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Preface
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The techniques of cardiac catheterization, coronary angiography, and
cardiovascular percutaneous interventions (PCIs) have seen dramatic
evolution during the last 25 years. Nonetheless, the basic approaches
to cardiac catheterization remain unchanged and central to the safe
performance of procedures. The catheterization laboratory is now a
major theater of operation for nonsurgical, percutaneous valve replacement and other structural heart repair that was previously provided
only by open heart surgery. Percutaneous coronary revascularization
for chronically occluded diseased vessels is a feat that likely was never
imagined by Dr. Gruentzig, the pioneer of PCI.
The complex nature of catheterization laboratory technology and
techniques requires study and a clear understanding by everyone
involved to perform the procedure in a safe and complete manner. As
with the earlier editions, the purpose of the sixth edition of The Cardiac
Catheterization Handbook is to provide a basic, straightforward, and
practical explanation of the cardiac catheterization laboratory and its
procedures. It is written for nurses, technologists, students, physician
trainees, physicians in practice, and anyone needing to know what
catheterization is all about.
What’s new to this edition? Because the field is replete with new
techniques and procedures, it is an honor for me to have the assistance
of two new co-editors: Drs. Michael Lim from Saint Louis University
and Paul Sorajja from the Minneapolis Heart Institute. Their experience and in-depth practical knowledge of the catheterization laboratory will keep this and future editions current and practical. With the
excellent contributions from my co-editors, substantial revisions and
updates are now incorporated herein.
The sixth edition is reorganized, refreshed, and, we believe, as up
to date as a handbook can be. Obsolete or outdated discussions and
methods have been replaced with the latest information. In Chapter 1,
The Cardiac Catheterization Laboratory, the focus is on procedural
indications, patient evaluation and preparation, strategies for teamwork, function of the imaging system, basic pharmacology, and credentialing requirements. Descriptions on how the procedure should
flow, what steps should be learned first, how to approach patients
undergoing this often frightening test, how to be part of the catheterization laboratory team, and similar work matters are presented. New
sections address recent requirements concerning conscious sedation,
“time outs,” informed consent, and workplace safety.
The technique of vascular access (Chapter 2) remains among
the most critically important areas, with radial artery access strongly
emphasized. The newest femoral vascular closure devices are briefly
presented. In addition to common and standard methods, multiple
techniques for large-bore sheaths and radial access are described
in more detail. The chapter also covers the diagnosis and management of periprocedural bleeding, for which adverse outcomes have
been increasingly recognized. In subsequent sections, angiography
(Chapter 3) focuses the reader on imaging projections, anatomic findings, anomalous arteries, ventriculography, and clinical application of
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Preface
fractional flow reserve (FFR), intravascular ultrasound (IVUS), and
optical coherence tomography (OCT). Radiation safety, the generation
of the radiographic image with the use of modern flat-panel image
detectors, and issues related to radiographic contrast media are
highlighted.
A detailed discussion of hemodynamic data and their correct
acquisition and interpretation (Chapter 4) remains a steadfast component, with new pressure tracings reviewed. Chapter 5, Peripheral
Artery Disease, Angiography, and Intervention, explains the diagnosis
and management of peripheral artery disease in the catheterization
laboratory and includes an examination of peripheral anatomy, the
role of adjunctive noninvasive testing, a description of various pathologies, and a synopsis of state-of-the-art peripheral interventional
therapies.
The chapter on electrophysiologic testing and device use in the
catheterization laboratory (Chapter 6) is updated with new modalities
of remote guidance of electrophysiology catheters and electrophysiologic arrhythmia ablations. For individuals working in electrophysiology laboratories and fellows entering this area while in training, this
section provides an excellent basic framework for understanding
when and how these very specialized procedures should be used.
The second half of the Handbook is dedicated to special techniques, starting with Chapter 7. Identification and management of
high-risk patients in the cardiac catheterization laboratory is elementary to the practice, and in Chapter 8, Complications and Management of the High-Risk Patient, the authors describe numerous
potential complications and strategies to minimize their occurrence.
Highlighted are approaches for advanced hemodynamic support in
the periprocedural period including pharmacologic management,
intraaortic balloon pump (IABP) use, and percutaneous ventricular
assist devices.
Chapter 9, Research Techniques, provides a detailed description
of current areas of catheterization laboratory research, with an emphasis on their clinical relevance. Techniques described include sophisticated methods for assessing coronary flow, vessel histology, and
ventricular function. Chapter 10, Interventional Cardiology Procedures, provides an elementary understanding of commonly performed
therapeutic interventions for both coronary arteries and structural
heart disease. These therapies include basic and complex coronary
intervention, structural heart procedures (including transcatheter
valve therapies), and congenital defect closure. Adjunctive imaging
with echocardiography, where relevant to practice in the catheterization laboratory, is described also. The documentation section in the
last chapter (Chapter 11) is worth reviewing for nurses and physicians
alike. The understanding of quality systems and its metrics, appropriate professional documentation, and risk management in the cardiac
catheterization laboratory are critical to good operations.
Speaking for the three of us, our goal for the Handbook is to
provide a state-of-the-art plain-spoken resource for use in the cardiac
catheterization laboratory. This achievement is made possible only
with the help of many colleagues, teachers, and mentors. These individuals have taught us not only the practice but also the importance
of inquiry and humility while having the privilege to care for patients
in the cardiac catheterization laboratory and beyond. We are deeply
indebted to all of these individuals, many of whom continue to teach
us both in and out of the catheterization laboratory today.
Morton J. Kern
Michael J. Lim
Paul Sorajja
Contents
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1 The Catheterization Laboratory, 1
MORTON J. K ERN
2 Arterial and Venous Access, 55
KIMBERLY A. SKELDING • JENNIFER A. TREMMEL
3 Coronary Angiography and Ventriculography, 99
MORTON J. KERN • ANDREW JOHN KLEIN • PRANAV M. PATEL
4 Hemodynamic Data, 175
MORTON J. K ERN • NAVIN K. KAPUR
5 Peripheral Arterial Disease and Angiography, 239
ANDRE W JOHN KLEIN • SUBHASH BANERJEE •
DOUGL AS EMMET DRACHMAN
6 The Electrophysiology Laboratory and Electrophysiologic
Procedures, 273
ALI A. MEHDIRAD • SCOTT W. FERREIRA
7 Special Techniques, 329
PAUL SORAJJA • CARLOS E. RUIZ • CHAD K LIGER •
MORTON J. KERN
8 High-Risk Cardiac Catheterization, 359
MICHAEL FORSBERG • MICHAEL J. LIM
9 Research Techniques, 385
BARRY A. BORLAUG • JOERG HERRMANN • MORTON J. KERN
10 Interventional Cardiology Procedures, 419
MORTON J. K ERN • MICHAEL LEE
11 Optimization of Clinical Outcomes and Quality in the
Cardiac Catheterization Laboratory, 461
MORTON J. K ERN • CHARLES CHAMBERS
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Contents
Appendices—Online only at www.ExpertConsult.Inkling
.com
Appendix A: Invasive Cardiovascular Examination and
Procedures
Appendix B: Heart Diagrams
Appendix C: Functional Anatomy of the Heart
Appendix D: Tables of Units, Calculations, and
Conversions
Appendix E: Radiologic Configuration of Prosthetic Heart
Valves
Appendix F: Basic Electrocardiography
Appendix G: Methods for Common Drugs
Video Contents
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Video 1-1: Cath Lab Equipment
Video 2-1: Femoral Artery Access
Video 2-2: Radial Artery Access
Video 2-3: Radial Artery Hemostasis
Video 3-1: Coronary and Ventricular Angiography
Video 3-2: Transfemoral Cardiac Catheterization
Video 3-3: Transradial Cardiac Catheterization
Video 11-1: FFR Demonstration
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1
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The Catheterization
Laboratory
MORTON J. KERN
Cardiac catheterization is the insertion and passage of small plastic
tubes (catheters) into arteries and veins to the heart to obtain x-ray
pictures (angiography) of coronary arteries and cardiac chambers and
to measure pressures in the heart (hemodynamics). The cardiac catheterization laboratory performs angiography to obtain images not only
of coronary arteries to diagnose coronary artery disease but also to
look for abnormalities of the aorta, pulmonary, and peripheral vessels.
In addition to providing diagnostic information, the cardiac catheterization laboratory performs catheter-based interventions (e.g., angioplasty with stent implantation, now called percutaneous coronary
intervention [PCI]) or catheter-based treatments of structural heart
disease for both acute and chronic cardiovascular illness. Table 1-1
lists procedures that can be performed with coronary angiography. Figure 1-1 shows common vascular access routes for cardiac
catheterization.
Indications for
Cardiac Catheterization
Cardiac catheterization is used to identify atherosclerotic coronary or
peripheral artery disease, abnormalities of heart muscle (infarction or
cardiomyopathy), and valvular or congenital heart abnormalities. In
adults the procedure is used most commonly to diagnose coronary
artery disease. Other indications depend on the history, physical
examination, electrocardiogram (ECG), cardiac stress test, echocardiographic results, and chest radiograph. Indications for cardiac catheterization are summarized in Table 1-2.
Elective Procedures
For most patients, diagnostic cardiac catheterization is performed as
an elective procedure. It should be deferred if the patient is not prepared either psychologically or physically.
Urgent Procedures
If the patient’s condition is unstable because of a suspected cardiac
disorder, such as acute myocardial infarction, catheterization must
proceed. In the event of decompensated congestive heart failure
(CHF) in patients with acute unstable coronar y syndromes, rapid
medical management is needed. Although a patient must be able to
lie flat for easy catheter passage, patients with acute cardiac decompensation may benefit more from aggressive management in the catheterization laboratory where intubation, intraaortic balloon pumping
or other mechanical support devices, and vasopressors can be instituted rapidly before angiography and a rapid decision made for
revascularization.
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The Catheterization Laboratory
Table 1-1
Procedures That May Accompany Coronary Angiography*
Procedure Comment
1. Central venous access Used as IV access for emer gency
2. Hemodynamic assessment
a. Left heart pressures Routine for nearly all studies (aorta,
b. Right hear t pressures Not routine for coronary arter y
3. Left ventricular angiography Routine for nearly all studies; may be
4. Internal mammary artery
selective angiography
5. Femoral angiography Routine for femoral ar terial access
a. IC/IV/sublingual NTG Useful during coronary angiogr aphy
6. Aortography Routine for aortic insufficiency, aortic
7. Cardiac electrophysiologic
studies
8. Inter ventional and special
techniques
9. Arterial closure devices Available to reduce access site
CFR, Coronary flow reserve; CHF, congestive heart failure; FFR, fractional flow
reser ve; IC , intracoronary; IV, intravenous; IV US, intravascular ultrasound imaging;
NTG, nitroglycerin; TAVR, tr ansaor tic valve replacement.
*See Table 1-2 for indications.
medications (femoral, internal
jugular, subclavian) or fluids,
temporary pacemaker (pacemaker
not mandator y for coronary
angiography)
left ventricle)
disease, combined pressures;
mandatory for valvular hear t
disease; routine for CHF, right
ventricular dysfunction, pericardial
diseases, cardiomyopathy,
intracardiac shunts, congenital
abnormalities
excluded with high -risk patients,
left main coronary or aortic
stenosis, severe CHF, renal failure
Not routine unless used as coronar y
bypass conduit
assessments before closure device
and intracoronary device
manipulations
dissection, aortic aneurysm, with
or without aortic stenosis; routine
to locate bypass graf ts not
visualized by selective angiography,
anomalous coronary origin
Arrhy thmia evaluation, conduction
tract catheter ablation procedures
Coronary stents, rotoblator, etc. FFR/
CFR/IVUS for lesion assessment
TAVR, Balloon valvuloplasty (see
Chapter 10, Interventional
Cardiology Procedures)
Myocardial biopsy
Transseptal or left ventricular
puncture
bleeding
Contraindications
Contraindications to cardiac catheterization include fever, anemia,
electrolyte imbalance (especially hypokalemia predisposing to
arrhythmias), and other systemic illnesses needing stabilization
(Box 1-1). The clinical necessity of cardiac catheterization also should
be carefully considered when the diagnostic information or therapeutic intervention from the procedure would not meaningfully impact
the management of a patient.
Catheter introduced
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Catheter introduced
into basilic vein, goes
via axillary, subclavian,
brachiocephalic veins
and superior vena cava
to right heart
Catheter may be
introduced via
jugular or
saphenous vein
(in infants)
1 —
The Catheterization Laboratory 3
RIGHT HEART CATHETERIZATION
LEFT HEART CATHETERIZATION
passed up inferior vena cava
to atrium; needle (now
unsheathed) punctures
interatrial septum to enter left
atrium; catheter may then
pass to left ventricle
Superior vena cava
Wedged in small
branch of
pulmonary artery
Pulmonary trunk
Right ventricle
Right atrium
Inferior vena cava
Transseptal
puncture: catheter
with sheathed
needle introduced
into saphenous or
femoral vein,
via basilic vein and
superior vena cava
to right side of
heart, passes
Catheter introduced into
brachial, radial, or
femoral artery and
passed retrograde via
aorta to left ventrical
Figure 1-1 Vascular access routes for cardiac catheterization (also see
Chapter 2). Radial and femoral ar teries are the most common approaches.
aorta (may also pass through
atrial septal defect)
through ventricular
septal defect to left
ventricle, thence to
Complications and Risks
For diagnostic catheterization, an analysis of the complications in
more than 200,000 patients indicated the incidences of risks: death,
~0.2%; myocardial infarction, ~0.05%; stroke, ~0.07%; serious ventricular arrhythmia, ~0.5%; and major vascular complications (thrombosis,
bleeding requiring transfusion, or pseudoaneurysm), ~1% (Box 1-2 and
Table 1-3). Vascular complications occurred more often when the
brachial approach was used and least when the radial approach was
used. Risks are increased in well-described subgroups (Box 1-3).
Catheterization Laboratory Data
Information gathered during the cardiac catheterization can be
divided into two categories: hemodynamic (see Chapter 4) and
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The Catheterization Laboratory
Table 1-2
Indications for Cardiac Catheterization
Indications Procedures
1. Suspected or known coronar y ar tery
disease
a. New-onset angina LV, COR
b. Unstable angina LV, COR
c. Evaluation before a major surgical
procedure
d. Silent ischemia LV, COR
e. Positive exercise tolerance test LV, COR
f. Atypical chest pain or coronary spasm LV, COR, vasomotor stimuli
2. Myocardial infarction LV, COR, PCI
a. Unstable angina postinfarction LV, COR, PCI
b. Failed thrombolysis LV, COR, PCI
c. Shock LV, COR, RH, LV suppor t
d. Mechanical complications (ventricular
septal defect, rupture of wall or
papillar y muscle)
3. Sudden cardiovascular death
4. Valvular hear t disease
5. Congenital heart disease (before
anticipated corrective surgery or ASD/PFO
closure)
6. Aortic dissection AO, COR
7. Pericardial constriction or tamponade
8. Cardiomyopathy
9. Initial and follow -up assessment for heart
transplant
AO, Aortogr aphy; ASD, atrial septal defe ct; BX, endomyoc ardial biopsy;
COR, coronary angiography; LV, left ventr iculography; PCI, percutaneous coronary
inter vention; RH, right hear t oxygen s aturations and hemodynamics (e.g., plac ement
of Swan- Ganz catheter); R + L, right and left hear t he modynamics; ±, optional.
LV, COR
LV, COR
LV, COR, RH, pacemaker,
LV support
LV, COR, R + L
LV, COR, R + L, ± AO
LV, COR, R + L, ± AO
LV, COR, R + L
LV, COR, R + L, ±BX
LV, COR, R + L, BX
Box 1-1 Contraindications to Cardiac Catheterization
Absolute Contraindications
Inadequate equipment or catheterization facility
Relative Contraindications
Acute gastrointestinal bleeding, anemia
Anticoagulation (or known, uncontrolled bleeding diathesis)
Electrolyte imbalance
Infection and fever
Medication intoxication (e.g., digit alis, phenothiazine)
Pregnancy
Recent cerebrovascular accident (<1 month)
Renal failure
Uncontrolled congestive heart failure, high blood pressure, arrhy thmias
Uncoop erative patient
angiographic (see Chapter 3). Electrophysiologic data are addressed
in Chapter 6). The term cineangiography describes the x-ray photography of cardiac structures from the era when film was the recording
medium. Use of this term (i.e., “cine”) persists even though the images
are now stored electronically on digital computer imaging media (e.g.,
CD-ROM) rather than on celluloid film. The digital “cineangiogram”
provides anatomic information about the chambers of the heart and
the coronary arteries. Hemodynamic information is recorded from
catheters inside the heart and consists of pressure tracings in a
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