Cardiac Catheterization in India: Read the Facts!

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Cardiac Catherization

Cardiac catheterization (heart cath) is the insertion of a catheter into a chamber or vessel of the heart. This is done for both investigational and interventional purposes. Coronary catheterization is a subset of this technique, involving the catheterization of the coronary arteries.

A small puncture is made in a vessel in the groin, the inner bend of the elbow, or neck area (the femoral vessels or the carotid/jugular vessels), then a guidewire is inserted into the incision and threaded through the vessel into the area of the heart that requires treatment, visualized by fluoroscopy or echocardiogram, and a catheter is then threaded over the guidewire. If X-ray fluoroscopy is used, a radiocontrast agent will be administered to the patient during the procedure. When the necessary procedures are complete, the catheter is removed. Firm pressure is applied to the site to prevent bleeding. This may be done by hand or with a mechanical device. Other closure techniques include an internal suture. If the femoral artery was used, the patient will probably be asked to lie flat for several hours to prevent bleeding or the development of a hematoma. Cardiac interventions such as the insertion of a stent prolong both the procedure itself as well as the post-catheterization time spent in allowing the wound to clot.

A cardiac catheterization is a general term for a group of procedures that are performed using this method, such as coronary angiography. Once the catheter is in place, it can be used to perform a number of procedures including angioplasty, angiography, and balloon septostomy.

History

The history of cardiac catheterization dates back to Claude Bernard (1813-1878), who used it on animal models. Clinical application of cardiac catheterization begins with Werner Forssmann in the 1930s, who inserted a catheter into the vein of his own forearm, guided it fluoroscopically into his right atrium, and took an X-ray picture of it. Forssmann won the Nobel Prize in Physiology or Medicine for this achievement. During World War II, André Frédéric Cournand and his colleagues developed techniques for left and right heart catheterization.

Indications for investigational use

This technique has several goals:

• Confirm the presence of a suspected heart ailment
• Quantify the severity of the disease and its effect on the heart
• Seek out the cause of a symptom such as shortness of breath or signs of cardiac insufficiency
• Make a patient assessment prior to heart surgery

Investigative techniques used with cardiac catheterization

A probe that is opaque to X-rays is inserted into the left or the right chambers of the heart for the following reasons:

• To measure intracardiac and intravascular blood pressures
• To take tissue samples for biopsy
• To inject various agents for measuring blood flow in the heart; also to detect and quantify the presence of an intracardiac shunt
• To inject contrast agents in order to study the shape of the heart vessels and chambers and how they change as the heart beats

Cardiac Catheterization (Left Heart)

In 1929, in Eberswalde, Germany, a 25-year-old surgical trainee named Werner Forssmann was the first to pass a catheter into the heart of a living person—his own. He passed the catheter into his right atrium via the left antecubital vein under fluoroscopic guidance and then climbed the stairs to the radiology department to undergo a chest roentgenogram. His efforts were not rewarded but, rather, stimulated considerable opposition and bitter criticism; however, in 1956, he shared the Nobel Prize in medicine with other pioneers of invasive cardiology.

Further developments in invasive cardiology were slow until the work of Andre Cournand and Dickenson Richards, who performed the first comprehensive studies of right heart physiology in humans.

In 1947, Louis Dexter expanded the clinical use of right heart catheterization with studies in patients with congenital heart disease and identified the pulmonary capillary wedge pressure as a useful clinical measurement. By this point, the value of hemodynamic measurements was being fully realized, and further developments came rapidly.

Cardiac catheterization and coronary angiography

Although the technique and accuracy of noninvasive testing continue to improve, cardiac catheterization remains the standard for the evaluation of hemodynamics. Cardiac catheterization helps provide not only intracardiac pressure measurements, but also measurements of oxygen saturation and cardiac output. Hemodynamic measurements usually are coupled with a left ventriculogram for the evaluation of left ventricular function and coronary angiography.

Coronary angiography remains the criterion standard for diagnosing coronary artery disease and is the primary method used to help delineate coronary anatomy. In addition to defining the site, severity, and morphology of lesions, coronary angiography helps provide a qualitative assessment of coronary blood flow and helps identify collateral vessels. Correlation of the coronary angiogram and left ventriculogram findings permits identification of potentially viable areas of the myocardium that may benefit from a revascularization procedure. Left ventricular function can be further evaluated during stress using atrial pacing, dynamic exercise, or pharmacologic agents.

Preparation of the Patient for Cardiac Catheterization

Before the procedure, the responsible cardiologist should fully explain the risks and benefits to the patient, should obtain written consent, and should answer questions asked by the patient or family. A close physician-patient relationship is important to reduce fears about the procedure. Before the procedure, a complete history, physical examination, complete blood count, blood chemistries, chest radiograph, and ECG should be obtained.

Special attention should be given to identifying patients with insulin-dependent diabetes mellitus, renal insufficiency, peripheral vascular disease, contrast allergy, or long-term anticoagulation use because these conditions are associated with a higher risk of procedure-related complications. Appropriate therapies before the procedure can minimize these risks. For example, adequate hydration before the contrast load will minimize the risk of contrast-induced nephropathy and pretreatment with corticosteroids will diminish the likelihood of an allergic reaction to contrast.

Patients should fast for at least 8 hours before the procedure. Premedication with a mild sedative is common, and some operators administer diphenhydramine or a narcotic.

Catheters & Associated Equipments

Numerous items of disposable equipment are used for the procedure, including various catheters, wires, needles, syringes, introducer sheaths, and stopcocks. Frequently, a Swan-Ganz catheter is used for measuring right heart pressures, collecting blood to measure oxygen saturation in various chambers, and determining cardiac output. Pressure measurements within the left ventricle usually are obtained using a pigtail catheter, and this same catheter is used for left ventricular and aortic angiography. A wide variety of preformed catheter shapes exist for coronary and bypass graft angiography. The outer diameter of a catheter is measured in French units (F); 1 F is 0.33 mm. The inner diameter of the catheter is smaller than the outer diameter because of the thickness of the catheter material.

Decisions about which catheter to use are based on several factors, including (1) the vascular and heart anatomy, (2) the necessity to adequately opacify the coronary arteries and cardiac chambers in different clinical situations, (3) the extent to which the catheter must be manipulated and the desire to limit vascular injury and complications, and (4) whether arterial access is obtained via the femoral artery or via an upper extremity artery. Larger-diameter catheters (7-10F) allow for greater catheter manipulation and excellent visualization, but they have a higher potential for trauma to the coronary or peripheral vasculature. In contrast, smaller catheters (4-6F) are less traumatic and permit earlier ambulation after catheterization, but contrast delivery may be limited in certain situations, thus compromising the quality of the procedure. The 6F diagnostic catheter is used widely for routine angiography because it has a good balance of the necessary requirements.

Although not a necessity, a short vascular access sheath often is used to facilitate arterial access and multiple catheter exchanges, which often are necessary. All catheters and sheaths are advanced over a guidewire to diminish the chance of trauma to the vasculature. A commonly used wire is a 150-cm, 0.035-in J-tipped guidewire.

Indications and Contraindications

Cardiac catheterization is a procedure undertaken for the diagnosis of a variety of cardiac diseases. As with any invasive procedure that is associated with important complications, the decision to recommend a cardiac catheterization must be based on a careful evaluation of the risks and benefits to the patient.

General indications for cardiac catheterization

Indications for cardiac catheterization are as follows:

• Identification of the extent and severity of coronary artery disease and evaluation of left ventricular function
• Assessment of the severity of valvular or myocardial disorders such as aortic stenosis and/or insufficiency, mitral stenosis and/or insufficiency, and various cardiomyopathies to determine the need for surgical correction
• Collection of data to confirm and complement noninvasive studies
• Determination of the presence of coronary artery disease in patients with confusing clinical presentations or chest pain of uncertain origin

Contraindications to cardiac catheterization

With the exception of patient refusal, cardiac catheterization has no absolute contraindications. Clearly, the risk-to-benefit ratio must be considered because a procedure associated with some risk should be contraindicated if the information derived from it is of no benefit to the patient. Relative contraindications are as follows:

• Severe uncontrolled hypertension
• Ventricular arrhythmias
• Acute stroke
• Severe anemia
• Active gastrointestinal bleeding
• Allergy to radiographic contrast
• Acute renal failure
• Uncompensated congestive failure (patient cannot lie flat)
• Unexplained febrile illness and/or untreated active infection
• Electrolyte abnormalities (eg, hypokalemia)
• Severe coagulopathy

Note that many of these factors can be corrected before the procedure, thereby lowering the risk. This always should be considered unless the procedure is being performed in an emergency situation.

FAQ’s

• • Who performs the cardiac catheterization?
    • A cardiologist or a radiologist performs cardiac catheterization procedure

• • How long does a cardiac catheterization take?
    • You will be in the Cath lab for about an hour’s time at least, including preparation and the actual procedure. Several hours may be required to do catheterization as a therapeutic procedure.

• • Can I have a cardiac catheterization if I’m allergic to dyes?
    • Most often, antihistamines and steroids can be given as a pretreatment to patients with previous allergic reactions to the contrast dye. This pretreatment should suffice in bringing down the risk of an adverse reaction to a minimum.

• • Am I being exposed to too much radiation during this procedure?
    • Since this procedure has live X-ray imaging, patients will be exposed to a small amount of radiation. However, it is not very harmful at these levels. Doctors and staff present in the lab protect themselves by wearing lead aprons.

• • Why should a patient choose India Cardiac Surgery Consultants for cardiac care?
    • India, Cardiac Surgery Consultants provide a vast number of high quality cardiac services. The cardiac team includes board-certified cardiologists and cardiac surgeons, specially trained nurses, and registered technologists. The cardiac team at uses the most advanced technologies available to perform the cardiac procedures at an affordable price and has a lower complication rate.

• • What mode of payment do you accept?
    • We accept different methods of payment like, cash, plastic cash, via net banking, etc.