Overview

Historical perspective of cardiac catheterization
In 1844, Claude Bernard passed a catheter into both the right and left ventricles of a horse's heart via a retrograde approach from the jugular vein and carotid artery. He was the first to perform a scientific study of cardiac physiology, and he set the stage for cardiac catheterization as it is known today. In 1929, in Eberswalde, Germany, a 25-year-old surgical trainee named Werner Forssmann was the first to pass a catheter into the heart of a living person²his own. He passed the catheter into his right atrium via the left antecubital vein under fluoroscopic guidance and then climbed the stairs to the radiology department to undergo a chest radiograph. His efforts were not rewarded but, rather, stimulated considerable opposition and bitter criticism; however, in 1956, he shared the Nobel Prize in medicine with other pioneers of invasive cardiology. Further developments in invasive cardiology were slow until the work of Andre Cournand and Dickenson Richards, who performed the first comprehensive studies of right heart physiology in humans. In 1947, Louis Dexter expanded the clinical use of right heart catheterization with studies in patients with congenital heart disease and identified the pulmonary capillary wedge pressure as a useful clinical measurement. By this point, the value of hemodynamic measurements was being fully realized, and further developments came rapidly.

The heart catheterization.

Cardiac catheterization and coronary angiography
Although the technique and accuracy of noninvasive testing continues to improve, cardiac catheterization remains the standard for the evaluation of hemodynamics. Cardiac catheterization helps provide not only intracardiac pressure measurements, but also measurements of oxygen saturation and cardiac output.[1] Hemodynamic measurements usually are coupled with a left ventriculogram for the evaluation of left ventricular function and coronary angiography. Coronary angiography remains the criterion standard for diagnosing coronary artery disease and is the primary method used to help delineate coronary anatomy.[2] In addition to defining the site, severity, and morphology of lesions, coronary angiography helps provide a qualitative assessment of coronary blood flow and helps identify collateral vessels. Correlation of the coronary angiogram and left ventriculogram findings permits identification of potentially viable areas of the myocardium that may benefit from a revascularization procedure. Left ventricular function can be further evaluated during stress using atrial pacing, dynamic exercise, or pharmacologic agents.

Indications
Cardiac catheterization is a procedure undertaken for the diagnosis of a variety of cardiac diseases. As with any invasive procedure that is associated with important complications, the decision to recommend cardiac catheterization must be based on a careful evaluation of the risks and benefits to the patient. Indications for cardiac catheterization are as follows: y y y y Identification of the extent and severity of coronary artery disease and evaluation of left ventricular function Assessment of the severity of valvular or myocardial disorders such as aortic stenosis and/or insufficiency, mitral stenosis and/or insufficiency, and various cardiomyopathies to determine the need for surgical correction Collection of data to confirm and complement noninvasive studies Determination of the presence of coronary artery disease in patients with confusing clinical presentations or chest pain of uncertain origin

Contraindications
With the exception of patient refusal, cardiac catheterization has no absolute contraindications. Clearly, the risk-tobenefit ratio must be considered because a procedure associated with some risk should be contraindicated if the information derived from it is of no benefit to the patient. Relative contraindications are as follows: y y y y y y Severe uncontrolled hypertension Ventricular arrhythmias Acute stroke Severe anemia Active gastrointestinal bleeding Allergy to radiographic contrast

and this same catheter is used for left ventricular and aortic angiography. and stopcocks. Larger-diameter catheters (7-10F) allow for greater catheter manipulation and excellent visualization. The inner diameter of the catheter is smaller than the outer diameter because of the thickness of the catheter material. a Swan-Ganz catheter is used for measuring right heart pressures. Frequently. Technique Patient Preparation Before the procedure. and determining cardiac output. the responsible cardiologist should fully explain the risks and benefits to the patient. needles. thereby lowering the risk. A commonly used wire is a 150-cm. Decisions about which catheter to use are based on several factors. Pressure measurements within the left ventricle usually are obtained using a pigtail catheter (see image below). thus compromising the quality of the procedure. Before the procedure. but contrast delivery may be limited in certain situations. Image courtesy of Olurotimi Badero. 0. smaller catheters (4-6F) are less traumatic and permit earlier ambulation after catheterization. A close physician-patient relationship is important to reduce fears about the procedure. but they have a higher potential for trauma to the coronary or peripheral vasculature. The 6F diagnostic catheter is used widely for routine angiography because it has a good balance of the necessary requirements. (2) the necessity to adequately opacify the coronary arteries and cardiac chambers in different clinical situations. All catheters and sheaths are advanced over a guidewire to diminish the chance of trauma to the vasculature. The outer diameter of a catheter is measured in French units (F). including (1) the vascular and heart anatomy.y y y y y Acute renal failure Uncompensated congestive failure (patient cannot lie flat) Unexplained febrile illness and/or untreated active infection Electrolyte abnormalities (eg. introducer sheaths. MD. Aortogram obtained with a 6F pigtail catheter showing the ascending aorta. Contraindications to radial artery access for left-heart cardiac catheterization include the following: y o o o o o o y o o o o o Absolute Absence of adequate collateral circulation Abnormal Allen test result or plethysmography Patients who may require intra-aortic balloon pump (IABP) Patients who may require devices not compatible with < 7F sheaths Patients with known upper extremity vascular disease Patients with Buerger disease or severe Raynaud syndrome Relative Patients with chronic kidney disease (CKD) who may need arteriovenous Fistula in the future Patients with Raynaud syndrome Women with short stature and weak radial pulses Patients with known severe innominate-subclavian artery disease Patients with known internal mammary grafts contralateral to site of entry Equipment Numerous items of disposable equipment are used for the procedure. which often are necessary.33 mm. Although not a necessity. wires. This always should be considered unless the procedure is being performed in an emergency situation. FACP. descending aorta. and great vessels. In contrast. a complete . and should answer questions asked by the patient or family.035-in J-tipped guidewire. a short vascular access sheath often is used to facilitate arterial access and multiple catheter exchanges. and (4) whether arterial access is obtained via the femoral artery or via an upper extremity artery. collecting blood to measure oxygen saturation in various chambers. hypokalemia) Severe coagulopathy Note that many of these factors can be corrected before the procedure. 1 F is 0. (3) the extent to which the catheter must be manipulated and the desire to limit vascular injury and complications. including various catheters. should obtain written consent. syringes. A wide variety of preformed catheter shapes exist for coronary and bypass graft angiography.

y The main advantages of the radial approach are a low incidence of serious vascular complications and the ability to mobilize the patient quickly after the procedure. arterial access from the upper extremity is preferred if the patient has important iliac or femoral artery atherosclerosis or has severe obesity that renders the normal landmarks for access difficult to appreciate. internal jugular.[4] Patients should fast for at least 8 hours before the procedure. physical examination. Alternatively. Evidence is strong that pretreatment with sodium bicarbonate. and some operators administer diphenhydramine or a narcotic. Despite the increase in popularity. Maneuver the catheters through the axillary and subclavian arteries into the ascending aorta. y Obtaining access from the radial artery is increasing in popularity. Although surgical exposure of the brachial artery still is used by some operators. After the procedure. Less widespread adoption in the United States may be because of the inability to introduce larger equipment and intra-aortic balloon pumps through the radial artery. the transradial approach is used in only 7% of coronary angiograms in the United States compared with approximately 50% in Asia. blood chemistries. complete blood count. or subclavian veins using percutaneous access methods. The following characteristics indicate an ideal patient for this approach: y y y y y y y y y Pannus or poor body habitus Severe peripheral vascular disease or fibrosis Elevated INR (prosthetic valves and atrial fibrillation on anticoagulation) Patient cannot lie supine or will not lie still Large abdominal aortic aneurysms Back pain Probable normals Patient preference In general. Arterial access from the upper extremity (modified Sones method) The classic brachial artery technique was developed by Mason Sones. the arteriotomy and then the skin were sutured closed. arterial spasm. and acetylcysteine are nephroprotective. contrast allergy. or a variety of preformed catheter shapes. access can be obtained from the axillary artery or radial artery. or long-term anticoagulation use because these conditions are associated with a higher risk of procedure-related complications. Although this classic brachial approach still is used by some operators. radial. access to the arterial system was obtained by direct exposure of the brachial artery and insertion of the catheters under direct visualization. most procedures now are performed using a percutaneous approach from the femoral. and several new shapes have been developed to facilitate easy cannulation of the coronary arteries. should the radial artery occlude during or after the procedure. Technique and Approach In the early days of cardiac catheterization. chest radiograph. and often is referred to as the Sones method. or axillary artery. MD. An Allen test needs to be performed before the procedure to ensure continuity of the arterial arch in the hand. and ECG should be obtained. which requires deflection of the catheter tip off the aortic valve cusps. renal insufficiency. and 40% in Europe. brachial. which impairs manipulation of the catheter. adequate hydration before the contrast load will minimize the risk of contrastinduced nephropathy[3] and pretreatment with corticosteroids will diminish the likelihood of an allergic reaction to contrast. Appropriate therapies before the procedure can minimize these risks. Right heart catheterization now is commonly performed from the femoral. peripheral vascular disease. Not all patients are ideal candidates for a radial artery approach to cardiac catheterization. percutaneous access now is commonly used. and the need for additional training with the technique.history. y Standard catheters may be used from the radial approach. . Perform coronary angiography using either a Sones catheter. Special attention should be given to identifying patients with insulin-dependent diabetes mellitus. 6] Difficulty accessing the relatively narrow radial artery and increased need for catheter manipulation for coronary engagement by less-experienced operators can also result in longer procedure times.[5. Access sites are shown in the illustration below. y y y Insert a 5F or 6F sheath into the brachial artery. theophylline. y The disadvantages of the radial approach are a longer learning curve for the operator and occasional severe arterial spasm. Radial artery spasm complicates transradial catheterizations in 2-6% of cases. Access from the axillary artery avoids the potential for injury to the median nerve and provides a better platform for compression of the artery against the humerus to obtain hemostasis. For example. Premedication with a mild sedative is common.

Image courtesy of Olurotimi Badero. the coronary sinus. thus.[7] Complications Intraprocedure Complications .tctmd. or the aortic root. such as the free wall of the right atrium. and coronary angiography can be performed using the standard catheter shapes. y Vascular complications are increased if the arterial puncture is made either above or below the common femoral artery. the more occlusive nature of the catheters. with several recent advances with new transseptal guidewires (TSP-GW) in cases of resistant atrial septum that did not allow the standard needle. Use transseptal catheterization in patients with mechanical aortic valves or if obtaining a true left atrial pressure is necessary. Many operators also administer heparin when access is from the femoral artery. especially if the procedure is prolonged and several catheter exchanges are required. Additional vascular approaches used for cardiac catheterization Rarely. MD. This approach has been used in ablation therapy in atrial fibrillation. A pigtail catheter frequently is used for measuring left heart pressures and performing a left ventriculogram. This technique requires a firm understanding of cardiac radiographic anatomy to avoid puncturing adjacent structures. Several types of arterial closure devices now are available that provide rapid hemostasis and shorten the period of bedrest considerably. anticoagulation is required for the procedure and unfractionated heparin is used frequently. Because of the smaller-diameter arteries in the upper extremity and. This widely used method requires separate preformed catheters for the right and left coronary arteries. Arterial access from the lower extremity The common femoral artery is the only access site used in the lower extremity. MD. severe atherosclerotic disease may affect both the upper and lower extremities and preclude vascular access at the usual sites. the method often is referred to as the Judkins technique. y The main advantages to this method are its ease and substantial safety record. thus. Catheterization of the left atrium and left ventricle can be performed using a transseptal approach.com. However. complication rates with these closure devices are similar to conventional manual compression. y Proper access to the common femoral artery is critical for this technique (see image below). y The main disadvantage is the need for an extended (2-6 h) period of bedrest after completion of the procedure.Cardiac catheterization sites. Access to the descending aorta can be obtained via a translumbar approach. as follows: y y y y Puncture the intra-atrial septum with a needle and advance a catheter into the left atrium and left ventricle. Femoral access. a direct left ventricular puncture may be the only option. If left ventricular hemodynamics are necessary in patients with mechanical valves in both the aortic and mitral position. Catheters used for performing coronary angiography via the femoral artery were developed by Melvin Judkins. FACP and www.

23% in 1973. myocardial ischemia with pain and ST-segment changes may occur. renal insufficiency. especially in patients with marginal left ventricular function. but it has decreased to 0. the multivariate predictors of complications were shock. Some patients are sensitive to the vasodilator effects of the contrast and may experience mild chest discomfort during each dye injection. However. patients older than 60 years and younger than 1 year have an increased mortality rate from catheterization. A high-risk subgroup can be defined based on characteristics identified in multiple large series. Although incidence of stroke has decreased. Patients with valvular heart disease. and a vasopressor agent should be administered if central perfusion is critically compromised. Stroke The procedure-related stroke rate was as high as 0. In high-risk patients. The first symptoms may develop hours after the procedure is completed when atherosclerotic debris loosened from plaques in the proximal aorta finally break . Major Complications The risk of a major complication during diagnostic cardiac catheterization is less than 1-2%. even in the absence of underlying coronary artery disease. A similar increase in risk is observed in those with severe narrowing of the left main coronary artery and poor left ventricular function (ie. In a large series reported from the Society of Cardiac Angiography and Interventions Registry.08%. severe hypertension. The risk-to-benefit ratio strongly favors performance of this procedure as part of the evaluation and treatment of potentially fatal or lifestylelimiting cardiac disease in appropriately selected patients. Chest pain Chest pain may occur. A stroke may not always be apparent during the procedure. The risk of precipitating an MI is influenced by patient-related and technique-related variables. insulin-dependent diabetes mellitus. especially during coronary angiography. it is one of the most devastating complications of cardiac catheterization. Risk factors that predispose patients to an MI during the procedure include (1) recent unstable angina or non±Q-wave infarction. brief episodes of supraventricular tachycardia) are common and usually resolve without treatment. aortic and mitral valve disease. renal insufficiency. This frequently resolves with sublingual or intravenous nitrogly cerin. Ventricular filling pressures can be quickly measured and corrected by volume administration if low. Concurrent drug therapies. Congestive heart failure Due to the osmotic effects of the contrast agents and fluid administration during the procedure. Mortality is especially high in those with preexisting renal insufficiency who have further deterioration of renal function within 48 hours after the procedure. The incidence of procedure related death is now approximately 0. left ventricular ejection fraction < 30%).03%. such as intravenous nitroglycerin. congestive heart failure may develop. atrial or ventricular premature beats. (2) severe of coronary artery disease. but persistent pain with evidence of myocardial ischemia may indicate the need for urgent revascularization. diuretics. poorly compensated congestive heart failure. Occult blood loss from a retroperitoneal hematoma should be evaluated if [8] hypotension persists. This usually requires no treatment. Myocardial infarction The current risk rate for procedure-related myocardial infarction (MI) is less than 0. New York Heart Association functional class IV is associated with nearly a 10-fold increase in mortality compared with classes I and II. or pulmonary insufficiency also have an increased incidence of death and major complications from left heart catheterization. Death Death rates from cardiac catheterization have declined steadily over the past 15 years. peripheral vascular disease. serial ECGs and cardiac enzyme measurements may be considered following the procedure. in patients with important coronary artery disease. cerebrovascular disease. Ventricular tachycardia or fibrillation is a rare occurrence but requires prompt defibrillation. cardiomyopathy.Hypotension Transient hypotension may occur when large volumes of ionic contrast agents are administered and often is more prominent if the ventricular filling pressures are low. and unstable angina. and nitroglycerin. and (3) the presence of important comorbidities. This may require aborting the procedure and instituting treatment with oxygen.[9] Arrhythmia Minor arrhythmias (eg.06% in contemporary registries. acute myocardial infarction (MI) within the past 24 hours. should be considered and regulated if necessary. Other causes of important hypotension require quick investigation and treatment. The risk of death varies with age. particularly when dialysis is required.

Some physicians also administer H1 and H2 receptor blockers. Allergies to local anesthetic usually occur with the older agents (eg. The American College of Cardiology/American Heart Association task force does not mandate full surgical scrubbing and attire for the femoral approach. and latex exposure. urticaria. A recent study demonstrated that premedication with N -acetylcysteine (Mucomyst) may prevent worsening of renal function in patients with renal insufficiency. if it is used. Systemic cholesterol embolization is another cause of renal failure after cardiac catheterization. Approximately 1% of patients eventually require long-term dialysis. although systemic reactions may occur. which develops over several days.[9] High-osmolar contrast agents in the carotid arteries may cause transient neurologic deficits. thus. dehydration. Treatment is purely supportive. but rather. Contrast nephropathy can be avoided by limiting contrast volume to the minimum required for completion of the procedure. which has a 10-fold higher infection risk (0. and profound hypotension. or those taking nephrotoxic medications are at an increased risk. Renal failure in these patients tends to develop slowly over weeks compared with contrast-induced nephropathy. and hypocomplementemia usually precede the signs of embolization.06%). the laboratory should be cleaned between procedures and multiuse drug vials should be avoided.62% vs 0. Maintain a very high level of suspicion. . Approximately 5% of patients experience a transient rise in plasma creatinine concentration (>1 mg/dL) after contrast exposure. Symptoms include sneezing.free and embolize. protamine sulfate. bronchospasm. procaine) rather than the newer agents. serious allergic reactions with profound hypotension can occur. Special care should be used in patients with femoral bypass grafts because these patients are prone to lifethreatening infections. Such reactions are reported to be more frequent in patients with diabetes who previously received neutral protamine Hagedorn (NPH) insulin. Protamine sulfate is now rarely given to reverse the anticoagulant effect of heparin. the incidence of infections is very low. Allergic reaction Allergic reactions during cardiac catheterization may be precipitated by local anesthetics. Severe reactions usually are reversed by an intravenous injection of dilute epinephrine. but patients with diabetes who have impaired renal function are at high risk. Some centers perform skin testing prior to the procedure to avoid reactions. To eliminate the risk of patient-to-patient infection. but it does recommend it for the brachial approach. Pyrogen reactions as a cause for fever are now very uncommon because almost all of the catheters used are single-use disposable devices. Latex-induced allergic reactions are being recognized more frequently. The risk of a contrast reaction is increased in patients with other atopic disorders. it is due to phlebitis or often is unexplained. transient eosinophilia. multiple myeloma. multiple other allergies. and approximately half of these patients progress to renal failure. This reaction is not a true anaphylactic reaction but. mostly in those with severe atherosclerosis. They usually are local. and evaluate patients after the procedure to assess any neurologic changes. Patients with preexisting renal insufficiency. These can be avoided by the use of latex -free materials in sensitive patients. but dialysis occasionally is necessary. Episodic hypertension. The hallmark of cholesterol embolization is peripheral embolization resulting in livedo reticularis. caused by preservatives in the older ester agents. Renal dysfunction Renal dysfunction is a potential complication of any angiographic procedure. angioedema. The risk of contrast-induced nephropathy is not increased in patients with diabetes who have normal renal function. foot pain. high-risk patients should be premedicated with corticosteroids and a nonionic contrast agent should be used.15% of patients. the result of direct complement activation and thus is an anaphylactoid reaction. rather. and purple toes. Low-osmolar contrast agents should be used because these appear to have less renal toxicity than high osmolar agents. Although many therapies have been tried. Fever occurring after the procedure usually is not due to infection. iodinated contrast agents. Contrast-induced renal failure usually is nonoliguric. Creatinine levels usually begin to rise 2-3 days after contrast exposure and slowly return to baseline within 7 days. This occurs in approximately 0. These reactions actually may be vasovagal in origin. The prior long-term exposure to protamine is thought to sensitize the patient to protamine. Reactions to iodinated contrast agents occur in approximately 1% of patients. However. the mainstay of prevention is adequate hydration with normal or half normal saline before and after the procedure[10] . Infection Cardiac catheterization is a sterile procedure. or history of a prior reaction to contrast agents. To decrease the risk of contrast reactions.

This requires a transseptal catheterization approach. The normal aortic valve area is 2. and hypotension. sweating. These arrhythmias may result from catheter manipulations or the injection of contrast directly into a coronary artery or bypass graft. Consultation with a vascular surgeon is necessary in case paresthesia or reduced distal pulses occur following catheterization. and female sex. Bleeding Bleeding is the most common vascular complication. aortic stenosis. supports aortic pressure. Arterial thrombosis is a greater concern with brachial access. severe blood loss may develop if bleeding occurs in the retroperitoneal space. Pseudoaneurysm is another potential cause of important groin bleeding and must be recognized. heparin is a requirement. It presents as a pulsatile mass. This is especially important in patients with a low pressure gradient and cardiac output.5 cm2 in adults. Unexplained hypotension and a decreasing hematocrit level should suggest the possibility of a retroperitoneal hematoma. Surgical correction is necessary for large pseudoaneurysms with a wide connection to the parent artery. Bradycardia occurs commonly at the end of a right coronary artery injection performed using high-osmolar agents. The 2 most common times for this to deve lop are during the administration of local anesthesia in the groin and after the application of pressure to obtain femoral artery hemostasis. In patients with aortic stenosis.6-3. second image). mitral stenosis. Vascular Complications Complications at the catheter insertion site are among the most common problems observed after cardiac catheterization. and thus. Tracings are shown in the images below (aortic stenosis. Valve areas of 0. or bleeding. Predisposing factors for arterial thrombosis include a small vessel lumen. Prompt treatment by cardioversion prevents progressive decompensation due to the arrhythmia. left ventricular-femoral artery pressure gradients may suffice as an estimate of the severity of aortic stenosis. Hemodynamic Data Mitral and Aortic Stenosis Determining the severity of a valvular stenosis based on the pressure gradient and flow across the valve is an important aspect of the evaluation in patients with valvular heart disease. Although measuring the gradient between the left ventricle and the femoral artery is convenient. Intravenous fluids and atropine are the treatments for a vasovagal reaction. In patients with mitral stenosis. hypertrophic c ardiomyopathy. These include acute thrombosis. nausea. Abdominal sonography or CT scanning usually is diagnostic. Management often is conservative. Most are of little clinical significance except for asystole or ventricular fibrillation. which supplies the right ventricular outflow tract. Bradycardia and hypotension also may occur during a vasovagal reaction. Bleeding from the arterial puncture may track into the adjacent venous puncture.4% of patients. arterial dissection. a true transvalvular pressure gradient should be obtained whenever possible. In many patients. first image. The measurement of the pressure gradient alone often is insufficient to distinguish significant from insignificant valvular stenosis. Other symptoms of a vasovagal reaction are yawning. pseudoaneurysm. A pseudoaneurysm develops if a connection persists between a hematoma and the arterial lumen. downstream augmentation of the pressure signal and delay in pressure transmission between the proximal aorta and femoral artery may alter the pressure waveform and introduce errors. However. peripheral vascular disease. the valve gradient usually is measured using the left ventricular and pulmonary capillary wedge pressure. Many of these are small and resolve spontaneously. and restores normal cardiac rhythm. However. Forceful coughing usually helps clear the contrast from the coronary arteries. or severe systolic dysfunction. The diagnosis is confirmed by duplex ultrasonography. Atrial fibrillation usually is well tolerated but may provoke hemodynamic decompensation in patients with severe coronary disease. This may simply result in a local hematoma of little clinical significance. diabetes mellitus. has a high likelihood of provoking ventricular fibrillation. especially if the gradient is high and the cardiac output is preserved. sometimes with a systolic bruit. . forming an arteriovenous fistula and a continuous bruit.Arrhythmias Arrhythmias and conduction disturbances can occur during cardiac catheterization. using prolonged compression or thrombin injection in selected patients. The pulmonary wedge pressure tracing must be realigned with the left ventricular tracing for accurate mean gradient determination. Surgical repair is required to fix enlarging fistulae before hemodynamic compromise develops. the most accurate method uses the left atrial and left ventricular pressure. Ventricular tachycardia and/or fibrillation occurs in approximately 0. Vigorous contrast injection into the conus branch of the right coronary artery. distal embolization.8 cm2 or smaller represent severe aortic stenosis.

with associated refluxing into the pulmonary veins during systole. Image courtesy of Olurotimi Badero. FACP. Mitral stenosis tracings. and myopathic heart disease. Acute severe mitral regurgitation.[11] It provides valuable information about global and segmental left ventricular function.Aortic stenosis tracings. . and www. mitral regurgitation. y An RF of 20% is approximately equivalent to grade 1+ regurgitation described visually. Grade 3+ (moderately severe): The left atrium is opacified completely and achieves equal opacification to the left ventricle. FACP and www. or dyskinetic or quantified using several computer algorithms. Grade 2+ (moderate): Regurgitation does not clear with 1 beat and opacifies the entire left atrium after several beats. and forward stroke volume is derived from cardiac output as determined by the Fick or thermodilution method and the heart rate.tctmd. The difference between the angiographic stroke volume and the forward stroke volume is the regurgitant volume. and hypertrophic cardiomyopathy. Angiographic stroke volume is computed from the left ventriculogram findings. Grade 4+ (severe): The entire left atrium is opacified within 1 beat and becomes denser with each beat. The ejection fraction may be estimated visually or computed using the area-length method to derive actual end-diastolic and end-systolic volume estimates.com. hypokinetic. The analysis should use a normal sinus beat if possible because ectopic and postectopic beats yield inaccurate information about ventricular function. RF is computed as the regurgitant stroke volume divided by angiographic stroke volume. The opacification is graded as follows: y y y y Grade 1+ (mild): Regurgitation essentially clears with each beat and never opacifies the entire left atrium. The RF is that portion of the angiographic stroke volume that does not contribute to the net cardiac output. The ventriculogram findings can be analyzed qualitatively and quantitatively.tctmd. MD. akinetic.0-1. Segmental wall motion also can be visually graded as normal. ventricular septal defect. Left Ventriculography This technique is used to define the anatomy and function of the left ventricle and related structures in patients with congenital.com.2 cm2.tctmd. FACP.com. valvular. Regurgitant fraction An estimate of the degree of valvular regurgitation may be obtained by computing the regurgitant fraction (RF). Image courtesy of Olurotimi Badero. and severe mitral stenosis is present with valve areas smaller than 1. and www. MD. using the opacification of the left atrium as a guide. Mitral regurgitation The severity of mitral regurgitation can be graded based on the amount of contrast regurgitation from the left ventricle through the incompetent mitral valve into the left atrium. The normal mitral valve area is 4-6 cm2. coronary. MD. Image courtesy of Olurotimi Badero. See image below.

y y y An RF of 21-40% is equivalent to grade 2+ regurgitation. An RF of 60% or more is equivalent to grade 4+ regurgitation. An RF of 41-60% is equivalent to grade 3+ regurgitation. .

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