Cardiovascular Tests and Procedures

Right Heart Catheterization with Heart Tissue Biopsy

(Heart Biopsy, Right Heart Cath with Biopsy)

Procedure overview

What is a right heart catheterization with heart tissue biopsy?

Right heart catheterization (often abbreviated as right heart cath) with heart tissue biopsy is a procedure in which tissue samples are taken directly from the heart muscle. This procedure may be done to see if the heart tissue is normal.

In a right heart cath, the doctor guides a special catheter (a small, thin tube) called a pulmonary artery (PA) catheter into the right side of the heart and passes it into the pulmonary artery, the main artery carrying blood to the lungs. As the catheter is advanced into the pulmonary artery, the doctor measures pressures in the right atrium (right upper heart chamber) and right ventricle (right lower heart chamber). In some cases, the doctor gives IV heart medications during the right heart cath to see how the heart responds. For example, if the pressure is high in the pulmonary artery, the doctor may give medications to dilate, or relax, the blood vessels in the lungs and help lower the pressure. Several pressure "readings" will be done during the procedure to measure your body's response to the medications.   

Indirect measurements of pressures in the left side of the heart can be made by inflating a small balloon at the tip of the catheter as well. The pressure detected in front of the balloon is known as the pulmonary capillary "wedge" pressure (PCWP), or pulmonary artery occlusion pressure (PAOP). The cardiac output, or the amount of blood pumped by the heart per minute, is also determined during a right heart catheterization.  

The biopsy portion of the procedure is usually performed at the end of a right heart cath. The doctor inserts a special catheter with a small tool called a bioptome into a vein, usually in the neck, and passes it into the right ventricle. Under X-ray guidance, the doctor uses the biopsy catheter to take tissue samples usually from the right ventricle. The tiny pieces of heart tissue are sent to the lab to be examined under a microscope. Special doctors, known as pathologists, will examine the tissue under a microscope for evidence of infection, inflammation, and abnormal cells.

Reasons for the procedure

A biopsy may be done to:  

  • Diagnose of the cause of heart failure or heart disease, such as dilated cardiomyopathy caused by bacterial or viral infection or restrictive cardiomyopathy that can be caused by many different pathological processes. Knowing the cause of heart failure can help to determine the treatment plan. 

  • Evaluate heart tissue after a heart transplant to make sure that the body is not rejecting the transplanted (donor) heart.

A right heart cath with biopsy may also be necessary as part of the evaluation before a heart transplant. Pressures in the lungs need to be as low as possible in order for a donor heart to work as well as possible. 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.

Risks of the procedure

Possible risks associated with a right heart catheterization  with biopsy include:

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

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

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

  • Perforation of the wall of the heart after pieces of tissue are removed from the ventricle (the lower pumping chamber of the heart)

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

  • Tricuspid valve damage (the valve on the right side of the heart)

  • 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)

  • Nerve damage

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 prior to the procedure. 

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

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

During the procedure

The right heart cath with biopsy will be done in the cardiac catheterization lab or in a special department.  In critically ill patients, the test may be done in the intensive care unit (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.

  • Sedation is generally not required for this procedure, but you may be given a medication to help you relax.

  • If the neck vein is to be used, you will be asked to turn your head away from the insertion site to help the doctor locate the proper location to insert the catheter.

  • Sterile towels will be place 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 insertion site will be 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 when 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 biopsy catheter will be inserted through the introducer. You may feel some pressure as the introducer is placed. You may hear sounds as tissue samples are taken from the heart, but you should not feel any pain. Only a very small amount of tissue is taken for the biopsy. 

  • You may feel a pulling or tugging sensation when the tissue sample is obtained.

  • If a right heart cath is done at the same time, a PA catheter will be placed through the right atrium, right ventricle, and into the pulmonary artery. Heart and lung pressures will be measured.  Special medications may be given through the IV to evaluate the heart's response. It may take about 30 minutes to monitor the heart's response to the medications.

  • Once the tissue samples and heart pressure 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

In the hospital

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 biopsy samples will be sent to a lab for final evaluation; this may take a few days. Your doctor will discuss the results right heart cath and the plan for treatment if needed.

The length of time you will be required to stay after the procedure will depend on the location of the insertion site. If a neck vein is used, you may be discharged very quickly if bleeding from the site stops within a few minutes. If a groin site is used, you will be kept for a few hours to make sure bleeding from the site has stopped.

At home

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. 

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