Review articleCardiac catheterization techniques in pulmonary hypertension
Section snippets
Indications and considerations for catheterization of the patient with pulmonary hypertension
Catheterization plays an integral part in the evaluation of the patient with pulmonary hypertension. The primary goals of catheterization are to determine right ventricular and pulmonary artery hemodynamics, to exclude left-to-right cardiac shunts and any significant left-sided cardiac disorder, to assist in the determination of the cause of pulmonary hypertension, and to test the response of therapeutic agents. In patients with suspected CTEPH, pulmonary angiography and angioscopy are used to
Safety considerations
Early case reports [1], [2], [3], [4] of fatalities associated with pulmonary angiography in patients with pulmonary hypertension have led to a lingering perception that the procedure is associated with considerable risk, primarily because of acute right ventricular failure and arrhythmias. Even right-heart catheterization alone [5] was reported to be potentially dangerous. Larger series have since been published, both in acute and chronic pulmonary embolism and in mild as well as severe
Right-heart catheterization
Evaluation of hemodynamics by right-heart catheterization plays an integral part of the evaluation of patients with pulmonary hypertension. The goals of right-sided catheterization are (1) to measure PAP directly and estimate pulmonary vascular resistance, (2) to evaluate for left-to-right shunts, and (3) to test the response to therapeutic agents.
During right-heart catheterization by balloon flotation catheter, rapid determination and continuous monitoring of pressures in the right ventricle,
Response of vasodilator challenge in the cardiac catheterization laboratory
Vasoconstriction of the pulmonary vessels is one of the prominent pathologic features seen in patients with pulmonary hypertension of any cause, particularly in those with PPH [14]. Unfortunately, no hemodynamic or demographic characteristics exist to predict which patients are likely to benefit from long-term vasodilator therapy [15], [16]. In more recent studies, Groves et al [17] illustrated that the initial response to vasodilatory therapy accurately predicts the patient with PPH who is
Pulmonary angiography: anatomy
Accurate evaluation of the pulmonary angiogram requires knowledge of the pulmonary vasculature anatomy (Fig. 2, Fig. 3). The main pulmonary artery arises from the pulmonary conus of the right ventricle, anterior and to the left of the aorta. It takes a posteromedial direction until its bifurcation into the right and left pulmonary arteries. The right pulmonary artery courses anterior to the right mainstem bronchus. It gives rise to the right upper lobe branch within the mediastinum. The left
Pulmonary angiography: interpretation in the patient with pulmonary hypertension
Pulmonary angiography of the patient with pulmonary hypertension plays a central role in delineating the precapillary cause of elevated pulmonary pressures. Distinguishing major-vessel from small-vessel disease allows the correct therapeutic approach to be determined.
Auger et al [26] described the angiographic patterns seen in patients with chronic thromboembolic disease. These patterns include pouching abnormalities, vascular webs or bandlike constrictions, intimal irregularities, abrupt
Pulmonary angioscopy
When there is significant proximal disease (eg, complete occlusions of lobar vessels), the interpretation of pulmonary angiograms is straightforward. In the UCSD experience the pulmonary angiogram is suggestive but not definitive in about 20% to 25% of cases. The recanalization of chronic clot allows contrast to permeate through the lesions, and the pulmonary angiogram can underestimate disease just as the perfusion scan can. In addition, the presence of defects at the transition between
Summary
Cardiac catheterization of the patient with pulmonary hypertension plays an integral part in the diagnostic evaluation. Right-heart hemodynamics, pulmonary angiography, and pulmonary angioscopy offer a way to determine the cause of disease safely and accurately and to offer potentially life-saving therapies.
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