Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Left and Right Heart Catheterization


Right and left heart catheterization is the introduction of a catheter into the right heart and left heart chambers, respectively. Right and left heart catheterization provide key hemodynamic data that can be used to diagnose various cardiac disorders. Left heart catheterization also allows for the performance of left ventriculography to assess left ventricular (LV) systolic function and valvular function. This chapter focuses on the procedural techniques, data interpretation, and clinical applications of right and left heart catheterization.

Right Heart Catheterization

Right heart catheterization generally involves the introduction of a balloon-tipped catheter into the right atrium (RA), right ventricle (RV), and pulmonary artery (PA). The use of an inflatable balloon on the tip enables rapid and safe passage of the catheter through the venous system and right heart chambers; this technique was developed in the 1970s by Dr. Harold Swan, Dr. William Ganz, and colleagues. A PA catheter has a port at the distal tip, a port that is approximately 30 cm proximal from the distal tip, an inflatable balloon at the distal tip, and a thermistor near the distal tip. The distal and proximal ports can be used to transduce pressure, or serve as access for fluids and medications. The balloon can be inflated to temporarily occlude the PA, which allows the distal port to transduce a “wedge” pressure. The thermistor can be used to measure the temperature change of fluid injected into the proximal port; this measurement is used in the calculation of cardiac output.

A comprehensive preprocedural evaluation that includes history, physical examination, routine laboratory data, a 12-lead ECG, and a transthoracic echocardiogram can help guide appropriate patient selection, procedural planning, and data interpretation.

Indications

The American College of Cardiology, the American Heart Association, the American College of Chest Physicians, the American Thoracic Society, the Society of Critical Care Medicine, and the American Society of Anesthesiologists have published guidelines and consensus statements on the indications for right heart catheterization. Box 13.1 lists the common indications for right heart catheterization. Although right heart catheterization is indicated for the diagnostic evaluation of many disease processes, there is much debate on the routine use of PA catheters to guide clinical management of critically ill patients. Several randomized trials have investigated the efficacy and safety of ongoing PA catheter-based clinical management in patients with heart failure, patients who have undergone high-risk noncardiac surgery, and patients with acute respiratory distress syndrome. These studies demonstrated that there is no improvement in survival, and that there is an increased risk of complications in patients randomized to PA catheter-based management. However, these studies have been criticized for their study design, improper patient selection, and variably experienced physicians who performed the catheter placement and data interpretation. As a result, there is no clear consensus on whether PA catheters are beneficial or harmful for guiding clinical management over time.

Box 13.1
Common Indications for Right Heart Catheterization

  • Determination of the cause of shock (vasodilatory vs. cardiogenic vs. hypovolemic)

  • Management of cardiogenic shock following acute MI

  • Diagnosis of RV ischemia during MI

  • Diagnosis and management of mechanical complications after acute MI

  • Diagnosis and localization of intracardiac shunts

  • Diagnosis and prognostic information in patients with valvular heart disease

  • Determination of the cause of pulmonary edema (cardiogenic vs. noncardiogenic)

  • Diagnosis and treatment of congestive heart failure

  • Diagnosis of restrictive cardiomyopathy

  • Diagnosis of constrictive pericarditis

  • Determination of the hemodynamic significance of a pericardial effusion

  • Diagnosis of pulmonary hypertension

  • Determination of reversibility of pulmonary hypertension by vasodilator challenge

  • Evaluation for heart, lung, or liver transplantation (because irreversible pulmonary hypertension provides information on potential benefit and risk of transplantation)

  • Hemodynamic monitoring in certain high-risk patients undergoing peripheral vascular, aortic, or cardiac surgery

  • Quantification of LV preload

LV , Left ventricular; MI , myocardial infarction; RV , right ventricular.

Contraindications

There are several absolute contraindications to right heart catheterization. First, lack of informed consent. Patients with a terminal illness in whom an invasive hemodynamic evaluation will not affect treatment or prognosis should not undergo right heart catheterization. Patients with a mechanical prosthetic tricuspid or pulmonic valve are at risk for catheter entrapment within the valve apparatus, and should not undergo right heart catheterization. Finally, patients with right-sided endocarditis, thrombus, or intracardiac tumor should not undergo right heart catheterization. Relative contraindications to right heart catheterization include active infection, active bleeding, severe thrombocytopenia, severe coagulopathy, and underlying left bundle branch block (which increases the risk of complete heart block if the PA catheter causes a right bundle branch block).

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts