This document provides an overview of cardiac catheterization procedures. It discusses how cardiac catheterization can be used to measure intracardiac pressures, oxygen saturation, and cardiac output. It also describes how it is used for angiography, angioplasty, valvuloplasty, and cardiac biopsy. Key indications for cardiac catheterization include valve disease, heart muscle disease, heart failure, congenital heart disease, and suspected cardiomyopathy. The document outlines techniques for measuring pressures in the heart chambers and great vessels, as well as complications. It also discusses coronary angiography and digital subtraction angiography.

1. CARDIAC
CATHETERIZATION
T SUNIL KUMAR

2. Introduction
It is an invasive procedure which can be
performed for:
Measurement of – (i) Intracardiac
pressures. (ii) Intracardiac oxygen
saturation. (iii) Cardiac output.
As part of: (i) Angiography. (ii)
Angioplasty. (iii) Valvuloplasty. (iv)
Cardiac biopsy

3. INDICATIONS
Valve disease: Severity of AS or PS.
Heart muscle disease–Both hypertrophic
and dilated cardiomyopathy can be
diagnosed by echo, and cardiac
catheterization can be only of benefit for the
information provided by coronary
angiography, or when cardiac biopsy is
indicated.
Heart failure – Right heart catheterization is
very useful for monitoring response to
treatment in acute heart failure.

4. Measurement of cardiac output is of little
value clinically but essential for
measurement of pulmonary or systemic
vascular resistance in management of
shock or as part of the work-up for cardiac
transplantation.
Congenital disease – Catheterization is
usually reserved for complex cases. A
balloon catheter can be used to create an
atrial septal defect in transposition of great
vessels in which intracardiac shunt can
preserve life.
Cardiac biopsy – in patient with suspected
cardiomyopathy.

5. Intracardiac Pressures
Pressures within the cardiovascular
system rise and fall. The changes are
converted into wave forms either by
moving a recording paper under a stylus
or by sweeping a spot across an
oscilloscope.

6. Normal range of pressure within
heart and great vessels

7. Techniques –
(a) Pressure in right chambers of heart
and pulmonary artery are obtained by
advancing a catheter through a vein
(antecubital or femoral). This can be
performed under fluoroscopic control or a
catheter with an inflatable balloon near its
tip can be carried by blood flow through
the right chambers of the heart (Swan-
Ganz technique) and the position of the
catheter identified from the pressure wave
form.

8. (b) Pressures in aorta and LV are measured
by passing a catheter against the blood flow
through femoral or brachial artery.
(c) Pulmonary capillary wedge (PCW)
pressure – If an end hole catheter passed
through a vein is wedged into a small
pulmonary artery, or if a balloon catheter is
‘floated’ as far as possible, and the balloon
inflated, the PA pressure will no longer be
recorded and the pressure measured will be
that of the pulmonary vein and left atrium.
This is the ‘indirect left atrial’ or ‘pulmonary
wedge pressure’.

9. Complications
Damage to arteries and veins with
possible thromboembolism.
Production of arrhythmia.
Introduction of infection.

10. Coronary Angiography
(CAG)
Coronary angiography is visualization by
X-ray of contrast material injected into
arteries, veins or heart chambers to
define anatomy, disease or direction of
blood flow.
Basically, there are 3 types of
angiography currently available

11. 1. Conventional film-screen angiography.
2. Intravenous digital subtraction angiography.
3. Intra-arterial digital subtraction angiography

12. Coronary cine-angiography – is
performed by arterial catheterization
under local anaesthesia, usually by
percutaneous puncture of femoral or
radial artery.
A catheter is introduced and guided
under radiological control to the left
ventricle and left and right coronary
arteries in turn.
Contrast medium is injected while video
and cine images of the recordings are
made

13. Percutaneous Coronary
Angioscopy
Conventional angiography though able
to diagnose presence of intra-coronary
stenosis, cannot provide information
regarding the lesion morphology and
intraluminal pathology.
PCA provides an accurate three-
dimensional view of coronary artery
lumen.

14. The chief utility of angioscopy has been
in assessing the results of coronary
interventions like balloon angioplasty,
atherectomies and stenting.
The limitations of this procedure are
that it cannot see forward beyond tight
stenosis or total occlusions and can
only gauge surface morphology, being
blind to subsurface pathology and
plaque composition.

15. DIGITAL SUBTRACTION
ANGIOGRAPHY (DSA)
Digital Subtraction Angiography is a
form of angiography where with the
help of a computer, a clear image of
the blood vessel (without bone
overlap) can be obtained.

16. Principle – The image acquisition
system in DSA consists of a specially
designed X-ray image intensifier and
television video chain coupled to an
image processor, where images are
recorded, manipulated and displayed on
a cathode ray tube. Images are
converted into a digital format.

17. Images obtained before the appearance of
contrast material are subtracted from the
images obtained after arrival of contrast
material in the vessels, so that the resultant
image is that of an isolated contrast contained
arterial structure.
The image is then electrically contrast
enhanced to display the final image to its best
advantage.

18. Technique – An antecubital vein is
punctured with an 18 gauge needle. A
guide wire is then threaded into SVC
through the needle. The needle is
withdrawn and a 5F high flow digital
catheter is introduced over the guide wire
and placed into the right atrium.

19. The patient is asked not to breathe for 20–
30 seconds during acquisition of the
images. The transit time for the contrast
material to reach the arterial vessel in
question ranges from 4 to 30 seconds.
Total dose of contrast material is 150–200
mL.

20. Indications for DSA in
cardiovascular cases

21. Advantages
Simple and safe method and out-patient
procedure.
Avoids arterial puncture complications.
Limitations
Patient should be co-operative and have
reasonable cardiac output.
Less spatial resolution.
Not suitable for patients with renal failure
because of high volume of contrast.

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