Key Points
- 1.
The cardiac catheterization laboratory has evolved from a purely diagnostic facility to a therapeutic one in which many facets of cardiovascular disease can be effectively modified or treated.
- 2.
Guidelines for diagnostic cardiac catheterization have established indications, contraindications, and criteria to identify high-risk patients.
- 3.
Interventional cardiology began in the late 1970s as balloon angioplasty, with a success rate of 80% and emergent coronary artery bypass graft surgery (CABG) rates of 3% to 5%. Although current success rates exceed 95%, with CABG rates of less than 1%, failed percutaneous coronary intervention (PCI) presents a challenge for the anesthesiologist because of hemodynamic problems, concomitant medications, and the underlying cardiac disease.
- 4.
Since the introduction of drug-eluting stents (DESs), acute closure owing to coronary dissection has diminished significantly, and restenosis rates have fallen precipitously.
- 5.
The first-generation DESs were extremely effective at reducing in-stent restenosis when compared with bare metal stents (BMSs). However, DESs have demonstrated higher rates of late stent thrombosis (LST), especially in the setting of premature discontinuation of dual antiplatelet therapy. Second-generation DESs have LST rates comparable to those of BMSs and therefore are the preferred stent type.
- 6.
In the United States, increasing numbers of diagnostic coronary angiograms and PCIs are performed from a transradial approach because of lower vascular complication rates and patient preference for this approach compared with the more traditional transfemoral approach.
- 7.
In multivessel coronary artery disease, an angiographic synergy between percutaneous coronary intervention with taxus and an angiographic (SYNTAX) score should be calculated to assist with decision making regarding percutaneous versus surgical revascularization. A multidisciplinary heart team meeting (including a cardiologist, a cardiovascular surgeon, and, occasionally, an anesthesiologist) should then convene to discuss and optimize patient care by providing an individualized treatment recommendation.
- 8.
Acute thrombotic PCI complications can usually be overcome with more aggressive antithrombotic and antiplatelet pharmacotherapy. These medications can complicate the management of a patient in an unstable condition who requires transfer for bailout CABG.
The cardiac catheterization laboratory (CCL) began as a diagnostic unit. In the 1980s percutaneous transluminal coronary angioplasty (PTCA) started the gradual shift to therapeutic procedures. Concomitantly, noninvasive modalities of echocardiography, computed tomography (CT), and magnetic resonance imaging (MRI) improved, and in some cases obviated, the need for diagnostic catheterization studies. The promise of PTCA led to various atherectomy and aspiration devices and stents, with or without drug elution. The evolution of the CCL has continued, with many laboratories commonly performing procedures for the diagnosis and treatment of peripheral and cerebral vascular disease. In addition, there has been an expansion of the treatment of noncoronary forms of cardiac disease in the CCL. Closure devices for patent foramen ovale (PFO), atrial septal defect (ASD), and ventricular septal defect (VSD) are emerging as alternatives to cardiac surgery. Many high-risk patients with valvular disease are now being treated with percutaneous valve repair and replacement, decreasing the incidence of balloon valvuloplasty.
This brief historical background serves as an introduction to the discussion of diagnostic and therapeutic procedures in the adult CCL. The reader must realize the dynamic nature of this field. In the past, up to 5% of percutaneous coronary interventions (PCIs) failed, but most centers now report procedural failure rates of less than 1%. Simultaneously, the impact on the anesthesiologist has changed. The high complication rates of years past required holding an operating room (OR) open for all PCIs, but complication rates are now so low that some procedures are performed at hospitals without on-site surgical backup. Despite the lower rate of adverse events, the anesthesiologist is occasionally confronted with a patient in need of emergent surgical revascularization. The anesthesiologist may find the information in this chapter useful in planning the preoperative management of these cardiac or noncardiac surgical procedures based on diagnostic information obtained in the CCL. When anesthesia is required for procedures in the hybrid laboratory or the CCL, this chapter will help the anesthesiologist, in collaboration with the cardiology and cardiac surgery team, to provide safe anesthesia care for these challenging patients.
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Patient Selection for Catheterization
Indications for Cardiac Catheterization in the Adult Patient
Box 2.1 lists indications for cardiac catheterization. The major indication is for the detection of coronary artery disease (CAD); the remaining indications are focused on hemodynamic assessment to evaluate valvular heart disease, pulmonary hypertension, and cardiomyopathies. With respect to CAD, approximately 20% of the adult population studied will be found to have normal coronary arteries. Despite continued improvements in noninvasive assessment, coronary angiography is currently considered the gold standard for diagnosing and defining the extent of CAD. With advances in MRI and multislice CT scanning, the next decade may well see a further evolution of the CCL to an interventional suite with fewer diagnostic responsibilities.
Coronary Artery Disease
Symptoms
Unstable angina
Postinfarction angina
Angina refractory to medications
Typical chest pain with negative diagnostic testing
Family history of sudden death
Diagnostic Testing
Strongly positive exercise tolerance test
Early positive, ischemia in ≥5 leads, hypotension, ischemia present for ≥6 min of recovery
Positive exercise testing after myocardial infarction
Strongly positive nuclear myocardial perfusion test
Increased lung uptake or ventricular dilation after stress
Large single or multiple areas of ischemic myocardium
Strongly positive stress echocardiographic study
Decrease in overall ejection fraction or ventricular dilation with stress
Large single area or multiple or large areas of new wall motion abnormalities
Valvular Disease
Symptoms
Aortic stenosis with syncope, chest pain, or congestive heart failure
Aortic insufficiency with progressive heart failure
Mitral insufficiency or stenosis with progressive congestive heart failure symptoms
Acute orthopnea/pulmonary edema after infarction with suspected acute mitral insufficiency
Diagnostic Testing
Progressive resting left ventricular dysfunction with regurgitant lesion
Decreasing left ventricular function and/or chamber dilation with exercise
Adult Congenital Heart Disease
Atrial Septal Defect
Age >50 years with evidence of coronary artery disease
Septum primum or sinus venosus defect
Ventricular Septal Defect
Catheterization for definition of coronary anatomy
Coarctation of the aorta
Detection of collaterals
Coronary arteriography if increased age and/or risk factors are present
Other
Acute myocardial infarction therapy—consider primary percutaneous coronary intervention
Mechanical complication after infarction
Malignant cardiac arrhythmias
Cardiac transplantation
Pretransplantation donor evaluation
Posttransplantation annual coronary artery graft rejection evaluation
Unexplained congestive heart failure
Research studies with institutional review board review and patient consent
Patient Evaluation Before Cardiac Catheterization
Diagnostic cardiac catheterization in the 21st century is universally considered an outpatient procedure except for the high-risk patient. Therefore the precatheterization evaluation is essential for quality patient care. Evaluation before cardiac catheterization includes diagnostic tests that are necessary to identify high-risk patients. An electrocardiogram (ECG) must be obtained for all patients shortly before catheterization. Necessary laboratory studies before catheterization include an appropriate coagulation profile (prothrombin time [PT], partial thromboplastin time [PTT], and platelet count), hemoglobin, and hematocrit. Electrolytes are obtained together with baseline blood urea nitrogen and creatinine (Cr) values to assess renal function. Recent guidelines express a preference for estimation of the glomerular filtration rate (GFR) using accepted formulas, and many clinical laboratories now report this value routinely. Urinalysis and chest radiography may provide useful information but are no longer routinely obtained by all operators. Prior catheterization reports should be available. If the patient had prior PCI or coronary artery bypass graft (CABG) surgery, anatomic information concerning stent or bypass placement also must be available.
Patient medications may need to be altered in preparation for a heart catheterization. On the morning of the catheterization, antianginal and antihypertensive medications are routinely continued, whereas diuretic therapy is withheld. Patients with diabetes are scheduled early, if possible, because the procedure requires nil per os (NPO) status. No short-acting insulin is given, and half of the long-acting insulin dose is usually administered. Patients on oral anticoagulation should stop warfarin (Coumadin) for 48 to 72 hours before catheterization to target an international normalized ratio (INR) of 1.8 or less if femoral artery access is used. Radial artery access is considered an option without discontinuation of warfarin. For patients who are managed with non–vitamin K antagonist novel oral anticoagulant (NOAC) therapy, the dose may need to be withheld for 24 to 48 hours depending on renal function and the bleeding risk of the procedure. In patients who are anticoagulated because of mechanical prosthetic valves, the best management may be intravenous (IV) heparin before and after the procedure, when the warfarin effect is not therapeutic. IV heparin is routinely discontinued 1 to 2 hours before catheterization, except in patients with unstable angina. Therapy with aspirin or P2Y12 platelet inhibitors or both is almost always continued for patients with angina or those with prior CABG.
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Patient Selection for Catheterization
Indications for Cardiac Catheterization in the Adult Patient
Box 2.1 lists indications for cardiac catheterization. The major indication is for the detection of coronary artery disease (CAD); the remaining indications are focused on hemodynamic assessment to evaluate valvular heart disease, pulmonary hypertension, and cardiomyopathies. With respect to CAD, approximately 20% of the adult population studied will be found to have normal coronary arteries. Despite continued improvements in noninvasive assessment, coronary angiography is currently considered the gold standard for diagnosing and defining the extent of CAD. With advances in MRI and multislice CT scanning, the next decade may well see a further evolution of the CCL to an interventional suite with fewer diagnostic responsibilities.
Coronary Artery Disease
Symptoms
Unstable angina
Postinfarction angina
Angina refractory to medications
Typical chest pain with negative diagnostic testing
Family history of sudden death
Diagnostic Testing
Strongly positive exercise tolerance test
Early positive, ischemia in ≥5 leads, hypotension, ischemia present for ≥6 min of recovery
Positive exercise testing after myocardial infarction
Strongly positive nuclear myocardial perfusion test
Increased lung uptake or ventricular dilation after stress
Large single or multiple areas of ischemic myocardium
Strongly positive stress echocardiographic study
Decrease in overall ejection fraction or ventricular dilation with stress
Large single area or multiple or large areas of new wall motion abnormalities
Valvular Disease
Symptoms
Aortic stenosis with syncope, chest pain, or congestive heart failure
Aortic insufficiency with progressive heart failure
Mitral insufficiency or stenosis with progressive congestive heart failure symptoms
Acute orthopnea/pulmonary edema after infarction with suspected acute mitral insufficiency
Diagnostic Testing
Progressive resting left ventricular dysfunction with regurgitant lesion
Decreasing left ventricular function and/or chamber dilation with exercise
Adult Congenital Heart Disease
Atrial Septal Defect
Age >50 years with evidence of coronary artery disease
Septum primum or sinus venosus defect
Ventricular Septal Defect
Catheterization for definition of coronary anatomy
Coarctation of the aorta
Detection of collaterals
Coronary arteriography if increased age and/or risk factors are present
Other
Acute myocardial infarction therapy—consider primary percutaneous coronary intervention
Mechanical complication after infarction
Malignant cardiac arrhythmias
Cardiac transplantation
Pretransplantation donor evaluation
Posttransplantation annual coronary artery graft rejection evaluation
Unexplained congestive heart failure
Research studies with institutional review board review and patient consent
Patient Evaluation Before Cardiac Catheterization
Diagnostic cardiac catheterization in the 21st century is universally considered an outpatient procedure except for the high-risk patient. Therefore the precatheterization evaluation is essential for quality patient care. Evaluation before cardiac catheterization includes diagnostic tests that are necessary to identify high-risk patients. An electrocardiogram (ECG) must be obtained for all patients shortly before catheterization. Necessary laboratory studies before catheterization include an appropriate coagulation profile (prothrombin time [PT], partial thromboplastin time [PTT], and platelet count), hemoglobin, and hematocrit. Electrolytes are obtained together with baseline blood urea nitrogen and creatinine (Cr) values to assess renal function. Recent guidelines express a preference for estimation of the glomerular filtration rate (GFR) using accepted formulas, and many clinical laboratories now report this value routinely. Urinalysis and chest radiography may provide useful information but are no longer routinely obtained by all operators. Prior catheterization reports should be available. If the patient had prior PCI or coronary artery bypass graft (CABG) surgery, anatomic information concerning stent or bypass placement also must be available.
Patient medications may need to be altered in preparation for a heart catheterization. On the morning of the catheterization, antianginal and antihypertensive medications are routinely continued, whereas diuretic therapy is withheld. Patients with diabetes are scheduled early, if possible, because the procedure requires nil per os (NPO) status. No short-acting insulin is given, and half of the long-acting insulin dose is usually administered. Patients on oral anticoagulation should stop warfarin (Coumadin) for 48 to 72 hours before catheterization to target an international normalized ratio (INR) of 1.8 or less if femoral artery access is used. Radial artery access is considered an option without discontinuation of warfarin. For patients who are managed with non–vitamin K antagonist novel oral anticoagulant (NOAC) therapy, the dose may need to be withheld for 24 to 48 hours depending on renal function and the bleeding risk of the procedure. In patients who are anticoagulated because of mechanical prosthetic valves, the best management may be intravenous (IV) heparin before and after the procedure, when the warfarin effect is not therapeutic. IV heparin is routinely discontinued 1 to 2 hours before catheterization, except in patients with unstable angina. Therapy with aspirin or P2Y12 platelet inhibitors or both is almost always continued for patients with angina or those with prior CABG.
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Cardiac Catheterization Procedures
Whether the procedure is elective or emergent, diagnostic or interventional, coronary or peripheral, certain basic components are relatively constant in all circumstances.
Patient Monitoring and Sedation
Standard limb leads with one chest lead are used for ECG monitoring during cardiac catheterization. One inferior and one anterior ECG lead are monitored during diagnostic catheterization. During an interventional procedure, two ECG leads are monitored in the same coronary artery distribution as the vessel undergoing PCI. Radiolucent ECG leads permit monitoring without interfering with angiographic data.
Sedation in the CCL, from preprocedural administration or from IV administration during the procedure, may lead to hypoventilation and hypoxemia. The administration of midazolam, 1 to 5 mg intravenously, with fentanyl, 25 to 100 µg, is common practice. Institutional guidelines for conscious sedation typically govern these practices. Light to moderate sedation is beneficial to the patient, particularly for angiographic imaging and interventional procedures. Sedation is critical for patients who undergo a radial artery approach; conscious sedation has been shown to reduce the incidence of radial artery spasm, which, when severe, may force the operator to adopt a transfemoral approach to complete the procedure. Deep sedation, in addition to its widely recognized potential to cause respiratory difficulties, poses distinct problems in the CCL. Deep sedation often requires supplemental oxygen, which complicates the interpretation of oximetry data and may alter hemodynamics.
More complex interventions have resulted in longer procedures. Although hospitals require conscious sedation policies, individual variation in the type and degree of sedation is common. General anesthesia is rarely required for coronary procedures, but it is frequently used for percutaneous valve procedures. Advancements in intracardiac echocardiography have decreased the need for intubation and transesophageal echocardiography (TEE) in certain patients and procedures. Pediatric procedures require general anesthesia more commonly than those in adults. As the frequency of noncoronary procedures increases, the presence of an anesthesiologist in the CCL will be required more often.
Left-Sided Heart Catheterization
Catheterization Site and Anticoagulation
Left-sided heart catheterization (LHC) traditionally has been performed by means of a brachial or femoral artery approach. The femoral approach became almost universally accepted. The percutaneous radial artery approach was later developed to improve patient comfort and reduce vascular complications, but its use remained relatively stagnant for more than 10 years. Currently, only a small percentage of procedures are performed via the radial approach in the United States, but that number is increasing rapidly. Over the most recently reported 6-year time period, there was a 13-fold increase in radial artery PCI, with wide geographic variation.
Right-Sided Heart Catheterization
Indications
In the CCL, right-sided heart catheterization (RHC) is performed for diagnostic purposes. Routine RHC cannot be recommended. Box 2.2 outlines acceptable indications for RHC during LHC. Cardiac output (CO) measurements during RHC using the thermodilution technique allow for a further assessment of ventricular function.
Significant valvular pathology
Suspected intracardiac shunting
Acute infarct—differentiation of free wall versus septal rupture
Evaluation of right- and/or left-sided heart failure
Evaluation of pulmonary hypertension
Severe pulmonary disease
Evaluation of pericardial disease
Constrictive pericarditis
Restrictive cardiomyopathy
Pericardial effusion
Pretransplantation assessment of pulmonary vascular resistance and response to vasodilators
Diagnostic Catheterization Complications
Complications are related to multiple factors, but severity of disease is important. Mortality rates are low. Complications are specific for RHC and LHC ( Box 2.3 ). The registry reported incidences of major complications as follows: death, 0.1%; myocardial infarction (MI), 0.06%; cerebrovascular accident, 0.07%; arrhythmia, 0.47%; contrast reaction, 0.23%; and vascular complications, 0.46%. Infectious complications are infrequent, although they may be underreported.
Left-Sided Heart Catheterization
Cardiac Complications
Death
Myocardial infarction
Ventricular fibrillation
Ventricular tachycardia
Cardiac perforation
Noncardiac Complications
Stroke
Peripheral embolization
Air
Thrombus
Cholesterol
Vascular surgical repair
Pseudoaneurysm
Arteriovenous fistula
Embolectomy
Repair of brachial arteriotomy
Evacuation of hematomas
Contrast-related complications
Renal insufficiency
Anaphylaxis
Right-Sided Heart Catheterization
Cardiac Complications
Conduction abnormality
RBBB
Complete heart block (RBBB superimposed on LBBB)
Arrhythmias
Valvular damage
Perforation
Noncardiac Complications
Pulmonary artery rupture
Pulmonary infarction
Balloon rupture
Paradoxic (systemic) air embolus
LBBB , Left bundle branch block; RBBB , right bundle branch block.
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Valvular Pathology
The number of patients presenting with valvular heart disease (VHD) in developed countries is growing, primarily because of the increasing age of the population. In 2014 the American College of Cardiology/American Heart Association (ACC/AHA) published updated practice guidelines for the management of VHD. These guidelines cover the invasive and noninvasive evaluation of valvular problems and the therapeutic approaches (see Chapter 15 ).
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Angiography
Ventriculography
Ejection Fraction Determination
Ventriculography routinely is performed in the single-plane 30-degree right anterior oblique (RAO) or biplane 60-degree left anterior oblique (LAO) and 30-degree RAO projections using 20 to 45 mL of contrast with injection rates of 10 to 15 mL/second ( Box 2.4 ). Complete opacification of the ventricle without inducing ventricular extrasystoles is necessary for accurate assessment during ventriculography. Premature contractions not only alter the interpretation of mitral regurgitation (MR) but result in a false increase in the ejection fraction (EF).
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