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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3597_Библиотеки_им_академика_М_И_Перельмана
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Special Techniques
into a cardiac chamber or laceration of an epicardial vessel. Chronic
effusions are often clear yellow, occasionally serosanguineous, or less
commonly, dark brown. Acute effusions resulting from trauma, cancer,
or artery perforation are frankly bloody.
To confirm passage into the pericardial space, the stopcock can
be turned for transduction of pressure. In this manner, inadvertent
ventricular puncture can be recognized at once. Of note, in cases of
tamponade, pericardial pressure resembles atrial pressure. For further
confirmation, agitated saline can be injected through the needle or
catheter with simultaneous echocardiographic imaging to demonstrate location in the pericardial space (Fig. 7-21). If the needle or
catheter is in a cardiac chamber (e.g., RV or LV), the bubbles will be
seen in the cavity and then dispersed rapidly by ventricular ejection.
Electrocardiographic guidance has been used historically, with the
current of injury seen on contact with the epicardium (Figs. 7-22 and
7-23). Hemodynamic monitoring and echocardiography is now the
favored approach for pericardiocentesis.
When the needle or catheter is in the pericardial space, a guide-
wire is passed under fluoroscopy high into the pericardial space
(transverse pericardial sinus) followed by an exchange for a multiple
side-hole catheter (e.g., pigtail) or sheath. Pericardial and atrial pressures are measured, effusion is aspirated, and pressures are measured
again after the pericardial space is empty (Fig. 7-24). Large syringes
(>
50 cc) or a vacuum jar can be used to facilitate rapid removal of
pericardial fluid. In the event of effusion due to cardiac perforation,
the removed blood can be placed in a cell saver for return to the
patient. If the position of the needle or catheter is uncertain, a small
amount of radiographic contrast medium or agitated saline under
echocardiographic guidance can be injected. Contrast medium pools
in the dependent portion of the pericardial space but rapidly washes
out of a vascular space if a cardiac chamber has been entered
inadvertently.
Samples of the pericardial fluid should be sent to the laboratory for appropriate chemistries, cultures, and cytology, as indicated
by clinical presentation. The multiple side-hole catheter or sheath is
left in place with a sterile dressing until serial echocardiography demonstrates no recurrent effusion. Catheter placement can cause residual chest discomfort that can be treated with systemic analgesia or
periodic injection of local anesthesia directly into the pericardial
space.
Figure 7-21 Echocardiogram with large amount of fluid in the pericardial
space.
1 sec
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Special Techniques 353
A
B
Figure 7-22
Note the normal ST segment when the tip is not touching the epicardium.
B, When the needle tip touches the epicardium, the current of injury (the
“contact” current) with an elevated ST segment is seen. (From Tilkian AG,
Daily EK: Cardiovascular procedures: diagnostic techniques and therapeutic
procedures, St Louis, 1986, Mosby.)
40 mm Hg
Figure 7-23 Electrocardiogram (ECG) method during pericardiocentesis.
Left, The ECG shows normal tracing; the ECG clip is attached to the pericardial needle. Right, On advancement of the needle through the pericardium, contact is made with the hear t, as shown by the ECG injury current.
RA, Right atrial pressure. (From Kern MJ, Aguirre FV: Interpretation of cardiac
pathophysiology from pressure waveform analysis: pericardial compressive
hemodynamics, Part III. Cathet Cardiovasc Diagn 26:152–158, 1992.)
A, Electrocardiographic monitoring of pericardial needle tip.
ECG
RA
ECG
RA
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Special Techniques
1 sec
200 mm Hg
40 mm Hg
Ao
RA
Peri
After 250 mL After 450 mL After 600 mL
A
Figure 7-24
pressure. B, Right atrial (RA) pressure before and after withdrawal of pericardial fluid. Note the elimination of pulsus paradoxus of aortic pressure
and the return of Y descent of the RA waveform after pericardiocentesis.
A
Hemodynamic results of pericardiocentesis. A, Aortic (Ao)
B
B
Ao
RA
Peri
Figure 7-25 A, A loop snare is used to capture a catheter end. B, The
loop snare can be used to capture catheter fragments. (Reproduced with
permission of Covidien.)
Intravascular Foreign
Body Retrieval
Catheter fragments can result from injudicious insertion or removal
of catheters from the subclavian, jugular, peripheral (portacaths), or
rarely, inferior vena caval approaches. Guidewire fragmentation, coronary stent loss, and embolization of structural devices (e.g., AMPLATZER occluders) can also occur in the systemic arterial circulation
during interventional procedures. Several catheter and wire loop
systems have been designed to retrieve intravascular foreign bodies.
Snares can have single (e.g., Amplatz GooseNeck, Covidien, Plymouth,
MA) or multiple (e.g., EN Snare, Hatch Medical, Atlanta, GA; MultiSnare Bi-Plane Design, B. Braun Interventional Systems, Inc.) loop
configurations, with a range of sizes and steerability (Fig. 7-25). An
intracoronary guidewire fragment can be retrieved from the coronary
artery with the use of a loop passed through a small intracoronary
guiding catheter. When performing such retrieval, it is important to
note that the size of the vascular access sheath should be generous
and based on the largest diameter of the foreign body, regardless of
its orientation, that is anticipated to occur during removal. If the sheath
is too small, severe vascular injury will occur during foreign body
retrieval. A delivery catheter is advanced to the snaring site over a
0.035- or 0.038-inch wire. Tightening of the snare occurs with retrieval
into the delivery catheter; this backward tension needs to be maintained to avoid loss of capture of the foreign body. Examples of foreign
body retrieval are shown in Figures 7-26 and 7-27.
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Special Techniques 355
A
B
Figure 7-26
snare. A, Stent loss during percutaneous coronary intervention of the right
coronary artery (arrow). A 15-mm GooseNeck snare is used to capture the
stent. B, The captured stent can be seen within the snare after removal.
A coronary stent is retrieved using a 15-mm GooseNeck
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A
Special Techniques
B
Figure 7-27 Retrieval of an embolized AMPLATZER Vascular Plug II. A,
Embolization of the 6-mm vascular plug (arrow) into the left ventricle (LV)
occurs during paravalvular leak closure. B, The embolized occluder becomes
embedded in the left femoral arter y (arrow).
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Special Techniques 357
C
D
Figure 7-27, cont’d
GooseNeck snare is placed antegrade into the left femoral artery to retrieve
the embolized plug. D, The plug is removed via the contralateral femoral
artery (arrow).
C, Through a right femoral ar tery sheath, a 10 -mm
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Special Techniques
Suggested Readings
Bell CA, Kern MJ, Aguirre FV, et al: Superior accuracy of anatomic positioning with
echocardiographic over fluoroscopic-guided endomyocardial biopsy. Cathet Cardiovasc Diagn 28:291–294, 1993.
Brockenbrough EC, Braunwald E: A new technique for left ventriculography and trans-
septal left heart catheterization. Am J Cardiol 6:1062–1064, 1960.
Croft CH, Lipscomb K: Modified technique of transseptal left heart catheterization. J Am
Coll Cardiol 5:904–910, 1985.
Holzmann M, Nicko A, Kuhl U, et al: Complication rate of r ight vent ricular endomyocar-
dial biop sy via the femoral approach: a retrospective and prospective study analyzing 3048 diagnostic procedures over an 11-year period. Circulation 118:1722–1728,
2008.
Hsu JC, Badhwar N, Gerstenfeld EP, et al: Randomized trial of conventional transseptal
needle versus radiofrequency energ y needle puncture for left atrial access (the
TRAVERSE-L A study). J Am Heart Assoc 2:e000428, 2013.
Kern MJ, Deligonul U: The interventional cardiac catheterization handbook, St Louis,
1996, Mosby.
Mason JW, O’Connell JB: Clinical method of endomyocardial biopsy. Circulation 79:971–
979, 1989.
Miller LW, Labovitz AJ, McBride LA, et al: Echocardiography-guided endomyocardial
biopsy: a 5 -year experience. Circulation 78(suppl 3):99–102, 1988.
Ross J, Jr: Transseptal left heart catheterization: a 50-year odyssey. J A m Coll Cardiol
51:2107–2115, 20 08.
Wadehra V, Buxton AE, Antoniadis AP, et al: The use of a novel nitinol guidewire to
facilitate transseptal puncture and left atrial catheterization for catheter ablation
procedure s. Europace 13:1401–1405, 2011.
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High-Risk Cardiac
Catheterization
MICHAEL FORSBERG • MICHAEL J. LIM
Since its inception, heart catheterization has evolved from a diagnostic modality used for hemodynamic assessment and visualization
of the coronary anatomy and ventricular function to a therapeutic
means to treat pathology, from atherosclerosis to congenital heart
defects. More than 1 million heart catheterizations are performed in
the United States each year. Complications for diagnostic procedures
in the catheterization laboratory principally include death, myocardial infarction, stroke, vascular complications, contrast reactions, and
arrhythmias. The rates for these complications are very low and have
not changed over the past decade (Table 8-1). As the procedure continues to mature, a comfort level has developed in performing procedures on higher-risk patients. It is becoming more common for patients
to undergo multivessel (including left main) percutaneous coronary
intervention (PCI) with hemodynamic support as an elective procedure within most catheterization laboratories.
High-Risk Patient: Definition
Patients classified as high risk are more likely to die or have complications during cardiac catheterization than are other patients. Numerous
studies have summarized the clinical and anatomic characteristics of
patients at high risk (Table 8-2). Patients with high-risk features resulting from stress testing, including ventricular dilatation with stress,
large amounts of ischemic myocardium, multiple territories of ischemia, and very poor exercise capacity, are at higher risk secondary to
the higher likelihood for these patients to have multivessel or left main
coronary disease. Patients with congestive heart failure (CHF), recent
acute myocardial infarction, unstable angina, and severe valvular
heart disease (especially critical aortic stenosis) have a high incidence
of morbidity and mortality during and after cardiac catheterization.
Prevention of Complications
Meticulous attention to the precatheterization patient assessment
and recognition of potential risks decreases procedure-related
complications.
“The best complications are those that never occur.”
—Anonymous
Patient Medications
Many medications can affect a patient’s catheterization risk (Box 8-1).
Warfarin (Coumadin) should be held for at least 72 hours before
the procedure, and the international normalized ratio (INR) should be
<1.8 for femoral access and <2.2 for radial access before the procedure
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High-Risk Cardiac Catheterization
Table 8 -1
Risk of Cardiac Catheterization and Coronary
Angiography
Complication Risk (%)
Mortality 0.11
Myocardial infarction 0.05
Cerebrovascular accident 0.07
Arrhy thmia 0.38
Vascular complications 0.43
Contrast reaction 0.37
Hemodynamic complications 0.26
Perforation of heart chamber 0.03
Other complications 0.28
Total of major complications 1.70
Adapted from Scanlon PJ, Faxon DP, Audet AM, et al: ACC/AHA guidelines for
coronary angiography: a report of the American College of Cardiology/Americ an
Hear t Association Task F orce on practic e guidelines (Commit tee on Coronary
Angiography). J Am Coll Cardiol 33 (6):1760, 1999.
Table 8 -2
Variables That Increase Risk in Cardiac Catheterization
and Coronary Angiography
Anatomic Clinical
Acute myocardial Infarction
Shock
Left main coronary disease Atrial/ventricular arrhythmias
Three -vessel obstructive disease Poorly controlled hypertension
Severe valvular disease (especially
severe aortic stenosis)
Severe left ventricular dysfunction
(EF <30%)
Severe perip heral vascular disease
(vascular access difficulty is also
included)
Saphenous vein grafts IV contrast allerg y
Females (?)
Very small or very large body habitus Medications
COPD, Chronic obst ructi ve pulmonar y disease; EF, ejection fr action;
GI, gastrointestinal; INR, international normalized r atio; IV, intravenous; NYHA , New
York Heart Association; OSA, obstr uctive sleep apnea.
Severe valvular disease
Decompensated hear t failure
(especially NYHA class IV )
Diabetes mellitus
Renal insufficiency
Pulmonary disease (COPD, asthma,
OSA)
Anemia ± bleeding diathesis, active
GI bleeding, elevated INR,
thrombocytopenia
Cerebrovascular disease
Age >60 years or <1 year
Erectile dysfunction drugs
Oral anticoagulants
Metformin
Insulin
Diuretics
Emergent procedure
to reduce the bleeding risk. Understanding why the patient has been
taking warfarin is important because high-risk patients may require
bridging therapy with heparin. Bridging should be considered for
patients taking warfarin for atrial fibrillation with a CHADS
5 or 6, recent stroke within 3 months, or rheumatic heart disease.
Patients on warfarin for mechanical heart valve with any mitral valve,
older mechanical aortic valve (ball in cage, tilting disc), or recent
stroke or transient ischemic attack (TIA) are considered to be high
risk, as are patients taking warfarin for venous thromboembolism with
any recent stroke or high-risk thrombophilia (protein C, protein S, or
score of
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High-Risk Cardiac Catheterization 361
Box 8 -1 Medications That May Affect Cardiac
Catheterization Risk
Oral anticoagulants
Furosemide
Metformin
Insulin (especially long acting)
Sildenafil, vardenafil, tadalafil
ACE-Is (lisinopril, ramipril, enalapril)
ARBs (losar tan, candesartan)
NSAIDs (ibuprofen, naproxen)
ACE-I, Angiotensin -converting enzyme inhibitor; ARB, angiotensin receptor blocker;
NSAID, nonsteroidal antiinflammatory d rug.
antithrombin deficiencies; antiphospholipid; homozygous factor V
Leiden or prothrombin genes).
Direct factor Xa inhibitors dabigitran (Pradaxa), rivaroxaban
(Xarelto), and apixiban (Eliquis) are now more widely used for anticoagulation, but they can increase procedural bleeding risk. Dabigitran should be discontinued 2 days before the procedure if creatinine
clearance (CrCl) ≥
50 mL/min and 5 days before if CrCl <50 mL/min.
Rivaroxaban should be discontinued 24 hours before the procedure,
and apixiban should be discontinued 48 hours before.
Generally, diuretics should not be taken on the morning of the
procedure because dehydration may decrease renal flow and increase
the risk of contrast nephropathy and hypotension.
On the morning of the procedure, patients with diabetes should
not take short-acting insulin. To avoid the risk of hypoglycemia, administer one-half to two-thirds of the daily total (for once-daily-dosing
patients) or morning insulin dose (for twice-daily-dosing patients) in
the form of long-acting insulin. Oral antiglycemic agents should also
be held on the morning of the procedure. Metformin poses a slight but
real risk of lactic acidosis and should be held both before the procedure and 48 hours following contrast administration. Creatinine levels
should be checked 2 to 3 days after the procedure, and metformin can
be restarted if there is no evidence of decrement in renal function.
Because of sedation during the procedure, it is difficult to monitor
the diabetic patient for signs/symptoms of hypoglycemia or hyperglycemia. One should check blood sugar before initiation of the procedure and as needed throughout the case to minimize risk. If appropriate,
the patient should have dextrose or insulin infusion maintained during
the periprocedure period in an attempt to avoid hypoglycemia or
hyperglycemia.
Erectile dysfunction medications can also cause significant harm
in the catheterization laboratory. When combined with nitrate therapy,
there can be a precipitous drop in blood pressure that does not
respond well to volume or vasopressor resuscitation. Therefore, sildenafil (Viagra) and vardenafil (Levitra) should be held for a minimum
of 24 hours before the procedure. Tadalafil (Cialis) has a half-life of
17.5 hours and must be held for 4 days before the procedure.
Radiographic Contrast Media
Contrast-induced nephropathy (CIN), the number one cause of acute
renal failure in hospitalized patients, increases morbidity and mortality. The pathogenesis is not completely understood but is felt to involve
acute tubular necrosis (ATN). Hypotheses regarding the cause of ATN
include direct toxic effects of contrast and renal vasoconstriction
leading to medullary hypoxia.
Multiple contrast agents are currently available, and differentiating between them requires knowledge of their characteristics
and recognition of their chemical and trade names (Table 8-3).
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