Prior to Gruentzig’s seminal development of balloon angioplasty, coronary arteriograms were largely used to discriminate patients with and without coronary artery disease and to select those who should be referred for coronary bypass surgery. In the modern era, the cardiac interventionalist must be supremely competent in performing, interpreting, and understanding the studies that define the coronary anatomy and cardiac function. The unique demands of decision making for interventional cardiology require a new understanding of the principles and procedures that enable percutaneous coronary revascularization to be performed. To this end, acquiring high-quality diagnostic cardiac angiographic studies is critical. This chapter will review special considerations of coronary and left ventricular angiography.
INDICATIONS FOR CORONARY ARTERIOGRAPHY
In the 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines,1 the indications for coronary arteriography are summarized as below:
Patients with stable angina or asymptomatic individuals with high-risk criteria on noninvasive testing.
Patients resuscitated from sudden cardiac death or having threatening ventricular arrhythmias.
Patients with unstable coronary syndromes of all varieties, including acute myocardial infarction as a preamble to primary angioplasty and those who developed complications of acute infarction.
Patients with ischemia at low levels of exercise in the recovery phase of myocardial infarction.
Patients with suspected or known coronary artery disease undergoing preoperative evaluation.
Patients undergoing heart valve replacement or in those patients in whom there is a need to establish the etiology of congestive heart failure. Table 21-1 lists indications and contraindications for cardiac catheterization and coronary angiography.
Table 21-1AIndications for Coronary Angiography ||Download (.pdf) Table 21-1A Indications for Coronary Angiography
|Indications ||Procedures |
|1. Suspected or known coronary artery disease || |
| a. New-onset angina ||LV, COR |
| b. Unstable angina ||LV, COR |
| c. Evaluation before a major surgical procedure ||LV, COR |
| d. Silent ischemia ||LV, COR, ERGO |
| e. Positive exercise tolerance test ||LV, COR, ERGO |
| f. Atypical chest pain or coronary spasm ||LV, COR, ERGO |
|2. Myocardial infarction || |
| a. Unstable angina post infarction ||LV, COR |
| b. Failed thrombolysis ||LV, COR, RH |
| c. Shock ||LV, COR, RH |
| d. Mechanical complications (ventricular septal defect, rupture of wall or papillary muscle) ||LV, COR, L+R |
|3. Sudden cardiovascular death ||LV, COR, R + L |
|4. Valvular heart disease ||LV, COR, R + L, AO |
|5. Congenital heart disease (before anticipated corrective surgery or ASD/PFO closure) ||LV, COR, R + L, AO |
|6. Aortic dissection ||AO, COR |
|7. Pericardial constriction or tamponade ||LV, COR, R + L |
|8. Cardiomyopathy ||LV, COR, R + L, BX |
|9. Initial and follow-up assessment for heart transplant ||LV, COR, R + L, BX |