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Home > Professional Reference > Cardiac Catheterisation

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Cardiac Catheterisation

This PatientPlus article is written for healthcare professionals so the language may be more technical than the condition leaflets. You may find the abbreviations list helpful.

Cardiac catheterisation with a venous or arterial long-line catheter allows:

  • Injection of radio-opaque dye for angiography
  • Measurement of intracardiac pressures and oxygen saturations
  • Passage of electrophysiological instruments
  • Passage of angioplasty and valvuloplasty balloons

The catheter is manipulated under fluoroscopic guidance. The patient is usually awake and on a cardiac monitor throughout. Most diagnostic studies are conducted as day-cases.

Left heart catheterisation

This is performed via the arterial route:

  • The femoral artery has been the most commonly used access point.
  • The brachial artery may be used. This is usually done percutaneously rather than with surgical exposure of the artery.
  • The radial artery is gaining favour as an access site and many studies report fewer local complications for a range of different interventions.1,2,3,4,5,6,7 It is useful particularly when:
    • There is significant femoral artery atherosclerosis.
    • Obesity obscures anatomical landmarks.
    The disadvantages are that the technique is technically more difficult. For example, manipulation of the catheter can be difficult because of arterial spasm.

Diagnostic uses

Cardiac catheterisation allows for more definitive testing in patients with confusing histories or clinical presentations of chest pain of uncertain origin. It also allows for diagnostic confirmation and more detailed information after noninvasive studies.
It can be used to assess:

The National Institute for Health and Clinical Excellence (NICE) recommends that angiography should be performed as soon as possible for patients who are clinically unstable or at high ischaemic risk.9

Therapeutic interventions

Detailed analysis of the merits of such interventions is beyond the scope of this article. Such interventions include:

  • Percutaneous transluminal coronary angioplasty (PTCA).
  • PTCA and stenting .
  • Treatment of acute coronary syndromes (ACS) by PTCA/stenting – a Cochrane review and others cautiously favour stents over PTCA due to reduced risk of reinfarction and recurrent vessel occlusion.10,11 Whether ACS are best treated by early invasive intervention is currently uncertain. This is one area that is subject to rapid change, with the introduction of new drugs, such as glycoprotein IIb/IIIa inhibitors, which have been shown to have clear benefit in high-risk ACS when used in combination with PTCA or stenting.
  • Treatment of acute myocardial infarction. There appear to be advantages to PTCA in terms of short-term outcome but there are some drawbacks as well.
  • Balloon valvuloplasty.
  • Septal infarction by alcohol injection for hypertrophic obstructive cardiomyopathy (HOCM).

Right heart catheterisation

This is performed by the venous route, via the femoral, internal jugular, subclavian veins or forearm veins.6

Diagnostic uses

Right heart catheterisation allows:

  • Measurement of cardiac output, left ventricular filling pressure and pulmonary artery wedge pressure.
  • Measurement of right heart oxygen saturations (for example, for septal defects).
  • Assessment of pulmonary hypertension (for example, prior to cardiac transplantation).
  • Electrophysiological provocation studies.

Therapeutic interventions

These include:

  • Right-sided valvuloplasties.
  • Radiofrequency ablation of (for example, the accessory pathway in Wolff-Parkinson-White syndrome).
  • Direct thrombolysis into the pulmonary artery for massive pulmonary embolism.
  • Insertion of electrodes for cardiac pacemaker devices.

In the critically ill patient, right heart catheterisation with a Swan-Ganz catheter may be used for acute monitoring of left and right ventricular function, to guide treatment and monitor the effects of intervention. It has no direct therapeutic function. The catheter is usually inserted via the internal jugular or subclavian vein.
Potential indications include:

  • Shock (cardiogenic versus noncardiogenic).
  • Respiratory distress (cardiogenic versus noncardiogenic).
  • Complicated myocardial infarction.
  • Monitoring effects of drugs (for example, cardiac inotropes).
  • Assessing fluid requirements in patients with, for example, multi-organ failure.
  • Thrombolysis for pulmonary embolism.

Preparation for cardiac catheterisation

This will include:

  • Investigations: day-case angiography does not usually require any routine pre-procedure investigations other than:
    • ECG.
    • Blood tests:
    • FBC
    • U&E
    • Clotting studies
    • Group and save
  • Full explanation of the procedure with informed consent: it is not usually painful, although the injection of dye causes a warm flushing sensation.
  • Premedication: anxious patients may require premedication with oral or IV diazepam.
  • Other considerations: patients with renal impairment (creatinine >200 μmol/L) require 1 litre of normal saline IV over 1 hour before and after angiography to prevent X-ray contrast nephropathy. This may be problematic where there is associated heart failure.

Contra-indications

Once consent has been given there are no absolute contra-indications to cardiac catheterisation. The outcome of the procedure should have potential benefit greater than the risk associated with the procedure. However, a widespread risk-averse strategy to angiography may be preventing higher-risk patients from having revascularisation procedures.12

Complications14

Complication rates are low. However, it is the view of the Joint Audit Committee of the British Cardiac Society and the Royal College of Physicians that they could be lower still, helped by an improved system of audit and formal reporting.14

  • Mortality for routine coronary angiography is between 0.08 and 0.1% in most centres.8,15
  • Haemorrhage from arterial puncture site – apply pressure.
  • False aneurysm (a firm, pulsatile swelling) – confirm with ultrasound.
  • Dye reaction – skin reactions, nausea and vomiting, transient cortical disturbance; usually settle <24 hours.
  • Infection – early fever is usually a dye reaction.
  • Loss of distal pulse(s).
  • Angina and myocardial infarction.
  • Arrhythmias.
  • Pericardial tamponade.
  • Stroke.
  • Infection (relatively low rate).
  • Renal dysfunction.

Historical perspective

  • Claude Bernard (1813-1878), France's most famous physiologist, was the first to experiment with cardiac catheterisation in horses.
  • Dr Werner Forssmann (1904-1979) was the first to pass a cardiac catheter, on himself, at the age of 25 in 1929. He was immediately fired for his efforts, and it is said that he only stopped when he had used all his veins with 17 cut downs. Discouraged by lack of acceptance he turned from cardiology to urology, though he was eventually rewarded with the Nobel Prize in 1956 (along with Cournand, and Richards) for his pioneering efforts.
  • André Cournand (1895-1988), and Richards (1895-1973), were the first to employ the cardiac catheter as a diagnostic tool in 1941, after 10 years of work together. André Cournand had the distinction of serving as auxiliary battalion surgeon even before his first year of medical school ended, gaining the Croix de Guerre with three bronze stars for his work in the trenches of World War I. Dickinson Richards had gained a degree in English and Greek at Yale, before serving as an artillery officer in World War I.

Document references

  1. Mann T, Cubeddu G, Bowen J, et al; Stenting in acute coronary syndromes: a comparison of radial versus femoral access sites. J Am Coll Cardiol. 1998 Sep;32(3):572-6. [abstract]
  2. Kiemeneij F, Laarman GJ, Odekerken D, et al; A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. J Am Coll Cardiol. 1997 May;29(6):1269-75. [abstract]
  3. Kassam S, Cantor WJ, Patel D, et al; Radial versus femoral access for rescue percutaneous coronary intervention with adjuvant glycoprotein IIb/IIIa inhibitor use. Can J Cardiol. 2004 Dec;20(14):1439-42. [abstract]
  4. Choussat R, Black A, Bossi I, et al; Vascular complications and clinical outcome after coronary angioplasty with platelet IIb/IIIa receptor blockade. Comparison of transradial vs transfemoral arterial access. Eur Heart J. 2000 Apr;21(8):662-7. [abstract]
  5. Bertrand OF, De Larochelliere R, Rodes-Cabau J, et al; A randomized study comparing same-day home discharge and abciximab bolus only to overnight hospitalization and abciximab bolus and infusion after transradial coronary stent implantation. Circulation. 2006 Dec 12;114(24):2636-43. Epub 2006 Dec 4. [abstract]
  6. Gilchrist IC, Moyer CD, Gascho JA; Transradial right and left heart catheterizations: a comparison to traditional femoral approach. Catheter Cardiovasc Interv. 2006 Apr;67(4):585-8. [abstract]
  7. Ziakas A, Gomma A, McDonald J, et al; A comparison of the radial and the femoral approaches in primary or rescue percutaneous coronary intervention for acute myocardial infarction in the elderly. Acute Card Care. 2007;9(2):93-6. [abstract]
  8. de Bono D; Complications of diagnostic cardiac catheterisation: results from 34,041 patients in the United Kingdom confidential enquiry into cardiac catheter complications. The Joint Audit Committee of the British Cardiac Society and Royal College of Physicians of London. Br Heart J. 1993 Sep;70(3):297-300. [abstract]
  9. Unstable angina and NSTEMI, NICE Clinical Guideline (March 2010); The early management of unstable angina and non-ST-segment-elevation myocardial infarction
  10. West R, Ellis G, Brooks N; Complications of diagnostic cardiac catheterisation: results from a confidential inquiry into cardiac catheter complications. Heart. 2006 Jun;92(6):810-4. Epub 2005 Nov 24. [abstract]
  11. Nordmann AJ, Hengstler P, Harr T, et al; Clinical outcomes of primary stenting versus balloon angioplasty in patients with myocardial infarction: a meta-analysis of randomized controlled trials. Am J Med. 2004 Feb 15;116(4):253-62. [abstract]
  12. Fox KA, Anderson FA Jr, Dabbous OH, et al; Intervention in acute coronary syndromes: do patients undergo intervention on the basis of their risk characteristics? The Global Registry of Acute Coronary Events (GRACE). Heart. 2007 Feb;93(2):177-82. Epub 2006 Jun 6. [abstract]
  13. Alexander KP, Newby LK, Cannon CP, et al; Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation. 2007 May 15;115(19):2549-69. [abstract]
  14. Oxford Textbook of Medicine 4th edition; Section 15.34.5-7; Aortic stenosis, mixed aortic valve disease and aortic regurgitation
  15. The Heart Disease Guidelines (2007); Scottish Intercollegiate Guidelines Network (SIGN)

Internet and further reading

  • Olade R; Cardiac Catheterization (Left Heart), eMedicine, Oct 2008
  • Acute coronary syndromes - glycoprotein IIb/IIIa inhibitors, NICE Technology Appraisal (2002)
  • Secondary prevention in primary and secondary care for patients following a myocardial infarction, NICE Clinical Guideline (2007)
  • Peters NS; Catheter ablation for cardiac arrhythmias. BMJ. 2000 Sep 23;321(7263):716-7.
  • Alexander KP, Newby LK, Armstrong PW, et al; Acute coronary care in the elderly, part II: ST-segment-elevation myocardial infarction: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation. 2007 May 15;115(19):2570-89. [abstract]
  • Mandelzweig L, Battler A, Boyko V, et al; The second Euro Heart Survey on acute coronary syndromes: Characteristics, treatment, and outcome of patients with ACS in Europe and the Mediterranean Basin in 2004. Eur Heart J. 2006 Oct;27(19):2285-93. Epub 2006 Aug 14. [abstract]
  • Van de Werf F, Gore JM, Avezum A, et al; Access to catheterisation facilities in patients admitted with acute coronary syndrome: multinational registry study. BMJ. 2005 Feb 26;330(7489):441. Epub 2005 Jan 21. [abstract]
  • Fox K, Garcia MA, Ardissino D, et al; Guidelines on the management of stable angina pectoris: executive summary: the Task Force on the Management of Stable Angina Pectoris of the European Society of Cardiology. Eur Heart J. 2006 Jun;27(11):1341-81. Epub 2006 May 30.
  • No authors listed; Coronary angioplasty: guidelines for good practice and training. Joint Working Group on Coronary Angioplasty of the British Cardiac Society and British Cardiovascular Intervention Society. Heart. 2000 Feb;83(2):224-35.

Acknowledgements

EMIS is grateful to Dr Richard Draper for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2011.
Document ID: 1907
Document Version: 22
Document Reference: bgp522
Last Updated: 27 Aug 2010
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