Cardiac catheterization

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Cardiac catheterization (heart cath) is the insertion of a catheter into a chamber or vessel of the heart. This is done for both investigational and interventional purposes. Coronary catheterization is a subset of this technique, involving the catheterization of the coronary arteries.

A small puncture is made in a vessel in the groin, the inner bend of the elbow, or neck area (the femoral vessels or the carotid/jugular vessels), then a guidewire is inserted into the incision and threaded through the vessel into the area of the heart that requires treatment, visualized by fluoroscopy or echocardiogram, and a catheter is then threaded over the guidewire. If X-ray fluoroscopy is used, a radiocontrast agent will be administered to the patient during the procedure. When the necessary procedures are complete, the catheter is removed. Firm pressure is applied to the site to prevent bleeding. This may be done by hand or with a mechanical device. Other closure techniques include an internal suture. If the femoral artery was used, the patient will probably be asked to lie flat for several hours to prevent bleeding or the development of a hematoma. Cardiac interventions such as the insertion of a stent prolong both the procedure itself as well as the post-catheterization time spent in allowing the wound to clot.

A cardiac catheterization is a general term for a group of procedures that are performed using this method, such as coronary angiography. Once the catheter is in place, it can be used to perform a number of procedures including angioplasty, angiography, and balloon septostomy.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

The history of cardiac catheterization dates back to Claude Bernard (1813-1878), who used it on animal models. Clinical application of cardiac catheterization begins with Werner Forssmann in the 1930s, who inserted a catheter into the vein of his own forearm, guided it fluoroscopically into his right atrium, and took an X-ray picture of it. Forssmann won the Nobel Prize for this achievement. During World War II, André Frédéric Cournand and his colleagues developed techniques for left and right heart catheterization.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Cardiac catheterization is performed to diagnose and assess the severity of aortic, coronary artery, pulmonary arterial, valvular, pericardial and myocardial disease.

• Confirm the presence of a suspected heart ailment
• Quantify the severity of the disease and its effect on the heart
• Seek out the cause of a symptom such as shortness of breath or signs of cardiac insufficiency
• Make a patient assessment prior to heart surgery
• To measure intracardiac and intravascular blood pressures
• To take tissue samples for biopsy
• To inject various agents for measuring blood flow in the heart; also to detect and quantify the presence of an intracardiac shunt
• To inject contrast agents in order to study the shape of the heart vessels and chambers and how they change as the heart beats

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

The ascending aorta is best visualized in the 45 degrees LAO, 0 degrees cranial or causal projection. This view of the aortic root optimizes the evaluation of aortic insufficiency. Placement of the catheter in the ascending aorta prior to the great vessels demonstrates the aortic arch and the origin of the vessels which is useful in planing the approach prior to percutaneous revascularization of these vessels. Dissection of the ascending aorta as well as some visualization of anomalous coronary origins. Some operators prefer to engage saphenous bypass grafts in this projection.

The RAO projection is optimal for left ventriculography (30 degrees RAO and 0 degrees cranial) and visualization of saphenous grafts.

A 4-6 F pigtail catheter is generally used to perform aortography. However, any non-end hole catheter may be used to perform the procedure. End hole catheters may risk aortic dissection or aortic valve damage during power injection. For aortic insufficiency quantification and bypass/anomalous vessel origination, the catheter is placed in the aortic root approximately 2 cm above the aortic valve. To delineate the great vessels, the catheter is placed proximal to the origin of the innominate artery. To optimize the origins of the vessels, the amount of LAO angulation is adjusted to maximize the elongation of the arch and the vessels.

Optimal aortography requires the use of a power injector to adequately opacify and fill the aorta. Adjustable settings on the power injector include pressure and flow rates, volume, rate of pressure rise. Each patient may require slight variation in the settings based on the size of the root and the presence of any aneurysmal dilatation or insufficiency, catheter type and patient size. Generally, 20-25 ml/sec for 40-50 cc will be sufficient to image a normal aorta.

A rate of rise of 0.4 cc/sec should prevent forward lunging of the catheter. The pressure rate setting is typically 600 psi for a 6 F, 900 psi for a 5 F system and 1200 psi for a 4F system. Careful attention is required to remove air from the injector system prior to use to prevent catastrophic air embolism during aortograpahy.

The pigtail catheter is placed a few centimeters above the aortic root. Grading the amount of aortic regurgitation is based on the amount of opacification of the ventricle 2 complete cardiac cycles after injection compared to that of the aortic root.

There is no sign of ventricular opacification during and after contrast injection to aortic root.

Brief and incomplete ventricular opacification. Clears rapidly.

Moderate opacification of the ventricle that clears in less that 2 cycles. Never greater than aortic root opacification. Video below shows grade 2 aortic insufficiency in patient with marfan syndrome.

Opacification of the ventricle equal to aortic root opacification within 2 cycles. Delayed clearing of ventricle over several cycles.

Opacification of the ventricle almost immediately that is greater than that of the aortic root with delayed clearing of the ventricle.

• Braunwald’s Heart Disease, Libby P, 8th ed., 2007, ISBN 978-1-41-604105-4
• Hurst’s the Heart, Fuster V, 12th ed. 2008, ISBN 978-0-07-149928-6
• Willerson JT, Cardiovascular Medicine, 3rd ed., 2007, ISBN 978-1-84628-188-4

• Aortic insufficiency
• Aortic stenosis
• Aorta

• Clinical Trial Results: An up to dated resource of Cardiovascular Research

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: coronary arteriography, cardiac arteriography, cardiac angiogram, coronary angio, coronary artery angio, coronary cath, cardiac cath

• Overview
• Historical perspective
• Contraindications
• Appropriate Use Criteria for Revascularization
• Complications
• Technique
• Film Quality

• Coronary arteries
• Left coronary artery | Left main coronary artery | Left anterior descending artery | Left circumflex artery | Ramus intermedius
• Right coronary artery
• Coronary artery dominance

• Separate ostia
• Anomalous origins of the coronary arteries
• Coronary artery fistula

• Standard angiographic views
• Left coronary artery
• Right coronary artery

• TIMI flow grade (TFG): TIMI flow grade 0 | TIMI flow grade 1 | TIMI flow grade 2 | TIMI flow grade 3
• TIMI frame count (TFC)
• Pulsatile flow
• Deceleration

• TIMI myocardial perfusion grade (TMPG): TIMI myocardial perfusion grade 0 | TIMI myocardial perfusion grade 0.5 | TIMI myocardial perfusion grade 1 | TIMI myocardial perfusion grade 2 | TIMI myocardial perfusion grade 3

• ACC-AHA characteristics of type A, B, and C coronary lesions
• SCAI Lesion Classification System

• TIMI thrombus grade: TIMI thrombus grade 0 | TIMI thrombus grade 1 | TIMI thrombus grade 2 | TIMI thrombus grade 3 | TIMI thrombus grade 4 | TIMI thrombus grade 5 | TIMI thrombus grade 6

• Quantitative angiography
• Definitions of Preprocedural Lesion Morphology
• Irregular lesion
• Disease extent
• Arterial foreshortening
• Infarct related artery (Culprit lesion)
• Restenosis
• Degenerated saphenous vein graft
• Collaterals
• Coronary artery ulceration
• Coronary artery aneurysm
• Coronary artery bifurcation
• Coronary artery trifurcation

• Technique
• Quantification of LV Function
• Quantification of Mitral Regurgitation
• Left Ventricular Ejection Fraction Assessment by Visual Estimation

Left Internal Mammary Artery

Risks stratification and benefits of PCI | Conscious Sedation | Preparation of the Patient for Diagnostic Catheterization | Technical Aspects of the Cardiac Catheterization Laboratory | Obtaining Venous and Arterial Access | Equipment Used in Diagnostic Cardiac Catheterizaiton | Hemodynamic Assessment in the Cardiac Catheterization Laboratory | Radiation Safety

Therapeutic procedures | Advances in catheter based physical treatments

Classification of the Lesion | The Calcified Lesion | The Ostial Lesion | The Angulated or Tortuous Lesion | The Bifurcation Lesion | The Long Lesion | The Bridge Lesion | Vasospasm | The Chronic Total Occlusion | Multivessel Disease | Distal Anastomotic Lesions | Left Main Intervention | The Thrombotic Lesion

Vessel Perforation | Dissection | Distal Embolization | No-reflow | Abrupt Closure | Restenosis | Late Acquired Stent Malapposition | Loss of Side Branch | Multiple Complications | Coronary stent thrombosis | Slow flow | Pulsatile flow | Deceleration | Ectasia | Intimal flap | Staining | Coronary air embolism

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Cardiac catheterization refers to the insertion of hollow tubes (catheters) into various structures of the heart. When catheters are inserted specifically into the left ventricle, the procedure is called left heart catheterization. This procedure is to be distinguished from coronary catheterization in which catheters are inserted specifically into the coronary arteries. Important internal heart and lung blood pressures, not measurable from outside the body, can be accurately measured during the test. Left heart catheterization involves insertion of catheters into the left ventricle to interrogate that filling pressures of the left heart. Left heart catehterization is used to diagnose and assess the severity of aortic stenosis, aortic insufficiency, hypertrophic obstructive cardiomyopathy, mitral stenosis, and mitral insufficiency.

• Aortic stenosis cardiac catheterization
• Aortic regurgitation cardiac catheterization

• Hypertrophic Obstructive Cardiomyopathy

• Mitral stenosis cardiac catheterization
• Mitral regurgitation cardiac catheterization

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

With the advancement of noninvasive imaging methods such as echocardiography, less emphasis has recently been placed on the ventriculogram as part of a cardiac catheterization. However, entry into the left ventricle with hemodynamic measurement and visualization of the left ventricle using contrast ventriculography remains an important aspect of a complete angiographic study.

In patients presenting acutely with ST elevation myocardial infarction, assessment of myocardial and valvular function with ventriculography may provide important prognostic information and may guide in part the management of the patient. In obese patients with difficult echocardiographic windows, ventriculography may provide diagnostic information that cannot be obtained from the echocardiogram.

• Assessment of left ventricular function including left ventricular ejection fraction, wall motion abnormalities, ventricular size and mass
• Identification and assessment of mitral regurgitation
• Identification and assessment of ventricular septal defects

• Decompensated heart failure
• Extreme elevation of LVEDP
• Critical aortic stenosis
• Left ventricular thrombus
• Iodinated contrast allergy

• Ventricular arrythmias
• Embolization of air or thrombus
• Contrast related complications
• Decompensated heart failure
• Myocardial staining

• Crossing the aortic valve in patients without significant aortic stenosis is fairly straight-forward.
• Ventriculography is best performed with an angled pigtail catheter which avoids some of the pitfalls such as myocardial staining and catheter movement which can occur with an end hole catheter.
• The angled pigtail catheter does not allow the measurement of precise pressure gradients (part of the catheter may lie proximal and the other part distal to the stenosis or obstruction).
• The aortic valve may be difficult to cross with an angled pigtail catheter in patients with aortic stenosis.

• To cross the valve in patients without stenosis, the 0.35 wire is left in the catheter slightly back from the tip and the pigtail catheter is placed above the valve forming a ‘6’ above the valve and advanced until it prolapses above the valve. Once a loop is formed above the valve with the prolapsed catheter, it is pulled back and rotated slightly clockwise. As the catheter falls into the aortic root it is advanced. This maneuver will usually facilitate entry into the left ventricle. Sometimes, the body of the catheter will prolapse across the valve. If this happens, advancement of the 0.35 wire will usually prolapse the catheter into the ventricle. Having the patient take a breath advancement of the pigtail into the ventricle during systole will sometimes facilitate ventricular entry.

• In patients with aortic stenosis crossing the aortic valve may be more difficult due to the profile of the pigtail. Also, the 0.035 J-tipped wire often will not engage the stenosed orifice.
• In cases of suspected severe stenosis, crossing the aortic valve is best accomplished using a catheter able to be directed toward the ostium such as an Amplatz Left-1 or an Amplatz Right-2. In this situation the catheter is advances into the aortic root and an 0.035 or 0.038 wire with either a tight curve or straight wire is advanced through the aortic orifice.
• Setting up to cross the valve is almost as important as crossing the valve itself. Before attempting to cross with this system, cinematography of the calcified valve in both the RAO and LAO tomographic projections will often give the operator clues in the direction and angulation of the orifice.
• Once proceeding, the catheter is placed in the root and the wire is advanced forward. As the catheter rotates through the orifice the wire will prolapse in one of the cusp. Quarter turns of the catheter and close attention to the direction of the wire will often allow the wire to cross the valve. Once the valve is crossed, the catheter is advanced into the ventricle and hemodynamic measurements can be made.
• Crossing a stenosed aortic valve carries risk of embolization from both the valve and also from thrombus organization on the wire while attempts are made. Due to this fact, crossing the valve should be reserved for cases where noninvasive imaging of the valve has provided inconclusive results. Also, the patient should be administered heparin (5000 U) and attempts to cross the valve should be limited to 3 minutes before flushing the catheter.

• Unfortunately, unless biplane angiography is available, ventriculography only provides a 2-dimensional projection of the ventricle and each image will not include all of the left ventricular segments.
• The 2 standard views for ventriculography are the RAO (30o) which demonstrates the Anterior, Apical and Inferior ventricular walls.
• A LAO 60o LAO 20o Cranial view allows for better imaging of the lateral and septal ventricular walls.
• The latter views are particular useful in patients with lateral ischemia (especially circumflex ischemia), suspected VSD and mitral regurgitation.
• Once advanced into the left ventricle, the pigtail should be located in the mid ventricular cavity.
• Too superior or apical positioning of the catheter may lead to excessive ectopy. Ectopy may interfere with interpretation of wall motion abnormalities.
• Too inferior of a position may interfere with the mitral apparatus leading to an overestimation of mitral regurgitation.
• Difficult manipulation or visual tanglement of the catheter may indicate involvement with the apparatus.
• Reposition of the catheter usually requires countering and pulling the catheter then advancing once the tip is free. A test injection of 5 cc of contrast medium may help to confirm correct positioning of the catheter and prevent wasted contrast from a poor ventriculogram.
• All hemodynamic measurements should be performed prior to ventriculography.
• Also, ventriculography should be avoided in patients with decompensated heart failure, severe aortic stenosis and ventricular thrombus. * If digital subtraction is available, a hand injection may be attempted with the patient holding their breath. This should only be used as a quick estimation as important pathology such as a VSD may be missed due to incomplete opacification with this method.

• Optimal ventriculography is performed using a power injector to fill the left ventricular cavity.
• Adjustable settings on the power injector include pressure and flow rates, volume, rate of pressure rise.
• Each patient will have slight variation in settings based on ventricular size, sex, and catheter type and size.
• Generally, 10-15 ml/sec for 30-40 cc will be sufficient to image a normal ventricle and heart rate.
• A rate of rise of 0.4 cc/sec in order to prevent lunging of the catheter leading to increased ectopy.
• The pressure rate settings is typically 600 psi for a 6 Fr, 900 psi for a 5 Fr system and 1200 psi for a 4Fr system.
• Careful attention is required to remove air from the injector system prior to use to prevent catastrophic embolism during ventriculography.

The operator should keep the left hand on the catheter during injection to change the position as required during the procedure. If the catheter is too far in the apex, pullback of 1-2 cm will usually reposition the catheter for several beats to obtain useful information.

• Depending on the tomographic projection, specific ventricular wall motion abnormalities may be identified.
• Hypokinesia refers to decreased but not absent motion of a ventricular segment.
• Akinesia refers to a complete absence of wall motion.
• Dyskinesia refers to a paradoxical expansion or wall motion usually due to tethering from the adjacent segments.
• The ejection fraction by ventriculography will usually be slightly higher than the corresponding echocardiographic measurments.

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Both the RAO and LAO/Cranial projections can be used to identify significant mitral regurgitation. Grading the amount of regurgitation is based on the amount of opacification of the atrium compared to the ventricular opacification, atrial size and the number of cycles required for maximal opacification. Elevation of left atrial pressure in acute regurgitation and dilation of the left atrium from chronic regurgitation can both interfere with the use of this grading system.

Brief and incomplete atrial opacification over several cycles. Clears rapidly. No atrial enlargement.

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Moderate opacification of the atria with each cycle. Never greater than LV opacification. No significant LA enlargement.

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opacification equal to ventricular opacification. Delayed clearing of atria over several cycles. Significant enlargement of the LA.

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Atrial Opacification immediate and greater than that of the ventricle. Severe enlagement of the LA. Opacification of the pulmonary veins.

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mahmoud Sakr, M.D. [2]

Synonyms and keywords: Pulmonary artery catheterization, wedge, PA line, Swan Ganz catheterization, right heart cath

Pulmonary artery catheterization is the insertion of a catheter into a pulmonary artery. Its purpose is diagnostic; it is used to detect heart failure or sepsis, monitor therapy, and evaluate the effects of drugs. The pulmonary artery catheter allows direct, simultaneous measurement of pressures in the right atrium, right ventricle, pulmonary artery, and the filling pressure (“wedge” pressure) of the left atrium.

The pulmonary artery catheter is frequently referred to as a Swan-Ganz catheter, in honor of its inventors Jeremy Swan and William Ganz, from Cedars-Sinai Medical Center. The idea for this catheter (as later revealed by Dr. Swan) came about from the observation of sailboats on the water.

• Management of complicated myocardial infarction:
  • To differentiate hypovolemia vs cardiogenic shock
  • To differentiate ventricular septal defect (VSD) vs acute mitral regurgitation
  • To tailor therapy in severe left ventricular failure
  • To manage volume administration in right ventricular infarction

• Assessment of respiratory distress
  • To differentiate cardiogenic vs non-cardiogenic pulmonary edema
  • To differentiate primary vs secondary pulmonary hypertension

• Assessment of type of shock

• Assessment of response to therapy
  • Afterload reduction
  • Vasopressors
  • Beta blockers
  • Intra-aortic balloon counterpulsation

• Assessment of fluid requirement in critically ill patients with:
  • Hemorrhage
  • Sepsis
  • Acute renal failure
  • Burns

• Management of postoperative open heart surgical patients

• Assessment of valvular heart disease

• Assessment of cardiac tamponade / constriction^[1]

• Indicated in patients with cardiogenic shock during supportive therapy

• Indicated in patients with discordant right and left ventricular failure

• Indicated in patients with severe chronic heart failure requiring inotropic, vasopressor, and vasodilator therapy

• Indicated in patients with suspected “pseudosepsis” (high cardiac output, low systemic vascular resistance, elevated right atrial and pulmonary capillary wedge pressures)

• Indicated in some patients with potentially reversible systolic heart failure such as fulminant myocarditis and peripartum cardiomyopathy

• Indicated for the hemodynamic differential diagnosis of pulmonary hypertension

• Indicated to assess response to therapy in patients with precapillary and mixed types of pulmonary hypertension

• Indicated for the transplantation workup

• The catheter is introduced through a large vein—often the internal jugular, subclavian, or femoral veins. From this entry site, it is threaded, often with the aid of fluoroscopy, through the right atrium of the heart, the right ventricle, and subsequently into the pulmonary artery.

• The standard pulmonary artery catheter is equipped with an inflatable balloon at the tip, which facilitates its placement into the pulmonary artery through the flow of blood. The balloon, when inflated, causes the catheter to “wedge” in a small pulmonary blood vessel. So wedged, the catheter can provide a measurement of the pressure in the left atrium of the heart.

• Arrhythmias
• Bleeding
• Infection
• Pneumothorax
• Rupture of the pulmonary artery
• Thrombosis

The benefit of the use of this type of catheter has been controversial. Therefore many clinicians minimize its use. Several studies in the 1980s seemed to show a benefit of the increase in physiological information. Many reports showing benefit of the PA catheter are from anesthestic and surgical settings. In these settings cardiovascular performance was optimized thinking patients would have supranormal metabolic requirements.

Contrary to earlier studies there is growing evidence the use of a PA catheter (PAC) does not necessarily lead to improved outcome. For example, see [3]. The following explanations have been advanced. One explanation could be that nurses and physicians were insufficiently knowledgeable to adequately interpret the PA catheter measurements. Also, the benefits might be reduced by the complications from the use of the PAC. Furthermore, using information from the PAC might result in a more aggressive therapy causing the detrimental effect. Or, it could give rise to more harmful therapies (i.e. achieving supranormal values could be associated with increased mortality).^[4]

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

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http://www.youtube.com/watch?v=Nf7vsj0H2Mw

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