Heart
The guidelines for management of heart transplant recipients consider coronary angiography the gold standard method to detect cardiac allograft vasculopathy, which ranges from 42% at 5 years to 50% at 10 years. These patients do not experience typical angina due to the the denervation of the transplanted heart [9].
In patients with orthotopic heart transplant the coronary angiography is technically difficult due to the presence of the aortotomy with anomalous implantation of the coronary ostia and to the position of the allograft. A transfemoral approach is usually preferred and its superiority was confirmed in a small, randomized study. [10]
In heterotopic heart transplant the heart of the donor and recipient are sewed in a parallel fashion. Nowadays, its role is limited to the presence of high pulmonary hypertension in patients who cannot receive a combined heart and lung transplant or in the case of significant donor‐recipient body size mismatch. A 1994 study showed that the success cannulation rate was 67%, that the preferred access was the femoral and that the most helpful angiographic views were the posterior‐anterior, left anterior oblique, and caudal right anterior oblique [11].
Interactive multiple choice questions are available for this chapter on www.wiley.com/go/dangas/cardiology
References
1 1 Di Mario C, Sutaria N. Coronary angiography in the angioplasty era: projections with a meaning. Heart 2005; 91:968–976.
2 2 Secco GG, Agostoni PF. Coronary interventions: 5F versus 6F to 7F. In: Bertrand O, Rao S. (eds) Best Practice for Transradial Approach in Diagnostic Angiography and Intervention. Wolters Kluwer: 2015.
3 3 Israeli Z., Lavi S., Pancholy S.B., et al. Radial versus femoral approach for saphenous vein grafts angiography and interventions. Am Heart J 2019 Apr; 210:1–8
4 4 Cha KS, Kim MH. Feasibility and safety of concomitant left internal mammary arteriography at the setting of the right transradial coronary angiography. Catheter Cardiovasc Interv 2002; 56(2):188–195.
5 5 Akpinar I, Sayin MR, Karabag T, et al. Differences in sex, angiographic frequency, and parameters in patients with coronary artery anomalies: single‐center screening of 25 368 patients by coronary angiography. Coron Artery Dis 2013; 24:266–271.
6 6 Yuksel S, Meric M, Soylu K, et al. The primary anomalies of coronary artery origin and course: a coronary angiographic analysis of 16,573 patients. Exp Clin Cardiol 2013; 18:121–123.
7 7 Earls JP. Coronary artery anomalies. Tech Vasc Interv Radiol. 2006 Dec; 9(4):210–7.
8 8 Angelini P, Uribe C. Anatomic spectrum of left coronary artery anomalies and associated mechanisms of coronary insufficiency. Catheter Cardiovasc Interv. 2018 Aug 1; 92(2):313–321
9 9 Kittleson MM. and Kobashigawa JA. Cardiac Transplantation Current Outcomes and Contemporary Controversies. JACC: Heart Failure 5:12, December 2017
10 10 Scalone G, Brugaletta S, Martín‐Yuste V, et al. RAndomized Comparison of raDIal vs. femorAL Access for Routine Catheterization of Heart Transplant Patients (RADIAL‐heart transplant study). Transplant Proc. 2014 Dec; 46(10):3262–7
11 11 Lowry RW, Bitar JN, Grinstead WC, et al. Heterotopic heart transplantation: catheterization, endomyocardial biopsy, and coronary angiography of the donor heart. Cathet Cardiovasc Diagn. 1994 May; 32(1):18–26.
CHAPTER 5
Material Selection
Alessio Mattesini, Pierluigi Demola, Sahil A. Parikh, Gioel Gabrio Secco, Michele Pighi, and Carlo Di Mario
Old photographs show Andreas Gruentzig working with his wife in a kitchen on the first coronary angioplasty balloons. They were very bulky, difficult to position as there was no guidewire lumen, and too compliant to safely expand resistant lesions in coronary arteries. Further understanding and development in manufacturing techniques and evolution of materials have reduced the profile of angioplasty balloons while increasing their robustness, deliverability, reliability, and safety profile. Similarly, workhorse guidewires have been developed with improvements in torque and force transmission while having more durable and less traumatic but shapeable tips. Specialty guidewires have been developed for the treatment of specific lesion types including chronic total occlusions. A wide range of guide catheters, guidewires, and angioplasty balloons are now available, and continue to evolve to overcome variations in anatomy, changes in vascular access, and evolution in technique. The appropriate selection and safe and optimal use of these devices can reduce procedural time and increase procedural success and safety with hopes of improving clinical outcomes.
Guide catheter selection
Functional design of modern guide catheters
Guide catheters permit safe intubation of the coronary ostia, accurate hemodynamic monitoring, injection of contrast, and passage of guidewires, balloons, and stents. The clinical, anatomic, and angiographic scenario must be considered when selecting the size, shape, and length of a guide catheter. Modern catheters have a soft tip to reduce the risk of vessel trauma during intubation or manipulation. The wall consists of an outer layer which retains a predefined curve and increases shaft stiffness to provide backup support during intervention, a middle layer of wire braid to increase kink resistance, improve torque transmission, and shaft radiopacity, and a smooth lubricated inner layer to facilitate the transit of equipment. Guide catheters have thinner walls than diagnostic catheters to increase inner lumen size and can be easily damaged by excessive rotation (Table 5.1).
Table 5.1 Guide catheter inner lumen size by manufacturer and outer lumen size.
| Guide/manufacturer | Outer lumen size (French) | ||||
|---|---|---|---|---|---|
| 5 | 6 | 7 | 8 | ||
| Launcher/Medtronic | Inner lumen (in) | 0.058 | 0.071 | 0.081 | 0.090 |
| Vista Brite Tip/Cordis | 0.056 | 0.070 | 0.078 | 0.088 | |
| Mach1/Boston Scientific | NA | 0.070 | 0.081 | 0.091 | |
| Viking/Guidant Abbott | NA | 0.068 | 0.078 | 0.091 | |
| Wiseguide/Boston Scientific | NA | 0.066 |
|
