2.3 Cardiac Catheterization, PCI & Structural Heart Procedures

Diagnostic vs. Interventional Catheterization

Diagnostic cardiac catheterization (coronary angiography) uses a catheter threaded through an artery to inject contrast dye and visualize the coronary arteries under fluoroscopy, identifying the location and severity of stenoses. It can also measure intracardiac pressures and assess valve function and ventricular performance, providing hemodynamic data similar to what a pulmonary artery catheter yields, but obtained directly. When a significant blockage is found, the procedure often proceeds directly to percutaneous coronary intervention (PCI) — the interventional extension of catheterization, in which a balloon is inflated to open the narrowed segment (balloon angioplasty) and, in the great majority of cases, a stent (bare-metal or drug-eluting) is deployed to hold the vessel open and reduce restenosis. Drug-eluting stents release antiproliferative medication and require longer dual antiplatelet therapy than bare-metal stents to prevent stent thrombosis, which the progressive care nurse must reinforce during discharge teaching.

Pre-Procedure Nursing Priorities

Before catheterization, the nurse confirms informed consent is on the chart, verifies NPO status, screens for allergies to iodinated contrast or shellfish (which may prompt a pre-medication protocol), documents baseline renal function and coagulation studies, and marks baseline distal pulses bilaterally so post-procedure perfusion checks have a reliable comparison point.

Access Sites, Sheaths & Closure

Catheterization requires arterial access, most commonly the radial artery or the femoral artery:

• Radial access has become preferred where feasible because it carries a substantially lower risk of major bleeding and vascular complications, allows earlier ambulation, and improves patient comfort. Post-procedure, the nurse monitors the hand for perfusion (color, warmth, capillary refill, pulses) and watches for compartment syndrome from a hematoma under the radial band.
• Femoral access is still used, particularly for larger sheaths needed in structural procedures, and requires the sheath to be removed with manual pressure, a mechanical compression device, or a vascular closure device (e.g., collagen plug or suture-mediated closure) to achieve hemostasis. After femoral access, the patient typically requires a period of bed rest with the affected leg straight, and the nurse assesses the groin site, distal pulses, and limb perfusion at frequent, defined intervals.

Post-Catheterization Complications

The progressive care nurse's most important post-cath responsibility is early recognition of bleeding and vascular complications:

• Access-site bleeding/hematoma: apply firm, direct manual pressure proximal to the puncture site and notify the provider; a rapidly expanding hematoma can compromise distal circulation or require surgical repair.
• Retroperitoneal hemorrhage: the most dangerous — and most easily missed — femoral-access complication, because bleeding tracks internally rather than presenting as visible external blood. Suspect it in a post-cath patient with new flank or back pain, unexplained hypotension, tachycardia, and a falling hemoglobin/hematocrit without an obvious external source. This is a surgical or interventional-radiology emergency and requires immediate escalation.
• Pseudoaneurysm and arteriovenous (AV) fistula: a pulsatile mass with a bruit at the access site suggests a pseudoaneurysm (a contained arterial leak); a continuous bruit suggests an AV fistula (an abnormal connection between artery and vein). Both are diagnosed by ultrasound and may require compression, thrombin injection, or surgical repair.
• Contrast-induced nephropathy: iodinated contrast dye is nephrotoxic, particularly in patients with pre-existing chronic kidney disease, diabetes, or dehydration. Prevention includes pre- and post-procedure IV hydration and monitoring creatinine trends; the nurse should hold nephrotoxic medications (e.g., metformin, NSAIDs) as ordered around the procedure.

Structural Heart Procedures

Beyond coronary work, the catheterization lab now performs structural heart procedures that repair valves without open-heart surgery, and progressive care nurses increasingly manage these patients post-procedure:

• Transcatheter aortic valve replacement (TAVR): a replacement aortic valve is delivered via catheter (typically through the femoral artery) and deployed within the diseased native valve, offering a less invasive option for patients with severe aortic stenosis who are at intermediate-to-high surgical risk. Because the new valve sits adjacent to the heart's conduction system, the most important post-TAVR nursing focus is continuous ECG monitoring for new conduction abnormalities — particularly new-onset heart block — which can require a permanent pacemaker. Nurses also monitor for vascular access complications, stroke, and paravalvular leak.
• Transcatheter mitral valve repair (MitraClip): a clip is delivered via transseptal puncture (crossing from the right atrium to the left atrium through the interatrial septum) to grasp and approximate the mitral valve leaflets, reducing severe mitral regurgitation in patients who are poor surgical candidates. Post-procedure monitoring includes watching for cardiac tamponade (a risk of transseptal puncture), residual mitral regurgitation, and access-site complications.

Transesophageal Echocardiography (TEE)

TEE places an ultrasound probe in the esophagus, providing a clearer view of posterior cardiac structures — the left atrium, left atrial appendage, and valves — than a transthoracic echo can achieve. TEE is used both diagnostically, most notably to rule out a left atrial appendage thrombus before elective cardioversion of atrial fibrillation (since cardioverting a patient with an undetected clot risks embolic stroke), and procedurally, to guide structural interventions like TAVR and MitraClip in real time. Because TEE requires moderate sedation and esophageal intubation with the probe, post-procedure nursing care includes airway monitoring, gag reflex assessment before resuming oral intake, and watching for the rare but serious complication of esophageal perforation (chest pain, fever, subcutaneous emphysema).