UNIVERSITY OF TENNESSEE

MEMPHIS, TENNESSEE

Department of Internal Medicine

Division of Cardiovascular Medicine

UT Bowld Hospital

CARDIAC CATHETERIZATION
LABORATORY
Brad S. Burlew, M.D., Director

AN INTRODUCTORY
MANUAL

July 2002
 Welcome to the University of Tennessee, Bowld Hospital Cardiac Catheterization Laboratory. It is
in this laboratory where you will be taught the fundamentals of hemodynamic assessment, coronary
angiography, ventriculography, endomyocardial biopsy, coronary angioplasty, stenting, atherectomy, and
occasional other procedures. You will be exposed to patients with ischemic heart disease, acquired
valvular disease, congenital anomalies, cardiomyopathies, and pericardial diseases. You will likely also
become involved in the placement of temporary pacemakers.

Because all of these procedures present very real risks to the patient under study, it is imperative
that the fellow fully understands:

1) the indications for the proposed procedure

2) the mechanistic details of the proposed procedure
3) the risk associated with each portion of the proposed procedure
4) which patients, by virtue of their specific diseases have a high risk of complications
5) what should be done to minimize these risks
6) to what extent each patient needs in-patient follow up

In view of the above, it should be clear that the performance of a cardiac catheterization involves
much more than the procedure itself. As the cath lab fellow, then, you will participate in:

A) the initial assessment of the patient,

B) clinical stabilization of the patient, if necessary,
C) explaining the procedure to the patient and obtaining consent for the procedure,
D) performing the procedure,
E) post-procedure care,
F) data evaluation and reporting
G) presentation at angiography conferences.

The purpose of this manual is to initially guide you and provide a framework as you learn how to
meet these responsibilities. This manual is not at all meant to be comprehensive, but to complement
those excellent texts which are already available (see Appendix D).

PATIENT RECRUITMENT

Patients are referred to the catheterization laboratory from a number of sources, including:

1) Private inpatients and outpatients of UT cardiologists

2) Patients from ER
3) Patients from the Bowld and the Regional Medical Center cardiology services
4) Patients from the Bowld and the Regional Medical Center via
a) consult service
b) outpatient cardiology clinic

It is worthwhile at this point to mention that there is a very strong correlation between the number
of cases referred and the perceived enthusiasm of the cath lab fellow. It will pay off in terms of cases
referred to you if you communicate often with the senior residents on the floors and with the cardiology
fellows responsible for the Cardiology inpatent service and the Consult service.

Cath Lab Manual - UT Bowld 1

 INDICATIONS for procedure include: (see also Appendix D, Ross et al.):

Right heart catheterization;

Ventricular dysfunction
Valvular heart disease
Congenital heart disease
To assess pulmonary vascular status, i. e. pulmonary hypertension

Left ventriculogram;
To assess global function (EF)
To assess regional wall motion
Mitral Regurgitation
Ventricular septal defect

Coronary angiography;
To assess coronary architecture in patients with:
positive non invasive tests
stable angina
unstable angina
new onset angina
acute MI and complications
poor prognostic indicators post infarction
valvular heart disease in older patients prior to surgery
cardiomyopathies
refractory dysrhythmias
To assess graft patency post CABG
Asymptomatic patients with:
sudden death
silent ischemia
To assess coronary architecture in congenital anomalies

Aortic angiography;
Aortic dissection or aneurysm
Aortic valvular insufficiency
To locate ostia of venous coronary bypass grafts
Aortic coarctation
Congenital anomalies of aorta

Percutaneous Transluminal Coronary Angioplasty (PTCA), stent or

Coronary Atherectomy;
Hemodynamically significant CAD or disease of venous (or LIMA) coronary bypass graft

Endomyocardial Biopsy;
Pre transplant evaluation and post-transplant monitoring of heart allograft recipients.
Patients presenting with heart failure
Patients presenting with arrhythmias
Patients presenting with restrictive disease
Constrictive pericarditis vs. restrictive cardiomyopathy

Cath Lab Manual - UT Bowld 2

 RISKS:

During the performance of the history and physical, the fellow should also explain to the patient
the risk of the procedure as described above, and should obtain written consent for the procedure. The
risk of a study is cumulative and depends on the risk of each individual component procedure performed.
As a general comment, the risk of "Death or a Major Complication" can be fairly stated as <2% overall.

(% risk)
COMPLICATION Sones Judkins R Heart Biopsy
DEATH <0.3 <0.3 0 <<0.01
MYOCARDIAL INFARCTION 0.09-2.6 0.09-2.6 0 0
CVA 0.07-.23 0.07-.23 0 0
ARRHYTHMIA & CONDUCTION DISTURBANCE
VT 0.1 0.1 3 0
V Fib 0.4 0.4 1.3 0
RBBB rare 5
nil nil
RBBB c pre-existing LBBB (asystole) 0.4 0.4
3 AV Block 0.06 0.06
Asystole
CARDIAC PERFORATION (especially older females) 0.2 0.2 0.4 0.2
PERFORATION OF GREAT VESSELS 0.2 0.2 0 0
COMPLICATION AT ACCESS SITE up to 28
Hematoma rare >10 rare rare
Surgical exploration/repair 5.4-9.6 0.6-3.6 0 0
Thrombosis (higher in women & ASVC) <4 <1 <0.5 <0.5
INFECTION, PHLEBITIS rare rare rare

Another complication associated with catheterization is pulmonary edema, which can be a

consequence of a new MI, or other factors complicating severe LV dysfunction including the stress of
angiographic contrast material and prolonged recumbency.

Uncommonly (<<.5% in this laboratory), severe Protamine reactions mimicking anaphylaxis can
occur immediately after administration of Protamine sulfate to reverse the effects of heparin. Those at
increased risk include patients allergic to fish and diabetics receiving NPH insulin.

Dye exposure can induce renal failure, though this is not as common as in the past with the older
dyes such as Renografin 76 and Hypaque 76. Predictors of this complication include diabetes,
dehydration, azotemia (Cr>2), and myeloma. There are various protocols utilizing volume expansion and
diuresis with mannitol drips or furosemide which were designed to protect against acute renal failure. A
recent study demonstrated that simple hydration is more effective than diuresis in protecting against dye-
induced nephropathy( see appendix D ). Dye exposure is also occasionally associated with an anaphylactoid
(i.e., not IgE-mediated) reaction which cannot be predicted other than by prior occurrence, and even then,
a reaction on re-exposure is not certain. Commonly used prophylactic measures are described on the
following page.

Cath Lab Manual - UT Bowld 3

 PATIENT EVALUATION and PREPARATION

Once the patient is referred for study, the cath fellow is to obtain the history, perform a physical
examination, and review all pertinent data (including prior angiograms, operative reports, etc.) so as to
clearly understand the indication for the proposed study and to help plan the procedure. All prior CABG or
LIMA procedures must be posted in the lab. The patient should then be presented to the staff invasive
cardiologist and the appropriate study proposed. The patient is then scheduled with the cath lab (call 448-
4195 or write the name and room number on the board) and pre op orders written (see Appendix A).
These orders should be written as early in the day as possible, and should include CBC, Prothrombin
Time, electrolytes, and EKG. Should abnormalities be detected which may increase the risk of dye
exposure, such as hypokalemia, uremia, diabetes, myeloma, dehydration and the like, the patient should
be stabilized and prophylaxis initiated. Depending on the likelihood of complications, especially ARF or
anaphylactoid dye reaction, appropriate orders and consults (to nephrology) should be written as
necessary. The currently accepted protocol for prophylaxis against transient dye-induced renal failure is
as follows:

Solution: .45 % NaCl

Infusion: 1 mg/kg/hr

Duration: start 12 hours before and continue for 12 hours after catheterization.

Prophylaxis against anaphylactoid dye reaction can be accomplished as follows:

Prednisone 50 mg p. o. 12 hr & 6 hr prior to and on call to scheduled cath,

Diphenhydramine 50 mg p. o. on call, and

Ephedrine 25 mg p. o. on call (except in patients with uncontrolled hypertension or unstable

angina).

special comments - Angioplasty, atherectomy, stenting, etc.

Indications for angioplasty include, but are not limited to patients who are acceptable surgical
candidates, and who have limited number of lesions suitable for dilation. Aside from the structural
considerations which you will be taught, physiologic consequences of the lesion such as symptomatic
angina or a positive treadmill test ( thallium) must be considered.
It will be necessary to make arrangements for an ICU bed for patients scheduled for these
procedures. Depending on the risk of the procedure, surgical back-up may need to be arranged. This
involves contacting the Thoracic Surgery nurse who will then schedule OR time and arrange anesthesia
coverage. It is imperative, when possible, to begin antiplatelet therapy BEFORE all elective angioplasties.

Typical orders for the interventional patient are included in Appendix A.

Cath Lab Manual - UT Bowld 4

 special comments (continued) - Same-day cath

The "same day cath" is designed for patients who are ambulatory and stable, and utilizes small
diameter catheters (5F, 6F) for angiography and ventriculography. The advantage of these smaller
catheters is that there is a smaller arterial puncture, a diminished likelihood of hemorrhage and less leg
immobility time required. Consequently the patient can expect to be sent home on the day of the test. For
this to work, we must have the data available before the patient comes to the cath lab. This can be
accomplished by writing the orders (including all lab studies, EKG's, IV's and preps) and submitting these
orders THE NIGHT BEFORE to Pre Admission Testing. If the patient is scheduled as a 2nd or 3rd case, it
is possible have the labs drawn and run on the morning of the study. After the case is completed, the
patient can be observed for 6 hours and if all is well, can be sent home that night. If the patient has a
complication after returning home, he should return by ambulance (especially if hemorrhaging) to the
Bowld ARA.

See Appendix D for a recent study of complications of this technique (Kern et al.).

CATHETERIZATION - the study

It is in the laboratory where you will learn the most, not so much because your cerebellum merely
needs practice to refine your motor skills (which is the most common misconception), but because it is in
the laboratory where you must think and think fast! You will discover that you will be called upon to
assimilate your clinical expertise, your knowledge of patholophysiology and pharmacology, your
knowledge of anatomic subtleties, and your ability to conceptualize in three dimensions. For instance, you
will frequently be presented with unexpected congenital anomalies requiring immediate recognition (in this
laboratory there are often unanticipated ASD's, coronary anomolies) with proper and complete data
acquisition. It is inadequate to merely document an ASD; we need to document which type of ASD is
present and which associated anomalies coexist. Even the "routine" (and use that word cautiously) left
heart cath will often have hidden traps including access problems, tortuous or aneurysmal vessels,
congenitally displaced (and hard to find) coronaries and other unpredictable misadventures in patients
who are often marginally stable.
Each staff cardiologist will have evolved his/her own individual approach to these various
problems; there are many "right" approaches. You are now in the position of being able to observe,
question, and sample the techniques of others, and based on how you think, gradually develop your own
"style" as a catheteer. Regardless of whom the staff is, the following issues will need to be addressed:

1) Vascular access - the Seldinger technique is very much the standard for nearly all Judkins cases
and some Sones. You will quickly master it. On occasion, though, you will assist in the more
classic Sones arterial cut down.

2) Right heart cath - aside from the Swan-Ganz catheter with which you are already familiar, you will
probably be introduced to the Cournand catheter, the Grollman, the Eppendorf, the transvenous
bioptome, temporary pacers, and possibly a transseptal catheterization. Cardiac outputs can be
obtained via the thermodilution technique, the Fick technique, the left ventricular angiogram, and
indicator dilution techniques (now of only historical interest).

Cath Lab Manual - UT Bowld 5

 3) Left heart cath - Because of the catastrophic nature of the embolic (clot or air) complications of
left heart catheterization, you will need to develop immaculate habits when handling catheters,
wires, and injection manifolds. You will initially be introduced to the Judkins catheters for
cannulating the coronaries and, depending on your abilities, will be exposed to less easily handled
(and more dangerous) catheters such as the Amplatz series and the multipurpose. You will also
learn the art of "setting up" the radiologic views so as to obtain the most data with the least
amount of dye.

4) After the patient is removed from the laboratory, he continues to require careful attention. At this
time, rashes suggesting dangerous reactions to dye or Protamine may be seen, symptoms of
incipient pulmonary edema may appear. Of course, if catheters are removed, hemostasis must
be achieved; if they are not removed, they must be secured with sutures and dressed. It is
important for you to develop expertise in achieving hemostasis by deploying hemostatic devices or
holding groins. Do not misinterpret mastery of this responsibility as being beneath you; when
your technicians cannot control bleeding, they will come to you.

5) Most importantly, as you concentrate on mastering the manipulation of all of the above mentioned
catheters while maximizing data acquisition and minimizing dye and radiation exposure, you can
never lose sight of the fact that your patient on the table is extremely vulnerable: watch every
heartbeat while catheters are in the heart, watch constantly for signs of impending complications.
At the risk of sounding redundant:

"THERE IS NO SUCH THING AS A ROUTINE

CASE"

POST-PROCEDURE CARE

In the catheterized patient, follow-up care is usually directed towards management of the vascular
access site and towards the management of complications of the procedure, if any. Bleeding represents
by far the most common complication of the procedure; it also represents one of the most potentially
dangerous. Means of monitoring for and preventing this complication include frequent pulse checks and
vital signs, leg immobilization, and follow-up hematocrits. Volume status and renal function must also to
be monitored overnight. Even these assessments may prove inadequate for detecting the rare
(fortunately) retroperitoneal hemorrhage.

The access site is managed according to the technique employed. In the patient who was studied
from the groin using the Judkins technique, the dressing is removed during early AM rounds, the site
inspected, and a note written documenting the presence of distal pulses or hematomas (including size and
location), the color and function of the distal extremity, and the appearance, if any, of any new neurologic
dysfunction.

If the patient underwent a brachial arterial cut down, arrangements for removal of the sutures in
10 -14 days should be made. At that time, a second note documenting the presence or absence of
complications must be written in the patient's record.

Cath Lab Manual - UT Bowld 6

 DATA PREPARATION
CARDIAC OUTPUT

Cardiac output has been assessed using a number of techniques over the years including
indicator dilution, thermodilution, direct visualization with calculated volumes (LV angiography), and
oxygen consumption.
Indicator dilution technique is presently rarely used. It is performed by injecting a visible dye into
the venous blood as a bolus and continuously recording the concentration of the dye flowing past a
sampling site in a peripheral artery. It has the advantage of being able to differentiate between R to L
shunts, L to R shunts, and valvular regurgitation.
Thermodilution is a variation on the indicator dilution technique, using iced saline as the indicator
dye, and measuring the thermal response in the blood flowing past a sampling site in a pulmonary artery.
Consequently, blood flow through the right heart is measured. This is currently the most commonly used
technique. Unfortunately, it cannot differentiate between the various shunts as indicator dyes can. The
accuracy of this method is diminished in the settings of tricuspid insufficiency and pulmonic regurgitation.
In this laboratory, the left ventricular cardiac output is calculated using images stored in the
laboratory computer or by using the Vanguard cine projector. Outlines of the ventricular cavity are drawn
in systole and diastole, volumes are calculated, and based on heart rate, cardiac output is determined. Of
course, in the normal state, the right heart, left heart, and total forward systemic flows are all identical
Total forward systemic circulation can be calculated based on the Fick equation. If the patient's
oxygen consumption, mixed venous oxygen content, and arterial oxygen content can be determined, the
total systemic forward flow can be calculated. The best way to accomplish this is to actually measure the
oxygen consumption by having the patient breathe air in a metabolic hood (Waters MRM2) and to sample
mixed venous and central aortic oxygen saturations. An approximation can be made by looking up the
oxygen consumption index (OCI) based on age, gender, and HR, and calculating rather than measuring
the oxygen consumption (see pg. 8).

--Equations used to calculate cardiac output by the Fick equation.--

VO2 = oxygen consumption: measured or determined from assumed OCI (pg. 8)

Oxygen content = 1.39 x [Hb] x SO2 + .0031 x PO2

where [Hb] is the concentration of hemoglobin of the sample (g/dl)
SO2 is the saturation of the hemoglobin sample (1.0)
PO2 is the partial pressure of O2 in the blood (torr)

CaO2 = arterial oxygen content

= 1.39 x [Hb] x SaO2 + .0031 x PaO2.

CvO2 = central venous oxygen content

= 1.39 x [Hb] x SvO2 + .0031 x PvO2.

Oxygen consumption VO2 ml/min

Cardiac output = Arteriovenous oxygen difference = Ca -Cv
O2 O2 ml/100cc

VO2
= 1.39x[Hb]x(Sa
O2-SvO2)+.0031x(PaO2-PvO2)

Cath Lab Manual - UT Bowld 7

OXYGEN CONSUMPTION INDEX (ml/min)/m2
BY SEX, AGE, AND HEART RATE
Heart Rate (beats/min)
Age
(yr.) 50 60 70 80 90 100 110 120 130 140 150 160 170
Males
3 155 159 163 167 171 175 178 182 186 190
4 149 152 156 160 163 168 171 175 179 182 186
6 141 144 148 151 155 159 162 167 171 174 178 181
8 136 141 145 148 152 156 159 163 167 171 175 178
10 130 134 139 142 146 149 153 157 160 165 169 172 176
12 128 132 136 140 144 147 151 155 158 162 167 170 174
14 127 130 134 137 142 146 149 153 157 160 165 169 172
16 125 129 132 136 141 144 148 152 155 159 162 167
18 124 127 131 135 139 143 147 150 154 157 161 166
20 123 126 130 134 137 142 145 149 153 156 160 165
25 120 124 127 131 135 139 143 147 150 154 157
30 118 122 125 129 133 136 141 145 148 152 155
35 116 120 124 127 131 135 139 143 147 150
40 115 119 122 126 130 133 137 141 145 149

Females
3 150 153 157 161 165 169 172 176 180 183
4 141 145 149 152 156 159 163 168 171 175 179
6 130 134 137 142 146 149 153 156 160 165 168 172
8 125 129 133 136 141 144 148 152 155 159 163 167
10 118 122 125 129 133 136 141 144 148 152 155 159 163
12 115 119 122 126 130 133 137 141 145 149 152 156 160
14 112 116 120 123 127 131 134 136 143 146 150 153 157
16 109 114 118 121 125 128 132 133 140 144 148 151
18 107 111 116 119 123 127 130 134 137 142 146 149
20 106 109 114 118 121 125 128 132 136 140 144 148
25 102 106 109 114 118 121 125 128 132 136 140
30 99 103 106 110 115 118 122 125 129 133 136
35 97 100 104 107 111 116 119 123 127 130
40 94 98 102 105 109 112 117 121 124 128

This table is useful for estimating oxygen consumption (VO2) as follows:

1 Obtain body surface area from facing page (using height and weight)
2 Oxygen consumption = OCI x BSA

Cath Lab Manual - UT Bowld 8

ANGIOGRAPHY

General - During the performance of the procedure, the operator is constantly assessing the
degree and location of coronary artery disease. While the case is in progress, the various lesions must
each be demonstrated in at least 2 orthogonal (at right angles to one another) views.

ORTHOGONAL VIEWS
postero-anterior vs. lateral
right anterior oblique vs. left anterior oblique
right anterior oblique, cranial vs. left anterior oblique, caudal
right anterior oblique, caudal vs. left anterior oblique, cranial

Special views such as lateral with cranial (axillary) or caudal angulations are often helpful to isolate
otherwise difficult to demonstrate lesions (See facing page). It is also often useful to focus down (4" view
or "double-mag") and magnify the lesion, especially with severe L main or LAD stenoses.

During the actual filming of the angiogram, because the optimal area of focus is in the central
portion of the screen, one should start the cine with the proximal portion of the vessel centered, then
should "pan" or move the table so that the more distal portions of the vessel are well seen. Panning
should be limited as much as possible or avoided altogether. If a lesion is being magnified for special
evaluation, it is best to center the lesion first during the cine. Finally, it is preferred to start the injection of
dye a brief period of time (such as one heartbeat) after the beginning of the cine. This allows electronic
equilibration of the focusing and contrast circuits of the equipment, and also allows assessment of the
degree of calcification of the vessels and of the coronary flow dynamics present.

After the film has been developed, each artery needs to be defined in terms of specific anatomy
and in terms of localization (see facing page) and severity of lesions. Each artery (the left main: LM, the
left anterior descending: LAD, the circumflex: Cx, and the right coronary: RCA) needs to be described.
The presence or absence of a ramus intermedius and the dominance of the posterior circulation needs to
be defined. An artery (RCA Vs Cx) is deemed dominant if it feeds the diaphragmatic portion of the heart
via the posterior descending artery (which takes off opposite to the A-V nodal artery).

After determining the major anatomy, the lesser vessels need to be assigned; the conus branch
(originates from a separate ostium about half the time) and the acute marginal branches feeding the RV
free wall are branches of the right, the septal perforators and the diagonal branches are from the LAD,
and the obtuse marginals originate from the Cx. The posterior descending artery (PDA) originates from
the RCA in around 85% of people, from the Cx in about 8%. In the remainder of patients, there is a
codominant or balanced system, with the inferior septal perfusion coming from the terminal branch of the
RCA and terminal posterolateral branches of the Cx.

Once the anatomy is defined, the location and severity of lesions need to be determined. Lesion
location is described using the above mentioned terminology. The severity of a lesion is

Cath Lab Manual - UT Bowld 9

communicated quantitatively in terms of percent decrease in vessel internal diameter. It is also useful to
qualitatively describe distal flow in terms of TIMI Grades (see below). One of the most common errors is
for an angiographer to "estimate" the degree of stenosis. DONT DO THIS. There are plenty of studies
demonstrating very poor correlation between estimated and measured stenoses. Don't try, you'll be
wrong. In this lab, every lesion is to be measured manually with calipers, or using our computer-assisted
quantitative angiography.

Definitions of perfusion in the TIMI trial

Grade 0 (no perfusion): There is no antegrade flow beyond the point of

occlusion.

Grade 1 (penetration without perfusion): The contrast material passes

beyond the area of obstruction but hangs up and fails to opacify the entire
coronary bed distal to the obstruction for the duration of the
cineangiographic filming sequence.

Grade 2 (partial obstruction): The contrast material passes acoss the

obstruction and opacifies the coronary bed distal to the obstruction.
However, the rate of entry of contrast material into the vessel distal to the
obstruction or its rate of clearance from the distal bed (or both) are
perceptibly slower than its entry into or clearance from comparable areas
not perfused by a previously occluded vessel e.g., the opposite coronary
artery or the coronary bed proximal to the obstruction.

Grade 3 (complete perfusion): Antegrade flow into the bed distal to the
obstruction occurs as promptly as antegrade flow into the bed proximal to
the obstruction, and clearance of contrast material from the involved bed is
as rapid as clearance from an uninvolved bed in the same vessel or the
opposite artery.

VENTRICULOGRAPHY

Cardiac ventriculography, especially left ventriculography, is performed to evaluate global and

segmental ventricular function, and to detect abnormalities such as asymmetric hypertrophy and VSD's. It
is usually performed in the RAO (and often LAO) projection using a 7 or 8F pigtail catheter. Other
catheters used include the multipurpose, the NIH, Eppendorf, Lehman ventriculography, and the Grollman
R ventriculography catheters. After setting up the LV gram, the cine is performed while injecting a minimal
but effective bolus into the LV over several seconds. Typical flow rates are on the order of 10 - 15 cc/sec
for 3 seconds. Pigtails are quite useful because the geometry permits high flow rates without a "fire
hosing" effect (where the catheter whips around inside the heart during the injection because of a jet
reaction at the hole at the tip of the catheter). Multiple side hole catheters are second best because the
dye escaping from the side holes lessens the jet reaction. If the jet is severe enough, it can actually cause
dye to burrow into the myocardium and cause "staining" (not acceptable). For this reason, end-hole
catheters should be used with lesser rates of injection (8 - 12 cc/sec) after carefully placing the catheter
along the long axis of the ventricle, as far away from endocardium as possible.

Once performed, the ventriculogram is evaluated on the cine projector by entering the data
requested by the computer and following the instructions to trace the end-diastolic and systolic
ventriculograms. The laboratory computer can also be used to give you information regarding the global
and regional (see facing page) ventricular function.

Cath Lab Manual - UT Bowld 10

 Hemodynamic Calculations - Oximetry

SHUNTS (See chapter on "Shunt detection and Measurement" in Grossman text)

The presence and extent of shunting is usually expressed as the ratio of pulmonary to systemic
blood flow: Qp/Qs. Normally, pulmonary blood flow(Qp) is very nearly the same as systemic blood flow
(Qs), the trivial difference being accounted for by the physiologic shunt (coronary and bronchial blood
drains into the left ventricle & atrium or pulmonary veins). As already described in the cardiac output
discussion,
Oxygen consumption VO2
Cardiac output = Arteriovenous oxygen difference = Ca -Cv
O2 O2

This concept is used to determine the flow across

the systemic capillary bed:
VO2
Qs = Ca -Cv
O2 O2
and
the pulmonary capillary bed:
VO2
Qp = CPV -CPA
O2 O2
where:
VO2 = oxygen consumption (measured or calculated)
CaO2 = systemic arterial O2 content (measured from aorta)
CvO2 = mixed venous O2 content (must be measured in chamber immediately
proximal to site of shunt - see below)
CPVO2 = pulmonary venous O2 content (measured from pulmonary vein, systemic
artery if PaO295%, or assumed to be 98% if PaO2<95% and R to L shunt
is demonstrated)
CPAO2 = pulmonary arterial O2 content (measured from PA)

LOCATION OF O2 STEP-UP USE CvO2 FROM

Pulmonary artery (i.e., PDA) Right Ventricle

Right Ventricle (i.e., VSD) Right Atrium

Right Atrium (i.e., ASD) CO2 (IVC)+3xCO2(SVC)

CvO2 = 4

In the setting of suspected congenital heart disease or acquired septal defects, the "sat run"
needs to be fairly extensive to increase the likelihood and precision of localizing the shunt. Samples
obtained in such a case should include:
Superior Vena Cava- high Inferior Vena Cava- high Pulmonary Artery-main PA
low low selective (R or L)

Right Atrium - high Right Ventricle - inflow "Wedge" saturation (optional)

middle outflow Left Ventricle
low Aorta
Compared to the complete sat run, the great majority of your cases will be abbreviated.
"Screening" sat runs are part of the routine right heart cath when a pathologic shunt is not suspected. In
these cases, single samples drawn from the IVC, mid RA, RV and PA are sufficient.

Cath Lab Manual - University of Tennessee / Bowld Hospital Page 11

 Hemodynamic Calculations - Oximetry

By way of example, Fig. 1 (facing page) demonstrates the saturation run measured in a patient with an
atrial septal defect. In this example, [Hb] = 12 g/dl

CaO2 = systemic arterial O2 content = 1.39 x [Hb] x SO2 + .0031 x PO2

= 1.39 x 12 x .96 + .0031 x 92
(using SaO2 measured from aorta of 96%, PaO2 of 92 mm Hg)
= 16.01 + .28 (note the 1.7% contribution (.28/16.01) from the plasma)
= 16.3
CO2(IVC)+3xCO2(SVC)
CvO2 = mixed venous O2 content = 4
CO2(IVC) = 1.39 x 12 x .73 +.0031x51,
(using SO2(IVC) = .73, PO2(IVC) = 51mm Hg)
= 12.17 +.15(again note the trivial contribution from the plasma)
= 12.32

CO2(SVC) = 1.39 x 12 x .68+.0031x48,

(using SO2(SVC) = .68, PO2(SVC) = 48mm Hg)
= 11.34 +.15(ditto) = 11.49

CO2 (IVC)+3xCO2(SVC) 12.32+3x11.49

CvO2 then, = 4 = 4 = 11.70

To demonstrate the relative contribution of the .0031 x PaO2 factor, I will now ignore the trivial
contribution from the plasma and calculate the CvO2 using:

CO2 (IVC)+3xCO2(SVC)
CvO2 = 4 =

.73x(1.39x12)+3x.68x(1.39x12) .73+3x.68
4 = 4 x(1.39x12)
=.6925x(1.39x12)= 11.55 ( a 1.3% error compared to 11.7).

Clinically, the .0031 factor is often ignored in patients with physiologic PO2's, and in this manual,
will be henceforth ignored.

CPVO2 = pulmonary venous O2 content

= 16.01 (measured from systemic artery in this case)

CPAO2 = pulmonary arterial O2 content (SPAO2 = 80%)

= 1.39 x 12 x .80 = 13.34

VO2 VO2
Qp = CPV -CPA and Qs = Ca -Cv
O2 O2 O2 O2

VO2
Qp CPVO2-CPAO2 CaO2-CvO2
Qs = VO2 = CPV -CPA
O2 O2
(VO2 cancels out)
CaO2-CvO2

Qp/Qs = (16.01 - 11.55)/(16.01 - 13.34) = 4.46/2.67 = 1.67

Cath Lab Manual - University of Tennessee / Bowld Hospital Page 12

 Hemodynamic Calculations - Oximetry

The next example, Fig. 2 (facing page) demonstrates the saturation run measured in a patient
with a large ventricular septal defect. In this example, [Hb] = 14.2 g/dl, and again, the O2 content of the
plasma will be ignored.

CaO2 = systemic arterial O2 content,

(using SaO2 measured from aorta of 96%, PaO2 of 92 mm Hg)
= 1.39 x 14.2 x .97
=19.14

CvO2 = mixed venous O2 content measured from the RA (average of samples=66%)

= 1.39 x 14.2 x .66
= 13.03

CPVO2 = pulmonary venous O2 content

=19.14 (measured from systemic artery)

CPAO2 = pulmonary arterial O2 content (SPAO2 = 88%)

= 1.39 x 14.2 x .88 = 17.36
VO2 VO2
Qp = CPV -CPA and Qs = Ca -Cv
O2 O2 O2 O2

Qp CaO2-CvO2
Qs = CPVO2-CPAO2 (VO2 cancels out as before)

Qp/Qs = (19.14- 13.03)/(19.14 - 17.36) = 6.11/1.78 = 3.43

Bi-directional shunts must be assessed in various PBF

complex congenital anomalies involving admixture of blood
from both sides of the circulation. In the figure to the right, the (Qp)
L R shunt is the difference between the total pulmonary
blood flow and the effective pulmonary flow (PBF-EPBF).
Likewise, the R L shunt is the difference between the
systemic blood flow and the effective pulmonary flow (SBF-
EPBF). The calculation of the bi-directional shunts can
therefore be accomplished with oxygen content RL
measurements: EPBF EPBF
RL
L R shunt = PBF-EPBF

VO2 VO2
= CPV -CPA - CPV -CV
O2 O2 O2 O2
Mixed
Venous
R L shunt = SBF-EPBF
Return SBF
VO2 VO2
= Ca -Cv - CPV -CV
O2 O2 O2 O2 (Qs)

Cath Lab Manual - University of Tennessee / Bowld Hospital Page 13

 Hemodynamic Calculations - Gorlin formula

VALVE REGURGITATION

The quantitation of valvular insufficiency is a relatively straightforward procedure which requires

the quantitation of:
a) the left ventricular stroke volume or cardiac output as measured by angiography
b) the actual forward flow (stroke volume or cardiac output) as determined by thermodilution or
Fick.
c) The regurgitant fraction = (a - b) / a

In a simple example, a patient with severe AI has an otherwise normal heart. On angiography,
the stroke volume is calculated as 132 ml. and her pulse is 107. The thermodilution cardiac output is 3.2
L/min. In this case, a = .132 x 107 = 14.1 L/min.
The regurgitant fraction = (14.1- 3.2) /14.1 = 10.9/14.1 = 77.3% (not good!)

VALVE STENOSIS

The quantitation of valvular stenosis requires the application of several measured or derived
parameters into the Gorlin equation with the empiric orifice constant corrected for the appropriate valve.
These parameters include:

1. The measured SYSTOLIC EJECTION PERIOD

2. The TOTAL SYSTOLIC CARDIAC OUTPUT, which in face of valvular insufficiency is not the
thermodilution CO, but the total systolic forward transvalvular flow, often best approximated by
the angiographically derived Stroke Volume x Heart Rate. This parameter is even harder to
determine in combined Aortic and Mitral regurgitation.
3. The CALCULATED MEAN SYSTOLIC TRANSVALVULAR GRADIENT.

Gorlin equation:
Flow
Valve Area = , where:
C x 44.3 P1-P2

Cardiac output(ml/min)
Flow = DFP or SEP

DFP = Diastolic filling period per minute (Diastolic filling time/beat x HR)

SEP = Systolic ejection period per minute (Systolic ejection time/beat x HR)

C = empiric orifice constant:

for semilunar (aortic, pulmonic) valves, patent ductus, septal defects;
C=1
for mitral valve calculations using DFP derived from PA catheter Vs LV;
C = 0.85
for mitral valve calculations using DFP derived from arterial pressure tracing;
C = 0.7

P1-P2 = CALCULATED MEAN TRANSVALVULAR GRADIENT.

This, as described on the next page, is derived by physically measuring with a planimeter the area
on the pressure tracing best representing the transvalvular gradient, and dividing by the linear dimension
on the tracing which represents the duration of the gradient (DF time or SE time for that heartbeat).

Cath Lab Manual - University of Tennessee / Bowld Hospital Page 14

 Hemodynamic Calculations - Gorlin formula

MEASURED PARAMETERS, using a case of aortic stenosis as an example, are obtained directly from
the pressure tracings as follows:
1) Using tracing paper or any paper through which you can easily see underlying print draw near
the bottom a horizontal line representing the baseline P=0. Matching this exactly with the baseline of
the pressure tracing, trace several cycles of the LV pressure curve as shown below:

Baseline P=0

2) In a similar fashion, trace the aortic pressure tracing, being careful to exactly match the
baseline and the systolic/diastolic periods. If there is a dichrotic notch, it will help you align the
tracings properly:

Baseline
P=0

Cath Lab Manual - University of Tennessee / Bowld Hospital Page 15

 Hemodynamic Calculations - Gorlin formula

3) Using the planimeter, measure the area representing the systolic transvalvular pressure gradient
(shaded):

The area obtained in this example is 5.125 cm2, which can be conceptualized as a rectangle with
the base representing the systolic ejection period in milliseconds and the height representing the mean
systolic transvalvular pressure gradient in mm Hg. It follows then that the way to calculate the mean
systolic transvalvular pressure gradient is to measure the shaded area in cm2 with the planimeter
(5.125cm2) and divide by the systolic ejection period measured directly off the pressure tracing in
centimeters (2.33 cm). This will yield a linear dimension (2.2 cm height) which, when
compared to the scale of the pressure tracing (200 mm
Hg calibrated over 10 cm total vertical span, or 20 mm
Hg/vertical cm), will convert to the mean systolic
transvalvular pressure gradient in mm Hg (44 mm Hg in
5.125 this example). Likewise, assuming a paper feed speed 5.125 sq. cm.
sq. cm. of 50 mm/sec, each horizontal centimeter (or 10 mm)
represents 200 mSec, and the systolic ejection period is
466mSec (2.33 cm x 200 mSec/cm).

4) Calculate the valve area with the Gorlin formula using

a. CO = 5.1 L/min (thermodilution)

b. SEP = 466 mSec (from above) x HR (91/min)
c. P1-P2 = 44 mm Hg (from above)
d. C = 1 (this example is a semilunar valve)

Flow 120.3 ml/sec

Valve Area = = = 0.4094 cm2 (severe)
C x 44.3 P1-P2 1 x 44.3 44 mm Hg

Cardiac output(ml/min) 5100ml/min

where Flow = DFP or SEP = .466 sec x 91/min = 120.3 ml/sec

Cath Lab Manual - University of Tennessee / Bowld Hospital Page 16

 Hemodynamic Calculations - Gorlin formula

The valve area in Mitral Stenosis is similarly calculated, although in this instance, the pressures on
both sides of the stenotic valve can be simultaneously recorded using the LV pressure and the PCWP
from the Swan Ganz catheter. A sample tracing is seen below:

Similarly, the area obtained in this example is 5.53 cm2, which can be conceptualized as another
rectangle with the base representing that heartbeat's diastolic filling period in milliseconds and the height
representing the mean diastolic transvalvular pressure gradient in mm Hg. Again, the mean diastolic
transvalvular pressure gradient is calculated by measuring a traced copy of the shaded area with the
planimeter (5.53cm2) and dividing by the diastolic filling period
measured directly off the pressure tracing in centimeters (2.7 cm).
This will yield a linear dimension (2.05 cm height) which, when
Mean gradient
compared to the scale of the pressure tracing (40 mm Hg calibrated 5.535 sq. cm.
over 10 cm total vertical span, or 4 mm Hg/vertical cm), will convert to (mm Hg)
the mean diastolic transvalvular pressure gradient in mm Hg (8.2 mm
Hg in this example). Likewise, assuming a paper feed speed of 50 Diastolic filling
mm/sec, each horizontal centimeter represents 200 mSec, and the
period (mSec)
diastolic filling period is 540mSec. Often, unfortunately, the patient
with mitral stenosis is in atrial fibrillation; these calculations can
performed and the valve area approximated by averaging the results of 10 to 15 consecutive cardiac
cycles (a tedious process, at best).
Calculate the valve area with the Gorlin formula using

a. CO = 4.8 L/min (thermodilution)

b. DFP = 540 mSec (from above) x HR (88/min)
c. P1-P2 = 8.2 mm Hg (from above)
d. C = .85 (this example is a mitral valve with an LV pressure tracing)

Flow 101 ml/sec

Valve Area = = = 0.9367 cm2
C x 44.3 P1-P2 .85 x 44.3 8.2 mm Hg

Cardiac output(ml/min) 4800ml/min

where Flow = DFP or SEP = .540 sec x 88/min = 101 ml/sec

Cath Lab Manual - University of Tennessee / Bowld Hospital Page 17

 Hemodynamic Calculations - Gorlin formula

DATA PRESENTATION

At the conclusion of every study, the data derived from the study need to be presented promptly to
the referring clinicians. This is accomplished in two stages; first in the chart, with a preliminary report
being written by the cath fellow or staff before the patient is returned to his room, and second, via the
formal final report. Copies of a preliminary report form and a final formal report are included in Appendix
B. The preliminary report MUST be on the chart immediately. The formal report is to be submitted
to the staff cardiologist for approval within 24 hours. No excuse for failing to meet this
responsibility will be acceptable; we are a consultative service with an absolute obligation to our
colleagues and their patients.

CATH CONFERENCE

This is a multidisciplinary educational conference designed to provide a forum wherein the most
appropriate management of selected patients can be determined. Participants in this forum include the
Cardiologists (staff & fellows), Thoracic Surgeons, Pediatric Cardiologists (as the case dictates),
representatives of the appropriate medical service, and any other interested party. Although this is an
invasive conference, the non invasive data are presented for purposes of demonstrating the indication for
procedures performed and for purposes of clinical correlation. The cath fellow's responsibilities include
organizing and presenting the cases as follows:

1) Determine with the staff physicians which cases are to be presented. It is best to keep an
ongoing list of appropriate cases so there is no last-minute scramble for cases.

2) Determine which of these cases have relevant echocardiograms and relay this information to
the Echo Labs. The noninvasive fellows or staff will then prepare to present the
echocardiographic data at the conference.

3) Know the patient's history and physical in detail. It is acceptable and reasonable to permit the
consult team or the floor resident to present the case, but it is your responsibility to know (or
arrange to have available) the pertinent and detailed cardiac H&P.

4) If available, present the CXR for each case.

5) Present the relevant EKG's for each case.

6) Have copies of relevant exercise studies thallium.

7) Make copies or transparencies of relevant hemodynamic data which will be presented just prior
to the cath films. As you develop more expertise, you will also present the angiograms to the
audience.

8) Be prepared to make recommendations based on the data available to you.

9) Assist in the communication of the recommendations of the group to the referring team.

Cath Lab Manual - University of Tennessee / Bowld Hospital Page 18

 APPENDIX A

UT Cardiac Catheterization Laboratory

PRE-CATHETERIZATION ORDERS
(Circle order number and check all boxes that apply. Uncircled orders will not be transcribed.)

1 Please have consent for cardiac cath and angioplasty (if applicable) on the chart prior to transfer to
cath lab.

2. Please obtain transfer authorization for cardiac catheterization BEFORE 06:00 (if the patient is from
the Regional Medical Center). Do not delay transport to cath lab for authorization.

3. Laboratory studies - PLEASE HAVE RESULTS ON CHART

Basmet CBC with platelet count
UA PT, PTT
EKG CXR
other:__________________________________________________

4. Height and weight and allergies on the front of the chart.

5. Prep and shave both groins .

6. Begin an IV of _______ to infuse at _______ cc/hr

Place in the left arm with an 18 gauge angiocath if possible.

7. NPO after midnight except for medications and sips of water.

The patient must receive all oral medications unless they are specifically ordered to be held.

8. Medications:
ASA, 325 mg p.o. now and on call to cath lab
Plavix 300 mg p. o. now and 75 mg p.o. q AM
heparin: __________________________________
Insulin: ___________________________________
_________________________________________
_________________________________________
_________________________________________

9. On call to the catheterization lab:

make certain the IV is patent,
allow the patient to void or have a bowel movement if needed.
Premedicate with:
Benadryl 25 mg p.o. Valium 5 mg p.o.
other:__________________________________________________

10. Please call me for any problems with the above orders - Thank you.

Also, the fellow should check and record peripheral pulses and previous cath entry sites. One should
administer steroids antihistamines for prior long term steroid Rx or contrast allergy.

Cath Lab Manual - University of Tennessee / Bowld Hospital -Appendices- a i

 APPENDIX A

UT Cardiac Catheterization Laboratory

POST-CATHETERIZATION ORDERS
(Circle order number and check all boxes that apply. Uncircled orders will not be transcribed.)

1. Strict bed rest for ____ hours. Keep ____ leg straight. Restrain foot if necessary.

2. BP and HR every 15 min. times 4, then every hour times 4, then resume precath orders for VS.
Foot pulse checks and dressing checks (hematoma, bleeding, etc.) with VS.
Document all of the above on chart.

3. Remove pressure dressing in A.M.

4. Resume pre-cath diet as tolerated

5. Encourage PO fluids as tolerated.

6. IV:
Remove IV when patient tolerates oral fluids and has voided
Continue IV at _____ cc/hr.
Resume heparin at U / hr
IV nitroglycerin at g / min

7. Medications:
Oral pain medication:
Resume pre-cath medications
heparin: __________________________________
Insulin: ___________________________________
_________________________________________
_________________________________________
_________________________________________

8. Labs:
PTT at ________ HR and in AM
Big 7 in AM
CBC with platelet count in AM
other:

9. EKG now and q A.M. x 2

10. Please review "post cardiac cath leg rules" sheet with patient.

11. Please call cardiology fellow below for:

SBP < _____
HR <_____ or >_____
angina
nausea or vomiting
cold painful pulseless leg
problems with the above orders.

12. Notify cardiology fellow by beeper (see below) or call 448-4195 STAT for active bleeding, growing
hematoma or severe pain at the dressing site.

Cath Lab Manual - University of Tennessee / Bowld Hospital -Appendices- a ii

 APPENDIX A

UT Cardiac Catheterization Laboratory

POST PTCA/STENT ORDERS

(Circle order number and check all boxes that apply. Uncircled orders will not be transcribed.)

PAGE 1 0F 2
Procedure: S/P PTCA with intra-coronary STENT of _______

1. Strict bed rest. Keep ____ leg straight. Restrain foot with Kerlex if necessary. HOB may be
elevated to 30 max.

2. Continuous cardiac monitoring.

BP and HR every 15 min. times 4, then every hour times 4, then resume precath orders for VS.
Foot pulse checks and dressing checks (hematoma, bleeding, etc.) with VS.
Document all of the above on chart.

3. Resume pre-cath diet as tolerated

4. Encourage PO fluids as tolerated.

5. Medications.
Oral pain medication:
NTG 1/150 s.l. q 5 min for angina x 3 doses and call physician.
Soluble ASA, 325 mg po q 12 hours
Plavix 75mg p. o. q AM
heparin: __________________________________
Insulin: ___________________________________
_________________________________________
_________________________________________
_________________________________________

6. IV:
Pressurized saline to femoral arterial sheath
NS through femoral venous sheath at _____ cc/hr..
Venous sheath may be used for meds.
IV nitroglycerin at _______________ g / min
IV heparin at _______________ U / hr
_________________________________________
_________________________________________

Maintain PTT between 45 - 80 using HEPARIN PROTOCOL:

if STAT PTT is: Heparin is to be:

>80 Decreased by 200 U/hr
45-80 not changed (higher end of range preferred)
40-44 Increased by 200 U/hr
35-39 Increased by 200 U/hr, and give 1000 U IV bolus
<35 Increased by 200 U/hr, and give 2000 U IV bolus

(orders continued on next page)

Cath Lab Manual - University of Tennessee / Bowld Hospital -Appendices- a iii

 APPENDIX A

UT Cardiac Catheterization Laboratory

POST STENT ORDERS

(Circle order number and check all boxes that apply. Uncircled orders will not be transcribed.)

(orders continued) PAGE 2 0F 2

7. EKG now and q A.M. x 2

8. Labs:
troponin now and q 8 hr x 2
PTT at _____ HRS and q 6 hrs. Run STAT - use results to titrate IV heparin
PT with INR q AM
Basmet in AM
CBC with platelet count in AM
_________________________________________
_________________________________________

9. Please call cardiology fellow by beeper (see below) for:

SBP < _____
HR <_____ or >_____
angina
nausea or vomiting
cold painful pulseless leg
PTT > 100 sec or < 35 sec on two consecutive samples
problems with the above orders.

10. Notify cardiology fellow by beeper (see below) or call 448-4195 STAT for:
active bleeding,
growing hematoma or
severe pain at the dressing site.

Cath Lab Manual - University of Tennessee / Bowld Hospital -Appendices- a iv

 APPENDIX A

UT Cardiac Catheterization Laboratory

POST SHEATH REMOVAL ORDERS

(Circle order number and check all boxes that apply. Uncircled orders will not be transcribed.)

Sheath removed at __________HRS.

1. Strict bed rest for _______ hours. Keep ____ leg straight. Restrain hand/foot with Kerlex if
necessary.

2. Please review "post cardiac cath leg rules" sheet with patient.

3. BP and HR every 15 min. times 4, then every hour times 4, then resume precath orders for VS.
Foot (wrist for arm case) pulse checks and dressing checks (hematoma, bleeding, etc.) with VS.
Document all of the above on chart.

4. Remove pressure dressing in A.M.

5. Oral pain medication:

6. Labs:
PTT at ____ HR and in AM
Basmet in AM
CBC
platelets
other:

7. For stent patients:

Plavix 75mg p.o. q AM.
Resume Heparin infusion one hour after sheath removal at_____U/hr.
Draw STAT PTT two hours after heparin is resumed and q 6 hours thereafter.
Maintain PTT between 45 - 80 using HEPARIN PROTOCOL:
if STAT PTT is: Heparin is to be:
>80 Decreased by 200 U/hr
45-80 not changed (higher end of range preferred)
40-44 Increased by 200 U/hr
35-39 Increased by 200 U/hr, and give 1000 U IV bolus
<35 Increased by 200 U/hr, and give 2000 U IV bolus
Other: ___________________________________________________

8. Please call cardiology fellow below for:

SBP < _______
HR <_______ or >_______
angina
nausea or vomiting
cold painful pulseless leg
PTT > 100 sec or < 35 sec on two consecutive samples
problems with the above orders.

9. Notify cardiology fellow by beeper (see below) or call 448-4195 STAT for:
active bleeding,
growing hematoma or
severe pain at the dressing site.

Cath Lab Manual - University of Tennessee / Bowld Hospital -Appendices- a v

 APPENDIX B Forms

PRELIMINARY REPORT

CARDIAC CATHETERIZATION LABORATORY

University of Tennessee, Wm. F. Bowld Hospital

Patient Name ................................................................. Date..................... MRN .........................

Clinical Diagnosis: ....................................................................................... Age ........ Sex .........

PROCEDURES: R heart Ventriculogram Angiogram Aortogram Biopsy PTCA/Stent

APPROACH: Right Left Brachial Femoral Other......................................

PRESSURES: Normal Abnormal (see values below)

Right Right Pulmonary Pulmonary Cardiac Left Central Heart

Atrium Ventricle Artery Wedge Output Ventricle Aorta Rate

VENTRICULOGRAM: Normal Abnormal ...................................................................

CORONARY ARTERIES:

Normal <50% >50% >70% >90% 100%

Left Main

LAD

Circumflex

RCA

Other:

SUMMARY:

COMPLICATIONS:

THIS IS A PRELIMINARY REPORT.

AN OFFICIAL REPORT, WHICH MAY VARY, WILL FOLLOW.

.....................................................................M.D., Pager................................
Dept. of Cardiology (448-4195)

Cath Lab Manual - UT Bowld Hospital -Appendices- b i

 APPENDIX C (sample dictations)
SAMPLE DICTATIONS: Organization of the procedure report is fairly easily accomplished using the
components listed below. Items in italics are most frequently modified according to the case.

i introductory The patient was premedicated with 5 mg of Valium and transported to the
catheterization laboratory. He was prepped and draped in the usual fashion"

ii venous access After infiltration of the area with local anesthesia (2% Xylocaine), using the
Seldinger technique, the R femoral vein was entered. Over a guide wire, a 7 F venous sheath
was placed.

iii right heart Through the venous sheath, a 7 F thermister tipped Swan-Ganz catheter was
advanced to the level of the pulmonary artery with appropriate pressures, oxygen saturations and
cardiac outputs recorded.

iv arterial access Again using the Seldinger technique, the R femoral artery was entered and
over a guide wire, a 7 F sheath was placed.

v left heart Through the arterial sheath, a 7 F pigtail catheter was advanced to the level of the
ascending aorta and appropriate pressures and oxygen saturations were recorded. The catheter
was then advanced retrograde across the aortic valve without difficulty and ventricular pressures
recorded. A left ventriculogram was then performed in the RAO and LAO projections using 45 cc.
of Cardiografin. After the ventriculogram was completed, the left ventricular and aortic pullback
pressures were recorded.

vi aortogram Using the pigtail catheter, an aortogram was then performed in the LAO view using
60 cc. of Omnipaque.

vii coronary angiography Over a guide wire, the pigtail catheter was exchanged for a 7 F 4 cm L
Judkins coronary catheter. The left main coronary ostium was cannulated without difficulty and
selective angiograms of the left coronary system were obtained in multiple projections. This
catheter was similarly exchanged for a 7 F 4 cm R Judkins coronary catheter. The right coronary
ostium was cannulated without difficulty and selective angiograms of the right coronary artery
were obtained in multiple projections.

viii biopsy Over a guide wire and after removal of the Swan-Ganz catheter the sheath in the
femoral vein was exchanged for a 7 F 125 cm. A-1 Multipurpose catheter with a 98 cm. biopsy
guiding sheath and the wire removed. Using hemodynamic and fluoroscopic guidance, the
catheter and sheath were advanced antegrade across the tricuspid valve into the right ventricle
and the sheath advanced over the catheter, which was then removed.. Through the guiding
sheath, after verifying proper position fluoroscopically, 7 F Mansfield transvenous bioptome was
used to obtain multiple biopsy specimens from the right ventricular surface of the interventricular
septum.

ix vascular egress and hemostasis The patient received 5,000 units of Heparin at the initiation of
the left heart catheterization and 40 mg. of Protamine at the end of the procedure. All catheters
and sheaths were removed and hemostasis achieved with manual pressure. There were good
right dorsalis pedis and posterior tibial pulses palpable at the end of the procedure.

x final - "The patient tolerated the procedure well and left the Catheterization Laboratory in
satisfactory condition. There were no apparent complications.

Cath Lab Manual - University of Tennessee / Bowld Hospital -Appendices- c i

 APPENDIX C (sample dictations)

SAMPLE DICTATION FOR FEMORAL APPROACH - Aortic and Mitral Valve disease

Procedure: Right and left heart catheterization, left ventriculography, aortography and coronary
angiography.

The patient was premedicated with 5 mg. of Valium and 25 mg. of Benadryl and transported to the
catheterization laboratory. He was prepped and draped in the usual fashion. After infiltration of the area
with local anesthesia (2% Xylocaine), using the Seldinger technique, the R femoral vein was entered.
Over a guide wire, a 7 F venous sheath was placed. Through the venous sheath, a 7 F thermister tipped
Swan-Ganz catheter was advanced to the level of the pulmonary artery with appropriate pressures,
oxygen saturations and cardiac outputs recorded. Again using the Seldinger technique, the R femoral
artery was entered and over a guide wire, a 7 F sheath was placed. Through this sheath, a 7 F A-II
Multipurpose catheter was advanced to the level of the ascending aorta and appropriate pressures and
oxygen saturations were recorded. The catheter was then advanced retrograde across the stenotic aortic
valve and ventricular pressures recorded. Simultaneous LV and wedge pressures were then recorded. A
left ventriculogram was subsequently performed in the RAO and LAO projections using 78 cc. of
Omnipaque After the ventriculogram was completed, the left ventricular and aortic pullback pressures
were recorded. An aortogram was then performed in the LAO view using 60 cc. of Omnipaque.
Using the Multipurpose catheter, the left main coronary ostium was cannulated without difficulty
and selective angiograms of the left coronary system were obtained in multiple projections. The right
coronary ostium was then cannulated without difficulty and selective angiograms of the right coronary
artery were obtained in multiple projections.
The patient received 5,000 units of Heparin at the initiation of the left heart catheterization and 50
mg. of Protamine at the end of the procedure. All catheters and sheaths were removed and hemostasis
achieved with manual pressure. There were good right dorsalis pedis and posterior tibial pulses palpable
at the end of the procedure. The patient tolerated the procedure well and left the Catheterization
Laboratory in satisfactory condition.
______________________

Cath Lab Manual - University of Tennessee / Bowld Hospital -Appendices- c ii

 APPENDIX C (sample dictations)
SAMPLE DICTATION FOR SONES APPROACH

Procedure: L&R heart cath, LV gram, aortogram

The patient was premedicated with 5 mg. of Valium and 25 mg. of Benadryl and transported to the
catheterization laboratory. His right arm was prepped and draped in the usual fashion. After infiltration of
right antecubital region with local anesthesia (2% Xylocaine), the right median antecubital vein and
brachial artery were isolated. A thermister tipped Swan-Ganz catheter was introduced through the vein
and was advanced to the level of the pulmonary artery with appropriate pressures, oxygen saturations and
cardiac outputs recorded. A #7 Sones catheter was then introduced through an arteriotomy in the brachial
artery and advanced to the aortic root. Appropriate pressures were recorded after which this catheter was
advanced retrograde across the aortic valve into the left ventricular cavity without difficulty. Appropriate
pressures were recorded. The left ventricular angiogram was then performed in the RAO projection using
45 cc. of Omnipaque After the ventriculogram was completed, the left ventricular and aortic pullback
pressures were recorded. Next an aortic root angiogram was performed in the left anterior oblique
projection injecting 50 cc. of dye at 30 ml. per second.
Using the Sones catheter, the left main coronary ostium was cannulated without difficulty and
selective angiograms of the left coronary system were obtained in multiple projections. The right coronary
ostium was then cannulated without difficulty and selective angiograms of the right coronary artery were
obtained in multiple projections.
Next, withdrawal pressures were obtained from the right side of the heart, the Swan-Ganz catheter was
removed and the vein repaired. The Sones catheter was removed and the brachial artery repaired with a
single inverted locking suture using OOOO Tevdek. There was a good left radial pulse palpable after
repair of the artery. The overlying skin was then sutured with interrupted silk sutures. The patient
received 6000 units of Heparin via the brachial artery at the initiation of left heart catheterization. The
patient tolerated the procedure well and left the Catheterization Laboratory in satisfactory condition. There
were no apparent complications
______________________

SAMPLE DICTATION FOR ENDOMYOCARDIAL BIOPSY

(this procedure rarely requires premedication)

Procedure: Endomyocardial biopsy

Mr. Green was brought to the catheterization laboratory, prepped and draped in the usual fashion.
Under local anesthesia, using the Seldinger technique the R femoral vein was cannulated. Over a guide
wire, a 7F 125 cm. A 1 Multipurpose catheter with a 98 cm. long venous sheath was advanced to the level
of the right atrium and the guide wire removed. Under hemodynamic and fluoroscopic guidance, the
catheter was advanced antegrade across the tricuspid valve and the sheath advanced over the catheter,
which was then removed. After checking sheath placement, a 7F Mansfield transvenous bioptome was
used to obtain multiple biopsy specimens from the right ventricular surface of the interventricular septum.
At the end of the procedure, the sheath and bioptome were removed and hemostasis achieved with
manual pressure. Mr. Green tolerated the procedure well, leaving the catheterization laboratory in
satisfactory condition. There were no apparent complications.

Cath Lab Manual - University of Tennessee / Bowld Hospital -Appendices- c iii

 APPENDIX D - Bibliography
Recommended Reading:

William Grossman: Cardiac Catheterization and Angiography An excellent established text which focuses
on the scientific basis of catheterization.

Spencer B King, John S Douglas, Jr.: Coronary Arteriography and Angioplasty. New York, McGraw Hill
Book Co.
This book examines in depth the Judkins, Sones, and multipurpose techniques. The focus is on
atherosclerosis.

Carl J. Pepine: Diagnostic and Therapeutic Cardiac Catheterization. Baltimore, Williams and Wilkins,
1989
A book which will serve nicely as a primer for the new cath fellow.

Sing San Yang, Lamberto G Bentivoglio, Vladir Marano, Harry Goldberg: From Cardiac Catheterization
to Hemodynamic Parameters, 3rd edition. Philadelphia, FA Davis Company,1988
According to the preface, the "main objective is to transform raw data into meaningful hemodynamic
parameters to be fused with the clinical data in cardiovascular diagnosis". This book accomplishes that goal
admirably.

Herbert L. Abrams: Coronary Arteriography - A Practical Approach. Boston, Little, Brown, and Co.,1983
A worthwhile guide for the beginner. Has lots of pictures with an excellent section on coronary congenital
anomalies.

Selected References are attached in the next section

Cath Lab Manual - University of Tennessee / Bowld Hospital -Appendices- d i