Cardiac Catheterization in Patients with Pulmonary Hypertension

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1 Cardiac Catheterization in Patients with Pulmonary Hypertension Russel Hirsch, M.D. And James Tarver, M.D. Cincinnati Chldren s Hospital Medical Center And Orlando Heart Center Disclosures Russel Hirsch no relevant financial and/or commercial relationships to disclose Objectives of this talk Review the need for cardiac catheterization Indications Describe the course of a standard cardiac catheterization Catheter manipulation and use of fluoroscopy Review therapeutic drug testing during cardiac catheterization Oxygen and inhaled nitric oxide Discuss the risks associated with cardiac catheterization Arrhythmias Low cardiac output syndrome 1

2 Indications for Cardiac Catheterization The current gold standard for measuring hemodynamics Cardiac output measurement and intra-cardiac shunts Absolute RV and PA pressures Pulmonary vascular resistance calculation Evaluation of any associated anatomic abnormalities Mitral valve stenosis Pulmonary vein stenosis Indications for Cardiac Catheterization Therapeutic drug testing Alternative ventilation / airway strategies Oxygen and nitric oxide Inotropes for cardiac output augmentation Institution of chronic therapy / immediate dose adjustment Commencement of prostanoid therapy Indications for Cardiac Catheterization ASD creation Improved left ventricular pre-load at expense of lower saturations Any other intervention that might require sedation or anesthesia at another time Central line placement Short-term or chronic (placement or removal) Bronchoscopy Ophthalmic surgery / Orthopedic surgery / Gynecological EUA / G-Tube placement, etc. 2

3 Cardiac Catheterization Suite Critical care facility with a unique combination of elements Not just equipment High grade angiography - essential Hemodynamic monitoring / recording facilities essential Dedicated staff - essential RN s, PNP s, PA s, Rad Techs Anesthesiologists, Adult and Pediatric Cardiologist Child Life Specialists Cardiac Catheterization Suite Hybrid capabilities nice, but not essential OR environment Sufficient space to accommodate people / equipment (ECMO etc.) Associated critical care / step down unit essential A mind-set, rather than just a physical space. Cardiac Catheterization Suite 3

4 Cardiac Catheterization Suite Cardiac Catheterization Suite Cardiac Catheterization Suite 4

5 Cardiac Catheterization Environment Clean / Sterile Standard monitoring Pulse / BP / Saturation / End-tidal CO 2 Additional monitoring depending on criticality (NIRS) Intra-vascular access Venous and / or arterial Cardiac catheters Oxygen sampling Pressure measurement Angiography Thermodilution measurement equipment / Oxygen consumption monitor Accurate cardiac output measurement Course of the Procedure Vascular access Venous sheath Femoral / Subclavian / Internal jugular Arterial sheath Femoral Insertion and removal of catheters without loss of access 5

6 Catheters End-whole Balloon-tipped Pigtail Course of the Procedure Pressure measurement Angiography End-Hole Catheter / Balloon Tipped Pigtail Catheter 6

7 Catheter Manipulation Direct vision under fluoroscopy Patient in steady state Sedation or anesthesia Hemodynamic steady state Normal ph Simultaneous pressure and blood sampling for oximetry measurement Right and Left Heart Catheterization Catheter advance from IVC RA SVC Simultaneous saturation and arterial blood gas from aorta Catheter withdrawn from SVC RA Catheter advanced from RA RV Catheter advanced from RV Branch PA, then; Arterial catheter advanced from Ao LV Saturation measurement Balloon on venous catheter inflated to advance to wedge position Simultaneous wedge pressure and LV end diastolic pressure measurement Balloon on venous catheter deflated Free PA pressure measurement 7

8 IVC RA RA SVC 8

9 SVC Pressure Catheter tip in the SVC Mean SVC pressure 9mmHg Right and Left Heart Catheterization Catheter advance from IVC RA SVC Simultaneous saturation and arterial blood gas from aorta Catheter withdrawn from SVC RA Catheter advanced from RA RV Catheter advanced from RV Branch PA, then; Arterial catheter advanced from Ao LV Saturation measurement Balloon on venous catheter inflated to advance to wedge position Simultaneous wedge pressure and LV end diastolic pressure measurement Balloon on venous catheter deflated Free PA pressure measurement 9

10 SVC RA RA Pressure Mean RA pressure 8-9mmHg Catheter tip in the RA Right and Left Heart Catheterization Catheter advance from IVC RA SVC Simultaneous saturation and arterial blood gas from aorta Catheter withdrawn from SVC RA Catheter advanced from RA RV Catheter advanced from RV Branch PA, then; Arterial catheter advanced from Ao LV Saturation measurement Balloon on venous catheter inflated to advance to wedge position Simultaneous wedge pressure and LV end diastolic pressure measurement Balloon on venous catheter deflated Free PA pressure measurement 10

11 RA RV RV and Aortic Pressure RV pressure 97/14 Catheter tip in the RV Aortic pressure 82/49, mean 64mmHg 11

12 Right and Left Heart Catheterization Catheter advance from IVC RA SVC Simultaneous saturation and arterial blood gas from aorta Catheter withdrawn from SVC RA Catheter advanced from RA RV Catheter advanced from RV Branch PA, then; Arterial catheter advanced from Ao LV Saturation measurement Balloon on venous catheter inflated to advance to wedge position Simultaneous wedge pressure and LV end diastolic pressure measurement Balloon on venous catheter deflated Free PA pressure measurement RV PA (Left) 12

13 Ao LV Right and Left Heart Catheterization Catheter advance from IVC RA SVC Simultaneous saturation and arterial blood gas from aorta Catheter withdrawn from SVC RA Catheter advanced from RA RV Catheter advanced from RV Branch PA, then; Arterial catheter advanced from Ao LV Saturation measurement Balloon on venous catheter inflated to advance to wedge position Simultaneous wedge pressure and LV end diastolic pressure measurement Balloon on venous catheter deflated Free PA pressure measurement PA Wedge Occlusion and LV Pressure Catheter tip in the LPA LV End Diastolic 10mmHg Catheter tip in the LV LVEDP a wave LPAW 10/10, mean 8mmHg 13

14 Right and Left Heart Catheterization Catheter advance from IVC RA SVC Simultaneous saturation and arterial blood gas from aorta Catheter withdrawn from SVC RA Catheter advanced from RA RV Catheter advanced from RV Branch PA, then; Arterial catheter advanced from Ao LV Saturation measurement Balloon on venous catheter inflated to advance to wedge position Simultaneous wedge pressure and LV end diastolic pressure measurement Balloon on venous catheter deflated Free PA pressure measurement Free PA and Descending Aorta Pressure PA balloon deflated; catheter free in LPA Ao 80/48, mean 62mmHg Catheter in Ao LPA 90/28, mean 54mmHg Hemodynamic Calculations Cardiac output Thermodilution ( gold standard) Fick principle (required if intra-cardiac shunts are present) Required indices for Pulmonary Vascular Resistance (Rp) Pulmonary blood flow (Qp) Cardiac index (cardiac output / BSA) = Qp if no intra-cardiac shunts Mean pulmonary artery pressure Mean left atrial pressure (pulmonary capillary wedge pressure) 14

15 Pulmonary Vascular Resistance (Rp) Rp* = Trans-Pulmonary Gradient Pulmonary Blood Flow = Mean PA Pressure Mean Wedge Pressure Cardiac Index * Normal Rp < 3.5 Wood Units x meters 2 Case Report 9 year old male, previously well Diagnosed 9 months prior to referral Treated with Sildenafil and Bosentan Increasing fatigue and exercise intolerance Unable to attend school Occasional chest pain No syncope Case Report Pulse 105, BP 105/68, O 2 sat 97% Cool peripheries, no edema, no pallor RV heave, palpable 2 nd heart sound Normal S1, loud S2 with prominent P2 split 1/6 holo-systolic murmur at tricuspid area ¼ early diastolic murmur at pulmonary area Liver edge 3cm below the right costal margin 15

16 Case Report ECG RA enlargement / RV hypertrophy / ST and T wave flattening ECHO RV dilation with decreased function RA dilation; no PFO TR velocity predicting RV pressure XX mmhg (+ RA pressure) PR velocity predicting PA diastolic pressure XX mmhg 6 Minute walk Terminated at 1 minute 15 seconds with inappropriate tachycardia (180/min) and pre-syncope Case Report Rp = Mean PA Pressure Mean Wedge Pressure Cardiac Index Rp = 55mmHg 2.2 l/min/m 2 7mmHg (Measured by thermo-dilution) Rp = 21.8 Wood Units x meters 2 Normal Rp < 3.5 Wood Units x meters 2 Summary / Conclusion 16

17 Given the risk, why do we need catheterization data? Baseline hemodynamic data to assess later response to therapy Responders versus non-responders Stratification of risk 17

18 13 x 18 = 235 (mrap x Rp ) 18

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