• Clinical science

Cardiac catheterization

Abstract

Cardiac catheterization is a procedure used in the diagnosis and treatment of cardiovascular conditions. It involves the insertion of a catheter into a cardiac vessel (coronary catheterization) or chamber by way of a suitable vascular access (usually a femoral or radial artery). Once in position, a cardiac catheter can help evaluate the blood supply to the cardiac musculature (angiography) or open up narrowed or blocked segments of a coronary artery by means of a coronary angioplasty with stenting (percutaneous coronary intervention, or PCI). Additionally, it can be used to perform a cardiac tissue biopsy, open narrowed heart valves via valvuloplasty, examine electrophysiological pathways, or measure pressure and oxygen levels in different chambers (hemodynamic assessment). The procedure is associated with a low rate of complications, with the most common among these being bruising and bleeding at the site of IV access. Rarer, more severe complications include arrhythmias, cardiac arrest, embolization of existing plaques, and infection.

Procedure/overview

General

Coronary angiography/ventriculography

  • Contrast-enhanced radiological analysis of the heart cavities (ventriculography) or coronary arteries (coronary angiography).
  • Indications
    • Coronary artery disease: to assess the exact location and extent of coronary vessel narrowing before possible PCI/surgery
      • Patients with unstable angina
      • Patients with adverse effects from medical therapy
      • Patients in which conservative control of symptoms has failed
      • High-risk patients (those with signs of ischemia during stress ECG)
    • Valvular or myocardial diseases with symptoms (e.g., shortness of breath)
    • Recurring chest pain of unidentified cause
    • Preoperative evaluation prior to noncardiac and planned cardiac surgery (CABG) in high-risk patients
    • To detect and quantify the presence of an intracardiac shunt

Coronary angiography is not a screening method for coronary heart disease in asymptomatic patients!

Percutaneous coronary intervention (PCI)/percutaneous transluminal coronary angioplasty (PTCA)

  • A therapeutic procedure carried out during cardiac catheterization in which a blocked coronary vessel is opened and appropriate blood flow is restored. A balloon catheter is used to dilate the narrowed section, with/without the placement of a stent to keep it patent.
  • Indications
    • Acute and chronic occlusion of coronary arteries
  • Procedure: a catheter is inserted through the IV access site → a deflated balloon catheter is advanced into the obstructed artery → balloon is inflated at the obstructed/narrowed section → the narrowing is relieved → stent may/may not be deployed to keep the blood vessel open
  • Types of stents

Electrophysiological examination

  • Testing of the electrical conduction system of the heart to assess electrical activity and conduction pathways via a cardiac catheter
  • Indications
    • Diagnostic: to evaluate various, repeatedly refractory cardiac arrhythmias
    • Therapeutic
      • Radioablation of areas of accessory pathways (areas that generate and conduct the arrhythmias)
      • Placement of intracardiac pacemakers or defibrillators

Right heart catheterization

  • Procedure: venipuncture (groin, arm, neck) → advancement of the Swan-Ganz catheter into the right heart

References:[1][1][2][3][4]

Contraindications

References:[5][2]

We list the most important contraindications. The selection is not exhaustive.

Complications

Periprocedural complications

Complications at the site of vascular access

  • Superficial hematoma formation
  • Retroperitoneal hematoma
    • Most common cause of unexpected mortality after diagnostic or interventional cardiac catheterization
    • Clinical features
      • Often asymptomatic
      • Suprainguinal tenderness and fullness
      • Sudden flank or back pain with hemodynamic instability
    • Prompt diagnosis is a priority: CT with contrast of the abdomen and pelvis in hemodynamically stable patients or sonography in unstable patients
    • Treatment
      • Predominantly supportive treatment: careful monitoring, fluid resuscitation, blood transfusion, and normalization of coagulation factors if abnormal
      • Surgical repair
        • Endovascular management options like intra-arterial embolization or stent-grafts to stop the bleeding
        • Open surgery to control active bleeding and/or to remove a large retroperitoneal hematoma
  • Pseudoaneurysms
  • Arterial injury (can include laceration, arteriovenous fistula formation, or thrombosis)

Complications at the cardiac level

Other complications

Delayed complications

  • Most common complication: restenosis
  • Stent thrombosis (0.5–5%)
  • Vascular complications
    • Spontaneous coronary artery dissection (SCAD; ∼ 5% after PTCA) → increased risk of infarction
    • Systemic embolisms: stroke due to cerebral emboli (< 1%)
  • Infection (localized or generalized bacteremia)

References:[1][6][7][8][9][10][11]

We list the most important complications. The selection is not exhaustive.

Alternative methods

Coronary artery bypass graft (CABG)/aortocoronary bypass (ACB)