14.16: Cardiac Catheterization II: Right Heart Catheterization

Right Heart Catheterization: An Overview

Right heart catheterization is an invasive diagnostic procedure that measures right-sided cardiac and pulmonary artery pressures, calculates cardiac output, and identifies intracardiac shunts. It provides detailed hemodynamic data essential for diagnosing and managing various cardiovascular conditions, such as pulmonary hypertension.

Access Sites

Common access sites for right heart catheterization include the internal jugular vein in the neck region, the antecubital veins in the arm, and the femoral vein in the leg, which are commonly accessed major veins for right heart catheterization. These veins drain directly into the right atrium, facilitating the smooth passage of the catheter into the right heart and pulmonary artery.

Indications and Contraindications

Indications for right heart catheterization include assessing pulmonary hypertension, evaluating congenital heart disease, and monitoring the hemodynamic status of patients with heart failure or shock. Contraindications include active right-sided endocarditis, obstructive right-sided tumors or thrombi, and severe coagulopathy.

Procedure

Pulmonary artery catheters for this procedure are typically 110 cm long, with French sizes ranging from 5F to 8F, depending on clinical indications and the patient's anatomy. After obtaining informed consent, the patient is positioned supine on the table in the cardiac catheterization lab. Patients are often given sedatives to help them relax and remain comfortable during the procedure. The access sites are cleaned and draped in a sterile manner. A local anesthetic is administered at the access site, and venous access is obtained using a needle and guidewire technique.

A sheath is then placed into the vein to facilitate catheter insertion. The pulmonary artery catheter is advanced via the sheath, guided through the right atrium and right ventricle and into the pulmonary artery. The movement is continuously monitored via fluoroscopy to ensure accurate placement and to avoid complications.

Once the catheter is properly positioned, further measurements, including pressure measurement and oxygen saturation, are obtained and recorded from the right atrium, right ventricle, and pulmonary artery to assess the function of the right heart and pulmonary circulation. Pulmonary artery pressures are specifically used to diagnose pulmonary hypertension. Additionally, a biopsy of a small piece of myocardial tissue can be obtained during a right heart catheterization to diagnose the etiology of cardiomyopathy (abnormality of the myocardium) or heart transplant rejection.

Post-Procedure Care

After completing the necessary measurements, the catheter is carefully withdrawn, and the sheath is removed. Pressure is applied to the catheter access site to prevent bleeding, and the site is dressed with a sterile bandage. The patient is then monitored for immediate complications and observed in the recovery area. Post-procedure care involves monitoring vital signs, assessing the access site for bleeding or infection, and providing the patient with appropriate recovery instructions. Patients should be instructed to watch for signs of complications such as increased pain, swelling, redness at the access site, or any unusual symptoms like shortness of breath or chest pain and to contact their healthcare provider immediately if these occur.

Complications

Complications of right heart catheterization can include arrhythmias, often resulting from the catheter's contact with the endocardium, and venous spasms caused by vessel irritation. Other risks include infection at the insertion site, right heart perforation, and air embolism if air inadvertently enters the catheter or pressure transducers.

Right heart catheterization is an invasive diagnostic procedure that directly measures right-sided cardiac and pulmonary artery pressures, calculates cardiac output, and identifies intracardiac shunts.

The primary veins commonly accessed for this procedure are the brachial, internal jugular, femoral, and antecubital veins.

These veins drain into the right atrium, facilitating the smooth passage of the catheter into the right heart and pulmonary artery.

During the procedure, position the patient supine, clean, and drape the access site using a sterile technique.

Administer a local anesthetic at the access site, then obtain venous access using a needle and guidewire technique. Insert a sheath into the vein to facilitate catheter placement.

Using fluoroscopic guidance, advance the pulmonary artery catheter through the sheath.

Obtain necessary measurements, such as pressures, as the catheter is moved into the right atrium, right ventricle, and pulmonary artery.

After completing the measurements, carefully withdraw the catheter and sheath, apply pressure to the access site to prevent bleeding, and dress the site with a sterile bandage.