Cardiac Catheterization

Why a cardiac catheterization?

What is generally referred to as “Heart Disease” is really referring to, not the heart
being diseased but really that it is being starved of the blood supply it needs in order to
perform its pumping function. The coronary circulation is responsible for providing this
supply. The coronary arteries are vital because they supply oxygen and nutrients to the
heart muscle. Without blood flow, the muscle would sustain permanent damage. Over
95% of heart failures are due to failure of the system to provide sufficient blood supply
to the heart for its own metabolic needs.

What is a cardiac catheterization?

A cardiac catheterization is a study of the heart during which a thin hollow flexible
catheter is inserted into the artery (left heart cath) or the vein (right heart cath) of the
groin (femoral) or arm (brachial). The term is most commonly used to describe testing
in which a catheter is fed into an artery of the heart. Under x-ray visualization
(fluoroscopy), the tip of the catheter is guided into the heart. Coronary angio’s
(visualization of the arteries) of the heart are obtained while injecting a colorless dye or
contrast through the catheter. The contrast material blocks the passage of x-rays
therefore allowing the coronary arteries to be visualized and x-rays obtained

Right Heart Catheterization / Swan Ganz catheter:

In reference to the cardiac cath lab, you may be told that a right heart cath was done.
This is done using a Swan Ganz catheter. This is a flow directed catheter with a balloon
on the tip. The Swan Ganz is used to measure pressures, cardiac output, and draw
blood samples. The cardiologist inserts the catheter into the right side of the heart
through a large vein. The vein is accessed, usually during the time the artery is
accessed. This procedure is also commonly done in the ICU by a trained physician,
usually an Intensivist or a Cardiologist. In ICU, it is common for a vein in the right side
of the neck to be used. However, the left side of the neck, either side of the groin (as
seen during cardiac catheterization) or other sites can be used.

The catheter enters the right atrium (upper chamber) of the heart, flows through the
tricuspid valve into the right ventricle (lower chamber), through the pulmonary valve,
and into the pulmonary artery. There is a balloon at the tip of the catheter that assists
with the advancement of the catheter. When it reaches the Pulmonary artery, the
balloon is wedged into a pulmonary capillary, which then measures the pressure
around it- giving you the Pulmonary Capillary Wedge Pressure or PCWP.
Measurements of the pressures in the pulmonary artery can be used to indirectly
measure the function of the left ventricle.

The position of the catheter within the heart is confirmed by a chest x-ray or by
fluoroscopy during the procedure and by monitoring devices that also read the
pressures within the heart. During the procedure, the heart's rhythm is monitored
continuously by electrocardiogram (ECG).

Left heart catheterization:

If the catheter is introduced through the artery, then it is known as a left heart
catheterization. The most common site used is the femoral artery. Once in the femoral
artery, the catheter is thread into the aorta, where the coronary arteries can then be
accessed, and the left ventricle. If there is significant vascular disease and/or the
physician has is unable to thread the catheter from the femoral site the procedure can be
performed using an artery in the arm.

Sheaths:

A majority of vascular procedures are performed through vascular access sheaths.

Sheaths are used for introduction of a catheter during a vascular procedure. The
standard is usually 10cm long with a side arm which allows continuous flush of saline
to prevent clot formation between the sheath ad the catheter. The cardiac catheter and
guidewire is passed through the sheath. The major advantage of a vascular sheath is
that it reduces the trauma from repeated punctures at the puncture site.
 Guidewire:

A small bendable wire that is threaded through the artery; it helps doctors position a
catheter. The guidewire is small enough that it can be inserted into the vessel through
a needle, but also stiff enough to be threaded “up” the artery.

Types and Sizes of Catheters:

Besides coming in different types of shapes and materials, catheters also come in many
sizes. Catheters are measured in French (FR) size. One French (FR) is equal to .33 mm.
An easier way to remember how to figure French size is 3FR is equal to 1mm. The three
French is usually used in newborns and infants, 4 and 5 french are usually used with
brachial. Cardiac catheter, the Sones catheter is used when you have to go in the
brachial artery. The Judkins and Amplatz catheters are used for selective catheterization
of the coronary arteries with a femoral approach. Most traditionally used is the Judkins
6fr, it is believed that a smaller catheter causes less bruising.

Complications / Risks Associated with Heart Catheterization:

The main risks of the procedure are bruising at the access site, trauma to the vein, and
puncturing the lung if the neck or chest veins are used. Very rare instances a patient
may suffer cardiac arrhythmias, cardiac tamponade, low blood pressure, infection, or
embolism caused by blood clots at the tip of the catheter (Freed, 1992).

AV fistula- During attempted vascular access, the needle may puncture both the femoral artery
and vein creating an abnormal arterial venous communication which may persist following
sheath withdrawal. This results in a “continuous murmur” at the site of the communication,
distal arterial insufficiency, and a swollen, tender extremity due to venous dilatation.
Diagnosed by color flow doppler imaging and ultrsonography. Usually repaired surgically.
Recent reports of successful treatment non- invasively by ultrasound-guided compression.

Amir Ziad Muhammed 21411253