1. Indication and contra-indications for cardiac catheterization
PUMCH
Shen zhujun

2. Cardiac catheterization
For diagnosis
Left heart cath.(inclu. CAG) : from artery, use a catheter to measure left cardiac chamber and large vessel pressure or CAG or blood gas measurement.
Right heart cath. : from vein, use a catheter to measure the pressure, angiogram or blood gas sample, EP test or cardiac biopsy.

3. Coronary angiogram

4. For stable angina or ischemia without symptom
AP CCS III or IV on medication (B)
No matter the degree of AP, non-invasive test show high risk* (A)
Aborted cardiac death, sustained VT (≥30sec) or non-sustained (<30sec) polymorphic VT (B)

5. High-risk CAD (annual death >3%) on non-invasive test
Severe LV dysfunction rest (LVEF< 35%)
High-risk on treadmill test (≤-11)
Severe LV dysfunction on exertion (LVEF< 35%)
Large area ischemic defect on stress test (esp. anterior wall, Dobutamine or the others)
Multiple ischemic segment on sress test

6. For non-cardiac surgery assess the risk with know or suspect CAD
High risk with non-invasive test (C)
Angina refractory to medication (C)
Unstable angina, esp. moderate or high risk surgery (C)
Undetermined with non-invasive test with high risk clinical risk factors before high risk surgery (C)

7. For valve patient
Adult valve patient with symptom need surgery or balloon therapy, non-invasive test suggest ischemia (B)
After middle age (male 45, female 50) with some risk factors without symptom before surgery (C)
Infective endocarditis with evidence of coronary embolism (C)

8. For heart failure patient
CHF with systolic dysfunction with angina or segmental wall motion abnomality or any evidence of reversible ischemia (B)
Before heart transplantation (C)
CHF duo to MI with ventricular aneurysm or any mechanical complication (C)

9. For STEMI --- indication
Suitable for primary or rescue PCI– within 12 hrs or over 12 hrs with persistent ischemia, cathlab facility needed (A)
Cardiogenic shock need revascularization– 36 hrs from onset or 18 hrs after shock (A)
Complicated with VSD or severe MR need repair (B)
Complicated with persistent hemodynamic unstable or electrical unstable condition (C)

10. For STEMI --- contra-indication
III
Multiple co-morbidities, revascularization may not help the patient (C)

11. For UA/STEMI --- indication
Recurrent ischemia after medication (B)
Moderate or High risk：TIMI score≥3. Age≥65yrs; ≥3 CAD risk factors; Known CAD; Aspirin in past 7 days; Recent (within 24hrs) severe angina; ST deviation≥0.5mm; cardiac markers elevation (A).
Low risk but non-invasive test show high risk：EF<0.35、large area ischemia (esp. anterior wall) or multiple segment ischemia (B)
UA post-PCI or CABG (C)
Prinzmetal angina (C)

12. For UA/STEMI --- contra-indication
III
Multiple co-morbiditis, cannot benefit from revascularization (C)
Chest pain with low risk UA (C)
Not a candidate for revascularization (C)

13. For recent MI --- indication
Any ischemic evidence on low level stress test (B)

14. Relative contra-indication
Unknow fever or fever not controlled
Severe or acute liver or renal dysfunction or failure
Severe anemia
Severe electrolyte disturbance
End stage carcinoma
Aortic valve IE
Severe bleeding disease or active bleeding

15. Relative contra-indication (Cont’)
stroke (acute phase)
Digoxin intoxication
CHF not controlled
Severe coagulation disease
Patient can’t co-operate
Any disease or condition make the patient can’t benefit from revascularization therapy

16. Factors increase the risk of CAG
age> 70 yr
Complicated congenital heart disease
Severe obesity
Cachexia
Uncontrolled hyperglycemia
Hypoxia
Severe COPD
CRF
Hyperthyroidism

17. Factors increase the risk of CAG (cont’)
Triple vessel disease
Left main disease
Heart failure, grade IV
Severe mitral valve 、aortic valve disease or after mechanical valve replacement
LVEF< 35 ％
High risk on treadmill test (with hypotension or severe ischemia)
Pulmonary hypertension
PCWP> 25 mm Hg

18. Factors increase the risk of CAG (cont’)
Coagulation or bleeding disturbance
Uncontrolled hypertension
Severe peripheral artery disease
Recent stroke
Severe aortic insufficency

19. LV-gram indication
Routine LV-gram should be done before or after CAG to evaluate the left ventricular function, mitral valve and aortic valve function
LV was not done regularly in daily practice because the advantage of Echocardiography

20. LV-gram Contra-indication
LV thrombus
Severe LV dysfunction, LVEDP≥20mmHg

21. R-cath. Indication
Complicated congenital heart disease need anatomical and physiological assessment.
Congenital heart disease complicated with pulmonary hypertension
EP test
Cardiac biopsy

22. R-cath. Contra-indication
Simple cases can be accurately diagnosed by echocardiography or other non-invasive procedures