Right Heart Catheterization

Right Heart

Catheterization

Professor of Medicine Heart & Vascular Institute Penn State/Hershey Medical Center

Hershey, PA

DUKE 2010

Duke 2010 Presenter Disclosure Information

Ian C. Gilchrist, MD, FSCAI

Following relationships exist related to this presentation: Honorarium for Educational Lectures

Terumo Medical Corporation

Research Grants to Penn State

Angel Medical Systems, AstraZeneca Boston Scientific, Bristol-Myers Squibb Merck, Osiris Therapeutics Portola Pharmaceuticals, Roche

Evolution of Technique Brachial Artery Cutdown Percutaneous Femoral Access Transradial Arterial Access Complete Forearm Vascular

Duke 2010 Transradial

“Great invention and I’d love to invest, but I need to do a right heart catheterization,

I’m just sticking with the femoral approach”

Right & Left Heart Catheterization

From the Wrist

Gilchrist IC. Cathet Cardiovasc Intervent 2002;55:20-22.

Left Heart Catheter (blue) Right Heart Catheter

(white)

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Forearm Venous System

Extreme anatomic variability

– Collaterals

– Redundant passages

Veins relatively distensible Low pressure vs arterial Venous spasm

– Less likely with soft catheters

– Not usually a problem

General Rules of the Road

Expect variability, but

– Radial (lateral) veins tend to

form Cephalic vein (50%)

– Ulnar (medial) veins continue

as Basilic vein (100%)

Cephalic vein joins with the Axillary vein at a “T-Junction”.

Defines start of the subclavian and central venous system

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Venous System Access

Before entering the cath lab

Nurse IV Catheter (20 g) Heparin Lock

Nurse places heparin lock in forearm for use in the catheterization lab for venous sheath access.

• saves time

• improves cath lab efficiency • fosters team building

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Exchange Heparin Lock for Vascular Sheath

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Heparin Locks, Needles & Wires

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Trouble Shooting Access

Nurses unable to get access?

– Try in cath lab ± tourniquet

– Inspect arm carefully, try other arm

– Ultrasound for deep vessels (next to arteries)

No blood return on sheath aspiration?

– Veins collapse easily, not a concern if flush flows

easily

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Passing Catheter to Central System

• Do not inflate balloon tips before subclavian • Passage should be without resistance • X-ray at shoulder to confirm approach to “T

Junction”

• If resistance, take limited venogram • Hydrophilic wire may be helpful

• Once in subclavian system, rest is like any other upper body venous approach

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Venogram of Left Upper Arm

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Trouble Shoot at the “T Junction”

Trouble Shoot at the “T Junction”

• Do not push!

• Do not inflate balloon in cephalic • Inspiration may change angle &

enhance central flow

• Hydrophilic or other small wire may be useful

• Confirm with venogram

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Finishing the Procedure

• Remove right heart catheter with balloon 

• Remove sheath

• Use local compression (elastic) & elevation for hemostasis

• Right heart catheter can potentially be left in place, although historical experience suggests a hazard of thrombosis.

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Central Venous Obstruction Obstruction

icg2009

Central Venous Obstruction

• Devices, s/p trauma, cancer therapy (lines/radiation)  risk • Venogram if obstruction to

catheter

• Try hydrophilic wire or other small wire

• May be able to recannulate, but also may perforate

solution

catheter obstruction

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icg2009

Obstruction at Shoulder Repair

• Prior shoulder fracture • Catheter not tracking over

hydrophilic wire

• Venogram shows problem • Unable to track course • Finished in left arm

wire catheter

collaterals

solution

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Left/Right Heart Procedures

Femoral vs Radial Time (minutes) Procedural Time Femoral (n=175) Radial (n=105) Arterial Time Femoral (n=175) Radial (n=105) Less radiation time

p<.001

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What else from the Arm?

Endomyocardial Biopsy Temporary Pacing Caval Filters

Cephalic/Axillary Junction •Cephalic vein makes 90° turn •Ulnar side access straightest course

Right Heart Catheterization

• Balloon-tip, 120 cm catheter Temporary Pacing Endomyocardial Biopsy Caval Filters

Venous Access

• Heparin lock placed by nurses • Exchanged for 5F sheath • NTG used for veno-spasm

Radial Artery Access

• 4-6 F Micropuncture Sheath • Nicardipine vasodilator • Systemic heparin Forearm Approach Duke 2010 Cautions Obstruction to drainage

– Radial breast surgery

– Trauma

– SVC disease

Prior brachial cutdown No visible veins

Ref (July 2006): http://assets.families.com/Encyclopedias/gea2_02_img0132.jpg

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Duke 2010

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