guide goes back- pull balloon slowly watching whether guide comes in- if so, push balloon again- repeat this again and again

Multipurpose guide    

• For engaging left
  • 30 deg RAO
  • Place in posterior sinus
  • Tip pointed to spine
  • Advance till guide buckles
  • Rotate clockwise
  • Now guide enters left cusp
  • Counter clockwise rotation to enter LAD
• For engaging right
  • 45 deg RAO
  • Place in left cusp
  • Tip pointed to anterior and right
  • Rotate clockwise and slightly withdraw

EBU

• Keep wire till guide goes into sinus

Diagnostic catheter for LM lesions

• Suspect LM lesion when
  • Rest angina
  • Angina at low level of activity
  • Post prandial angina
  • Angina at early stage of TMT
  • Diffuse ST depression in TMT
  • During TMT, BP does not increase or decreases
• Tips
  • Use short tip JL
  • Keep below ostium and inject 10 cc contrast
  • Then slowly engage avoiding uncontrolled jump into LM
  • Inject only if no ventricularization or damping
  • Inject only 2 to 3 cc
  • Only AP cranial and AP caudal views are needed for surgeon
  • Do not hit and run- catheter tip may be under a plaque- dissection may occur

Guide for LAD lesions

• JL is a good option as it points superiorly

Guide for LCx lesions

• Short LM and no acute angle of LCx origin- select JL.
• Long LM or acute angle of LCx origin- select EBU. JL is not a good option as it points superiorly
• If JL is not hooking well
  • Rotate clockwise
  • Select larger size
• AL is also a good option.
• Power position for JL-
  • Better than this will be EBU or AL.
  • Do over stent or balloon
  • Gently push guide with gentle clockwise torque till whole curve sits well in left sinus.
  • Now guide looks like AL.
  • After purpose, remove by opposite torque and withdrawal
  • Do only if no proximal or ostial disease

Guide for RCA lesions

• Takeoff
  • Horizontal- usual one
  • Upward looking- shepherd’s crook
  • Downward looking
• Horizontal
  • First choice- JR, usually 4
  • Second choice- AR
  • Third choice- AL (with backup from opposite aortic wall)
• Upward looking
  • AL
  • Other choices- hockey stick, IMA guide, left venous bypass guide
  • (JR will not give enough backup)
• Downward looking
  • AR
  • Multipurpose
  • Right venous bypass
  • (JR may dissect lateral wall)
• Guide entering conus repeatedly
  • Engage by counterclockwise rotation
  • Change over to higher sized guide
• Deep seating RCA guide
  • Do not do if artery is small or if there is a proximal plaque.
  • In LAO view, additional clockwise rotation will deep seat the guide
  • If balloon or stent is in the coronary, the guide may be deep seated with gentle clockwise rotation. After purpose is served, guide should be withdrawn with counterclockwise rotation.
  • When balloon or stent is advanced, assistant should hold the guide firmly near the femoral sheath
  • When balloon or stent is advanced, assistant should pull back wire slowly to decrease friction between wire and balloon/stent.
• Rotational Amplatz maneuver
  • JR guide is pushed with counterclockwise rotation- it forms a loop resting in the coronary sinus- looks like Amplatz
  • Gives backup from opposite aortic wall
  • Excessive push may prolapse guide into LV
  • Do only with 6F or 5F- higher sized guides will prolapse into LV
  • Like any power position, do not do if there is ostial lesion
• Guide for aortic aneurysm and dissections
  • Aortic aneurysm
    • Guide may not seat well
    • Guide may not be long enough
  • Aortic dissection
    • Guide may enter false lumen
    • Guide may extend dissection
    • Guide may perforate aortic wall, especially with injection
    • Guide may dislodge thrombus distally
  • If there is BP difference between arms, use radial route in arm with higher BP
  • If thoracoabdominal aorta is dissected or aneurismal, choose radial route
  • If arch vessels are affected, choose femoral route
  • If entire aorta is aneurismal, choose femoral route for better catheter manipulation
  • Straight soft tipped catheters like Sones or Multipurpose are safer
  • To make sure that catheter is in true lumen- enter LV or cannulate coronaries
  • Ascending aortogram- LAO view- 60 cc contrast at 25 to 40 cc/sec
  • Never do ascending aortogram unless it is absolutely certain that guide is in true lumen
    • No delay in contrast washout
    • No contrast swirling
    • No dampening of pressures
    • Brisk return of blood

Bigeminal rhythm due to alternate atrial ectopic beats originating probably from near the AV node.

Your thoughts are welcome.

Waveform

• Carotids- Percussion wave due to LV ejection, then tidal wave which is a reflected wave from the periphery
• Radials- single sharp peaked wave

Rate

Rhythm

Character

• Pulsus bisferiens
  • Two systolic waves (percussion and tidal)
  • Causes
    • Severe AR
    • AS with AR when AR is the predominant lesion
    • HOCM-
      • Often recorded, not palpated
      • Dip is due to LVOT obstruction, second wave is tidal wave
      • Can be precipitated by Valsalva maneuver and amyl nitrite
    • Large PDA
    • AV fistula
    • MVP- uncommon
  • Mechanism-
    • Large LV stroke volume rapidly ejected
• Dicrotic pulse
  • A diastolic wave called dicrotic wave also after the normal systolic wave
  • Difficult to distinguish from pulsus bisferiens at bedside
  • Causes
    • Fever
    • Heart failure
    • Hypovolemic shock
    • Cardiac tamponade
    • Immediately after aortic valve replacement
    • After exercise
• Waterhammer pulse or Corrigan pulse
  • Rapid upstroke, ill sustained peak, rapid downstroke
  • Raise arm and feel
  • Due to rapid ejection of large stroke volume and low systemic vascular resistance
  • Seen in chronic severe AR
• Pulse in severe AS
  • Anacrotic pulse
    • Anacrotic notch immediately after onset of upstroke
  • Pulsus parvus et tardus
    • Parvus refers to low volume
    • Tardus refers to slow upstroke and delayed peak- peak is closer to S2 (normal pulse- closer to S1)
  • Carotid shudder
    • Thrill on ascending limb
  • Above findings may be absent in atherosclerotic carotids.

Volume

• High volume
• Low volume
• Pulsus alternans
  • Also called mechanical alternans
  • Apply light pressure on a peripheral pulse
  • Can be confirmed by BP measurement
  • Alternate beats are strong and weak, rhythm is normal
  • Causes
    • LV systolic failure
    • Cardiac tamponade- rare
    • Tachypnoea with respiratory rate half of pulse rate- rare
  • Mechanism
    • Alternating preload (Frank Starling mechanism)
    • Incomplete relaxation
    • Alternating afterload
    • Alternating contractility- due to change in sarcoplasmic calcium pumps
• Pulsus paradoxus
  • Normal inspiratory fall is 8 to 12 mm Hg
  • More than 20 mm Hg defines pulsus paradoxus
  • Better appreciated with BP measurement
  • Measure during normal respiration- not Valsalva
  • Common causes-
    • Cardiac tamponade
    • COPD
    • Hypovolemic shock
  • Uncommon causes-
    • Constrictive pericarditis
    • Restrictive cardiomyopathy
    • Pulmonary embolism
    • Pregnancy
    • Marked obesity
    • Partial SVC obstruction
  • Cardiac tamponade, but no pulsus paradoxus-
    • Severe AR
    • ASD
  • Mechanism
    • Cardiac tamponade- Reverse Bernheim effect- venous return during inspiration shifts IVS to left- decreased LVEDV
    • COPD- during exaggerated inspiratory effort, pulmonary venous return to left side of heart decreases
  • Reversed pulsus paradoxus- HOCM

Condition of vessel wall

Peripheral pulses

• Decreased volume of a peripheral pulse may be due to
  • Atherosclerosis
  • Embolism
  • Takayasu arteritis
  • Aortic dissection
  • Aortic aneurysm
  • Coarctation of aorta
  • Supravalvular aortic stenosis (Coanda effect- selective streaming to right- right carotid and upper limb pulses are stronger)
  • Cervical rib

Radiofemoral delay

• Coarctation of aorta

Radioradial delay

• Takayasu arteritis
• Aortic dissection
• Aortic aneurysm
• Coarctation of aorta
• Supravalvular aortic stenosis (Coanda effect- selective streaming to right- right carotid and upper limb pulses are stronger)
• Cervical rib

• Tumor of chromaffin cells of adrenal medulla
• Some also include catecholamine secreting paragangliomas

Epidemiology

• < 0.2 % of hypertensives have pheochromocytoma
• Most common in 4^th and 5^th decades, but may occur at any age
• Equal incidence in both sexes

Clinical features

• Classic triad
  • Episodic headache
  • Sweating
  • Tachycardia
• Hypertension
  • Sustained or paroxysmal
  • Absent in 5 to 10 %
  • Orthostatic hypotension may occur
• Other features
  • Palpitations
  • Dyspnoea
  • Weakness, weight loss
  • Panic attacks
  • Visual blurring, papilledema
  • Polyuria, polydipsia, constipation
• Cardiomyopathy due to cathecholamine excess
• Raised ESR, hyperglycemia, leucocytosis
• Secondary erythrocytosis due to increased erythropoietin

• Diseases caused by hypertension-
  • Myocardial infarction
  • Heart failure
  • Atrial fibrillation
  • Aortic dissection
  • Peripheral vascular disease
  • Stroke
• Hypertension is defined as BP of
  • 140/90 mm Hg or above
• Hypertension is primary in
  • 90 to 95% (rest- secondary)
• Behaviours which increase risk of hypertension
  • Smoking
  • Heavy drinking (3 drinks daily- one drink is 13.7 gm or 0.6 ounce of pure alcohol) (1 to 2 drinks decrease BP)
  • Caffeine
  • Obesity
  • Excess calorie intake
  • Excess sodium intake (potassium decreases BP)
  • Physical inactivity
  • Low intake of fresh fruits

Mechanism of primary hypertension

• Hemodynamic subsets of primary hypertension
  • Systolic hypertension in young adults
    • 17 to 25 yrs
    • Mechanism- sympathetic overactivity leading to increased cardiac output and stiffening of aorta
  • Diastolic hypertension in middle age
    • 30 to 50 yrs
    • Mechanism- elevated systemic vascular resistance due to vasoconstriction of resistance arterioles
  • Isolated systolic hypertension in older adults
    • > 55 yrs
    • Systolic BP increases with age. Diastolic BP increases till 55 yrs and then falls. Pulse pressure widens.
    • Mechanism- aortic stiffening due to increased collagen- elastin ratio.
    • More in women
• Neural mechanism- sympathetic overactivity
  • Seen in-
    • Systolic hypertension in young adults
    • HT due to obesity (sympathetic stimulation to burn fat)
    • HT due to sleep apnoea (daytime normoxia is misinterpreted as hypoxia, due to baroreceptor resetting, leading to sympathetic stimulation)
    • HT with diabetes
    • HT with CKD
    • HT with heart failure
    • HT due to cyclosporine
  • Mechanisms by which sympathetic overactivity contributes to hypertension-
    • Increased cardiac output
    • Alpha mediated peripheral vasoconstriction
    • Increased renin (beta 1 stimulation of juxtaglomerular apparatus)
    • Renal sodium retention (alpha 1 stimulation of Na K ATP ase of collecting duct)
  • Adverse effects of sympathetic overactivity-
    • Norepinephrine causes alpha 1 mediated hypertrophy of myocardium leading to sudden cardiac death
  • Practical applications-
    • Carotid baroreceptor pacemaker
    • Radiofrequency ablation of renal sympathetic nerves
  • Baroreceptors
    • In every hypertensive patient, baroreceptors are reset to higher BP.
    • Baroreceptor control of sinus node is impaired in HT.
    • Baroreflex failure-
      • Complete
        • Due to radiation for throat cancer
        • Causes labile HT
      • Partial
        • Common in elderly hypertensives
        • Triad
          • Supine hypertension
          • Orthostatic hypotension
          • Symptomatic post prandial hypotension- due to splanchnic pooling after carbohydrate rich meals
• Renal mechanisms