Patent Ductus Arteriosus (PDA)
DEFINITION: The ductus arteriosus is patent in all newborns at the time of delivery It is closed by 48 h after birth in 100 of infants delivered at ≥40 wks gestation and by 72 h after birth in 90 of infants delivered at ≥30 wks gestation A ductus open beyond 72 h
Patent Ductus Arteriosus
The literature on diagnosis of PDA is confused by poorly defined terminology with terms such as ‘symptomatic’, ‘clinically apparent’ and ‘haemodynamically significant’ often used interchangeably
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Universal Scaling and Design Rules of Hydrogen- Induced
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Basic Coronary Angiography
The Definition of Coronary Dominance Definition 1: the coronary artery which reaches the crux of the heart and then gives off the PDA Definition 2: (Allows for codominance) the artery which gives off the PDA as well as a large posterolateral branch
FEMA PDA Pocket Guide
Overview The Preliminary Damage Assessment (PDA) Pocket Guide serves as a quick reference tool for FEMA, state, local, tribal, and territorial
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the Planning and Urban Development Master Plan (PDAU) which detemiined the urban sectors and overall land use in relation to communal lands; and * the Land Occupancy Plans (POS) which defined the rights of construction on plots These instrurnents, open to challenge by third parties, were widely adopted, with 1233 of the
Chemical Bonding - Colorado State University
CHEMICAL BONDING Metallic Malleable solid High melting point and boiling point Insoluble in H 2 O Insoluble in nonpolar solvents Conducts heat and electricity
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Basic Coronary Angiography
DAVID SHAVELLE MD
Basic Coronary Angiography: Take Home Points
Cardiovascular Medicine Boards and Clinical PracticeBasic Coronary Angiography: Take Home Points
Cardiovascular Medicine Boards and Clinical Practice coronary angiograms interpreting a coronary angiogram is more difficult comfortable with angiographic projections and the assessment of disease severity rotations, cardiac catheterization conference, angiographic review sessions and when seeing patients in the Cardiology Clinic Figure 1. Cine frame from the first selective coronary arteriogram taken by F. Mason Sones, MD, on October 30, 1958.The First Coronary Angiogram
Right Coronary Artery
Origin Right aortic sinus (lower origin than LCA)
Course Down right AV groove toward crux of the heart, gives off PDA (85%) from which septals arise, continues in LAV groove giving off posterior LV branches (posterolaterals). PDA may originate more proximally, NLIXUŃMPH HMUO\ RU NH VPMOO RLPO SMUP RI ´LPV PHUULPRU\µ supplied by an acute marginal branch.
Supplies 25% to 35% of Left Ventricle
Right Coronary Artery: other branches
Right Coronary Artery: Engagement
the time. Adjust catheter size to aorta. pigtail if unable to cannulate or using the JR4 coiled in the RCCLeft Coronary Artery System
Upper portion of left aortic sinus just below the sinotubular ridge. Typically 0-10 mm in length. Rarely no LM (separate origins of LAD and LCx). ´7OH Judkins· 4-Left coronary catheter will find the LCA orifice unless thwarted by the RSHUMPRUµB -XVP LQ ŃMVH-other Judkins sizes for smaller or larger aortas. If a JL4 coils upon itself AE JL4.5. Amplatz, XB or various guide catheters. If a JL4 is too long (can not form) AE JL3.5. LAO caudal and cranial; AP-caudal, cranial or flat. Limit views. May need IVUSLeft Main Coronary Artery
Left Anterior Descending Artery or LAD
Left Circumflex Artery or LCx
from distal LMCA. down distal left AV groove. obtuse marginal and posterolaterals-supply posterolateral LV, anterolateral papillary muscle. SA node artery ~ 38%.15%-25% of LV, unless dominant (supplies 40-50% of LV).
The Definition of Coronary Dominance
the coronary artery which reaches the crux of the heart and then gives off the PDA the artery which gives off the PDA as well as a large posterolateral branchManifold vs Medrad/Automatic Injection
System
Coronary Angiography: Using the Manifold
Engaging the Coronary Artery
An example of what you should NOT do
Cranial and Caudal Angulation
RAO and LAO Angulation
Left Coronary System
Right Coronary System
RAO with caudal angulation
LAO with cranial angulation
Steep LAO (> 60 degrees)
Lateral or True Lateral (90 degrees)
Very good LIMA to
LAD insertion view
Arms up
LAO with Cranial (40/20 degrees)
RAO (30 degrees)
In most patients,
Cranial angulation
is needed to see bifurcation to PDA bottom of heart ² look for septals (diagram 5, 11)LAO/Cranial
LAD DxLCx LM
RAO/Cranial
LAD Dx
LCx LM
septalNote: LCx is high ²
out of way of LADLAO/Caudal or Spider View
LADLCx LM
OMRAO/Cranial
LAD Dx LCx LMLCX ² high in
cranial viewsLCx ² low in
caudal viewsRAO/Caudal
LCxLCX ² high in
cranial viewsLCx ² low in
caudal views LM LADDx LCx
OMLAO/Cranial
LCx LCx
RCA PDAPosterolateral
(PLVEB)LAO/Cranial
RCA PDAPosterolateral
(PLVEB)RAO without Cranial
? Posterolateral (PLVEB) RCA ? PDA ? Posterolateral (PLVEB) RVMWhat is this View?
What is this View?
RAOCaudal
What is this View?
What is this View?
LAOCranial
What is this View? What is this vessel?
What is the View? What is the vessel?
LAOCaudal
Famous
RamosACC/AHA LESION CLASSIFICATION
TYPE B
Tubular
Eccentric
Moderate tortuousity
Moderately angulated (45-90)
Irregular contour
Moderate-heavy calcification
Total occlusion (< 3 mos)
Ostial
Bifurcation
Thrombus present
TYPE A
Discrete
Concentric
Readily Accessible
Smooth Contour
Little or no calcification
Non-ostial
No major side branch
involvedAbsence of thrombus
TYPE C
Diffuse
Excessive tortuousity
Extremely angulated
Total occlusion (> 3 mos)
Inability to protect major side branch
Degenerated SVG
ULCERATED PLAQUE
THROMBUS
CIRCULAR FILLING DEFECT
THROMBUS VS AIR
EMBOLIZATION: AIR VS THROMBUS
MYOCARDIAL BRIDGING
diastolic relaxation of the vesselIntramyocardial Segment
Tarantini G, Migliore F, Cademartiri F, Fraccaro C, Iliceto S. Left Anterior Descending Artery Myocardial Bridging:A Clinical Approach. J Am Coll Cardiol. 2016 Dec
27;68(25):2887-2899.
CORONARY ARTERY FISTULA
rupture of aneurysmal fistula. 50% are asymptomatic. angiogramLAD to PA Fistula
LAD LM LCxLAD to PA Fistula
How could you evaluate an LAD
to PA Fistula in terms of hemodynamic significance?Anomalous Coronary Arteries
Normal
LM from RCC
RCA from LCC
Benign Anomalous Coronary Arteries
(0.5 to 1 %)ANOMALOUS ORIGIN OF LCX FROM RCC (PROXIMAL RCA)
Collaterals
Coronary Artery Aneurysms
Coronary Aneurysm: Vessel diameter > 1.5x
neighboring segmentIncidence: 0.15%-4.9%; very rare in LMCA
Etiology: mainly atherosclerosis; other causesLQŃOXGH .MRMVMNL·V 3FH LQIOMPPMPRU\ GLVHMVH
trauma, connective tissue diseaseTreatments: include observation, surgery,
occlusive coiling, covered stentsTIMI flow grade
TIMI 0 flow: absence of any antegrade flow beyond a coronary occlusion TIMI 1 flow: (penetration without perfusion) faint antegrade coronary flow beyond the occlusion, with incomplete filling of the distal coronary bed TIMI 2 flow: (partial reperfusion) delayed or sluggish antegrade flow with complete filling of the distal territory TIMI 3 flow: (complete perfusion) is normal flow which fills the distal coronary bed completelyMyocardial Perfusion Grade
Grade 0: (LPOHU PLQLPMO RU QR JURXQG JOMVV MSSHMUMQŃH ´NOXVOµ RI POH P\RŃMUGLXP LQ POH
distribution of the culprit artery Grade 1: Dye slowly enters but fails to exit the microvasculature. Ground glass appearance´NOXVOµ RI POH P\RŃMUGLXP LQ POH GLVPULNXPLRQ RI POH ŃXOSULP OHVLRQ POMP IMLOV PR ŃOHMU IURP POH
microvasculature, and dye staining is present on the next injection (approximately 30 seconds between injections) Grade 2: Delayed entry and exit of dye from the microvasculature. There is the ground glassMSSHMUMQŃH ´NOXVOµ RI POH P\RŃMUGLXP POMP LV VPURQJO\ SHUVLVPHQP MP POH HQG RI POH RMVORXP SOMVH
(i.e. dye is strongly persistent after 3 cardiac cycles of the washout phase and either does not or only
minimally diminishes in intensity during washout). Grade 3: Normal entry and exit of dye from the microvasculature. There is the ground glass MSSHMUMQŃH ´NOXVOµ RI POH P\RŃMUGLXP POMP ŃOHMUV QRUPMOO\ MQG LV HLPOHU JRQH RU RQO\ mildly/moderately persistent at the end of the washout phase (i.e. dye is gone or is mildly/moderately persistent after 3 cardiac cycles of the washout phase and noticeably diminishes in intensity during the washout phase), similar to that in an uninvolved artery.