American College of Cardiology

Although no rigid protocol is commonly followed for all patients or environments, some general procedural issues are pertinent to most cardiac catheterizations. The following discussion is meant to provide a general approach to some of the issues that frequently arise in the performance of cardiac catheterization.

A. Patient Preparation

1. Sedatives and Relaxants
Appropriate sedation ensures the comfort of the patient during the procedure. Initial premedication with diphenhydramine (Benadryl®) and/or diazepam (Valium®) is used in most catheterizations because of their respective antiallergic and sedative properties. If more sedation or relaxation is necessary once the patient is in the catheterization laboratory setting, additional sedatives can be given. Conscious-sedation protocols should be followed, with documentation of vital signs and oxygen saturations during the study in accordance with individual institutional guidelines. Alternative sedatives often used during the procedure include IV midazolam (Versed®), hydromorphone hydrochloride (Dilaudid®), and fentanyl citrate. Excessive sedation should be avoided so that the patient’s state of consciousness is not severely altered, which would render the patient unable to report discomfort or symptoms that might herald a potential complication during the procedure. All patients should have pulse oximetry monitoring during conscious sedation, with periodic checks of blood pressure, heart rate, and blood oxygen saturation documented during the procedure ⁽⁴⁷⁾.

2. Prevention of Contrast “Allergy”
The preprocedural history should document any previous exposure to x-ray contrast and whether any reaction occurred. A complete description of the allergic reaction should be obtained to ascertain its validity and importance. When patients have previously had an allergic reaction to intravenously administered contrast material, a subsequent allergic reaction to intra-arterially administered radiographic contrast is rare, but these patients are at higher risk ⁽⁴⁸⁾.

Given the rarity of true contrast-allergic reactions in the cardiac catheterization laboratory, it is difficult to recommend a preventive therapy with confidence. There are data that suggest that premedication with steroids before the administration of radiographic contrast for IV pyelography reduces contrast reactions in high-risk patients ⁽⁴⁹⁾. This has led to the recommendation to administer an oral steroid 1 to 2 days before the procedure to patients at risk. In most cardiac catheterization laboratories, however, steroids are often only given intravenously a few hours (or less) before the procedure. There are no data to support or refute the advantages of this practice. In addition, diphenhydramine (Benadryl®) and cimetidine (Tagamet®) or much more potent H₁ and H₂ blockers are often used to further reduce the possibility of an allergic reaction ⁽⁵⁰⁾.

In addition to these precautions, a few laboratories give a 1-mL test dose of the contrast agent intra-arterially, then follow it with a 3-minute observation period to watch for any signs of an anaphylactoid reaction ⁽⁴⁹⁾. Anaphylactoid reactions are characterized by profound hypotension, hives, and bronchospasm. Treatment includes administration of large volumes of fluid to restore blood pressure. Antihistamines and epinephrine are also used to reduce the urticarial reaction and resulting bronchospasm. Anaphylactoid reactions must be differentiated from vagal reactions, a common event during the initial stages of the catheterization procedure, or contrast-induced bradycardia and hypotension, especially during coronary injections that involve the atrioventricular nodal artery. Anaphylactoid reactions generally result in more profound hypotension and are more prolonged than vagal episodes. Anaphylactoid reactions may not respond to the use of atropine and fluids, as would be expected with a vagal reaction. Tachycardia is usually present during anaphylactoid reactions, as opposed to the bradycardia seen with stimulation of the vagus nerve.

3. Patients With Renal Insufficiency
Patients with known renal insufficiency (creatinine >1.8 mg/dL) should be treated with preprocedural and postprocedural hydration and observed. There is suggestive evidence that there may be an advantage in the use of nonionic contrast compared with ionic contrast agents in these patients ^(50-52). Diabetic patients with renal dysfunction are at particularly high risk for acute renal failure after exposure to contrast agents ⁽⁵³⁾. The amount of contrast used during the study should be minimized, and if possible, a biplane laboratory should be used to obtain the maximum information with each injection. Eliminating left ventriculography may further minimize the contrast load because the same information may be available from noninvasive studies. Postprocedural hydration should be considered in all cases and is mandatory in patients with severe renal dysfunction. Because the rise in creatinine level after the use of radiographic contrast may continue for up to 72 or more hours after the procedure, appropriate laboratory follow-up to document any late worsening of renal function should be arranged for those at risk. Pretreatment with acetylcysteine holds promise for reducing the risk of contrast nephrotoxicity ⁽⁵⁴⁾, although confirmatory data are needed to validate this approach. Despite the popularity of ad hoc interventional procedures after a diagnostic angiogram, this practice should be discouraged in patients with renal insufficiency (in a nonemergent setting) to prevent excessive use of contrast.

4. Patients With Diabetes Mellitus
In patients who are insulin dependent, the dosage of insulin should be adjusted to correspond with food intake before the procedure, and if possible, catheterization for these patients should be scheduled early in the day to avoid a long period of altered food intake and insulin administration. Often half of the usual insulin dosage is administered on the morning of the procedure. Blood sugar should be monitored if any symptoms of hypoglycemia emerge. In patients with diabetes who take metformin (Glucophage®), there is a potential for development of profound lactic acidosis should contrast-induced renal dysfunction develop. As a position paper from the Society for Cardiac Angiography and Interventions points out, this is an extremely rare event and has occurred only in patients with abnormal renal function ⁽⁵⁵⁾. Metformin is relatively contraindicated in diabetic patients with significant renal insufficiency. Because of the potential hazard, however, the current recommendation is that metformin be discontinued the morning of the procedure and not restarted until the creatinine level is shown to be stable, usually 48 h after the procedure ⁽⁵⁵⁾.

5. Patients Receiving Antiplatelet or Antithrombotic Medications
Patients who take warfarin (Coumadin®) should generally discontinue their drug for 3 doses before the cardiac catheterization procedure. An acceptable INR just before the cardiac catheterization varies according to individual practitioners, but the consensus is that an INR of <1.8 is acceptable without an increased risk of bleeding after the procedure. The overuse of vitamin K reversal of warfarin effects may make it difficult to re-establish a warfarin effect afterward. Patients receiving heparin may undergo cardiac catheterization without concern, although longer periods are required for hemostasis, and reversal of the heparin effects with protamine sulfate after completion of the study may be warranted. Closure devices may also help reduce groin bleeding in certain situations ⁽⁵⁶⁾. Heparin activity may be estimated by the ACT. A fully heparinized patient in the cardiac catheterization laboratory would be expected to have an ACT >300 s, while it is generally safe to remove the catheters and sheaths once the ACT is <175 s. Heparin can be reversed by protamine, but profound allergic reactions may occur, especially in diabetic patients receiving NPH insulin ⁽⁵⁷⁾. Aspirin is not stopped before cardiac catheterization. Use of the newer antiplatelet agents such as ticlopidine (Ticlid®), clopidogrel (Plavix®), eptifibatide (Integrilin®), tirofiban (Aggrastat®), or abciximab (ReoPro®), does not preclude a patient from undergoing cardiac catheterization; although the combination of GP IIb/IIIa inhibitors and standard heparin dosage (100 units/kg) results in a higher rate of groin bleeding complications ⁽²⁹⁾. In patients receiving GP IIa/IIIb inhibitors, the heparin dose should be reduced to 70 units/kg.

B. Procedural Issues

1. Sterile Preparation of the Access Site and Vascular Access
Infection is rare after invasive cardiovascular procedures. In a retrospective study of 385 laboratories, an infection rate of 0.35% was noted, with the incidence for cut-downs 10 times higher than that for percutaneous sites (0.62% vs. 0.06%) ⁽⁵⁸⁾. The Occupational Safety and Health Administration (OSHA) recommends that preparation of all patients include the removal of hair from the site, application of antiseptic to the skin, and the use of sterile drapes. Systemic antibiotics are not required, although some operators use them with large-vessel noncoronary stents or other devices that will be left in the body. Operators should wear a sterile scrub suit. A generally sterile environment should be maintained during the procedure. Disposal of all materials should also follow local safety and infection control guidelines.

Although the sterile techniques used in the operating room are not necessary for most cardiac catheterization laboratory procedures, the operator should use appropriate hand washing and wear a sterile gown and gloves. Masks, eye shields, and protective caps are probably more important for keeping the patient's blood from splattering onto the operator than for protecting the patient from infection. In cases where greater wound exposure is necessary, such as pacemaker implantation or brachial cut-downs, the full surgical sterile technique should be used. A vascular sheath should be used to minimize vascular trauma, especially when multiple catheter changes are anticipated. Each percutaneous vascular site (femoral, brachial, radial, subclavian, transhepatic, or internal jugular) requires that the operator have specialized training. Although some aspects of percutaneous vascular access are similar for all sites, certain issues (e.g., compression and/or administration of heparin or intravascular verapamil or nitroglycerin) are unique to each site.

The Sones brachial cut-down technique has largely been replaced by percutaneous methods. The Sones cut-down technique requires more specialized training, proctorship, and credentialing because of the unique training and skill level necessary for its safe use. This technique requires a more extended skin incision, blunt dissection, and arteriotomy and repair. Currently, the most common site for percutaneous arterial access for both diagnostic and interventional cardiac procedures is the femoral artery region. The radial artery approach is gaining some favor, especially for obese patients and outpatients. If venous access is required, in most cases it should be performed using the femoral vein or the internal jugular vein. Multiple venous catheters can be safely inserted in the same femoral vein; multiple arterial catheters require separate arterial access sites. Strict sterile procedures should be followed at each site.

2. Right-Heart Catheterization During the Evaluation of Coronary Artery Disease
The routine use of right-heart catheterization in a patient whose symptoms and objective studies suggest coronary artery disease without associated mitral regurgitation or congestive heart failure is discouraged ⁽⁵⁹⁾. The additional information gained from a right-heart catheterization in patients with chest pain and suspected coronary artery disease is minimal. Unless concomitant valvular heart disease, presumed pulmonary hypertension, intracardiac shunts, or other diagnoses are suspected, a routine right-heart catheterization should not be performed. If it is anticipated that knowledge of right-heart pressures and cardiac output would be helpful in patients with left ventricular dysfunction and provide information that would enhance the safety of the procedure or affect decision making afterward, right-heart catheterization is acceptable.

3. The Routine Use of Temporary Pacing
Routine use of a temporary pacemaker during coronary angiography or interventional procedures is not indicated. However, use of a rotational atherectomy device ⁽⁶⁰⁾ in right coronary artery disease or use of the Angiojet device ⁽⁶¹⁾ has been associated with an increased incidence of atrioventricular block. This is also true during percutaneous aortic balloon valvuloplasty or with alcohol ablation for hypertrophic cardiomyopathy. Thus, temporary pacing may be warranted in these instances. In patients with left bundle-branch block in whom a right-heart catheterization is being performed, there is a clear risk of complete heart block if the right bundle branch is injured during the procedure. Thus, temporary placement of a pacemaker may be appropriate. If it is anticipated that catheter manipulation or coronary obstruction during an interventional procedure might produce a bradyarrhythmia for which a temporary transvenous pacemaker would be necessary, a temporary pacemaker should be positioned before the need arises.

4. Transseptal Cardiac Catheterization and Percutaneous Balloon Mitral Valvuloplasty
The need for transseptal cardiac catheterization has persisted with the necessity of percutaneous mitral balloon valvuloplasty and the need to enter the left atrium during certain electrophysiological procedures. The technique is also useful in congenital heart disease and when left ventricular pressures and angiography are vital in patients with disk-type prosthetic aortic valve replacements. The technique is safe when performed by experienced operators ⁽²¹⁾.

Although percutaneous balloon mitral valvuloplasty can also be performed transseptally via the internal jugular vein ⁽⁶²⁾ or retrogradely across the mitral valve via the arterial system ⁽⁶³⁾, most procedures use the transseptal technique from the femoral vein. Single-balloon (primarily Inoue) or double-balloon methods are both effective ⁽⁶⁴⁾. The Committee is not aware of any specific data regarding the minimum numbers for competency because the procedure is, for the most part, limited to major medical centers with a specific interest and expertise. Previous guidelines ⁽⁵⁾ suggested a minimum caseload of 25 per year, and although this seems reasonable, there are no data to support this number. As with many “orphan” procedures, it is critical that the QA system be operative and that all transseptal procedures be closely monitored and any complications reviewed. Percutaneous balloon mitral valvuloplasty carries a small but well-documented risk ⁽⁶⁵⁾, and its performance should be restricted to those operators who are aware of the appropriate indications for the procedure, skilled in the technique, and capable of handling any complications that may arise.

5. Role of Left Ventricular Puncture in the Era of Echocardiography
In the current era, the information gained from both transthoracic and transesophageal echocardiography allows for an excellent estimation of ventricular function and a reasonable sense of the severity of stenotic or regurgitant valvular lesions. The use of direct left ventricular puncture thus provides minimal additional information beyond that gained by echocardiography yet exponentially increases the chance of a serious complication even in experienced hands. The need most often arises in patients with 2 disk-type prosthetic mitral and aortic valves that prevent left ventricular access by any other means. It is the consensus of the Committee that left ventricular puncture should be used only in very rare instances in which the information needed to make a diagnostic or therapeutic decision is not available by any noninvasive method.

6. Use of Provocative Agents During Diagnostic Cardiac Catheterization
Certain provocative pharmacological agents may be used during cardiac catheterization to unmask pathology that is not evident without the intervention. Fluid loading may unmask latent pericardial constriction or tamponade. Afterload reduction or inotropic stimulation may be used to increase the outflow tract gradient in hypertrophic cardiomyopathy. Similarly, the use of afterload reduction or an inotropic agent may assist in the assessment of the severity of aortic stenosis in patients with low cardiac output and low transvalvular gradient ⁽⁶⁶⁾. The use of provocative coronary vasoreactive agents (e.g., methylergonovine, acetylcholine, adenosine, or papaverine) should be confined to situations in which specific coronary artery questions are being asked, because they have little clinical utility otherwise. Measures of coronary flow reserve or pressure-derived fractional flow reserve (FFR), by use of methods such as the Doppler or pressure sensor guidewires often require the use of coronary vasodilators such as adenosine, dipyridamole, or papaverine. A variety of pulmonary vasoreactive agents (e.g., oxygen, calcium channel blockers, adenosine, nitric oxide, or prostacyclin) may help define prognosis and potential responders to drug therapy in patients with primary pulmonary hypertension ⁽⁶⁷⁾. These agents are only now being studied in secondary pulmonary vascular disease. The use of any of these agents carries potential risks, and the risk/benefit ratio of the procedure must be determined by the individual cardiologist. In each case, however, the catheterization laboratory committee should have a detailed and approved procedural protocol for the use of these agents. This protocol should include the steps to be taken immediately to treat any potential complications that may arise.

7. Operator Safety During Cardiac Catheterization in Patients With Communicable Diseases
All cardiac catheterization procedures must be conducted as as if there were a risk of infection. Heightened protective care should be taken in any case in which a communicable disease such as hepatitis or human immunodeficiency virus (HIV) positivity is present. Because there is no assurance that individual patients without these diagnoses do not carry a serious communicable disease such as HIV, the prudent operator must always use optimum care during each study. Every cardiac catheterization laboratory should have an approved additional sterile technique protocol for known highly infectious cases. This protocol should include the use of surgical caps and masks, as well as eye protection. Double gloving has been shown to reduce the chances of a puncture. In addition to the usual surgical gown, disposable shoe covers for the cardiologist and all technicians in the room should be considered. The careful disposal of all needles, catheters, sheaths, tubing, and other instruments, as well as fluids that come in contact with the infected patient is obviously important. Extra clean-up of the laboratory space should also be performed before it is used again.

C. Performance Issues

1. Injection of Coronary Arteries
The safe injection of a contrast agent into coronary arteries is predicated on the coaxial placement of the coronary catheter in the coronary ostium and the correct positioning of the tip of the catheter in the coronary artery. Assurance of a bubble-free connection between the contrast manifold port or syringe and the catheter must be established. Careful replenishment of contrast in the injection syringe and the maintenance of a bubble-free environment is the responsibility of the operating cardiologist. Most invasive cardiologists inject the coronary arteries manually, although power injectors can be used safely with appropriate equipment and training. Coronary injections should include a tiny test dose of contrast once the catheter tip is in position to be certain that the catheter is not subintimal or under a plaque that might result in an extensive coronary artery dissection if a full injection of contrast were administered. Monitoring catheter tip pressure is obligatory. A “flush” injection into the respective coronary sinus may help define ostial coronary disease.

The use of nurses, cardiovascular technicians, or physician's assistants to inject the coronary arteries has become increasingly popular. It remains the responsibility of the individual invasive cardiologist to ascertain whether paramedical personnel or power injectors are capable of administering contrast into the coronary arteries. Physician extenders should always be viewed as extensions of the primary operator’s hands, with the responsibility for safety ultimately residing with the invasive cardiologist.

2. Angiography
In the majority of cases, the use of single-plane x-ray imaging is satisfactory, recognizing that many laboratories do not have biplane capabilities. Laboratories contemplating angiographic evaluation of patients with congenital heart disease, however, should have biplane capabilities. In the case of left ventriculography in patients with coronary artery disease, an appropriate view should be selected to gain the most information regarding left ventricular function.

The use of multiple orthogonal views of the coronary arteries is of obvious importance. The invasive cardiologist must be certain that appropriate information is obtained and recorded in order to make an accurate diagnosis and help determine suitability for PCI. Each segment of the coronary artery should be seen in at least 2 orthogonal views. Angulation to obtain the “worst stenosis” of any lesion is important. Although it may be helpful and expeditious to have routine views performed on each coronary study, additional views should be obtained if the anatomy is not clearly presented or there are overlapping structures. The knowledge and application of additional views is the hallmark of excellence for angiographers ⁽⁶⁸⁾. Table 10 lists suggested appropriate views of each coronary as a guideline.

In the case of right-heart and pulmonary angiography, it is important that the appropriate views be obtained to demonstrate the anatomy being interrogated. Because most cardiac catheterization laboratories have only a 9-inch image intensifier, multiple images of the lung are usually required to interrogate the entire lung fields. If the aorta is to be investigated, cine aortography can be performed in the catheterization laboratory to ascertain the size of the aorta (in cases of aortic stenosis with anticipated aortic valve replacement) and to visualize the arch vessels. If detailed examination of the lung and aorta and arch vessels is required, it is often better to use a system with a larger-size image intensifier designed for that purpose.

Because there is considerable degradation in the image quality when copies of cineangiograms are transferred onto videotape, diagnostic decisions are best made on original cinefilm or digital media.

3. Pressure Measurement
The importance of high-quality pressure measurements unfortunately has been deemphasized in many laboratory facilities. The availability of numerous types of hemodynamic equipment precludes detailed description here. Appropriate filtering of the hemodynamic signal is important for adequate interpretation of individual waveforms. Careful balancing and zeroing of the system at the level of the atria are necessary for each procedure. Often simultaneous pressures are important, and frequently higher-speed recordings (100 mm per second) are needed to obtain adequate data for waveform analysis. It is the responsibility of the laboratory director to ensure that the equipment available produces the information desired. Detailed knowledge of each laboratory’s transducers and recorders should be part of the requirement for credentialing of invasive cardiologists in a particular catheterization laboratory. It is each invasive cardiologist’s responsibility to direct the acquisition of appropriate pressures. Invasive cardiologists using the laboratory should review the quality of the pressure recordings obtained, and any deficiency should be corrected by the company providing the equipment.

During a routine left-heart and coronary arterial catheterization, a preprocedural and postprocedural aortic pressure tracing as well as the recording of the left ventricular systolic and end-diastolic pressure should be obtained. Some laboratories find it useful to repeat the left ventricular pressure after the left ventriculogram, although the actual value of this exercise is questionable. During right-heart catheterization, the acquisition of right atrial, right ventricular, pulmonary artery, and pulmonary artery wedge tracings is routine, and sufficiently long strips of phasic recordings should be obtained to assess respiratory variation. Obtaining the end-expiratory pressure may help reduce the respiratory variation, although some patients are unable to hold their breath without performing a Valsalva maneuver, and thus the pressures are influenced by the resultant high intrathoracic pressure generated. The mean pressure in atrial and pulmonary chambers should be obtained over 10 beats to allow for correction of respiratory changes. If pullback pressures are used to measure valvular gradients, the patient should be in as steady a state as possible to diminish the likelihood of any respiratory variation between pressure measurements from one chamber to another. Simultaneous pressures to gauge gradients across valvular lesions are preferred. Care should be taken if the femoral artery pressure is used as a substitute for aortic pressure in younger patients. If femoral pressure is to be used as the aortic pressure surrogate, documentation should be obtained that the pressures between the 2 sites are similar. On occasion, the pulmonary capillary wedge pressure will also not correspond well to the left atrial pressure (especially after mitral valve replacement), and a transseptal puncture with simultaneous measurement of the left atrial and left ventricular pressure is required for an accurate transmitral gradient.

Rarely a pressure gradient across a lesion in a coronary vessel may provide information regarding the hemodynamic significance of that lesion. Coronary pressure wires and flow wires may be used to help evaluate severity of coronary stenosis.

4. Measurement of Cardiac Output
Cardiac output measurements commonly used in the cardiac catheterization laboratory include the use of indicator dilution methods (typically thermodilution), the Fick method (use of pulmonary and arterial blood oxygen saturations and oxygen consumption), angiographic methods, and impedance estimates. Indocyanine green dye is now rarely used. As a consequence, most cardiac catheterization laboratories rely on thermodilution methods or the Fick method for determination of cardiac outputs. Thermodilution methods use a thermistor on the end of a right-heart catheter. As a proximally injected bolus of saline traverses past the thermistor, the temperature change results in a curve similar to that observed with dye dilution methodology. Analysis of this curve allows determination of cardiac output by a variety of methods. Accurate measurement requires a concentrated bolus of saline. Thus, tricuspid or pulmonary insufficiency may significantly alter the results obtained. Fick cardiac outputs require measurement of oxygen saturation, hemoglobin, and oxygen consumption. Oxygen consumption is usually the most difficult variable to obtain. Most laboratories use an assumed value, either from an established reference table or the following formula: oxygen consumption = 125 mL/min/m² BSA. Direct measurement of oxygen consumption provides a more accurate assessment using a variety of instruments, but the unstable nature of some of these devices and the expense and time involved have discouraged direct oxygen consumption measurements in most catheterization laboratories. Angiographic cardiac output using area-length assumptions or Simpson’s rule provides left ventricular volumetric data useful for estimating valvular stenosis severity in the presence of valvular regurgitation (assuming only 1 left-sided valve demonstrates regurgitation). The regurgitant fraction can also be derived. Angiographic methods suffer from vagaries in the accuracy of the prolated ellipse shape assumptions and from the determination of the requisite correction factors needed because of x-ray divergence. Whatever method is used for determining cardiac output should be well understood by all personnel. Each cardiac output method has limitations and errors that can be minimized with careful attention to the inherent vagaries of each technique.

D. Postprocedural Issues

1. Vascular Hemostasis
The most frequent complication of coronary angiography and coronary interventions occurs at the vascular access site. Careful vascular entry is the first guard against such complications. Unfortunately, the use of heparin and/or thrombolytic or antiplatelet agents sets the stage for vascular complications (see Tables 5 and 6). Vascular hemostasis obtained after the procedure should be viewed as a crucial component of the procedure. In cases of femoral puncture, where a vascular closure device is not used, it should be routine to assess the influence of procedural heparin using the ACT value before access-site compression. Once the ACT has returned to near normal (<175 s), sheaths can be removed and manual pressure or mechanical pressure clamps applied. If lytic agents have been used, prolonged vascular compression may be necessary. Most patients should be confined to bed for a minimum of 2 h after the procedure. The use of the radial or brachial artery approaches obviates the need for prolonged bed rest, but hemostasis must still be achieved by manual or device pressure.

The use of percutaneous vascular closure devices is becoming increasingly popular, and although these devices carry their own set of complications, they provide excellent hemostasis and allow for early ambulation of most patients. Operators who use vascular closure devices should first undergo careful training and proctorship before accreditation. Table 11 outlines some general recommendations regarding postprocedural hemostasis after femoral artery access.

In cases of both diagnostic and interventional procedures, it is the responsibility of the QA program to ascertain that careful clinical follow-up during time in-hospital and for 24 h after the procedure are reported in terms of vascular complications for each practitioner and the laboratory as a whole.

2. Reporting of Cardiac Catheterization Results
The formal cardiac catheterization and angiographic report should contain a certain critical amount of information. The indication for the procedure should be clearly stated. The time course of the procedural events should be documented and recorded. The time and dose of all medications used during the procedure should be noted. All catheters, sheaths, and special guidewires used should be reported in a procedural section. Any pertinent hemodynamic data obtained should also be reported. The minimum hemodynamic data that should be reported from a left-heart catheterization and coronary angiography study with left ventriculography should be the initial and ending aortic pressures and the left ventricular systolic and end-diastolic pressure. If right-heart catheterization is performed, the right atrial, pulmonary artery, and pulmonary artery wedge pressure values should be reported, as well as mean pressures. The right ventricular pressure should include the systolic and end-diastolic pressures. Transvalvular mean and peak pressure gradients and valve area determinations should be reported when appropriate, along with the cardiac output determination and any shunt data if indicated.

In addition to a detailed summary of the procedure, a description of the angiographic findings is required. A visual diagram of the coronary tree is helpful to communicate vascular anatomy and lesion location. Minimum findings to be reported should include (1) the presence or absence of the right and left coronary ostia and detailed descriptions of any abnormalities in the left main coronary artery; (2) the left anterior descending coronary artery and its diagonal and septal branches; (3) the left circumflex coronary artery and its obtuse marginals and inferolateral branches; and (4) the right coronary artery and its posterior descending and posterolateral branches. The dominance of the coronary vessels should also be noted. The left ventriculogram assessment should include the regional wall motion abnormalities seen in the left ventricle contour in terms of anterior, inferior, apical, posterior, and lateral segments. Terminology for each segment should include normal, hypokinesia, akinesia, dyskinesia, and aneurysmal wall motion. Quantitative methods are also useful when available. A measured or estimated ejection fraction should also be reported and the presence and severity of any valvular regurgitation noted. Pertinent additional details such as calcium in the coronary arteries, valves, or pericardium should also be included if these data have potential clinical relevance. A final diagnosis should be clearly stated. In some laboratories, the management decision is also included in the report.

Procedural and hemodynamic records should be stored in some form for at least 7 years and should be accessible within a reasonable time frame. Angiographic findings should also be available for subsequent review for 7 years, although the quality of cineangiograms clearly degrades over time. The findings of catheterization or angiography should be available to the patient and any physician or facility that the patient so designates by written request.