261.1 🎓 醫孞生版

261.1.0.1 📌 䞀頁重點

261.1.0.1.1 Types
  • Left Heart Catheterization (LHC): coronary angiography + LV pressures + LVgram
  • Right Heart Catheterization (RHC): PA pressures, cardiac output, pulmonary hypertension workup, shock evaluation
  • PCI (Percutaneous Coronary Intervention): stenting + balloon angioplasty
  • Structural interventions: TAVR, MitraClip, ASD/PFO closure, atrial appendage occlusion, etc.
  • Electrophysiology: ablation procedures (separate field)
261.1.0.1.2 Indications
261.1.0.1.2.1 Diagnostic LHC
  • STEMI (emergent — primary PCI)
  • NSTEMI / Unstable Angina (within 24-72 hr typically)
  • Refractory or progressive angina
  • Positive stress test (significant ischemia)
  • Pre-operative cardiac risk assessment
  • HF evaluation (etiology — ischemic vs non-ischemic)
  • Cardiomyopathy workup
  • Valvular disease pre-surgery
261.1.0.1.2.2 RHC
  • Pulmonary hypertension workup (Group 1 PAH diagnosis)
  • Cardiogenic shock hemodynamic assessment
  • Heart transplant evaluation
  • Constrictive vs restrictive cardiomyopathy differentiation
  • Pre-LVAD / heart transplant
261.1.0.1.3 Access
261.1.0.1.3.1 Radial Access (Preferred 2024+)
  • Less bleeding + fewer access site complications
  • More comfortable for patient
  • Earlier ambulation
  • ESC + ACC/AHA recommendations
  • Some operator dependence
261.1.0.1.3.2 Femoral Access
  • Traditional
  • For complex procedures + structural intervention
  • Higher bleeding risk
261.1.0.1.3.3 Ulnar Access
  • Alternative if radial fails
261.1.0.1.4 Coronary Anatomy (Coronary Tree)
261.1.0.1.4.1 Left Main (LM)
  • Bifurcates to LAD + LCx
  • Left main disease = high-risk (CABG often preferred)
261.1.0.1.4.2 Left Anterior Descending (LAD)
  • Anterior wall + septum
  • Diagonal branches
  • “Widow maker” if proximal occlusion
261.1.0.1.4.3 Left Circumflex (LCx)
  • Lateral wall
  • Obtuse marginal branches
  • Sometimes posterior descending (left dominance)
261.1.0.1.4.4 Right Coronary Artery (RCA)
  • Right ventricle + inferior wall
  • Posterior descending artery (right dominance — 80%)
  • AV node + SA node arteries (often)
261.1.0.1.4.5 Dominance
  • Right dominant (80%): PDA from RCA
  • Left dominant (~ 10%): PDA from LCx
  • Co-dominant (~ 10%)
261.1.0.1.5 Lesion Assessment
261.1.0.1.5.1 Visual Estimation
  • Stenosis percentage

  • 70% = significant typically

  • 90% = severe

  • 50% in left main = significant
261.1.0.1.5.2 Functional Assessment (Intermediate Lesions 50-70%)
261.1.0.1.5.3 FFR (Fractional Flow Reserve)
  • Wire-based pressure measurement
  • Distal-to-aortic pressure ratio during max hyperemia (adenosine)
  • FFR < 0.80 = ischemia-causing → PCI
  • FFR ≥ 0.80 = not significant → medical therapy
  • FAME trial: FFR-guided PCI improves outcomes
261.1.0.1.5.4 iFR (Instantaneous Wave-Free Ratio)
  • No adenosine needed (during specific cardiac cycle phase)
  • iFR < 0.89 = ischemia-causing
  • Equivalent to FFR (iFR-SWEDEHEART trial)
  • Simpler workflow
261.1.0.1.5.5 Other
  • IVUS (intravascular ultrasound) — plaque morphology + stent optimization
  • OCT (optical coherence tomography) — high-resolution
  • NIRS (near-infrared spectroscopy) — vulnerable plaque
261.1.0.1.6 Treatment Options
261.1.0.1.6.1 Balloon Angioplasty (POBA)
  • Older; mostly historical
  • Modern: as part of stenting or rare standalone
261.1.0.1.6.2 Bare Metal Stent (BMS)
  • Older; replaced by DES
  • Use in select scenarios (e.g., bleeding risk, short DAPT requirement)
261.1.0.1.6.3 Drug-Eluting Stent (DES)
  • Current standard
  • Antiproliferative drugs (sirolimus, everolimus, zotarolimus) coat the stent
  • Reduces restenosis rate
  • Requires DAPT (dual antiplatelet therapy)
261.1.0.1.6.4 Newer Stent Technology
  • Biodegradable polymer stents
  • Bioresorbable stents (Absorb — withdrawn 2017 due late thrombosis; future generations in development)
  • Drug-Coated Balloon (DCB) — for in-stent restenosis + small vessel disease
261.1.0.1.6.5 Specific Lesion Approaches
  • Left main: increasingly PCI in EXCEL + NOBLE trials (controversial); often CABG preferred for complex
  • Multi-vessel: SYNTAX score guides PCI vs CABG; high SYNTAX > 32 = CABG often preferred
  • Bifurcation: provisional stenting or two-stent techniques
  • Chronic total occlusion (CTO): specialized techniques
261.1.0.1.7 Antithrombotics
  • DAPT (Dual Antiplatelet Therapy):
    • Aspirin lifelong + P2Y12 inhibitor (clopidogrel, prasugrel, ticagrelor) typically 12 months post-DES (some shorter for high bleeding risk)
    • Newer P2Y12 (prasugrel, ticagrelor) more potent
  • Anticoagulation peri-PCI: heparin, bivalirudin
  • GP IIb/IIIa inhibitors: less used in modern era
261.1.0.1.8 Complications
261.1.0.1.8.1 Bleeding
  • Access site (especially femoral)
  • Retroperitoneal (femoral)
  • Hematoma
  • Radial occlusion (rare)
261.1.0.1.8.2 Vascular
  • Pseudoaneurysm
  • AV fistula
  • Distal embolization
261.1.0.1.8.3 Contrast Nephropathy
  • AKI from iodinated contrast
  • Risk: CKD, diabetes, elderly, dehydration
  • Prevention: hydration (IV saline), limit contrast, consider preventive measures
261.1.0.1.8.4 Stroke
  • ~ 0.1-0.5%
  • Embolic (cholesterol, thrombus) or hemorrhagic
261.1.0.1.8.5 MI / Stent Thrombosis
  • Acute stent thrombosis (< 24 hr) — rare but catastrophic
  • Late stent thrombosis (DES)
  • Risk: DAPT non-compliance
261.1.0.1.8.6 Dissection
  • Coronary dissection (procedure-related)
  • Aortic dissection (rare; very serious)
261.1.0.1.8.7 Death
  • ~ 0.1% for elective diagnostic; higher for PCI in ACS
261.1.0.1.9 Cardiac Catheterization for Pulmonary Hypertension
  • RHC = gold standard for PAH diagnosis
  • PAH defined as: mean PA pressure ≥ 25 mmHg + PAWP ≀ 15 mmHg + PVR > 3 Wood units
  • Cardiac output, oxygen saturations (estimate shunts)
  • Vasoreactivity testing (for treatment guidance)

261.1.0.2 1⃣ Indications Detailed

261.1.0.2.1 Diagnostic Coronary Angiography
261.1.0.2.1.1 ACS (Acute Coronary Syndromes)
  • STEMI: Primary PCI within 90 min door-to-balloon (gold standard; <60 min ideal)
  • NSTEMI / UA: within 24-72 hr (early invasive strategy for high-risk; ESC TIMACS trial)
  • High-risk NSTEMI: within 24 hr (GRACE score > 140)
261.1.0.2.1.2 Chronic Stable Angina
  • After medical therapy failure or significant ischemia on stress test
  • Refractory symptoms
  • High-risk features
261.1.0.2.1.3 Heart Failure
  • Etiology workup (ischemic vs non-ischemic cardiomyopathy)
  • Especially with risk factors or chest pain
  • Often combined with revascularization (REVIVED, ROTIC trials)
261.1.0.2.1.4 Pre-Operative (Major Surgery)
  • High-risk surgery in patients with significant CV risk
  • Limited indication in modern era (decreasing routine)
261.1.0.2.1.5 Suspected Coronary Anomaly
  • Anomalous coronary
  • Coronary aneurysm
261.1.0.2.2 Right Heart Catheterization (RHC)
261.1.0.2.2.1 Pulmonary Hypertension
  • Required for PAH diagnosis
  • Hemodynamics + vasoreactivity + cardiac output
261.1.0.2.2.2 Cardiogenic Shock
  • Hemodynamic profile (cardiac index, PAWP, PVR)
  • Guides therapy
261.1.0.2.2.3 Heart Transplant Evaluation
  • Pulmonary vascular resistance check
261.1.0.2.2.4 Constrictive vs Restrictive
  • Equalization of diastolic pressures
  • Square root sign (dip and plateau in ventricular pressure)
  • Discordance / concordance of LV vs RV pressure with respiration
261.1.0.2.2.5 Pre-LVAD
  • Hemodynamics
  • PVR

261.1.0.3 2⃣ FFR + iFR Detail

261.1.0.3.1 FFR (Fractional Flow Reserve)
261.1.0.3.1.1 Mechanism
  • Pressure wire crosses lesion
  • Hyperemia induced (adenosine IV or intracoronary)
  • Ratio of distal-to-aortic pressure during hyperemia
  • Quantifies hemodynamic significance
261.1.0.3.1.2 Threshold
  • FFR ≀ 0.80 = ischemia-causing → PCI improves outcomes
  • FFR > 0.80 = not significant → medical therapy
261.1.0.3.1.3 Trials
  • FAME (NEJM 2009): FFR-guided PCI superior to angiography-guided
  • FAME 2: FFR + medical Tx vs medical Tx alone for stable CAD
  • DEFER: FFR > 0.75 patients did well without PCI
261.1.0.3.2 iFR (Instantaneous Wave-Free Ratio)
261.1.0.3.2.1 Mechanism
  • Diastolic period only (wave-free)
  • No hyperemia needed
  • Faster workflow
261.1.0.3.2.2 Threshold
  • iFR < 0.89 = ischemia-causing → PCI
  • iFR ≥ 0.89 = not significant
261.1.0.3.2.3 Trials
  • iFR-SWEDEHEART (NEJM 2017): non-inferior to FFR
261.1.0.3.3 Combined or Alternative
  • IVUS-guided + OCT-guided for stent optimization
  • Hybrid approaches

261.1.0.4 3⃣ PCI Procedure

261.1.0.4.1 Workflow
  1. Access (radial preferred)
  2. Catheterize coronary arteries → angiography
  3. Identify culprit lesion
  4. Guide wire across lesion
  5. Balloon angioplasty + stent deployment
  6. Post-PCI angiography for adequacy
  7. Hemostasis at access site (radial band; femoral closure device or manual compression)
  8. Antiplatelet therapy (DAPT)
261.1.0.4.2 Stent Selection
261.1.0.4.2.1 Drug-Eluting Stent (DES) — Modern Standard
  • 2nd + 3rd generation DES: thinner struts, biocompatible polymers, optimized drug elution
  • Examples: Xience (everolimus), Resolute (zotarolimus), Synergy (everolimus + bioresorbable polymer)
  • Reduces restenosis vs BMS
  • Requires DAPT
261.1.0.4.2.2 Bare Metal Stent (BMS)
  • Older
  • Use in:
    • Inability to take prolonged DAPT (impending surgery, bleeding risk)
    • Short DAPT requirement
  • Higher restenosis (15-20% vs 5-10% DES)
261.1.0.4.2.3 Drug-Coated Balloons
  • For in-stent restenosis
  • Small vessel disease
  • Some bifurcation
  • No metal implant left behind
261.1.0.4.3 DAPT Duration (2024 ACC/AHA/ESC)
  • Standard post-DES: 6-12 months DAPT
  • High bleeding risk + DES: 1-3 months DAPT then aspirin alone
  • High ischemic risk: prolonged DAPT (12-36 months) consider
  • ACS post-PCI: 12 months DAPT
  • Stable CAD elective PCI: 6 months DAPT typically
261.1.0.4.4 P2Y12 Inhibitor Choice
  • Clopidogrel: standard
  • Prasugrel: more potent; avoid in elderly, low body weight, prior stroke/TIA
  • Ticagrelor: more potent; reversible; some breath issues (dyspnea)
  • Bypass with cangrelor (IV, peri-PCI)
261.1.0.4.5 CABG vs PCI Decision
261.1.0.4.5.1 Factors
  • SYNTAX score (lesion complexity)
  • Left main disease
  • Multi-vessel disease
  • Diabetic status (CABG preferred in T1DM + multivessel — FREEDOM trial)
  • LV function
  • Surgical risk (STS, EuroSCORE)
  • Patient preference
261.1.0.4.5.2 General Guidelines
  • Single-vessel + uncomplicated: PCI
  • Multi-vessel + low SYNTAX (< 22): PCI or CABG equivalent (favor PCI typically)
  • Multi-vessel + intermediate SYNTAX (23-32): case-by-case
  • Multi-vessel + high SYNTAX (> 32): CABG preferred
  • Left main + complex anatomy: CABG preferred
  • Diabetic + multi-vessel: CABG preferred (FREEDOM)

261.1.0.5 4⃣ Cardiac Catheterization Complications

261.1.0.5.1 Bleeding
  • Most common
  • Access site hematoma
  • Retroperitoneal bleed (femoral)
  • Treatment: compression, transfusion, occasionally vascular surgery
261.1.0.5.2 Vascular Access
  • Pseudoaneurysm (treated with ultrasound-guided thrombin or compression)
  • AV fistula
  • Arterial occlusion
261.1.0.5.3 Contrast-Induced Nephropathy (CIN)
  • Definition: 25% increase in Cr or absolute increase 0.5 mg/dL within 48-72 hr
  • Risk factors: CKD, diabetes, elderly, dehydration, contrast volume, prior CIN
  • Prevention: hydration (IV normal saline), limit contrast, withhold metformin, low-osmolar non-ionic contrast
  • AKINE / N-acetylcysteine — equivocal evidence
  • Most reversible; some progress to permanent CKD
261.1.0.5.4 Stroke
  • 0.1-0.5%
  • Embolic (cholesterol from atheroma) or hemorrhagic
  • Higher risk: aortic atheroma, valvular disease, severe vascular disease
261.1.0.5.5 MI / Stent Thrombosis
  • Procedure-related MI (~ 1-3%)
  • Acute stent thrombosis (< 24 hr) — rare but catastrophic
  • Subacute (24 hr - 30 d), late (30 d - 1 yr), very late (> 1 yr)
261.1.0.5.6 Dissection
  • Coronary (procedure-related; usually treated with stent)
  • Aortic (rare but serious)
261.1.0.5.7 Cardiac Tamponade
  • Coronary perforation → bleeding into pericardium
  • Treatment: pericardial drainage + stent / surgery
261.1.0.5.8 Allergic Reaction
  • Iodinated contrast (mild — common; severe — rare)
  • Premedicate if prior reaction (steroid + diphenhydramine)
261.1.0.5.9 Radiation Exposure
  • Cumulative over years
  • Cancer risk (theoretical, low)
  • Operator + patient exposure
261.1.0.5.10 Death
  • 0.1% for elective diagnostic
  • Higher in unstable patients + emergent PCI

261.1.0.6 5⃣ Right Heart Catheterization Detail

261.1.0.6.1 Indications
  • Pulmonary hypertension workup
  • Cardiogenic shock
  • Heart transplant evaluation
  • Constrictive vs restrictive cardiomyopathy
  • Severe HF assessment
  • Pre-LVAD
261.1.0.6.2 Measurements
261.1.0.6.2.1 Pressures
  • RA pressure (CVP equivalent)
  • RV pressure (systolic + diastolic)
  • PA pressure (systolic + diastolic + mean)
  • PAWP / PCWP (Pulmonary Capillary Wedge Pressure) = LA pressure equivalent
  • Cardiac output (Fick or thermodilution)
  • Pulmonary vascular resistance (PVR)
261.1.0.6.2.2 Normal Values
Pressure Normal (mmHg)
RA 0-8
RV systolic 15-30
RV diastolic 0-8
PA systolic 15-30
PA diastolic 4-12
PA mean 9-19
PAWP 2-12
CO 4-8 L/min
CI 2.5-4 L/min/m²
SVR 800-1200 dyn·s/cm⁵
PVR < 250 dyn·s/cm⁵ (or 1-3 Wood units)
261.1.0.6.3 Pulmonary Hypertension Hemodynamic Definitions
261.1.0.6.3.1 PAH (Group 1)
  • Mean PA pressure ≥ 25 mmHg at rest (2018 WHO definition; some now ≥ 20)
  • PAWP ≀ 15 mmHg (excludes left heart disease)
  • PVR > 3 Wood units (excludes high flow states)
  • Vasoreactivity testing (NO inhalation): positive if mean PA drops ≥ 10 mmHg to ≀ 40 mmHg
261.1.0.6.3.2 Pulmonary Hypertension Due to Left Heart Disease (Group 2)
  • Mean PA ≥ 25 + PAWP > 15 (elevated LV filling)
  • HFpEF / HFrEF / valvular
261.1.0.6.3.3 Pulmonary Hypertension Due to Lung Disease (Group 3)
  • COPD, ILD, OSA, hypoventilation
261.1.0.6.3.4 CTEPH (Group 4)
  • Chronic thromboembolic pulmonary hypertension
  • VQ scan + CTPA + pulmonary angiography for confirmation
261.1.0.6.3.5 Group 5
  • Multifactorial / unclear mechanisms
261.1.0.6.4 Constrictive vs Restrictive (RHC)
  • Constrictive pericarditis:
    • Equalization of diastolic pressures (LV + RV + RA + PAWP all approximately equal)
    • Discordance of LV vs RV systolic pressures with respiration
    • Square root sign (dip and plateau)
  • Restrictive cardiomyopathy:
    • LV diastolic > RV diastolic
    • Concordance of LV vs RV systolic pressures with respiration