SELECTIVE ANGIOCARDIOGRAPHY OF RIGHT - Thorax · "elema" roll film changer. The pressure selected depends on the internal diameter of the catheter and varies inversely with it. The

Thorax (1958), 13, 89.

SELECTIVE ANGIOCARDIOGRAPHY OF THE RIGHT HEARTBY

S. HOLESH AND H. M. T. COLESFrom the Westminster Hospital, London

(RECEIVED FOR PUBLICATION JANUARY 26, 1958)

The value of angiocardiography in the investi-gation of congenital heart disease has been en-

hanced by the development of the technique ofselective injection of the contrast medium througha cardiac catheter. Several Swedish workers havebeen responsible for many of the important ad-vances in this method, especially the introductionof rapid film exposures in two planes and the de-livery of the contrast medium in a short time bymeans of mechanical pumps. Both these innova-tions have increased the scope and diagnostic sig-nificance of the method.With the increasing success of surgical correc-

tion of defects, precise and accurate anatomicalvisualization before operation is of great value,even negatively, as it may demonstrate that thelesions are inoperable. The results obtained in 58cases during the first year of the routine appli-cation of selective angiocardiography at West-minster Hospital have shown some pitfalls andcomplications which are avoidable. With the ex-

ception of six adults all the patients were infantsor children (see Addendum).

TECHNIQUESelective angiocardiography is best performed in

conjunction with formal cardiac catheterization,provided facilities are available for the immediateestimation of oxygen saturations and direct recordingof pressures. In this way a provisional diagnosismakes it possible to select the site for injection of thecontrast medium and the position of the catheter canbe checked by manometry. If the patient is con-sidered unfit for full catheterization but angiocardio-graphy is required before surgery, it is still desirableto have manometry available to make quite sure thatthe catheter is in the correct chamber.The largest possible catheter is introduced into the

internal saphenous vein in the groin or the medianbasilic vein in the antecubital fossa. The former isthe site of choice in children as it is easier to find a

suitable vein and gives more room to the anaesthetistand radiologist.

Catheters smaller than No. 6 Cournand do not, inour experience, give diagnostic results, because the

pressure required to inject the contrast medium is toohigh to be within safe limits and also invariablycauses the catheter to recoil from the chamber ofchoice. Before inserting the catheter we test it forfaults by attempting to inject saline through it withthe distal end occluded. Leaks from holes or cracksin the plastic material will then become apparent.We have also invariably tested for iodine sensitivityby injecting i-1 ml. of contrast medium through thecatheter before proceeding with the full injection.

Preliminary films are essential to ensure that theapparatus is working properly and that the correctfilm densities are obtained. The average exposure hasben 88-96 kV., 400 mA., 0.003-0.01 sec.For the injection we have used a " gidlund " com-

pressed air pump, which is linked with a two-plane"elema " roll film changer. The pressure selecteddepends on the internal diameter of the catheter andvaries inversely with it. The volume of the injectionand the pulse rate of the patient are other determiningfactors. We have never exceeded 6 kg. per sq. cm.,and have found that a considerably lower pressure issufficient with Lehmann catheters. These have awider lumen than the Cournand type of the same ex-ternal diameter. With a No. 7 Lehmann catheterit is practicable to inject by hand.The maximum speed of the " elema " apparatus

used is eight films per second and this was alwaysmaintained during the first three seconds in infants.Varying speeds were selected for the later phases ofthe circulation of the contrast medium. It is im-portant to start the exposure shortly after the injec-tion and particularly so in atrial and ventricular septaldefects, because the first passage of contrast mediumacross the defect takes place almost immediately andis frequently obscured later by filling of otherchambers and vessels. Thus if 8 ml. of 70%"diaginol" is required, the exposure should beginafter 2 ml. has been injected.The volume of contrast medium used has been

calculated on the basis of 1 ml. per kg. body weightwith a minimum quantity of 5 ml. in small infants.

DISCUSSIONThere is no doubt that the selective technique,

when correctly applied, increases the diagnosticrange and exactitude of angiocardiography. The

on August 28, 2021 by guest. P

rotected by copyright.http://thorax.bm

j.com/

Thorax: first published as 10.1136/thx.13.2.89 on 1 June 1958. D

ownloaded from

http://thorax.bmj.com/

S. HOLESH and H. M. T. COLES

clarity of the examination is increased by the useof a mechanical pump injecting the contrastmedium into the selected situation at the correcttime, thus avoiding filling of vessels and chamberswhich are unimportant. This refers in particularto the right atrium, which, in venous angiocardio-graphy, overlies and masks the infundibulum ofthe right ventricle and the pulmonary valves in thelateral plane. The best position for the cathetertip is therefore in the outflow tract of the rightventricle or the main pulmonary artery. On twooccasions we found that injection into one orother main branch of the pulmonary arterycaused intense constriction of the pulmonaryvessels of the homolateral lung with resultantpooling of the contrast medium throughout theseries of exposures, thus reducing the value of theexamination. These patients had no untowardsymptoms and the complication was only dis-covered on developing the film.The selection of the best site for injection de-

pends on the nature of the defects. The rightventricle is most commonly used, particularly forshowing pulmonary valvular and infundibularstenosis as well as ventricular septal defects withor without a normal aortic root (Fig. 1). If thecatheter is too high in the infundibulum the con-trast medium may fail to pass into the left ventriclevia a ventricular septal defect if the defect is small.The diagnosis can then only be inferred if subse-quently the right ventricle is filled again. Withcorrect positioning of the catheter a ventricularseptal defect will be visualized by right-to-leftpassage of some of the contrast medium in theearly phase, regardless of the direction of theshunt, i.e., left to right or right to left (Fig. 2).

In Fallot's tetralogy it is important not to placethe catheter tip too high as it may pass into theleft ventricular outflow tract or even into the baseof the aorta (Figs. 3 and 4a and b). This willprevent visualization of the infundibulum of theright ventricle, the pulmonary valves and vessels.These are of great importance when contemplat-ing a Blalock-Taussig operation or valvotomyand infundibular resection.The main pulmonary artery is chosen when one

of the following conditions is present, namely,patent ductus arteriosus, aorto-pulmonary fistula,arterio-venous communications in the lungs,anomalous pulmonary veins, and an atrial septaldefect with a left-to-right shunt. Moreover, ifthere is a coarctation of the aorta or aorticstenosis, this position is most satisfactory if leftheart catheterization or retrograde aortographycannot be performed (Fig. 5).

When there are combined atrial and ventricularseptal defects, injection into the main pulmonaryartery should be avoided because it is impossibleto decide whether the right ventricle has filledfrom the atrial or ventricular defect. The cathetershould, in such instances, be placed in the rightventricle which will show the ventricular septaldefect separately in the first series of films, whilelater opacification of the right atrium will provethe presence of an atrial septal defect. Majoranomalous drainage of the pulmonary veins intothe right side of the heart can usually be excludedif the left atrium opacifies before the right atrium.

If there is anomalous pulmonary venous drain-age it is desirable to inject into the left and rightpulmonary arteries separately. In this way it ispossible to determine into which vessel or cham-ber the anomalous veins are draining (Fig. 6).This is considered a safe procedure provided thecontrast medium is injected by hand or mechani-cally, using a much lower pressure than normally,e.g., 2 kg. per sq. cm. with a No. 7 Lehmanncatheter.The right atrium is rarely used as the site of

injection except in atrial septal defects. Mostauthorities consider that right heart catheteriza-tion is dangerous in obstructive tricuspid lesionsand some advise injecting the contrast mediuminto the left ventricle. This is claimed to give agood visual estimate of the size of the rightventricle. In this series we have had no experi-ence of such lesions.We feel that selective angiocardiography should

be performed, when possible, in conjunction withformal cardiac catheterization. In experiencedhands the whole procedure can be completed inone hour, thus reducing the screening time andnumber of anaesthetics. Careful screening in theantero-posterior and lateral planes is essential toensure that the tip of the catheter is not lyingagainst the ventricular wall. Unfortunately itmay assume such a position during the injection,when blobs of contrast medium may be forcedbetween the fibres of the myocardium. This is apotential danger, but, in our experience, smallleaks into the myocardium have produced no illeffects and are rapidly absorbed (Fig. 7).A troublesome complication is recoil of the

catheter tip from the selected position during theinjection. This, for example, may result in itsflipping back from the right ventricle into the rightatrium (Fig. 8). In the cases under review we didnot use catheters with side openings which cer-tainly reduce the recoil effect. We cannot confirmthe view of Kjellberg, Mannheimer, Rudhe, and

90



j.com/


ownloaded from


FIG. 1.-C. J., aged 3 years. Valvular pulmonary stenosis showingthe " jet sign." Note the translucent areas indicating the siteof the thickened valves. Marked post-stenotic dilatation of themain pulmonary artery. The infundibulum of the right ven-tricle is narrowed.

FIG. 2.-W. R., aged 2 years. A ventricular septal defect is demonstrated on the first film after injectionof the contrast medium into the right ventricle. There is, in addition, a pulmonary valvularstenosis; the doming of the valves is well shown.



j.com/


ownloaded from


FIG. 3.-J. H., aged 3 months. The catheter has slipped through aventricular septal defect into the left ventricle and base of theaorta which is over-riding. The main bulk of the contrastmedium has entered the aorta and the pulmonary vessels are notclearly visible.

FIG. 4b.-Marked narrowing of the infundibulum and doming ofthe pulmonary valves.

FIG. 4a.-R. J., aged 1 year. Fallot's tetralogy. The size of theventricular septal defect and the degree of over-riding of theaorta are well shown. The aortic and pulmonary valves areclearly visible. Good position of the catheter in the rightventricle without recoil.

FIG. 5.-J. B., aged 7 months. The contrast medium was injectedinto the right ventricle. A coarctation of the aorta is clearlyshown and there is aneurysmal dilatation of the origin of the leftsubclavian artery. There is marked hypertrophy of the wall ofthe left ventricle and considerable dilatation of the left auricle.An anomalous coronary artery is marked on the film.



j.com/


ownloaded from


SELECTIVE ANGIOCARDIOGRAPHY OF THE RIGHT HEART

FIG. 6.-M. W., aged 40 years. The right pulmonary veins are draining into the superior venacava. The contrast medium was injtcted into the right pulmonary artery. The leftpulmonary veins drainod into the left auricle.

Jonsson (1955) that recoil is less likely when thecatheter makes a wide loop in the right atrium.In 26 cases the catheter was looped in this wayand in 10 of these it did not recoil significantly.In the remaining 32 cases in which the catheterwas not looped or only slightly kinked, 18 didnot recoil. We think that the condition of thecatheter is a more important factor; stiff, firmcatheters maintain their position better than soft,floppy ones. In addition, Lehmann catheters,requiring lower pressures for injection of thecontrast medium, are less liable to recoil thanthe Cournand variety.

Reflux of contrast medium from the right ven-tricle into the right atrium may at times occur

in the early phase of the examination if thecatheter tip is near the tricuspid valve. This weattribute to functional incompetence of the valvedue to separation of the cusps by the expansilemovement of the catheter during the pressure in-jection. The reflux is very transitory and neverinvalidates the series of films. It should not bemistaken for anomalous pulmonary drainage intothe right atrium. The reflux is maximal at thetime of initial pulmonary arterial filling and be-fore a demonstrable pulmonary venous phase hasbeen reached (Fig. 9).

In some cases where it may be impossible toadvance the catheter into the right ventricle it isworth while injecting the contrast medium into

93



j.com/


ownloaded from



FIG. 7.-S. H., aged 5 weeks. Contrast medium is visible in the myocardium of the rightventricle. The child suffered no ill effects. The aorta is clearly visible ieven thoughonly 5 ml. of contrast medium was injected.

the right atrium. In other instances we havemade the injection into the azygos vein if thelatter is anomalous in origin and prevents entryinto the right atrium via the inferior vena cava.This has either been done by hand or mechani-cally, using a very low pressure. Although theresult simulates an ordinary venous angiocardio-gram it may still give diagnostic information.The main value of selective angiocardiography

through the right heart is in depicting pulmonaryvalvular and infundibular stenosis and demon-strating the degree of aortic over-riding andpatency of the pulmonary vessels in Fallot'stetralogy. It is also useful in giving a visual im-pression of the size and site of a ventricular oratrial septal defect. In other complicated cases itmay give little more help than a venous angio-cardiogram and in fact be impossible to interpret.Even with combined selective angiocardiographyand full catheterization it may at times be impos-sible to arrive at a correct diagnosis, a case of

atrial and ventricular septal defect being a goodexample.

In atrio-ventricularis communis selective angio-cardiography gives a confusing picture since, re-gardless of the site of injection, there is simultan-eous filling of all heart chambers (Fig. 10). Cortriloculare bi-atriale may be equally difficult. Inone case we diagnosed this anomaly as a largeventricular septal defect on the basis of thecatheter findings and a pseudo filling defect in thesupposed position of the septum on the first seriesof films. There appeared to be a separate rightventricular chamber with contrast medium passingfrom it into the left ventricle via a localized de-fect. This is contrary to the experience of Rowe,Vlad, and Keith (1956).

SUMMARY

There are many technical causes of failure inselective angiocardiography. Mechanical failure

94



j.com/


ownloaded from


SELECTIVE ANGIOCARDIOGRAPHY OF THE RIGHT HEART

FIG. 8.-P. W., aged 1 year. Fallot's tetralogy. The catheter has recoiled into theright auricle. The auricular appendage is obscuring the detail of the infundi-bulum of the right ventricle and the over-riding aorta prevents visualizationof the pulmonary valves.

of the x-ray equipment or pump should be elimin-ated so far as possible by routine testing of theapparatus before each examination. Similarly,faults in the catheter will be detected if it is testedin the way we have described. The risk of the endof the catheter recoiling during the injection canbe minimized by using only stiff, resilient catheters,preferably with side openings near the tip. The

proper selection of the site for injection is prob-ably the most important factor, and this can onlybe decided in the majority of cases following fullcatheterization. The 58 selective angiocardio-grams we have reviewed were obtained in thefirst year of using an " elema " two-plane x-rayapparatus and thus represent the results of a pro-cess of trial and error with this technique.

95



j.com/


ownloaded from



FIG. 9.-C. J., aged 3 years. Reflux into the right auricle during thefirst second after the injection. There is a pulmonary valvularstenosis and post-stenotic dilatation of the pulmonary artery(same case as Fig. 1).

FIG. 10.-S. I., aged 11 weeks. Atrio-ventricularis communis. Allthe cardiac chambers are filled in addition to the aorta andpulmonary vessels. The injection of contrast medium was intothe left auricle. The appendage of the latter is overlying thebase of the aorta.

We are indebted to Dr. I. M. Anderson and Dr.Peter Kerley for their advice and constructivecriticism, and to Mr. Charles Drew, Dr. C. J. Gavey,and Dr. A. Leatham for permission to publish theircases. We should also like to thank Miss K. C. Clarkand her staff for the care they took with the repro-ductions.

REFERENCESKjellberg, S. R., Mannheimer, E., Rudhe, U., and Jonsson, B. (1955).

Diagnosis of Congenital Heart Disease. The Year Book Pub-lishers, Chicago.

Rowe, R. D., Vlad, P., and Keith, J. D. (1956). Radiology, 66, 344.

ADDENDUMThe patients examined were aged as follows:

Age of Patients No. Examined

2 weeks - 1 year .. 181 year - 5 years .. 235 years -10 910 ,, -15 ,, 2Over 15 years 6

Total 58

The conditions diagnosed were as follows

Fallot's tetralogyPulmonary stenosis and ventricular septal defect with

normal aortic rootVentricular septal dcfectAnomalous pulmonary venous drainagePulmonary stenosis (including one with atrial septal

defect and one with patent ductus arteriosus)Truncus arteriosusAtrial septal defect .. ..

Coarctation of the aorta ..

Mitral stenosis .. .

No abnormality detected .

Atrial and ventricular septal defects

Atrio-ventricularis communis

Ventricular septal defect and mitral stenosis,,~~ ~,, ,, I, patent ductus arteriosus

(with arterio-venous anomaly in the right upperlobe) .. ,.

Coarctation of the aorta and mitral stenosisI I aorta, atrial septal defect, and

partial anomalous pulmonary venous drainageCor triloculare bi-atriumLeft coronary arterio-venous aneurysmBicuspid aortic valve

7

5

65

44

3

3

5

Miscellaneous:Agenesis of right lung .

Arterio-venous anomalies of both lungsBilateral obstructive emphysemaUnsatisfactory ..

T(

... II..... II..

Iotal . 58

FI BI

96

FIG. 9

II

IIII



j.com/


ownloaded from


Documents

SELECTIVE ANGIOCARDIOGRAPHY OF RIGHT - Thorax · "elema" roll film changer. The pressure selected depends on the internal diameter of the catheter and varies inversely with it. The