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, [email protected]
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 [email protected]
Asia Pacific Congress of Hypertension, 2014, February
Cebu city, Phillipines
Seminar on Management of Hypertension,
Gulshan, Dhaka