What is a Right Heart Study?
Right Heart Study is a diagnostic procedure by which blood pressures in your heart and main vessels in the lungs are measured. It also allows accurate assessment of how well the heart is pumping. Done under local anaesthetic and X-ray guidance, a small Swan-Ganz catheter is advanced from the neck or groin to your heart before measurements are made.
Also known as Right Heart or Pulmonary artery Catheterization, this procedure was first performed by Dr Werner Forssmann on himself in 1929 and is the Gold Standard by which the diagnosis of pulmonary hypertension is made.
Why do I need a right heart study?
Right-sided heart catheterization is the procedure of choice in the diagnosis, quantification, and characterization of pulmonary hypertension. Left-sided heart dysfunction and intracardiac shunts can be excluded, and the cardiac output can be measured.
The indications for a right heart study are as follows:
- Making a definitive diagnosis of pulmonary hypertension
- Measuring pulmonary pressures accurately (ie, when there is difficulty in measuring pulmonary pressures with Doppler echocardiography)
- Conducting a vasoreactivity test for assessment of the acute response to vasodilators like prostacyclin, inhaled nitric oxide or adenosine. An acute response often predicts a beneficial effect from oral agents, such as calcium channel blockers.
- You may also need a right heart catheterization if you are being evaluated for a heart, lung or other organ transplant.
What are the physiological measurements that can be made?
- 1Direct Measurements
- Central Venous Pressure (CVP)
- Right-sided intracardiac pressures (Right atrium and ventricle)
- Pulmonary Arterial Pressure (PAP)
- Pulmonary Arterial Wedge Pressure (PCWP)
- Cardiac Output (CO)
- Mixed Venous Oxyhemoglobin Saturation (SvO2)
- 2Indirect measurements
- Systemic vascular resistance
- Pulmonary vascular resistance
- Cardiac Index
- Stroke Volume Index
- Left Ventricular Stroke Work Index
- Right Ventricular Stroke Work Index
- Oxygen Delivery and Uptake
- 3Definition of a positive vasoreactivity test
- Decrease in mean pulmonary artery pressure of at least 10 mm Hg or to a value less than 40 mm Hg and without a concurrent decrease in blood pressure.
How should I prepare for procedure?
Before the day of the procedure
- The doctor will explain how the procedure is performed, the risks and benefits and expected duration of stay in the hospital.
- Informed consent will be obtained.
- Routine blood tests and ECG will be done before the procedure.
- Instructions for medications
Blood thinners should be stopped 2 days before the procedure at the advise of your doctor. These include:
- Continue Aspirin and/or Clopidogrel if prescribed by your doctor
On the day of the procedure
- ARRIVE PUCTURALLY – Proceed to the admission office where the staff will settle you comfortably in your room.
- FASTING - You may drink water, consume a light breakfast (eg cereal/eggs/toast/milo) 4 hours before your procedure. Please keep nil by mouth thereafter. Food will be provided for you after the procedure.
- MEDICATIONS - Please consume all your prescribed medications (eg Aspirin and/or Clopidogrel) with plain water on the morning of your procedure. Bring all your medications with you.
- ATTIRE - Come in casual comfortable attire and bring your toiletries, an extra set of clothes & undergarments.
- A SMALL IV CANNULA will be inserted in one of the veins of your hand to facilitate administration of medications.
Where is the procedure performed?
This test is usually done as a Day Surgery procedure in the Cardiovascular Lab in the X-ray department (not in the operating theatre).
How is the procedure performed?
Before the procedure
- You will be asked to empty your bladder before the procedure.
- You will change into a hospital gown and brought to the Cardiovascular Lab where your cardiologist together with a specialized team of cardiac technologists, radiographers and nurses will be on standby to do the procedure.
- The nurse will record your height, weight and blood pressure and insert an intravenous (IV) cannula into a vein in your arm.
- You will lie on a movable X-ray table equipped with X-ray cameras and heart monitors.
- Three electrodes (small flat sticky patches) will be placed on your chest wall and attached to an ECG monitor that charts your heart’s electrical activity during the test.
- A mild sedative may be given and this will make you sleepy but arousable.
- You will be covered with a sterile drape and a nurse will clean your neck or groin (depending on the access site chosen by your cardiologist) with a cool antiseptic solution.
During the procedure
- The procedure is broken up into 2 parts. The first part is obtaining vascular access and the second part is obtaining the pressures in your heart and the required physiological measurements.
- Obtaining vascular access
- A local anaesthetic is injected into the skin of your neck or groin, causing a temporary stinging sensation. Once the site is numb, a small 2-3 mm plastic sheath is inserted into the internal jugular vein or femoral vein.
- This step typically takes 5 to 10 mins.
- Obtaining the required pressure measurements and cardiac output
- Through this small sheath, the Swan Ganz catheter will be advanced to the right side of your heart under-X-ray guidance. You will not feel any discomfort during this part of the procedure.
- Your doctor will ask you to hold your breath, bear down, cough and do other activities during the test.
- You may get nitric oxide to help the blood vessels in your lungs relax.This will help assess if the medication affects the blood pressure in the vessels in your lungs (pulmonary arteries).
- If you are having this procedure because you have had a heart transplant, your cardiologist will take a small tissue sample (biopsy) to check for signs of organ rejection and see how your new heart is working.
- This step typically takes another 15 to 30mins.
How does the doctor use the results to treat me?
Your cardiologist will explain to you the results once all the measurements and tests have been satisfactorily obtained and discuss with you the options of treatment.
The options for treatment (often a combination of the following) include:
- Lifestyle modifications with heart healthy diet and exercise
- Optimization of medications
- Surgery eg pulmonary thromboendarterectomy
What happens after the procedure is completed?
- The sheath in your neck or groin will be removed with a pressure dressing compressing the site of puncture.
- You will be brought back to the day surgery ward to rest for a few hours.
- You will be able to have your breakfast or lunch with your medications.
- Once the puncture site is stable with no bleeding, you will be able to leave the hospital.
- Clear instructions about how to take care of the access site following the procedure will be given.
- It is recommended that you do not drive after the procedure and have someone accompany you home after the procedure to rest.
- An appointment will be given for your follow-up visit.
Is this procedure safe?
Complications are rare, but can include:
- Bleeding at the catheter insertion site
- Abnormal heart rhythm
- Mild skin reactions (like a sunburn) from X-ray exposure
- Cardiac tamponade - A build-up of fluid around your heart
- Pulmonary artery rupture (extremely rare)
Please tell your doctor if you are:
- Allergic to latex, tape, local or general anesthesia (numbing medicines or medicines used to make you sleepy).
- Pregnant or think you may be pregnant. You may need a pregnancy test before the procedure for your safety.
- Taking any medication to thin your blood. Examples are Coumadin (warfarin), Eliquis (apixaban), Pradaxa (dabigatran), Xarelto (rivaroxaban).
History of Right Heart Catheterization: 100 Years of Experimentation and Methodology Development - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2857603/
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