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Why a cardiac catheterization?

What is generally referred to as “Heart Disease” is really referring to, not the
heart being diseased but really that it is being starved of the blood supply it
needs in order to perform its pumping function. The coronary circulation is
responsible for providing this supply. The coronary arteries are vital because
they supply oxygen and nutrients to the heart muscle. Without blood flow,
the muscle would sustain permanent damage. Over 95% of heart failures are
due to failure of the system to provide sufficient blood supply to the heart for
its own metabolic needs.

What is a cardiac catheterization?

A cardiac catheterization is a study of the heart during which a thin hollow

flexible catheter is inserted into the artery (left heart cath) or the vein (right
heart cath) of the groin (femoral) or arm (brachial). The term is most
commonly used to describe testing in which a catheter is fed into an artery
of the heart. Under x-ray visualization (fluoroscopy), the tip of the catheter is
guided into the heart. Coronary angio’s (visualization of the arteries) of the
heart are obtained while injecting a colorless dye or contrast through the
catheter. The contrast material blocks the passage of x-rays therefore
allowing the coronary arteries to be visualized and x-rays obtained
(Healthcenter, 2006).

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Right Heart Catheterization / Swan Ganz catheter:
In reference to the cardiac cath lab, you may be told that a right heart cath
was done. This is done using a Swan Ganz catheter. This is a flow directed
catheter with a balloon on the tip. The Swan Ganz is used to measure
pressures, cardiac output, and draw blood samples. The cardiologist inserts
the catheter into the right side of the heart through a large vein. The vein is
accessed, usually during the time the artery is accessed. This procedure is
also commonly done in the ICU by a trained physician, usually an Intensivist
or a Cardiologist. In ICU, it is common for a vein in the right side of the neck
to be used. However, the left side of the neck, either side of the groin (as
seen during cardiac catheterization) or other sites can be used.

The catheter enters the right atrium (upper chamber) of the heart, flows
through the tricuspid valve into the right ventricle (lower chamber), through
the pulmonary valve, and into the pulmonary artery. There is a balloon at the
tip of the catheter that assists with the advancement of the catheter. When it
reaches the Pulmonary artery, the balloon is wedged into a pulmonary
capillary, which then measures the pressure around it- giving you the
Pulmonary Capillary Wedge Pressure or PCWP. Measurements of the
pressures in the pulmonary artery can be used to indirectly measure the
function of the left ventricle (Seattleavir, 2006).

The position of the catheter within the heart is confirmed by a chest x-ray or
by fluoroscopy during the procedure and by monitoring devices that also
read the pressures within the heart. During the procedure, the heart's
rhythm is monitored continuously by electrocardiogram (ECG).

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The main risks of the procedure are bruising at the access site, trauma
to the vein, and puncturing the lung if the neck or chest veins are
used.

Left heart catheterization:

If the catheter is introduced through the artery, then it is known as a left
heart catheterization. The most common site used is the femoral artery.
Once in the femoral artery, the catheter is thread into the aorta, where the
coronary arteries can then be accessed, and the left ventricle. If there is
significant vascular disease and/or the physician has is unable to thread the
catheter from the femoral site the procedure can be performed using an
artery in the arm.

The Coronary Tree:

There are three major arteries that run on the surface of the left ventricle
(LV). This is the most important pumping chamber of the heart and supplies
oxygenated blood to the body. The aorta arises from the left ventricle and
gives out a series of branches as it makes its way from the heart to the lower
portion of the abdomen. The coronary arteries are the very first branches
that arise from the aorta. The first one that arises from the left is known as
the Left Main Coronary Artery. This immediately divides into the Left
Anterior Descending (LAD) and the Circumflex (Circ). The right coronary
artery arises from the right side of the aorta.

The LAD supplies blood to the anterior wall of the LV and the septum. The
circumflex wraps around the heart and supplies blood to the back or
posterior wall of the left ventricle. The right coronary artery supplies blood to
the bottom or inferior wall of the LV. It also supplies branches to the Right
ventricle.

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Sheaths:
A majority of vascular procedures are performed through vascular access
sheaths. Sheaths are used for introduction of a catheter during a vascular
procedure. The standard is usually 10cm long with a side arm which allows
continuous flush of saline to prevent clot formation between the sheath ad
the catheter. The cardiac catheter and guidewire is passed through the
sheath. The major advantage of a vascular sheath is that it reduces the
trauma from repeated punctures at the puncture site.

Guidewire:
A small bendable wire that is threaded through the artery; it helps doctors
position a catheter. The guidewire is small enough that it can be inserted
into the vessel through a needle, but also stiff enough to be threaded “up”
the artery.

Types and Sizes of Catheters:

Besides coming in different types of shapes and materials, catheters also
come in many sizes. Catheters are measured in French (FR) size. One French
(FR) is equal to .33 mm. An easier way to remember how to figure French
size is 3FR is equal to 1mm. The three French is usually used in newborns
and infants, 4 and 5 french are usually used with brachial. Cardiac catheter,
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the Sones catheter is used when you have to go in the brachial artery. The
Judkins and Amplatz catheters are used for selective catheterization of the
coronary arteries with a femoral approach. Most traditionally used is the
Judkins 6fr, it is believed that a smaller catheter causes less bruising.

Intravascular contrast:
Diagnostic procedures involve the use of iodinated intravascular contrast. It
is used to enhance the imaging and define cardiac structures including the
coronary arteries, chambers of the heart and assess wall motion.

The contrast used in the Mercy Hospital Cardiac Cath Lab is called Optiray
350. It is intended for intravascular administration as a radiopaque media.
As with all radiopaque contrast agents, only the lowest dose necessary
to obtain adequate visualization should be used.

Personnel should be educated on recognizing and treating adverse reactions

of all types. Sever delayed reactions have been known to occur 30-60
minutes after administration. Rare undesirable reactions, ranging from mild
nausea to life threatening anaphylaxis have occurred.

Hemodynamic effects- Transient impairment in ventricular contractility,

relaxation and hypotension.

Electrophysiologic effects- Bradycardia, AV Block, ST segment and T wave

changes, prolonged QT interval and Ventricular tachycardia/fibrillation have
been attributed to the calcium channel binding buffers used in contrast
media.

Dye induced renal dysfunction is the most common cause of renal

insufficiency. Defined as a rise in the serum creatinine >25%. The dye can
cause direct tubular injury. Patient with pre-existing renal insufficiency and
diabetic nephropathy are most susceptible to the development of dye
induced nephrotoxicity (Optiray, 2006).

If possible, and not contraindicated, pre-cath patient should be well hydrated

prior to the administration of contrast in the cardiac cath lab.

If there has been a question, and or know sensitivity to iodine

premedications should be considered to reduce the risk of anaphylaxis.
Administration of premedications should be administered 12 hours before
exposure to the contrast. Although prescriptions may vary all include the
administration of a steroid, an H2 receptor antagonist and an antihistamine
(Optiray,2006).

Mild contrast reactions; Nausea, burning sensation, flushing, mild

urticaria, bradycardia vasovagal episodes- treated with Oral benadryl and
atropine.

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Moderate contrast reactions; Persistent nausea, vomiting, urticaria with
hives and tongue swelling, bradycardia vasovagal episodes that persist with
hypotension- treated with IVF, benadryl, steroids (hydrocortisone) centrally-
acting antimedic and atropine.

Sever contrast reactions; can also include bronchospasm, laryngeal

edema and/or profound hypotension. Treated with epinephrine 0.1-0.5 mg
IV, repeated every 5minutes as necessary, steroids (hydrocortisone 100mg
IV followed by solumedrol 125mg IV) benadryl 50mg IV, and possible
intubation. Bronchodilators may be administered- albuterol aerosol.

Complications / Risks Associated with Heart

Catheterization:
The main risks of the procedure are bruising at the access site, trauma to the
vein, and puncturing the lung if the neck or chest veins are used. Very rare
instances a patient may suffer cardiac arrhythmias, cardiac tamponade, low
blood pressure, infection, or embolism caused by blood clots at the tip of the
catheter (Freed, 1992).

AV fistula- During attempted vascular access, the needle may puncture

both the femoral artery and vein creating an abnormal arterial venous
communication which may persist following sheath withdrawal. This results
in a “continuous murmur” at the site of the communication, distal arterial
insufficiency, and a swollen, tender extremity due to venous dilatation.
Diagnosed by color flow doppler imaging and ultrsonography. Usually
repaired surgically. Recent reports of successful treatment non- invasively by
ultrasound-guided compression.

Coronary artery spasm- Mostly experienced during the cardiac

catheterization procedure. Usually immediately reversed with intracoronary
nitroglycerin and can be further prevented with a continuous infusion of
nitroglycerine. If intracoronary spasms persist despite initial steps,
administration of a calcium channel antagonist- verapamil or nifidepine will
be administered intracoronary (Freed, 1992).
Dissection: Rarely, a dissection occurs accidentally when doctors are
inserting a catheter into an artery on the heart or blood vessels. Within the
vessel, the dissection usually occurs between the intima (inner wall) and
media (middle wall), called a subintimal dissection. Pain frequently travels
along the path of the dissection as it advances along the aorta. As the
dissection advances, it can close off the points at which one or more arteries
branch off from the aorta, blocking blood flow. The consequences vary
depending on which arteries are blocked (Freed, 1992)..

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Consequences include stroke (if the cerebral arteries, which supply the brain,
are blocked), heart attack (if the coronary arteries, which supply the heart
muscle, are blocked), sudden abdominal
pain (if the mesentery arteries, which supply
the intestines, are blocked), lower back pain (if
the renal arteries, which supply the kidneys,
are blocked) and nerve damage that causes
tingling or an inability to move a limb (if the
spinal arteries are blocked). In about two
thirds of people with aortic dissection, pulses in
the arms and legs are diminished or absent. A
dissection that is moving backward toward
the heart may cause a murmur that can be
heard through a stethoscope. Computed tomography (CT) performed after
injecting a radiopaque dye can quickly and reliably detect aortic dissection and
thus is useful in an emergency (Freed, 1992)..

People with an aortic dissection are admitted to intensive care units, where
their vital signs (pulse, blood pressure, and rate of breathing) are closely
monitored. Death can occur a few hours after an aortic dissection begins.
Therefore, as soon as possible, drugs, usually sodium nitroprusside plus a
beta-blocker, are given intravenously to reduce the heart rate and blood
pressure to the lowest level that can maintain a sufficient blood supply to the
brain, heart, and kidneys. Soon after drug therapy begins, doctors must
decide whether to recommend surgery or to continue drug therapy without
surgery.

Perforation- The catheter, although seen in very few cases, can perforate
any area it passes through. The risk of perforation is seen in about 8%. The
right atrium and ventricle are common sites. In the myocardium it can
perforate the atrium or ventricle (which can cause a tamponade), the
septum, and through the coronary arteries themselves including the arch of
the aorta. It can also perforate any layer of the vessel wall (Freed, 1992)..

Pseudoaneurysm- A pseudoaneurysm is an encapsulated hematoma in

communication with the artery. Can be difficult to distinguish from an
expanding hematoma, although hematomas resolve spontaneously and
pseudoaneurysms usually require surgery. Classic findings are a tender,
pulsatile mass with a systolic bruit in the involved area. Confirmation may
be made by a local ultrasound or repeated angiography Freed, 1992). .

Broken catheters- There are a variety of prevenous retrieval of broken

catheters. Cardiac catheters, rigid bronchoscopic forceps, endomyocardial
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biotomes and flexible endoscopy forceps have all been used successfully to
remove the retained catheters but none have been reported with a uniform
success . (Freed, 1992).

Cardiac tamponade- more common following left heart catheterization.

Seen following direct LV puncture or LA puncture.

Inflammatory reaction and bacteriemia- The inflammatory reaction from

the presence of a foreign body (catheter) and bacteriemia account for 5-8%
of all complications following cardiac catheterization. Studies show the risk to
increase significantly when the patient has to undergo emergency cardiac
surgery following complications of cardiac catheterization (Freed, 1992).

Neuro-Opthalmological complication- Rare but documented

complication: Evidence suggests that artery-to-artery emboli are the
pathogenic factor. Patients usually complain of a migraine during
catheterization.

Retroperitoneal hematoma- a complication that may occur when arterial

access of the femoral artery is above the inguinal ligament. Effective
compression may not be possible. Hemorrhage from the puncture site may
accumulate posteriorly rather than in the inguinal area. The patient will
complain of abdominal, back and flank pain. Physical exam may reveal a
palpable mass with discoloration (grey turners sign), over the flank region of
the abdomen. A digital rectal exam may reveal a compressive mass. A fairly
large hematoma may displace the ipsilateral ureter and kidney. A CT scan is
the most precise way of determining the diagnosis and treatment. The
majority of retroperitoneal bleeds will spontaneously tamponade.
Hematocrit needs to be monitored continuously. The patient may require a
blood transfusion but if there is a decline in HCT and the patient is
hemodynamically unstable it may result in a surgical exploration.

Atheroembolization- because of the clinical presentation, cholesterol

emboli may be overlooked. When a catheter or guidewire is introduced
there may be mechanical trauma to a friable atherosclerotic lesion. Distal
emobolization may occur to the lower extremities, as well as abdominal
viscera, including the spleen, liver, kidney and pancreas.

“Blue toe syndrome”- or livedo reticularis involving the extremities and the
trunk may be the cardinal sign of manifestation of peripheral microemboli.

The chief manifestation of macroembolic disease may be acute arterial

ischemia, gangrenous transformation or ulceration of the distal extremity
may rarely occur. Renal failure has been reported as secondary
manifestation (Freed, 1992). .

Nursing specific assessments and interventions

Pre-Cardiac Catheterization:
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A patient teaching plan must be established and initiated. Although taking

care of the cardiac catheterized patient may be a routine practice for the
nurse it is a procedure that is foreign to the patient. The teaching plan must
be individualized to fit the patients’ needs.

If the patient is an “In-patient” on the unit, try to arrange a visit from the
nurse from the cath lab. Among the things she should accomplish is to ;
introduce herself, advise the patient as to what time the procedure may
occur, check the patients chart for pre-cath orders, allergies, signed
permission, verify counseling by the physician and establish the patients
knowledge level. The most important purpose of the visit is to
alleviate fears the patient may have and provide the opportunity for the
patient to answer questions.

Physicians orders may include fasting for 3 to 8 hours before the procedure
and withholding or decreasing the dosage of scheduled medications
(including insulin, antihypertensive drugs, and diuretics-unless otherwise
instructed by a physician).

Before sending the patient to the cardiac cath lab make sure the pre-cardiac
cath checklist is completed and assess them for allergies, especially to iodine
or shellfish; some contrast material often contain iodine.

Nursing specific assessments and interventions

Post-Cardiac Catheterization:

The hemodynamic stability of the patient should be assessed immediately

when the patient returns from the cath lab. The initial assessment should
include vital signs, O2 level, urine output, strength and presence of pulses in
the extremities and assessment of the affected puncture site. Followed by
assessment of cardiac, respiratory, pulmonary, and gastrointestinal.

When the patient returns they will be placed on bedrest with the head of the
bed no higher than 30 degrees. The patients affected extremity must be
kept straight.

Once the patient is fully awake and their condition warrants, encourage the
patient to drink fluids during the first 12 hours post-cath, unless
contraindicated by physician.

Maintain hourly intake and output.

If the patients puncture site starts to bleed, pressure should be held just
above the insertion site until bleeding stops. If able, find the pulse just

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above the insertion site and apply pressure until hemostasis is obtained.
Note: Do Note obliterate the distal pulses. It is not recommended to
hold pressure directly on the pressure site. Notify the physician.

References

Aortic Dissection. (2006) Online home edition. Merck & Co., Inc., Whitehouse
Station, NJ. Retrieved from
http://www.merck.com/mmhe/sec03/ch035/ch035c.html

Ayers, D. (2002). Preparing a patient for cardiac catheterization. Nursing,

2002; Sep. p.22

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Cardiac Catheterization. (2006). Retrieved from
http://heart.healthcentersonline.com/cardiaccatheterization)

Cardiac Cath. (2006). Retreived from;

http://www.heartsite.com/html/cardiac_cath.html.

Cardiology in Critical Care Cardiac Catheterization Pre and Post Care. (2000).
Retrieved from
http://www.rnbob.tripod.com/cardiaccathpreandpostcare.htm

Freed, M., Grines, C., (1992). Manual of Interventional Cardiology. Physicians

Press, Birmingham, Michigan, p248-258.

Mitty, H., (2003). Advances in Angiography and Their Impact on

Endovascular Therapy. Mount Sinai JM, Vol.70, No.6, November 2003.

Optiray.(2006). Package insert. Mallinckrodt Inc.

Right Heart Catheterization.(2006). Retrieved from

(http://www.seattleavir.com/equipsup.html#Catheters).

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