INTRAMURAL DEPOSITION OF CONTRAST AGENT DURING SELECTIVE ANGIOCARDIOGRAPHY.

Abstract

Intramyocardial injection of contrast agent is a unique complication of selective angiocardiography and has been recognized with increasing frequency in recent years. Its potential gravity prompted us to investigate its cause, effects, and possible prevention, and this report comprises the results of this study. Bjöork et al. (2) report 3 intramyocardial injections with 1 death in a series of 142 transthoracic needle punctures. In a review article, Greenberg and Knox (5) cite 19 instances of intramural injection in a total of 437 percutaneous ventriculographies, with 3 fatalities. From experience with the catheter approach, Keith et al. (6) mention 3 cases of subintimal injection, all in infants, apparently producing no significant clinical manifestations. Also in reference to catheter studies, Bagger et al. (1) found 4 right ventricular intramural injections in a series of 1,375 angiocardiograms, with no late sequelae. Dotter et al. (4) report 1 case in which the intramural injection through a catheter was held responsible for the patient's death eight hours later. Davidsen et al. (3), in a series of 500 selective studies, and Kjellberg et al. (7), in a series of 728 angiocardiograms (the number of selective studies is not stated), do not refer to this complication. Clinical Material and Methods During the past five years, the present authors have recognized 16 intramural injections. Of 248 selective catheter angiocardiographic studies made between June 1957 and September 1962, 13 gave evidence of partial intramural injection. Of 4 transthoracic needle injections into the left ventricle during this same period, 3 were partially intramural. Side-hole catheters were either #5 or #6 Eppendorf or NIH aortographic. End-side-hole catheters were #8 Teflon except for one #6 woven nylon. All catheter injections were performed at pressures between 525 and 675 lb. per square inch. The contrast agent was usually Ditriokon, but in some of the earlier studies, 70 per cent Urokon or 75 per cent Hypaque was used. Clinical Manifestations: Clinical manifestations were apparent in only 2 of the 16 cases of intramural injection. These will be briefly reported. Case I: In B. S., a four-year-old boy with severe aortic valvular stenosis, retrograde left ventricular catheterization revealed a 90 mm. gradient across the aortic valve. A selective left ventricular angiocardiogram was planned. Prior to the high-pressure injection of contrast medium, several hand injections of saline failed to provoke ectopic ventricular systoles, and the catheter tip was thought to lie freely within the left ventricular cavity. Accordingly, 20 c.c. of Ditriokon was injected at a pressure of 675 lb. per square inch through a #6 side-hole catheter.