A Resident's Guide to the CCU
Pump Problems

Right Heart Catheterization vs. Left Heart Catheterization vs. Coronary Angiogram

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Case Presentation:

A 62-year-old female with PMH of hypertension, diabetes, and tobacco use presents with exertional angina that comes and goes with activity, as well as dyspnea on exertion that has progressively worsened over the past 2 months. On physical exam, she has 2+ pitting edema of bilateral lower extremities and JVD suggesting a right atrial pressure of 14. Crackles are heard on auscultation and the patient is saturating 90% on 2L of nasal cannula. BNP is 340 without prior baseline. EKG is without ST changes. She is admitted for further workup. A TTE is obtained and demonstrates normal LVEF (35%) and moderate tricuspid regurgitation. To further investigate her symptoms, she undergoes a left heart catheterization (LHC), right heart catheterization (RHC), and coronary angiogram.

Ask Yourself:

Questions:

1. What are the common indications for the procedures this patient will undergo?

2. What information can be obtained and how can the data be used to guide diagnosis and management of the patient’s condition?

3. What are the most common complications and what is the management?

Background

When patients present with symptoms suggestive of ischemia, the first step is to risk stratify and determine if the patient is a high risk for adverse cardiac events due to acute coronary syndrome (ACS). Higher risk patients should be triaged to an early invasive strategy to assess coronary anatomy via coronary angiography (Figure 2). Patients with findings concerning for structural heart disease or decompensated heart failure may also benefit from invasive hemodynamic testing with left and right heart catheterization (Figures 3 and 4, respectfully). 

Lower risk patients may be assessed with non-invasive modalities, such as stress testing or CT coronary angiograms. Risk assessment tools, like the GRACE scale, HEART score, and TIMI risk index, use variables such as age, past medical history, EKG changes, biomarkers, vital signs, and physical exam to objectively predict the risk of acute adverse clinical events. 

Figure 2 represents a coronary angiogram, which helps us determine the extent of the coronary artery disease. In this procedure, access is usually obtained via the radial or femoral artery (left). Dye is then injected into the coronary arteries (right). This allows us to visualize the anatomy of the coronary arteries and intervene via stent placement if the occlusion is significant.

Figure 3 shows a Left Heart Catheterization. Note how the catheter cross the aortic valve. 

Unlike the coronary angiogram and LHC that is done via arterial access, the Right Heart Catheterization shown in Figure 4 is done through venous access.

Coronary Angiogram and PCI:

1. Coronary Angiogram: 

Indication: Defining coronary anatomy 

Procedure: a catheter is advanced through the femoral or radial artery into the ascending aorta. Contrast media is injected into the coronary arteries, which allows for visualization of the anatomy of the coronary arteries via multiple orthogonalviews. Standard viewing angles are necessary to account for the limitations of two-dimensional radiographic images. (figure 5).

Pros: High negative predictive value, i.e. absence of obstruction suggests absence of epicardial coronary disease as cause of symptoms

Cons: Invasive, risk of contrast induced nephropathy, radiation exposure, expensive

During a coronary angiogram, a percutaneous coronary intervention (PCI) can be done. 

1a. Percutaneous Coronary Intervention (PCI): 

Purpose: To correct obstructive lesions that are diagnosed via the coronary angiogram 

Procedure: Once a lesion is demonstrated on angiogram, wires are advanced through the catheter until the lesion is crossed. The lesion may then be treated with a combination of lesion preparation (angioplasty, atherectomy, lithotripsy) and stenting.

The pictures above represent a cardiac catheterization, which helps us determine the extent of the coronary artery disease. In this procedure, access is usually obtained via the radial or femoral artery (left). Dye is then injected into the coronary arteries (middle). This allows us to visualize the anatomy of the coronary arteries (right) and intervene via stent placement if the occlusion is significant.

What Happens in the Cath Lab:

When patients are in the cath lab, they lay on a table that has a C shaped machine around them (Figure 6). The top of the machine has the X-ray, while the bottom of the machine below the patient is the intensifier. This C-shaped machine, known colloquially as the C-arm, can move to the right, left, up, and down. Since the coronary arteries do not all sit or travel through the same plane, being able to move the X-ray source to different angles allows for better visualization of the coronary arteries.


If we move the C-arm 30o to the right of the patient and up towards their head, this would be a right anterior oblique (RAO) at 30o towards the cranial direction. In the cath lab, we would call this an RAO 30o, cranial view.

Pictures courtesy of Dr. David Shavelle, Basic Coronary Angiography 

Left Heart Catheterization (LHC):

2. Left Heart Catheterization (LHC): 

Indication: To assess LV end-diastolic pressure, measure the gradient between the LV and the aorta (aortic stenosis, obstructive cardiomyopathy), and perfom LV ventriculography (assess LV systolic function and quantify mitral valve regurgitation)

Procedure:  A pigtail catheter is advanced through the femoral or radial artery into the ascending aorta and then across the aortic valve into the left ventricle (Figure 7). Contrast is injected into the LV using a mechanical injector in the LAO and RAO projections.

Complications: Ventricular arrhythmia (corrected with repositioning of the catheter or removal), ventricular perforation, pericardial effusion, tamponade (corrected with immediate pericardiocentesis and or surgical repair), air embolism, or thromboembolism


*LVEDP: directly measured during LHC. LVEDP is an index of LV diastolic function. It can also represent degree of cardiac preload. Normal LVEDP is 4-12mmHg. Elevated LVEDP is indicative of heart failure which may be due to systolic heart failure, diastolic heart failure, or valvular heart disease. Knowing the LVEDP (or its surrogate the pulmonary capillary wedge pressure) can help distinguish between cardiac and non-cardiac causes of pulmonary edema.

During a left heart catheterization, a Left Ventriculogram (LVG) can be performed to help better assess LV structure and function. 

Purpose: Assess global and segmental LV function, wall motion abnormalities, potential wall perforations, presence of masses, thrombi, mitral valve regurgitation, aortic function, and presence of VSD. For example, a LVG is a great test to diagnose apical ballooning (as seen below): 

Complications:

  • Ventricular arrhythmia corrected with repositioning of the catheter or removal

  • Ventricular perforation, pericardial effusion, tamponade corrected with immediate pericardiocentesis and or surgical repair

  • Air embolism or thromboembolism

Right Heart Catheterization:

3. Right heart catheterization (RHC)

Right heart catheterization measures chamber pressures and cardiac output. Along with the LHC and systemic aortic pressure the RHC can provide a comprehensive picture of the patient’s hemodyanmic status. Hemodyanmic data can help determine volume status and differentiate between cardiogenic and non-cardiogenic shock. Within cardiogenic shock RHC derived data can identify right sided vs. left sided pathology. These data can be critical when managing patients with shock in the intensive care unit and can help guide the use of pressors, inotropes and mechanical circulatory support.

Procedure: The procedure is performed via venous access from any of the arms (brachial, antecubital) neck (internal jugular or subclavian) or legs (common femoral).

Complications:

-Ventricular Arrhythmia, RBBB, Complete heart block (increased risk if prior LBBB), air embolism, pulmonary artery perforation (~0.03% if prolonged balloon inflation & distal placement into pulmonary arteries with mortality is 33-80%), arterial injury due to inadvertent puncture, pneumothorax

Figure 8 demonstrates a Right heart catheterization and the different pressures and waveforms seen as the catheter is progressed. CVP- central venous pressure at the right atria; RVP- right ventricular pressure; PAP- pulmonary artery pressure, Wedge--a surrogate for left atrial pressure

Indications: 

1. Measuring Cardiac Pressures:  Right Atrial Pressure (central venous pressure) > Right Ventricular Pressure > Pulmonary Artery Pressure > Pulmonary Capillary Wedge Pressure (surrogate for Left Atrial Pressure which is a surrogate of LVEDP)

2. Measuring Cardiac Output/Cardiac Index: CO adjusted for body surface area)

A. Fick: Cardiac output is calculated based on the difference between the aortic and mixed venous oxygenation when hemoglobin and oxygen consumption are known. More commonly the “Estimated Fick” is calculated based on assumptions of oxygen consumption based on height and weight.

B. Thermodilution: specific volume of fluid (often chilled D5W) at a known temperature is injected via a port proximal to the thermometer at the distal tip of the catheter. The rate of temperature change is used to calculate flow and thus provide the cardiac output.

3. Diagnose Pulmonary Hypertension

Access Complications:

The risk of major complications is low (<1%). These complications include death, myocardial infarction, and stroke. 

  1. Death (0.05%)

  2. MI (0.1%)

  3. Stroke (0.05-0.1%)

  4. Atheroembolism

  5. Allergic Reaction - Contrast (1%)

  6. Contrast induced nephropathy - Transient increase in Creatinine varies from 3-16%

  7. Arrhythmia: Vfib, Vtach, heart block

Figure 10: Demonstrates compartment syndrome of the arm. Top picture shows normal compartments, while the bottom picture shows swelling in the compartments. The right picture shows compartment syndrome and treatment with fasciotomy. Picture courtesy of TrialEx 

Back to the Case:

1. What are the common indications for the procedures this patient will undergo?

The patient presents with a constellation of signs and symptoms that are concerning for ischemic heart disease and heart failure. She has signs of fluid overload on exam and dyspnea on exertion which can be due to heart failure, valve disease or non-cardiac causes. The patient’s hemodynamics are studied with RHC and LHC followed by coronary angiography to determine her anatomy. 

2. What information can be obtained and how can the data be used to guide diagnosis and management of the patient’s condition?

If obstructive lesions were identified on coronary angiogram, PCI could have been performed. LHC showed normal LVEDP and essentially ruled out left sided heart failure which has important implications for treatment of her symptoms. Finally, with the hemodynamic data obtained from RHC, she was diagnosed with pulmonary artery hypertension, likely Group I and started on appropriate treatment. Her negative response to vasodilation indicated unlikely benefit from CCB. 

3. What are the most common complications and what is the management?

The most common complications residents will likely see are those related to vascular access, which can be very dangerous and life-threatening. It is crucial that you understand the potential vascular complications, including hematoma, pseudoaneurysm formation, dissection, retroperitoneal bleed, and compartment syndrome. As such, ALL patients who have undergone any arterial access procedures (such as coronary angiogram, LHC, Impella or balloon pump placement) MUST have frequent site checks.

Further Learning:

Attending / Fellow pearls: 

  • When patients get radial access, they will come back from the cath lab with a TR (transradial) band (Figure 9). When these are put on in the cath lab, they are done so in such a way that they are holding enough pressure without cutting off blood supply to the hand. Each hospital has its own protocol in terms of how to deflate the TR band; however, the general idea is that it is on for about 1 – 2 hours and then is deflated slowly  (~2cc every 15 minutes). If there is any bleeding, the band may be re-inflated . This is done until the TR band is fully deflated. Note: If the TR band is kept on too long or applied inappropriately, it can cause digital ischemia and compartment syndrome. Therefore, it is important to personally evaluate any nursing or patient concerns regarding the TR band and to call the fellow.

  • If you are concerned about a hematoma, make sure to demarcate! This will allow you to see how fast the hematoma is growing.

  • Be careful when holding pressure on any arterial access! Too much pressure can inhibit blood flow and lead to downstream ischemia!

  • Anytime patients have their femoral arteries access, they must lay flat after the procedure and minimize leg movements! This will help to prevent femoral artery bleeding.

Resident responsibilities:

  • We take care of many patients after catheterization procedures so monitoring for post procedural complications is important. Take changes in vital signs seriously when alerted to them by nursing staff and go assess the patient.

  • If the patient is becoming hemodynamically unstable, make sure to check the access site! If there is ever a question about hematoma or bleed, you MUST  HOLD PRESSURE call the fellow, prepare for transfusion (have large bore venous access, type and cross) especially when arterial access was used.

Further Readings:

How’d we do?

The following individuals contributed to this topic: Shaina Cherniak, DO, Amer Ardati, MD

Chapter Resources

RHC Resources:

  • Bayliss M, Andrade J, Heydari B, et al.. Jeremy Swan and the pulmonary artery catheter: paving the way for effective hemodynamic monitoring Issue. BCMJ 2009;51:302–7.

  • Binanay C, Califf RM, Hasselblad V, et al.; ESCAPE Investigators and ESCAPE Study Coordinators. Evaluation study of congestive heart failure and pulmonary artery catheterization effectiveness: the ESCAPE trial. JAMA. 2005;294:1625–1633.

  • Callan P, Clark AL. Right heart catheterisation: indications and interpretation. Heart. 2016;102:147–157.

  • Chen Y, Shlofmitz E, Khalid N, et al. Right Heart Catheterization-Related Complications: A Review of the Literature and Best Practices. Cardiol Rev. 2020;28(1):36-41. doi:10.1097/CRD.0000000000000270

  • Chokkalingam Mani B, Chaudhari SS. Right Heart Cardiac Catheterization. [Updated 2022 May 9]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557404/

  • Connors AF Jr, Speroff T, Dawson NV, et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators. JAMA. 1996;276:889–897.

  • Cruz K, Franklin C. The pulmonary artery catheter: uses and controversies. Crit Care Clin 2001;17:271–91. doi:10.1016/S0749-0704(05)70167-6

  • Meyer JA. Werner Forssmann and catheterization of the heart, 1929. Ann Thorac Surg 1990;49:497–9. doi:10.1016/0003-4975(90)90272-8

  • Kanwar MK, Tedford RJ, Thenappan T, De Marco T, Park M, McLaughlin V. Elevated Pulmonary Pressure Noted on Echocardiogram: A Simplified Approach to Next Steps. J Am Heart Assoc. 2021;10(7):e017684. doi:10.1161/JAHA.120.017684

  • Hoeper M, Lee S, Voswinckel R, et al.. Complications of right heart catheterization procedures in patients with pulmonary hypertension in experienced centers. J Am Coll Cardiol 2006;48:2546–52.

  • Humbert M, Montani D, Evgenov OV, Simonneau G. Definition and classification of pulmonary hypertension. Handb Exp Pharmacol. 2013;218:3-29. doi:10.1007/978-3-642-38664-0_1

  • Klok FA, Couturaud F, Delcroix M, Humbert M. Diagnosis of chronic thromboembolic pulmonary hypertension after acute pulmonary embolism. Eur Respir J. 2020;55(6):2000189. Published 2020 Jun 25. doi:10.1183/13993003.00189-2020

  • Robin ED. The cult of the Swan-Ganz catheter. Overuse and abuse of pulmonary flow catheters. Ann Intern Med. 1985;103:445–449

  • Rose-Jones LJ, Mclaughlin VV. Pulmonary hypertension: types and treatments. Curr Cardiol Rev. 2015;11(1):73-9. doi: 10.2174/1573403x09666131117164122. PMID: 24251459; PMCID: PMC4347212.

LHC Resources:

  • Ahmed I, Hajouli S. Left Heart Cardiac Catheterization. [Updated 2023 Jan 28]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK564323/

  • Ajayi NO, Lazarus L, Vanker EA, Satyapal KS. The impact of left main coronary artery morphology on the distribution of atherosclerotic lesions in its branches. Folia Morphol (Warsz). 2013;72(3):197-201. doi:10.5603/fm.2013.0033

  • Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64-multidetector row coronary computed tomographic angiography for evaluation of coronary artery stenosis in individuals without known coronary artery disease: results from the prospective multicenter ACCURACY (Assessment by Coronary Computed Tomographic Angiography of Individuals Undergoing Invasive Coronary Angiography) trial. J Am Coll Cardiol. 2008;52(21):1724-1732. doi:10.1016/j.jacc.2008.07.031

  • DISCHARGE Trial Group, Maurovich-Horvat P, Bosserdt M, et al. CT or Invasive Coronary Angiography in Stable Chest Pain. N Engl J Med. 2022;386(17):1591-1602. doi:10.1056/NEJMoa2200963

  • Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015;372(14):1291-1300. doi:10.1056/NEJMoa1415516

  • Houssany-Pissot S, Rosencher J, Allouch P, et al. Screening coronary artery disease with computed tomography angiogram should limit normal invasive coronary angiogram, regardless of pretest probability. Am Heart J. 2020;223:113-119. doi:10.1016/j.ahj.2019.12.023

  • Jolly SS, Amlani S, Hamon M, Yusuf S, Mehta SR. Radial versus femoral access for coronary angiography or intervention and the impact on major bleeding and ischemic events: a systematic review and meta-analysis of randomized trials. Am Heart J. 2009 Jan;157(1):132-40.

  • Min JK, Hachamovitch R, Rozanski A, Shaw LJ, Berman DS, Gibbons R. Clinical benefits of noninvasive testing: coronary computed tomography angiography as a test case. JACC Cardiovasc Imaging. 2010;3(3):305-315. doi:10.1016/j.jcmg.2009.04.017

  • Nishimura RA, Rihal CS, Tajik AJ, Holmes DR Jr. Accurate measurement of the transmitral gradient in patients with mitral stenosis: a simultaneous catheterization and Doppler echocardiographic study. J Am Coll Cardiol. 1994;24(1):152-158. doi:10.1016/0735-1097(94)90556-8

  • SCOT-HEART Investigators, Newby DE, Adamson PD, et al. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. N Engl J Med. 2018;379(10):924-933. doi:10.1056/NEJMoa180597