Cardiac catheterization is an invasive procedure where a catheter is inserted into the heart via arteries or veins to perform diagnostic testing or interventions. It can be used to assess heart structure and function through angiography, assess blood flow and pressures, and treat conditions like coronary artery disease. Potential risks include bleeding, infection, arrhythmias, and contrast-induced kidney injury. Post-procedure care involves bed rest, monitoring for complications, and follow up. Other cardiac tests discussed include radionuclide imaging, electrophysiology studies, and coronary angiography.

2. The topics for the day
CORONARY
ANGIOGRAPHY
ELECTRO-
PHYSIOLOGY
RADIO-
NUCLEOTIDE
IMAGING
CARDIAC
CATHERTERISATION

3. CARDIAC CATHERTERISATION
 An invasive technique of passing a specialised catheter through peripheral artery or vein into the
heart under X-Ray guidance
 Usually performed in conjunction with coronary angiography
 Gold standard diagnostic test for assessing heart and its vasculature
CONTRAINDICATIONS
1. Acute Decompensated heart failure
2. CKD- contast induced AKI
3. Bacteremia- lead to sepsis
4. Active GI bleeding
5. Contrast allergy- anaphylactic
reaction
6. On anticoagulant therapy- can lead
to vascular site bleeding
7. Electrolyte imbalance

4. CARDIAC CATHERTERISATION
COMPLICATIONS OF CATHETERIZATION
1. Tachy/brady-arrythmia
2. Vascular site bleeding- most common
complications. 1.5 to 2%
3. Contrast induced AKI- increase in serum
creatinine >0.5mg/dl. Seen in patients with risk
factors- DM, CKD, CHF, Anemia
4. Contrast allergy- IgE type hypersensitivity
reaction. If history is suggestive, treat with
antihistamines 24 hours prior
5. Myocardial infarction, stroke and death-
very rare complications. Less than 1%
POSTOPERATIVE CARE
• Remove vascular sheath, achieve
homeostasis
• Bed rest- 2 hours
• Advise adequate fluid intake
• Avoid strenuous activity
• Discharge same day, overnight
hospitalization only in high rise
cases(comorbities present)
• Patient with radiation exposure,
clinical follow up after 1 month

5. CARDIAC CATHERTERISATION
 Patient must be fasted for 6 hours prior procedure
 IV conscious sedation, but remain awake
 In suspected CAD, administer 325 mg aspirin
 Stop all anticoagulants 2-3 days prior to surgery- maintain INR <1.7
 No prophylactic Abx- sterile procedure
 Vascular Access: cardiac catheter is introduced percutaneously
under local anesthetic
 Via femoral or radial artery- Left heart catheterization
 Via femoral, radial or internal jugular vein- Right heart
catherterization
 Left heart catheterization: pass the guide wire through the artery
to aorta, inject dye for coronary angiography/ measure
hemodynamics/ ventriculography/ aortography
 Right heart catheterization: not performed as routine
catheterization. Indicated in unexplained dyspnea, PAH, CHD. A
balloon tiped SWAN GANZ catheter is used for measuring PCWP

6. CARDIAC CATHERTERISATION
 Patient must be fasted for 6 hours prior procedure
 IV conscious sedation, but remain awake
 In suspected CAD, administer 325 mg aspirin
 Stop all anticoagulants 2-3 days prior to surgery- maintain INR <1.7
 No prophylactic Abx- sterile procedure
 Vascular Access: cardiac catheter is introduced percutaneously
under local anesthetic
 Via femoral or radial artery- Left heart catheterization
 Via femoral, radial or internal jugular vein- Right heart
catherterization
 Left heart catheterization: pass the guide wire through the artery
to aorta, inject dye for coronary angiography/ measure
hemodynamics/ ventriculography/ aortography
 Right heart catheterization: not performed as routine
catheterization. Indicated in unexplained dyspnea, PAH, CHD. A
balloon tiped SWAN GANZ catheter is used for measuring PCWP

7. CARDIAC CATHERTERISATION
A: x ray source
B: movable patient table
C: Lead shield
D: Video display

8. CARDIAC CATHERTERISATION
DIAGNOSTIC USES OF CARDIAC CATHETERISATION
HEMODYNAMICS
• Detect pressure and volumes in all chambers of the heart in systole and diastole
• AS- systolic pressure gradient between LA and LV
• MS- Diastolic pressure gradient between LA and LV
• HOCM- brackenborough-braunwald sign: post PVC increase in aortic-LV pressure and decrease in aortic PP
• Regurigitant volume in MR and TR
• To differentiate between CCP, CT and RCM- RAP, Y descent, square root sign
CARDIAC OUTPUT
• Using FICK’S PRINCIPLE- total oxygen consumption is equal to the product of cardiac output and
arteriovenous oxygen difference.
• 𝐶𝑂 =
𝑣𝑂2
𝐶𝑎−𝐶𝑣
• THERMODILUTION- injection of 10ml NS into right atrium(room temperature)measuring the temperature
deviations in pulmonary artery using a thermistor tipped catheter

9. CARDIAC CATHERTERISATION
DIAGNOSTIC USES OF CARDIAC CATHETERISATION
VASCULAR RESISTANCE
• Using ohms law. Resistance(for e.g. systemic) is equal to mean pressure(mean aortic pressure- mean RAP) and mean
flow(cardiac output)
• Measured in Wood units(x 80 to dynes-s-cm2)
• SVR 11-15 woods or 900-1200 dynes-s-cm2 – increased in stress, low output syndrome, hypertension
• PVR less than 2 woods or 50-250 dynes-s-cm2- PAH
VALVE AREA
• Gorlin formula and modified Hakki formula
• <1 cm2 severe AS
• <1.5 cm2 severe MS
INTRACARDIAC SHUNTS
• Congenital heart disease
• Using oxygen saturation. Step up saturationleft to right shunt. Step down right to left shunt
• Shunt ratio ratio of pulmonary blood flow by systemic blood flow(difference in mean arterial and venous oxygen
content
• Shunt ratio >1.5 ASD

10. CARDIAC CATHERTERISATION
DIAGNOSTIC USES OF CARDIAC CATHETERISATION
VENTRICULOGRAPHY
• Assessment of left ventricular function. Pigtail cathetercontrastvisualise cardiac cycle
• Hypokinetic movements, akinetic or dyskinetic(paradoxical)
• Can detect MVP, severity of MR(contrast reflux)-1+ tp 4+, LV aneurysm, VSD
AORTOGRAPHY
• Aneursym, coarctation and PDA
CINEFLOUROGRAPHY OF PROSTHETIC VALVES
• Detect any prosthetic valve dysfuntion)(immobility or fixity), thrombus or pannus
INTERVENTIONAL USES
• Coronary artery balloon angioplasty
• Stent placement
• Transcatheter abortive valve replacement(TAVR)
• Ablation
• Biopsy

11. CARDIAC CATHERTERISATION

12. CORONARY ANGIOGRAPHY
INJECTION OF RADIOOPAQUE CONTRAST IN THE CORONARY
ARTERIES WITH SERIAL RADIO IMAGING
• 2 coronary ostia,3 main coronary arteries- RCA, LAD and
LCX
• Ramus intermedius- posterior interventricular branch
directly from main LCA
• RCA- supplies SA node(60%) and AV node(90%), posterior
descending branch(right dominant in
90%)inferoposterior LV, Right AV groove RA and RV.
• LAD- anterior septal perforators, anterior, later and apical
LV
• LCX- lateral, posterior and inferior parts of LV, Posterior
descending branch(left dominance in 10%)
• 1-2% have coronary anomalies; separate ostia for LAD and
LCXmost common(0.41%)

13. CORONARY ANGIOGRAPHY
INJECTION OF RADIOOPAQUE CONTRAST IN THE CORONARY
ARTERIES WITH SERIAL RADIO IMAGING
• 2 coronary ostia,3 main coronary arteries- RCA, LAD and
LCX
• Ramus intermedius- posterior interventricular branch
directly from main LCA
• RCA- supplies SA node(60%) and AV node(90%), posterior
descending branch(right dominant in
90%)inferoposterior LV, Right AV groove RA and RV.
• LAD- anterior septal perforators, anterior, later and apical
LV
• LCX- lateral, posterior and inferior parts of LV, Posterior
descending branch(left dominance in 10%)
• 1-2% have coronary anomalies; separate ostia for LAD and
LCXmost common(0.41%)

14. CORONARY ANGIOGRAPHY
 Coronary circulation is visualized in multiple orthogonal
projections by angiography
 Luminal narrowings are visualised indicating coronary artery
stenosis.
 Narrowings are compared to “normal” segment and expressed
as percentage
 >50% stenosis  significant
 Myocardial bridge a kink in the LAD normal present, mistaken
for stenosis. It is due to the dip of the vessel from epicardium to
myocardium consequent contraction in systole
compression. In contrast to stenosis, returns to normal in
diastole
 Thrombolysis in Myocardial Infaction(TIMI) flow grade- relative
duration of the time taken for contrast to fill the artery
 TIMI grade 1 minimal filling. TIMI grade 2 gradual filling.
These suggest severe CAD

15. RADIO-
NUCLEOTIDE IMAGING
Used for evaluating cardiac function but MRI have replaced due to superior quality
and lesser radiation exposure
Myocardial perfusion scanning:
• IV injection of technetium
• Induce stress(exercise or dopamine)
• Scintiscan using gamma camera of myocardium
• Assess myocardial metabolism/function
Blood pool imaging:
• Injection of radio-isotope labelled RBCs
• Using gamma camera evaluate the heart 4 to 5 min after injection
• Shows ejection fractions, size and shape of cardiac chambers

16. ELECTRO-PHYSIOLOGY
Used for patients with arrythmia
Percutaneous placemtn of electrode catheters on the
heart
Via femoral or neck veins by cardiac catheterization
EPS- electrophysiological study, done is association
with cardiac ablation
Used for risk stratifaction of patients are risk of
ventricular arrythmia