A Proposal for the Core Curriculum for Training of “Advanced Level Cardiology Specialist Assistants”

For the Performance of Diagnostic Invasive Cardiology Procedures: Report of the International Society of Advanced Level Medical Imaging Physician Specialists (ALMIPS) and the Committee on Training Standards© Writing Committee Members Jack P. Chen, MD, FACC, FSCAI, FCCP Chuck Williams, BS, RPA, RT(R) (CV) (CI), RCIS, FSICP Harvey A. Koolpe, MD1 Manuel Viamonte, Jr., MD Morton Kern, MD David E. Allie, MD Craig Walker, MD Douglas C. Morris, MD Michele Doughty Voeltz, MD Constantin Cope, MD Siro Buendia, MD Jackson Thatcher, MD Phyllis Williams, RN, ASN, CEN, CVT Neil E. Holtz, RCIS, BS, EMT-P Pattie Freschett, RN, BSN, BBA, CVT Nicole Geiger, RCIS, AS Trevor E. Smith, HM-1, USN Harrell Carmicheal, SFC, USA Dereck Carver, RCIS, AS Betty Brooks, RN, ASN, CEN, TNCC, CVT Joe Brown, RCPT Marsha Holton, CCRN, RCIS, FSICP Wes Todd, BS, RCIS Kathy A. Groce, RN, MSN, RCPT Alexander Andreu, RT(R), AS, CVT Williams Embil, BS, CVT Jill Kathe, RN, ASN, BS, CVT Lynn Taillon, BS Wayne Cochran, BS, RCIS Adele Serio, RN, BSN, RCIS Amanda Walters, RT(R), BS, AS Ashley Williams, BS Brent Rodriquez, RCIS, RCPT, RPFT, BS Christine Lucas-Testa, APRN, MSN Craig Cummings, RCIS, FSICP Christine Bienvenue-Kauffman, RT(R), CVT Daniel R. Jones, RCIS, BS Deborah Curl, RN, BSN, CVT Harvey McKinley, RCIS Jarrod A.Williams, BA Jason Wilson, RCIS Jeff Mays, RN, ASN, CVT Jennifer Malecki, RN, ASN, CVT Kacie Reynolds, AS, CVT Kenneth A.Gorski, RN, RCIS, FSICP Kristen Williams, RT(R)(MR) Lorena Hendry, PA-C, BS Melissa Broddle, RT(R), AS, CVT Patricia Thomas, MBA, RCIS, FSICP Patrick Hoier, BS, RCIS, FSICP Rhoda Hammer, RN, MS, BSN, RCIS Ray Lenius, MEd, RCIS Ronald B.Williams, RT(R)(MR) Sheila Debastiani, RT(R) Shataundia Reese, RN, BSN, CVT Stacey Funicello, CMOA Susan Steinbis, ARNP, MSN Teresa B.Waters, MBA, BS, RT(R) Terry Scott, RN, BSN, CVT Tiffany Prats, BS, BBA Tim Rohrschneider, RT(R), BMSc, CVT Preamble There are a number of advanced level allied health specialty fields within the realm of medical imaging in which many men and women, who function at advanced levels, assess patients and perform diagnostic procedures in cardiology, radiology and sonography units. Over the past decade, physician assistants and nurse practitioners have populated the medical imaging areas and have been clinically trained without education that deals with the principles of radiation imaging and safety, diagnostic cardiac catheterizations, interventional cardiology procedures, echocardiography, peripheral interventional studies and cardiovascular laboratory pharmacology. Two groups of advanced level medical imaging specialists, Radiology Practitioner Assistants (RPAs) and Registered Radiologist Assistants (RRAs), have been registered as radiologic technologists by the American Registry for Radiologic Technologists (ARRT).These allied health professionals have been either certified as RPAs through the Certification Board for Radiology Practitioner Assistants (CBRPA) and/or through the ARRT as Registered Radiologist Assistants (RRAs). The two groups are required to work under the sole supervision of radiologists. A small percentage of RPAs do function in the realm of cardiology. These persons are included in this advanced level program, provided they hold a current Cardiovascular-Interventional (CV) credential or Cardiac-Interventional (CI) credential from the ARRT and are actively employed in an invasive cardiology setting. Another body of allied health professionals, Registered Cardiovascular Invasive Specialists (RCISs), are educated and trained to function specifically in cardiac catheterization laboratories. In addition, other allied health caregivers such as registered nurses, registered or state licensed respiratory therapists, registered or state licensed radiographers, and emergency medical technician-paramedics (EMT-P) have been certified as RCISs. All of these men and women with an advanced education have been trained on-the-job and are functioning at advanced levels of clinical practice, assisting supervising cardiologists, cardiothoracic surgeons, vascular surgeons and other interventionalists to perform and complete cardiovascular procedures. This assistance is under direct and indirect supervision of a physician who has been educated and trained to perform angiographic procedures in invasive and/or interventional cardiology settings. With this knowledge, we note that men and women who function at the advanced levels in cardiovascular medical imaging have a separate level of knowledge, experience and skills to assist physicians. The purpose of the curricula set forth herein is to develop content specifications that will define the tertiary/graduate-level knowledge and skill sets required to train advanced level allied healthcare workers to perform diagnostic and interventional cardiovascular procedures. The writing committee has common knowledge that allied health professionals are performing diagnostic and interventional cardiac and non-cardiac cardiovascular procedures under the direct supervision of cardiologists, cardiothoracic surgeons, electrophysiologists, and vascular surgeons in Canada, the United Kingdom, and in underserved medical facilities in the United States. The scope of this material focuses on the training of the Advanced Level Cardiology Specialist Assistant, who participates in the treatment of patients with cardiovascular disease under the guidance of sponsoring board-certified/eligible physicians educated and trained to perform invasive and interventional cardiology and non-cardiac cardiovascular procedures with the use of fluoroscopy, radiography, angiography and other complex procedures, as well as non-invasive cardiology procedures such as echocardiography, echo stress tests, electrocardiographic studies, Holter monitoring, and radio-isotopic stress tests. The intention of the International Society of Medical Imaging Physician Specialists and the Committee is to develop a set of standards that require sound decisions based on cognition and technical skills that are obligatory in order to assist or perform invasive and non-invasive cardiology procedures under the direct tutelage of a board certified/eligible cardiologists, cardiothoracic surgeons, or vascular surgeons. The curriculum is divided into six sections: I. Introduction II. Diagnostic Cardiac Catheterization III. Angiographic Cardiac Anatomy IV. Hemodynamics, Physiology and Pathophysiology V. Cardiac Pharmacology VI. Radiation Safety Guidelines, Dose Limits, Safety and Biology It also includes a bibliography. The curriculum for interventional cardiology procedures will be developed as a separate set of standards (a summary will be published in the September 2008 issue of Cath Lab Digest). A suggested evaluation form for an advanced level trained allied health professional will also be developed. I. Introduction The curriculum for competency training for an advanced level cardiology specialist assistant requires that the candidate to have a Bachelor of Science degree and/or equivalent; a minimum of five (5) continuous years of clinical experience; completion of one (1) year of clinical and didactic training in invasive diagnostic cardiology procedures, and/or one (1) year of clinical and didactic training in non-invasive cardiology procedures; and one (1) year in interventional cardiology procedures under the direct supervision of a board-certified interventional cardiologist or an assigned associate cardiologist, cardiothoracic surgeon, or vascular surgeon. II. Diagnostic Cardiac Catheterization A. Clinical Training Pathway 1. Be supervised by an attending board-certified/eligible cardiologist. 2. Be involved in the planning of the procedure and versed in the indications for the procedure. 3. Assist in selecting the instruments for the procedure. 4. Be able to handle technical manipulations of a case. 5. Complete at least 350 therapeutic procedures. B. Clinical Practice Pathway 1. Understands roles of the team members. a. Physicians 1) Direct supervision 2) Indirect supervision b. Registered nurses c. Licensed/Registered Radiologic Technologists and/or equivalent 1) ARRT Cardiovascular-Interventional credentials 2) ARRT Cardiac-Interventional credentials 3) Radiology Practitioner Assistants d. CCI-Registered Cardiovascular Invasive Specialists (RCISs) e. CCI-Registered Cardiovascular Electrophysiology Specialists (RCESs). f. Certified Physician Assistants g. Advance Practice Registered Nurses h. Other certified and/or licensed allied healthcare workers, who hold CCI credentials RCIS or RCES. 1) Registered nurses with RCIS or RCES 2) Registered and/or licensed respiratory therapists 3) Registered radiographers 4) Emergency Medical Technician-Paramedics (EMT-P) a) State licensed with CCI RCIS or RCES b) National certification with RCIS or RCES 5) Internationally certified allied health professionals with CCI RCIS or RCES credentials 2. Maintains ACLS certification (PALS if involved with pediatric studies). 3. Develops effective rapport with patient which includes bedside manner. 4. Handles adverse events professionally without causing alarm with patient or support staff. 5. Establishes professional rapport with support staff team members that conveys confidence and direction as an advanced practice team member. 6. Remains focused on the mental well-being of patient throughout procedure and on vital signs (blood pressure, cardiac rhythms and respiratory status) and has plan to correct any untoward events. 7. Able to handle procedure-induced cardiac events such as bradycardia, supraventricular tachycardia, 1st, 2nd and 3rd degree heart blocks, atrial fibrillation, atrial flutter, ventricular tachycardia with or without pulse, ventricular fibrillation, asystole and pulseless electrical activity. 8. Knows when to ask for help or when to discontinue a procedure that cannot be completed safely. 9. Exhibits knowledge of managing patient’s discomfort with the use of appropriate analgesic and sedative medications 10. Has extensive knowledge and experience with emergency lab protocols and procedures. 11. Understands the need for a standard work protocol. C. Indications 1. Unstable angina 2. Post myocardial infarction (MI) angina 3. Post cardiac surgery angina 4. Non Q-wave MI 5. MI at young age 6. Complicated Q-wave MIs 7. Post MI – Cardiac mechanical complications (mitral regurgitation, ventricular septal defect) 8. Post MI – Congestive heart failure (CHF) 9. Idiopathic chest pain 10. Valvular heart disease 11. Valvular heart disease with coronary artery disease (CAD) 12. Left ventricular (LV) dysfunction 13. Coronary artery anomalies 14. Post cardiac transplants 15. Donors for cardiac transplants 16. Right and left cardiac catheterization 17. Congestive heart failure 18. Cardiomyopathy a. Restrictive c. Hypertrophic obstructive b. Constrictive d. Ischemic e. Medication-induced 19. Pulmonary hypertension 20. Cardiogenic shock D. Contraindications 1. Electrolyte imbalances/Digitalis intoxification 2. Malignant hypertension 3. Febrile illness 4. Congestive heart failure 5. Hemorrhage (anticoagulation with INR >2, PTT >18 sec) 6. Severe contrast media sensitivities 7. GI bleeding 8. Mental and physical incapacitation that limits cooperation 9. Refusal to undergo coronary artery bypass graft surgery (CABG) after outcome of coronary study. 10. Absolute reasons a. Unable to sign informed consent due to mental incompetence. b. Inexperienced cardiologist and lack of proper imaging equipment. c. Inexperienced advanced level medical imaging specialist assistants. d. Inexperienced advanced level physician extenders with lack of education in use of ionizing or non-ionizing radiation and experience. E. Education and Informed Consent of Patients 1. Physician and advanced level allied health professional meet with patient and family in a serene setting. 2. Informed consent is obtained after indications, potential risks and expectations, are discussed with patient. 3. Does not underestimate discomfort and duration of procedure. 4. Explanation of breathing and coughing during coronary angiography. 5. If procedure is for evaluation of the coronary arteries, explanation for possible percutaneous coronary intervention (PCI) or CABG procedures is completed. F. History and Physical 1. A complete cardiac history and physical must be completed. 2. Documentation of angina, dyspnea, syncope, and other cardiovascular disease must be recorded. 3. Previous medical records must be obtained, with focus on conditions such as advanced cerebrovascular disease, diabetes Type II, peripheral vascular disease, pulmonary hypertension, and renal insufficiency or failure. 4. Documentation of contrast media and/or medication allergies and reactions. 5. Physical exam should be performed and process should focus on the cardiopulmonary system and vascular system. 6. Palpation of peripheral pulses should be done and charted. 7. Auscultation for vascular bruits should be done so an appropriate vascular access site is chosen. G. Laboratory and Other Clinical Examinations 1. Current chest radiographs, ECG and laboratory data should be reviewed. 2. Echocardiograms and previous cardiac catheterization should be reviewed. 3. An ECG, CBC with platelet count, serum electrolytes, serum creatinine, BUN, GFR and PT/PTT should be performed and reviewed prior to the procedure. 4. Evaluation of the coagulation system is mandated if a history of blood loss, anemia, or other bleeding diathesis exists. 5. Evaluation of the coagulation system is required if the patient has a history of anticoagulation therapy. 6. Glomerular filtration rate (GFR) and creatinine values are required if a patient has a history of renal impairment or renal failure. H. Procedural Requirements 1. Evaluation and monitoring of patient a. The choice of the appropriate vascular approach is based on the history and physical examination, types of procedures to be performed and clinical laboratory data. b. Positioning of the patient on the procedural table is important for obtainment of proper cineangiographic projections. c. Access sites 1) Brachial site requires proper positioning of arm-board 2) Femoral sites require shaving and proper surgical type of preparation to reduce possibilities of site wound infections 3) Radial sites require the Allen Test, proper positioning of arm and wrist, and surgical-style preparation d. A functional IV access with an 18 ga or 20 ga Angiocath® or equivalent is required. e. Use of table pads, arm rests, and pillows are required for comfort. f. Continuous ECG monitoring is required. g. Vital signs should be recorded at the following durations 1) Pre-procedure – every 15 minutes 2) During procedure (conscious sedation) – every 5 minutes 3) Post procedure – every 15 minutes for 2 hours, then every 30 minutes h. Radiolucent defibrillation pads should be placed appropriately if high-risk patient with histories of ventricular dysrhythmias, which may be acute and/or have prior incidences. i. Defibrillation, intravenous access, intubation and suction equipment, as well as emergency medications required by current AHA/ACLS guidelines must be available and in proximity of the patient in the procedure rooms as well as the pre-procedural and post-procedural patient areas. j. Arterial blood pressure should be constantly monitored directly and/or by automated cuff or finger probe. k. Arterial oxygen saturations must be done with pulse oximetry on all patients pre-procedural, during procedure and post-procedure, whether the patient has respiratory issues or will be administered conscious sedation. l. Patient education about the procedures and equipment should be done in a non-threatening and considerate manner in order to lower anxiety. m. Assessment of urinary output needs should be addressed and be based on the duration of the procedure, urinary retention, ease of bedpan or urinal placement, and length of required bed rest. n. Principles of IV sedation, as approved by the hospital conscious sedation committee. o. Current ACLS certification and PALS (if pediatric studies are performed) is a requirement for the attending physician and the physician extenders. 2. Planning of the procedure a. Before initiation of the procedure, the order of events should be discussed with the attending and support staff. This process shall be individualized to the specific needs of each patient and should include focus on: 1) Condition and stability of patient 2) Length of arterial access time 3) Reduction in repeated measurements 4) Reduction in number of catheter exchanges 5) Grouping of hemodynamic measurements so calculations can be completed with less procedure (vessel) time b. Diagnostic questions must be answered logically during each procedure. Diagnostic results should include: 1) Left ventricular function (ejection fraction, wall motion) 2) Left heart pressures [left ventricle (LV), left ventricular end diastolic pressure (LVEDP), aortic (AO)] 3) Aortic root anatomy/disease 4) Coronary arterial anatomy/disease/anomalies. 5) Right heart pressures [right atrium (RA), right ventricle (RV), mean pulmonary arterial pressure (mPA), pulmonary wedge capillary pressure (PWCP)] 6) Vascular resistances (VR), systemic (SVR) and pulmonary (PVR) 7) Valvular disease a) Regurgitation (cuspid valves and semilunar valves) b) Stenosis (semilunar and cuspid valves) c) Prosthetic valves d) Congenital anomalies 8) Intracardiac shunts a) Atrial septal defects (ASDs) b) Patent foramen ovale (PFOs) c) Ventricular septal defects (VSDs) d) Coronary A-V malformations e) Coronary ≥ pulmonary artery fistulas 9) Congenital anomalies a) Coronary arteries c) Situs Inversus b) Dextrocardia 10) Pericardial disease 3. Equipment needed to perform procedure should include: a. Preformed catheters, which include backup catheters when the most standard choices are not successful at cannulating the chamber or ostia of the coronary arteries in a timely manner. b. Pressure transducers c. Oximeter for oxygen saturation levels d. Cardiac outputs 1) Thermodilution 2) Fick Cardiac Output e. Temporary pacemaker and pacing catheters 1) Single chamber (VVI, asynchronize) 2) Dual chamber (DVI, AAI, VVI, asynchronize, overdrive) 3) Transthoracic external pacing f. External defibrillator (biphasic), with ability to perform synchronization for cardioversions as well as defibrillation g. Transseptal needle (Brockenbrough) and sheath (Mullins) h. Variety of teflon-coated guide wires and hydrophilic wires i. Pressure and Doppler arterial wires j. Intravascular ultrasound unit with IVUS catheters k. Intracardiac echocardiography unit with ICE catheters l. Rotablation unit, advance devices and burrs m. Photo-ablation unit and catheters n. Endocardial biopsy equipment and sheaths o. Thrombectomy devices (e.g. AngioJet, Pronto catheter, Export catheter, Fletch catheter) p. Percutaneous left ventricular assist devices 1) Intra-aortic balloon pump (IABP) 3) Cancion System 2) TandemHeart I. Vascular Access 1. If jugular, subclavian, brachial, radial and femoral sites are used for arterial or venous access, knowledge of anatomy, appropriate indications and palpations are important and must be indicated. 2. Knowledge of sterile procedure, draping and local anesthesia must be known and demonstrated. 3. Arterial and venous percutaneous and cut-down access methods must be appropriate and practiced with proficiency. 4. Dexterity of the hands must be developed for recognition of proper wire movement for sheath and catheter placements. 5. Knowledge of how to avoid access site complications such as site dissections, air emboli, thrombus, embolization or displacement of lines. 6. Difficult accesses require awareness of useful methods (techniques) to gain entry. Knowledge of the following techniques should be ascertained before any procedure begins: a) Hydrophilic wires b) Steerable wires c) Long sheaths in tortuous proximal and external iliac arteries, and moderately or severely dilated aortic areas d) Contrast media and fluoroscopy for guidance e) Valsalva maneuver to access common femoral veins f) Fluoroscopy to identify the appropriate femoral puncture site g) Micropuncture techniques h) Vascular ultrasound to gain access J. Angiography 1. Size and style of catheters are chosen accordingly. 2. Knowledge of Judkins, Amplatz and other catheters used to perform cardiac angiography. 3. Recognition of pressure dampening quickly, understands implications and non-seating of catheters. 4. Observes ostial pressures before, during and after contrast media injections. 5. Ensures adequate vessel opacification with appropriate amount of contrast media and force during systole and diastole cycles, without injecting an air embolus or thrombus. 6. Limits the number of left main coronary artery (LCMA) injections if LMCA disease is clinically suspected or angiographically present. 7. Responds rapidly to post-injection dysrhythmias and/or hypotension. 8. Determines angiographic views that permit quality imaging with the lesser use of contrast media and radiation exposure. 9. Communicates expectations with patient during procedure: a) Discomfort caused by local anesthetic, contrast media injections b) Procedural cause of transient angina 10. Couples knowledge with dexterity to cross normal or diseased aortic valves with appropriate techniques, projections, catheters and guide wire options. 11. Understands necessity of proper panning sequences with excellent hand coordination. 12. Understands importance of panning when collateral vessels fill distal areas of contralateral and ipsilateral occluded arteries. 13. Understands how to use exchange wires to change catheters. 14. Specifies adequate metered contrast media injection rates for coronary angiography, ventriculography, aortography (ascending, arch, descending, abdominal) and right heart injections. 15. Correlates hemodynamic values with contrast media studies of the heart chambers and pulmonary circulation. 16. Operates IABPs and manages patients in cardiogenic shock. K. Post-Procedure Care 1. Technical cognition a) Evaluation and documentation of vascular integrity b) Immediate post-procedural patient care c) Monitoring and location of patient for post-procedural care d) Length of bed rest and immobilization of extremity 2. Management of complications a) Adverse contrast media sensitivities 1) Urticaria (mild, moderate, severe) 2) Anaphylactoid reactions (mild, moderate, severe) 3) Anaphylactic shock a) Respiratory distress and arrest b) Cardiac arrest 4) Current ACLS and PALS guidelines b) Adverse medication sensitivities 1) Urticaria (mild, moderate, severe) 2) Anaphylaxis (mild, moderate, severe) 3) Anaphylactic shock a) Respiratory distress and arrest b) Cardiac arrest 4) Current ACLS and PALS guidelines c) Knowledge of ECG rhythms and cardiac dysrhythmias d) Systolic and diastolic left ventricular dysfunction 1) Hypertrophy 2) Cardiomyopathy a) Ischemic c) Restrictive b) Constrictive d) Idiopathic 3) Left heart failure 4) Mechanical dysfunction a) Dissections b) Perforation e) Access sites 1) Hematoma 3) A-V fistulae 2) Hemorrhage 4) Pseudoaneurysms (retroperitoneal, external) 5) Thrombotic and embolic events f) Neurologic events 1) Transient ischemic attack (TIA) 2) Blurred or loss of vision 3) Loss of sensory function 4) Stroke or cerebrovascular accident (CVA) 5) Loss of motor function 6) Paresis or paralysis 3. Hemodynamic and angiographic interpretation a) Hemodynamic analyses 1) Principles and methods of calculating cardiac output 2) Calculations of stenotic valvular areas (hand method, computer- assisted) 3) Detection of intra-cardiac shunts a) Left to right d) Balanced b) Right to left e) Echocardiographic correlation c) Bidirectional 4) Calculation of intracardiac shunt ratios a) Oxygen saturation determination b) Qp: Qs ratio determination c) Correlation with echocardiography 5) Analyses and explanation of pressure waveforms and measurements. b) Rapport with patient 1) Discusses diagnosis with a patient and family members. 2) Discusses prognosis, alternative treatment regimens and need for compliance of medical management plans with patients, family members, referring physician and involved healthcare team members, so continuity of education and care occurs. III. Angiographic Cardiac Anatomy An Advanced Level Cardiology Specialist Assistant must have excellent knowledge of cardiac anatomy from normal, congenital, and post-surgical standpoints in order to understand the processes of congenital or acquired cardiopulmonary disease processes. A. Cardiac Chambers/Valves 1. Left atrium 3. Right atrium 5. Pulmonary system 2. Left ventricle 4. Right ventricle B. Coronary Artery Anatomy 1. Sinuses of Valsalva 2. Sinotubular ridge 3. Aortic valve leaflets 4. Left main coronary artery (LMCA) a. Left anterior descending artery (LAD) 1) Proximal 2) Mid 3) Distal b. Diagonals 1) First 2) Second 3) Third c. Septal perforators 1) Superior origin a) From LAD b) From diagonals 2) Inferior origin a) From RPDA (Dominant RCA) b) From LPDA (Non-Dominant RCA) d. Left circumflex artery 1) Proximal 2) Mid 3) Distal 4) Obtuse Marginals a) First OM (OM-1) c) Third OM (OM-3 or PLOM) b) Second OM (OM-2) 5) Left atrio-ventricular branch 6) Left posterior descending artery 5. Right coronary artery a. Conus branch (50%) g. Distal b. Proximal h. RPDA (90% of population) c. Sino-nodal branch i. Atrio-ventricular nodal artery d. Mid j. Inferior septal branches e. Acute marginal branches k. Posterior lateral branches (RV branches) 1) Continuation of RCA f. Acute marginal 2) LV branches 6. Intercoronary and extracoronary anastomoses a. Anterior interventricular vein (Great cardiac vein) b. Posterior interventricular vein (Middle cardiac vein) c. Posterior left ventricular vein (Left marginal vein) d. Oblique vein of Marshall e. Anterior cardiac vein f. Cardiac veins of Thebesius 7. Congenital anomalies of coronary arteries a. LCA from PA b. LCX from PA c. RCA from PA d. Left/right coronaries form PA e. Coronary-cardiac fistulae f. Coronary arteriovenous fistulae g. Single coronary arteries h. Ectopic coronary arteries 8. Congenital heart disease/Anomalous coronary artery anatomy a. Tetralogy of Fallot 1) Normal origins 2) RCA courses over infundibulum of RV (Type I) 3) Single RCA with LCA (courses anterior of PA, Type II) 4) Late bifurcation of LMCA (courses anterior of PA, Type III) 5) LAD from RCA/LCX from Sinus of Valvsalva (Type IV) 6) Single LCA/RCA originates from LMCA b. Complete transposition of the great vessels 1) Right/ non-coronary sinuses reversed. 2) LMCA originates anterior of PA with normal bifurcation of LAD and LCX (Type I) 3) LAD originates from left sinus of Valvsalva, LCX originates from RCA, and courses posterior of PA, and to extends into left sulcus groove (Type II) 4) LCX originates from posterior sinus of Valvsalva, courses posterior of PA, and LAD arises from left sinus of Valvsalva (Type III) c. Corrected transposition of great vessels 1) Oversize anterior leaflet 2) Right and posterior leaflets normal or smaller in size 3) RCA originates from right sinus and bifurcates into RCA and LAD 4) LCX arises as single vessel from left sinus and supplies posterior area of myocardium d. Double outlet right ventricle 1) Great vessels arise from RV 3) Origin of coronaries are mostly normal 2) VSD e. Single ventricle 1) Usually associated with complete or corrected transposition of the great vessels 2) Aorta arises from ventricular infundibulum 3) PA originates from 4) Coronary arteries arise as indicated under complete transposition 5) Coronaries originate as listed under corrected transposition 9. Non-congenital heart disease/anomalous coronary anatomy a. Single coronary artery 1) Originates from ascending aorta in most patients 2) May arise from carotid artery 3) May originate from descending aorta 4) Types of single coronary arteries a) Vessel courses normal pathway of RCA or LCA and supplies area of absent vessel (Type I) b) Single RCA or LCA bifurcates early and branches into area of the missing artery (Type II) (1) LCA absent with RCA that supplies a branch posterior of aorta that bifurcates into the LAD and LCX (2) RCA trifurcates into a normal RCA system, LCX that reaches the posterior A-V groove, and a LAD that courses between the AO and the PA (3) RCA is absent and an anomalous branch and may cross the infundibulum of the PA to reach the anterior A-V groove 5) Single vessel is very atypical in that the RCA and LCA pattern is not easily identifiable (Type III) b. Ectopic coronary arteries 1) RCA originates from left sinus of Valvsalva 2) Separate ostia of LAD and LCX ( LMCA is absent) 3) LMCA arises from right sinus of Valvsalva and bifurcates into the LAD and LCX 4) LCX arises from the RCA 5) LAD and LCX have separate origins from the right sinus of Valvsalva. 10. Collateral pathways of coronary arteries a. Right coronary artery 1) Direct bridging collaterals a) Homocoronary b) Vasa vasorum 2) Distal LCX to distal LV branches of RCA 3) Left atrial circumflex to distal RCA or A-V nodal artery 4) Obtuse marginal to posterior lateral branch of distal RCA 5) Diagonal of LAD to posterior lateral branch of RCA 6) LAD septal perforators to RPDA 7) Proximal acute marginals to lower acute marginal arteries 8) Conus to acute marginal artery 9) Right or left Kugel’s artery through A-V nodal artery to distal RCA 10) Sino-atrial nodal artery through left atrial artery to distal RCA artery 11) LAD branches to anterior RV wall to acute marginal to distal RCA 12) Distal LAD (apex) to RPDA 13) Inferior acute marginals to distal RPDA b. Left Coronary Artery 1) Conus artery to LAD 2) Acute marginal to LAD 3) Obtuse marginal to distal LAD 4) Distal RPDA to distal LAD 5) Obtuse marginal to diagonal branches 6) RPDA to LAD through septal perforators 7) Diagonal septal perforators through LAD perforators to LAD c. Left circumflex artery 1) Bridging collaterals 2) Diagonals to occluded obtuse marginal 3) RPDA to occluded obtuse marginal 4) Distal RCA to distal LCX 5) Superior obtuse marginal to inferior obtuse marginal 6) Left atrial branch to distal LCX 11. Post coronary-bypass graft angiographic anatomy a. Internal mammary arteries 1) LIMA to LAD (mid, distal) 2) LIMA to diagonal 3) LIMA to diagonal and LAD (Jump graft) 4) RIMA to RCA (distal, RPDA) 5) RIMA to LAD b. Saphenous vein grafts 1) To LAD (mid, distal) 2) To diagonals (1st, 2nd) 3) To ramus intermediatus 4) To mid LCX 5) To obtuse marginals (1st, 2nd, 3rd) 6) To left posterior descending artery (LPDA) 7) To acute marginal 8) To distal RCA 9) To right posterior descending artery (RPDA) 10) To continuation of RCA c. Y-grafts (vessels indicated in surgical reports) d. Jump grafts (vessels indicated in surgical reports) e. Free radial artery grafts (vessels indicated in surgical reports) 12. Common pitfalls of coronary angiography a. Congenital small arteries 1) Non-dominant RCA with large LCX (LPDA) 2) Dominant RCA with small LCX system b. Cardiac veins misinterpreted as coronary arteries c. Catheter-induced vasospam of a coronary artery (i.e. RCA) d. Ectopic ostiae of LCA or RCA e. Myocardial bridging of LAD f. Separate origin of conus artery (may collateralize occluded LAD g. Ostial stenosis of LMCA or RCA h. Short LMCA with early origin of LAD and LCX i. Separate origins of LCA and LCX from sinus IV. Hemodynamics, Physiology and Pathophysiology A. System Instrumentation 1. Fluid-filled pressure recording systems a. Calibration of transducers b. Troubleshooting system c. Physics of fluid-filled electromechanical pressure systems d. Knowledge of operation 2. Pressure wire systems a. Physics of fluid-filled electromechanical pressure systems b. Calibration of pressure wire/guiding catheter c. Troubleshooting pressure wire system d. Knowledge of operation of equipment 3. Calculation of cardiac output a. Oxygen consumption (all methods) b. Body surface area c. Methods 1) Fick Cardiac Output (FCO) 2) Thermodilution (TDCO) 4. Oximetry and oxygen saturations B. Normal Cardiac Physiology 1. Left heart pressures [AO, LV, LVEDP, left atrium (LA)] 2. Right heart pressure (RA, RV, RVEDP, mPA, RPA, LPA, PWCP) 3. Oximetry 4. Cardiac output/index 5. Vascular resistance (SVR, PVR) 6. Cardiac pharmacology 7. Exercise physiology C. Cardiac Pathophysiology 1. Valvular disease a. Aortic 1) Stenosis a) Critical (AVA ≤ 1.0 cm2) b) Low cardiac output syndrome/low gradient stenosis 2) Regurgitation a) Acute b) Chronic 3) Exercise physiology 4) Mixed disease b. Mitral 1) Stenosis a) Critical (MVA ≤ 1.0 cm2) b) Low cardiac output syndrome 2) Regurgitation a) Acute (Post MI) b) Chronic 3) Exercise physiology 4) Mixed disease c. Pulmonic d. Tricuspid 2. Pulmonary Hypertension a. Fixed pulmonary hypertension b. Vasoactive pulmonary hypertension c. Pseudo or flow hypertension d. Etiology 1) Primary 2) Secondary e. Differentiation 1) Unilateral pulmonary occlusion 2) Embolization 3. Pharmacological a. Acetylcholine d. Oxygen b. Nitroprusside e. Milrinone c. Nitric oxide 4. Pericardial Disease a. Pericarditis 1) Acute 2) Recurrent 3) Constrictive b. Tamponade 5. Myocardial Disease a. Hypertrophic obstructive cardiomyopathy 1) Pacing effects 2) Mitral valve replacement b. Dilated cardiomyopathy 1) Alcoholism 2) Hypertension 3) Pregnancy 4) Viral 5) Drug toxicity (e.g. cobalt, daunorubicin, selenium deficiency) 6) Restrictive (endocardial fibrosis, amyloidosis, hemochromatosis) 6. Cardiogenic a. Ischemic b. Non-ischemic c. Myocarditis (viral, bacterial, mycotic, rickettsial, parasitic) 7. Hypotensive cardiac disease a. Vaso-vagal reflex reactions b. Non-cardiac etiologies 1) Allergies a) Antibiotics b) Contrast medias c) Analgesics (e.g. Dilaudid, fentanyl, morphine) d) Benzodiazepines (e.g. Valium, Versed) 2) Volume-dependent 8. Congenital heart disease a. Origins of anomalies of the coronary arteries 1) Aortic 3) Pulmonary artery 2) Coronary to coronary 4) Arteriovenous fistulae b. Aortic anomalies 1) Aortic atresia 3) Aortopulmonary septal defect 2) Aortic stenosis 4) Coarctation c. Atrial defects 1) Atrial septal defect 2) Patent formen ovale 3) Atrioventricular 4) Total anomalous pulmonary venous return 5) Cor triatriatum d. Valvular disease 1) Mitral regurgitation 6) Pulmonary atresia without VSD 2) Mitral stenosis 7) Tricuspid atresia 3) Pulmonary valve atresia 8) Tricuspid valve regurgitation 4) Pulmonary valve regurgitation 9) Ebstein’s anomaly 5) Pulmonary atresia with VSD e. Ventricular disease 1) Double inlet ventricle 3) Double outlet right ventricle 2) Double outlet left ventricle 4) Ventricular septal defect f. Other congenital heart defects 1) Tetralogy of Fallot 2) Pentalogy of Fallot 3) Complete transposition of the great vessels 4) Congenital corrected transposition 5) Patent ductus arteriosus (PDA) 6) Endocardial fibroelastosis 7) Anomalous pulmonary venous return without an ASD or PFO 8) Hypotensive pulmonary insufficiency 9) Malposition of the heart (dextrocardia, situs inversus) 10) Sinus of Valsalva fistula 11) Truncus arteriosus 12) Uhl’s malformation g. Oximetry and hemodynamic studies 1. ASD/PFO a. Shunts 1) Left ≥Right shunt 3) Bidirectional shunt 2) Right ≥Left shunt 4) Balanced shunt b. Right heart pressures c. Cardiac outputs (Fick) d. Acquired heart disease 2. VSD a. Shunts 1) Left ≥Right shunt 3) Bidirectional shunt 2) Right ≥Left shunt 4) Balanced shunt b. Right heart pressures 1) Cardiac outputs (Fick) 2) Acquired heart disease 3. Patent ductus arteriosus (PDA) a. Shunts 1) Left ≥Right shunt 3) Bidirectional shunt 2) Right ≥Left shunt 4) Balanced shunt b. Right heart pressures c. Cardiac outputs (Fick) d. Acquired heart disease 4. Epstein’s anomaly: diagnostic and surgical approach 5. Surgical interventions a) Types of repair procedures b) Diagnosis, evaluation and assessment c) Acquired heart disease V. Cardiac Pharmacology An Advanced Level Cardiology Specialist Assistant must have the knowledge and understanding of the use of medications, which includes controlled substances, indications, incompatibilities with other medications, indications for use, side effects, dosage and reversal of controlled substances during treatment of the patient in the cath lab suites before, during and after the procedure. A. Pre-procedure preparation for diagnostic and interventional studies 1. Preparation of the patient and previously prescribed medications. a. No PO clear liquids except sufficient amount to take oral medications 3 hours pre-procedure. No full liquids or solid food for 7 hours before elective procedures. b. Scheduled oral medications and anti-anginal medications should be continued. Aspirin, clopidogrel, nonsteroidal anti-inflammatory medications need not be discontinued. c. If a heparin IV infusion is being administered for unstable or crescendo angina, discontinuance is not necessary. d. IV access should be obtained. IV fluids may be necessary to maintain hydration of the renal bodies, except for patients with a history of CHF or pulmonary edema. 0.9% NaCl solution is the most common IV fluid administered at least 75 ml/hr. 2. Diabetic patients should have blood glucose levels done before the procedure. a. If blood glucose readings are over 200, short-acting Lipro or Aspart insulin should be given (1 unit of insulin per 50 points above 200). b. D5W IV infusion may be warranted in diabetics if hypoglycemia occurs. c. Beta blockers may mask usual symptoms of hypoglycemia. d. If sudden changes in consciousness or other physiological parameters occur, then administration of D50 must occur. e. If procedure is delayed significantly, blood glucose levels should be repeated prior to procedure. 3. INR levels should be less then 2.0, oral anticoagulation medications should be discontinued. a. If chronic anticoagulation exists, admission to a hospital needs to occur so IV administration of weight-based heparin may be given over 48 hours prior to procedure. b. Anticoagulation may require reversal with fresh frozen plasma. c. If vitamin K is administered, patient must be assessed for induction of a hypercoagulation state. d. Alternative vascular access should be considered (radial approach). 4. Diuretics are usually held prior to cath. 5. Anti-anginals and antihypertensive medications may be given with small sips of water (vital signs are recorded before medications are given). B. Premedications administered prior to procedure 1. Allergy preparation (contrast media), per Society for Cardiovascular Angiography and Interventions (SCAI) guidelines: a. Antihistamines (H1 Blockers, e.g. diphenhydramine) b. Histamines (H2 antagonists, e.g. cimetidine, famotidine) c. Steroids (e.g. prednisone, hydrocortisone) d. Bronchodilator (albuterol inhaler) e. Standard protocol for prophylaxis should be established 2. Beta blockers: discontinue in allergic patients if possible 3. Pre-cath sedation a. Benzodiazepines 1) Oral (diazepam) 2) IV (diazepam, midazolam) b. Antihistamines 1) H1 Blocker-diphenhydramine (oral, IV) 2) H2 histamine antagonists, cimetidine, famotidine (IV) c. Analgesics 1) Sublimaze 3) Morphine sulfate 2) Hydromorphone HCl C. Medications used during procedure 1. Contrast medias a. Ionic b. Nonionic c. Low osmolality d. Nonionic and low osmolality e. Cost containment factors f. Indications and benefits g. Complications 1) Nephrotoxicity 3) Dysrhythmias 2) Myocardial depression 4) Thrombotic events h. Known renal impairment or failure 1) GFR 1.4 should be used 2. Medications during procedures a. Oxygen (maintain pulse-ox levels between 96-100%) b. Sedatives (diazepam, midazolam) c. Analgesics – pain management (Sublimaze, hydromorphone, morphine) d. Reversal agents 1) Nalozone HCl (narcotics) 2) Flumazenil (benzodiazepines) e. Bradycardia-Atropine f. Supraventricular tachycardia 1) Adenosine 2) Amiodarone HCl 3) Calcium channel blockers (e.g. Diltiazem HCl, Verapamil HCL) 4) Ibutilide fumarate g. Hypertension 1) Nitroglycerin (sublingual or IV) 2) Beta blockers (e.g. metoprolol HCl, propanolol HCl) 3) Nitroprusside h. Hypotension 1) Dopamine 2) Dobutamine 3) Epinephrine 4) Norepinephrine 5) Phenylephrine [only pressor used with subvalvular left ventricular outflow obstruction (SVLVOFO)-hypertrophic obstructive cardiomyopathy (HOCM)] 6) Vasopressin i. Nausea 1) Metoclopramide 2) Ondansetron HCl 3) Promethazine HCl (may lower level of consciousness, cause transient hypertension or hypotension, disturbed coordination, coordination and restlessness) 4) Droperidol (may cause hypotensive event) 5) Hydroxyzine HCl (only IM or PO) j. Anaphylaxis/allergic reactions (SCAI guidelines) 1) Albuterol inhaler (bronchospasm) 2) Hydrocortisone 3) H1 antihistamines (diphenhydramine HCl) 4) H2 histamine antagonists (cimetidine, famotidine) 5) ACLS guidelines for respiratory arrest and cardiac arrest k. Ventricular ectopy 1) Lidocaine HCl 2) Amiodarone HCl 3) Procainamide HCl l. Anticoagulants 1) Heparin sodium 2) Bivalirudin 3) Glycoprotein llb/llla platelet aggregation inhibitors a) Abciximab [acute coronary syndrome (ACS) with planned PCI ≤24 hours] b) Eptifibatide (ACS with planned PCI ≤ 24 hours) c) Tirofiban (ACS or PCI) d) Clopidpgrel (Loading dose 600-900mg, then 75 mg PO OD for 3 months ≥ indefinite duration) m. Renal insufficiency/renal failure (GFR ≤ 60) 1) Acetylcysteine (600mg PO) 2) Sodium bicarbonate IV infusion 3) Hydration 4) Hemodialysis after procedure, if patient is on dialysis n. Fibrinolytics 1) Alteplase 2) Reteplase 3) Streptokinase o. Seizures 1) Diazepam 2) Phenytoin 3) Clonazepam p. Provocative medications 1) Pulmonary hypertension a) Oxygen d) Nitric oxide b) Acetylcholine e) Dobutamine HCl c) Hydralazine HCl f) Prostaglandins 2) LV outflow tract obstruction (HOCM) a) Amyl nitrite c) Nitroglycerin IA (100-200mcg) b) Isoproterenol HCl 3) Coronary vasospasm a) Methylergine b) Nitroglycerin IC (Reverse methylergine effects due to possible delay of action of spasmodic agent at end of procedure) VI. Radiation Safety Guidelines, Dose Limits, Safety and Biology A. Radiation safety guidelines/ radiation dose limits 1. Maximum permissible doses (MPD) a. Physician responsibilities are to reduce radiation doses to patients, support staff, and himself or herself through awareness of general exposure guidelines for occupational workers and non-occupational persons. b. Advanced Level Cardiology Specialist Assistant, as well as members of the support staff, are responsible for adhering to the general guidelines for occupational and non-occupational persons. c. General exposure guidelines for occupational workers. d. Tissue weighting factors, along with sensitive organs 2. Fluoroscopy vs. digital imaging radiation exposure a. Basic fluoroscopy – 5 R/min (Most systems function between 2-3 R/min) b. Digital imaging angiography @ 15 fps for 7-8 seconds can generate exposure levels that exceed levels produced with fluoroscopy. c. High-dose fluoroscopy 1) No limit on exposure (R/min) 2) Most have a continuous audible sound when used 3) Requires constant manual pedal usage 3. Radiation dosage a. Patient exposure 1) Source to tabletop shall not be less than 18 inches (45.72 cm) 2) Use proper collimation (shutters should always be noticeable at edges of viewing field during fluoroscopy and imaging) 3) Use least amount of fluoroscopy 4) Use least amount of digital imaging time (6-8 seconds per run) 5) Use lowest clinically acceptable frame rate (15 fps) 6) Use lowest acceptable magnification for coronary angiography (17-18 cm or 20-22 cm) 7) Perform pregnancy test on all female patients between 12-60 years of age b. Understands Consumer-Patient Radiation and Safety Act of 1981 1) Statement of purpose 5) Compliance 2) Definitions 6) Federal radiation guidelines 3) Promulgation of standards 7) State radiation guidelines 4) Model statute 8) Applicability to federal agencies c. Physician and support staff exposure 1) Distance (Inverse square law) 2) As Low As Reasonably Achievable (ALARA) 3) 1° beam exposure 4) Scatter radiation (2° exposure) a) From patient b) From lateral filtration areas of x-ray tube (3 meters) 5) Record total fluoroscopic time 6) Record total time of angiographic runs 7) Angulation of imaging views (caudal views) 8) Brachial and radial arterial access cases double the dose to the operators 9) Use lowest frames per sec (15 fps) and acceptable magnification for ventriculography and coronary angiography d. Shielding 1) Wrap-around lead aprons a) Two-piece (blouse and kilt is recommended for ergonomic reasons, e.g. cervical and lower back repetitive injuries). b) Recommend sleeve on left arm area of blouse to protect left humerus area from radiation. 2) Thyroid collars 3) Lead glasses 4) Movable lead barriers a) Tableside, to protect lower extremities b) Ceiling suspended to protect upper torso B. Radiation Safety 1. Methods of measurement a. Film badge b. Thermoluminescent dosimeters (TLD) c. Thermoluminescent dosimeter – ring badges d. Optical stimulated luminescence dosimeters e. Pocket ionization chambers (not commonly used) f. Ionization chamber-type survey meter (“cutie pie”) g. Proportional counters h. Geiger-Müller (G-M) detector (nuclear medicine) 2. Units of measurement a. Exposure (Roentgen, R) b. Absorbed dose (Rad, r) 1 Gray (Gy) = 100 rads c. Dose equivalent (Rem) 1 Sievert (Sv) = 100 Rems d. Effective Dose Equivalent (EDE) 1) Refers to the overall effect to an entire patient as a result of the total dose received and depends on where it was received. 2) Measured in sieverts (Sv) 3) Replaced the concept of MPD in 1977 3. Types of radiation injury a. Nonstochastic deterministic effects (direct-threshold doses) 1) Early effects a) Erythema c) Epilation b) Decreased white cell count 2) Acute radiation syndromes a) Hematopoietic c) Cerebral vascular b) Gastrointestinal 3) Late effects a) Formation of cataracts b) Fibrosis c) Loss of parenchymal cells d) Organ atrophy e) Reduced fertility f) Reproductive sterility b. Stochastic (probabilistic) effects 1) Assumption that no threshold exists 2) Probability of injury is proportional to dose at any level 3) Carcinogenic effects (delayed) a) Breast b) Bone marrow (leukemia) c) Salivary glands d) Skin e) Thyroid f) Lymphatic 4) Mutagenetic effect (reproductive cells before conception) 5) Teratogenetic events (in utero fetal exposure) Those interested in receiving continuing information about this program, please contact: Dr. Jack Chen at chenjackapollo@yahoo.com; Dr. David Allie at david.allie@cardio.com; Phyllis Williams at pcwcen@aol.com; Pattie Freschett at pattie99@yahoo.com; Neil Holtz at emta1497@aol.com; or Chuck Williams at iraa.rpa@gmail.com. Acknowledgements The authors would like to thank Drs. Constantin Cope, Douglas Morris, Jackson Thatcher, Michele Voeltz, and Morton Kern for taking time from their busy daily schedules to proofread and edit the manuscripts that the Writing Committee developed for the Advanced Level Cardiology Specialist Assistant Program. The Committee would like to thank the International Society of Medical Imaging Physician Specialists, Inc., that asked the members of the committee to develop the curricula for this program, of which the intention is to educate and train allied healthcare professionals to function at a level between the Registered Cardiovascular Invasive Specialists (RCISs) certified by Cardiovascular Credentialing International (CCI) and cardiologists, cardiothoracic surgeons, and vascular surgeons who perform percutaneous cardiovascular studies. We would also like to thank Dr. Jane Van Valkenburg, Emeritus Professor-Radiologic Sciences, Weber State University, Ogden, Utah, for her suggestions to the proposed educational curriculum. In addition, the allied health professionals on the committee would like to express our gratitude to Dr. Jack Chen, interventional cardiologist, who provided the leadership to accomplish this task. We graciously thank Mrs. Eileen Koolpe for granting us permission to add her late husband’s name to the list of writers, because Dr. Harvey Koolpe and Charles “Chuck” Williams had initiated the work-in-progress starting in late 2006. Finally, the committee would like to thank Dr. Manuel Viamonte, Jr., for the suggestion to develop an advanced program for men and women who served on cardiac cath lab support staffs so they could perform procedures under the direct supervision and direct assistance of board-certified/eligible cardiologists, cardiothoracic surgeons and vascular surgeons.

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