Transseptal Left Heart Catheterization Research Articles

Right and left heart functions in pulmonary congestion and pulmonary edema.

THE development of pulmonary edema in heart disease is closely related to the cardiac decompensation. Its fundamental disorder is generally believed to be the intensification of pulmonary congestion due to the cardiac decompensation. This concept, however, depends on the indirect evidences such as clinical symptoms, chest X-ray findings and the measurement of pulmonary vascular pressures and central blood volume.With the introduction of left heart catheterization by transseptal route, it has become possible to study the dynamics of the left heart with safety and little discomfort to the patient. Utilization of indicator-dilution technique, combined with simultaneous right and transseptal left heart catheterizations, has made it possible to estimate more precise quantitation of pulmonary congestion, i. e., the true pulmonary blood volume and pulmonary circulation time.The purpose of this presentation is to report the role of heart failure in the pathogenesis of pulmonary congestion and edema in heart disease.

The oxygen- and carbon-dioxide tensions in the pulmonary veins.

The technique of transseptal left heart cathe-terization has been adapted for selective catheterization of the pulmonary veins in order to establish ventilation/ perfusions ratios in term of local pO2 and pCO2.Data from a patient with normal pulmonary function is presented as well as results from patients with localized lung disease in order to demonstrate the diagnostic applicability of the method.

Considerations regarding the technique for transseptal left heart catheterization.

Improvements in the equipment and technique for transseptal left heart catheterization appear to have largely overcome the major problems and complications that have been encountered in recent years with this procedure. Improvements in equipment have included the addition of a stylet for the needle, modifications in the design of the catheter, and the use of a catheter tip occluder both for manipulation of the catheter within the left heart and to close the end hole during selective angiography. The steps employed for insertion of the catheter and needle were described in detail, and the use of landmarks such as the left main-stem bronchus, the spine, the left atrial shadow, and the aortic bulge was discussed. The indications for, and relative contraindications to, transseptal catheterization currently applied in this laboratory were also described. The relative contraindications consist of (1) a giant right atrium, (2) severe rotational anomalies of the heart or great vessels, and kyphoscoliosis; (3) marked dilation of the ascending aorta; (4) anticoagulant therapy, and (5) a history of recent systemic arterial embolization. Since the introduction of these technical changes and precautions, with the exception of one nonfatal aortic puncture, the problems previously encountered during transseptal catheterizations have been avoided in more than 350 consecutive transseptal left heart studies in this laboratory.

Pulmonary Blood Volume in Congestive Heart Failure

By utilizing indicator-dilution techniques, determinations of the pulmonary blood volume (PBV) and central blood volume (CBV) were made in 25 patients during simultaneous right and transseptal left heart catheterization. Of these, 12 patients had normal hemodynamics, six had heart failure associated with mitral stenosis, and seven had heart failure secondary to nonvalvular myocardial disease. In the normal patients the PBV averaged 271 ml/m2 (se, ±10.0) and the CBV 596 ml/m2 (se, ±25.7). The mean value for PBV and CBV in the patients with heart failure associated with mitral stenosis was 238 ml/m2 (se, ±26.3) and 600 ml/m2 (se, ±40.9), respectively. Among the patients with nonvalvular heart failure the PBV averaged 292 ml/m2 (se, ±21.4) while the CBV averaged 679 ml/m2 (se, ±45.8). In 12 of the 13 patients with heart failure, the individual values for PBV and CBV did not differ significantly from normal. However, in each of the 13 patients pulmonary artery, left atrial, and mean pulmonary distending press...

Complications in 1,056 investigations of the left side of the heart

The frequency and type of complications in a material consisting of 832 suprasternal and/or percutaneous left ventricular punctures, 72 retrograde left ventricular catheterizations, and 152 transseptal left heart catheterizations performed in this laboratory are reported. The patient material consisted of 726 persons, mainly adults and older children. Two deaths occurred during the 1,056 investigations (0.19 per cent), one after a combined suprasternal and left ventricular puncture, and the other after a transseptal left heart catheterization. Serious complications were seen a total of 19 times (1.7 per cent), as shown in Table VIII.

Complications in Transseptal Left Heart Catheterization

Complications in Transseptal Left Heart Catheterization

1. Hemodynanlic Aspect of Left Ventricular Failurei

A total of 52 cases including 4 normal subject and 48 patients with various heart diseases with or without failure were studied in resting state and under the acute effects of drugs with right and trans-septal left heart catheterization, and radioisotope indicator-dilution method. In this study, special attention was directed to the analysis of myocardial mechanics regulating the left ventricular performance and the following conclusions were obtained : 1) Patients with moderate or severe failure showed a decrease in cardiac index, stroke index, left ventricular fraction ejected per beat, MCSR, MSER and an increase in EDV, where-as patients without failure or those with mild failure had normal or increased cardiac index and stroke volume. 2) Measurements of EDP and EDV in association with the calculation of CSR, T and F as shown in our study proved to be useful in the analysis of the effects of drugs on inotropism, chronotropism or afterload of the left ventricle.

THE EFFECT OF NITROGLYCERIN ON LEFT VENTRICULAR WALL TENSION IN FIXED ORIFICE AORTIC STENOSIS.

Symptoms of myocardial ischemia occur in aortic stenosis in the absence of coronary artery disease. Increased left ventricular wall tension, a principal determinant of myocardial oxygen requirements, may contribute to these symptoms. This investigation was undertaken during the course of transseptal left heart catheterization in order to study the effect of nitroglycerin on left ventricular wall tension in eight patients with fixed orifice aortic stenosis. In seven of the subjects, nitroglycerin significantly reduced tension-time index per beat and per minute. In addition, left ventricular size may have diminished as a consequence of lower diastolic filling pressure. In view of the relationship between wall tension and myocardial oxygen consumption, these effects should favorably influence the balance between oxygen availability and oxygen requirements in patients with fixed obstruction to left ventricular outflow. The eighth patient experienced an appreciable increase in tension-time index, suggesting secondary hypertrophic subaortic stenosis.

Transseptal Left Heart Dynamics in Thirty-Two Normal Subjects

SUMMARY The results of right heart catheterization and transseptal left heart catheterization in 32 normal subjects have been outlined. These data will serve as a baseline for comparison with left heart data in patients with various types of heart disease. The normal levels of left atrial and left ventricular pressure and the normal levels of cardiac index as well as the normal true pulmonary blood volume hâve been given as part of this study.

Mitral stenosis: Hemodynamic, electrocardiographic, and vectorcardiographic studies

The data of transseptal left heart and right heart catheterization were correlated with the phonocardiographic, electrocardiographic, and vectorcardiographic findings in 75 patients with significant mitral stenosis. Measurement of the rate of the “y” descent in the first tenth of a second after the opening of the mitral valve was helpful in detecting the presence of significant mitral stenosis. In the absence of tachycardia, the value of the formula P 1-P 2 MLAP was 0.3 or less among patients who had predominant mitral stenosis. No significant difference was seen between patients with normal sinus rhythm and those with atrial fibrillation. In the 54 available phonocardiograms, Q-1 minus 2-O.S. was equal to or greater than 0 in all but 7 patients. The electrocardiograms revealed evidence of right ventricular hypertrophy in 26 instances, whereas the vectorcardiograms revealed evidence of right ventricular hypertrophy in 31 instances. Forty-one patients had neither electrocardiographic nor vectorcardiographic evidence of isolated right ventricular hypertrophy. Both the electrocardiogram and vectorcardiogram failed to show patterns typical of right ventricular hypertrophy in 15 patients despite the significantly elevated resting right ventricular pressure. There were 9 patients who had posterior displacement of the QRSsÊ loop.

CLINICAL STUDIES ON THE CARDIAC PERFORMANCE BY MEANS OF TRANSSEPTAL LEFT HEART CATHETERIZATION. THE ACUTE EFFECTS OF DIGITALIS ON LEFT VENTRICULAR FUNCTION IN PATIENTS WITH VALVULAR STENOSIS.

In 13 patients with various heart diseases, the acute effects of digitalis on the left ventricular performance were studied by the transseptal left heart catheterization using external monitoring of radioisotope dilution and following results were obtained:(1) In patients with mitral stenosis, in whom heart rate was not altered after digitalization, the cardiac output did not increase significantly presumably because of mitral obstruction, while the left ventricular end-diastolic pressure and volume decreased. This may be interpreted as a result of positive inotropic effect of digitalis.(2) In patients with mitral stenosis, in whom heart rate was decreased, cardiac output increased significantly in association with an increase of left ventricular end-diastolic pressure and volume. This may be interpreted as a result of negative chronotropic effect of digitalis; that is increased left ventricular filling secondary to increased diastolic filling period.(3) In patints with aortic stenosis, left ventricular systolic and enddiastolic pressure and volume and systolic tension increased with decrease of left ventricular circumferential shortening rate. This may be interpreted as a result of increased resistance at the aortic ostium and increased contractility of the left ventricle.These effects of digitalis were compared with those of theophylline ethylenediamine and induced hypervolemia. It is concluded that the modes of action of digitalis on left ventricular function are multiple depending on the state of the heart, and that the effects may generally be expressed as the summation of positive inotropic and negative chronotropic effect.

Clinical studies on the cardiac performance by means of transseptal left heart catheterization. II. Left ventricular function in high output heart diseases, especially in hyperthyroidism.

In the resting state of 6 cases of hyperthyroidism and 2 cases of anemia, and before and after infusion of 6% PVP 5 ml./Kg. body weight in 3 normal and 3 hypertensive cases, the left ventricular performance was studied by the transseptal left heart catheterization using radioisotope dilution method and compared with those of normal and low output failure. Thus following results were obtained;In hyperthyroidism, with the increase of heart rate, stroke volume was increased, which may be caused by the acceleration of left ventricular function shown by the change of CSR and MSER, and by the increase of blood inflow shown by increase of LVEDV.The high output state in induced hypervolemia is due to the increase of blood inflow, but the left ventricular function is rather depressed.In conclusion, thyrotoxic heart is not only accelerated by thyroid hor-mone but also overloaded by increased venous return.

LEFT VENTRICULAR PERFORMANCE FOLLOWING DIGITALIZATION IN PATIENTS WITH AND WITHOUT HEART FAILURE.

Nine patients, three with left ventricular failure and six with compensated heart disease, were studied by means of right and transseptal left heart catheterization during acute digitalization with acetyl strophanthidin. One of the patients with heart failure and a compensated subject with the Wolff-Parkinson-White syndrome were also studied during supine left leg exercise. In the decompensated group, digitalization produced a decrease in heart rate and increases in stroke index, stroke work, mean stroke power, mean systolic ejection rate, and the rate of pressure rise in the left ventricle. Left ventricular end-diastolic pressures were markedly lowered after digitalization. In the compensated group, no significant changes in cardiac index, stroke index, or mean systolic ejection rate were observed. Although there were small increases in stroke work and power and moderate decreases in left ventricular diastolic pressures, the most striking finding was an increase in the rate of rise of left ventricular systolic pressure. Digitalization produced considerable improvement in the circulatory response to light exercise in a patient with left ventricular failure. Less marked improvement in the exercise response was observed in a patient with normal hemodynamics. After digitalization, left ventricular function points plotted on the stroke work end-diastolic pressure diagram tended to shift upward and to the left in both decompensated and compensated patients. The shift of function points was most prominent in the decompensated group. This study demonstrates that, in the presence of myocardial failure, acetyl strophanthidin markedly augments left ventricular performance. Furthermore, the data suggest that digitalization also improves left ventricular performance in patients with left ventricular enlargement but no clinical manifestations of heart failure.

EFFECT OF TRANSSEPTAL LEFT ATRIAL PUNCTURE UPON CARDIAC OUTPUT.

Comparisons of cardiac index, mean transit time, and "pulmonary" blood volume were made with indocyanine green dilution curves before and after transseptal left atrial puncture in 105 patients in sinus rhythm and 52 with atrial fibrillation. The results demonstrated that the steady state was not disturbed by transseptal left heart catheterization.

Cardiac tamponade: A complication of the transseptal technic of left heart catheterization resulting in a fatality

A case report of inadvertent right atrial perforation and fatal cardiac tamponade during transseptal left heart catheterization is recorded. Hazards of the procedure are reviewed. It is concluded that gross right atrial enlargement constitutes a strong relative contraindication to the use of this technic, and the reasons for this are outlined.

TRANSSEPTAL LEFT HEART CATHETERIZATION WITH PUNCTURE OF THE INTERATRIAL SEPTUM.

TRANSSEPTAL LEFT HEART CATHETERIZATION WITH PUNCTURE OF THE INTERATRIAL SEPTUM.

Intracardiac phonocardiography of the left heart by transseptal left atrial puncture: Technique and preliminary results

A new technique for intracardiac phonocardiography of the left side of the heart is described. If a catheter with an inside diameter of 1.75 mm. is used for transseptal left heart catheterization, a microphone catheter with a diameter of 1.50 mm. can be introduced into the left side of the heart through the transseptal catheter. Preliminary results in 25 patients are presented.

LEFT VENTRICULAR ANGIOCARDIOGRAPHY BY TRANSSEPTAL PUNCTURE OF THE LEFT ATRIUM.

Experiences with 90 left heart angiocardiograms in 170 patients with transseptal left heart catheterizations are discussed. Selective left heart angiocardiograms of patients with aortopulmonary septal defect, patent ductus arteriosus, coarctation of the aorta, different types of ventricular septal defect, and isolated congenital mitral regurgitation are discussed. Examples of valvular, supravalvular, organic subvalvular, and functional hypertrophic subaortic stenosis are shown. The method is also suitable for the demonstration of endocardial fibroelastosis, truncus arteriosus, and hypoplasia of the aorta.

Massive retroperitoneal hemorrhage: A complication of attempted percutaneous transseptal left heart catheterization

Massive retroperitoneal hemorrhage requiring immediate surgery occurred during an attempted transseptal left heart catheterization in which the percutaneous approach to a femoral vein was used. Considerations of the anatomy of the area, the structure of venous walls, the pressure relationships in and around veins, and the technics used suggest that this complication should be watched for carefully.

Left Atrial Mural Thrombus Secondary to Transseptal Left Heart Catheterization

Left Atrial Mural Thrombus Secondary to Transseptal Left Heart Catheterization