Angiocardiography; its application to the diagnosis of coarctation of the aorta.

Abstract

The advent of surgical relief for coarctation of the aorta makes its diagnosis of more than academic importance (1, 2). The exact location of the constriction, the size of the aorta above and beneath the coarctation, the development of the collateral circulation, and the size and position of the innominate, the left common carotid, and subclavian arteries should be recognized radiologically. This may be done by angiocardiography, as in the three cases to be reported here, one in a forty-two-year-old woman and the other two in children, a boy of thirteen and a girl of fourteen years. A modification of the Robb-Steinberg technic was used in which 14 × 17-inch cassettes were changed manually at intervals of one and a half to two seconds. A limiting cone confining the x-ray beam to the film area and protective side screens were provided. Case Reports Case I: R. R., a 42-year-old housewife, was first told she had hypertension during a pregnancy sixteen years earlier. A second pregnancy four years later was uneventful. There was a history of occasional palpitations but there had been no symptoms of heart failure or rheumatic fever. Physical examination showed the heart to be enlarged to the left. A loud precordial systolic murmur transmitted to the neck and back was present. The blood pressure in the right arm was 216/126 mm. Hg, left arm 220/120, right leg 158/135, and left leg 160/135. Pulsations were felt in the femoral arteries. There were no visual evidences of collateral circulation. Fluoroscopic and radiographic examination of the chest showed the lungs to be normal. Slight notching was observed on the postero-inferior aspects of the third to ninth ribs bilaterally. The left ventricle was considerably enlarged, and the right ventricle presented moderate anterior enlargement. The barium-filled esophagus was not displaced from its usual course. The ascending aorta was not dilated, but its pulsations were increased in amplitude as compared with the transverse and descending thoracic aorta, which were visible in the left anterior oblique position. The aortic knob was rather prominent and pulsated less vigorously than the adjacent aortic segments and the left ventricle. The lower portion of the descending thoracic aorta was displaced medially and anteriorly. Angiocardiograms showed the right lower heart border to be formed by the right atrium. The superior vena cava and convex portion of the ascending aorta formed the upper part of the right cardiovascular outline. Immediately medial to the superior vena cava was the dilated innominate artery. The left superior mediastinal border was formed by the overlapping innominate vein and the dilated left subclavian artery. The latter was laterally convex and inclined medially and upward, presenting a nick as it passed from its aortic origin. The dilated left common carotid artery was medial to the left subclavian artery and was about half its size.