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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.
 
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.
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[[File:RightHeart_Technique_Fig2.svg | thumb | right | 300px | Figure 2. Part of the venous and arterial system.]]
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[[File:RightHeart_Technique_Fig2.svg | thumb | left | 500px | 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).  
 
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).  
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[[File:RightHeart_Technique_Fig3.svg | thumb | left | 300px | Figure 3. Right heart catheterization from the femoral vein<cite>Braunwald</cite>]]
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[[File:RightHeart_Technique_Fig3.svg | thumb | left | 500px | Figure 3. Right heart catheterization from the femoral vein<cite>Braunwald</cite>]]
 
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.  
 
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.
 
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.
    
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===  Normal and abnormal waveforms ===
 
===  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<cite>Images</cite>, normal values and causes of 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<cite>Images</cite>, normal values and causes of abnormal waveforms.
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[[File:RightHeart_Waveforms_Fig1.svg | thumb | left | 600px | Figure 4. Normal pressurewaves.]]
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[[File:RightHeart_Waveforms_Fig1.svg | thumb | left | 700px | Figure 4. Normal pressurewaves.]]
 
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Figure 5. Normal values right heart catheterization<cite>Braunwald</cite>
 
{| class="wikitable" border="0" width="600" style="float:left;"
 
{| class="wikitable" border="0" width="600" style="float:left;"
 
|- align="left'
 
|- align="left'
! colspan="3" style="background: #abcdef;" | Table 19-3: Normal Pressures and Vascular Resistances<cite>Braunwald</cite><br />
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! colspan="3" style="background: #abcdef;" | Table 19-3: Normal Pressures and Vascular Resistances<br />
 
|- align="center" border="0"
 
|- align="center" border="0"
 
! scope="col" width="400pt" | Pressures
 
! scope="col" width="400pt" | Pressures
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|style="text-align: center;border-bottom: 3px solid grey;" |85
 
|style="text-align: center;border-bottom: 3px solid grey;" |85
 
|style="text-align: center;border-bottom: 3px solid grey;" |70-105
 
|style="text-align: center;border-bottom: 3px solid grey;" |70-105
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|- align="center" border="0"
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! scope="col" width="400pt" | Vascular Resistance
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! scope="col" width="400pt" | Mean (dyne-sec &middot; cm <sup>-5</sup>)
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! scope="col" width="400pt" | Range (dyne-sec &middot; cm <sup>-5</sup>)
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|- align="left"
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|colspan="3" | Right atrium
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|- align="left" border="0"
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|style="padding-left: 2em;border-bottom: 3px solid grey;" |Systemic vascular resistance
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|style="text-align: center;border-bottom: 3px solid grey;" |1100
 +
|style="text-align: center;border-bottom: 3px solid grey;" |700-1600
 +
|- align="left"
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|style="padding-left: 2em; border-bottom: 3px solid grey;" |Total pulmonary resistance
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|style="text-align: center;border-bottom: 3px solid grey;" |200
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|style="text-align: center;border-bottom: 3px solid grey;" |100-300
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|- align="left"
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|style="padding-left: 2em; border-bottom: 3px solid grey;" |Pulmonary vascular resistance
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|style="text-align: center;border-bottom: 3px solid grey;" |70
 +
|style="text-align: center;border-bottom: 3px solid grey;" |20-130
 
|}
 
|}
 
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== Right atrium ==
 
== Right atrium ==
[[File:RightAtrium_Fig1.png | thumb | 300px | a = atrial systole <br/>
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[[File:RightAtrium_Fig1.svg | thumb | 300px | a = atrial systole <br/>
 
x= atrial relaxation, decrease of pressure<br/>
 
x= atrial relaxation, decrease of pressure<br/>
 
c= closure of the tricuspid valve<br/>
 
c= closure of the tricuspid valve<br/>
 
v= ventricular systole, atrial diastole<br/>
 
v= ventricular systole, atrial diastole<br/>
y= passive filling of right ventricle]]
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y= passive filling of right ventricle<cite>Gore</cite>]]
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#Kussmaul sign (aspiratory rise of lack of decline in RA pressure): constrictive pericarditis, RV ischemia
 
#Kussmaul sign (aspiratory rise of lack of decline in RA pressure): constrictive pericarditis, RV ischemia
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[[File:RightAtrium_Fig2.png | thumb | left | 300px | Figure 8 Elevated v wave and prominent y descent in tricuspid regurgitation]]
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[[File:RightAtrium_Fig2.svg | thumb | left | 300px | Figure 8 Elevated v wave and prominent y descent in tricuspid regurgitation]]
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[[File:RightAtrium_Fig3.png | thumb | left| 300px | Figure 9 Prominent y descent (with square root sign) and equalization of RA and RVEDP: tamponade, constrictive pericarditis, restrictive cardiomyopathy]]
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[[File:RightAtrium_Fig3.svg | thumb | left| 300px | Figure 9 Prominent y descent (with square root sign) and equalization of RA and RVEDP: tamponade, constrictive pericarditis, restrictive cardiomyopathy]]
 
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== Right ventricle ==
 
== Right ventricle ==
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[[File:RightVentricle_Fig1.png | thumb | left | 300px | sys= systole
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[[File:RightVentricle_Fig1.svg | thumb | left | 300px | sys= systole
 
ed= end-diastolic pressure (RVEDP)
 
ed= end-diastolic pressure (RVEDP)
 
RF= rapid filling fase (60% of RV filling)
 
RF= rapid filling fase (60% of RV filling)
 
SF= slow filling (15% of RV filling)
 
SF= slow filling (15% of RV filling)
a= atrial contraction (corresponding with a wave of RA curve) (25% of RV filling)]]
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a= atrial contraction (corresponding with a wave of RA curve) (25% of RV filling)<cite>Gore</cite>]]
    
''Normal RV pressure = 25 / 4 mmHg''<br/>
 
''Normal RV pressure = 25 / 4 mmHg''<br/>
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== Pulmonary artery pressure ==
 
== Pulmonary artery pressure ==
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[[File:PulmonaryArtery_Fig1.png | thumb | 300px | left | sys= RV systole
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[[File:PulmonaryArtery_Fig1.svg | thumb | 300px | left | sys= RV systole
 
D= dicrotic notch = closure of the pulmonic valve
 
D= dicrotic notch = closure of the pulmonic valve
ed= end-diastolic pressure]]
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ed= end-diastolic pressure<cite>Gore</cite>]]
    
''Normal PA pressure 25 / 9 mmHg (mean 15)''<br/>
 
''Normal PA pressure 25 / 9 mmHg (mean 15)''<br/>
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== Pulmonary capillary wedge pressure (PCWP) ==
 
== Pulmonary capillary wedge pressure (PCWP) ==
[[File:PulmonaryCapillary_Fig1.png | thumb | 300px | left | a= atrial contraction
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[[File:PulmonaryCapillary_Fig1.svg | thumb | 300px | left | a= atrial contraction
 
x= atrial relaxation
 
x= atrial relaxation
 
v= atrial diastole (ventricular contraction)
 
v= atrial diastole (ventricular contraction)
y= passive filling of the LV after mitral valve opening]]
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y= passive filling of the LV after mitral valve opening<cite>Gore</cite>]]
    
''Normal PCWP pressure range = 4-12 mmHg (mean 9)<br/>''
 
''Normal PCWP pressure range = 4-12 mmHg (mean 9)<br/>''
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[[File:PulmonaryCapillary_Fig2.png | thumb | 300px | left | Figure 10. Prominent v wave in mitral regurgitation.]]
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[[File:PulmonaryCapillary_Fig2.svg | thumb | 300px | left | Figure 10. Prominent v wave in mitral regurgitation.<cite>DailyEK</cite>]]
 
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== References ==
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== References ==  
 
<biblio>
 
<biblio>
 
#Braunwald Braunwald E et al. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th edition: page 445.
 
#Braunwald Braunwald E et al. Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 8th edition: page 445.
#Images from Up tot date online: Pulmonary artery catheterization: Interpretation of tracings.
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#Gore Redrawn from Gore, JM, Alper, JS, Benotti, JR, et al. Handbook of hemodynamic monitoring, 1st ed, Boston, Little Brown & Co, 1985.
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#DailyEK Redrawn from Daily EK, Schroeder JS, Hemodynamic Waveforms: Exercises in Interpretation and Analysis, St. Louis, CV Mosby, 1983, p. 139.
 
</biblio>
 
</biblio>

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