Cardiac VentriculographyCardiac Ventriculography

Grossman’s cardiac catheterization, Grossman’s cardiac catheterization, angiography, and interventionangiography, and intervention

CV R5 CV R5 許志新醫師許志新醫師Supervisor:Supervisor: 詹世鴻醫師詹世鴻醫師

Left VentriculographyLeft Ventriculography

Valuable information about global and segmValuable information about global and segmental left ventricular functionental left ventricular function

Mitral valvular incompetenceMitral valvular incompetence Ventricular septal defectVentricular septal defect Hypertrophic cardiomyopathy Hypertrophic cardiomyopathy

Injection CathetersInjection Catheters

It is necessary to deliver a relative large It is necessary to deliver a relative large amount of contrast material in a relative amount of contrast material in a relative short timeshort time

In adults, 6F,7F, or 8F catheter with multiple In adults, 6F,7F, or 8F catheter with multiple side-holesside-holes allow the catheter to remain in a allow the catheter to remain in a stable position during injection stable position during injection

Sones

Lehman NIH

Gensini

Pigtail

Pigtail CatheterPigtail Catheter

The loop shape keeps the end-hole away froThe loop shape keeps the end-hole away from direct contact with the endocardiumm direct contact with the endocardium

Multiple side-holes stabilize the catheter witMultiple side-holes stabilize the catheter within the left ventricle during contrast injection hin the left ventricle during contrast injection and reducing the magnitude of catheter recoand reducing the magnitude of catheter recoil il

Pigtail cathetersPigtail catheters

Pigtail catheters can also be passed retrogrPigtail catheters can also be passed retrograde across a ball valve prosthesis (Starr-Edade across a ball valve prosthesis (Starr-Edwards), Only smallest diameter catheter showards), Only smallest diameter catheter should be used for this purpose.uld be used for this purpose.

No catheter should ever be passed across a No catheter should ever be passed across a tilting disc aortic valve prosthesis(Bjork-Shiltilting disc aortic valve prosthesis(Bjork-Shiley, Medtroni-Hall or St.Jude) ey, Medtroni-Hall or St.Jude)

Sones CatheterSones Catheter

The Sones catheters is used widely for left vThe Sones catheters is used widely for left ventriculography when catheterization is perfentriculography when catheterization is performed from the ormed from the brachial approachbrachial approach

Sones catheter should be positioned in an aSones catheter should be positioned in an axial orientation, with its tip midway between txial orientation, with its tip midway between the aortic valve and left ventricular apexhe aortic valve and left ventricular apex

Operator should Operator should holdhold the catheter the catheter during injduring injectionection

NIH and Eppendorf CathetersNIH and Eppendorf Catheters

The NIH and Eppendorf catheters have multThe NIH and Eppendorf catheters have multiple side-holes and iple side-holes and no end-holeno end-hole

Lehman CatheterLehman Catheter

The Lehman ventriculographic catheter has The Lehman ventriculographic catheter has a a tapered, closed tiptapered, closed tip that extends beyond m that extends beyond multiple side-holes.ultiple side-holes.

The tapered tip may assist the operator in mThe tapered tip may assist the operator in manipulating the catheter through tortuous artanipulating the catheter through tortuous arteries and across a stenotic aortic valve. eries and across a stenotic aortic valve.

Injection SiteInjection Site

In the left ventricle, the optimal catheter posiIn the left ventricle, the optimal catheter position is the tion is the midcavity.midcavity.

A) adequate contrast is delivered to the chaA) adequate contrast is delivered to the chamber’s body and apexmber’s body and apex

B) Catheter does not interfere with mitral valB) Catheter does not interfere with mitral valvular functionvular function

C) Holes are not wedged within the ventriculC) Holes are not wedged within the ventricular trabeculae ar trabeculae

Injection SiteInjection Site

In some patients, a midcavitary position induIn some patients, a midcavitary position induces repetitive ventricular ectopy.ces repetitive ventricular ectopy.

In these individuals, the tip of the catheter is In these individuals, the tip of the catheter is best positioned in the left ventricular inflow trbest positioned in the left ventricular inflow tract, immediately in front of the posterior leaflact, immediately in front of the posterior leaflet of the mitral valve. et of the mitral valve.

Injection SiteInjection Site

In the right ventricle, the optimal catheter poIn the right ventricle, the optimal catheter position is the midcavity.sition is the midcavity.

If ectopy is uncontrollable, the catheter may If ectopy is uncontrollable, the catheter may be positioned in the outflow tract, below the be positioned in the outflow tract, below the pulmonic valve.pulmonic valve.

Injection Rate and VolumeInjection Rate and Volume

For the pigtail, Eppendorf, and NIH catheterFor the pigtail, Eppendorf, and NIH catheters, an injection rate of s, an injection rate of 10-16mL/sec10-16mL/sec(higher fo(higher for high cardiac output and large ventricular chr high cardiac output and large ventricular chamber and total volume of amber and total volume of 30-55mL30-55mL ( depen ( depending on ventricular size) ding on ventricular size)

Injection rate and VolumeInjection rate and Volume

If a Sonos catheter is used, the rate of injectiIf a Sonos catheter is used, the rate of injection should not exceed 7 to 12 mL/sec, to minon should not exceed 7 to 12 mL/sec, to minize the chance of recoil and staining ize the chance of recoil and staining

Injection Rate and VolumeInjection Rate and Volume

In the patient with hemodynamic evidence of In the patient with hemodynamic evidence of severe left ventricular dysfunction ( mean Psevere left ventricular dysfunction ( mean PCWP higher than 25 mmHg ), left ventriculoCWP higher than 25 mmHg ), left ventriculography should be performed with the use of graphy should be performed with the use of a a low-osmolarlow-osmolar contrast agent. contrast agent.

Low-osmolar agents produce only minor decLow-osmolar agents produce only minor decreases in ionized calcium in the coronary cirreases in ionized calcium in the coronary circulation and therefore have a minimal myocculation and therefore have a minimal myocardial depressant effect. ardial depressant effect.

Injection rate and VolumeInjection rate and Volume

If filling pressures are markedly elevated, lefIf filling pressures are markedly elevated, left ventriculography should be performed durit ventriculography should be performed during the administration of nitroglycerin or soding the administration of nitroglycerin or sodium nitroprussideum nitroprusside

If the pulmonary capillary wedge pressure is If the pulmonary capillary wedge pressure is greatly elevated because of mitral stenosis, lgreatly elevated because of mitral stenosis, left ventriculography should be preceded by teft ventriculography should be preceded by the administration of morphine and furosemihe administration of morphine and furosemidede

Injection Rate and VolumeInjection Rate and Volume

The injector is loaded with contrast material The injector is loaded with contrast material through a short U-shaped straw while the sythrough a short U-shaped straw while the syringe barrel is pointed ringe barrel is pointed upwardupward

With the injector still in the vertical position, With the injector still in the vertical position, a 30-inch length of sterile roentgeography tua 30-inch length of sterile roentgeography tubing is connected to the syringe and all air is bing is connected to the syringe and all air is expelled from the syringe and tubing expelled from the syringe and tubing

Injection Rate and VolumeInjection Rate and Volume

Before the left ventriculographic run, a Before the left ventriculographic run, a test itest injectionnjection of a small amount of contrast materi of a small amount of contrast material is performed under fluoroscopic visualizatial is performed under fluoroscopic visualizationon

1) assess catheter and patient position1) assess catheter and patient position 2) confirm that ventricular ectopy does not o2) confirm that ventricular ectopy does not o

ccurccur 3) exclude a reaction to contrast material. 3) exclude a reaction to contrast material.

Filming Projection and TechniqueFilming Projection and Technique

In the patient with coronary artery disease, In the patient with coronary artery disease, biplane is superior to single plane in biplane is superior to single plane in providing information on the location and providing information on the location and severity of segmental wall motion severity of segmental wall motion abnormalities.abnormalities.

Biplane Ventriculography DisadvantaBiplane Ventriculography Disadvantagesges

Increased expense of biplane cineangiograpIncreased expense of biplane cineangiographic equipmenthic equipment

Reduced quality of cineangiographic imaginReduced quality of cineangiographic imaging in each plane that results from the radiatiog in each plane that results from the radiation scatter caused by the opposite planen scatter caused by the opposite plane

Addition time to position the biplane equipmAddition time to position the biplane equipmentent

Addition radiation exposureAddition radiation exposure

Filming Projection and TechiniqueFilming Projection and Techinique

Most laboratories doing biplane left ventriculMost laboratories doing biplane left ventriculography prefer a ography prefer a 3030° right anterior oblique ( ° right anterior oblique ( RAO ) and a 60 °left anterior oblique ( LAO ) RAO ) and a 60 °left anterior oblique ( LAO ) view.view.

30 30 ° RAO projection elimnates overlap of the ° RAO projection elimnates overlap of the left ventricle and the vertebral column; allowleft ventricle and the vertebral column; allows one to assess anterior, apical, and inferior s one to assess anterior, apical, and inferior segmental wall motion; and providing a reliasegmental wall motion; and providing a reliable assessment of the presence and angiogrble assessment of the presence and angiographic severity of mitral regurgitation. aphic severity of mitral regurgitation.

60 60 ° LAO view allows one to assess ventricu° LAO view allows one to assess ventricular septal integrity and motion, lateral and polar septal integrity and motion, lateral and posterior segmental function, and aortic valvulsterior segmental function, and aortic valvular anatomy.ar anatomy.

To prevent the foreshortening of the left venTo prevent the foreshortening of the left ventricle and visualize the entire length of the inttricle and visualize the entire length of the interventricular septum in profile, erventricular septum in profile, 15 ° to 20 ° c15 ° to 20 ° cranial angulationranial angulation should be added. should be added.

Analysis of the VentriculogramAnalysis of the Ventriculogram

The most common analysis is a qualitative The most common analysis is a qualitative assessment of global and regional systolic assessment of global and regional systolic functionfunction

Analysis should use a Analysis should use a normal sinus beatnormal sinus beat that follows a previous normal sinus beat.that follows a previous normal sinus beat.

Ejection FractionEjection Fraction

Normal: 50 % to 69%Normal: 50 % to 69% Hyperdynamic: more than 70 %Hyperdynamic: more than 70 % Mildly hypokinetic: 35% to 49%Mildly hypokinetic: 35% to 49% Moderaely hypokinetic: 20% to 24 %Moderaely hypokinetic: 20% to 24 % Severely hypokinetic: less than 20% Severely hypokinetic: less than 20%

Regional Wall MotionRegional Wall Motion

NormalNormal HypokineticHypokinetic AkineticAkinetic DyskineticDyskinetic

Degree of Mitral RequrgitationDegree of Mitral Requrgitation

Looking for leakage of contrast material froLooking for leakage of contrast material from the left ventricle back into the left atrium am the left ventricle back into the left atrium and the relative opacification of the left atriumnd the relative opacification of the left atrium

Mild ( 1+ ): less than 30 %Mild ( 1+ ): less than 30 % Moderate ( 2+ ): 30% to 39 %Moderate ( 2+ ): 30% to 39 % Moderately severe ( 3+ ): 40% to 49%Moderately severe ( 3+ ): 40% to 49% Severe: greater than 50 % Severe: greater than 50 %

Intervention VentriculographyIntervention Ventriculography

Segmental dysfunction can be caused by isSegmental dysfunction can be caused by ischemia or infarctionchemia or infarction

Abnormal wall motion caused by ischemia sAbnormal wall motion caused by ischemia show improvement by following techniqueshow improvement by following techniques

Administration of catecholamines, nitroglyceAdministration of catecholamines, nitroglycerin, or postextrasystolic potentiation rin, or postextrasystolic potentiation

ComplicationsComplications

Complication of injectionComplication of injection Complication of contrast materialComplication of contrast material

Complication of injectionComplication of injection

ArrhymiasArrhymias Intramyocardial injection ( Endocardial stainiIntramyocardial injection ( Endocardial staini

ng)ng) Fascicular blockFascicular block EmbolismEmbolism

ArrhymiasArrhymias

Ventricular extrasystoles occur frequently duVentricular extrasystoles occur frequently during ventriculographyring ventriculography

Rarely, ventricular tachycardia is sustained Rarely, ventricular tachycardia is sustained even after catheter removal, it should be treeven after catheter removal, it should be treated quickly with a bolus of intravenous lidocated quickly with a bolus of intravenous lidocaine or direct current countershock. aine or direct current countershock.

Intramyocardial InjecionIntramyocardial Injecion

Intramyocardial injection is usually caused bIntramyocardial injection is usually caused by y improper positionimproper position of the catheter. of the catheter.

Although a small endocardial stain usually cAlthough a small endocardial stain usually cause no problem, a large stain may lead to vause no problem, a large stain may lead to ventricular tachycardia or fibrillation.entricular tachycardia or fibrillation.

Rarely, the power injection of contrast materRarely, the power injection of contrast material caused myocardial perforation. ial caused myocardial perforation.

Fascicular BlockFascicular Block

Because of the proximity of the anterior Because of the proximity of the anterior fascicle of left bundle to the left ventricular fascicle of left bundle to the left ventricular outflow tract, transient left anterior fascicular outflow tract, transient left anterior fascicular block may occur during retrograde left-sided block may occur during retrograde left-sided heart catheter.heart catheter.

Catheter –induced fascicular block usually Catheter –induced fascicular block usually resolves within 12 to 24 hours. resolves within 12 to 24 hours.

Complication of Contrast MaterialComplication of Contrast Material

For 20 to 30 seconds after ventriculography For 20 to 30 seconds after ventriculography with high-osmolar agent, the patient will expwith high-osmolar agent, the patient will experience a “hot flash” owing to the powerful verience a “hot flash” owing to the powerful vasodilation.asodilation.

Transient nausea and vomiting may also in Transient nausea and vomiting may also in 20 % to 30% patients20 % to 30% patients

These complication are uncommon with low-These complication are uncommon with low-osmolar contrast agents osmolar contrast agents

Complication of Contrast MaterialComplication of Contrast Material

The immediate but short-lived hemodynamiThe immediate but short-lived hemodynamic effects of ventriculography with ion contrasc effects of ventriculography with ion contrast agents include a modest fall in systemic artt agents include a modest fall in systemic arterial pressure, a reflex increase in heart rate,erial pressure, a reflex increase in heart rate, and a transient depression of left ventricular and a transient depression of left ventricular contractility, these resolve within 1 to 2 minucontractility, these resolve within 1 to 2 minutes. tes.

Measurement of Ventricular Measurement of Ventricular Volumes, Ejection fraction, Mass, Volumes, Ejection fraction, Mass, Wall Stress, and Regional Wall Wall Stress, and Regional Wall

MotionMotion Grossman’s cardiac catheterization, Grossman’s cardiac catheterization,

angiography, and interventionangiography, and intervention

CV R5 CV R5 許志新醫師許志新醫師Supervisor:Supervisor: 詹世鴻醫師詹世鴻醫師

VolumesVolumes

In the first step in assessing left ventricular cIn the first step in assessing left ventricular chamber volume, the ventricular silhouette shhamber volume, the ventricular silhouette should be traced at the outermost margin of viould be traced at the outermost margin of visible radiographic contrast.sible radiographic contrast.

The aortic valve border is defined as a line cThe aortic valve border is defined as a line connecting the inferior aspects of the sinuses onnecting the inferior aspects of the sinuses of Valsalva of Valsalva

To facilitate the calculation of left ventricular To facilitate the calculation of left ventricular volume, the ventricle is usually volume, the ventricle is usually approximated by an approximated by an ellipsoid.ellipsoid.

Ventricular volumes calculated by most Ventricular volumes calculated by most mathematical techniques mathematical techniques overestimateoverestimate, so , so that that regression equationsregression equations must be used to must be used to correct for the overestimation correct for the overestimation

Biplane FormulaBiplane Formula

V=4/3V=4/3ππx L/2 x M/2 x N/2x L/2 x M/2 x N/2 AARAO RAO = = ππLLRAORAO/2 x M/2/2 x M/2

AALAO LAO = = ππLLLAOLAO/2 x N/2/2 x N/2

V= 8/ 3V= 8/ 3ππ x A x ARAO RAO AALAOLAO/L/Lminmin

Single-plane FormulaSingle-plane Formula

V= V= ππ/6 LMN/6 LMN M=4A /M=4A /ππLL V = 8AV = 8A2 2 / 3/ 3ππLL

Regression equationsRegression equations

Ejection FractionEjection Fraction

EF = ( EDV-ESV ) / EDVEF = ( EDV-ESV ) / EDV

Regurgitant FractionRegurgitant Fraction

RF = SV RF = SV angiographic angiographic - SV - SV forward forward / SV / SV angiographic angiographic

Other Techniques for Measuring Other Techniques for Measuring Ventricular Volume and Ejection Ventricular Volume and Ejection

FractionFraction

Multielectrode catherterMultielectrode catherter : 12 platinum ring el : 12 platinum ring electrodes mounted at 1 cm intervals along thectrodes mounted at 1 cm intervals along the distal end of an 8F or 9 F end-hole cathetee distal end of an 8F or 9 F end-hole catheter.r.

Regional Left Ventricular Wall Regional Left Ventricular Wall MotionMotion

End-diastolic and end-systolic ventricular End-diastolic and end-systolic ventricular silhouettes are superimposed.silhouettes are superimposed.