# RHC with Shunt Study



## pJohnson15 (Dec 27, 2017)

Can anyone give me some guidance on this? If anyone has any resources or can direct me to any documents that would help with these it would be appreciated!

PROCEDURES:
1. Right heart catheterization with shunt study.
2. Arterial line placement.

INDICATIONS:
Hypoxemia

COMPLICATIONS:
None

DESCRIPTION OF PROCEDURE:
A full PARQ discussion was held with the patient and informed consent was obtained. All questions were answered. He asked us to proceed. He was brought to cardiac catheterization lab, prepped and draped in the usual manner. Local anesthesia given. An 8-French sheath was placed into his right internal jugular vein using direct ultrasonic guidance. Fluoroscopy also confirmed position of the wire prior to sheath insertion. A right radial artery line was then placed using an Angiocath 0.021-inch angled guidewire. The patient was on 3 L nasal cannula for the shunt study. An 8-French Swan-Ganz catheter was then slowly advanced under fluoroscopy into the right atrium, right ventricle, pulmonary artery and pulmonary capillary wedge positions. Pressures recorded in each of these positions. Cardiac output and cardiac index were measured both using thermodilution and Fick methods. Oxygen saturations were also drawn using the Swan-Ganz catheter in the SVC, IVC, high RA, mid RA, low RA, RV base, RV apex, RVOT, main PA, RPA, and wedge positions. Arterial saturation was also drawn from the A line. This was all done on oxygen. In order to enter the inferior vena cava, a 5-French multipurpose diagnostic catheter was advanced over a 0.035-inch angled guidewire into the IVC. IVC saturation was drawn with the multipurpose catheter. The patient then underwent a repeat wedge saturation and arterial saturation on room air. The patient's O2 saturation on pulse oximetry dropped initially to the 75-78% range within 2 minutes of oxygen discontinuation. After saturations were drawn, peripheral oxygen saturation dropped to as low as 68%. Because of this, oxygen was turned back up to 3 L nasal cannula and a repeat shunt study was not performed on room air. The sheath was removed and hemostasis achieved using manual compression. The patient tolerated the procedure well. There were no complications. 

SUMMARY:
1. Mildly elevated right-sided filling pressures with mean RA pressure of 10 mmHg and pulmonary capillary wedge pressure of 17 mmHg.
2. Mean pulmonary artery pressure of 33 mmHg.
3. Normal cardiac output and cardiac index by thermodilution and low-normal cardiac output and cardiac index by Fick methods.
4. No significant left-to-right cardiac shunt is seen.
5. A 9-10% oxygen saturation drop is seen between the pulmonary capillary wedge positions and peripheral arterial saturations consistent with right-to-left shunt.
6. The patient's hypoxemia is likely related to both cardiac and non-cardiac contributions. The patient was significantly hypoxemic on room air with a pulmonary capillary wedge saturation of 86-87%. This suggests underlying hypoxemia from pulmonary causes. However, the patient also has cardiac etiologies for hypoxemia, including a 9-10% oxygen saturation drop between the pulmonary capillary wedge position and right radial artery consistent with a right-to-left shunt.
7. Mild fluid overload may also contribute.

I came up with 93451 (RHC), and 36620 (arterial line placement). Am I on the right path with those?

Thanks for any and all comments!


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