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Cardiology
Right Heart Catheterization Cardiac Output, Vascular Resistance, Shunt Detection, and Quanti
Built from Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
What’s inside
10 sections · 118 slides
Overview
- Scope of this topic
- Primary data obtained at right heart catheterization
- Clinical indications for right heart catheterization
- Historical development of right heart catheterization
- Pulmonary artery catheters in cardiogenic shock
- Right heart catheterization as a diagnostic tool
Fundamentals and Equipment
- Preprocedural preparation
- Equipment for right heart catheterization
- Access and safety equipment
- Pulmonary artery catheter design
- The distal port
- The proximal port
- The thermistor port
- The balloon port
- Preparation of the pulmonary artery catheter
- Levelling the pressure transducer
- Zeroing the transducer
Step-by-Step Procedure
- Venous access options
- Comparison of venous access sites
- Positioning, sterility and the timeout
- Ultrasound-guided venous puncture
- Seldinger technique and sheath placement
- Micropuncture access technique
- Advancing the catheter through the sheath
- Sequence of chambers during catheter advancement
- Pressure and saturation sampling in the right atrium
- Catheter depths and chamber transitions
- Advancing to the pulmonary artery from femoral access
- Obtaining the wedge position
- Confirming the wedge position
- West lung zones and wedge pressure accuracy
- West lung zones
- Recognising a catheter outside Zone 3
- Steps after obtaining the wedge tracing
- Implanted devices and anatomic variants
- Timing of measurements in the respiratory cycle
- Patient coaching and choice of anaesthesia
Troubleshooting
- Repositioning an indwelling pulmonary artery catheter
- Ideal radiographic catheter position
- Management of a proximal-appearing catheter
- Distal catheter position and rupture risk
- Damping and resonance in pressure systems
- Overdamped waveform features
- Causes and correction of overdamping
- Underdamping and catheter ringing
Complications
- Overall complication rates
- Access site complications by site
- Management of suspected arterial puncture
- Arrhythmia during catheter insertion
- Conduction block during catheterization
- Pulmonary infarction
- Pulmonary artery rupture: incidence and presentation
- Immediate management of pulmonary artery rupture
- Definitive management after stabilisation
- Thrombosis and infection with indwelling catheters
Clinical Interpretation of Waveforms
- Normal right atrial pressure waveform
- The a wave and x descent
- The c wave, v wave and y descent
- Cannon a-waves in atrioventricular dissociation
- Right atrial waveform in atrial fibrillation
- Large v-waves in tricuspid regurgitation
- Right atrial waveform in cardiac tamponade
- Normal right ventricular pressure physiology
- Phases of right ventricular diastole
- Normal right ventricular waveform features
- Constrictive pericarditis and the square root sign
- Normal pulmonary artery pressure waveform
- Principle of the pulmonary capillary wedge pressure
- Normal pulmonary capillary wedge tracing
- Wedge waveform in mitral stenosis
- Wedge waveform in mitral regurgitation
Cardiac Output
- Two methods of measuring cardiac output
- Principle of thermodilution
- Thermodilution technique
- Accuracy of thermodilution
- The Fick principle
- Oxygen content and the AV-O2 difference
- Sampling sites and normal values
- Direct and indirect Fick
- Conditions that distort the indirect Fick calculation
Vascular Resistance
- Basis of vascular resistance
- Limits of Ohm's law in the circulation
- Systemic vascular resistance
- Pulmonary vascular resistance
- Clinical applications of vascular resistance
- Cardiac output measurement on VA-ECMO
Intracardiac Shunts
- Indications for shunt assessment
- Physiology of a left-to-right shunt
- The oximetry run
- Step-up and step-down
- Calculation of pulmonary blood flow
- Substituting systemic arterial oxygen content
- Calculation of systemic blood flow
- Flamm formula for mixed venous saturation
- Shunt quantification by Qp/Qs
- Shunt detection and quantification workflow
- Bidirectional shunts and effective blood flow
Summary
- Key procedural points
- Key interpretive points
- Key calculated values
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
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- References (continued)
- Cardiovascular Catheterization and Intervention: A Textbook of Coronary, Peripheral, and Structural Heart Disease
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