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Right heart catheterization: Difference between revisions
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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. | 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. | ||
[[File:RightHeart_Technique_Fig1.jpg | thumb | 300px | | [[File:RightHeart_Technique_Fig1.jpg | thumb | 300px | left | Figure 1. Swan-Ganz catheter.]] | ||
Ports left to right: thermistor connector, medication portal, proximal injection hub, distal lumen hub, balloon inflation valve with syringe. | 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. | 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. | 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. | ||
[[File:RightHeart_Technique_Fig2.jpg | thumb | right | 300px | 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.jpg | thumb | left | 300px | Figure 3. Right heart catheterization from the femoral vein<cite>Braunwald</cite>]] | [[File:RightHeart_Technique_Fig3.jpg | thumb | left | 300px | 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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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. | ||
[[File:RightHeart_Waveforms_Fig1.png | thumb | left | | [[File:RightHeart_Waveforms_Fig1.png | thumb | left | 600px | Figure 4. Normal pressurewaves.]] | ||
[[File: | [[File:RightHeart_Waveforms_Fig2_sml.png | thumb | left | 300px | Figure 5. Normal values right heart catheterization<cite>Braunwald</cite>]] | ||
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