section name header

Introduction ⬇

A cardiac catheterization is an invasive procedure that requires a special sheathed catheter, which can carry contrast material into the right and left sides of the heart and measure pressures, to be inserted into an artery (femoral or radial). As these catheters are introduced and advanced toward the heart, fluoroscopy and high-speed x-ray pictures projected onto monitors show actual heart function and motion. An angiography is the injection of contrast medium to provide a visual definition of cardiac structures. Coronary artery patency and circulation is filmed as well. The patient's heart rate, rhythm, and pressures are monitored continuously.

These procedures are performed to evaluate the coronary vessels and function of the heart. The method chosen—that is, a left heart or right heart catheterization—is determined by the cardiologist in order to study and diagnose defects of the chambers of the heart, the heart valves, and certain blood vessels.

Coronary arteriograms are useful for evaluating abnormal stress tests, diagnosing heart disease, assessing the complications of an MI, diagnosing congenital abnormalities, identifying cardiac structure and function, and measuring hemodynamic pressures within heart chambers and great vessels. They are used to measure cardiac output using contrast dilution, thermodilution, and Fick method and to obtain cardiac blood samples for measuring oxygen content and oxygen saturation.

Cardiac catheterization combined with angiography is indicated for patients who exhibit angina, chest pain, syncope, valve problems, ischemic heart disease, hypercholesterolemia, symptoms with history of familial heart disease, abnormal resting or exercise ECGs, and recurring cardiac symptoms after revascularization. Other indications include young patients with a history of coronary insufficiency or ventricular aneurysm and patients who experience coronary neurosis and need assurance that their cardiac status is normal. This test can be performed during the acute stage of an MI, and, if necessary, intervention can be accomplished without significant delay. Although cardiac catheterization poses some risk, it is highly accurate diagnostic resource.

Procedure ⬆ ⬇

  1. The test is normally done in a special, darkened procedure room.

  2. To decrease anxiety, explain the procedure and provide information about sensations the patient may experience.

    1. For right heart catheterization, the medial cubital, brachial, or femoral vein is accessed and catheterized. The catheter is threaded through the vena cava to the right atrium, through the tricuspid valve and right ventricle, to the pulmonary artery. Take pressure measurements and O2 saturations from these areas as you manipulate the catheter.

    2. For left heart catheterization procedure, the femoral or brachial artery is accessed and catheterized. The catheter is advanced through the femoral or brachial artery, the aortic valve, and to the left ventricle. Again, take pressure readings. Introduction of contrast material, if done, provides data about left ventricular contractility, contour size, and presence of mitral regurgitation.

    3. Observe sterile surgical conditions. Prepare the skin with an antiseptic solution scrub. Inject a local anesthetic into the catheter insertion site area (e.g., groin [femoral artery], antecubital [brachial artery]). Small incisions may be made to facilitate insertion. Once inserted, gently advance the catheters to the heart and great vessels.

  3. If left-to-right shunt is suspected, also obtain blood samples from the superior and inferior vena cava.

  4. Have the patient lie on a special x-ray table and monitor the ECG continuously. Use IV sedation if necessary. During the procedure, the patient is placed in several different positions. The patient may be asked to exercise to evaluate heart changes associated with activity. Atrial pacing can also be done as part of the procedure in persons who cannot walk (e.g., paraplegics) or use a treadmill. In these instances, there is a sequence of events that stress the heart followed by a rest period; then, measurements are taken. The heart is paced again, followed by another rest period.

  5. The patient may be able to observe the procedure on a television monitor if it happens to be positioned properly.

  6. After x-ray films have been taken from all angles, remove the catheters and apply manual pressure to the site for 20-30 minutes. Apply a sterile pressure bandage for several additional hours, if necessary. Some facilities no longer use pressure bandages. There are several devices on the market to close the access site (vascular closure devices) following the procedure. These devices can be separated into two categories: self-adsorbing sutures and hemostasis-promoting pads or patches. Less pressure and less time may be required for venous sites. Give protamine sulfate to reverse the effects of heparinization.

  7. Reassure the patient frequently.

  8. Follow guidelines in Chapter 1 for safe, effective, informed intratest care.

Procedural Alert

  1. Left atrial function and measurements are usually calculated from other measurements. If direct measurements are necessary, a transseptal approach must be done by advancing the catheter through the saphenous leg vein into the right atrium and then passing a needle through the catheter to puncture the atrial septum so that direct pressure readings may be obtained. The patient may be asked to exercise during the procedure to evaluate consistent changes; atrial pacing may be done during the procedure to incrementally stress and rest the heart for those patients unable to move normally (e.g., patients with paraplegia).

  2. Complications include the following:

    1. Dysrhythmias

    2. Allergic reactions to contrast agent (evidenced by urticaria, pruritus, conjunctivitis, or anaphylaxis)

    3. Thrombophlebitis

    4. Insertion site infection

    5. Pneumothorax

    6. Hemopericardium

    7. Embolism

    8. Liver lacerations, especially in infants and children

    9. Excessive bleeding or hematoma at the catheter site

  3. Notify the healthcare provider immediately if increased bleeding, hematoma, dramatic fall or elevation in blood pressure, or decreased peripheral circulation and abnormal or changed neurovascular findings are noted. Rapid treatment may prevent more severe complications.

  4. The following equipment should always be available to treat complications of angiography:

    1. Resuscitation equipment

    2. Direct current defibrillator

    3. External pacemaker

    4. Oxygen

    5. Emergency drugs

Clinical Implications ⬆ ⬇

  1. Abnormal results include the following:

    1. Altered hemodynamic pressures.

    2. Injected contrast agent reveals altered ventricular structure and dynamics of occluded coronary arteries.

    3. Blood gas analysis confirms cardiac, circulatory, or pulmonary problems.

  2. Abnormal hemodynamic pressures may indicate the following conditions:

    1. Valve stenosis or insufficiency

    2. Left or right ventricular failure

    3. Idiopathic hypertrophic subaortic stenosis

    4. Rheumatic fever sequelae

    5. Cardiomyopathies

  3. Abnormal blood gas results may indicate the following conditions:

    1. Congenital or acquired circulatory shunting

    2. Septal defects

    3. Other cardiac and pulmonary defects or pathology

  4. When a contrast agent is injected into the ventricles, abnormalities (of size, function, structure, EFs), aneurysms, leaks, stenosis, and altered contractility can be detected.

  5. When contrast is injected into coronary arteries, occluded vessels and circulatory function can be recorded. See Chart 16.2.

Interventions ⬆ ⬇

Pretest Patient Care

  1. Explain test purpose (determine whether arteries are obstructed and show evidence of lesions, grade the occlusions, and assess left ventricular function), procedure, benefits, and risks. A consent form must be signed before the examination. Always check for allergies, especially to iodine and contrast media. Extensive teaching may be necessary.

  2. Have the patient fast for 6-8 hours before the procedure. Give routine, scheduled medications, such as cardiac drugs or insulin, before the procedure unless directed otherwise. Discontinue anticoagulants at least 1-2 days before the procedure.

  3. Give analgesic agents, sedatives, or tranquilizers before the procedure.

  4. Ask the patient to void before the procedure.

  5. Tell the patient they may wear dentures; have the patient remove jewelry and other accessories.

  6. Instruct the patient regarding the need to perform deep breathing and coughing during the test and inform the patient that they may feel certain sensations.

    1. Catheter insertion through antecubital or groin sites may produce significant pressure sensations when the sheath, through which the catheter is inserted and advanced, is introduced.

    2. A slight shock or "funny bone" sensation may be felt if the nerve adjacent to the artery is touched. A tiny "bump" in the neck may be felt as the catheter is inserted into the heart. Normally, pain is not felt.

    3. When the contrast agent is injected into the catheter, a pumping sensation with feelings of palpitations and hot flashes may last 30-60 seconds. Skin vessels vasodilate, and blood rises to the skin surface for a short time.

    4. Patients may experience nausea, vomiting, headache, and cough.

    5. Angina may occur with exercise or with the contrast agent injection. Nitroglycerin or narcotics may be given.

  7. Follow guidelines in Chapter 1 for safe, effective, informed pretest care.

Clinical Alert

This procedure is contraindicated in patients with gross cardiomegaly

Posttest Patient Care

  1. Bed rest is usually maintained for 6 hours after the test based on the nature of the procedure, site of catheter insertion, healthcare provider's protocols, and patient status. The patient is usually not permitted to raise the head more than 30° during this time because greater angles put strain on the insertion site. Conversely, movement of the uninvolved extremities should be promoted.

  2. Check vital signs frequently according to institution protocols. At the same time, check catheter insertion site for hematomas, swelling, bleeding, or bruits. Normal or other mechanical pressure to the catheter insertion site may be necessary if bleeding or hematoma develops. A bruised appearance around the site is normal. Swelling or lumps should be promptly reported to the healthcare provider. Neurovascular checks should be done along with assessment of vital signs in bilateral extremities and results compared. Assess color, motion, sensation, capillary refill times, temperature, and pulse quality. Report significant changes immediately.

  3. Administer prophylactic antibiotics as necessary.

  4. Encourage fluid intake. Unless contraindicated, an IV infusion site may be maintained while the patient is on bed rest in the event that rapid IV access is needed.

  5. Keep the affected extremity extended, not elevated or flexed. Immobilize the legs with sandbags if necessary. Apply ice packs or sandbags to the catheter site, if ordered; this pressure can be very painful. Prescribed analgesic agents can be administered for pain of hematomas or discomfort.

  6. Sutures, if used, are removed per healthcare provider's instructions.

  7. Review test results; report and record findings. Modify the nursing care plan as needed.

  8. Monitor the patient for cardiac, circulatory, neurovascular, and pulmonary problems.

    1. Risk factors for complications following cardiac catheterization include age older than 60 years, hypertension, peripheral vascular disease, and procedure done on an emergency basis or at same time as angioplasty. Risk factors for complications may be as high as 10% when more than three factors are present.

    2. Complications associated with risk factors include MI, stroke, or death within 24 hours of procedure; hemorrhage requiring transfusion; pseudoaneurysm; fistula; or femoral thromboses.

  9. Treatment may include percutaneous transluminal coronary angioplasty, coronary artery stent placement, coronary rotablation, or medications (see Chart 16.3).

  10. Follow guidelines in Chapter 1 for safe, effective, informed posttest care.

Reference Values ⬆

Normal Cardiac Catheterization

Normal Cardiac Volumes

  • End-diastolic volume (EDV): 50-90 mL/m2 (body surface area)

  • End-systolic volume (ESV): 25 mL/m2

  • Stroke volume (SV): 45 ± 12 mL/m2

  • EF: 0.67 ± 0.07

Normal Hemodynamic Pressure (mm Hg)
AverageRange
Right atrium
A wave61-10
U wave5
Mean30-8
Right ventricle
Peak systolic2515-30
End diastolic41-7
PAP
Peak systolic2515-30
End diastolic93-12
Mean159-19
PCWP94-12
Left atrium
A wave103-15
U wave126-21
Mean82-12
Left ventricle
Peak systolic130100-140
End diastolic83-12
Complete aortic
Peak systolic130100-140
End diastolic7060-90
Mean8570-105

PAP, pulmonary artery pressure; PCWP, pulmonary capillary wedge pressure.