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

5. Complications Access Access Pneumonthorax Pneumonthorax Hemothorax Hemothorax Tracheal perforation Tracheal perforation Intracardiac Intracardiac Stimulation of the RVOT – ventricular arrhythmias Stimulation of the RVOT – ventricular arrhythmias AV block- be aware in patients with a LBBB (consider a temporary pacemaker prior to proceding) AV block- be aware in patients with a LBBB (consider a temporary pacemaker prior to proceding) Causing a RBBB Causing a RBBB Atrial arrhythmias Atrial arrhythmias Pulmonary rupture Pulmonary rupture Pulmonary infarct Pulmonary infarct RV puncture 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: 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 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]) 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. 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 A. Puncture vessel by needle B. Flexible guidewire placed into vessel via 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 C. Needle removed and guidewire left in place, hole in skin is enlarged with a scalpel D. Sheath and dilator placed over the guidewire D. Sheath and dilator placed over the guidewire E. Sheath and dilator advanced into the vesssel E. Sheath and dilator advanced into the vesssel F. Dilator and sheath removed while sheath remains in the vessel F. Dilator and sheath removed while sheath remains in the vessel Modified Seldinger’s technique

8. Right Heart Pressures Tracings

9. Advancing Your Right Heart Catheter Advance the SGC to about 20cm and inflate the balloon tip. 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 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 There will be an x and y descent

10. Right Atrial Pressure Tracing a wave – results from atrial systole a wave – results from atrial systole c wave – occurs with the closure of the tricuspid valve and the initiation of atrial filling 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 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 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) c wave – when present occurs at the end of the QRS complex (RST junction) v wave – occurs after the T wave 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 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 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 The v wave is usually smaller than the a wave in the right atrium

13. Right atrial hemodynamic pathology Elevated a wave Elevated a wave Tricuspid stenosis Tricuspid stenosis Decreased RV compliance Decreased RV compliance e.g. pulm htn, pulmonic stenosis e.g. pulm htn, pulmonic stenosis Cannon a wave Cannon a wave AV asynchrony – atrium contracts against a closed tricuspid valve AV asynchrony – atrium contracts against a closed tricuspid valve e.g. AVB, Vtach e.g. AVB, Vtach Absent a wave Absent a wave Atrial fibrillation or standstill Atrial flutter Elevated v wave 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 Tricuspid Stenosis Large jugular venous a waves on noted on exam Large jugular venous a waves on noted on exam Notable elevated a wave with the presence of a diastolic gradient - >5mmHg gradient is considered signficant Notable elevated a wave with the presence of a diastolic gradient - >5mmHg gradient is considered signficant

16. Advancing Your Right Heart Catheter Continue advancing the catheter into the right ventricle Continue advancing the catheter into the right ventricle The right and left ventricular pressure tracings are similar. The right and left ventricular pressure tracings are similar. The right ventricular has a shorter duration of systole 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 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 Note the notch on the top of RV pressure waveform This represents “ringing” of a fluid- filled catheter This represents “ringing” of a fluid- filled catheter Ringing can also be noted on the diastolic portion of the waveform 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 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. 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 Closure of the pulmonic valve is indicated by the dicrotic notch

19. Timing of the PA pressure Peak systole correlates with the T wave Peak systole correlates with the T wave End diastole correlates with the QRS complex End diastole correlates with the QRS complex

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

21. Pulmonary artery hemodynamic pathology Elevated systolic pressure Elevated systolic pressure Primary pulmonary hypertension Primary pulmonary hypertension Mitral stenosis or regurgitation Mitral stenosis or regurgitation Restrictive myopathies Restrictive myopathies Significant L to R shunt Significant L to R shunt Pulmonary disease Pulmonary disease Reduced systolic pressure Reduced systolic pressure Pulmonary artery stenosis Pulmonary artery stenosis Ebstein’s anomaly Ebstein’s anomaly Tricuspid stenosis Tricuspid stenosis Tricuspid atresia Tricuspid atresia Reduced pulse pressure Reduced pulse pressure Right heart ischemia Right heart ischemia Pulmonary embolus Pulmonary embolus Tamponade Tamponade Bifid pulmonary artery waveform Bifid pulmonary artery waveform Large left atrial v wave transmitted backward Pulmonary artery diastolic pressure > pulmonary capillary wedge pressure Pulmonary artery diastolic pressure > 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) 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 Similar waveform to the left atrial waveform although damped

23. Pulmonary artery occlusive pressure A wave – represents left atrial contraction A wave – represents left atrial contraction C wave – represents closure of the mitral valve although rarely actually seen 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 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 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) 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. 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 Elevated mean pressure Increased volume Increased volume Left ventricular failure Left ventricular failure Tamponade Tamponade Obstructive atrial myxoma Obstructive atrial myxoma Elevated a wave Elevated a wave Mitral stenosis Mitral stenosis decreased LV compliance decreased LV compliance Cannon a wave Cannon a wave AV dysynchrony AV dysynchrony Elevated v wave Elevated v wave Mitral regurgitation Mitral regurgitation VSD VSD PCWP does not = left ventricular end-diastolic pressure 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 Mitral Stenosis Simultaneous wedge and left ventricular pressures are shown demonstrating a gradient at the end of diastole – this is consistent with 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. 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? How does the wedge tracing and LA tracing differ?

28. Hemodynamic Pathology Severe mitral Regurgitation Severe mitral Regurgitation Note the large CV waves – this is due to ventricular systolic pressures reflected through the pulmonary circulation 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 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… 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 > a wave Similar waveform to the right atrial pressure tracing. Typically involves higher pressures and the v wave is > a wave V wave is greater due to resistance from the pulmonary veins whereas the right atrium can decompress into the SVC and IVC. 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 Mitral Regurgitation Simultaneous left atrial and left ventricular pressures demonstrate huge v waves present. Simultaneous left atrial and left ventricular pressures demonstrate huge v waves present. The PCWP has a slight delay in the pressure tracing 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 Will increase the PCWP and in acute setting triggers pulmonary edema from the increase osmotic forces Bad to have happen during valvuloplasty 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 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 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 Waveform appears similar to the PA waveform with a smooth rounded peak Dicrotic notch noted – represents sudden closure of the aortic valve Dicrotic notch noted – represents sudden closure of the aortic valve Remainder represents smooth run-off in diastole Remainder represents smooth run-off in diastole

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

35. Hemodynamic Pathology Aortic Regurgitation Aortic Regurgitation Note the rapidly increasing left ventricular end- diastolic pressure and equilibration of aortic and LV pressures at end- diastole 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 Most commonly used methods are Thermodilution method Thermodilution method Fick method Fick method There is no completely accurate way to assess cardiac output There is no completely accurate way to assess cardiac output

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

38. Fick Method Fick Principle – first described by Adolph Fick in 1870… 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 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 So cardiac output is expressed in the equation to the right Measurements should be made in the steady state. Measurements should be made in the steady state. O2 consumption can be estimated O2 consumption can be estimated 3ml O2/kg or 125ml/min/m2 3ml O2/kg or 125ml/min/m2 AV O2 difference is arterial – venous O2 content AV O2 difference is arterial – venous O2 content = saturation X1.36 X Hgb = 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

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