Download Cardiac catheterization

Cardiac Catheterization
Xin Yang MB Bchir, MA(Cantab), MRCP(Lond)
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Purposes of Right Heart Cath
► Hemodynamic assessment to record pressure in the
cardiac chambers and the vessels.
► Determination of cardiac function and evaluation of
shunts.
► Oxygen delivery and utilization.
► Guide inotrope and vasopressor therapy
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
RHC: Swan-Ganz Catheter
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Access
► Seldinger technique to
gain access through RIJ, L
subclavian or femoral
vein.
► Place Cordis sheath.
► Don’t forget the Swandom.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Positioning of PAC
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Positioning of PAC
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
PAC Tracings
► Cardiac cycle:
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2008
A: atrial systole
B: Isovolumetric contraction
C: Rapid ejection
D: Reduced ejection
E: Isovolumetric relaxation
F: Rapid ventricular filling
G: Reduced ventricular filling
Zoll Firm Lecture Series
Joyce Meng, M.D.
http://img.tfd.com/dorland/thumbs/cycle_cardiac.jpg
Eli V. Gelfand, M.D, F.A.C.C.
PAC Tracing
2008
http://domain675291.sites.fasthosts.com/anae/paop.
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
RA Tracing
www.uptodate.com
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Hemodynamics
Parameter N Value
Route
Significance
CVP
RAP (m)
PAP (S/D)
PCWP (m)
SVO2
Cordis
Prox port
Dist port
Dist port
Dist port
RV preload
RV preload
RV afterload
LV preload
Cardiac output
2008
<6
<8
15/30-4/12
<10
>75%
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Hemodynamics
Cardiac output:
Assumed O2 consumption
A-V O2 difference
125 x BSA
A-V O2 difference x Hgb x 13.6
Cardiac index : Cardiac output / BSA
(Nl values are: 2.4 – 4.2 l/min/m2)
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Hemodynamics
SVR:
(MAP-CVP) / CO x 80
PVR:
(MPA-MPCW) / CO x 80
Qp/Qs:
(SaO2-MvO2) / (PvO2-PaO2)
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Clinical Scenarios
2008
Shock
PCWP
CO
SVR
MVO2
Hypovolemia
↓
↓
↑
↓
Cardiogenic
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↑
↓
Distributive
↓
↑
↓
↑
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
PAC Complications
► Bleeding
► Pneumothorax
► Sustained ventricular arrythmia
► Right bundle branch block
► Infection
► Cardiac / Pulmonary artery perforation
► Pulmonary artery infarction
► Thromboembolism
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Purpose of Left Heart Cath
► Angiography to evaluate the presence of vascular
obstruction, contractile function of cardiac chambers,
and regurgitation or shunting of blood.
► Interventional procedures.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Pre-procedural Preparations
► Labs: CBC, Chem7, coagulation.
► NPO after midnight.
► IV rehydration (follow pre-cath order set).
► Discontinue
appropriate medications (metformin,
coumadin).
► Informed consent.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Cath Lab
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Post LHC Complications
► Bleeding:
 Hemostasis with manual compression (no sand bags or water
bags).
 IV fluid.
 Check vitals / labs / type & screen.
 Unstable, Stat page vascular surgery & cards fellow.
 If stable, page cards fellow, consider USS/CT abdo.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Post LHC Complications
► Pseudoaneurysm.
 USS.
 Thrombin injection if > 2cm.
 If AV fistulae is present, get vascular surg consult.
► Vagal reaction.
 Fluid.
 atropine.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Post LHC Complications
► Thromboembolism:
 Stroke: stat consult neuro, consider stat NCCT of head and
thrombolysis.
 Cholesterol emboli: skin/renal/GI involvement, treat
underlying risk factors.
 Acute limb ischemia: page Duane/Lawrence.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Post LHC Complications
► Recurrent ischemia:
 12 lead EKG.
 Anti-anginal therapy.
 Page on call fellow if concerning EKG changes, persistent
symptoms or any concern.
2008
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.
Post LHC Complications
► Dissection:
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2008
Bilateral pulses and BP.
CBC, coag and type and cross.
Stat portable CXR
CT chest.
Echo
Call on call fellow.
Zoll Firm Lecture Series
Joyce Meng, M.D.
Eli V. Gelfand, M.D, F.A.C.C.