What is the procedure for performing a right heart catheterization?

Right Heart Catheterization Procedure

Right heart catheterization involves inserting a catheter into the venous system to record right heart and pulmonary pressures, perform angiography, and obtain blood samples. 1

Preparation and Patient Assessment

• The physician must thoroughly review the patient's history, physical examination, and laboratory data before the procedure, ideally the day before 2
• Informed consent must be obtained by the physician performing the procedure, with a detailed discussion of reasons, benefits, complications, and procedure description 2
• All patients should be evaluated for bleeding risk and kidney function before the procedure 2
• For patients with chronic kidney disease (creatinine clearance <60 mL/min), contrast media volume should be minimized 2

Anticoagulation Management

• For patients on oral anticoagulants, management depends on the type of anticoagulant 2
• Patients already on daily aspirin therapy should take 81-325 mg before the procedure 2
• Patients not on aspirin therapy should be given non-enteric aspirin 325 mg before the procedure 2

Procedural Steps

1. Venous Access:

   • The procedure begins with obtaining venous access, typically through the femoral, internal jugular, or subclavian vein 3, 4
   • The femoral approach is common for diagnostic procedures, while the internal jugular approach may be preferred for prolonged monitoring 5

2. Catheter Advancement:

   • Under fluoroscopic guidance, the catheter is advanced through the venous system into the right atrium 5, 6
   • From the right atrium, the catheter is directed through the tricuspid valve into the right ventricle 3, 5
   • The catheter is then advanced through the pulmonary valve into the pulmonary artery 3, 6

3. Pressure Measurements:

   • Pressure measurements are recorded at each chamber (right atrium, right ventricle, pulmonary artery) 5, 6
   • Pulmonary capillary wedge pressure is obtained by inflating the balloon at the catheter tip to occlude a small pulmonary artery branch 5, 6

4. Blood Sampling:

   • Blood samples may be collected from different locations to measure oxygen saturation and calculate cardiac output and shunts 6

5. Cardiac Output Measurement:

   • Cardiac output is typically measured using the thermodilution technique or Fick method 5, 6

6. Angiography:

   • If indicated, contrast material may be injected to visualize the pulmonary vasculature 1

Post-Procedure Care

• Standard post-procedural orders should include checking and recording vital signs, distal pulses, and bandage sites every 15-30 minutes for 2 hours, then hourly 2
• A member of the catheterization team should examine the patient later in the day and subsequently as indicated 2

Potential Complications

• Access site-related issues such as carotid artery injury or arteriovenous fistula formation 4
• Catheter-related complications including injury to the tricuspid valve 4
• Other complications include vascular injury, cardiac perforation, arrhythmias, and rarely death (0.1-0.2% in elective cases) 4, 7
• Complication rates are higher in patients with severe left ventricular dysfunction, neonates, elderly patients, and those with severe arterial hypoxemia or pulmonary hypertension 8

Quality Considerations

• Right heart catheterization should be performed in specialized centers by experienced operators following strict protocols 8, 5
• The procedure should never be viewed as a routine technical service but as a specialized consultation requiring sophisticated techniques and experienced personnel 8
• A prospective registry of complications should be maintained by each catheterization laboratory to monitor performance 8

Common Pitfalls to Avoid

• Inadequate hydration before contrast administration increases the risk of contrast-induced nephropathy 2
• Improper management of anticoagulation, particularly when bridging is required 2
• Misinterpretation of pressure waveforms can lead to diagnostic errors 5, 6
• Failure to recognize and promptly address complications can lead to adverse outcomes 4