history, indications, contraindications, swan-gauge catheter, catheter, pulmonary artery catheterization, shunt calculation, equipment,equipments

1. Right Heart Catheterization
Dr. Md.Toufiqur Rahman
MBBS, FCPS, MD, FACC, FESC, FRCPE, FSCAI,
FAPSC, FAPSIC, FAHA, FCCP, FRCPG
Associate Professor of Cardiology
National Institute of Cardiovascular Diseases(NICVD),
Sher-e-Bangla Nagar, Dhaka-1207
Consultant, Medinova, Malibagh branch
Honorary Consultant, Apollo Hospitals, Dhaka and
STS Life Care Centre, Dhanmondi
drtoufiq19711@yahoo.com
CRT 2014
Washington
DC, USA

3. Q.1

4. Q.2

5. Q.3

6. Q.4

7. Q.5

8. Q.6

9. Overview
Right Heart Catheterization (RHC)
 Indications
 Contraindications / Caution
 Equipment
 Technique
 Precautions
 Cardiac Cycle
 Pressure monitoring
 Zeroing and Referencing
 Fast flush test/ Square wave test
 Pressure wave interpretation
 Cardiac output
 Derived measurements

10. History
• First Cardiac catheterization –
▫ According to Andre Cournand, it was first performed by Claude
Bernard in 1844, in a horse, both rt and lt ventrilces were
entered by retrograde approach from the jugular vein and
carotid artery
▫ Werner Forssmann is credited with performing the
first cardiac catheterization of a living person
himself, at the age of 25 yrs
• Forssmann for his contribution and foresight shared
the Nobel Prize in Medicine with Andre Cournand and
Dickinson Richards in 1956

11. History
• 1929- Dr. Warner
Forssman proven that
right heart catheterization
is possible in humans
• 1964- Dr. Bradley
introduced small
diagnostic catheter
• 1970- Balloon Flotation
Catheter by Doctor H.J.C
Swan and William Ganz

12. Cardiac catheterization implies the insertion
of flexible tube into one or more heart
chambers usually under fluoroscopic guide
for diagnostic or therapeutic purpose
Definition

15. Indication of cardiac catheterization
1. Diagnostic indication
-Collects data to evaluate PT’s condition
2. Therapeutic indication
3. Prognostic indication

16. 1. Diagnostic catheterization is in the routine preoperative evaluation of
most congenital defects, such as VSDs, ASD, TOF, DORV, CoA and other
complex CHD.
2. Before interventional catheterization
a. Assessment of patient hemodynamics and anatomy
b. to confirm congenital or acquired heart disease in infants and children
3. When the anatomy of a CHD is inadequately defined by noninvasive
means
4. in very complex lesions  specific details about the anatomy or
hemodynamics
5. High-flow or low-flow physiology associated with semilunar valve
stenosis
a.Combined aortic stenosis (AS) and insufficiency
b.Combined Pulmonary stenosis and insufficiency
6. In cavopulmonary anastomosis and after Fontan completion 
Diagnostic catheterization is useful in the evaluation for proceeding
with completion of Fontan, revision of Fontan, or transplantation
Diagnostic indication-

17. Diagnostic indication-
7. EP study
1. His bundle electrocardiography in 1st degree, 2nd
degree & CHB
2. Endocardial mapping in WPW syndrome
8. Endocardial biopsy
1. DCM
2. HCM
3. Amyloidosis
4. sarcoidosis

18. Diagnostic indication
 Angiocardiography –
1. Rt and lt ventriculography –
a) Chamber size
b) Wall thickness
c) Wall motion
d) Aneurysm
e) Volume
f) Dimension
g) Fractional shortening
and
h) Ejection fraction
2. Aortography –
a) AR
b) AS
c) Co of Aorta
d) PDA
e) Aortic arch
syndrome
3. CAG – determine
coronary artery
anatomy

19. Diagnostic indication
 Pressure study –
a) it means measurement of pressure and recording of its wave
form.
b) High RV pressure in catheterization found in the following
condition –
a) VSD
b) PS
c) PH in MS, COPD
d) Ruptured sinus of valsalva into RV
c) Trans-valvular pressure difference can grade the severity of –
a) AS
b) PS
c) MS
d) PCW help to find out LVEDP
 Oxymetry –
a) Shunt calculation
b) To determine Cardiac output

20. Therapeutic indication
1. Closure of the following defects –
1. ASD
2. VSD
3. PDA
4. MAPCA
2. PTMC
3. Thrombolytic therapy – intracoronary, systemic
4. PTCA
5. PTA – for peripheral artery stenosis
6. Valvuloplasty – PS, MS, AS
7. Dilatation of coarctation of aorta

21. Therapeutic indication
9. Introduction of ‘’UMBRELLA’’ in to IVC for
recurrent pulmonary emboli from DVT
10. Rushkind procedure in TGA, for balloon
rupture of interatrial septum by
brockenbergh needle
11. Cardiac pacing
12. Peripheral arterial balloon dilatation
13. Hemodynamic monitoring and treatment of
pt with cardiogenic shock by swan gauze
catheter

22. Prognostic indication
1. Post CABG catheter for assessment of –
1. cardiac function and
2. coronary perfusion
2. Post PTCA
3. After thrombolytic therapy
4. After repair of VSD
5. After valve replacement
6. Prior to any cardiac operation to estimate
the prognosis of operation

23. Contraindication of cardiac catheterization
• Absolute contraindication – In expert
hand none is contraindicated
1. Patient refusal
2. IE

24. 1. Recent AMI usually within 3 week  in case of adult
pt
2. Intercurrent febrile illness
2. CCF
3. Severe or malignant hypertension  predispose to
myocardial ischaemia and/or heart failure during
angiography
4. Life threatening arrhythmia, but it is indicated in-
1. While myocardial mapping and subsequent electrotherapy
2. Surgery is contemplated for treatment of arrhythmia
Relative contraindications

25. 5. Severe renal failure
6. Allergy to dye
7. Severe hypokalaemia
8. Anticoagulant state  PT > 18 s
9. Moribund pt
10. Primary pulmonary hypertension
11. Presence of LBBB
12. Digitalis toxicity
13. Severe anaemia
14. Severe PS
Relative contraindications

28. MEDICATIONS USED
 Premadication –
 Inj Pethidine
 Inj Phenargoan
 Saline infusion
 Heparin -
 For Pt
 flushing all tubing, catheters, sheaths
 Lidocaine for tissue numbing
 Anaesthetic medication for relaxing the pt
 Water soluble contrast

29. EQUIPMENT NEEDED
 Procedure tray should include:
1. sterile –
1. gowns and gloves
2. sterile towels and drapes for procedure
3. Sterile gauze
4. scalpel, needles, scissors, hemostats
5. syringes for heparin/saline flush, lidocaine,
and blood oximetry
1. labels with marking pen for any item filled with a solution
2. basin for heparin/saline mixture & waste fluids,
3. skin prep solution
4. connection tubing

30. EQUIPMENT NEEDED
 Anaesthesia machine
 Oxygen supply
 Suction apparatus
 Defibrillator
 Temporary pacemaker
 Pulse oximeter
 NIBP
 Equipment to perform cardiac output studies
 Activated clotting time (ACT) equipment
30

31. EQUIPMENT NEEDED
1. Needle
2. Sheath
3. Wires
4. Catheters
5. Fluroscopic machine
6. Power injector

32. Vascular access
Venous Access Arterial Access
Femoral vein
Median basalic vein
Subclavian vein
Internal jugular vein
Umbilical vein
Transhepatic route
Femoral artery
Radial artery
Umbilical artery
Carotid artery

33. Needles for percutaneous puncture
• Angiographic needle – designed for single wall puncture
– small in diameter,
– thin walled,
– short beveled
– very sharp.
– Hub  clear
• True Seldinger needle
• Chiba™ needle percutaneous transhepatic access

34. Angiographic Needle with Protector, Seldinger Hub, Thin Wall
True Seldinger Needle
Chiba Needle

35. Needle size chosen:
Age Diameter Length Wire
Infants and small
children
21 G 3 cm 0.018
Larger children and
young adults
19 G 5 cm 0.025’’
Adult and obese pt 18 G 7 / 8 cm 0.035’’

36. Technique for vascular access:
 The true “Seldinger™ technique” is not used
for percutaneous puncture into vessels.

37. Technique for vascular access:
• Modified Seldinger technique for vascular
access with single wall puncture into vessels.

38. Vascular Sheath
 Percutaneous introduction and then the use of an
indwelling vascular sheath in vessels is the standard
technique for catheterization of pediatric and congenital
heart patients.
 Ideal sheath should have:
1. Dilator 
1. long, fine and smoothly tapered tip.
2. inner lumen of the dilator tip should tightly fit over the guide wire
3. tip of the dilator should have a smooth, fine transitional taper onto
the surface of the wire.
2. female Lure™ lock connecting hub at the proximal end
3. back-bleed valve
4. Lateral tube / flush port

39. Vascular Sheath
When introduced from the inguinal area, the sheath should be long enough to
extend into the common iliac vein.
In small infants a sheath into the femoral vein should extend proximal to the
formation of the inferior vena cava.

40. Vascular Sheath
 Ideal short sheath (7.5 cm long) for venous site –
 5 Fr for an infant or child (<15– 20 Kg) and
 7 Fr for a larger child or adult
 Extra long sheaths (45 to 90 cm ) are used to –
1. guide catheters directly and repeatedly to an area
within the heart itself (biopsies, blade catheters),
2. for trans septal procedures,
3. to deliver special devices within the heart or great
vessels (stents, occlusion devices), and
4. for the withdrawal of foreign bodies from the vascular
system.

41. Swan-Ganz Catheter(Pulmonary
Artery Catheterization)
• Swan-Ganz Catheter-
Balloon flotation
Pulmonary Artery catheter
• Use for monitoring
critically ill patients
(mostly in the ICU)
• Catheterization only
possible on the right side
of the heart
• Catheter is hooked up to a
Cardiac Output computer

42. Chest X-Ray

43. Usage
• Detection of Heart
Failure and Septic
Shock
• Measures indirect left
ventricular pressure
• Measure Cardiac
Output by
thermodilution for:
Right Atrial and Right
Ventricular pacing and
right-sided pressures

44. Indications for Use

45. Indications
• Assess volume status
• Assess RV or LV failure
• Assess Pulmonary Hypertension
• Assess Valvular disease
• Cardiac Surgery

46. Heart Failure Sensor
• Wireless
Radiofrequency; no
direct connection to
Cardiac Output
Computer
• Reduced
hospitalization among
heart failure patients
• Longer duration of use
• No batteries required
• No wearable parts

47. Advantages
• Ability to monitor
patient’s blood
flow through the
heart when
critically ill
• Detect of the
effectiveness of
certain
medications,
Heart Failure, and
Shock

48. Benefits
• Effect on Treatment Decisions: information gathered
from PA catheter data can beneficially change
therapy
• Preoperative Catheterization: information gathered
prior to surgery can lead to cancellation or
modification of surgical procedure, thereby
preventing morbidity and mortality
• Perioperative Monitoring: provides invasive
hemodynamic monitoring in the surgical setting

49. Disadvantages
• Over usage of the
balloon
• If fluid bag is not under
pressure, patient can
bleed to death
• Ventricular tachycardia
can occur if catheter
slides back into the
Right Ventricle
• Short duration of use

50. Hemodynamic Parameters

51. Hemodynamic Parameters - Measured
• Central Venous Pressure (CVP)
– recorded from proximal port of PAC in the superior vena cava or right atrium
– CVP = RAP
– CVP = right ventricular end diastolic pressure (RVEDP) when no obstruction exists between
atrium and ventricle
• Pulmonary Artery Pressure (PAP)
– measured at the tip of the PAC with balloon deflated
– reflects RV function, pulmonary vascular resistance and LA filling pressures
• Pulmonary Capillary Wedge Pressure (PCWP)
– recorded from the tip of the PAC catheter with the balloon inflated
– PCWP = LAP = LVEDP (when no obstruction exists between atrium and ventricle)
• Cardiac Output (CO)
– Calculated using the thermodilution technique
– thermistor at the distal end of PAC records change in temperature of blood flowing in the
pulmonary artery when the blood temperature is reduced by injecting a volume of cold
fluid through PAC into the RA

52. Oxygen Transport Parameters
• Oxygen Delivery (DO2)
– Rate of oxygen delivery in arterial blood
DO2 = CI x 13.4 x Hgb x SaO2
• Mixed Venous Oxygen Saturation (SVO2)
– Oxygen saturation in pulmonary artery blood
– Used to detect impaired tissue oxygenation
• Oxygen uptake (VO2)
– Rate of oxygen taken up from the systemic
microcirculation
VO2 = CI x 13.4 x Hgb x (SaO2 - SVO2)

53. ASA Practice Guidelines for Pulmonary
Artery Catheterization (2003)
• Appropriateness of PA catheterization depends on the risks
associated with the:
– (a) Patient: Are there presexisting medical conditions that may
increase the risk of hemodynamic instability?
– (b) Surgery: Is the procedure associated with significant hemodynamic
fluctuations which may cause end organ damage?
– (c) Practice setting: Could the complications associated with
hemodynamic disturbance be worsened if the technical or cognitive
skills of the physicians or nurses caring for the patient are poor?

54. ASA Practice Guidelines for Pulmonary
Artery Catheterization (2003)
• According to the Task Force on Pulmonary Artery
Catheterization, PAC monitoring was deemed appropriate
and/or necessary in the following patient groups:
– 1) surgical patients undergoing procedures associated with
a high risk of complications from hemodynamic changes
– 2) surgical patients with advanced cardiopulmonary disease
who would be at increased risk for adverse Perioperative
events

55. Complications
• Establishment of central venous access
– Accidental puncture of adjacent arteries
– Bleeding
– Neuropathy
– Air embolism
– Pneumothorax

56. Complications
• Pulmonary artery catheterization
– Dysrhythmias
• Premature ventricular and atrial contractions
• Ventricular tachycardia or fibrillation
– Right Bundle Branch Block (RBBB)
• In patients with preexistinh LBBB, can lead to complete
heart block.
– Minor increase in tricuspid regurgitation

57. Complications
• Pulmonary catheter residence
– Thromboembolism
– Mechanical, catheter knots
– Pulmonary Infarction
– Infection, Endocarditis
– Endocardial damage, cardiac valve injury
– Pulmonary Artery Rupture
• 0.03-0.2% incidence, 41-70% mortality

62. Thank Youdrtoufiq19711@yahoo.com
Asia Pacific Congress of
Hypertension, 2014, February
Cebu city, Phillipines
Seminar on Management
of Hypertension,
Gulshan, Dhaka