CLINICAL PROGRESS

Retrograde Arterial Catheterization of theLeft Heart

Experience with 500 Infants and Children

By PETER VLAD, M.D., ARNO HOHN, M.D., AND EDWARD C. LAMBERT, M.D.

HISTORICALLY, retrograde catheteriza-tion of the arterial circulation appears

to have been the first method employed inthe study of the left heart. Cournand1 citesthe physiologic studies of Chauveau andMarey. They recorded pressure tracings ob-tained from the left ventricle of the erect,unanesthetized horse in 1861.2 3

Almost 100 years later, in 1950, three groupsof workers reported application of this ap-proach to man. Zimmerman, Scott, and Beck-er4 were first to publish. However, they weresuccessful only in patients with aortic regurgi-tation, being unable to pass through the nor-mal aortic valve. Furthermore, one of their 11patients succumbed from ventricular fibrilla-tion during the procedure and another died4 days later. Limon, Rubio, and Bouchard5were the first to establish this method as asafe, effective approach in man, allowing pas-sage of the catheter across the normal aorticvalve in 17 patients without complications.Later in that year Sodi-Pallares 6 and his groupconfirmed Limon's success in 25 patients stud-

From the Children's Hospital of Buffalo and theDepartment of Pediatrics, State University of NewYork at Buffalo, School of Medicine, Buffalo, NewYork.

Supported by grants from the National Institutesof Health, U. S. Public Health Service (Grant HTS-5335), The Richard W. Goode and Mae Stone GoodeGift, The Patterson-Wheeler Fund, and the HeartAssociation of Erie County, Inc.

Dr. Hohn was a Postdoctoral Research Fellow, Na-tional Heart Institute, U. S. Public Health Service.

Circulation, Volume XXIX, May 1964

ied in order to obtain the left intraventricularpotentials of the human heart.

Unfortunately the morbidity and mortalityencountered by Zimmerman's group4 in man,and those experienced in dogs by Hellems andhis associates 7 and by Haddy and co-work-ers 8 appears to have delayed general accept-ance of this method. Only in the past five yearshas it been recognized as acceptable for diag-nostic use for pressure measurements and ofspecial value for selective ventriculography.9-12More recent is the recognition that it is a use-ful tool even in the presence of aortic steno-sis.10 13

The following is a report of an experiencewith 542 consecutive catheterizations by theretrograde arterial approach.

Material and Methods

MaterialA total of 542 left heart catheterizations were

performed in 500 patients by the retrograde ar-terial method between July 1957 and May 1963.Of these, 499 were accompanied by simultaneousright heart catheterization performed by usualmethods. Forty-two patients had two retrogradecatheterizations (table 1).The patients ranged in age from 1 week to

21 years, and 151 of these (30 per cent) wereinfants (patients under 2 years of age). Table 2shows the age distribution of the cases. The small-est patient weighed 1.87 Kg. and the largest 80.6Kg.

Cases were selected for left heart study when(1) significant hemodynamic data were neededfrom the left heart, (2) the possibility existed ofassociated anomalies that would be found onlyby studying the left heart, and (3) it was neces-sary to exclude an associated ventricular septal

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Table 1

Retrograde Arterial Left Heart Catheterization in 500 Patients

Numb

Total attempted retrograde catheterizations 542Successful entry of left ventricle 499Angiocardiograms from the left ventricle 337Simultaneous right heart catheterization 499

defect, pateint ductus arteriosus, mitral regurgita-tion, or coarctation of the aorta.

These catheterizations were done without re-gard to age. The seriousness of the abnormalitywas not used as a, contraindication. In all, 32 sep-arate anomalies were studied; 203 cases had morethan one hemodynamically significant defect (ta-ble 3).

MethodThe patients were sedated with an ataractic

mixture.)14 Under local anesthesia a peripheralartery (the right or left brachial artery or a super-ficial femoral artery) was isolated and a transverseinlcisioni was imtade. 13leedin1g w1as conitrolled byrubber bands encircling the artery above and be-low the arteriotomy. Five to 10 ml. of a diluteheparin-saline mixture were infused into the distalsegment of the artery. An ordinary cardiac cath-eter with a preformed, suitable curve was theninserted into the vessel by a simple metal intro-ducer.'5 , The catheter was then directed underfluoroscopic control into the ascending aorta.

Directing the catheter tip through the aorticvalve was accomplished by either a straight orlooped tip. To pass the catheter as a straight tipinto the left ventricle it was positioned with thetip pointing toward the left aortic sinus andihythmically tapped on the valve. After repeatedgentle tapping the catheter usually slipped intothe left ventricle (much as originally described bySodi-Pallares et al.6) where it could he positioned

Table 2

Five Htundred and Forty-twoLeft Heart Catheterizations: /Patients

Age group

0-1 mo.

1-6 mo.

2i-2 yr.

2-6 yr.

6-12 yr.

12-16 yr.

Over 16 yr.Total

Totalcases

18

70

63

117166

80

28

542

as niecessary (fig. 1A). This is the maneuver nec-essary in aortic stenosis. The second approach,that of Limon, Rubio, and Bouchard,j-, consistedof forming a small loop near the end of the cath-eter and passing it in this doubled form throughthe aortic valve (fig. 1B). Care was taken incatheter manipulation to avoid coronary arteryocclusion. When the approach was from the groin,passage of the catheter around the arch of theaorta had to be gentle in order to avoid vesseltrauma.

Entrance into the left atrium was obtained byforming a clockwise half loop of the catheter inthe left ventricle with the tip cephalad. Partialwithdrawal of the catheter hooked the tip throughthe mitral valve into the left atrium.Upon withdrawal of the catheter, free bleediing

from the artery both proximal and distal to thearteriotomy was induced. Repair of the vessel wasperformed by a purse string suture, continuousrunning suture, or continuous horizontal mattresssuture with 6-0 mersilene or silk on an atraumatic

Table 3

Retrograde Arterial Left Heart Catheterization:Defects Studied

Anomalous pulmonaryvenous return

Aortic regurgitationAortic septal defectAnrtir, Qfr.nnQiz0111 tlt: IS LllV5lsi

Atrial septal defectChronic constrictive

Retrograde Arterial pericarditisAge Groups in 500 Coaretation of the aorta

Coarctation of the psul-monary artery

Common A-V canalSuccess Per eceit Complete transposition of

15 83 the great vessels57 81 Congenital A-V block55 87 Cor triatriatum

111

1567728

499

959497

10(0)92

Coronary arterio-cameralfistula

Corrected transposition ofthe great vessels

Dextrocardia

Double outlet rightveentricle

Ebstein's malformationEndocardial fibro-

elastosisHemitruncus arteriosusIdiopathic cardio-myopathy

Marfan's syndromeMitral regurgitationPatent ductus arteriosusPulmonic regurgitationPulmonic stenosisRuptured sinlus of

ValsalvaSingle ventricleTetralogy of FallotTricuspid atresiaTruncus arteriosuisVascular ringVentricular septal defect

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LEFT HEART CATHETERIZATION

Table 5

One Hundred and Fifteen Retrograde ArterialLeft Heart Catheterizations in 93 Patients withAo'rtic Stenosis

Arm cutdownGroin cutdown

Total

Figure 1

The two common technics of passing the aortic valve:A, straight catheter; B, looped catheter.

needle. Early in the series and with small arteriesthe vessels were ligated with 3-0 silk.

During the entire procedure right and leftheart pressures and electrocardiograms were con-tinuously monitored on an oscilloscope.

ResultsIn 542 arterial catheterizations failure to

enter the left ventricle occurred 43 times, an

over-all success rate of 92 per cent (table 1).Fifteen per cent of 203 attempts in which thecutdown was performed in the groin were un-

successful, while 4 per cent of 339 attemptsfrom the antecubital fossa failed (table 4).Of the 115 catheterizations in patients with

aortic stenosis, it was impossible to enter theleft ventricle 13 times (table 5). Thus, foraortic stenosis (of all types), a success rate of89 per cent was obtained. Seven of eight cases

failed in which the approach was from thegroin.

In the absence of aortic stenosis 18 of the30 failures were in patients under 2 years ofage, a failure rate of 12 per cent. In 14 of the

Table 4

Approach Used in 542 RetrogradeHeart Catheterizations

GroinSuccessFailure

ArmSuccessFailure

Arterial Left

173(85%)30(15%)203

326(96%)13( 4%)

339

Number Success

107 101

8 1115 102

Per cent

941389

30 failures it was not possible to enter theascending aorta.The left atrium was entered from the left

ventricle 51 times in approximately 90 in-stances when a deliberate attempt was madeto enter this chamber with a curved-tipcatheter.

Morbidity and MortalityTwo deaths occurred. In addition, there

were four cases of ventricular fibrillation. Onepatient developed a transient hemiparesis andin two patients a laceration was produced inthe ductus arteriosus. In a single instancepostcatheterization peripheral vascular insuffi-ciency was observed. In 49 patients who diedfrom causes unrelated to catheterization no

evidence of injury to the heart valves or endo-cardium was seen at postmortem examination.

DiscussionAnalysis of the data presented confirms the

value of retrograde arterial left heart cathe-terization, particularly in a pediatric agegroup. The over-all success rate presented (92per cent) compares favorably with any pub-lished reports employing any technic in infantsand children. Brockenbrough et al.16 noted an

88-per cent success rate in 51 children withthe anterior percutaneous puncture of the leftventricle, and Roveti, Ross and Bahnson 17 hadan 85-per cent success rate with the transseptalroute in 20 pediatric patients. This high rateof success with retrograde methods has also

been reported by Green, Ziegler, and Kava-nagh-Gray.10 They were successful in enteringthe left ventricle in 88 of 100 patients.

Retrograde arterial left heart catheterizationas described has certain advantages. Access toa peripheral artery through an already estab-

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lished cutdown (for venous catheterization)without the use of additional anesthesiamakes the procedure convenient. All meas-urements may be made on unanesthetized pa-tients. In the method outlined no specialcatheters, guides, or other equipment is neces-sary. Closed-tip catheters can be used. Theseoffer distinct advantages in that during selec-tive angiocardiography they diminish the in-cidence of catheter recoil with poweredinjectionis and minimize the hazard of myo-cardial infiltration and perforation. In con-trast, catheters introduced by percutaneousmethods must be open tipped. In addition,pereutaneous methods of retrograde arterialleft heart catheterization do not lend them-selves readily to infants because of the smallsize of the arteries involved.Another virtue of retrograde arterial cathe-

terization is that valuable information can begathered from the central aortic system. Pres-sure determinations and selective angiog-raphy can exclude or detect coarctation ofthe aorta, vascular rings, patent ductus arte-riosus, supravalvular chambers, coronary anom-alies, and aortic regurgitation. In addition, itconstitutes an excellent method for localizingthe site of aortic stenosis.The results described indicate that the fail-

ure rate varied with the cutdown site (table4). The vessels of the antecubital fossa offereda higher rate of success (96 per cent) thandid those of the groin (85 per cent). Eitherarm was used with excellent chance of suc-cess. Only five instances of failure to pass thecatheter into the ascending aorta from the armwere recorded. Access to the left heart wasgained in 291 of 301 attempts from the rightarm, and 35 of 37 from the left arm. The latterprocedure was more difficult, however, asoriginally pointed out by Sodi-Pallares et al.6This is due to the arrangement of the vesselsarising from the arch of the aorta. Frequentlyin such instances the catheter passed into thedescending aorta instead of into the arch. Asimilar situation existed when the right armwas used and there was an anomalous originof the right subclavian artery distal to the left.This occurred in two patients in this series.

In infants and small children, when the ap-proach was from the groin, the technic offered11 per cent less chance of success than whenthe procedure was used in older patients. In151 tests (in 146 infants) data from the leftventricle were obtained in 127, for a successrate of 84 per cent. Closer analysis of the 151tests disclosed the following reasons for fail-ure in the 24 cases: aortic stenosis (six), theinability to round the arch of the aorta (eight-four cases of coarctation of the aorta, twoinappropriate catheter curves, two caseswhere the patent ductus arteriosus could notbe avoided), and 10 unexplained. When therewas no aortic stenosis, and the catheter couldbe passed aroulnd the arch of the aorta to thevalve, we were able to enter the left ventri-cle in 126 of 137 cases (92 per cent).

Reference has been made to the fact thataortic stenosi.s presents special problems. Theover-all success rate was 89 per cent. Retro-grade arterial catheterization was unsuccessfulin all but one of seven infants. These sevenand one 5-year-old boy were the only pa-tients with this anomaly in whom the heartwas approached from the groin, and all butone failed.

In the other cases of aortic stenosis whenthe valve was approached from the arm asuccess rate of 94 per cent was obtained. Thisis essentially the same as that obtained incases with unobstructed valves. The severityof stenosis had no bearing on the rate offailure. Four of the six failures with a brachialapproach occurred in two patients.

Similarly, the site of stenosis had little bear-ing on the success rate. Of the 13 failures, onehad subvalvular stenosis and one had com-bined supravalvular and subvalvular obstruc-tions.

It is obvious that the presence of a catheterin a stenotic orifice may exaggerate the degreeof obstruction. Only two cases of aortic steno-sis were studied by both retrograde methodsand anterior percutaneous puncture of theleft ventricle. These two cases had peak sys-tolic gradients across the stenosis of 68 and 78mm. Hg, respectively. The gradients were un-affected by the presence of the catheter.

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Table 6

Hazards Encountered in 542 Retrograde ArterialLeft Heart Catheterizations

Number Per cent

Mortality 2 0.4Morbidity

Ventricular fibrillation 4 0.7Other serious arrhythmias 0 0Cerebral vascular accident 1 0.2Trauma to ductus arteriosus 2 0.4Peripheral vascular insufficiency 1 0.2

Total 8 1.5

Passing a catheter across the aortic orificemay be time consuming. For this reason it isessential to use radiation-saving devices (im-age intensification and pulsing fluoroscopy).The difficulties encountered during retro-

grade arterial catheterization of babies withaortic stenosis also occurred in babies withcoarctation of the aorta. A catheter could not

be passed across the coarctation in four of 15infants with this obstruction. In another threethe aortic valve was not crossed, bringing theleft heart catheterization failures to seven.

Diagnostic aortograms were obtained in allcases, however.

Left atrial catheterization with the retro-grade arterial method was first reported indogs by Hellems et al.,7 and in occasional in-stances in man by Biermanl8 and by Fisher.19Despite the fact that catheterization of theleft atrium was not consistently sought, it waspossible to enter this chamber from the leftventricle 51 times. (None of the patients hadmitral stenosis.) Use of a straight-tip catheter,such as in cases of aortic stenosis, precludesany trial for left atrial entry. However, the51 successes indicate that left atrial cathe-terization by the retrograde arterial approachmay be accomplished in a significant numberof cases.

The complications encountered (table 6)have been experienced by others,20 21 and

were no more frequent than those recordedby other methods.22 Of the two deaths, one

occurred 5 days following catheterization in

an 11-month-old baby with complex anomaliesincluding a single ventricle, transposition of

Ciculation, Volume XXIX, May 1964

the great vessels, and severe coarctation of theaorta. On postmortem examination death ap-peared to be due to renal artery thrombosis,which may have been related to the arterialcatheterization. The only other deaith occurredin a 6-week-old baby with a single ventricleand associated cardiac anomalies as a resultof perforation of the left ventricle related toleft ventriculography.Of the few arrhythmias observed, ventricu-

lar fibrillation was the most frequent (fourcases). This occurred in conjunction withselective angiocardiography and was lessfrequent than with the right heart catheteriza-tions performed during the same time period.Two cases of fibrillation followed injection ofthe contrast media. The other two precededinjection and were due to faulty ground con-nection of an automatic power syringe andwere, therefore, avoidable. All four werepromptly and successfully treated by externaldefibrillation without complication.The incidence of premature beats resulting

from manipulation of the catheter in the leftventricle appeared less frequently than duringright heart catheterization. Serious arrhyth-mias such as significant ventricular tachy-cardia, atrial flutter or fibrillation, supraven-tricular tachycardia and complete heart blockdid not occur in this series.The single case of a cerebral vascular ac-

cident took the form of a transient hemipare-sis occurring 3 hours following catheterizationin a 4-year-old acyanotic girl. Two previouscatheterizations and open-heart surgery hadbeen performed elsewhere. Complete recoveryfollowed, but later the child died after asecond open-heart operation. At postmortemexamination no evidence of subacute bacterialendocarditis, mural thrombosis, or trauma to

the valves was noted. A similar lack of valvepathology has already been referred to pre-viously in the 48 other autopsied cases.An occluded ductus and a patent ductus

arteriosus were lacerated in two infants withcomplex anomalies while the catheter wasbeing manipulated around the arch of theaorta. Prompt thoracentesis successfullytreated the resulting hemothorax. This empha-

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sizes the need to be gentle in maneuvering thecatheter tip around the aortic arch in infants.

Arteriotomy repair with loss or diminutionof peripheral pulsations has been noted inabout one third of the patients. In spite of ab-sent peripheral pulses, only one case of pe-ripheral vascular insufficiency was noted. Thisproblem occurred in a 12-year-old boy whounderwent a combined right and left heartcatheterization to evaluate a ventricular septaldefect complicated by aortic regurgitation.Four hours following the catheterization theforearm and hand were noted to be cold, cya-notic, and pulseless. Both arterial and venousthrombosis occurred. Treatment consisted ofstellate ganglion block, heparin, and throm-bolytic agents. Color and temperature returnedto normal within 6 days. While the radial pulseremains absent, function is returning.* It isnot certain whether this problem is related tothe arteriotomy repair or to venous obstruction.The need for meticulous arteriotomy repair isto be emphasized. If free bleeding from thedistal arterial segment is not obtained, it mustbe cannulated with large bore polyethylenetuLbing. Suction may then be applied and clotsfrom previous stasis removed. Free flow fromthis segment should then ensue.

Early in our series all small arteries wereligated. No disparity of limb growth has beennoted. Many patients have been followed 3 to5 years.

Voci and Hamer23 reported that about onethird of 80 patients studied had absent pe-ripheral pulses following arteriotomy repair.Vengsarkar and Swan 24 noted transient reduc-tion or absent peripheral pulses in 31 per centof 125 arteriotomies. Most of these returnedto normal within 3 days and there was notissue morbidity.The two deaths and eight complications ob-

served give a mortality rate of 0.4 per centand a morbidity rate of 1.5 per cent. This is arelatively low risk considering that many ofthe patients were critically ill, and 10 per cent

* Examination 8 months after catheterization rexvealssome loss of thumb function but all tissues are viable.The pulse remains absent.

of these patients went on to die of theirdisease at a later date.

Summary and ConclusionsFive hundred forty-two retrograde arterial

left heart catheterizations were performed in500 infants and children with a successful entryinto the left heart in 92 per cent of all at-tempts. When the brachial artery could beused, the success rate was even higher (96per cent).A unique advantage of the retrograde ap-

proach was that it permitted a detailed studyof the left ventricular outflow tract and cen-tral aorta. This information was obtained in89 per cent of 115 cases of aortic stenosis.Two critically ill infants died as a result of

the test, and there were eight other complica-tions.As a result of the above findings we believe

retrograde arterial catheterization of the heartto be a relatively safe, practical, and effectivemethod for studying the left heart of infantsand children.

References1. COURNAND, A.: The historical development of the

concepts of pulmonary circulation. In Adams,W. R., and Veith, I.: Pulmonary Circulation.New York, Grune & Stratton, 1959, p. 13.

2. CHAUVEAU, A., AND MAREY, H.: Determinationgraphique des rapports du choc du coeur avecles mouvements des oreillettes et des ventri-cules; experience faite a lYaide d'un appareilenregistreur (sphymographe). Compt. rend.Acad. Sc. 53: 622, 1861.

3. MAREY, E. J.: Physiologie me'dicale de la circula-tion du sang. Paris, A. Delahaye, Libraire-tditeur, 1863, p. 83.

4. ZIMMERMAN, H. A., SCOTT, R. W., AND BECKER,N. 0.: Catheterization of the left side of theheart in man. Circulation 5: 357, 1950.

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6. SODI-PALLARES, D., ESTANDiA, A., SOBEERON, J.AND RODRIGUEZ, M. I.: The left intraventricularpotential of the human heart. I. Method. Am.Heart J. 40: 650, 1950.

7. HELLEMS, H. K., HAYNEs, F. W., DEXTER, L.,AND KINNEY, T. D.: Pulmonary capillary pres-

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sure in animals estimated by venous and arte-rial catheterization. Am. J. Physiol. 155: 98,1948.

8. HADDY, F. J., CAMPBELL, G. S., ADAMS, W. L.,AND VISSCHER, M. B.: A study of pulmonaryvenous and arterial pressures and other vari-ables in the anesthetized dog by flexiblecatheter techniques. Am. J. Physiol. 158: 89,1949.

9. VLAD, P., AND LAMBERT, E. C.: Simultaneousright and left heart catheterization employingretrograde arterial catheterization in the in-vestigation of congenital cardiovascular mal-formations of infants and children. Abstr., Am.J. Dis. Child. 98: 654,1959.

10. GREEN, E. W., ZIEGLER, R. F., AND KAVANAGH-GRAY, D.: Clinical use of retrograde left ven-tricular catheterization in congenital heartdisease. Abstr., Circulation 20: 704, 1959.

11. GRUNDEMANN, A. M., VERHEUCT, A. P. M., BOSCH,G. A. C., SCHWANTJE, E. J. M., AND AREIJNs,G.: Retrograde catheterization of the left ven-tricle. Third World Congress of Cardiology,Brussels. Abstracts of Communications 1958,p. 482.

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24. VENGSARKAR, A. S., AND SWAN, H. J. C.: Arte-riotomy for cardiac catheterization and angio-cardiography in infants and children. Proc.Staff Meet., Mayo Clin. 37: 619, 1962.

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PETER VLAD, ARNO HOHN and EDWARD C. LAMBERTInfants and Children

Retrograde Arterial Catheterization of the Left Heart: Experience with 500

Print ISSN: 0009-7322. Online ISSN: 1524-4539 Copyright © 1964 American Heart Association, Inc. All rights reserved.

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