Cardiac Ventriculography - DR SANJAY.pptx

BASICS OF CARDIAC
VENTRICULOGRAPHY

 Introduction
 Indications
 Contraindications
 Preparation of patient
 Access – techniques
 Catheters
 Angiographic Views
 Interpretation
 Complications

Introduction
 In 1929 Werner Forssman, inserted a urologic catheter into his right atrium from a
left antecubital vein cut down he had performed on himself using a mirror.
 Retrograde left heart catheterization was first done by Zimmerman,Limon Lason &
Bouchard in 1950’s (Nobel prize in 1956).
 Used to be the only method available for assessing LV segmental dysfunction.

 Cardiac ventriculography is used to define the anatomy and function of the
ventricles and related structures in patients with congenital, valvular, coronary, or
myopathic heart disease.
 Provides valuable information about global and segmental left ventricular function,
mitral valvular regurgitation, and the presence, location, and severity of a number
of other abnormalities such as ventricular septal defect and hypertrophic
cardiomyopathy.
 Included as part of the routine diagnostic cardiac catheterization protocol in a
patient being evaluated for coronary artery disease, aortic or mitral valvular
disease, unexplained left ventricular failure, or congenital heart disease .

Indications
 Usually an elective procedure.
 Diagnostic – discreprancy between the symptoms and clinical features of patient.
 Valve area, cardiac output and resistance.
 Quantification of shunts
 Pressure gradients
 Therapeutic – useful for assessing the pressure gradients before and after
 Mitral Stenosis – PBMV
 Aortic Stenosis – PBAV
 PDA device closure
 HOCM – alcohol septal ablation
 Cooarctation of Aorta
 Aorto Pulmonary Window closure

Contraindications
 The only absolute contraindication to cardiac catheterization is the refusal of a
mentally competent patient to consent to the procedure

Preparation and premedication
 Informed consent – simple terms, steps of procedure, complications (usually taken by
operator).
 All peripheral pulses to be felt.
 The guidelines by the American Society of Anesthesiologists currently recommend a
minimum of 2 hours fasting period after clear liquids, and 6 hours after a light meal.
 For diabetic patients – dose of NPH insulin should be cut by 50% (overnight fast with
normal dosing of insulin – hypoglycemia).
 To stop metformin – 48 hrs before procedure – lactic acidosis.(no evidence for clinical
benefit).
 Adequate hydration. (urine output > 50ml/h)
 Anxiolytic
 Shaving of the both forearms and inguinal regions.
 IE prophylaxis if valvular heart disease.

Cardiac Ventriculography - DR SANJAY.pptx

Local anesthesia
 Once the inguinal ligament and femoral artery have been identified, the femoral
artery is palpated along its course using the three middle fingers of the left hand,
with the uppermost finger positioned just below the inguinal ligament.
 Without moving the left hand, a linear intradermal wheal of l% or 2% lidocaine is
raised slowly by tangential insertion of a 25- or 27 -gauge needle along a course
overlying both the femoral artery and vein at the desired level of entry.
 The smaller needle is then replaced by a 22-gauge 1.5-inch needle, which is used to
infiltrate the deeper tissues along the intended trajectory for arterial and venous
entry.
 Approximately 10 to 20 ml 1% or 2% Xylocaine administered in this fashion usually
provides adequate local anesthesia.

Access
 Femoral artery/vein
 Modified Seldinger technique.
 Fluoroscopy guidance

Femoral Artery Puncture
 The original Seldinger technique for cannulation of
the femoral artery consists of advancing the
Seldinger needle completely through the artery until
the periosteum is encountered.
 The obturator is then removed, and the hub of the
needle is depressed slightly toward the anterior
surface of the thigh .
 Arterial pressure makes it unnecessary to attach a
syringe to the cannula, so that both hands can be
used to stabilize the needle as it is slowly withdrawn
 When the needle comes back into the lumen of the
femoral artery, as evidenced by vigorous pulsatile
flow of arterial blood, a 0.035- or 0.038-inch J
guidewire is advanced carefully into the needle .

 The guidewire introduced through the needle should move freely up the aorta
(located to the right [patient's left] side of the spine on fluoroscopy) up to the level
of the diaphragm.
 When difficulty in advancing the guidewire is encountered at or just beyond the tip
of the needle and is not corrected by slight depression or slight withdrawal of the
needle, the guidewire should be withdrawn to ensure that brisk arterial flow is still
present before any further wire manipulation is attempted.
 If flow is not brisk or if the wire still cannot be advanced, the needle should be
removed and the groin should be compressed for 5 minutes.
 The operator should verify the correctness of the anatomic landmarks and attempt
repuncture of the femoral artery.
 If the second attempt is also unsuccessful in allowing wire advancement, a third
attempt on the same vessel is unwise, and an alternative access site should
generally be selected.

Catheterizing left heart from femoral artery
 Once the guidewire has been advanced to the level of the diaphragm and
the needle has been removed, the catheter is introduced directly into the
artery, the soft tissues are predilated by brief introduction of a Teflon
arterial dilator one F size smaller than the intended catheter before
insertion into the left heart catheter itself
 The 15 - cm-long sheath is commonly used for diagnostic catheterization,
but can reach only the midiliac.
 In the presence of severe tortuosity, it may be preferable to use the 23-cm-
long sheath designed for interventional procedures, which is sufficiently
long to enter the distal aorta above the bifurcation.
 This helps improve the torque responsiveness of diagnostic catheters
under those circumstances

 The chosen sheath is introduced over the guidewire with a rotational
motion, following which the guidewire and dilator are removed and the
sheath is aspirated and flushed.
 The sheath can be connected to a pressurized flush system (Intraflo II [ 3 0
mUh ] , Abbot Critical Care , North Chicago, IL) to avoid clot formation
in the sheath.
 Alternatively, this side arm can be connected to a manifold for
monitoring arterial pressure at a separate site (e.g. , during passage of a
pigtail catheter across a stenotic aortic valve) .
 This sheath should be flushed before insertion and after removal of each
catheter.

 In the classic approach, the guidewire was removed once the sheath had
been inserted.
 This required that the desired left heart catheter be flushed and loaded
with a 145-cm J guidewire before its nose was introduced into the back-
bleed valve of the sheath. The soft end of the guidewire was then
advanced carefully through the catheter, out the end of the sheath, and to
the level of the diaphragm before the catheter itself was advanced.
 Once the catheter has been advanced to the desired level (either above the
diaphragm or into the ascending aorta) , the guidewire is removed so that
the catheter can be connected to the arterial manifold and double-flushed
(withdrawal and discarding of 10 mL of blood, followed by injection of
heparinized saline solution).

A word about Heparin
 Early catheterizations from the femoral artery had a higher incidence of major
complications than catheterization from the brachial artery.
 Brachial catheterization used systemic heparinization to avoid thrombosis in the
smaller diameter brachial artery.
 When systemic heparinization was adopted in femoral procedures, the rates of
complications became equivalent, and it became standard practice to achieve full
intravenous heparinization ( 5,000 U) immediately after the left-sided sheath was
inserted.
 Lesser amounts of heparin ( 2,500 to 3,000 U ) were used, particularly in smaller
patients , and additional heparin (up to a total of 50 to 70 U/kg) was given if the
procedure went on to a coronary intervention.
 This type of higher heparin dosing is routinely monitored by an activated clotting
time (ACT) and titrated to an ACT of roughly 300 seconds.

Catheter selection
 The initial left heart catheter in most cases is a pigtail catheter
with end- and multiple side holes
 Developed by Judkins
 Its end hole permits its insertion over a J-tipped guidewire.
 The loop shape keeps the end hole away from direct contact
with the endocardium, while the multiple side holes on the
catheter shaft located up to several centimeters proximal to the
pigtail loop provide numerous simultaneous exit paths for the
contrast material.
 These offset jet directions help stabilize the catheter within the
left ventricle during contrast injection and reduce the
magnitude of catheter recoil.
 This virtually eliminates the possibility of endocardial staining,
since the end hole usually is not positioned adjacent to
ventricular trabeculae, and substantially reduces the
occurrence of ventricular ectopic beats

 The original Judkins pigtail design had a straight shaft leading up to the
pigtail end.
 Designed to sit directly under the aortic valve, and just in front of mitral
inflow, relying on that inflow to distribute contrast to the apex of the left
ventricle. In routine practice, this has been replaced by angled pigtail
catheters , which have a 145° to 155 ° shaft angle at its distal end
 This angle mimics the angle between the aortic root and the long axis of
the left ventricle and helps the catheter achieve a central position within
the left ventricle.

Straight tip left ventriculographic catheters
 Sones catheter: widely used for left ventriculography when catheterization was
performed from the brachial approach
 Suitable for left ventriculography because it has four side holes in addition to its
end hole. This catheter comes in 5F, 6F,7F, and 8F sizes; it tapers to a smaller
external diameter near its tip.
 The catheter will accept a 0.035-inch guidewire which can be useful in crossing
severely stenotic aortic valves.
 For left ventriculography, the Sones catheter should be positioned in an axial
orientation (parallel to the ventricular long axis), with its tip midway between the
aortic valve and left ventricular apex.
 Low injection rates usually minimize the extent and forcefulness of catheter recoil.
 Catheter recoil may still occur with induction of multiple ventricular extrasystoles
and potential danger of endocardial staining

 The NIH and Eppendorf catheters have multiple side holes and no end hole
 They are easily inserted through an arteriotomy (by the brachial approach) or
percutaneously through a femoral arterial sheath.
 The NIH and Eppendorf can be gently prolapsed across the aortic valve, but of
course cannot be aided by a leading guidewire because of the lack of an end hole.
 The Cordis NIH (polyurethane) and Cook NIH Torcon blue (polyethylene)
catheters are relatively soft and unlikely to cause dissection or perforation.
 The Lehman ventriculographic catheter has a tapered closed tip that extends
beyond the multiple side holes
 The tapered tip may assist the operator in manipulating the catheter through
tortuous arteries and across a stenotic aortic valve.
 Once in the left ventricle, the tip lessens the likelihood of endocardial staining, but
may increase the chance of ventricular ectopy during the injection of contrast
material.

Balloon tip ventriculographic catheters
 The Berman angiographic catheter is a balloon tip catheter
 Available in 4F, 5F, 6F, 7F, and 8F sizes.
 Used for right ventriculography, pulmonary angiography, peripheral angiography,
and in the reverse configuration for balloon occlusion angiography
 The balloon tip provides the advantage of easier advancement in the right ventricle
or in the pulmonary artery, and by keeping the catheter and side holes away from
the endocardium, it can reduce the risk of myocardial staining and ventricular
arrhythmias.

Crossing the aortic valve
 After measurement of the ascending aortic pressure, the pigtail catheter is then
advanced across the aortic valve and into the left ventricle.
 If the aortic valve is normal and the pigtail is oriented correctly, it will usually cross
the valve directly.
 In many cases it may be necessary to advance the pigtail down into one of the
sinuses of Valsalva to form a secondary loop.
 As the catheter is withdrawn slowly, this loop will open to span the full diameter of
the aorta, at which point a very subtle further withdrawal will often cause the
pigtail to fall across the valve.

 If significant aortic stenosis is present, the pigtail must be advanced across the
valve with the aid of a straight 0.038-inch guidewire.
 Approximately 6 cm of the guidewire is advanced beyond the end of the pigtail
catheter, and the catheter is withdrawn slightly until the tip of the guidewire is
leading.
 The position of the tip of the guidewire within the aortic root can then be controlled
by rotation of the pigtail catheter and adjustment of the amount of wire that
protrudes; less wire protruding directs the wire tip more toward the left coronary
ostium, whereas more wire protruding directs the wire more toward the right
coronary ostium.
 With the wire tip positioned so that it is directed toward the aortic orifice, the tip of
the wire usually quivers in the systolic jet.
 Wire and catheter are then advanced as a unit until the wire crosses into the left
ventricle .

 If promising wire positions are not obtained, the process should be repeated using
a different catheter: a left Amplatz (AL l ) catheter if the aortic root is normal or
dilated or a Judkins right coronary catheter if the aortic root is unusually narrow
together with a straight wire.
 It is important to note that when crossing the aortic valve with catheters other than
the pigtail, a left anterior oblique (LAO) or anteroposterior view should be used in
order to prevent inadvertent advancement of the straight wire in the coronary
ostium.
 Once the tip of the wire has crossed the valve , the RAO angle should be used to
visualize the position of the wire in the ventricular cavity and prevent perforations.
 Once the catheter is in the left ventricle, the wire is immediately withdrawn and the
catheter is aspirated vigorously, flushed, and hooked up for pressure monitoring,
so that a gradient can be measured even if the catheter is rapidly ejected from the
left ventricle or must be withdrawn because of arrhythmias.

 The same approach applies to retrograde catheterization across a porcine aortic
valve prosthesis , although it is more common to use a J-tip guidewire to help
avoid the area between the support struts and the aortic wall.
 Ball valves (Starr-Edwards) can be crossed retrograde with this approach, but use
of a small (4F or 5F) catheter will minimize the amount of aortic regurgitation
resulting from catheter interference with diastolic ball seating.
 Tilting disc valves (Bjork-Shiley, St. Jude , Carbomedics) should not be crossed
retrograde because of the potential for producing torrential aortic regurgitation,
catheter entrapment, or even disc dislodgement if the catheter passes across the
smaller (minor) orifice.

Injection site
 Adequate opacification of either ventricle is accomplished only if a large amount of
contrast material is delivered in a short period of time.
 Satisfactory opacification of the left ventricle can sometimes be achieved by
injection of contrast material into the left atrium - requires trans-septal
catheterization, does not allow evaluation of mitral valvular incompetence, and
may obscure the basal portion of the left ventricle and the aortic valve.
 Similarly, the left ventricle may be opacified by aortography in patients with
significant aortic regurgitation, and the right ventricle may be opacified by
injecting contrast material into the venae cavae or right atrium.
 The best approach to ventriculography in the adult patient is via injection of
contrast material directly into the ventricular chamber in question.

 In the left ventricle, the optimal catheter position is the midcavity.
 The midcavitary position ensures
 (a) adequate delivery of contrast material to the chamber's body and
apex;
 (b) lack of interference with mitral valvular function, which would have
otherwise produced factitious mitral regurgitation;
 (c) positioning of the holes through which the contrast material is injected
away from ventricular trabeculae

Power injectors
 Flow injectors (Medrad)
- volume and rate of delivery can be
selected
- maximal pressure limit of 1000psi to
minimize the risk of catheter burst
- this high pressure is not actually delivered
to the catheter tip , but is dissipated as
frictional losses in the shaft of the catheter
- can be synchronised with R wave, so that
a set flow rate is delivered in each of
several successive diastolic intervals
- hand injection should be avoided

Procedure
 Cine left ventriculography with
1. contrast vol – 30-36ml
2. rate – 10-12ml/sec(pig tail)
7-10 ml/sec(sones)
 Older imaging systems required image acquisition at deep inspiration.
 Newer imaging systems permits imaging during normal quite breathing.

Transseptal catheterization
 PBMV,Access to pulmonary veins.
 Complication rate <1%.
 Procedure:
• 8F Mullins transseptal sheath and dilator
• Brockenbrough needle. 18 G -21G at tip.
• 0.032 inch guide wire – FV - RA – SVC.
• Mullins sheath and dilator advanced over the wire into SVC.
• Guidewire is removed and replaced by Brockenbrough needle.
• Catheter is rotated from 12 o’– 5 o’ clock position.
• Two abrupt right ward movements. – SVC to RA, Limbic edge
of fossa ovalis.
• Septal puncture done under fluoroscopy guidance.
• LA pressure recorded.
• LV angiography if needed – slight counterclockwise rotation.

Apical left ventricular puncture
 Measure LV pressure and perform ventriculography in patients with mechanical
prosthetic valves in both the mitral and aortic positions that prevent both
retrograde and transseptal catheterization.
 Crossing of tilting disks to be avoided – catheter entrapment, occlusion of the
valve, possible dislodgement and embolization of the disc.
 Localization of LV apex by palpation or by echocardiography.
 18 G 6” inch Teflon catheter system is inserted at upper rib margin, directed
slightly posteriorly and toward the right second intercostal space.
 Needle and sheath are advanced into the LV.
 Stylet and the needle removed.
 Sheath connected for pressure measurement.

Filming projection and technique
 Projection – max delineation of
structure of interest and min
overlapping of other structures
 Cine left ventriculography
– 15-30 frames/sec
 Typically 30 deg RAO and 60
deg LAO views are obtained
 30 deg RAO
 eliminates overlap of LV and the
vertebral column
 anterior apical inferior
segmental wall motion
 mitral valve profile ideal for
assessment of MR

 60 deg LAO
- assess ventricular septal integrity and
motion
- lateral and posterior segmental
function
- aortic valvular anatomy
- 15-30 deg cranial angulation for
profiling entire IVS in case of VSD and
the associated left to right shunting or
the septal bulge and SAM in HOCM or
isolated LW motion abnormalities

Normal LV angiogram - schematic

Normal LV angiogram
 RAO diastolic frame RAO systolic frame

Biplane ventriculography
 Better than single plane ventriculography.
-more information at no additional risk.
-single injection of contrast.
-coronary artery disease, biplane left ventriculography provides
more information on the location and severity of segmental wall
motion abnormalities
-in the patient with congenital heart disease biplane right
ventriculography allows one to assess accurately the anatomy of
the right ventricular outflow tract, the pulmonic valve , and the
proximal portions of the pulmonary artery.
 Disadvantages
1. Higher cost
2. Additional time
3. Reduced quality of
cineangiographic images
4. Additional radiation exposure

Steps in LV volume calculation
1.Tracing LV outline or
silhoutte
2.Marking aortic valve
border
3.Calculation of LV
volume by computer
based algorithms
4.Magnification
correction
5.Applying Regression
Equation

LV function assessment
 Cineventriculography was the first method introduced
in the routine practice to determine the LVEF.
 The area-length technique is the most widely used
method to quantify the left ventricular diastolic and
systolic volumes.
 In the first step in assessing left ventricular chamber
volume, the left ventricular outline or silhouette is
traced.
 The ventricular silhouette should be traced at the
outermost margin of visible radiographic contrast so as
to include trabeculations and papillary muscles within
the perimeter
 To facilitate the calculation of left ventricular volume,
the ventricle is often approximated by an ellipsoid

Biplane formula
 May be performed in the anteroposterior (AP)
and lateral projections, the 30° right anterior
oblique (RAO) and 60° left anterior oblique
(LAO) projections, or angulated projections
(e.g. , 45° RAO and 60° LA0- 25° cranial).
 The vol of an ellipsoid is given by the
equation
 V is volume, L is the long axis, and M and N
are the short axes of the ellipsoid. The long
axis, L, is taken practically to be Lmax the
longest chord that can be drawn within the
ventricular silhouette in either projection

 For biplane oblique (RAO/LAO) left ventriculography, for example, the areas of
the two ventricular silhouettes are given as
 LRAo and LLAo are the longest chords that can be drawn in the RAO and LAO
silhouettes
 The area of each traced silhouette is obtained by planimetry, and M and N are
calculated by rearrangement as follows

Single plane formula
 The area-length ellipsoid method for estimating left ventricular chamber volume
has been modified for use in the usual situation in which only single-plane
measurements obtained in the AP or RAO projection are available
 Inherent in single-plane methods is the assumption that the left ventricular shape
may be approximated by a prolate spheroid-that is, an ellipsoid in which the two
minor axes are equal
 If only single-plane (e.g. , RAO) ventriculography is done, it is assumed that M = N
and that L in the plane presented is the true long axis of the ellipsoid. M is
calculated from the single plane silhouette area (A) and L by the area-length
method as M = 4A/πL.
 Therefore, the single-plane volume calculation becomes

Magnification correction: Single Plane
 Because the x-rays emanate from a point source, they are nonparallel, correction
must be made for magnification of the ventricular image onto the detector
 Correction may be accomplished by imaging a calibrated grid at the estimated level
of the ventricle and submitting the grid to the same magnification process as that to
which the ventricle is subjected.
 In the single-plane formula, the cube of the linear correction factor adjusts the
volume for magnification:

Magnification correction: Biplane
 In biplane studies , a correction factor ( CF) must be calculated separately for each
projection, yielding, in the case of biplane oblique cineangiography, CF RAO and
CF LAO·
 The linear correction factor is multiplied by the measured lengths , and the square
of this correction factor is multiplied by planimetered areas to convert to true
lengths and areas.
 Accordingly the corrected volume of ventricle is

Regression equations
 Ventricular volumes calculated by most mathematical techniques overestimate true
ventricular chamber volume, so that regression equations must be used to correct
for the overestimation
 This overestimation results in large part from the papillary muscles and trabeculae
carneae, which do not contribute to blood volume but are nevertheless included
within the traced left ventricular silhouette

Calculation of LVEF
 Visual inspection of the cine images allows selection of frames depicting the
maximum (end-diastolic) and minimum (end systolic) ventricular volumes
 Angiographic stroke volume
SV = EDV – ESV
 Ejection fraction, EF = (EDV – ESV) / EDV

Calculation of RF
 In patients with aortic and/or mitral regurgitation, comparison of the
angiographically determined stroke volume with the forward stroke volume
determined by the Fick technique or (in the absence of concomitant tricuspid
regurgitation) the thermodilution technique yields the regurgitant stroke volume,
that portion of the ejected volume that is regurgitated and therefore does not
contribute to the net cardiac output.

Regional LV dysfunction
 Regional wall motion can be graded qualitatively as normal, hypokinetic, akinetic,
dyskinetic, or hyperkinetic.
 The analyses of the RAO and LAO projections as the following segments:

 Permanent segmental dysfunction of the left ventricular wall can be caused by
frank infarction, but reversible segmental dysfunction can also be caused by
ischemia
 Left ventricular segmental wall motion can be improved substantially by the
administration of catecholamines.
 Two left ventriculograms are performed-the first in the resting (baseline) state and
the second during a steady state infusion of epinephrine (l to 4 mg/minute) or
dobutamine ( 10 to 15 microg/kg per minute) .
 Alternatively, left ventricular segmental wall dysfunction can often be improved by
administration of nitroglycerin, either by improving collateral blood flow, reducing
myocardial oxygen consumption to match available supply, or simply by reducing
the after load against which the left ventricle must eject

 Left ventricular segmental wall motion can be influenced by postextrasystolic
potentiation when a single ventricular premature beat is introduced during left
ventriculography and is followed by a potentiated beat.
 Segmental wall motion during one of the preceding sinus beats is compared with
that of the postextrasystolic beat and improvement on the potentiated beat as
compared with the preceding sinus beat suggests ischemia rather than infarction.
 Segments in which wall motion improves with intervention generally maintain
same level of improvement after successful surgical revascularization.

Calculation of stenotic valve area
 GORLIN FORMULA
1. Torricelli's law:
Flow across a round orifice F = AV CC
A = F/VCc
F = Flow rate A = Orifice area
V = Velocity of flow CC = Coefficient of orifice contraction

 2. Pressure gradient and velocity of flow Relation - Torricelli's law
V = velocity of flow
Cv = coefficient of velocity - correcting for energy loss as pressure energy is
converted to kinetic or velocity energy
h = pressure gradient in cm H2O
g = gravitational constant (980 cm/sec2
) for converting cm H2O to units of
pressure

 Flow (F) = Total cardiac output expressed in terms
of the seconds per minute during which there is
actually forward flow across the valve.
 F= CO (ml or cm3
/min)/SEP/DFP (sec/min) x HR
 The diastolic filling period begins at mitral valve
opening and continues until end-diastole.
 The systolic ejection period begins with aortic
valve opening and proceeds till the dicrotic notch
or some other evidence of aortic valve closure.

SYSTOLIC EJECTION PERIOD CALCULATION

AREA CALCULATION FOR MITRAL VALVE & AORTIC VALVE

Mitral valve area
 By rearranging the terms of Eq., one sees that for the mitral valve,
 where ∆P is the mean transmitral pressure gradient and MVA is the mitral valve
area.
 Thus, by doubling cardiac output one will quadruple the gradient across the valve,
if heart rate and diastolic filling period remain constant.
 The normal mitral orifice in an adult has a cross-sectional area of 4 . 0 to 5 . 0 cm2
when the mitral valve is completely open in diastole.
 Considerable reduction in this orifice area can occur without symptomatic
limitation, but when the area is 1.0 cm2 or less , a substantial resting gradient will
be present across the mitral valve and any demand for increased cardiac output
will be met by increases in left atrial and pulmonary capillary pressure that lead to
pulmonary congestion and edema.

Example of valve area calculation in MS
 40 year woman with RHD and severe MS,
HTN
 In this patient, five beats were chosen from the
recordings taken closest in time to the Fick
cardiac output determination.
 Planimetry of the area between PCW and LV
pressure tracings was done for these five beats,
and these areas were divided by the length of
the diastolic filling periods for each beat,
giving an average gradient deflection in
millimeters

 The mean gradient in millimeters of mercury was calculated as the average
gradient deflection in millimeters multiplied by the scale factor (mmHg/mm
deflection).
 In this case, the mean gradient was 30 mmHg.
 Next, the average diastolic filling period was calculated using the average
measured length between initial PCW-LV crossover in early diastole and end-
diastole (peak of the R wave by ECG).
 This average length in millimeters was divided by the paper speed (mm/second) to
give the average diastolic filling period, which in this case was 0.40 second.
 Heart rate and cardiac output are recorded, ideally from data collected
simultaneously with the recording of the PCW-LV pressure gradient.
 Heart rate was 80 bpm and cardiac output was 4,680 cm3/minute

Aortic valve area
 For the aortic valve the Eq can be rearranged as
 At a normal resting cardiac output of 5.0 L/minute, an aortic orifice area of 0. 7 cm2 will result
in a pressure gradient of approximately 33 mmHg across the aortic valve.
 Doubling of the cardiac output, as might occur with exercise, would increase the gradient by a
factor of 4 to 132 mmHg if the systolic time per minute did not change.
 This increase in gradient would require a peak LV pressure in excess of 250 mmHg to maintain
a central aortic pressure of 120 mmHg.
 Such a major increase in LV pressure obviously increases myocardial oxygen demand and
limits ejection performance.
 These factors contribute to the symptoms of angina and congestive heart failure , respectively.
 The limitations in cardiac output imposed by high afterload may contribute to hypotension
when peripheral vasodilation occurs during muscular exercise.

 Actually, the systolic time per minute does not remain constant during
the increase in cardiac output associated with exercise.
 As heart rate increases during exercise , the systolic ejection period tends
to become shorter, but the tendency is counteracted by both increased
venous return and systemic arteriolar vasodilation, factors that normally
help to maintain LV stroke volume constant (or even allow it to increase)
during exercise.
 Thus, the heart rate is increasing but the systolic ejection period is
diminishing only slightly so that their product (the systolic ejection time
per minute) increases

Example
 Simultaneous pressure tracings from the left ventricle (LV) and right femoral
artery (RFA) in a patient with exertional syncope.
 Because the pulse wave takes a finite period of time to travel from the left ventricle
to the femoral artery, the femoral artery tracing is somewhat delayed
 LV and RFA tracings realigned to correct for the delay in transmission time.
 This is accomplished by using tracing paper and aligning the arterial upstroke to
coincide with the LV upstroke. After such an alignment, the mean pressure
gradient can now be obtained by planimetry
 For this example, the average aortic pressure gradient is 40 mmHg, the systolic
ejection period is 0.33 second, the heart rate is 74 bpm, and the cardiac output is
5,000 mL/minute.

Gradient calculation LV-Ao
For accurate LV –AO gradient
calculation by cath
1) Preferred catheter position for LV-
Ao gradient calculation is LV body
& Ascending aorta rather than LV
& FA
2) Pressure recording simultaneously
taken from AO and LV
3) Use Two catheter or Dual Lumen
catheter (Langston Catheter)

Errors in gradient measurement
1) Systolic amplification and widening of pressure waveform
A) LV-AO Gradient overestimated by 9 mm Hg
B) LV- AO Gradient underestimated by 10mm Hg

 2) LV Catheter placed in LVOT
Substantial pressure gradient between the body of the LV & LVOT . This is due to
acceleration of blood as it enters the relatively narrow outflow tract

 When the aortic valve area is diminished to 0.6 cm2 or less, a 7F or 8F
catheter placed retrograde across the valve takes up a significant amount
of the residual orifice area, and the catheter may actually increase the
severity of stenosis.
 Conversely, removal of the catheter reduces the severity of stenosis.
 A peripheral pressure rise occurs in severe aortic stenosis when the LV
catheter is removed from the aortic valve orifice.
 An augmentation of more than 5 mmHg i n peripheral systolic pressure at
the time of LV catheter pullback indicates that significant aortic stenosis is
present.
 This sign is present in > 80% of patients with an aortic valve area of 0.5
cm2 or less

Alternative formula to Gorlin: Hakki formula
 Assumption: Heart rate x SEP or DFP x Constant ≈1
 When compared to the traditional Gorlin formula the above formula may lead to
significant disparity if tachycardia is present (heart rate >100 beats/min).

Assessment of AS in patients with low cardiac output
 Valve calculations made using the Gorlin formula are flow dependent
 That is, as cardiac output increases, calculated area increases, and as cardiac output
decreases, calculated area decreases
 Two potential mechanisms exist by which calculated valve orifice area increases
with cardiac output:
(a) Increased flow through the stenotic aortic valve in conjunction with increased LV
pressure physically opens the valve to a larger orifice area, and thus the valve
orifice really is wider during increased flow, and
(b) Inaccuracies in the Gorlin formula cause the calculated area (but not necessarily the
actual orifice area) to be flow dependent.
 The Gorlins themselves had noted that they had no data based on which they could
derive an empirical constant for the aortic valve

 Consider a patient with a reduced cardiac output and low LV ejection fraction who
has both cardiomyopathy and mild aortic stenosis.
 Despite a calculated valve area of 0.7 cm2, such a patient will probably not benefit
from aortic valve replacement because aortic stenosis was not the cause of the LV
dysfunction.
 On the other hand, although patients with low aortic valve gradients are generally
at higher risk for perioperative death associated with aortic valve replacement,
many patients with low gradients may improve substantially following surgery.
 It is likely that such patients have truly severe aortic stenosis, which is the cause of
their hemodynamic decompensation; in these patients , correcting the aortic
stenosis is beneficial.

 Cautious hemodynamic manipulation in the catheterization laboratory can
distinguish between these two different clinical entities
 In patients with mild aortic stenosis, an infusion of nitroprusside or dobutamine
increases forward output substantially, but may actually decrease the transvalvular
gradient.
 In such cases, the calculated aortic valve area increases dramatically and is no
longer within the critical range.
 In patients with truly severe aortic stenosis, infusion of nitroprusside widens the
transvalvular gradient and increases the calculated aortic valve area only slightly, if
at all.

 The patient's initial calculated valve orifice area was 0.6 cm2 , which would
indicate a need for surgery.
 Following nitroprusside infusion, the gradient actually fell and calculated valve
area increased.
 The patient improved on chronic vasodilator therapy, usually contraindicated in
aortic stenosis unless the disease is mild.
 Infusion of nitroprusside in patients with suspected aortic stenosis must be
performed with great caution, because if true aortic stenosis is present, hypotension
may result.
 If it is known that the patient has normal coronary arteries, dobutamine, which
produces similar changes in cardiac output, can be infused instead of nitroprusside.

Mitral regurgitation
 Diagnosis and assessment of severity of MR

 Angiographic quantification of MR
 Total Stroke Volume (TSV = EDV – ESV) calculated from LV angiogram.
 Forward Stroke Volume(FSV) calculated by Fick method or indicator dilution
technique.
 Regurgitant Stroke Volume (RSV) = TSV – FSV
 Regurgitant Fraction (RF) = RSV/TSV

Aortic regurgitation
 + small regurgitant jet only, LV ejects contrast each systole.
 + + regurgitant jet faintly opacifies LV cavity, not cleared with each systole.
 +++ persistent LV opacification = Aortic root density; LV enlargement.
 ++++ Persistent LV opacification > Aortic root concentration, often marked LV
enlargement.

Hypertrophic cardiomyopathy
 In HCM, cavity obliteration is
commonly seen together with
small ventricular end systolic
volumes .
 Systolic anterior motion of the
mitral valve may result in
severe degrees of mitral
regurgitation.
 The ventriculogram in the apical
variant typically appears with a
“spade”- shaped contour.

Tako Tsubo Cardiomyopathy
 Diffuse akinesis of LV apex with preserved basal contractilty.
 Characteristically resemble the shape of a japanese octopus trap(tako-tsubo)

Ventricular septal defect
 A standard view in the evaluation of patients with ASDs or muscular VSDs is the
hepatoclavicular view at 30◦ to 45◦ LAO and 30◦ to 45◦ cranial

Complications
 Ventricular extrasystole – mechanical stimulation
 Ventricular tachycardia – mostly NSVT
 Intramyocardial injection/endocardial staining
 Myocardial perforation
 Left anterior fascicular block
 Transient complete heart block
 Embolism- air/thrombus
 Complications of contrast media

Conclusion
 Left heart catherization has a significant role in quantifying the pressure gradients
across the valve and within the left ventricle.
 Mostly being used presently during therapeutic indications rather than diagnostic
indications.
 Optimal pressure tracings with all necessary precuations and knowing the
limitations of each helps in judging the severity of the clinical condition to the
nearest accuracy.

Cardiac Ventriculography - DR SANJAY.pptx

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