Right heart catheterization

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E. Wierda MD, PhD and H.C. Hoftijzer, MD, PhD from the OLVG, The Netherlands


Right heart catheterization

Introduction

Right heart catheterization (or pulmonary artery catheterization) provides information about hemodynamics of the circulation. An important goal is precise assessment of pressure waves generated by the different cardiac chambers. It is used to differentiate forms of shock (cardiac vs non-cardiac) and measurement of cardiac output in the ICU, and monitor the effect of inotropic and vasopressive medication. In the cathlab it is used to differentiate origin of pulmonary hypertension (primary vs secondary), as assessment of valve abnormalities, cardiac shunts and tamponade. Simultaneous measurement of left and right sided pressures can be used to precisely determine whether constrictive pericarditis is present.

It was once common to perform a right heart catheterization in every patient that came into the cathlab. The use of it has fallen because nowadays left heart catheterization alone is adequate for most patients undergoing evaluation of coronary artery disease.

Technique

For right sided pressure monitoring a catheter is inserted into the pulmonary artery. The pulmonary artery catheter (PAC) is frequently referred to as a Swan-Ganz catheter, named after its inventors Jeremy Swan and Willam Ganz in 1970.

A PAC is a 5-7 french catheter which consists of 2-5 lumina with different purposes: a lumen for inflation of the balloon, a proximal and distal lumen for infusion of fluid or extraction of blood, a temperature thermistor and one for RV pacing.

Figure 1. Swan-Ganz catheter.

Ports left to right: thermistor connector, medication portal, proximal injection hub, distal lumen hub, balloon inflation valve with syringe.

Following local anesthesia, the femoral, jugular, brachial or subclavian vein is punctured, then a guidewire is introduced into the vein by Seldinger technique. Next a sheath is introduced. Femoral access is associated with increased risk of local hemorrhage. When the catheter is left indwelling, the jugular or subclavian vein is preferable, because it allows the patient to sit. The jugular approach is preferred to the subclavian to lessen the risk of pneumothorax and is easiest performed ultrasound guided. The basilica or medial antibrachial vein (the continuation of the basilica in the underarm, see figure 2) can also be used, while contrast via an radial arterial sheath (for cardiac output measurement) will visualize the vein.

Figure 2. Part of the venous and arterial system.

After placement of the sheath, the flushed catheter is introduced into the vein and advanced into the inferior vena cava, superior vena cava, right atrium, right ventricle and pulmonary artery (figure 3).



Figure 3. Right heart catheterization from the femoral vein[1]

Top row: the PAC is placed in the right atrium aimed at the lateral wall. Counterclockwise rotation aims the catheter posteriorly and allows advancement into the superior vena cava. Centre row: the catheter is then withdrawn into the right atrium and aimed laterally. Clockwise rotation causes the tip to cross the tricuspid valve. With the tip in a horizontal position, it is positioned below the right ventricular outflow tract. Additional clockwise rotation causes the catheter to point straight up, allowing it to advance into the pulmonary artery and from there into the right pulmonary artery.


Normal and abnormal waveforms

The normal pressure waves in the cardiac chambers during right heart catheterization with normal values shown are shown in figure 4 and 5. After that, we discuss per chamber the pressure curve[2], normal values and causes of abnormal waveforms.

Figure 4. Normal pressurewaves.



Figure 5. Normal values right heart catheterization[1]

Table 19-3: Normal Pressures and Vascular Resistances
Pressures Average (mm Hg) Range (mm Hg)
Right atrium
a wave 6 2-7
v wave 5 2-7
Mean 3 1-5
Right ventricle
Peak systolic 25 15-30
End-diastolic 4 1-7
Pulmonary artery
Peak systolic 25 15-30
End-diastolic 9 4-12
Mean 15 9-19
Pulmonary capillary
Wedge
Mean 9 4-12
Left atrium
a wave 10 4-16
v wave 12 6-21
Mean 8 2-12
Left ventricle
Peak systolic 130 90-140
End-diastolic 8 5-12
Central aorta
Peak systolic 130 90-140
End-diastolic 70 60-90
Mean 85 70-105
Vascular Resistance Mean (dyne-sec · cm -5) Range (dyne-sec · cm -5)
Right atrium
Systemic vascular resistance 1100 700-1600
Total pulmonary resistance 200 100-300
Pulmonary vascular resistance 70 20-130


Right atrium

a = atrial systole
x= atrial relaxation, decrease of pressure
c= closure of the tricuspid valve
v= ventricular systole, atrial diastole
y= passive filling of right ventricle[3]


Normal RA pressure = 6 mmHg (3 mean)
Higher RA pressure in RV infarction, pulmonary hypertension, left to right shunts, tricuspid regurgitation, tamponade, pericarditis constrictiva, restrictive cardiomyopathy.

Abnormal right atrium pressure waves

  1. Elevated a wave: tricuspid stenosis, decreased ventricular compliance due to ventricular failure, pulmonic valve stenosis
  2. Absent a wave: atrial fibrillation
  3. Sawtooth a wave: atrial flutter
  4. Elevated v wave: tricuspid regurgitation (prominent y descent), RV failure
  5. Prominent x descent: tamponade
  6. Kussmaul sign (aspiratory rise of lack of decline in RA pressure): constrictive pericarditis, RV ischemia
Figure 8 Elevated v wave and prominent y descent in tricuspid regurgitation
Figure 9 Prominent y descent (with square root sign) and equalization of RA and RVEDP: tamponade, constrictive pericarditis, restrictive cardiomyopathy


Right ventricle

sys= systole ed= end-diastolic pressure (RVEDP) RF= rapid filling fase (60% of RV filling) SF= slow filling (15% of RV filling) a= atrial contraction (corresponding with a wave of RA curve) (25% of RV filling)[3]

Normal RV pressure = 25 / 4 mmHg
When there are no abnormalities in the right heart: CVP = RA pressure = RVEDP. The pressure curve consists of a fast upstroke, a rounded top, directly after the QRS complex. Higher RV pressure in pulmonary hypertension, pulmonic valve stenosis, significant ASD or VSD, pulmonary embolism (in acute pulmonary embolism mostly not above 40-50mmHg).

Abnormal right ventricle pressure waves

  1. Systolic pressure reduced: hypovolemia, cardiogenic shock, tamponade
  2. Elevated end diastolic pressure: cardiomyopathy, RV ischemia and infarction, RV failure, tamponade, pericarditis constrictiva
  3. Decreased end diastolic pressure: tricuspid stenosis
  4. Dip-and-plateau in constrictive pericarditis and restrictive myopathies


Pulmonary artery pressure

sys= RV systole D= dicrotic notch = closure of the pulmonic valve ed= end-diastolic pressure[3]

Normal PA pressure 25 / 9 mmHg (mean 15)

Abnormal pulmonary artery pressure waveforms

  1. Elevated systolic pressure: idiopathische pulmonary hypertension, pulmonary disease, hypoxemia with pulmonary vasoconstriction, mitral stenosis or regurgitation, restrictive cardiomyopathies, significant cardiac left to right shunt, pulmonary embolism
  2. Reduced pulce pressure: RV ischaemia or infarction, pulmonary embolism, tamponade


Pulmonary capillary wedge pressure (PCWP)

a= atrial contraction x= atrial relaxation v= atrial diastole (ventricular contraction) y= passive filling of the LV after mitral valve opening[3]

Normal PCWP pressure range = 4-12 mmHg (mean 9)
When there is no obstruction between left atrium and left ventricle: PCWP = LA pressure = LVEDP. A true wedge pressure can be measured only in the absence of flow”, meaning with a vessel closed for flow by a balloon.

Normally PCWP equals LAP equals LVEDP. The PCWP is higher than the LVEDP in:

  • Mitral stenosis
  • LA obstruction by myxoma
  • Mitral regurgitation
  • Pulmonary embolism or veno-occlusive disease
  • Respiratory failure (hypoxemia and pulmonary vasoconstriction)


The LVEDP is higher than the wedge in:

  • Diastolic dysfunction, positive end-expiratory airway pressure
  • Myocardial infarction
  • Tamponade
  • Aortic regurgitation (early closure mitral valve)


4.8 Abnormal PCWP pressure

  1. Low mean pressure: hypovolemia
  2. Elevated mean pressure: intravascular overload, LV failure caused by myocardial disease, systemic hypertension or valvular disease (MS, AoS, AoR), pericardial effusion with tamponade
  3. Elevated a wave: mitral stenosis, diastolic dysfunction, LV volume overload
  4. Cannon a wave due to atrial-ventricular asynchrony
  5. Elevated v wave: mitral regurgitation, LV failure, VSD


Figure 10. Prominent v wave in mitral regurgitation.[4]


Complications

Possible complications of right heart catheterization are (next to complications at the puncture site) are rhytm disorders (atrial extrasystole, ventricular extrasystole, ventricular tachycardia, ventricular fibrillation), conduction disorders (RBBB, this can be exceptionally dangerous in case of a preexisting LBBB, when a complete heart block develops), damage to the pulmonic or tricuspid valve (this can be prevented by pull back with a deflated balloon), thrombo-emolism of pulmonary infarction. In 0.03-0.2% a pulmonary rupture is described.




References

  1. Braunwald E et al. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th edition: page 445. [Braunwald]
  2. Redrawn from Gore, JM, Alper, JS, Benotti, JR, et al. Handbook of hemodynamic monitoring, 1st ed, Boston, Little Brown & Co, 1985. [Gore]
  3. Redrawn from Daily EK, Schroeder JS, Hemodynamic Waveforms: Exercises in Interpretation and Analysis, St. Louis, CV Mosby, 1983, p. 139. [DailyEK]