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1. Right Heart Catheterization
Chairperson: Dr. Jahanara Arzu
Professor
Department of Cardiology, UCC, BSMMU
Presenter : Dr. Al-Amin
Resident(Phase B)

2. Werner Forssman Dr. Swan Dr Ganz
In 1929 Werner Forssmann from Germany first performed right heart catheter on himself
Dr Swan added a balloon tip the catheter and Dr. Ganz added thermistor at the tip

3. Introduction
Promoting catheters in the right heart chambers
and branches of the pulmonary artery in order to:
1.Record pressures and their waveforms
2.Measure cardiac output
3.Evaluate O2 saturation and content – oximetry run.
4. Evaluation of intracardiac shunt and other congenital heart
disease

4. Diagnostic indication
 Differentiation of various etiologies of shock and pulmonary
edema
 Diagnosis of intracardiac shunts
 hemodynamic assessment of shunt operability
 postoperative assessment
 Evaluation of pulmonary hypertension
 Quantification of pulmonary pressure
 Calculation of PVR
 Response to vasodilators

5. Therapeutic indication
Guide to fluid management and
Hemodynamic monitoring of patients after
 surgery,
 complicated myocardial infarction,
 shock & heart failure

6. Contraindications
Absolute
 Endocarditis(right cavities)
 Clot / mass in the right cavities
 Mechanical valves in the tricuspid / pulmonary
Relative
 Hemorrhagic diathesis (INR> 2, platelet count < 50,000 )
 Ventricular Arrhythmia
 Poor life expectancy
 Poor cooperation / patient
 Bioprosthetic valves
 Recent installation PM / ICD
 Contralateral pneumothorax

7. Complications
• Arrhythmia (Atrial and ventricular)
• Pulmonary Infarction
• Pulmonary artery rupture
• Air embolism
• Endocarditis
• Venous thrombosis
• Bleeding At the vascular access site
• Arterial puncture
• Pneumothorax

8. Technical aspects
 Instrument for vascular access establishment
 Connecting tube
 3 ways channel/manifold
 Catheters (NIH, Berman catheter , Cournand,Swan-Ganz,Pigtail catheter
for left heart catheter
 Test tube (heparinized for oximetry)
 Oximetry machine
 Syringes
 Hemostatic material
 Over heparinization should be avoided
 Prevention of air bubble
 After flushing, the tableside transducers are zeroed at the mid-chest level
of the patient

10. Swan Ganz catheter

11. venous access sites
 Internal jugular vein
 Subclavian vein
 Basilic vein (Right)
 Basilic vein (Left)
 Femoral vein

12. Procedure
• Establishment of vascular access
• Location of the catheter can be
determined by pressure recorded in
different chamber
• Advance the catheter into IVCRA
counterclock wise rotation to enter
SVC
• Record O2 saturation in SVC (high &
low)
• Record O2 saturation in RA (high,mid
& low)
• Record phasic & mean pressure of RA

13. Procedure
• Clockwise rotation to advance into the RV 
Rotation & gentle traction to flick catheter into
RVOT MPA & out to the periphery
• The balloon is then inflated with 1cc air which
occludes the branch of the pulmonary artery
• The pressure rapidly decrease and reaches a
stable lower value which is the PCWP
• record phasic & mean pressure
• The ballon is deflated
• Withdraw wedge catheter slightly & record PA
phasic & mean pressure
• Obtain O2 saturation from MPA, RPA & LPA
• With a pigtail catheter in LV, measure & record the
LV pressure simultaneously

14. Procedure
• Withdraw the pulmonary catheter
to the RV
• Measure & record simultaneous
RV & LV pressure
• Withdraw the catheter to RA & pull
the catheter in the IVC (high &
low) to get the oximetry
• The LV catheter should be pulled
back to ascending aorta for
recording of pressure & O2
saturation

15. Pressure recordings
Always record pressure at end expiration
Pressures will be lower in inspiration due to decrease in
intrathoracic pressure
Before any pressure measurements are taken, it is
imperative to perform zeroing and referencing of the
system

16. Normal pressure at different chambers of heart

17. Saturation run
• For shunts, a full saturation run should
be performed by obtaining 2 ml sample
from each of the location
– Left and right pulmonary artery
– Main pulmonary artery
– Right ventricle outflow tract, mid and apex
– Right atrium low, mid and high
– Superior vena cava low, high
– Inferior vena cava high, low
– Left ventricle
– Aorta
• Saturation syringe are heparinized and
new sample is taken after discarding few
ml of blood to avoid contamination

18. The normal pressure waves in the cardiac chambers during right heart catheterization with normal values

19. Right atrial pressure wave
Low RAP
• Hypovolemia
• Improper zeroing of the tranducer
Elevated RAP
• Volume overload
• Right heart failure
• Valvular heart disease (TS, TR, PS,
PR)
• RV infarction
• Increased pulmonary resistance
• Cardiac Tamponade

20. Right atrial pressure wave in different condition
 Elevated a wave:
tricuspid stenosis
decreased ventricular compliance due to ventricular
failure
pulmonic valve stenosis
 Elevated v wave:
tricuspid regurgitation (prominent y descent)
RV failure
 Absent a wave:
atrial fibrillation
 Equalization of a and v wave
ASD
 Prominent x descent and absent or reduced y
descent
Cardiac tamponade
 Prominent y descent
 Constrictive pericarditis
 Kussmaul sign
constrictive pericarditis,
RV infarct

21. Right ventricle pressure waves and abnormality
 Elevated Systolic pressure
 Pulmonary Hypertension
 Pulmonary stenosis
 Systolic pressure reduced:
 hypovolemia,
 cardiogenic shock,
 tamponade
 Elevated end diastolic pressure:
 cardiomyopathy,
 RV ischemia and infarction,
 RV failure
 tamponade
 Constrictive pericarditis
 Decreased end diastolic pressure:
tricuspid stenos

22. Pulmonary arterial pressure wave
 Elevated systolic pressure:
 idiopathic pulmonary hypertension,
 pulmonary disease like COPD,ILD
 mitral stenosis or regurgitation,
 significant cardiac left to right shunt,
pulmonary embolism
 Restrictive cardiomyopathy
 Decreased systolic pressure
 Hypotension
 Pulmonary stenosis
 Tricuspid valve stenosis
 Tricuspid valve atresia
 Ebstein’s anomaly

23. Pulmonary capillary wedge pressure
1. Low mean pressure:
– hypovolemia
2. Elevated mean pressure:
– intravascular overload,
– LV failure caused by myocardial disease,
– systemic hypertension
– valvular disease (MS, AoS, AoR)
– pericardial effusion with tamponade
3. Elevated a wave:
– mitral stenosis,
– diastolic dysfunction,
– LV volume overload
4. Cannon a wave
– atrial-ventricular asynchrony(3rd degree AVB, VT, V-pacer)
5. Elevated v wave:
– mitral regurgitation,
– LV failure,
– VSD
• Equal a and v waves
– Cardiac Tamponade
– Constrictive pericarditis

24. Pulmonary capillary wedge pressure
 PCW tracing “approximates”
actual LA tracing but is slightly
delayed since pressure wave is
transmitted retrograde through
pulmonary veins
 Normal LA pressure slightly higher
 Normal PCWP pressure range = 4-12 mmHg
(mean 9)
 When there is no obstruction between left
atrium and left ventricle: PCWP = LA
pressure = LVEDP. = PA diastolic pressure
 PCWP higher than LVEDP in
 MS,MR
 Pulmoary embolism
 A true wedge pressure can be measured
only in the absence of flow”, meaning with a
vessel closed by a balloon.

25. Pulmonary capillary wedge pressure
importance of measurement
It is important to measure PCWP to diagnose
 left ventricular failure
Quantify degree of mitral stenosis
Titration of I/V fluid or diuretics
Evaluation of pulmonary hypertension

26. Pulmonary Hypertension in Adult Congenital Heart Disease
Definition
Haemodynamic
characteristicsa Clinical settings
Pulmonary Hypertension (PH) Mean PAP >20 mmHg All
Pre-capillary PH (PAH)
•Mean PAP >20 mmHg
•PAWP ≤15 mmHg
•PVR ≥3 WU
•Shunt lesions prior to and after
repair (including Eisenmenger
syndrome)
•Complex CHD (including UVH,
segmental PAH)

27. Definition Haemodynamic
characteristicsa Clinical settings
isolated post-capillary PH
•Mean PAP >20 mmHg
•PAWP >15 mmHg
•PVR <3 WU
•Systemic ventricular dysfunction
•Systemic AV valve dysfunction
•Pulmonary vein obstruction
•Cor triatriatum
Combined pre- and post-capillary
PH
•Mean PAP >20 mmHg
•PAWP >15 mmHg
•PVR ≥3 WU
•Settings listed under isolated
post-capillary PH
•Settings listed under isolated
post-capillary PH in combination
with shunt lesions/complex CHD

28. Vasoreactivity test
• to detect residual properties of vasodilatation of small pulmonary arteries and
arterioles
• recommended in pt with group 1 PAH
• done by administration of short acting vasodilator drug then recording
hemodynamic response
• commonly used drugs for vasoreactivity testing-
– Inhaled nitric oxide
– Adenosine
– Epoprostenol
– Inhaled 100% oxygen
• Positive response is defined as reduction of mean PAP>10 mmhg to reach a
mean PAP < 40 mmhg with a increased or unchanged cardiac output

31. Cardiac output measurement
Fick-Oxygen Method
Thermodilution technique

32. Fick O2 method
 CO = O2 consumption/ arteriovenous 02 concentration difference
 O2 consumption roughly (3xwt in kg) ml/min
 LVO2 content= (1.36 x Hb x LVO2 sat x 10)
 Pulmonary arterial O2 content = (1.36 x Hb x PAO2 sat x 10)
 Arteriovenous 02 concentration difference = ( LVO2 content - Pulmonary arterial O2
content)
The value 1.36 is derived from the fact that 1 gram of hemoglobin, when 100%
saturated, combines with 1.36 ml of oxygen

33. Thermodilution indicator method
 Principle:
 injection of a given quantity of cold N / S to the
central circulation changes the temperature of
blood distally.
 Technique:
Injecting 10ml N /S at room temperature within 2
seconds from the proximal channel of the
Swan-Ganz record temperature -time curve
Catheter
 Complete mixing of the indicator causes a
decrease in blood tempdetected by distal
thermistor  CO computer calculates the
change in indicator concentration (temp over
time) to determine CO

34. Oximetry run
• Normally, pulmonary blood flow and systemic blood flow are equal
• When there is an abnormal communication between intracardiac
chambers or great vessels, blood flow is shunted either
– from the systemic circulation to the pulmonary circulation (left-to-right
shunt)
– from the pulmonary circulation to the systemic circulation (right-to-left
shunt)
– in both directions (bidirectional shunt)

35. Oximetry run
• Blood sampling from various cardiac chambers for oxygen
saturation determination
• A left-to-right shunt is detected when there is a significant
increase in blood oxygen saturation between two right-
sided vessels or chambers (step up)
• Despite its lack of sensitivity, clinically significant shunts
are generally detected by this technique

36. Step up for left to right shunt

37. Oxygen saturation values for shunt
detection
Level of shunt Significant step up
of O2
saturation(differen
ce between distal
and proximal
chamber
Possible causes of step up
Atrial(SVC/IVC
to rt atria)
>7 ASD,PAPVD
Ventricular(RA
to RV)
>5 VSD,Primum ASD
Great vessel(RV
to PA)
>5 PDA,Aortopulmonary widow

38. O2 step up in ASD and VSD
VSD
RA
RV
LV

39. ASD Secondum
RA LV
RV

40. • The flow ratio PBF/SBF (or QP/QS) is used clinically to
determine the significance of the shunt
• A flow ratio of less than 1.0 indicates a net right-to-left shunt
• A ratio of 1-1.5 indicates a small left-to-right shunt
• A ratio of 1.5- 2.0 or more indicates a large left-to-right shunt and
generally requires repair in order to prevent future pulmonary
and/or right ventricular complications

41. Shunt calculation
 Pulmonary flow(Qp)= O2 consumption ml/min
( pulmonary venous- pulmonary arterial) O2 content
 Systemic flow(Qs) = O2 consumption ml/min
( arterial- mixed venous )O2 content
 EPBF = O2 consumption ml/min
( pulmonary venous- mixed venous) O2 content
Mixed venous O2 content = 3 SVC+ 1 IVC
4
Effective pulmonary blood flow = systemic flow + shunt flow( left to right shunt)
(when shunt present) = systemic flow– shunt flow (right to left shunt)
PVR = (mean PAP-PCWP)X 80/CO
O2 consumption roughly (3xwt in kg) ml/min
O2 content= (1.36 x Hb x O2 sat x 10)

42. Example for Left to Right ASD shunt
calculation
Step 1- compute O2 content:
Arterial O2 content- 1.36x14.1x.98x10=188
Mixed venous O2content- 1.36x14.1x.71x10=136
Pulmonary artery O2 content- 1.36x14.1x.81x10=155
Pulmonary vein O2 content- 1.36x14.1x.98x10=188
Step 2- compute Qs
O2 Consumption/ (arterial- mixed venous) O2 content
= 225/(188-136)
=225/52
=4.3 L/min

43. Step 3- compute Qp
O2 Consumption/ (pulmonary venous-pulmonary artery) O2 content
=225/(188-155)
=225/33
=6.8L/min
Step 4- compute Qp/Qs
Qp/Qs= 6.8/4.3=1.6
The left to rt shunt is (6.8-4.3)=2.5 L/min

44. Rt to left shunt/bi-directional calculation
1. Compute O2 content
2. Compute Qs8.5
3. Compute Qp6.7
4. Qp/Qs= 6.7/8.5=0.79
< 1
(Right to Left shunt)