Diagnostic cardiac catheterization and coronary angiography are considered the gold standard in the assessment of the anatomy and physiology of the heart and its associated vasculature. In 1929, Forssmann demonstrated the feasibility of cardiac catheterization in humans when he passed a urological catheter from a vein in his arm to his right atrium and documented the catheter's position in the heart by x-ray. In the 1940s, Cournand and Richards applied this technique to patients with cardiovascular disease to evaluate cardiac function.These three physicians were awarded the Nobel Prize in 1956. In 1958, Sones inadvertently performed the first selective coronary angiography when a catheter in the left ventricle slipped back across the aortic valve, engaged the right coronary artery, and power-injected 40 mL of contrast down the vessel. The resulting angiogram provided superb anatomic detail of the artery, and the patient suffered no adverse effects. Sones went on to develop selective coronary catheters, which were modified further by Judkins, who developed preformed catheters and allowed coronary artery angiography to gain widespread use as a diagnostic tool. In the United States, cardiac catheterization is the second most common operative procedure, with nearly 3 million procedures performed annually.
INDICATIONS, RISKS, AND PREPROCEDURE MANAGEMENT
Cardiac catheterization and coronary angiography are indicated to evaluate the extent and severity of cardiac disease in symptomatic patients and to determine if medical, surgical, or catheter-based interventions are warranted (Table 13-1). They are also used to exclude severe disease in symptomatic patients with equivocal findings on noninvasive studies and in patients with chest-pain syndromes of unclear etiology for whom a definitive diagnosis is necessary for management. Cardiac catheterization is not mandatory prior to cardiac surgery in some younger patients who have congenital or valvular heart disease that is well defined by noninvasive imaging and who do not have symptoms or risk factors that suggest concomitant coronary artery disease.
TABLE 13-1INDICATIONS FOR CARDIAC CATHETERIZATION AND CORONARY ANGIOGRAPHY |Favorite Table|Download (.pdf) TABLE 13-1INDICATIONS FOR CARDIAC CATHETERIZATION AND CORONARY ANGIOGRAPHY
|CORONARY ARTERY DISEASE |
Asymptomatic or Symptomatic
High risk for adverse outcome based on noninvasive testing
Sudden cardiac death
Sustained (>30 s) monomorphic ventricular tachycardia
Nonsustained (<30 s) polymorphic ventricular tachycardia
Canadian Cardiology Society class III or IV angina on medical therapy
Unstable angina—high or intermediate risk
Chest-pain syndrome of unclear etiology and equivocal findings on noninvasive tests
Acute Myocardial Infarction
Reperfusion with primary percutaneous coronary intervention
Persistent or recurrent ischemia
Severe pulmonary edema
Cardiogenic shock or hemodynamic instability
Mechanical complications—mitral regurgitation, ventricular septal defect
VALVULAR HEART DISEASE
Suspected valve disease in symptomatic patients—dyspnea, angina, heart failure, syncope
Infective endocarditis with coronary embolization
Asymptomatic patients with aortic regurgitation and cardiac enlargement or ↓ ejection fraction
Prevalve surgery in older patients with coronary artery disease risk factors
CONGESTIVE HEART FAILURE
New onset with angina or suspected undiagnosed coronary artery disease
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