Right Heart Catheterization

1
Right Heart Catheterization basic right heart
pressure tracings

• University of Kansas
• August 20, 2004
• Cardiac catheterization conference

2
The Heart

• Year 1 Cardiology Fellowship

3
Right heart catheterization and the Swan Ganz
catheter

• The first to demonstrate that a catheter could be
  advanced safely into the human heart was the
  German surgeon Werner Forssmann (1904-1979) who
  did the experiment on himself. A catheter similar
  to the Swan-Ganz was originally developed in 1953
  and used in dogs by the U.S. physiologists
  Michael Lategola and Hermann Rahn (1912-1990).
  Swan and Ganz introduced their catheter into
  clinical practice in 1970.Bibliography
• W. Forssmann Die Sondierung des Rechten
  Herzens. Klinische Wochenschrift, Berlin, 1929,
  8 2085.Experiments on myself. Translated by H.
  Davies. London, St. James Press, 1974.

4
Right Heart Catheterization

• Indications
• Diagnosis of shock states
• Differentiation of high- versus low-pressure
  pulmonary edema
• Diagnosis of primary pulmonary hypertension (PPH)
  
• Diagnosis of valvular disease, intracardiac
  shunts, cardiac tamponade, and pulmonary embolus
  (PE)
• Monitoring and management of complicated AMI
• Assessing hemodynamic response to therapies
• Management of multiorgan system failure and/or
  severe burns
• Management of hemodynamic instability after
  cardiac surgery
• Assessment of response to treatment in patients
  with PPH
• Contraindications
• Tricuspid or pulmonary valve mechanical
  prosthesis
• Right heart mass (thrombus and/or tumor)
• Tricuspid or pulmonary valve endocarditis

5
Complications

• Access
• Pneumonthorax
• Hemothorax
• Tracheal perforation
• Intracardiac
• Stimulation of the RVOT ventricular arrhythmias
• AV block- be aware in patients with a LBBB
  (consider a temporary pacemaker prior to
  proceding)
• Causing a RBBB
• Atrial arrhythmias
• Pulmonary rupture
• Pulmonary infarct
• RV puncture

6
Basics - Insertion

• The SGC is inserted percutaneously into a major
  vein (jugular, subclavian, femoral) via an
  introducer sheath. The predominance of right
  heart catheterization is performed in the
  invasive lab utilizing the femoral approach.
  Preference considerations for cannulation of the
  great veins are as follows
• Right internal jugular vein (RIJ) - Shortest and
  straightest path to the heart
• Left subclavian - Does not require the SGC to
  pass and course at an acute angle to enter the
  SVC (compared to the right subclavian or left
  internal jugular LIJ)
• Femoral veins - These access points are distant
  sites, from which passing a SGC into the heart
  can be difficult, especially if the right-sided
  cardiac chambers are enlarged. Often,
  fluoroscopic assistance is necessary, but these
  sites are compressible and may be preferable if
  the risk of hemorrhage is high.

7
Sheath Insertion

• A. Puncture vessel by needle
• B. Flexible guidewire placed into vessel via
  needle
• C. Needle removed and guidewire left in place,
  hole in skin is enlarged with a scalpel
• D. Sheath and dilator placed over the guidewire
• E. Sheath and dilator advanced into the vesssel
• F. Dilator and sheath removed while sheath
  remains in the vessel

Modified Seldingers technique
8
Right Heart Pressures Tracings
9
Advancing Your Right Heart Catheter

• Advance the SGC to about 20cm and inflate the
  balloon tip.
• Initial chamber entered will be the right atrium
  and the initial pressure waveform will have 3
  positive deflections, the a, c and v waves
• There will be an x and y descent

10
Right Atrial Pressure Tracing

• a wave results from atrial systole
• c wave occurs with the closure of the tricuspid
  valve and the initiation of atrial filling
• v wave occurs with blood filling the atrium
  while the tricuspid valve is closed

11
Timing of the positive deflections

• a wave occurs after the p wave during the PR
  interval
• c wave when present occurs at the end of the
  QRS complex (RST junction)
• v wave occurs after the T wave

12
Right Atrial Chamber

• Height of the v wave is related to the atrial
  compliance and the volume of blood returning from
  the periphery
• Height of the a wave is related to the pressure
  needed to eject forward blood flow
• The v wave is usually smaller than the a wave in
  the right atrium

13
Right atrial hemodynamic pathology

• Elevated a wave
• Tricuspid stenosis
• Decreased RV compliance
• e.g. pulm htn, pulmonic stenosis
• Cannon a wave
• AV asynchrony atrium contracts against a closed
  tricuspid valve
• e.g. AVB, Vtach

• Absent a wave
• Atrial fibrillation or standstill
• Atrial flutter
• Elevated v wave
• Tricuspid regurgitation
• RV failure
• Reduced atrial compliance
• e.g. restrictive myopathy

14
Right atrial hemodynamic pathology
Note the Cannon a wave that is occurring during
AV dysynchrony atrial contraction is occurring
against a closed tricuspid valve.
Note the large V wave that occurs with Tricuspid
regurgitation
15
Hemodynamic Pathology

• Tricuspid Stenosis
• Large jugular venous a waves on noted on exam
• Notable elevated a wave with the presence of a
  diastolic gradient - gt5mmHg gradient is
  considered signficant

16
Advancing Your Right Heart Catheter

• Continue advancing the catheter into the right
  ventricle
• The right and left ventricular pressure tracings
  are similar.
• The right ventricular has a shorter duration of
  systole
• Diastolic pressure in the right ventricle is
  characterized by an early rapid filling phase,
  then slow filling phase followed by the atrial
  kick or a wave

a
17
Normal RV waveform artifact

• Note the notch on the top of RV pressure waveform
• This represents ringing of a fluid-filled
  catheter
• Ringing can also be noted on the diastolic
  portion of the waveform

18
Advancing Your Right Heart Catheter

• Advancing out the RVOT to the pulmonary artery
• There is a systolic wave indicating ventricular
  contraction followed by closure of the pulmonic
  valve and then a gradual decline in pressure
  until the next systolic phase.
• Closure of the pulmonic valve is indicated by the
  dicrotic notch

19
Timing of the PA pressure

• Peak systole correlates with the T wave
• End diastole correlates with the QRS complex

20
Hemodynamic Pathology

• Pulmonic Stenosis
• Notable large gradient across the pulmonic valve
  during PA to RV pullback.
• Notable extreme increases in RV systolic
  pressures and a damped PA pressure

21
Pulmonary artery hemodynamic pathology

• Elevated systolic pressure
• Primary pulmonary hypertension
• Mitral stenosis or regurgitation
• Restrictive myopathies
• Significant L to R shunt
• Pulmonary disease
• Reduced systolic pressure
• Pulmonary artery stenosis
• Ebsteins anomaly
• Tricuspid stenosis
• Tricuspid atresia
• Reduced pulse pressure
• Right heart ischemia
• Pulmonary embolus
• Tamponade

• Bifid pulmonary artery waveform
• Large left atrial v wave transmitted backward
• Pulmonary artery diastolic pressure gt pulmonary
  capillary wedge pressure
• Pulmonary disease
• Pulmonary embolus
• Tachycardia

22
Advancing Your Right Heart Catheter

• With the balloon inflated advance the catheter
  until the pressure tip wedges into the distal
  pulmonary artery (pulmonary capillary wedge
  pressure)
• Similar waveform to the left atrial waveform
  although damped

23
Pulmonary artery occlusive pressure

• A wave represents left atrial contraction
• C wave represents closure of the mitral valve
  although rarely actually seen
• V wave represents filling of the left atrium
  while the mitral valve is closed

24
Pulmonary artery occlusive pressure

• PAOP or wedge represents a static column of blood
  from the catheter tip to the pulmonary v. to
  the left atrium
• Note the a wave is now past the QRS complex and
  the V wave is after the T wave (all delayed
  pressure transmission)

25
Pulmonary artery occlusive pressure

• The mean PAOP or wedge pressure occurs at the QRS
  complex can also be derived from the mean
  variance.

26
Pulmonary capillary wedge pressure hemodynamic
pathology

• Elevated mean pressure
• Increased volume
• Left ventricular failure
• Tamponade
• Obstructive atrial myxoma
• Elevated a wave
• Mitral stenosis
• decreased LV compliance
• Cannon a wave
• AV dysynchrony
• Elevated v wave
• Mitral regurgitation
• VSD

• PCWP does not left ventricular end-diastolic
  pressure
• Mitral stenosis
• Left atrial myxoma
• Cor triatriatum
• Pulmonary venous obstruction
• Decreased ventricular compliance
• Increased pleural pressure

27
Hemodynamic Pathology

• Mitral Stenosis
• Simultaneous wedge and left ventricular pressures
  are shown demonstrating a gradient at the end of
  diastole this is consistent with mitral
  stenosis.
• A second tracing is shown demonstrating a
  simultaneous left atrial and left ventricular
  pressure tracing once again note the gradient.
• How does the wedge tracing and LA tracing differ?

28
Hemodynamic Pathology

• Severe mitral Regurgitation
• Note the large CV waves this is due to
  ventricular systolic pressures reflected through
  the pulmonary circulation
• This patient had severe MR from a ruptured
  papillary muscle

29
Advancing Your Right Heart Catheter

• Not a good place to be during your right heart
  cath
• Similar waveform to the right atrial pressure
  tracing. Typically involves higher pressures and
  the v wave is gt a wave
• V wave is greater due to resistance from the
  pulmonary veins whereas the right atrium can
  decompress into the SVC and IVC.

30
Hemodynamic Pathology

• Mitral Regurgitation
• Simultaneous left atrial and left ventricular
  pressures demonstrate huge v waves present.
• The PCWP has a slight delay in the pressure
  tracing
• Will increase the PCWP and in acute setting
  triggers pulmonary edema from the increase
  osmotic forces
• Bad to have happen during valvuloplasty

31
Hemodynamic Pathology
Mitral Stenosis This patient underwent mitral
valvuloplasty resulting in a reduction of the
resting gradient by 10mmHg and an increase in CO
from 3.7 to 5.5LPM and a valve area from about
1.1 to 2.9 cm2
32
Left Ventricular Pressure Tracing

• Typically obtained by passing a pigtail catheter
  across the aortic valve
• Gives information regarding pressure changes
  across the aortic valve as well as the end
  diastolic pressures

33
Aortic Pressure waveform

• Waveform appears similar to the PA waveform with
  a smooth rounded peak
• Dicrotic notch noted represents sudden closure
  of the aortic valve
• Remainder represents smooth run-off in diastole

34
Hemodynamic Pathology

• Aortic Stenosis
• This reflects a pullback while continuously
  recording.
• The presence of significant aortic stenosis is
  reflected by the pressure gradient

35
Hemodynamic Pathology

• Aortic Regurgitation
• Note the rapidly increasing left ventricular
  end-diastolic pressure and equilibration of
  aortic and LV pressures at end-diastole

36
Measuring Cardiac Output

• Most commonly used methods are
• Thermodilution method
• Fick method
• There is no completely accurate way to assess
  cardiac output

37
Thermodilution

• Requires bolus injection of liquid commonly
  saline - into the proximal port.
• The change in temperature is measured by a
  thermistor mounted in the distal portion of the
  catheter
• Pitfalls
• Not accurate with TR
• Overestimates cardiac output at low output states

Birkbeck injection
38
Fick Method

• Fick Principle first described by Adolph Fick
  in 1870
• Assumes the rate at which O2 is consumed is a
  function of the rate of blood flow times the rate
  of O2 pick up by the red blood cells

39
Fick Method

• So cardiac output is expressed in the equation to
  the right
• Measurements should be made in the steady state.
• O2 consumption can be estimated
• 3ml O2/kg or 125ml/min/m2
• AV O2 difference is arterial venous O2 content
• saturation X1.36 X Hgb

e.g. AO sat 95, PA sat 65 Patient wght 70kg
and Hgb 13.0
210________ (0.95-0.65) X 1.36 X 13.0 X 10 3.96
L/min
40
(No Transcript)
41
A
42
B
43
C
44
D
45
E
46
F
47
G
48
H
49
I -PCWP tracing
50
J -PCWP
51
K
52
L
53
M
54
N