Cardiac Catheterization Xin Yang MB Bchir, MA(Cantab), MRCP(Lond) 2008 Zoll Firm Lecture Series

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

RHC: Swan-Ganz Catheter 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series Access Seldinger technique to gain access through RIJ, L subclavian or femoral vein. Place Cordis sheath. Don’t forget the Swan-dom. 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series Positioning of PAC 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series Positioning of PAC 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series PAC Tracings Cardiac cycle: A: atrial systole B: Isovolumetric contraction C: Rapid ejection D: Reduced ejection E: Isovolumetric relaxation F: Rapid ventricular filling G: Reduced ventricular filling 2008 Zoll Firm Lecture Series http://img.tfd.com/dorland/thumbs/cycle_cardiac.jpg

Zoll Firm Lecture Series PAC Tracing http://domain675291.sites.fasthosts.com/anae/paop. 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series RA Tracing A fib, canon a wave, TR, www.uptodate.com 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series Hemodynamics Parameter N Value Route Significance CVP < 6 Cordis RV preload RAP (m) < 8 Prox port RV preload PAP (S/D) 15/30-4/12 Dist port RV afterload PCWP (m) <10 Dist port LV preload SVO2 >75% Dist port Cardiac output 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series 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

Zoll Firm Lecture Series Hemodynamics SVR: (MAP-CVP) / CO x 80 PVR: (MPA-MPCW) / CO x 80 Qp/Qs: (SaO2-MvO2) / (PvO2-PaO2) 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series Clinical Scenarios Shock PCWP CO SVR MVO2 Hypo-volemia ↓ ↑ Cardiogenic Distributive 2008 Zoll Firm Lecture Series

Zoll Firm Lecture Series 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

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

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

Zoll Firm Lecture Series Cath Lab 2008 Zoll Firm Lecture Series

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

Post LHC Complications Pseudoaneurysm. USS. Thrombin injection if > 2cm. If AV fistulae is present, get vascular surg consult. Vagal reaction. Fluid. atropine. is a leakage of arterial blood from an artery into the surrounding tissue with a persistent communication between the originating artery and the resultant adjacent cavity. 2008 Zoll Firm Lecture Series

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

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

Post LHC Complications Dissection: Bilateral pulses and BP. CBC, coag and type and cross. Stat portable CXR CT chest. Echo Call on call fellow. 2008 Zoll Firm Lecture Series