EXAMINATION TECHNIQUES IN CARDIOLOGY •Non-invasive methods • • • •Invasive methods • •(by puncture needle or catheter) The picture shows the most basic division of investigative methods in clinical practice. Invasive methods violate the integrity of the body, old physicians from internal medicine always pointed out the possibility of infection even from small superficial wounds ... they said, "on the body of a rank— to death the gate"... before the era of antibiotics certainly true. Even nowadays, we try to make more use of non-invasive methods that sense signals from the surface of the body, without breaking the skin surface, thus giving us information about the physiology of the basic parameters of human body functionality. NON – INVASIVE METHODS Basic – used together with examination of patients Inspection Palpation Percussion Auscultation The picture shows the basic examination methods based on our sensory functions – vision (inspection)=already when looking at the patient, you can notice certain differences from physiology – skin color (diagnosis of jaundice), posture, walking style (diagnosis of neurological problems – sciatica(ischia), back pain, muscle palsy... etc., psychological – mania – depressive states, localization of pain); palpation – pulse examination, abdominal pain, etc.; listening – auscultative method of measuring blood pressure, listening to respiratory murmurs, heart sounds, peristaltic movements, fetal heart sounds...; tap – the day is usually performed in neurology with a neurological hammer, however, previously it was also represented by a double tap in the examination of the lungs (diagnosis of pneumonia, fluid in the lungs, tuberculosis , etc.), abdominal examination, etc. Even our fifth sense (taste) used to be represented – doctors (in history) tasted, for example, urine of their patients for the diagnosis of sugar in the urine. •PHONOCARDIOGRAPHY S1 S2 S3 S1 S2 S3 This slide shows - Just for the demonstration – I choose a well-known record of heart sounds by the method of phonocardiography X-ray RTG Helán Chest x-ray provides useful information about cardiac size and shape, as well as the state of the pulmonary vasculature, and may identify noncardiac causes of the patient´s symptoms I'm sure you know the principle of an X-ray machine ELECTROCARDIOGRAPY •A routine 12-lead ECG •The major importance of the ECG is to assess cardiac rhythm and determine the presence of left ventricle hypertrophy or prior myocardial infarction or QRS width •Normal ECG excludes left ventricle dysfunction ... and ECG principle . ELECTROCARDIOGRAPY •HOLTER MONITORING • 24-hour ECG record • • ü estimation of heart rate variability § time analysis § spectral analysis • Here we stop in modern times: today there is a commonly used improvement in the time of ECG monitoring for 24 hours – Mr Holter from the Netherlands first described this record, which is why this record is called Holter monitoring, and that is always the way to monitor the electrical activity of the heart. The patient has a so-called monitoring electrodes on the chest (in the number 5 or 7), in the morning the nurse sticks everything to him, instructs him, and the next morning disconnects the patient from the device. The record is then downloaded to the computer and processed using the program. This method brings new information to cardiologists . In addition to the capture of the type of arrhythmia (which is probably the main reason for the use of Holtra ECG), we can also evaluate the variability of fluctuations in cardiac frequvence – referred to as heart rate variability (HRV) and is processed either by classical time analysis (in the form of statistical data mean and standard deviation) or spectral analysis (for more information see the lecture Variability of circulatory parameters –dr. Nováková or Dr. Svačinová). In the picture , you can see in the left part of the spectrum and their representation in a healthy person, in the right part you can see reduced variability in the sick person. ELECTROCARDIOGRAPY •HOLTER MONITORING • ülate potencials We continue to evaluate 24-hour ECG monitoring – when tens of thousands of QRS complexes taken in 24 hours are translated over each other (we average, the following effect occurs: periodic repetitive information appears to us, irregularly emerging as if disturbing)... we see in the picture ... note the length of the QRS complex... in the left part we see a QRS complex corresponding to the physiological range up to 100 ms, in the right part we see between the value of 100-450 ms small waves – they represent the capture of the so-called „late potentials“... their presence means an increased risk of sudden cardiac death in patients after myocardial infarction Reveal - implantable recorder reveal & act white carelink_pgmr §small device, without electrodes §recorder of ECG during syncope - activation by patients - or autoactivation §continuously monitoring 36 month, 42 min episodes at memory §simple implantation, simple evaluation. Patient Activator and Reveal® Plus ILR Medtronic CareLink® Programmer This small device (size as flashdisk) is implanted under the skin on the upper part of the chest. BLOOD PRESSURE MEASUREMENT AUSCULTATORY METHOD OSCILOMETRIC METHOD You should already know everything about this topics (see lecture on this topic). I will just repeat that the main principle of these methods – both auscultation and oscillometric - is the change of laminar to turbulent blood flow. BLOOD PRESSURE MEASUREMENT •AMBULATORY BLOOD PRESSURE MONITORING - ABPM • Because the technique is constantly going forward, there are also technical options for recording blood pressure to monitor it in a longer period of time (the main is the battery life for inflating the cuff). This examination is referred to as 24-hour ambulatory blood pressure monitoring (24ABPM). The patient comes in the morning to deploy the device and the next morning to take it off, always writing in a small diary, what he did all day, not to bathe, etc. The device is programmed to be inflate the cuffs and measured BP every 15-20 minutes in the daytime, and every 30-60 minutes of the night. The device at the beginning of the measurement alerts the beep, it should stop, (be at rest), the measured limb hanging along the body, loose (do not hold a bag in it, etc.). This creates a 24-hour blood pressure profile – SBP, DBP, MAP, HR (see figure). Quite physiologically we see the presence of a rise in BP after awakening and a decrease in blood pressure at night. This decrease is called dip – patients are dippers (as healthy) and non-dippers (=pathology, it is necessary to look for the cause). BLOOD PRESSURE MEASUREMENT •continuously beat-to-beat measurement •Peňáz principle - photopletysmography •It is based on clamping the volume of finger arteries by fast changes of pressure in a special cuff equipped with a photoelectric plethysmograph to measure the vascular volume. IMG_0869 For more information, see the lecture on blood pressure •We need than pressure in the cuff corresponded to the pressure of the digital artery •Method: photopletysmography •Recorded photoelectric plethysmogram •The new term: Transmural pressure – Pt (the pressure across the wall of the artery) •BP, Pc (pressure in cuff), Pt •We estimated: BP=Pc - - - Pt=0 - - - photoplethysmogram registered the highest amplitude of oscilation --- we measure the MAP •Step by step increase of Pc, in the moment of the highest amplitude – feed-back loop started for obtained(keeping) the constant volume of the finger For more information, see the lecture on blood pressure ECHOCARDIOGRAPHY most widespread methods APICAL VIEW PARASTERNAL LONG-AXIS VIEW These and other images are to illustrate an overview of non-invasive examination methods in cardiology – the principle of echo examination should be known from biophysics. COMPUTED TOMOGRAPHY •CT is a fast, simple, noninvasive technique that provides images of the myocardium and great vessels; •CT uses x-rays to create tomographic slices of objects-this is acomplished by rotating an x-ray bea around the object and measuring the trasmission of x-rays through the object at many angles,called projections • aorta Left anterior descending artery left atrium Left circumflex •Based on the magnetic properties of hydrogen nuclei •Used to quantify accurately EF, ESV, EDV, cardiac mass •Without the need for ionizing radiation • • MAGNETIC RESONANCE IMAGING NUCLEAR CARDIOLOGY •Nuclear (or radionuclid) imaging requires intravenous administration of isotopes •Single photon emission computed tomography SPECT and positron emission tomography PET This method stands on the border of invasiveness and non-invasiveness, since an intravenous imaging substance must already be injected into the patient's body. INVASIVE TECHNIQUES •CARDIAC CATHETERIZATION •Right heart catheterization – uses a balloon-tipped flotation catheter that is inserted into the femoral or jugular vein. Using fluoroscopic guidance, the catheter is advanced to the right atrium - right ventricule – pulmonary artery and pulmonary wedge position (as a surrogate for left atrial pressure = wedge pressure) This is an important slide, you can apply the information here in the oral examination of physiology – the question of cardiac catheterization!!!! Don't forget the concept of wedge pressure – it's a pressure that reminds (and thus replaces) the direct measurement of pressure in the left atrium. We get it during right heart catheterization, when we continue from the right ventricle to a.pulmonalis and into its branches, we are in the pulmonary stream until we get through the catheter so far that the catheter size will be the same as the size of the vessel –we will no longer get, i.e. we will not get to the catheter - that the catheter seems to be wedged in that place, and that's when we measure the pressure in the wedge, which is the transferred pressure in the left heart atrium. INVASIVE TECHNIQUE •CARDIAC CATHETERIZATION •Left heart catheterization – with the aid of fluoroscopy, the catheter is guided to ascending aorta – across the aortic valve into left ventricule (inserted into a.femoralis,a.axillaris, a.brachialis) •A needle-tipped catheter to puncture the atrial septum during right heart catheterization •+ coronary angiography Left heart catheterization - access through the arterial system, we go through the catheter upstream of the blood flow, only through the aortic valve to the left ventricle. From this approach we perform coronarography – we determine the state of the coronary vessels (even with spraying with a contrast agent under skiascopic control – see the picture, the arrow shows the presence of narrowing of the vessel). INVASIVE TECHNIQUE •How do we use cardiac catheterization? • üPressure measurement üBlood flow measurement üBiopsy of tissue üBlood samples for oxygen-saturation analysis to screen for intracardiac shunts üElectric potentials measurement • This slide gives an overview of the possibilities of catheter examination – again important information for the oral examination!!! Intracardiac Echocardiography Is an intravascular ultrasound modality that provides diagnostic imaging of cardiac structures from within the heart. The first catheters used high frequency tranducers (20-40 MHz) containing a single ultrasound crystal that rapidly rotated at the end of catheter INVASIVE TECHNIQUE •ELECTROPHYSIOLOGY EXAMINATION Today in cardiology for determination - diagnosis of problematic arrhythmias that do not respond to pharmacological treatment, an electrophysiological examination is used. This is quite a complex examination, 3-4 catheters are introduced into the heart, placed near individual places of the cardiac conductive system, potentials are record – the main goal is to find the place of arrhythmia and this place with the help of radiofrequency ablation "burn"(to interrupt the pathological formation of action potential). Activation map - Activation map of right atrium in left sloping projection - Sinus rhythm Activation propagation map - propagation of left ventricular map Different types of mappings Voltage map – red color – places with a lower voltage, violet – healthy myocardium Voltage map in network design – visibility of the catheter Different types of mappings •THANK YOU FOR YOUR ATTENTION