Heart Catheterization - 2 
Medical specialty:  Cardiovascular / Pulmonary
 Right heart catheterization.   Refractory CHF to maximum medical therapy.

PROCEDURE PERFORMED:,  Right heart catheterization.,INDICATION: , Refractory CHF to maximum medical therapy.,PROCEDURE: , After risks, benefits, and alternatives of the above-mentioned procedure were explained to the patient and the patient's family in detail, informed consent was obtained both verbally and in writing.  The patient was taken to Cardiac Catheterization Suite where the right internal jugular region was prepped and draped in the usual sterile fashion.  1% lidocaine solution was used to infiltrate the skin overlying the right internal jugular vein.  Once adequate anesthesia has been obtained, a thin-walled #18 gauge Argon needle was used to cannulate the right internal jugular vein.  A steel guidewire was then inserted through the needle into the vessel without resistance.  Small nick was then made in the skin and the needle was removed.  An #8.5 French venous sheath was then advanced over the guidewire into the vascular lumen without resistance.  The guidewire and dilator were then removed.  The sheath was then flushed.  A Swan-Ganz catheter was inserted to 20 cm and the balloon was inflated.  Under fluoroscopic guidance, the catheter was advanced into the right atrium through the right ventricle and into the pulmonary artery wedge position.  Hemodynamics were measured along the way.  Pulmonary artery saturation was obtained.  The Swan was then kept in place for the patient to be transferred to the ICU for further medical titration.  The patient tolerated the procedure well.  The patient returned to the cardiac catheterization holding area in stable and satisfactory condition.,FINDINGS:,  Body surface area equals 2.04, hemoglobin equals 9.3, O2 is at 2 liters nasal cannula.  Pulmonary artery saturation equals 37.8.  Pulse oximetry on 2 liters nasal cannula equals 93%.  Right atrial pressure is 8, right ventricular pressure equals 59/9, pulmonary artery pressure equals 61/31 with mean of 43, pulmonary artery wedge pressure equals 21, cardiac output equals 3.3 by the Fick method, cardiac index is 1.6 by the Fick method, systemic vascular resistance equals 1821, and transpulmonic gradient equals 22.,IMPRESSION:  ,Exam and Swan findings consistent with low perfusion given that the mixed venous O2 is only 38% on current medical therapy as well as elevated right-sided filling pressures and a high systemic vascular resistance.,PLAN: , Given that the patient is unable to tolerate vasodilator therapy secondary to significant orthostasis and the fact that the patient will not respond to oral titration at this point due to lack of cardiac reserve, the patient will need to be discharged home on Primacor.  The patient is unable to continue with his dobutamine therapy secondary to nonsustained ventricular tachycardia.  At this time, we will transfer the patient to the Intensive Care Unit for titration of the Primacor therapy.  We will also increase his Lasix to 80 mg IV q.d.  We will increase his amiodarone to 400 mg daily.  We will also continue with his Coumadin therapy.  As stated previously, we will discontinue vasodilator therapy starting with the Isordil.