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 your doctor takes tissue samples directly from your heart muscle.

In a right-heart cath, your doctor guides a special catheter (a small, thin tube) into the right side of your heart. The catheter is passed into your pulmonary artery. This is the main artery that carries blood to your lungs. As the catheter is advanced into your pulmonary artery, your doctor measures pressures in your right atrium (right upper heart chamber) and right ventricle (right lower heart chamber). In some cases, your doctor gives you intravenous (IV) heart medicines during the right-heart cath to see how your heart responds. For example, if the pressure is high in your pulmonary artery, your doctor may give you medicines to dilate, or relax, the blood vessels in your lungs and to help lower the pressure. Healthcare providers will take several pressure readings  during the procedure to measure your body's response to the medicines.

Your doctor can take indirect measurements of pressures in the left side of your heart, by inflating a small balloon at the tip of the catheter as well. The amount of blood your heart pumps per minute is also measured during a right-heart catheterization.  

Your doctor usually does the biopsy at the end of the right-heart cath. Another catheter is inserted into a vein, usually in your neck. At the end of the catheter is a tool to take a tissue sample. The tiny pieces of heart tissue are sent to the lab for examination under a microscope. Doctors, known as pathologists, examine your tissue under a microscope for signs of infection, inflammation, or abnormal cells. Your doctor does the biopsy to see if your heart tissue is normal.

Why might I need a right heart catheterization with heart tissue biopsy?

A biopsy may be done to:  

• Diagnose the cause of heart failure or heart disease, such as dilated cardiomyopathy. This is caused by a  bacterial or viral infection. The procedure can also diagnose restrictive cardiomyopathy, caused by many different conditions such as amyloidosis. Amyloidosis is caused by irregular deposits of proteins in the heart that affect the contraction and relaxation of the heart muscle. Knowing the cause of heart failure can help to determine the treatment plan. 
• Determine how well or poorly your heart is responding to heart failure treatment. Your healthcare team may need the information to adjust medicines used to treat heart failure.
• Evaluate heart tissue after a heart transplant, to make sure your body is not rejecting the transplanted (donor) heart.

A right-heart cath with biopsy may also be needed as part of your evaluation before a heart transplant. Pressures in your lungs need to be as low as possible for a donor heart to work as well as possible. Excessive pressures will make it hard for the new (donor) heart to pump effectively. A right- heart cath will help to see if pulmonary pressures can be decreased with medicines (vasodilators) to ensure successful transplantation. 

Your healthcare provider may have other reasons to recommend a right-heart cath with biopsy.

What are the risks of a right heart catheterization with heart tissue biopsy?

Possible risks of 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 catheter is inserted into your neck or chest veins.
• Perforation of the wall of your 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 its ability to pump blood effectively), rarely resulting in death
• Low blood pressure
• Tricuspid valve damage (the valve on the right side of your heart)
• Infection
• Air embolism (air leaking into your heart or chest area), rarely resulting in death
• Blood clots at the tip of the catheter that can block blood flow
• Pulmonary artery rupture (damage to the main artery in your lung, which can result in serious bleeding and make it hard to breathe)
• Nerve damage

For some people, 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 healthcare provider before the procedure. 

How do I get ready for a right heart catheterization with heart tissue biopsy?

• Your healthcare provider will explain the procedure to you and you can ask questions.
• 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 unclear.
• Tell your healthcare provider if you are sensitive to or are allergic to any medicines, latex, tape, or anesthetic agents (local and general).
• If you are pregnant or think you could be, you should tell your healthcare provider.
• Tell your healthcare provider of all medicines (prescription and over-the-counter) and herbal supplements that you are taking.
• Tell your healthcare provider if you have a history of bleeding disorders, or if you are taking any anticoagulant (blood-thinning) medicines such as warfarin, aspirin, or other medicines that affect blood clotting. You may need to stop some of these medicines before the procedure.
• Tell your healthcare provider if you have a pacemaker, an implantable defibrillator, or another implanted device.
• If you have an artificial heart valve, your healthcare provider will decide if you should stop taking warfarin before the procedure. 
• You may be asked not to eat or drink anything after midnight or within 8 hours before the procedure.

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

What happens during a right heart catheterization with heart tissue biopsy?

Your doctor will do the right-heart cath with biopsy in the cardiac cath lab or in a special department.  If you are critically ill, your doctor may give you the test in the intensive care unit (ICU). A right-heart cath may be done 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 need 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 need to remove your clothing and will be given a gown to wear.
• You will need to empty your bladder before the procedure.
• An IV line will be started in your hand or arm before the procedure to inject medicine, and give fluids, if needed.
• You will lie on your back on the procedure table.
• You will be connected to an electrocardiogram (ECG) monitor. An ECG records the electrical activity of your heart during the procedure, through small, adhesive electrodes. Your doctor will closely monitor your vital signs (heart rate, blood pressure, breathing rate, and oxygenation level) during the procedure.
• Sedation is generally not required for this procedure, but you may be given a medicine to help you relax.
• If your 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. Next, a thin tube called a catheter will be inserted into the vein. You may feel some burning or stinging when the numbing medicine is given and some pressure when the needle punctures your vein.
• Your doctor will place an introducer sheath (a slightly larger, hollow tube) into your vein first. Next, he or she will insert the biopsy catheter into 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 taken.
• If a right heart cath is done at the same time, another catheter will be placed through your right atrium, right ventricle, and into your pulmonary artery. Heart and lung pressures will be measured. Special medicines may be given through the IV to evaluate our heart's response. It may take about 30 minutes to monitor your heart's response to the medicines.
• Once your doctor gets information from your tissue samples and heart pressure, the catheter and introducer will be removed, unless your doctors decide you need additional monitoring in the ICU or post procedure recovery area.

What happens after a right heart catheterization with heart tissue biopsy?

Medical staff will put pressure over the insertion site for a minute or two, to make sure 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 your neck vein was used (most commonly), you will be able to sit up comfortably. If your groin was 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. Your healthcare provider will monitor the insertion site for bleeding and check your blood pressure, heart rate, and breathing while you recover. Let your healthcare provider know if you have any chest pain or trouble 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 of the right-heart cath and the plan for treatment if needed.

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

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, tell your healthcare provider.

It will be important to keep the insertion site clean and dry. Your healthcare provider will give you specific bathing instructions.

You may be told not to participate in any strenuous activities. Your healthcare provider will instruct you about when you can return to work and resume normal activities.

Tell your healthcare provider to report any of the following:

• Shortness of breath or trouble breathing
• Fever with a temperature greater than or equal to 100.4°F (38°C) or chills
• Increased pain, redness, swelling, or bleeding or other drainage from the insertion site
• Coolness, numbness or tingling, or other changes in the affected extremity
• Chest pain or pressure, nausea or vomiting, profuse sweating, dizziness, or fainting

Your healthcare provider may give you other instructions after the procedure, depending on your situation.

Next steps

Before you agree to the test or the procedure make sure you know:

• The name of the test or procedure
• The reason you are having the test or procedure
• What results to expect and what they mean
• The risks and benefits of the test or procedure
• What the possible side effects or complications are
• When and where you are to have the test or procedure
• Who will do the test or procedure and what that person’s qualifications are
• What would  happen if you did not have the test or procedure
• Any alternative tests or procedures to think about
• When and how will you get the results
• Who to call after the test or procedure if you have questions or problems
• How much will you have to pay for the test or procedure