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CHAPTER 20: CARDIAC CATHETERIZATION, CARDIAC ANGIOGRAPHY, AND CORONARY BLOOD FLOW AND PRESSURE MEASUREMENTS

Morton J. Kern; Arnold H. Seto

CARDIAC CATHETERIZATION

In 1929, Werner Forssman, a resident surgeon at Eberswalde in Germany, inserted a urologic catheter into his right atrium from a left antecubital vein cut down he had performed on himself using a mirror. After walking downstairs to the radiology suite, the position of the catheter tip was verified by a roentgenogram. This was the beginning of cardiac catheterization: the insertion and passage of small plastic catheters into arteries, veins, the heart, and other vascular structures to obtain angiographic images of coronary arteries and cardiac chambers and to measure hemodynamic data (pressure and flow) in the heart. Cardiac angiography images not only diagnose coronary artery disease (CAD) but are used to visualize abnormalities of the aorta as well as the pulmonary and peripheral vessels.

Equally important, the modern cardiac catheterization laboratory is a therapeutic theater of operations for catheter-based interventions (eg, stent implantation, atherectomy, thromboaspiration), collectively called percutaneous coronary intervention [PCI]) or catheter-based treatment of structural heart disease (Table 20–1). Figure 20–1 shows a typical modern cardiac catheterization laboratory.

FIGURE 20–1.

The modern catheterization laboratory. 1 AP imaging C-arm, with the image intensifier above the patient and the x-ray tube below; 2 lateral imaging C-arm with the x-ray system to the patient’s right; 3 the lateral plane imaging intensifier on the patient’s left side; 4 table pad position for patient’s head; 5 contrast media power injector; 6 angiographic and hemodynamic monitors; 7 crash cart; 8 pressure transducer holders; 9 table controls for integrated intravascular ultrasound and coronary hemodynamics system; 10 control panel for x-ray images; 11 table controls for movement of x-ray system; 12 undertable lead shield; and 13 foot pedal controls for fluoroscopy and cineangiography imaging. Reproduced with permission from Kern MJ, Lim MJ, Sorajja P: The Cardiac Catheterization Handbook, 6th edition. Philadelphia: Elsevier; 2016.1

A photo of a standard modern catheterization laboratory.
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TABLE 20–1.Diagnostic and Therapeutic Interventional Procedures That May Accompany Coronary Angiography
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TABLE 20–1. Diagnostic and Therapeutic Interventional Procedures That May Accompany Coronary Angiography
Diagnostic Procedures Comment
Central venous access (femoral, brachial, internal jugular, subclavian) Access for emergency medications or fluids, temporary pacemaker
Hemodynamic assessment
 Left heart pressures (aorta, left ventricle) Routine for all studies
 Right and left heart combined pressures Not routine for coronary artery disease; mandatory for valvular heart disease; CHF, right ventricular dysfunction, pericardial diseases, cardiomyopathy, intracardiac shunts, congenital abnormalities
 Transseptal or LV puncture Valvular heart disease
 Intracoronary pressure/flow Coronary lesion assessment
Left ventricular angiography Routine for all studies; may be excluded with high-risk patients, left main coronary or aortic stenosis, severe CHF, renal failure
Internal mammary artery and saphenous vein bypass graft selective angiography Routine for coronary bypass conduit assessment
Pharmacologic studies
 Ergonovine/acetylcholine Specialized studies for suspected coronary vasospasm
 

IC/IV/sublingual nitroglycerin

Inhaled nitric oxide

Routine for all coronary angiography

Evaluation of pulmonary vasoreactivity
Aortography Routine for aortic ...

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