Cardiac Catheterization Studies Research Articles

Three-Dimensional Remodeling of Cardiomyocytes in a Patient With Aortic Stenosis

A 77-year-old man was admitted to our hospital because of anterior chest pain. An echocardiogram demonstrated aortic valvular stenosis with calcification of the whole aortic root, concentric left ventricular hypertrophy, and slightly reduced left ventricular wall motion. Cardiac catheterization study showed a peak transaortic pressure gradient of 89 mm Hg and an aortic valve area of 0.52 cm2. We were planning surgical treatment, but the patient suddenly …

A Case of Iron Overload Cardiomyopathy Beneficial Effects of Iron Chelating Agent and Calcium Channel Blocker on Left Ventricular Dysfunction

We experienced an 81 year-old man with heart failure and macrocytic anemia. His serum ferritin level was extremely high (> 3,000 ng/mL). Echocardiography showed a normal left ventricular (LV) ejection fraction (EF), although the total ejection isovolume index (TEI index) was markedly elevated (0.60). In a cardiac catheterization study, cardiac index, pulmonary arterial wedge pressure, LV wall motion, and coronary arteries were shown to be normal. However, atrial pacing demonstrated a negative force-frequency relationship (a decrease in arterial blood pressure with higher pacing rates). Pathological study showed hemosiderin accumulation in his liver, but not in his myocardial tissue. As earlier studies have reported that iron may play an important role in oxidative cell damage and that this ion can enter cardiomyocytes through L-type Ca(2+) channels, we started an iron chelating agent (deferoxamine) and a calcium channel blocker (verapamil) in this case. Eighteen months later, his serum ferritin levels fell significantly without any changes in anemia. The TEI index was normalized (0.21) and the atrial pacing provoked a less negative force-frequency relationship. Thus, this combination treatment may be effective in iron overload cardiomyopathy at its early stage, when LV diastolic dysfunction is dominant and LV systolic dysfunction is only latent.

Controlled Release of Matrix Metalloproteinase-1 Plasmid DNA Prevents Left Ventricular Remodeling in Chronic Myocardial Infarction of Rats

The present study investigated whether administration of controlled release matrix metalloproteinase-1 (MMP-1) plasmid DNA prevents left ventricular (LV) remodeling in a rat chronic myocardial infarction (MI) model. Rats with a moderate-sized MI were randomized to 2 groups: injection of phosphate buffered saline (PBS) containing microspheres into the peri-infarct area (MI group, n=14) and injection of cationized gelatin microspheres incorporating MMP-1 plasmid DNA (MI+MMP-1 group, 50 microg MMP-1/20 microl; n=14). As a control group (n=14), rats received neither the coronary artery ligation nor the injection of PBS. Echocardiography, cardiac catheterization and histological studies were performed. At 2 and 4 weeks after the treatment, the MI+MMP-1 group had smaller LV end-diastolic and end-systolic dimensions, better fractional area change and smaller akinetic areas than the MI group. The LV end-systolic elastance and time constant of isovolumic relaxation were also better in the MI+MMP-1 group compared with the MI group 4 weeks after the treatment. Fibrosis evaluated with Masson's trichrome staining was less in the MI+MMP-1 group than the MI group. Gelatin microspheres for the controlled release of MMP-1 plasmid DNA are promising for improving cardiac remodeling and function when they are administered during the chronic phase of MI.

Diagnosis and management of cyanotic congenital heart disease: Part I

Most commonly encountered cyanotic cardiac lesions in children, namely, tetralogy of Fallot, transposition of the great arteries and tricuspid atresia are reviewed. Pathology, pathophysiology, clinical features, non-invasive and invasive laboratory studies and management are discussed. The clinical and non-invasive laboratory features are sufficiently characteristic for making the diagnosis and invasive cardiac catheterization and angiographic studies are not routinely required and are needed either to define features, not clearly defined by non-invasive studies or as a part of catheter-based intervention. Surgical correction or effective palliation can be undertaken with relatively low risk. However, residual defects, some requiring repeat catheter or surgical intervention, are present in a significant percentage of patients and therefore, continued follow-up after surgery is mandatory.

Heartbreaking Case of Acetaminophen Poisoning

A 23-year-old woman was brought to the emergency room after ingesting 50 g of acetaminophen. Her blood acetaminophen level was 158 mg/L, and she later developed fulminant hepatic failure. Sixty-three hours after ingestion, ECG displayed signs suggestive of acute ischemic injury (Figure 1A). Serum enzymes revealed a Troponin-I of 227.2 ng/mL. The patient’s declining clinical status precluded a cardiac catheterization study. She died within 72 hours of admission in spite of orthotopic liver transplantation. Autopsy revealed normal patent coronary arteries, and cardiac tissue histology displayed patchy subendocardial necrosis and hemorrhage in the ventricles and septum (Figure 1B and 1C) probably due to direct acetaminophen toxicity …

Postoperative ventricular tachycardia in patients with congenital heart disease: diagnosis and management

Ventricular tachycardia (VT) after palliative repair of congenital heart disease is relatively rare. Despite this rarity, VT is a known cause of early, intermediate and late morbidity and mortality in these patients. A number of factors have been linked to the development of VT in this unique patient population. The purpose of this article is to provide a concise overview regarding the etiology, diagnosis and treatment of VT in patients with congenital heart disease. In-depth information will be provided to aid diagnosis and the treatment of early postoperative VT. The use of additional diagnostic methods such as echocardiography, cardiac catheterization and electrophysiology studies to risk assess patients with postoperative VT will also be discussed. In addition, I examine the long-term management strategies for VT in these patients, from medical management and cardiovascular surgery to implantation of cardioverter-defibrillators.

Doppler echocardiography assessment of hemodynamic values and additional heart defects in atrial septal defects

Due to the rapid progress in (Doppler-) echocardiography "one must question whether cardiac catheterisation remains a necessary prelude to cardiac surgery in atrial septal defects" (8). Although the estimation of the magnitude of the intracardiac shunt and the anatomical size of the defect ist possible by (Doppler-) echocardiography there remains the problem of associated disorders (e.g. anomalies of the pulmonary venous connection) which may not be detected by transthoracic echocardiography. In 25 children submitted to cardiac catheterisation studies in the period between 1990 and 1992, the anatomical size of an atrial septal defect was measured echocardiographically. The haemodynamic parameters Qp/Qs and Rp/Rs were employed to calculate the so-called effective resistance of the defect (Rd/Rs), which was derived from an electrical analogue and represents the ratio of the resistance of the defect (Rd) to the systemic vascular resistance (Rs). The echocardiographically measured anatomical size (expressed as the ratio of the area of the defect to the cross-sectional area of the ascending aorta) was related to the effective resistance of the defect. A significant (non-linear) correlation was found between Rd/Rs and the anatomical size of defect. Based on these data we developed a nomogram describing the relationship of the size of the defect to the haemodynamic parameters (Qp/Qs and Rp/Rs). If the data of a patient do not comply with this nomogram there is strong evidence of an additional cardiovascular malformation, necessitating further evaluation. A second cohort of four patients with associated defects (partial and total anomalous pulmonary venous connection and a corresponding sinus venosus defect) was clearly identified by the nomogram method.

A Case of Pulmonary Artery Dissection during a Cardiac Catheterization Study of a Beagle Dog

A Case of Pulmonary Artery Dissection during a Cardiac Catheterization Study of a Beagle Dog

Post coital hemoptysis

Ischemic mitral regurgitation is a complication of coronary artery disease specifically in the settings of prior myocardial infarction. It is a dynamic lesion and its severity may increase with different forms of exercise leading to flash pulmonary edema. We present the case of an 81-year-old man with ischemic mitral regurgitation who presented with long standing history of hemoptysis limited to sexual intercourse only. After a thorough negative work-up for the usual causes of hemoptysis, comprehensive right and left cardiac catheterization studies revealed marked increase in baseline mitral regurgitation and pulmonary capillary wedge pressure with isometric exercise. This case illustrates that sexual intercourse, a form of isometric exercise, can cause severe increase in ischemic mitral regurgitation and more so compared to other forms of exercise due to heightened sympathetic activity, leading to flash pulmonary edema and hemoptysis.

An interesting case of infrarenal aortic coarctation without any complication

Coarctation of abdominal aorta is a very rare vascular disease. In etiology; congenital, acquired, inflammatory and infectious mechanisms have been proposed. Patients typically present with severe hypertension.We report an atypical case of infrarenal abdominal aortic coarctation without any complication diagnosed during a cardiac catheterization study and demonstrated by multislice computed tomography.

A comparative study of thoracic radiation doses from 64-slice cardiac CT

The goal of this study was to measure radiation doses for 64-slice cardiac CT angiography studies and to study the dose-savings features of these CT scanners. This was done using various phantoms. These radiation doses were compared with those from typical helical body CT scans, fluoroscopy cardiac catheterization studies and mammography examinations. Radiation measurements were made with a CT ionization detector and a solid state dosimeter. A GE 64-slice Lightspeed VCT and a Siemens Somatom Sensation 64 CT were used to scan a standard 32 cm acrylic phantom and an anthropomorphic phantom. Data were collected in axial and various gated cardiac helical modes. Organ doses and the effective doses were calculated from the measurements. In gated CT cardiac mode with the 32 cm acrylic phantom, the measured radiation doses per study were generally three to seven times greater than those from typical body helical CT examinations; the range depended upon selectable scan parameters. With the anatomical phantom, the surface doses in the anteroposterior (AP) plane were typically 20-60% higher than those measured using the 32 cm phantom. The lateral surface doses were -4% to +15%. These results can be attributed to the shorter AP dimension and the air in the lungs. The CT skin entrance radiation doses were 80-90% less than diagnostic cardiac catheterization studies, and organ doses were similar. Because 64-slice cardiac gated CT uses pitches equal to 0.20-0.27 and high mAs values, the patient radiation doses are appreciably higher than in routine body CT examinations. The female breast, which could receive a radiation dose 10-30 times that received from mammography screening, is an organ of particular concern.

Not All Systolic Velocities Indicate Obstruction in Hypertrophic Cardiomyopathy: A Simultaneous Doppler Catheterization Study

A 43-year-old man with the diagnosis of hypertrophic cardiomyopathy presented with symptoms of dyspnea on exertion. Magnetic resonance imaging and echocardiography showed severe hypertrophy but no evidence of outflow tract obstruction at rest, by either visualization of systolic anterior motion (SAM) of the mitral valve or turbulent high-velocity jets (Figure 1 and Movie 1). On physical examination, he had no murmur at rest or with provocative maneuvers. Because the clinical symptoms were out of proportion to the noninvasive findings, a cardiac catheterization study with simultaneous transthoracic Doppler echocardiography was undertaken to determine whether a dynamic outflow tract obstruction was present. A high-fidelity micromanometer catheter advanced through a transseptal approach was used to measure the left ventricular (LV) pressure at the base and the apex with a simultaneous central aortic pressure recording. There was no catheter pressure gradient between the aorta and LV apex either at rest or after provocation with isoproterenol (Figure 2). There was no SAM of the mitral valve. Despite the absence of pressure gradient and SAM, there was a systolic late-peaking velocity of 4 m/s on continuous wave Doppler interrogation from the apical window during the isoproterenol infusion (Figure 3). The LV pressure catheter was confirmed to be in the LV apex by 2-dimensional echocardiography during these recordings (Figure 4 and Movie 2).

Estimation of Left Ventricular Filling Pressure with Exercise by Doppler Echocardiography in Patients with Normal Systolic Function: A Simultaneous Echocardiographic–Cardiac Catheterization Study

Doppler echocardiography is now used to evaluate left ventricular filling pressures in patients at rest. However, the clinical use of Doppler echocardiography in the determination of filling pressures with exercise has been less well studied. The aim of this prospective study was to confirm the validity of an accepted Doppler parameter (ratio of transmitral E velocity to Doppler tissue annular e' velocity [E/e']) as a measure of filling pressure in patients with normal systolic function during rest and exercise. Twelve patients who presented with symptoms of dyspnea and ejection fraction greater than 50% underwent an exercise right heart catheterization during a symptom-limited bicycle exercise test. Simultaneous Doppler assessment of transmitral flow and tissue Doppler annulus motion was recorded. The transmitral E velocity increased from 0.88 +/- 0.2 to 1.29 +/- 0.4 cm/s whereas the mitral annular e' velocity increased from 0.08 +/- 0.02 to 0.11 +/- 0.06 with exercise. The E/e' ratio increased from 11.7 +/- 0.5 to 14.4 +/- 0.6. Pulmonary artery wedge pressure (PAWP) increased from 14 +/- 4 to 23 +/- 10 mm Hg at peak exercise. The sensitivity of an E/e' of 15 or less as a predictor for a normal PAWP during exercise was 89%. Conversely, in all cases where the E/e' was greater than 15, the PAWP was elevated during exercise. Noninvasively obtained Doppler of mitral and mitral annulus velocities provides a reliable estimation of PAWP not only at baseline, but also with exercise. Specifically, an E/e' ratio of greater than 15 during exercise is associated with a significantly elevated PAWP of greater than 20 mm Hg.

Effects of Heart Rate on Brachial-Ankle Pulse Wave Velocity and Ankle-Brachial Pressure Index in Patients Without Significant Organic Heart Disease

This study evaluated the effects of heart rate (HR) on brachial-ankle pulse wave velocity (baPWV) and ankle-brachial pressure index (ABI). Thirty-two patients without significant organic heart disease underwent elective cardiac catheterization or electrophysiologic study, and were then enrolled in right atrial pacing (RAP; 11 men, 9 women; aged 48 -/+ 15 years) or right ventricular pacing (RVP; 6 men, 6 women, aged 45 -/+ 13 years) studies. Three different HR levels (90, 100, and 110 beats per minute) were paced in random order. By stepwise, multiple linear regression analysis, age, systolic blood pressure (SBP), and pulse pressure (PP) correlated positively with baseline baPWV. In the RAP group, as HR increased, baPWV and left brachial diastolic blood pressure increased significantly (p < or = 0.015), while ABI, left ankle SBP, left brachial PP, and left ankle PP decreased significantly (p < or = 0.013). In the RVP group, as HR increased, baPWV also increased significantly (p = 0.001), while ABI, left ankle SBP, and PP decreased significantly (p < or = 0.034). Values of baPWV and ABI may be influenced by HR in young and middle-aged patients without significant organic heart disease. When these values are used to evaluate and follow up cardiovascular risk in patients, HR changes should be considered.

Potential use of isovolumic contraction velocity in assessment of left ventricular contractility in man: A simultaneous pulsed Doppler tissue imaging and cardiac catheterization study

Echocardiographic techniques have so far provided suboptimal estimates of myocardial contractility in humans. Longitudinal myocardial motion during the isovolumic contraction (IVC) phase, measured by colour tissue Doppler imaging (TDI), has recently been shown in experimental animal models to reflect the state of myocardial contractility. The aim of the present study was to investigate the relationship between left ventricular (LV) isovolumic contraction velocities (IVCv) using pulsed Doppler tissue imaging (DTI) and global LV contractility as measured during cardiac catheterization. Cardiac catheterization and pulsed DTI were simultaneously performed in 16 consecutive patients (13 males, mean age 55+/-10years) with a variety of cardiac diseases. Relationships between the peak positive IVCv as measured at basal levels of the lateral, septal, anterior and posterior walls and the first derivative of LV pressure (+dP/dt(max)), were investigated. Peak IVCv measurements were obtainable in 81-100% of the four LV wall segments. Statistically significant linear relationships were found between IVCv and +dP/dt(max) at the lateral (r=0.58, P<0.05), septal (r=0.66, P<0.01), anterior (r=0.73, P<0.01) and posterior (r=0.81, P<0.001) segments of the LV. IVCv of the basal four LV walls correlates strongly with peak +dP/dt. IVCv is a readily obtainable non-invasive parameter, which correlates with the classical invasive measurement of global LV contractility. It appears likely that there are regional differences in wall motion when DTI is used to determine state of LV contractility.

Abstracts for the British Congenital Cardiac Association Annual Meeting: The Barbican, London, 24–25 November 2005: Poster Presentations: Epoprostenol treatment in children with pulmonary arterial hypertension

Background: Continuous intravenous Epoprostenol treatment has been shown to be beneficial in patients with severe pulmonary arterial hypertension (PAH). We report the experience of the UK Pulmonary Hypertension Service for Children treating 39 children with this therapy. Patients and methods: The patients were aged 4 months to 17 years (median 5.4 years), male: female ratio was 1: 1.2. Eleven children were treated with Epoprostenol alone. Twenty-eight were also treated with Sildenafil, Bosentan, Nifedipine or a combination of these. Twenty-five children had idiopathic PAH and 14 had PAH associated with congenital heart disease (9), connective tissue disease (2), chronic lung disease (2) or HIV (1). Cardiac catheter studies made before treatment began showed that in 26 patients the pulmonary artery pressure equalled or exceeded the systemic pressure. Thirty-four patients had a pulmonary vascular resistance (PVR) study with a mean PVR of 23 ± 12 units m2. After initial evaluation children were monitored by ECG, transthoracic echocardiography, weight, 6-minute-walk test and WHO functional class. Results: Follow-up was 1–90 months (mean 27). Twenty-four children remain stable and well, 8 have been transplanted and 7 died on treatment. There was no deterioration in the ECG; the 6-minute walk distance and right ventricular function assessed by echocardiography remained stable. WHO functional class improved from 3.6 to 2.6 during the first year (n = 38) (p &lt; 0.001) and remained stable for up to 3 years (n = 17). Weight improved significantly (p &lt; 0.05). A Kaplan Meier survival curve showed that survival was 94.4% at 1 year, 90.3% at 2 years and 83.9% at 3 years.Conclusions: Epoprostenol treatment improved survival, clinical status and WHO functional class in children with severe PAH. Survival in the children on intravenous Epoprostenol with and without combination therapy was better than that described in adult studies (McLaughlin VV, et al. Circulation 2002; 106: 1477–1482).

Surgical correction of ventricular septal defect with aortic regurgitation in a dog

An 8-month-old entire Miniature Dachshund, weighing 4.2 kg, was presented for examination following delvelopment of a cough. Ventricular septal defect had been diagnosed tentatively in its infancy on the basis of a cardiac murmur detected by auscultation and echocardiography. Echocardiography using a B mode right parasternal long-axis view showed a defect at the atrioventricular junction and a thickened cusp of the aortic valve prolapsing into the defect. Colour-flow Doppler showed shunt blood flow across the defect at the level of the atrioventricular junction, from left to right. The sinus of Valsalva was dilated, with turbulent blood flow. Aortic regurgitation was also observed. Cardiac catheterisation studies confirmed the diagnosis of a supracristal ventricular septal defect with aortic regurgitation. Despite medication with digoxin, enalapril and aminophylin, started from the first admission, left ventricular internal dimensions gradually increased, and fractional shortening of the left ventricle gradually decreased. Surgery, with the aid of extracorporeal circulation, to close the ventricular septal defect, was performed 1 year after the initial examination. The aortic valve was left untreated. Postoperatively, the systolic murmur disappeared. Shunt flow from the left to the right ventricle was no longer observed on echocardiography, however there was still a small amount of aortic regurgitation during diastole visualised with colour-flow Doppler echocardiography. The prolapse of the cusp of the aortic valve on B-mode echocardiography was no longer observed and thickening of the cusp had not progressed. Left ventricular function measurement using M mode echocardiography showed a reduced left ventricular volume overload with reduced left ventricular internal dimensions and increased fractional shortening. The cough was relieved and no follow-up medication was scheduled. Early surgical closure of the ventricular septal defect improved the patient's condition and controlled prolapse and thickening of the aortic valve.

Considerations in Retransplantation of the Failed Renal Allograft Recipient

Routine success in kidney transplantation has significantly improved the quality and length of life for the majority of recipients and made this option the treatment of choice for suitable candidates. Improved patient survival combined with a relative static improvement in long-term graft outcomes has led to an increasing number of transplant recipients with failed allografts who face the eventual option of either returning to dialysis or seeking retransplantation. Although retransplantation is presumed to be a favorable option for many, data to support this belief is limited. Given the wide variance in predicted outcomes for retransplantation, on the basis of the underlying kidney disease and other individual patient comorbidities as well as the expected wait time for a second transplant, each case should be evaluated independently. This review discusses available data and individual considerations that should be taken into account when retransplantation is proposed after failure of a primary allograft.

Vascular injuries resulting from arterial puncture of catheterization.

Abstract Diagnostic puncture or catheterization is probably the commonest cause of serious arterial injury in current civilian surgical practice. The most frequent complications are arterial thrombosis, bleeding from the puncture site, false and arteriovenous aneurysm formation, and cerebral embolism. Eight instances of arterial occlusion have been treated in one hospital in less than 18 months–1 followed arterial puncture, 3 followed operative insertion of catheters maintained for repeated blood-sampling, I followed Seldinger catheterization for arteriography, and 3 followed cardiac catheter studies–during which time 1400 such procedures were carried out. Arterial spasm and trauma, large catheter size, protracted catheter maintenance, and low cardiac output seem to be factors particularly liable to produce sufficient damage to precipitate complications, together with thrombosis consequent to sustained heavy local pressure to arrest haemorrhage from the site of arterial puncture. Early surgical correction was successful on each of 6 occasions, but in the 2 cases in which procrastination had occurred major arm amputations became necessary.

ACC/AHA/AAP RECOMMENDATIONS FOR TRAINING IN PEDIATRIC CARDIOLOGY

ACC/AHA/AAP RECOMMENDATIONS FOR TRAINING IN PEDIATRIC CARDIOLOGY