Right heart catheterization (RHC) and endomyocardial biopsy are mainstay procedures for patients with heart failure and heart transplantation. Approaches are predominantly neck (internal jugular) or leg (femoral vein). We describe a novel arm (brachial/basilica vein) approach. Over 5.5 years, 1,130 right-sided cardiac procedures in 276 patients were analyzed retrospectively and divided into either neck or arm approach. Comparative analyses of procedural success, time, safety, efficacy, and cost were performed. Patient preference was assessed for those who had both neck and arm approaches. In patients receiving RHC (174 neck and 121 arm cases) and in those receiving RHC + biopsy (594 neck and 141 arm cases), mean elapsed and fluoroscopic times (minutes), respectively, were 60 ± 20 versus 62 ± 19 and 3.43 ± 3.8 versus 4.99 ± 5.2 (RHC neck vs arm, respectively), and 55 ± 19 versus 63 ± 17 and 4.14 ± 3.4 versus 5.22 ± 2.6 (RHC + biopsy neck vs arm, respectively). Procedural complications were low (n = 7, 0.6%) and restricted to the neck approach. Patients surveyed preferred the arm approach. In conclusion, RHC and endomyocardial biopsy through the brachial vein can be performed safely, timely, effectively, and at equivalent cost compared with a neck approach. We advocate that an arm approach be the preferred method for these procedures.
Right heart catheterization (RHC) and hemodynamic assessment remain common diagnostic procedures when caring for patients with advanced heart failure. Similarly, endomyocardial biopsy remains the criterion standard to evaluate for post–heart transplant allograft rejection and is advocated for the assessment of new-onset heart failure in select patients. These procedures are predominantly performed from approaches that originate in the femoral vein (leg) or internal jugular vein (neck). These various approaches have established risks, ranging from minor pain, ecchymosis, hematoma, arterial puncture, nerve injury, or pneumothorax. To mitigate some of these risks, ultrasound-guided central venous access has been advocated. Despite these advances, patients continue to experience anxiety and reluctance to undergo initial and, in the case of heart allograft rejection surveillance, serial procedures. Recognizing these concerns, we developed a safe and reliable arm approach for RHC and RHC + biopsy procedures.
Methods
A total of 1,130 procedures were retrospectively identified over 5.5 years. After approval from the institutional review board was obtained, charts were abstracted for clinical data and procedural specifics. Data were grouped by procedure type, RHC or RHC + biopsy, and procedure approach, neck or arm ( Table 1 ). Of the 1,130 procedures, 100 were accessed through the femoral or subclavian vein and therefore excluded from comparative analysis. All procedures were performed by 1 of 2 experienced board-certified heart failure/transplant cardiologists (n = 1,011 performed by VT, n = 119 by EC).
| Variable | Right Heart Catheterization (n=181) | Right Heart Catheterization +Biopsy (n=146) | |||||
|---|---|---|---|---|---|---|---|
| Neck (n=174) | Arm (n=121) | P Value | Neck (n=594) | Arm (n=141) | P Value | ||
| Mean age (years) | 54.8±11.7 | 55.4±11.6 | 58.1±11.9 | 0.05 | 53.8±11.9 | 56.5±10.5 | 0.02 |
| Men | 797 (70.5%) | 122 (70.1%) | 67 (55.4%) | 0.01 | 430 (72.4%) | 127 (90.1%) | <0.001 |
| Mean height (cm) | 172.9±8.8 | 173.8±9.7 | 171.5±9.4 | 0.04 | 172.9±8.4 | 174.3±7.3 | 0.09 |
| Mean weight (kg) | 82.04±18.54 | 87.43±22.16 | 83.02±21.44 | 0.09 | 81.17±16.46 | 83.55±17.9 | 0.13 |
| Mean body surface area (m 2 ) | 1.95±0.23 | 2.02±0.27 | 1.95±0.27 | 0.05 | 1.95±0.21 | 1.98±0.22 | 0.11 |
| Mean body mass index (kg/m 2 ) | 27.3±5.5 | 28.8±6.7 | 28.1±6.7 | 0.38 | 27.1±4.9 | 27.5±5.6 | 0.38 |
| Mean elapsed time (min.) | 59±21 | 60±20 | 62±19 | 0.24 | 55±19 | 63±17 | <0.001 |
| Mean fluoroscopy time (min.) | 4.46±3.85 | 3.43±3.81 | 4.99±5.15 | <0.01 | 4.14±3.40 | 5.22±2.63 | <0.001 |
| Indications | |||||||
| Heart failure | 204 (18.1%) | 81 (46.6%) | 69 (57.0%) | 0.08 | 25 (4.2%) | 8 (5.7%) | 0.45 |
| Cardiomyopathy | 103 (9.1%) | 37 (21.3%) | 23 (19.0%) | 0.65 | 30 (5.1%) | 6 (4.3%) | 0.70 |
| Heart transplant | 724 (64.1%) | 10 (5.7%) | 4 (3.3%) | 0.02 | 517 (87.0%) | 126 (89.4%) | 0.45 |
| Pulmonary hypertension | 40 (3.5%) | 20 (11.5%) | 18 (14.9%) | 0.40 | 1 (0.2%) | 0 | 0.62 |
| Other | 59 (5.2%) | 26 (14.9%) | 7 (5.8%) | 0.01 | 21 (3.5%) | 1 (0.7%) | 0.08 |
| Inpatient | 286 (25.3%) | 76 (43.7%) | 37 (30.6%) | 0.02 | 127 (21.4%) | 14 (9.9%) | <0.01 |
| Outpatient | 844 (74.7%) | 98 (56.3%) | 84 (69.4%) | 0.02 | 467 (78.6%) | 127 (90.1%) | <0.01 |
The neck approach was performed with ultrasound-guided identification of the internal jugular vein and modified Seldinger technique for insertion of a 7Fr sheath. The arm approach used ultrasound-assisted access of a right upper arm deep vein (basilic or brachial) with a staged 5Fr micropuncture catheter and upsizing to establish venous access with a standard 7Fr sheath (identical to that used for the neck) for either RHC or RHC + biopsy procedures. The RHC + biopsy procedure incorporated a 5Fr pediatric Mullins sheath, which was passed through the 7Fr sheath over a 0.25-in guidewire from the arm to the superior vena cava. Fluoroscopic confirmation of RHC or RHC + biopsy procedure during either neck or arm approach was similar. Preprocedural and postprocedural care, including sterile technique and manual hemostasis, were identical. Postprocedural chest X-ray was not routinely performed after either technique.
Results
Over a total of 5.5 years, 276 patients underwent 1,130 right-sided cardiac procedures. Of the 1,030 procedures that used an arm- or neck-based approach, 295 were RHC and 735 were RHC + biopsy. Baseline demographic data did not indicate clinically substantive differences between neck and arm approaches that were relevant to the procedural approach ( Table 1 ). Statistically significant differences were noted in mean fluoroscopic time in RHC cases (3.43 ± 3.81 neck vs 4.99 ± 5.15 arm, p <0.01) and RHC + biopsy cases (4.14 ± 3.40 neck vs 5.22 ± 2.63 arm, p <0.001), whereas only RHC + biopsy procedures demonstrated statistically significant differences in mean elapsed time (55 ± 19 neck vs 63 ± 17 arm, p <0.001).
All attempted procedures were successful. There were 7 complications (0.6%), all occurring from neck-access procedures, including 6 arterial punctures (2 neck RHC, 4 neck RHC + biopsy) and 1 right ventricular perforation (neck RHC + biopsy) without long-term sequela.
There were 44 unique patients who underwent both neck and arm approaches during the study interval; 7 of these patients also had both RHC and RHC + biopsy procedures ( Table 2 ). Because these cohorts comprised exactly the same patients having serial procedures, we were able to query them on patient-related preference. A standard scripted questionnaire was posed verbally to patients, who were asked to grade each procedure on a scale of 1 to 5 ( Figure 1 ). Statistically significant lower anxiety and pain (p <0.05) were noted in the arm approach, whereas total procedure time and postprocedural concerns were not perceived differently. Finally, patients significantly preferred the arm approach to the neck approach (p <0.05) in either procedure.
| Variable | Right Heart Catheterization (23 procedures) | Right Heart Catheterization+Biopsy (28 procedures) | ||||
|---|---|---|---|---|---|---|
| Neck (n=36) | Arm (n=40) | P Value | Neck (n=235) | Arm (n=127) | P Value | |
| Mean procedures/patient | 1.6 | 1.7 | NS | 8.4 | 4.5 | NS |
| Altered approach | 1 (CHD) | 2 (CD) | NS | 2 (VA) | 1 (pain) | NS |
| Mean elapsed time (min±SD) | 53±14 | 57±18 | 0.28 | 56±17 | 63±17 | <0.001 |
| Mean fluoroscopy time (min±SD) | 3.13±3.83 | 5.40±7.86 | 0.12 | 4.24±3.48 | 5.21±2.66 | <0.01 |
| Complications | 0 | 0 | NS | 1 (ART) | 0 | NS |
| Cost | $162.57 | $180.36 | NS | $351.57 | $475.83 | NS |
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