right heart catheterization

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Right Heart Catheterization. Sripal Bangalore, M.D., M.H.A. and Deepak L. Bhatt, M.D., M.P.H., F.A.H.A. Overview. Right Heart Catheterization (RHC) Indications Contraindications / Caution Equipment Technique Precautions Cardiac Cycle Pressure monitoring Zeroing and Referencing - PowerPoint PPT Presentation

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  • Right Heart Catheterization

    Sripal Bangalore, M.D., M.H.A.and Deepak L. Bhatt, M.D., M.P.H., F.A.H.A

  • OverviewRight Heart Catheterization (RHC)IndicationsContraindications / CautionEquipmentTechniquePrecautionsCardiac CyclePressure monitoringZeroing and ReferencingFast flush test/ Square wave testPressure wave interpretationCardiac outputDerived measurements

  • No universally accepted indication as right heart (pulmonary artery, PA) catheterization has not been shown to improve outcomes1However it is useful in the following diagnostic and therapeutic applicationsDiagnosticDifferentiation of various etiologies of shock and pulmonary edemaEvaluation of pulmonary hypertensionDifferentiation of pericardial tamponade from constrictive pericarditis and restrictive cardiomyopathyDiagnosis of left to right intracardiac shuntsTherapeuticGuide to fluid management and hemodynamic monitoring of patients after surgery, complicated myocardial infarction, patients in shock, heart failure, etc.

    Indications1Sandham JD et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003;348(1):5-14

  • No absolute contraindications for use of PA catheter. Extreme care needed particularly in patients with severe pulmonary hypertension and in the elderlyFluoroscopic guidance recommended in patients with pre-existing left bundle branch block (risk of complete heart block if right bundle damaged during catheter insertion)

    Contraindications / Caution

  • Equipment

    2% chlorhexidine skin prepSterile gown, gloves, hat and maskSterile drape2% lidocaine solution for local anesthesiaMicropuncture needle and sheath (optional)Sterile ultrasound probe cover and gelIntroducer sheath and needlePulmonary artery (Swan-Ganz) catheterSterile flushPressure tubing, transducer and monitor

  • EquipmentPulmonary Artery (Swan-Ganz) CatheterThese are 7F to 7.5F system catheters and are available as femoral vein insertion to continuous cardiac output catheters

    Balloon inflation valveProximal injectate lumen hubVIP lumen hubDistal PA lumen hubBalloon inflation syringeThermistor connectorReproduced with permission from Edward Lifesciences, Irvine, California

  • Technique- MicropunctureInsertion site: Internal jugular vein, subclavian vein, antecubital vein, or femoral veinAfter the site is prepped and draped, local anesthesia is administered at the site by giving 5 to 10 cc (depending on the site) of 2% lidocaine using a 25G needleVein entered using a needle (preferably micropuncture) and preferably under ultrasound guidance (especially for internal jugular vein)After ensuring that the needle is indeed in a vein (dark, non-pulsatile flow or checking pressure or oxygen saturation), the guidewire is introduced into the micropuncture needle and the needle exchanged for a micropuncture sheathIf there is difficulty in wiring and the micropuncture wire needs to be removed, remove both the needle and the wire as a unitAttempting to remove just the guidewire can result in the guidewire tip shearing off the needle tip with subsequent guidewire embolizationExchange the micropuncture catheter for the introducer sheath

  • TechniquePreparing the catheterUnder sterile conditions, remove the pulmonary artery catheter from the packagingFlush the proximal and distal ports with saline to ensure an air free system and place stopcocks on the endsFill the balloon inflation syringe with 1.5 cc of air and inflate the balloon under saline to ensure no air leaks in the balloonPrepare the pressure monitoring system for use according to institutional practice, ensuring an air free system

  • TechniqueInserting the catheterThe pulmonary artery (PA) catheter can be inserted either under fluoroscopic guidance (preferred) or under the guidance of the pressure wave formsFluoroscopic guidance is recommended in patients with markedly enlarged RA or RV, severe tricuspid regurgitation, or in those with left bundle branch blockA PA catheter with the balloon inflated is designed to be flow-directed and will follow the direction of blood flow (right atrium to pulmonary arteries)The catheter should be advanced to the vena cava/RA junction, the approximate distance (as measured on the PA catheter) from the site insertion is belowRA = right atrium

    Site of InsertionDistal to the Vena Cava/RA junction (cm)Internal jugular vein15 to 20Subclavian vein10 to 15 Antecubital vein (Right)35 to 40Antecubital vein (Left)45 to 50Femoral vein25 to 30

  • TechniqueInserting the catheterOnce the catheter tip reaches the junction of the vena cava and right atrium, the balloon is inflated with 1.5 cc of air and the pressure waveforms notedThe following sequential waveforms will be noted as the catheter passes through the cardiac chambersRight atrial (RA) waveform

    Right ventricular (RV) waveform

    acvxyacvxyacvxy

  • TechniqueInserting the catheterPulmonary artery (PA) pressure waveform

    Pulmonary capillary wedge pressure (PCWP) waveformSimilar to RA pressure waveform except slightly higher

    Normal insertion tracing will therefore appear as belowFor RV to PA - observe changes in diastolic pressure (increase) as the systolic pressure stays the same

    acvxy

  • TechniqueInserting the catheterOnce a PCWP tracing is seen, deflate the balloonThe catheter should be withdrawn 1-2 cm to remove any redundant length or loop in the RA or RV. Keep the tip in a position where full or near full inflation volume is necessary to produce a wedge tracingThe balloon should be deflated and the pressure wave form seen should now be that of the PA. If still the PCWP, it is likely that the catheter is distal and should be retracted until a PA pressure tracing is seenThe ideal position of the catheter is the zone 3 region of the lung (lower zone)For subsequent wedge tracings, the balloon should be inflated with the minimum amount of air to produce a wedge tracing. Excess can cause overwedging where the PCWP will be higher due to transmittal of pressure from the balloon and with loss of characteristic waveforms

    Removing the catheterThe catheter should always be removed with the balloon deflated to avoid damaging the valves

  • TechniquePrecautionAlways advance the catheter with the balloon inflated (catheter is flow-directed, also reduces ventricular irritability and ectopy)Never leave the catheter wedged in the PA for longer than necessary, to avoid the risk of pulmonary artery rupture/pulmonary infarctionDo not overinflate the balloonIf wedge is obtained at volumes
  • 01002003004005006007008000306090120Atrial SystoleVentricular Systole

    Ventricular Diastole

    EKGTime (msec) Pressure (mm Hg)PQRS ComplexTPAortaDicrotic NotchLeft Ventricular PressureacvxyLeft Atrial Pressure

    Cardiac CycleLeft Sided Pressures

  • 010020030040050060070080001530Atrial SystoleVentricular Systole

    Ventricular Diastole

    EKGTime (msec) Pressure (mm Hg)PQRS ComplexTPPA PressureDicrotic NotchRight Ventricular PressureacvxyRight Atrial Pressure

    Cardiac CycleRight Sided Pressures

  • Pressure RecordingsAlways record pressure at end expiration (except in patients on PEEP)Under normal conditions, pressures will be lower in inspiration due to decrease in intrathoracic pressureBefore any pressure measurements are taken, it is imperative to perform zeroing and referencing of the systemZeroing- accomplished by opening the system to air so as to equilibrate with atmospheric pressure Referencing- accomplished by ensuring that the air-fluid interface of the transducer is at the level of the patient heart (phlebostatic axis) (4th intercostal space midway between anterior and posterior chest wall)For every inch the heart is offset from the reference point of the transducer, a 2mm Hg of error will be introduced. If the heart is lower than the transducer, the pressure will be erroneously low and if the heart is higher, the pressure will be erroneously high.Fast flush test/ Square wave testingThe dynamic response of the pressure monitoring system is determined by measuring the resonant frequency and the damping coefficient of the system using the fast flush test

  • Pressure RecordingsPerformed by briefly opening and closing the valve in the continuous flush deviceThis produces a square ware pattern on the oscilloscope, an initial steep rise followed by a plateau, followed by steep fall below baseline which is then followed by oscillations. The pattern determines optimal versus suboptimal dampingOptimal damping- usually 1.5 to 2 oscillations before returning to baseline. This is ideal Over damping- None to 2 oscillations before returning to baseline. Common cause - excessive tube length, multiple stopcocks in the circuit, etc. Overestimated systolic pressure and underestimated diastolic pressureOptimal DampingOver DampingUnder DampingFast flush test / Square wave testing

  • Pressure RecordingsAlways record pressure at end expiration (except in patients on PEEP)Under normal conditions, pressures will be lower in inspiration due to decrease in intrathoracic pressurePCWP reflects left atrial pressure and hence the left ventricular end diastolic pressure as long as ventricular compliance is normal or unchangingPCWP > LVEDP: Mitral valve stenosis or regurgitation, left atrial myxoma, pulmonary vascular disease/embolism, increased pulmonary vascular resistance, cor pulmonalePCWP < LVEDP: Early stages of diastolic dysfunction, aortic regurgitation, decreased ventricular compliance due to myocardial ischemia/infarction, positive pressure ventilation, etc.PCWP = Pulmonary Capillary Wedge Pressure

    SiteNormal Values (mm Hg)Mean Pressure (mm Hg)Right Atrium0-84Right Ventricle15-25/0-8 5-12Pulmonary Artery15-25/8-1210-20PCWP

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