Non-Emergent Right Heart Catheterizations can be Performed in Patients with Elevated INR: Clinical Outcomes at the University of Maryland Medical Center

Abstract

Introduction Right heart catheterizations (RHC) remains the gold standard for pulmonary hypertension (PH) diagnosis, and a key component to heart failure (HF) risk assessment and in advanced heart failure planning. Many patients with HF and PH require anticoagulation (AC) which cannot be safely held without enoxaparin bridging, due to mechanical heart valves, left ventricular assist devices (LVAD), or chronic thromboembolic pulmonary hypertension (CTEPH). While it is increasingly common to perform RHC without interruption of warfarin AC, no studies have analyzed complication rates in this population. RHC in patients on AC with elevated INR does not lead to more frequent adverse events. Methods We performed a retrospective analysis of patients over 18 years old with PH and/or HF who underwent RHC at the University of Maryland Medical Center during 2013 calendar year to determine the complication rate and assess for potential pre-procedural predictors of complications. Those with heart transplants undergoing surveillance endomyocardial biopsy were excluded. Results A total of 270 right heart catheterizations were reviewed . There were 41 heart transplants that were excluded. Of the remaining 229 cases, 163 (71%) patients had heart failure—110 (48%) with reduced ejection fraction. There were 170 (74%) patients with pulmonary hypertension and 9 patients with an LVAD. Of these cases, 80 (34%) had an INR >1.5 with 27 (12%) having an INR >2 . There were 62 (78%) patients on warfarin. The most common indication for AC was atrial fibrillation/flutter—37 (60%)—with 8 (13%) requiring AC for cardiac thrombus, 7 (11%) for pulmonary embolism/deep vein thrombosis, 4 (6%) for valvular pathology, and 3 (5%) for LVAD. A majority of cases, 179 (78%) gained access via the right internal jugular vein. Micro-puncture kit was used 3 cases. There were no reported cases of hematoma, major bleeding (hemoglobin drop >2gm/dL), pulmonary hemorrhage, or cardiac tamponade. Two patients reported site discomfort—neither had an elevated INR. Conclusion RHC can be safely performed in patients with an elevated INR. In light of a growing population of LVAD's, and increasing awareness of CTEPH, a growing population of patients with advanced cardiopulmonary disease requires uninterrupted AC. If confirmed on a larger patient population, these findings would improve patient comfort and significantly reduce health care costs by eliminating the need for enoxaparin bridging or hospital admission for intravenous unfractionated heparin.