Diagnostic cardiac catheterization and coronary angiography are considered the gold standard in the assessment of the anatomy and physiology of the heart and its associated vasculature. In 1929, Forssmann demonstrated the feasibility of cardiac catheterization in humans when he passed a urological catheter from a vein in his arm to his right atrium and documented the catheter’s position in the heart by x-ray. In the 1940s, Cournand and Richards applied this technique to patients with cardiovascular disease to evaluate cardiac function. These three physicians were awarded the Nobel Prize in 1956. In 1958, Sones inadvertently performed the first selective coronary angiography when a catheter in the left ventricle slipped back across the aortic valve, engaged the right coronary artery, and power-injected 40 mL of contrast down the vessel. The resulting angiogram provided superb anatomic detail of the artery, and the patient suffered no adverse effects. Sones went on to develop selective coronary catheters, which were modified further by Judkins, who developed preformed catheters and allowed coronary artery angiography to gain widespread use as a diagnostic tool. In the United States, cardiac catheterization is the second most common operative procedure, with more than one million procedures performed annually.
INDICATIONS, RISKS, AND PREPROCEDURE MANAGEMENT
Normal hemodynamic waveforms recorded during right heart catheterization. Atrial pressure tracings have a characteristic “a” wave that reflects atrial contraction and a “v” wave that reflects pressure changes in the atrium during ventricular systole. Ventricular pressure tracings have a low-pressure diastolic filling period and a sharp rise in pressure that occurs during ventricular systole. d, diastole; PA, pulmonary artery; PCWP, pulmonary capillary wedge pressure; RA, right atrium; RV, right ventricle; s, systole.
Cardiac catheterization and coronary angiography are indicated to evaluate the extent and severity of cardiac disease in symptomatic patients and to determine if medical, surgical, or catheter-based interventions are warranted (Table 272-1). They are also used to exclude severe disease in symptomatic patients with equivocal findings on noninvasive studies and in patients with chest-pain syndromes of unclear etiology for whom a definitive diagnosis is necessary for management. Cardiac catheterization is not mandatory prior to cardiac surgery in some younger patients who have congenital or valvular heart disease that is well defined by noninvasive imaging and who do not have symptoms or risk factors that suggest concomitant coronary artery disease.
TABLE 272-1Indications for Cardiac Catheterization and Coronary Angiography |Favorite Table|Download (.pdf) TABLE 272-1Indications for Cardiac Catheterization and Coronary Angiography
|Coronary Artery Disease |
|Asymptomatic or Symptomatic |
|High risk for adverse outcome based on noninvasive testing |
|Sudden cardiac death |
|Sustained (>30 s) monomorphic ventricular tachycardia |
|Nonsustained (<30 s) polymorphic ventricular tachycardia |
|Canadian Cardiology Society Class II, III, ...|