Left Cardiac Catheterization


Access to the left heart is usually retrograde, using arterial approach (femoral, radial or brachial). Left heart catheterization can be achieved using trans-septal approach with the passage of the catheter in the right atrium to the left atrium through a patent foramen ovale, atrial septal defect, ventricular septal defect or trans-septal puncture.

“Pigtail” catheter is the catheter of choice for access to the ascending aorta and left ventricle through the femoral arterial puncture.

Percutaneous vascular access

It is made using the Seldinger technique and its variants. These involve the following steps:212

–        Percutaneous puncture of the vessel;

–        Passing a guide atraumatic into the puncture needle through the vessel lumen and advancing the guide in vessel;

–        removing the needle, leaving the guide in bowl;

–        Introducing a sheath into the vessel through the guide;

–        Removal the guide the sheath leaving into the vessel, on the path that the catheters will be introduced later;

Arterial approach

Most often left heart catheterization and coronary angiography are performed using the femoral approach path. The right femoral artery is most often used because it is technically easy to access. Catheters are used with specific forms that facilitate access to the coronary ostia or the left ventricular cavity, taking into account the curvature of the aortic arch.

Alternative ways of approaches are necessary when arterial femoral access is difficult, impossible or when they don’t permit penetration into the target vessel for anatomical or technical reasons. Depending on experience and preference of the doctor, he can use brachial or radial approach.

The most common situations that require choosing alternative ways of approach are:Picture-1

–        The presence of peripheral vascular disease or peripheral grafts;

–        Abdominal aortic aneurysm;

–        Coarctation of the aorta;

–        Coronary artery bypass with internal artery graft;

–        Patients receiving chronic anticoagulation therapy;

–        Uncontrolled hypertension.

In case of arterial approach is needed of intravenous administration or intra-arterial heparin (2000-5000 units) to prevent catheter thrombosis.

Venous approach

Venous access is necessary to achieve right heart catheterization, pulmonary angiography, myocardial biopsy. Approach path is chosen depending on the nature of the procedure, factors related to the patient and examiner experience. The most common ways to approach these:

The femoral vein

Indications:

–        the most commonly used for right heart catheterization

–        Can be used for placement of temporary cardioverters or central venous catheters in patients with chronic anticoagulation or with abnormal coagulation

Complications

–        Artery puncture;

–        Local hematoma;

–        Infection.

Internal jugular vein

Indications:internal_jugular

–        Pulmonary artery catheterization;

–        Myocardial biopsy;

–        Central venous access in patients with coagulopathy or chronic anticoagulation, or to patients with high risk of pneumothorax;

–        Pulmonary angiography in patients with thrombus (for example filter or other obstructions in situ) into the inferior vena cava.

Complications

–        artery puncture;

–        Local hematoma;

–        Infection;

–        Cervical plexus damage;

–        Pneumothorax, hemothorax, chylothorax

Subclavian vein

Indications:

–        Most commonly used for insertion of permanent pacemakers cardio or long-term central venous catheters;

–        Pulmonary artery catheterization.

Complications:

–        Artery puncture;

–        Pneumothorax;

–        Hemothorax;

–        Infection.


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