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Key Concepts

  • The most common complications of cardiac catheterization include groin complications (0.43 percent) such as hematomas, retroperitoneal bleeding, pseudoaneurysm, and arteriovenous fistulas. Other complications include contrast reactions, renal failure, perforation, dissection, hypotension, and bradycardia.

  • When performing coronary angiography, at least two orthogonal views are needed for each vessel to assess the severity of eccentric lesions, and at least five views are recommended to adequately evaluate the left coronary system.

  • By coronary angiography, a lesion is considered to be severe if there is a greater than 70 percent narrowing of the luminal diameter.

  • For intermediate lesions of uncertain significance on coronary angiography, intravascular ultrasound (IVUS) and fractional flow reserve (FFR) can be useful. IVUS delineates and quantifies the atherosclerotic burden and consistently demonstrates that lesions are underestimated using angiography alone. FFR is probably the best test to determine both physiologic ischemia (i.e., disease severity) and the need for revascularization.

  • Balloon angioplasty alone is associated with a 5 percent risk of abrupt closure and a 50 percent risk of angiographic restenosis within 6 months. Bare metal intracoronary stents decrease restenosis by nearly 50 percent compared to balloon angioplasty with a 20 to 30 percent risk of in-stent angiographic restenosis after 6 months.

  • Drug-eluting intracoronary stents are associated with lower in-stent restenosis rates as low as 5 percent at 12 months, but also carry a higher risk of late and very late stent thrombosis. Patients receiving drug-eluting stents (DESs) must take aspirin for life and clopidogrel for at least 12 months after implantation to mitigate the risk of stent thrombosis.

  • Cardiac output measurements can be obtained during right-heart catheterization by the Fick and/or thermodilution method. The thermodilution method is more accurate at high-output states, whereas the Fick method is more accurate with low-output conditions and atrial fibrillation.

  • Aortic valve gradients can be estimated by several methods: (1) Peak-to-peak gradient, (2) “pull-back” method, and (3) simultaneous pressure measurements in the left ventricle (LV) and aorta using a double-lumen catheter (most accurate). The modified Hakki equation can be used to measure the aortic valve area: aortic valve area = cardiac output/square root of the peak-to-peak pressure gradient.

  • Balloon aortic valvuloplasty (BAV) rarely increases aortic valve area greater than 1.0 cm2 and, although it improves symptoms, clinical deterioration frequently occurs within 6 to 12 months.

  • Percutaneous patent foramen ovale (PFO) closure devices are associated with high procedural success and low complication rates. Complication rates are around 5 percent and include device migration, pericardial tamponade, and arrhythmias.

Indications for Cardiac Catheterization

The first coronary angiogram was performed by Dr. F. Mason Sones, Jr. at the Cleveland Clinic in 1958, and he published the results of approximately 1000 procedures in 1962.1 With the development of improved catheter designs by pioneers such as Drs. Kurt Amplatz and Melvin Judkins, the number of diagnostic cardiac catheterizations performed annually began to expand exponentially. The rapid growth of cardiac catheterization coincided with Dr. ...

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