left heart catheterization

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1. Dr. Nagula Praveen, Final yr PG 2. Introduction Indications Contraindications Preparation of patient Access techniques Catheters Angiographic Views Pressure wave forms Interpretation Complications Case profile examples 3. Cardiac catheterization the insertion and passage of small plastic catheters into arteries,veins,the heart,and other vascular structures. Standard medical procedure guides treatment decision, we can measure intracardiac pressures, cardiac output, oximetry data, have radiographic images of coronaries, aorta and peripheral vessels for anomalies, obstruction. Presently more of therapuetic concern eg; angioplasty, stenting and closure of ASD,VSD. 4. Usually an elective procedure. Diagnostic discreprancy between the symptoms and clinical features of patient. Valve area, cardiac output and resistance. Quantification of shunts Pressure gradients Therapeutic useful for assessing the pressure gradients before and after Mitral Stenosis PBMV Aortic Stenosis PBAV PDA device closure HOCM alcohol septal ablation. Cooarctation of Aorta Aorto Pulmonary Window closure 5. Absolute patient not prepared either psychologically or physically. Relative Fever Anemia Electrolyte abnormalities (Hypokalemia) Systemic illness Anticoagulation (INR >1.6) Using medications (digitalis,phenothiazines) Renal failure Uncontrolled CHF Pregnancy 6. Informed consent simple terms, steps of procedure, complications (usually taken by operator). All peripheral pulses to be felt. For diabetic patients dose of NPH insulin should be cut by 50% (overnight fast with normal dosing of insulin hypoglycemia). To stop metformin 48 hrs before procedure lactic acidosis.(no evidence for clinical benefit). Adequate hydration. (urine output > 50ml/h) Anxiolytic Shaving of the both forearms and inguinal regions. IE prophylaxis if valvular heart disease. 7. Femoral artery/vein Modified Seldinger technique. Fluoroscopy guidance medial edge of the middle of the head of the femur. 30 angle to the vessel. A syringe may be attached to seldinger needle and gently aspirated while advancing-in case of femoral vein access. 8. Angiographic catheters Pigtail catheter 1.Quanticor - cardiomarker pigtail radioopaque markers set 2cm apart. Exact LV distances, volumes and stroke volume can be calculated using these markers as a ruler. 2.Angiographic Pigtail - MC used 3.Van Tassel angled pigtail 145-155 angle ,dilated aorta. 4.Groll man Pigtail curve generally on reverse side RV selective angiography,PA angiography. 5.Elliptical or Oval - small aortic valves 6.Tennis Racquet reduced risk of vessel wall extravasation 9. Woven dacron catheter with polyurethane coating. Tapered tip. Three pairs of laterally opposed oval side holes within 1.5 cm of its open tip. Right and left angiography studies. Disadvantages Straight tip more arrhythmogenic. Catheter recoil during high flow rates. Risk of intramyocardial injection. 10. NIH catheter. no end hole, six sideholes. Multitrack catheter. end hole and side hole catheter. useful to record pressure while wire inside pull back gradient across valvular stenosis. Angiography while wire inside. 11. Retrograde Techniques The Judkins technique - Femoral artery. Percutaneous Radial technique. Percutaneous Brachial artery technique Sones Technique. Antegrade technique Transeptal Catheterization. Apical Approach Direct Transthoracic Left ventricular puncture. 12. Relatively easy, speed, reliability,low complication rate. MC method for left heart catheterization. 1% xylocaine infiltrated at the puncture site. Artery to be punctured 3cms below the inguinal ligament, not the inguinal crease. Modified Seldinger technique is used(double wall puncture leads to hematoma). 18 G thin walled needle is used. 0.035-0.038 J tip PTFE coated guidewire is advanced through the needle.(hot knife passing through the butter). A sheath atleast equal size of the catheter to be passed over the guide wire after small nick by scalpel. Heparin - 2000 to 3000 units. 13. LV systolic and end diastolic pressures can be recorded by advancing a pigtail into the LV. For assessing AS, LV and Aortic pressure should be recorded simultaneously with two transducers. Femoral artery pressure not to be taken attenuation in pressure can occur in older patients,with PAD. Pigtails with both distal and proximal lumen to be used. LV Aangiography - pigtail is used to assess LV function. Intraventricular gradients multipurpose catheter to be used. 14. PBMV,Access to pulmonary veins. Complication rate Aortic root concentration, often marked LV enlargement. 23. Pressure measurements Measurement of flow (eg: cardiac output,shunt flow,flow across a stenotic orifice,regurgitant flow,and coronary blood flow) Determination of vascular resistance. 24. Normal left atrial pressure is higher than the right atrium.(high pressure system of the left side of the heart). The v wave is generally higher than the a wave. Left atrium is constrained posteriorly by the pulmonary veins whereas the right atrium can easily decompress through the SVC and IVC. Height of the left atrial v wave most accurately reflects the left atrial compliance. 25. Similar to left atrial pressure Slightly damped and delayed (transmission through the lungs). c waves may not be seen. PADP = mean PCWP - as pulmonary circulation has low resistance. PCWP may overestimate true left atrial pressure - High PVR Hypoxemia Pulmonary embolism Chronic pulmoanry hypertension After mitral valve surgery(accurate gradients across MV LA pressure needed) 26. RV and LV pressure waveforms are similar in morphology,differ with repsect to magnitudes. Early rapid filling wave Slow filling phase Atrial systole. LV RV ISVC Longer Shorter ISVR Longer shorter DURATION OF SYSTOLE longer shorter EJECTION PERIOD shorter longer 27. End diastolic pressure is generally measured at the C point rise in ventricular pressure at the onset of isovolumic contraction. When the C point is not well seen, a line drawn from the R wave on the simultaneous ECG to the ventricular pressure waveform is used as enddiastolic pressure. 28. Systolic wave The incisura (indicating the closure of the semilunar valves) Gradual decline in pressure until the following systole. Pulse pressure reflects stroke volume and compliance of the arterial system. Mean aortic pressure peripheral resistance(accurately). 29. Systolic wave increases in amplitude becomes more triangular. Diastolic wave decreases(until the midthoracic aorta),and then increases. Mean aortic pressure similar. Mean peripheral arterial pressure is typically lower than mean central aortic pressure by 5 mm Hg or less. 30. Difference between the central aorta and the periphery(femoral,brachial,or radial arteries) is greatest in younger patients increased vascular compliance. Imp. in patients with stenotic lesions. When a transvalvualr gradient is present, the most accurate measure of aortic pressure is obtained at the level of the coronary arteries(to avoid the pressure recovery). 31. SV is the quantity of blood ejected with each beat. EDV is the maximum volume in LV and occurs before the onset of systole. It occurs directly after atrial contraction in patients with sinus rhythm. ESV minimum volume of LV during cardiac cycle. Angiographic cardiac output can be estimated by LVED and LVES tracings. Inaccuracies in calibrating angiographic volumes. Cannot be used in AF, regurgitant lesions. 32. Across the valve Mitral valve,Aortic valve Peripherally Coarctation of aorta Intraventricularly Assessing the severity of stenosis,valve area,resistance Cardiac output 33. Simultaneous LV,LA pressure tracings. Check zero pressures of the PCWP,FA,LV after catheters and sheath have been flushed. LV pressure tracing 200mmHg scale at 50 mm/sec paper speed. PCWP pressure tracing 40 mm Hg scales at 50mm/sec paper speed. Use 100mm/sec speed if a mitral valve gradient is present. 34. Advance a pigtail into the LV. Check the zero pressures of both sheath and pigtail catheter after flushing. Record LV and FA pressure (25mm/sec speed,200mmHg scale) 100mm/sec speed if an aortic valve gradient is present. 35. Access site complications. Contrast induced reactions. Procedure related complications. 36. Left heart catherization has a significant role in quantifying the pressure gradients across the valve and within the left ventricle. Mostly being used presently during therapeutic indications rather than diagnostic indications. Optimal pressure tracings with all necessary precuations and knowing the limitations of each helps in judging the severity of the clinical condition to the nearest accuracy..

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