Right Heart Catheterization

(Right Heart Cath; Pulmonary Artery Catheterization; Catheterization, Right Heart; Swan-Ganz "Swan" Catheterization)

Procedure overview

What is a right heart catheterization?

A right heart catheterization is performed to determine how well the heart is pumping and to measure the pressures in the heart and lungs.

In a right heart cath, the doctor guides a special catheter (a small, hollow tube) called a pulmonary artery (PA) catheter to the right side of the heart and passes it into the pulmonary artery, the main artery carrying blood to the lungs. The doctor observes blood flow through the heart and measures the pressures inside the heart and in the lungs.

As the catheter is advanced toward the pulmonary artery, the doctor measures pressures along the way, inside the chambers on the right side of the heart—the right atrium and right ventricle. Indirect measurements of pressures on the left side of the heart are made, as well, by inflating a tiny balloon at the tip of the catheter once the catheter reaches the pulmonary artery. This pressure measurement is called the pulmonary artery occlusion pressure (PAOP), or pulmonary capillary "wedge" pressure (PCWP). The cardiac output—the amount of blood pumped by the heart per minute—is also determined during a right heart catheterization.  

 In some cases, IV heart medications are given during the right heart cath to see how the heart responds. For example, if the pressure is high in the pulmonary artery, the doctor will give medications to dilate, or relax, the blood vessels in the lungs and lower the pressures. Several pressure measurements will be done during the procedure to assess your body's response to the medications.   

If output from the heart is low and/or the pressures in the heart and lungs are too high, the PA catheter may be left in place to monitor the effects of different IV medications. You will most likely be monitored in the intensive care unit (ICU) if this is the case. This allows your doctors to determine the best medication plan needed to improve your heart's function.

Reasons for the procedure                                              

A right heart cath may be performed to assist in the diagnosis and/or management of the following conditions:  

• Heart failure. A condition in which the heart muscle has become weakened to an extent that blood cannot be pumped efficiently, causing fluid buildup (congestion) in the blood vessels and lungs, and or edema (swelling) in the feet, ankles, and other parts of the body.

• Shock. A syndrome that causes reduced flow of blood and oxygen to the tissues of the body. Shock can be caused by a sudden onset of heart failure (cardiogenic), severe bacterial infection of the blood stream (sepsis), or severe blood loss (hemorrhagic).

• Congenital heart disease. Defects in one or more heart structures that develop before birth, such as a ventricular septal defect (VSD)—a hole in the wall between the two lower chambers of the heart.

• Valvular heart disease. Malfunction of one or more of the heart valves that may interfere with normal blood flow within the heart.

• Cardiomyopathy. An enlargement of the heart because of thickening or weakening of the heart muscle; this can eventually lead to heart failure.

• Pulmonary hypertension. Increased pressures within the blood vessels in the lungs that can lead to difficulty breathing and right-sided heart failure.

A right heart cath with biopsy may also be performed as part of the evaluation before a heart transplant. Pressures in the pulmonary (lung) circulation need to be as low as possible in order for a donor heart to be transplanted. Excessive pressures will make it difficult for the new (donor) heart to pump effectively. A right heart cath will help to see if pulmonary pressures can be decreased with special medications (vasodilators) to ensure successful transplantation. 

Your doctor may have other reasons to recommend a right heart cath with biopsy, particularly if you've already undergone a heart transplant in the past.

Risks of the procedure

Possible risks associated with a right heart catheterization include:

• Bruising of the skin at the site where the catheter is inserted 

• Excessive bleeding because of puncture of the vein during catheter insertion  

• Pneumothorax (partial collapse of the lung) if the neck or chest veins are used to insert the catheter

Other, rare complications may include:

• Abnormal heart rhythms, such as ventricular tachycardia (fast heart rate in the lower heart chambers)

• Cardiac tamponade (fluid buildup around the heart that affects the heart's ability to pump blood effectively)

• Low blood pressure

• Infection

• Air embolism (air leaking into the heart or chest area)

• Blood clots at the tip of the catheter that can block blood flow

• Pulmonary artery rupture (damage to the main artery in the lung, which can result in serious bleeding, making it difficult to breathe)

For some patients, having to lie still on the cardiac catheterization table for the length of the procedure may cause some discomfort or back pain.

There may be other risks, depending on your specific medical condition.  Be sure to discuss any concerns with your doctor before the procedure. 

Before the procedure

Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.

• You will be asked to sign a consent form that gives your permission to do the test. Read the form carefully and ask questions if something is not clear.

• Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, or anesthetic agents (local and general).

• If you are pregnant or suspect you may be pregnant, you should notify your doctor.

• Notify your doctor of all medications (prescription and over-the-counter) and herbal supplements that you are taking.

• Notify your doctor if you have a history of bleeding disorders or if you are taking any anticoagulant (blood-thinning) medications such as warfarin, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop some of these medications prior to the procedure.

• Notify your doctor if you have a pacemaker or an implantable defibrillator (ICD).

• If you have an artificial heart valve, your doctor will decide if you should stop taking warfarin before the procedure. 

• You may be asked not to eat or drink anything after midnight or within eight hours before the procedure.

• The area around the catheter insertion site may be shaved if the groin site is used.

Based upon your medical condition, your doctor may request other specific preparation.

During the procedure

The right heart cath will be done in the cardiac catheterization lab or in a special department.  In critically ill patients, the test may be done in the ICU. A right heart cath may be performed on an outpatient basis or as part of your hospital stay. The procedure may vary depending on your condition and your doctor's practices.

• You will be asked to remove any jewelry or other objects that may interfere with the procedure. You may wear your dentures or hearing aids if you use either of these.

• You will be asked to remove your clothing and will be given a gown to wear.

• You will be asked to empty your bladder before the procedure.

• An IV line will be started in your hand or arm before the procedure for injection of medication and to administer IV fluids, if needed.

• You will lie on your back on the procedure table.

• You will be connected to an ECG monitor that records the electrical activity of the heart during the procedure using small, adhesive electrodes. Your vital signs (heart rate, blood pressure, breathing rate, and oxygenation level) will be monitored closely during the procedure, as well.

• You may be given a mild sedative to help you relax, but you will not be put to sleep.

• Sterile towels will be placed over your chest and neck if your neck vein is used. 

• If your groin is used, sterile towels will be place over the groin area. 

• The skin over the neck or groin is cleaned and numbed with a local anesthetic. A small needle will be used to find the vein and then a thin tube called a catheter will eventually be inserted into the vein. You may feel some burning or stinging when the numbing medication is given and some pressure as the needle is used to puncture the vein.

• An introducer sheath (a slightly larger, hollow tube) will be placed into the vein first and then the PA catheter will be inserted through the introducer. You may feel some pressure as the introducer is placed. Once the PA catheter is in place, heart pressures will be measured.

• Intravenous heart medications may also be given to evaluate the heart's response. It may take about 30 minutes to monitor the heart's response to the medications.

• Once all the necessary information has been obtained, the catheter and introducer will be removed, unless your doctors decide you need additional monitoring in the ICU.

After the procedure

Medical staff will put pressure over the insertion site for a minute or two to make sure that you are not bleeding. If the catheter was placed in your groin vein, pressure will be placed over the insertion site for a few minutes longer.

If the neck vein is used (most commonly), you will be allowed to sit up comfortably. If the groin is used for the procedure, you will have to lie flat in bed for a few hours so the puncture site can heal properly.

You can eat and drink normally after the procedure. The nurse will monitor the insertion site for bleeding and check your blood pressure, heart rate, and breathing while you recover. Let the nurse know if you have any chest pain or difficulty breathing.

The doctor will discuss the findings of the right heart cath and plans for treatment, if needed. Most of the time, you will be able to go home a few hours after the procedure.

Once at home, you should monitor the insertion site for bleeding, unusual pain, swelling, and abnormal discoloration or temperature change at or near the insertion site. A small bruise is normal. If you notice a constant or large amount of blood at the site that cannot be contained with a small bandage, or dressing, notify your doctor.

It will be important to keep the insertion site clean and dry. Your doctor will give you specific bathing instructions.

You may be advised not to participate in any strenuous activities. Your doctor will instruct you about when you can return to work and resume normal activities.

Notify your doctor to report any of the following:

• Shortness of breath or difficulty breathing

• Fever and/or chills

• Increased pain, redness, swelling, or bleeding or other drainage from the insertion site

• Coolness, numbness and/or tingling, or other changes in the affected extremity

• Chest pain/pressure, nausea and/or vomiting, profuse sweating, dizziness, and/or fainting

Your doctor may give you additional or alternate instructions after the procedure, depending on your particular situation.