When should a clinician consider left heart catheterization?

Indications for Left Heart Catheterization

Left heart catheterization is indicated primarily for patients with suspected coronary artery disease, heart failure with suspected ischemic contribution, valvular heart disease requiring hemodynamic assessment, and specific clinical scenarios where noninvasive testing is inadequate or inconclusive. 1

Primary Indications

• Left heart catheterization or coronary angiography is indicated for patients with heart failure and angina 1
• Coronary arteriography is reasonable when ischemia may be contributing to heart failure in patients eligible for revascularization 1
• Cardiac catheterization should be performed in patients with respiratory distress or impaired systemic perfusion when clinical assessment is inadequate 1
• Left heart catheterization may be useful for patients without angina but with left ventricular dysfunction to evaluate for underlying coronary artery disease 1

Heart Failure-Specific Indications

• Invasive hemodynamic monitoring can be useful for carefully selected patients with acute heart failure who have persistent symptoms despite empiric adjustment of standard therapies and: 1
  • Uncertain fluid status, perfusion, or systemic/pulmonary vascular resistance
  • Low systolic pressure associated with symptoms despite initial therapy
  • Worsening renal function with therapy
  • Requirement for parenteral vasoactive agents
  • Consideration for mechanical circulatory support or transplantation

Valvular Disease Indications

• Left heart catheterization is indicated in patients with suspected severe valvular disease, particularly aortic stenosis, when clinical assessment and noninvasive testing are inconclusive 1
• Transseptal catheterization may be necessary for assessment of mitral valve disease, especially when retrograde access is contraindicated or challenging 1, 2

Contraindications and Cautions

• Routine use of invasive hemodynamic monitoring is not recommended in normotensive patients with acute heart failure who have a symptomatic response to diuretics and vasodilators 1
• Patients with NYHA functional class III or IV heart failure, severe right ventricular failure, or severe pulmonary hypertension require special consideration and may need inpatient monitoring 1
• Patients with suspected active endocarditis should not undergo ambulatory cardiac catheterization procedures 1
• Patients requiring continuous anticoagulation need careful management and may require inpatient procedures 1

Special Considerations

• Transseptal left heart catheterization should be performed only with cardiac surgical support due to risk of complications (1.3% major complication rate including cardiac tamponade) 2
• In patients with prosthetic valves, transseptal approach may be preferred to avoid retrograde crossing of the prosthesis 2, 3
• For post-myocardial infarction patients, cardiac catheterization provides powerful prognostic information, especially in those with recurrent ischemia, heart failure, complex ventricular arrhythmias, or abnormal noninvasive test results 4

Pediatric and Congenital Heart Disease Considerations

• Cardiac catheterization is indicated in patients with complex pulmonary atresia for detailed characterization of pulmonary vascular supply when noninvasive imaging is inadequate 1
• Cardiac catheterization is reasonable to assess pulmonary pressure/resistance before staged palliation in single-ventricle patients 1, 5
• In hypoplastic left heart syndrome, catheterization may be needed to assess pulmonary vascular resistance and perform interventions like atrial septostomy 5

Key Pitfalls to Avoid

• Performing routine right-sided cardiac catheterization during left-sided catheterization without specific indications rarely provides clinically useful information (changes management in only 1.5% of cases) 6
• Routine use of invasive hemodynamic monitoring in stable heart failure patients has not shown benefit and should be avoided 1
• Performing cardiac catheterization without considering whether the patient is a candidate for revascularization or other interventions that might result from the findings 1