LEFT HEART CATHETERIZATION

Dr. Nagula Praveen,
Final yr PG

 Introduction
 Indications
 Contraindications
 Preparation of patient
 Access – techniques
 Catheters
 Angiographic Views
 Pressure wave forms
 Interpretation
 Complications
 Case profile examples

 Cardiac catheterization – “the insertion and passage of small plastic
catheters into arteries,veins,the heart,and other vascular structures.”
 Standard medical procedure – guides treatment decision, we can
measure intracardiac pressures, cardiac output, oximetry data, have
radiographic images of coronaries, aorta and peripheral vessels for
anomalies, obstruction.
 Presently more of therapuetic concern – eg; angioplasty, stenting and
closure of ASD,VSD.

 Usually an elective procedure.
 Diagnostic – discreprancy between the symptoms and clinical features
of patient.
 Valve area, cardiac output and resistance.
 Quantification of shunts
 Pressure gradients
 Therapeutic – useful for assessing the pressure gradients before and
after
 Mitral Stenosis – PBMV
 Aortic Stenosis – PBAV
 PDA device closure
 HOCM – alcohol septal ablation.
 Cooarctation of Aorta
 Aorto Pulmonary Window closure

 Absolute – patient not prepared either psychologically or physically.
 Relative –
 Fever
 Anemia
 Electrolyte abnormalities (Hypokalemia)
 Systemic illness
 Anticoagulation (INR >1.6)
 Using medications (digitalis,phenothiazines)
 Renal failure
 Uncontrolled CHF
 Pregnancy

 Informed consent – simple terms, steps of procedure, complications (usually
taken by operator).
 All peripheral pulses to be felt.
 For diabetic patients – dose of NPH insulin should be cut by 50% (overnight
fast with normal dosing of insulin – hypoglycemia).
 To stop metformin – 48 hrs before procedure – lactic acidosis.(no evidence
for clinical benefit).
 Adequate hydration. (urine output > 50ml/h)
 Anxiolytic
 Shaving of the both forearms and inguinal regions.
 IE prophylaxis if valvular heart disease.

 Femoral artery/vein
 Modified Seldinger technique.
 Fluoroscopy guidance – medial edge of the middle of the head of the
femur.
 30 angle to the vessel.
 A syringe may be attached to seldinger needle and gently aspirated
while advancing-in case of femoral vein access.

 Angiographic catheters
 Pigtail catheter
• 1.Quanticor - cardiomarker pigtail – radioopaque markers set
2cm apart.
• Exact LV distances, volumes and stroke volume can be calculated
using these markers as a ruler.
• 2.Angiographic Pigtail - MC used
• 3.Van Tassel angled pigtail – 145-155 angle ,dilated aorta.
• 4.Groll man Pigtail – curve generally on reverse side
 RV selective angiography,PA angiography.
• 5.Elliptical or Oval - small aortic valves
• 6.Tennis Racquet – reduced risk of vessel wall extravasation

 Woven dacron catheter with polyurethane coating.
 Tapered tip.
 Three pairs of laterally opposed oval side holes within 1.5 cm of
its open tip.
Right and left angiography studies.
Disadvantages
 Straight tip – more arrhythmogenic.
 Catheter recoil during high flow rates.
 Risk of intramyocardial injection.

 NIH catheter. – no end hole, six sideholes.
 Multitrack catheter.
• end hole and side hole catheter.
• useful to record pressure while wire inside – pull back
gradient across valvular stenosis.
• Angiography while wire inside.

 Retrograde Techniques
 The Judkins technique - Femoral artery.
 Percutaneous Radial technique.
 Percutaneous Brachial artery technique – Sones Technique.
 Antegrade technique
 Transeptal Catheterization.
 Apical Approach
 Direct Transthoracic Left ventricular puncture.

 Relatively easy, speed, reliability,low complication rate.
 MC method for left heart catheterization.
 1% xylocaine infiltrated at the puncture site.
 Artery to be punctured 3cms below the inguinal ligament, not the inguinal
crease.
 Modified Seldinger technique is used(double wall puncture leads to
hematoma).
 18 G thin walled needle is used.
 0.035-0.038 J tip PTFE coated guidewire is advanced through the
needle.(hot knife passing through the butter).
 A sheath atleast equal size of the catheter to be passed over the guide wire
after small nick by scalpel.
 Heparin - 2000 to 3000 units.

 LV systolic and end diastolic pressures can be recorded by advancing a
pigtail into the LV.
 For assessing AS, LV and Aortic pressure should be recorded
simultaneously with two transducers.
 Femoral artery pressure not to be taken – attenuation in pressure
can occur in older patients,with PAD.
 Pigtails with both distal and proximal lumen to be used.
 LV Aangiography - pigtail is used – to assess LV function.
 Intraventricular gradients – multipurpose catheter to be used.

 PBMV,Access to pulmonary veins.
 Complication rate <1%.
 Procedure:
• 8F Mullins transseptal sheath and dilator
• Brockenbrough needle. 18 G -21G at tip.
• 0.032 inch guide wire – FV - RA – SVC.
• Mullins sheath and dilator advanced over the wire into SVC.
• Guidewire is removed and replaced by Brockenbrough needle.
• Catheter is rotated from 12 o’– 5 o’ clock position.
• Two abrupt right ward movements. – SVC to RA, Limbic edge of
fossa ovalis.
• Septal puncture done under fluoroscopy guidance.
• LA pressure recorded.
• LV angiography if needed – slight counterclockwise rotation.

 Measure LV pressure and perform ventriculography in patients with
mechanical prosthetic valves in both the mitral and aortic positions that
prevent both retrograde and transseptal catheterization.
 Crossing of tilting disks to be avoided – catheter entrapment, occlusion of the
valve,possible dislodgement and embolization of the disc.
 Localization of LV apex by palpation or by echocardiography.
 18 G 6” inch Teflon catheter system is inserted at upper rib margin, directed
slightly posteriorly and toward the right second intercostal space.
 Needle and sheath are advanced into the LV.
 Stylet and the needle removed.
 Sheath connected for pressure measurement.

 Left ventriculography
 RAO 30  - Anterior ,apical and inferior walls.
 LAO 60 and Cranial 20 - lateral and septal ventricular walls.
• Suspected VSD,MR.
 Aortography
 LAO view – Ascending aorta, Aortic arch, innominate,carotids,left
subclavian arteries.
 RAO view – lower thoracic aorta, assessing AR.
 The descending aorta and ascending aorta are superimposed across the
arch in AP projection.

 Power injection of 30-40ml of contrast medium into the left
ventricle at 12-15ml/sec is used to assess LV function and the
severity of MR.

RAO DIASTOLIC FRAME RAO SYSTOLIC FRAME

 60 LAO
- assess ventricular septal
integrity and motion
- lateral and posterior
segmental function
- aortic valvular anatomy
-15-30 cranial angulation for
profiling entire IVS

PROJECTION DEGREES VESSEL/
CHAMBER
IMAGED
LESIONS
Long axial
oblique
70 LAO,30Cranial LV LVOT
obstruction
Hepatoclavicular
view
45 LAO ,
45 Cranial
Four chambers LV –RA
connection
Lateral view 90 Descending aorta Coarctation,
PDA
LAO 60 -70 LAO Aorta Coarctation/
Aortic valve
disease
RAO 30- RAO with or
without caudal
angulation
LV Mitral valve
disease

Judkins:
 Pigtail catheter – FA – Abdominal aorta – Thoracic aorta – Aortic arch –
Ascending aorta – Aortic sinus – Aortic valve – LV.
Transseptal Technique
 Femoral vein – IVC - SVC – RA – PFO/Puncture - LA – MV – LV .
Pull BACK
 LV – LVOT – AV – Aortic sinus – Ascending aorta – arch – descending
aorta.

 + small regurgitant jet only, LV ejects contrast each systole.
 + + regurgitant jet faintly opacifies LV cavity, not cleared with each
systole.
 +++ persistent LV opacification = Aortic root density; LV
enlargement.
 ++++ Persistent LV opacification > Aortic root concentration, often
marked LV enlargement.

 Pressure measurements
 Measurement of flow (eg: cardiac output,shunt flow,flow
across a stenotic orifice,regurgitant flow,and coronary blood
flow)
 Determination of vascular resistance.

 Normal left atrial pressure is higher than the right atrium.(high
pressure system of the left side of the heart).
 The v wave is generally higher than the a wave.
 Left atrium is constrained posteriorly by the pulmonary veins whereas
the right atrium can easily decompress through the SVC and IVC.
 Height of the left atrial v wave –most accurately reflects the left
atrial compliance.

 Similar to left atrial pressure
 Slightly damped and delayed (transmission through the lungs).
 c waves may not be seen.
 PADP = mean PCWP - as pulmonary circulation has low resistance.
 PCWP may overestimate true left atrial pressure - High PVR
• Hypoxemia
• Pulmonary embolism
• Chronic pulmoanry hypertension
• After mitral valve surgery(accurate gradients across MV – LA pressure needed)

 RV and LV pressure waveforms are similar in
morphology,differ with repsect to magnitudes.
 Early rapid filling wave
 Slow filling phase
 Atrial systole. LV RV
ISVC Longer Shorter
ISVR Longer shorter
DURATION OF
SYSTOLE
longer shorter
EJECTION
PERIOD
shorter longer

 End diastolic pressure is generally measured at the C point – rise in
ventricular pressure at the onset of isovolumic contraction.
 When the C point is not well seen, a line drawn from the R wave on
the simultaneous ECG to the ventricular pressure waveform is used
as enddiastolic pressure.

 Systolic wave
 The incisura (indicating the closure of the semilunar valves)
 Gradual decline in pressure until the following systole.
 Pulse pressure – reflects stroke volume and compliance of the
arterial system.
 Mean aortic pressure – peripheral resistance(accurately).

 Systolic wave increases in amplitude – becomes more
triangular.
 Diastolic wave decreases(until the midthoracic aorta),and
then increases.
 Mean aortic pressure similar.
 Mean peripheral arterial pressure is typically lower than mean
central aortic pressure by 5 mm Hg or less.

 Difference between the central aorta and the
periphery(femoral,brachial,or radial arteries) is greatest in younger
patients – increased vascular compliance.
 Imp. in patients with stenotic lesions.
 When a transvalvualr gradient is present, the most accurate measure of
aortic pressure is obtained at the level of the coronary arteries(to avoid
the pressure recovery).

 SV is the quantity of blood ejected with each beat.
 EDV is the maximum volume in LV and occurs before the onset of
systole.
 It occurs directly after atrial contraction in patients with sinus rhythm.
 ESV – minimum volume of LV during cardiac cycle.
 Angiographic cardiac output can be estimated by LVED and LVES
tracings.
 Inaccuracies in calibrating angiographic volumes.
 Cannot be used in AF, regurgitant lesions.

 Across the valve –Mitral valve,Aortic valve
 Peripherally – Coarctation of aorta
 Intraventricularly
 Assessing the severity of stenosis,valve area,resistance
 Cardiac output

 Simultaneous LV,LA pressure tracings.
 Check zero pressures of the PCWP,FA,LV after catheters and
sheath have been flushed.
 LV pressure tracing 200mmHg scale at 50 mm/sec paper speed.
 PCWP pressure tracing 40 mm Hg scales at 50mm/sec paper
speed.
 Use 100mm/sec speed if a mitral valve gradient is present.

 Advance a pigtail into the LV.
 Check the zero pressures of both sheath and pigtail catheter
after flushing.
 Record LV and FA pressure (25mm/sec speed,200mmHg
scale)
 100mm/sec speed if an aortic valve gradient is present.

 Access site complications.
 Contrast induced reactions.
 Procedure related complications.


 Left heart catherization has a significant role in quantifying the
pressure gradients across the valve and within the left ventricle.
 Mostly being used presently during therapeutic indications rather
than diagnostic indications.
 Optimal pressure tracings with all necessary precuations and
knowing the limitations of each helps in judging the severity of
the clinical condition to the nearest accuracy..

LEFT HEART CATHETERIZATION

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LEFT HEART CATHETERIZATION