Cardiac catheterization

Definition

Cardiac catheterization (also called heart catheterization) is a diagnostic procedure which does a comprehensive examination of how the heart and its blood vessels function. One or more catheters is inserted through a peripheral blood vessel in the arm (antecubital artery or vein) or leg (femoral artery or vein) with x-ray guidance.

(Fig 3.2a; Fig 3.2b; Fig 3.2c.)
During cardiac catheterization, a catheter is fed into the femoral artery of the upper leg (A). The catheter is fed up to coronary arteries to an area of blockage (B). A dye is released, allowing visualization of the blockage (C).



This procedure gathers information such as adequacy of blood supply through the coronary arteries, blood pressures, blood flow throughout chambers of the heart, collection of blood samples, and x rays of the heart's ventricles or arteries.

A test that can be performed on either side of the heart, cardiac catheterization checks for different functions in both the left and right sides. When testing the heart's right side, tricuspid and pulmonary valve function are evaluated, in addition to measuring pressures of and collecting blood samples from the right atrium, ventricle, and pulmonary artery. Left-sided heart catheterization is performed by way of a catheter through an artery which tests the blood flow of the coronary arteries, function of the mitral and aortic valves, and left ventricle.

Purpose

The primary reason for conducting a cardiac catheterization is to diagnose and manage persons known or suspected to have heart disease, a frequently fatal condition that leads to 1.5 million heart attacks annually in the United States.

Symptoms and diagnoses that may lead to performing this procedure include:

  • chest pain, characterized by prolonged heavy pressure or a squeezing pain
  • abnormal treadmill stress test
  • myocardial infarction, also known as a heart attack
  • congenital heart defects, or heart problems that originated from birth
  • a diagnosis of valvular-heart disease
  • a need to measure the heart muscle's ability to pump blood

Typically performed along with angiography, a technique of injecting a dye into the vascular system to outline the heart and blood vessels, a catheterization can aid in the visualization of any blockages, narrowing, or abnormalities in the coronary arteries. If these signs are visible, the cardiologist may assess the patient's need and readiness for coronary bypass surgery, or perhaps a less invasive approach, such as dilation of a narrowed blood vessel either surgically or with the use of a balloon (angioplasty).

When looking at the left side of the heart, fluoroscopic guidance also allows the following diagnoses to be assessed:

  • enlargement of the left ventricle
  • ventricular aneurysms (abnormal dilation of a blood vessel)
  • narrowing of the aortic valve
  • insufficiency of the aortic or mitral valve
  • the detour of blood from one side of the heart to the other due to septal defects (also known as shunting)

Precautions

Cardiac catheterization is categorized as an "invasive" procedure which involves the heart, its valves, and coronary arteries, in addition to a large artery in the arm or leg. Due to the nature of the test, it is important to evaluate for the following conditions before considering this procedure:

  • A diagnosis of a bleeding disorder, poor kidney function, or debilitation. Any of these pre-existing conditions typically raises the risk of the catheterization procedure andmay be reason to cancel the procedure.
  • A diagnosis of heart valve disease. If this is detected, antibiotics may be given before the test to prevent inflammation of the membrane which lines the heart (endocarditis).


Description

To understand how a cardiac catheterization is able to diagnose and manage heart disease, the basic workings of the heart muscle must also be understood. Just as the body relies on a constant supply of blood to aid in its everyday functions, so does the heart. The heart is made up of an intricate web of blood vessels (coronary arteries) that ensure an adequate supply of blood rich in oxygen and nutrients. It is easy to see how an abnormality in any of these arteries can be detrimental to the heart's function. These abnormalities cause the heart's blood flow to decrease and result in the condition known as coronary artery disease or coronary insufficiency.

Catheterization is a valuable tool in detecting and treating abnormalities of the heart. Through the use of fluoroscopic (x-ray) guidance, a catheter, which may resemble a balloon-tipped tube, is strung through the veins or arteries into the heart, so the cardiologist can monitor a body's various functions at each moment.

Generally a test that lasts two to three hours, a patient should expect the following prior to and during the catheterization procedure:

  • A mild sedative may be given that will allow the patient to relax but remain conscious during the test.
  • An intravenous needle will be inserted in the arm to administer medication. Electrodes will be attached to the chest to enable the painless procedure known as an electrocardiograph.
  • Prior to inserting a catheter into an artery or vein in the arm or leg, the incision site will be made numb by injecting a local anesthetic. When the anesthetic is injected it may feel like a pin-prick followed by a quick stinging sensation. Pressure may also be experienced as the catheter travels through the blood vessel.
  • After the catheter is guided into the coronary-artery system, a dye (also called a radiocontrast material) is injected to aid in the identification of any abnormalities of the heart. During this time, the patient may experience a hot, flushed feeling or a quickly passing nausea. Coughing or breathing deeply aids in any discomfort.
  • Medication may be given during the procedure if chest pain is experienced, and nitroglycerin may also be administered to allow expansion of the heart's blood vessels.
  • When the test is complete, the physician will remove the catheter and close the skin with several sutures or tape.

Preparation

Prior to the cardiac catheterization procedure, it is important to relay information to the physician or nurse regarding allergies to shellfish (such as shrimp or scallops) which contain iodine, iodine itself, or the dyes that are commonly used in other diagnostic tests.

Because this procedure is categorized as a surgery, the patient will be instructed not to eat or drink anything for at least six hours prior to the test. Just before the test begins, the patient will urinate and change into a hospital gown, then lie flat on a padded table that may also be tilted in order for the heart to be examined from a variety of angles.

Aftercare

While cardiac catheterization may be performed on an out-patient basis, a patient may require close monitoring following the procedure while remaining in the hospital for at least 24 hours. The patient will be instructed to rest in bed for at least eight hours immediately after the test. If the catheter was inserted into a vein or artery in the leg or groin area, the leg will be kept extended for four to six hours. If a vein or artery in the arm was used to insert the catheter, the arm will need to remain extended for a minimum of three hours.

The patient should expect a hard ridge to form over the incision site that diminishes as the site heals. Bluish discoloration under the skin at the point of insertion should also be expected but fades in two weeks. It is also not uncommon for the incision site to bleed during the first 24 hours following surgery. If this should happen, the patient should apply pressure to the site with a clean tissue or cloth for 10-15 minutes.

Risks

Similar to all surgical procedures, the cardiac catheterization test does involve some risks. Complications that may occur during the procedure include

  • cardiac arrhythmias (an irregular heart beat)
  • pericardial tamponade (a condition that causes excess pressure in the pericardium which affects the heart due to accumulation of excess fluid)
  • the rare occurrence of myocardial infarction (heart attack) or stroke may also develop due to clotting or plaque rupture of one or more of the coronary or brain arteries.

Before left-side catheterization is performed, the anticoagulant medication heparin may be administered. This drug helps decrease the risk of the development of a blood clot in an artery (thrombosis) and blood clots traveling throughout the body (embolization).

The risks of the catheterization procedure increase in patients over the age of 60, thosewho have severe heart failure, or persons with serious valvular heart disease.

Normal results

Normal findings from a cardiac catheterization will indicate no abnormalities of heart chamber size or configuration, wall motion or thickness, the direction of blood flow, ormotion of the valves. Smooth and regular outlines on the x ray indicate normal coronary arteries.

An essential part of the catheterization is measuring intracardiac pressures, or the pressure in the heart's chambers and vessels. Pressure readings that are higher than normal are significant for a patient's overall diagnosis. The pressure readings that are lower, other than those which are produced as a result of shock, typically are not significant.

An ejection fraction, or a comparison of how much blood is ejected from the heart's left ventricle during its contraction phase with a measurement of blood remaining at the end of the left ventricle's relaxation phase, is also determined by performing a catheterization. The cardiologist will look for a normal ejection fraction reading of 60-70%.

Abnormal results

Cardiac catheterization provides valuable still and motion x-ray pictures of the coronary arteries that help in diagnosing coronary artery disease, poor heart function, disease of the heart valves, and septal defects (a defect in the septum, the wall that separates two heart chambers).

The most prominent sign of coronary artery disease is the narrowing or blockage in the coronary arteries, with narrowing that is greater than 70% considered significant. A clear indication for intervention (by angioplasty or surgery) is a finding of significant narrowing of the left main coronary artery and/or blockage or severe narrowing in the high, left anterior descending coronary artery.

A finding of impaired wall motion is an additional indicator of coronary artery disease, aneurysm, an enlarged heart, or a congenital heart problem. Using the findings from an ejection fraction test which measures wall motion, cardiologists look at an ejection fraction reading under 35% as increasing the risk of complications while also decreasing a successful long term or short term outcome with surgery.

Detecting the difference in pressure above and below the heart valve can verify heart valve disease. The greater narrowing correlates with the higher pressure difference.

To confirm septal defects, a catheterization measures oxygen content on both the left and right sides of the heart. The right heart pumps unoxygenated blood to the lungs, and the left heart pumps blood that contains oxygen from the lungs to the rest of the body. Right side elevated oxygen levels indicate left-to-right atrial or ventricular shunt. A left side that experiences decreased oxygen indicates a right-to-left shunt.