Right Heart Catheterization

Dr. Md.Toufiqur Rahman

MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI,

FAPSC, FAPSIC, FAHA, FCCP, FRCPG

Associate Professor of CardiologyNational Institute of Cardiovascular Diseases(NICVD),

Sher-e-Bangla Nagar, Dhaka-1207

Consultant, Medinova, Malibagh branch

Honorary Consultant, Apollo Hospitals, Dhaka and

STS Life Care Centre, Dhanmondidrtoufiq19711@yahoo.com

CRT 2014Washington

DC, USA

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OverviewRight Heart Catheterization (RHC)

Indications

Contraindications / Caution

Equipment

Technique

Precautions

Cardiac Cycle

Pressure monitoring

Zeroing and Referencing

Fast flush test/ Square wave test

Pressure wave interpretation

Cardiac output

Derived measurements

History• First Cardiac catheterization –▫ According to Andre Cournand, it was first performed by Claude

Bernard in 1844, in a horse, both rt and lt ventrilces were entered by retrograde approach from the jugular vein and carotid artery

▫ Werner Forssmann is credited with performing the first cardiac catheterization of a living person himself, at the age of 25 yrs

• Forssmann for his contribution and foresight shared the Nobel Prize in Medicine with Andre Cournand and Dickinson Richards in 1956

History

• 1929- Dr. Warner Forssman proven that right heart catheterization is possible in humans

• 1964- Dr. Bradley introduced small diagnostic catheter

• 1970- Balloon Flotation Catheter by Doctor H.J.C Swan and William Ganz

Cardiac catheterization implies the insertionof flexible tube into one or more heartchambers usually under fluoroscopic guidefor diagnostic or therapeutic purpose

Definition

Indication of cardiac catheterization

1. Diagnostic indication

-Collects data to evaluate PT’s condition

2. Therapeutic indication

3. Prognostic indication

1. Diagnostic catheterization is in the routine preoperative evaluation ofmost congenital defects, such as VSDs, ASD, TOF, DORV, CoA and othercomplex CHD.

2. Before interventional catheterizationa. Assessment of patient hemodynamics and anatomyb. to confirm congenital or acquired heart disease in infants and children

3. When the anatomy of a CHD is inadequately defined by noninvasivemeans

4. in very complex lesions specific details about the anatomy orhemodynamics

5. High-flow or low-flow physiology associated with semilunar valvestenosis

a.Combined aortic stenosis (AS) and insufficiencyb.Combined Pulmonary stenosis and insufficiency

6. In cavopulmonary anastomosis and after Fontan completion

Diagnostic catheterization is useful in the evaluation for proceedingwith completion of Fontan, revision of Fontan, or transplantation

Diagnostic indication-

Diagnostic indication-

7. EP study

1. His bundle electrocardiography in 1st degree, 2nd

degree & CHB

2. Endocardial mapping in WPW syndrome

8. Endocardial biopsy

1. DCM

2. HCM

3. Amyloidosis

4. sarcoidosis

Diagnostic indication

Angiocardiography –1. Rt and lt ventriculography –

a) Chamber size

b) Wall thickness

c) Wall motion

d) Aneurysm

e) Volume

f) Dimension

g) Fractional shortening and

h) Ejection fraction

2. Aortography –a) AR

b) AS

c) Co of Aorta

d) PDA

e) Aortic arch syndrome

3. CAG – determine coronary artery anatomy

Diagnostic indication Pressure study –

a) it means measurement of pressure and recording of its wave form.

b) High RV pressure in catheterization found in the following condition –a) VSDb) PSc) PH in MS, COPDd) Ruptured sinus of valsalva into RV

c) Trans-valvular pressure difference can grade the severity of –a) ASb) PSc) MS

d) PCW help to find out LVEDP

Oxymetry –a) Shunt calculationb) To determine Cardiac output

Therapeutic indication1. Closure of the following defects –

1. ASD

2. VSD

3. PDA

4. MAPCA2. PTMC

3. Thrombolytic therapy – intracoronary, systemic

4. PTCA

5. PTA – for peripheral artery stenosis

6. Valvuloplasty – PS, MS, AS

7. Dilatation of coarctation of aorta

Therapeutic indication9. Introduction of ‘’UMBRELLA’’ in to IVC for

recurrent pulmonary emboli from DVT

10. Rushkind procedure in TGA, for balloon rupture of interatrial septum by brockenbergh needle

11. Cardiac pacing

12. Peripheral arterial balloon dilatation

13. Hemodynamic monitoring and treatment of pt with cardiogenic shock by swan gauze catheter

Prognostic indication

1. Post CABG catheter for assessment of –

1. cardiac function and

2. coronary perfusion

2. Post PTCA

3. After thrombolytic therapy

4. After repair of VSD

5. After valve replacement

6. Prior to any cardiac operation to estimate the prognosis of operation

Contraindication of cardiac catheterization

• Absolute contraindication – In expert hand none is contraindicated

1. Patient refusal

2. IE

1. Recent AMI usually within 3 week in case of adult pt

2. Intercurrent febrile illness

2. CCF

3. Severe or malignant hypertension predispose to myocardial ischaemia and/or heart failure during angiography

4. Life threatening arrhythmia, but it is indicated in-

1. While myocardial mapping and subsequent electrotherapy

2. Surgery is contemplated for treatment of arrhythmia

Relative contraindications

5. Severe renal failure

6. Allergy to dye

7. Severe hypokalaemia

8. Anticoagulant state PT > 18 s

9. Moribund pt

10. Primary pulmonary hypertension

11. Presence of LBBB

12. Digitalis toxicity

13. Severe anaemia

14. Severe PS

Relative contraindications

MEDICATIONS USED

Premadication – Inj Pethidine Inj Phenargoan

Saline infusion Heparin -

For Pt flushing all tubing, catheters, sheaths

Lidocaine for tissue numbing Anaesthetic medication for relaxing the pt Water soluble contrast

EQUIPMENT NEEDED Procedure tray should include:

1. sterile –1. gowns and gloves

2. sterile towels and drapes for procedure

3. Sterile gauze

4. scalpel, needles, scissors, hemostats

5. syringes for heparin/saline flush, lidocaine,

and blood oximetry

1. labels with marking pen for any item filled with a solution

2. basin for heparin/saline mixture & waste fluids,

3. skin prep solution

4. connection tubing

EQUIPMENT NEEDED

Anaesthesia machine

Oxygen supply

Suction apparatus

Defibrillator

Temporary pacemaker

Pulse oximeter

NIBP

Equipment to perform cardiac output studies

Activated clotting time (ACT) equipment

30

EQUIPMENT NEEDED

1. Needle

2. Sheath

3. Wires

4. Catheters

5. Fluroscopic machine

6. Power injector

Vascular access

Venous Access Arterial Access

Femoral veinMedian basalic veinSubclavian veinInternal jugular veinUmbilical veinTranshepatic route

Femoral arteryRadial arteryUmbilical arteryCarotid artery

Needles for percutaneous puncture

• Angiographic needle – designed for single wall puncture

– small in diameter,

– thin walled,

– short beveled

– very sharp.

– Hub clear

• True Seldinger needle

• Chiba™ needle percutaneous transhepatic access

Angiographic Needle with Protector, Seldinger Hub, Thin Wall

True Seldinger Needle

Chiba Needle

Needle size chosen:

Age Diameter Length Wire

Infants and small children

21 G 3 cm 0.018

Larger children and young adults

19 G 5 cm 0.025’’

Adult and obese pt 18 G 7 / 8 cm 0.035’’

Technique for vascular access:

The true “Seldinger™ technique” is not used for percutaneous puncture into vessels.

Technique for vascular access:

• Modified Seldinger technique for vascular access with single wall puncture into vessels.

Vascular Sheath

Percutaneous introduction and then the use of an indwelling vascular sheath in vessels is the standard technique for catheterization of pediatric and congenital heart patients.

Ideal sheath should have:1. Dilator

1. long, fine and smoothly tapered tip. 2. inner lumen of the dilator tip should tightly fit over the guide wire 3. tip of the dilator should have a smooth, fine transitional taper onto

the surface of the wire.

2. female Lure™ lock connecting hub at the proximal end 3. back-bleed valve4. Lateral tube / flush port

Vascular Sheath

When introduced from the inguinal area, the sheath should be long enough to extend into the common iliac vein.

In small infants a sheath into the femoral vein should extend proximal to the formation of the inferior vena cava.

Vascular Sheath

Ideal short sheath (7.5 cm long) for venous site – 5 Fr for an infant or child (<15– 20 Kg) and 7 Fr for a larger child or adult

Extra long sheaths (45 to 90 cm ) are used to –1. guide catheters directly and repeatedly to an area

within the heart itself (biopsies, blade catheters), 2. for trans septal procedures, 3. to deliver special devices within the heart or great

vessels (stents, occlusion devices), and 4. for the withdrawal of foreign bodies from the vascular

system.

Swan-Ganz Catheter(Pulmonary

Artery Catheterization)• Swan-Ganz Catheter-

Balloon flotation Pulmonary Artery catheter

• Use for monitoring critically ill patients (mostly in the ICU)

• Catheterization only possible on the right side of the heart

• Catheter is hooked up to a Cardiac Output computer

Chest X-Ray

Usage

• Detection of Heart Failure and Septic Shock

• Measures indirect left ventricular pressure

• Measure Cardiac Output by thermodilution for: Right Atrial and Right Ventricular pacing and right-sided pressures

Indications for Use

Indications• Assess volume status

• Assess RV or LV failure

• Assess Pulmonary Hypertension

• Assess Valvular disease

• Cardiac Surgery

Heart Failure Sensor

• Wireless Radiofrequency; no direct connection to Cardiac Output Computer

• Reduced hospitalization among heart failure patients

• Longer duration of use

• No batteries required

• No wearable parts

Advantages

• Ability to monitor patient’s blood flow through the heart when critically ill

• Detect of the effectiveness of certain medications, Heart Failure, and Shock

Benefits• Effect on Treatment Decisions: information gathered

from PA catheter data can beneficially change therapy

• Preoperative Catheterization: information gathered prior to surgery can lead to cancellation or modification of surgical procedure, thereby preventing morbidity and mortality

• Perioperative Monitoring: provides invasive hemodynamic monitoring in the surgical setting

Disadvantages

• Over usage of the balloon

• If fluid bag is not under pressure, patient can bleed to death

• Ventricular tachycardia can occur if catheter slides back into the Right Ventricle

• Short duration of use

Hemodynamic Parameters

Hemodynamic Parameters - Measured

• Central Venous Pressure (CVP)– recorded from proximal port of PAC in the superior vena cava or right atrium– CVP = RAP– CVP = right ventricular end diastolic pressure (RVEDP) when no obstruction exists between

atrium and ventricle

• Pulmonary Artery Pressure (PAP)– measured at the tip of the PAC with balloon deflated– reflects RV function, pulmonary vascular resistance and LA filling pressures

• Pulmonary Capillary Wedge Pressure (PCWP)– recorded from the tip of the PAC catheter with the balloon inflated– PCWP = LAP = LVEDP (when no obstruction exists between atrium and ventricle)

• Cardiac Output (CO)– Calculated using the thermodilution technique– thermistor at the distal end of PAC records change in temperature of blood flowing in the

pulmonary artery when the blood temperature is reduced by injecting a volume of cold fluid through PAC into the RA

Oxygen Transport Parameters

• Oxygen Delivery (DO2)– Rate of oxygen delivery in arterial blood

DO2 = CI x 13.4 x Hgb x SaO2

• Mixed Venous Oxygen Saturation (SVO2)– Oxygen saturation in pulmonary artery blood– Used to detect impaired tissue oxygenation

• Oxygen uptake (VO2)– Rate of oxygen taken up from the systemic

microcirculationVO2 = CI x 13.4 x Hgb x (SaO2 - SVO2)

ASA Practice Guidelines for Pulmonary Artery Catheterization (2003)

• Appropriateness of PA catheterization depends on the risks associated with the:

– (a) Patient: Are there presexisting medical conditions that may increase the risk of hemodynamic instability?

– (b) Surgery: Is the procedure associated with significant hemodynamic fluctuations which may cause end organ damage?

– (c) Practice setting: Could the complications associated with hemodynamic disturbance be worsened if the technical or cognitive skills of the physicians or nurses caring for the patient are poor?

ASA Practice Guidelines for Pulmonary Artery Catheterization (2003)

• According to the Task Force on Pulmonary Artery Catheterization, PAC monitoring was deemed appropriate and/or necessary in the following patient groups:

– 1) surgical patients undergoing procedures associated with a high risk of complications from hemodynamic changes

– 2) surgical patients with advanced cardiopulmonary disease who would be at increased risk for adverse Perioperative events

Complications

• Establishment of central venous access

– Accidental puncture of adjacent arteries

– Bleeding

– Neuropathy

– Air embolism

– Pneumothorax

Complications• Pulmonary artery catheterization

– Dysrhythmias• Premature ventricular and atrial contractions

• Ventricular tachycardia or fibrillation

– Right Bundle Branch Block (RBBB)• In patients with preexistinh LBBB, can lead to complete

heart block.

– Minor increase in tricuspid regurgitation

Complications

• Pulmonary catheter residence

– Thromboembolism

– Mechanical, catheter knots

– Pulmonary Infarction

– Infection, Endocarditis

– Endocardial damage, cardiac valve injury

– Pulmonary Artery Rupture

• 0.03-0.2% incidence, 41-70% mortality

Thank Youdrtoufiq19711@yahoo.com

Asia Pacific Congress of Hypertension, 2014, February

Cebu city, Phillipines

Seminar on Management of Hypertension,

Gulshan, Dhaka