Quantitation of shunting at the atrial level using rapid acquisition computed tomography with comparison with cardiac catheterization.

Contrast-enhanced rapid acquisition computed tomography was employed to quantitate intracardiac shunts in two adult patients. Contrast medium was injected through a median antecubital vein and data were accumulated using the R wave-triggered flow mode. Time-density curves from a region of interest were generated by a gamma variate fit method and areas under the curves were calculated. Comparisons of calculated left to right shunts (Cases 1 and 2) with results of computed tomography and right to left shunt (Case 2) with cardiac catheterization data resulted in close agreement. This is the first report of quantitation of intracardiac shunts at the atrial level in humans by rapid acquisition computed tomography.

Tricuspid regurgitation by radionuclide angiography and contrast right ventriculography: a preliminary observation.

In a retrospective study correlating the degree of tricuspid regurgitation seen on first-pass radionuclide angiography with that seen on contrast right ventriculography in 51 patients, ten had no tricuspid regurgitation by contrast ventriculography, whereas by radionuclide angiography nine had no regurgitation and one had minimal regurgitation. Of eight patients with minimal tricuspid regurgitation by contrast ventriculography, five had minimal regurgitation by nuclide angiography and three had no regurgitation. Of the 11 patients with mild to moderate tricuspid regurgitation by contrast studies, ten had mild to moderate regurgitation and one had severe regurgitation by nuclide angiography. Of 22 patients with moderate to severe tricuspid regurgitation by contrast studies, 15 had moderate to severe regurgitation and seven had mild to moderate regurgitation by nuclear angiography. In this preliminary study comparing radionuclide angiography with contrast right ventriculography, there were three false-negative and one false-positive nuclide angiograms, giving a sensitivity of 93% and a specificity of 90%.

Intracardiac phonocardiography in tricuspid regurgitation: relation to clinical and angiographic findings.

Intracardiac phonocardiograms were obtained from the right atrium in order to study the relation between the clinical signs of tricuspid regurgitation, intracardiac murmurs and the degree of regurgitation demonstrated on right ventriculography with use of a preshaped catheter. In five patients with no heart disease, right ventriculograms showed no evidence of tricuspid regurgitation and intracardiac phonocardiograms in the right atrium demonstrated no murmur. Among 35 patients with valvular heart disease, a Carvallo sign (increased intensity of systolic murmur during inspiration) was present in 19 and absent in 16. All 19 patients with a Carvallo sign had variable degrees of tricuspid regurgitation on right ventriculography, and intracardiac phonocardiograms were positive for tricuspid regurgitation in 18. Among 16 patients with an absent Carvallo sign, neither right ventriculography nor intracardiac phonocardiography was indicative of tricuspid regurgitation in 5. Five patients had 1+ regurgitation and the intracardiac phonocardiogram was positive in three of these five patients. The other six patients showed 3+ to 4+ regurgitation and the intracardiac phonocardiogram was positive for tricuspid regurgitation in all. In conclusion, (1) the Carvallo sign is a reliable indicator of tricuspid regurgitation but its absence does not rule it out, and (2) right ventriculography using a preshaped catheter and intracardiac phonocardiography are useful in detecting clinically unrecognized tricuspid regurgitation.

Diagnosis of severe tricuspid regurgitation.

Fifty-nine patients were studied who had severe tricuspid regurgitation which was confirmed by right ventriculography and during surgery in order to determine the incidence of clinical, radiologic, and hemodynamic clues of severe tricuspid regurgitation. Eighty-eight percent of patients had Carvallo sign alone or in combination with pulsatile liver or prominent jugular venous V waves, and the classic triad was present in 42 percent. Most patients had enlargement of the right atrium on chest x-ray film. The classical "ventricularization" pattern of right atrial pressure was seen in 30 percent, prominent V waves with rapid Y descents were present in 37 percent, and normal contour of right atrial waves with normal mean pressure was seen in 33 percent. The inspiratory maneuver was helpful to induce the ventricularization pattern or prominent V waves with rapid Y descents especially in patients with normal right atrial pressure waves. In conclusion, right ventriculography is a sensitive and accurate method for detecting and quantitating tricuspid regurgitation in the absence of the diagnostic physical findings.

Ventricular function before and after mitral valve replacement.

To evaluate right ventricular function following mitral valve replacement, we studied 84 patients with isolated mitral valve disease with the use of first-pass radionuclide angiography before, 1 week after, and up to 1 year after operation. The right ventricular ejection fraction for the entire group improved from 29% +/- 11% to 43% +/- 10% (p less than 0.001) at 1 week. This increase was maintained at 3 months (41% +/- 10%) and up to year after operation (40% +/- 12%). The improvement was found not to be influenced by either the type of valvular lesion or the presence and/or level of pulmonary hypertension. When the patients were grouped according to the type of prosthetic valve placed at operation, the right ventricular ejection fraction increased in all patients within 1 week of operation, with sustained improvement at 3 months postoperatively. Thereafter, it began to decline in patients receiving a Carpentier bioprosthesis while being maintained in those patients who received disc valves. Further analysis revealed that those patients who receiving the larger Carpentier bioprostheses had a greater deterioration of right ventricular function than those receiving the smaller Carpentier valves. Left ventricular function in the entire group was normal preoperatively (62% +/- 16%) and was unchanged at 1 week (60% +/- 16%) and a 1 year (59% +/- 16%) after operation.

Results of mitral valve replacement with the Beall prosthesis in 209 patients.

In this 3 year study of 209 patients who underwent mitral valve replacement with the newer Beall prostheses (Models 104 and 105) the operative mortality rate was 5.2 per cent. None of these deaths was related to the valve. This prosthesis features a larger frustrum area and a "turtle-neck" sewing ring which permits its rapid insertion with a continuous suture technique. Of the 20 (9.5 per cent) late deaths, two were due to thrombosis of the valve. Among the 178 survivors, 17 developed thromboembolic complications; however, 10 of these patients recovered. Late clinical results have been quite satisfactory in over 90 per cent of the survivors. In the 15 patients who underwent hemodynamic studies postoperatively, the cardiac index and pulmonary artery pressure showed significant improvement; however, they still had transvalvular gradients at rest. The improvement in the design of this prosthesis has been an important factor in lowering the operative risk and improving the late results of mitral valve replacement.

Late thrombosis of the aortic Bjork-Shiley prosthesis. Its clinical recognition and management.

Seven cases of massive thrombosis of an aortic Bjork-Shiley prosthesis were encountered among 433 valvular implants. Four patients died before treatment could be instituted, and three underwent repeat surgery successfully. Anticoagulation therapy was probably well maintained in four, and poorly maintained in three patients. These cases illustrated the need for a high index of suspicion and prompt recognition of this complication in patients with Bjork-Shiley prostheses. The diagnosis of massive thrombosis should be suspected with the rapid onset of (1) signs of congestive heart failure, (2) absence or attenuation of valvular clicks, (3) aortic regurgitation, or (4) hemolytic anemia. Salvage of these patients requires emergency replacement of the thrombosed prosthesis or removal of the thrombus.

Radionuclide angiography in the quantitation of mitral regurgitation.

First pass radionuclide angiography (RA) was used to assess its ability to detect and quantitate the presence of left-sided regurgitation due to isolated mitral regurgitation (MR). In this study the nuclear regurgitant fraction (NRF) obtained from first pass RA was correlated with the results of contrast ventriculography (CV) in 50 patients, 18 with and 32 without MR. The correlation between CV and RA in the confirmation and quantification of isolated MR revealed a sensitivity of 100 percent and a specificity of 97 percent in patients with LVEF greater than or equal to 35 percent.

The use of the hepatic pressure maneuver to identify the murmur of tricuspid regurgitation.

To enhance the bedside diagnosis of tricuspid regurgitation, the influence of manual pressure applied below the liver on lower left sternal border murmurs was determined in 23 patients. All 23 subjects had right ventriculograms and right atrial phonocardiograms. The sign was positive in 13 cases, including 3 who were without a Carvallo sign. The application of manual pressure below the liver is a simple and valid additional maneuver for identifying the murmur of tricuspid regurgitation.

Long-term follow-up by exercise radionuclide angiography of patients after valve replacement for aortic regurgitation.

The long-term effects of valve replacement for chronic isolated aortic regurgitation as assessed by first-pass exercise radionuclide angiography have never been reported. We studied 20 males and 5 females before, 15 months postoperatively, and from 29 to 109 (mean 62 +/- 21) months following valve replacement with exercise radionuclide angiography. Mean peak heart rate did not change for the three studies. Peak systolic blood pressure decreased from 201 +/- 42 mmHg to 185 +/- 24 mmHg at 15 months and further declined to 177 +/- 32 mmHg by the long-term study (p less than 0.03). The mean resting left ventricular ejection fraction improved from 44 +/- 15% preoperatively to 57 +/- 18% at 15 months (p less than 0.002) with no further improvement by the long-term evaluation. The postexercise ejection fraction improved from 42 +/- 13% preoperatively to 61 +/- 21% at 15 months (p less than 0.002) also with no change by the long-term study. The duration of exercise improved from 9.7 +/- 4.6 min to 11.9 +/- 3.4 min (p less than 0.03) at 15 months with no additional improvement long term. Improvement in resting and postexercise ejection fraction and in exercise duration is maximal at 15 months. Accuracy and cost containment suggest that assessment of the maximal change in ejection fraction by exercise radionuclide angiography after aortic valve replacement in asymptomatic patients be limited to the 15-month interval.

Atrial natriuretic peptide response to ionic and nonionic contrast left ventriculography.

Atrial natriuretic peptide (ANP) levels were measured prior to and at 1 and 5 minutes postcontrast left ventriculography with an ionic contrast agent (diatrizoate), and a nonionic agent (iopamidol) and the results were compared. Since ionic contrast agents have been found to cause an increase in left ventricular end-diastolic pressure (LVEDP) and nonionic agents have been found to have less of an effect on LVEDP, we investigated the response of ANP levels, which have been found to increase secondary to increased LVEDP (atrial pressure), with both agents. A group of 38 patients who were scheduled for left heart catheterization for suspected coronary artery disease was included (19 in each group) and blood samples for ANP levels were drawn from the left ventricles. At the same time, heart rate, LVEDP, and left ventricular systolic pressure (LVSP) were also measured. It was found that the LVEDP increased significantly for both agents at 1 minute postventriculography, but no further change occurred at 5 min. Heart rate increased significantly in the diatrizoate group at 1 minute with a return of heart rate to preventriculography levels at 5 min, while the ANP level and LVSP remained unchanged at 1 minute postventriculography with both agents but increased significantly at 5 min in the diatrizoate group only. This difference in ANP response is not correlated with the LVEDP. The response of ANP may be related to heart rate and/or LVSP.

Giant Lambl's excrescences of papillary muscle and aortic valve: echocardiographic, angiographic, and pathologic findings.

A 54-year-old female with rheumatic heart disease was found to have a mass in the left ventricle by echocardiography and angiography. Subsequently, giant Lambl's excrescences of papillary muscle and aortic valve were confirmed by operation and pathologic examination. Possible complication from cardiac catheterization could be avoided by the utilization of echocardiography prior to catheterization.

Left ventricular function after elective aneurysmectomy.

Employing rest and exercise first-pass radionuclide angiography before and 3 months after surgery, we studied patients with hemodynamically stable left ventricular aneurysm (LVA) undergoing both coronary artery bypass surgery to relieve angina pectoris and elective aneurysmectomy. There were 15 patients, 14 men and 1 woman with a mean age of 54 +/- 7 years. All patients had anterior and/or apical LVA. After surgery the postexercise mean left ventricular ejection fraction (LVEF) for the whole group improved significantly (p less than 0.004) compared with the preoperative value, but the resting LVEF did not change. The duration of exercise improved (p less than 0.01) after surgery, but not the double product. However, based upon the preoperative LVEF response to exercise, two groups were seen: Group A (n = 5) had greater than or equal to 5% increase in their LVEF with exercise versus Group B (n = 10), who had less than 5% increase or a decrease in their LVEF. Postoperatively, Group A decreased their LVEF with exercise and failed to improve exercise capacity or double product. Postoperatively, Group B increased the LVEF by greater than or equal to 5% as well as increasing exercise capacity (p less than 0.01), and double product (p less than 0.03). Group A had lower preoperative LVEF than Group B (p less than 0.01) and larger LVA. Patients with hemodynamically stable LVA who require coronary artery bypass surgery for angina should not have aneurysmectomy. The presence of hemodynamically stable LVA is not a contraindication to deriving benefit from myocardial revascularization.

Rest-exercise radionuclide angiographic assessment of left ventricular function in chronic aortic regurgitation: significance of serial studies in medically versus surgically treated groups.

Forty consecutive asymptomatic patients with chronic aortic regurgitation who underwent three serial yearly rest and postexercise radionuclide angiograms were compared with 27 consecutive patients with chronic aortic regurgitation and aortic valve replacement who were studied preoperatively, 3 and 15 months postoperatively. Patients were divided into four subgroups based upon the resting left ventricular ejection fraction and the functional reserve on the initial study. Of the 40 medically treated patients, 19 (47.5%) and 24 (60%) demonstrated a response at least one type lower at 12 months and 24 months, respectively. Initial functional reserve, initial duration of exercise, and the change in exercise duration during the 24 months was not associated with changes in resting or postexercise left ventricular ejection fraction. A seesaw pattern was observed between the resting and the postexercise left ventricular ejection fraction as ventricular function deteriorated. We observed in the surgical groups a reversal of the seesaw interaction between the resting and postexercise ejection fraction seen in the medical patients. In the surgical groups the left ventricular end-diastolic pressure, initial functional reserve, initial duration of exercise, and change in exercise duration postoperatively were not predictors of improvement in left ventricular function at 15 months. Comparing medical and surgical serial data, we suggest yearly radionuclide angiographic determination of rest left ventricular ejection fraction in asymptomatic patients with chronic aortic regurgitation. When the rest ejection fraction is less than 50%, exercise angiography should be performed to determine functional reserve. When functional reserve is also abnormal, surgery should be recommended.

An unusual case of pulmonary emboli.

The authors present an interesting case of pulmonary embolus serendipitously diagnosed during an evaluation for a presumed metastatic pulmonary nodule.

Acute hemodynamic effects of nifedipine during supine exercise in patients with prior myocardial infarction.

Twelve male patients age 36-66, 8 on clinical doses of beta blocker, with old transmural myocardial infarction underwent rest and matched workload exercise before and 30 min after 20 mg sublingual nifedipine during cardiac catheterization. For the group, resting heart rate, aortic pressure, pulmonary wedge pressure, systemic vascular resistance, cardiac index, and left ventricular ejection fraction were normal. Exercise duration was 12.5 +/- 1.5 min. Comparing exercise before and after nifedipine, heart rate, cardiac index, and mean velocity circumferential fiber shortening increased, while mean aortic pressure, systemic vascular resistance, pulmonary wedge pressure, right atrial pressure, left ventricular end-diastolic volume and left ventricular end-systolic volume decreased with no significant change in double product, pulmonary arteriolar resistance and left ventricular ejection fraction. Therefore, for the range of left ventricular dysfunction in this study group and with 8 patients concurrently on beta blocker, nifedipine 20 mg s.l. produced significant improvement in hemodynamics at rest and exercise.

Angiographic recognition of ostial left main coronary artery stenosis: case report.

Ostial left main coronary stenosis has a poor prognosis and increased mortality rate with coronary arteriography. Due to its anatomic location, visualization of the stenosis may be difficult. A high index of suspicion based upon only a few signs should prompt the physician to perform certain maneuvers to obtain the correct diagnosis. Four illustrative cases are presented and discussed.

Comparison of left ventricular ejection fraction by cine computed tomography and single plane right anterior oblique ventriculography.

Cine Computed Tomography (CCT) is a minimally invasive technique which offers high temporal (50 msec scan time) and spatial (2 line pairs) resolution. Left ventricular ejection fraction (LVEF) has been determined by this technique in dogs and normal subjects but no comparison has been made with contrast left ventriculography by cardiac catheterization. Ten patients, 9 male and 1 female, mean age 61 (range 46-70) had LVEF determined by both single plane RAO left ventriculography and CCT. Patients were studied in the fasting state, on different days without change in medication. LVEF by CCT was determined in the long axis, a new view which has been developed for CCT to be comparable to the RAO view of contrast left ventriculography by catheterization. This view is obtained by positioning the patient head first into the scanner, supine, with a counterclockwise table slew (20 degrees) without table tilt. Contrast is introduced via a median antecubital vein, and injected in a prolonged bolus of 7-13 seconds dependent on arm to heart circulation time. Scans are performed in the cine mode (17 frames/sec) timed during maximal opacification of the right and left ventricles. Four or six contiguous levels are imaged as required to slice the entire left ventricular cavity. End-systolic and end-diastolic frames are identified. Left ventricular cavity areas are determined by computerized planimetry after the Hounsfield level number is set at half the difference between the contrast in the cavity and the myocardium and setting the window width at one giving a black and white image. Left ventricular end-diastolic volume (LVEDV) and end-systolic volume (LVESV) per slice are summated to obtain LVEDV and LVESV from which LVEF is desired.(ABSTRACT TRUNCATED AT 250 WORDS)

Rapid acquisition computed tomographic assessment of left ventricular regional wall motion using a new long axis view.

A long axis view to demonstrate left ventricular regional wall motion was devised for the ultrafast CT scanner. The patients are positioned supine, head first, into the scanner. The scan table is slewed 20 degrees counter-clockwise in the horizontal plane without tilt. A bolus of contrast is injected via a median antecubital vein. Contiguous level R wave triggered cine studies are obtained during peak passage of contrast through the heart to image the entire left ventricular cavity. Fourteen patients had left ventricular wall motion compared by long axis CT and RAO 30 degrees single plane ventriculography at catheterization. In all cases, regional wall motion in comparable segments by both methods was in agreement. It is concluded that the ultrafast CT long axis view permits diagnosis of left ventricular regional wall motion abnormalities. This view images the apex and sections the interventricular septum and lateral free wall horizontally. Unlike conventional CT views, it is comparable to the RAO left ventriculogram.

Exercise first-pass radionuclide assessment of left and right ventricular function and valvular regurgitation in symptomatic mitral valve prolapse.

The changes in right ventricular (RV) and left ventricular (LV) function and in regurgitant fractions on first-pass exercise radionuclide angiography (RNA) were assessed in 29 consecutive patients with symptomatic mitral valve prolapse (MVP). The mean right ventricular ejection fraction (RVEF) was 35 +/- 8% at rest and 46 +/- 15% after exercise (p less than 0.001). The mean left ventricular ejection fraction (LVEF) was 62 +/- 11% at rest and 74 +/- 13% after exercise (p less than 0.001). Seven of 29 patients had an abnormal RV response and 6 had an abnormal LV response. Eight had abnormal wall motion after exercise. A total of 12/29 patients (41%) had one or more abnormalities. The mean left-sided regurgitant fraction before exercise was 27 +/- 17% in 21/29 patients (72%) and 31 +/- 21% after exercise (p = ns). An additional 5 patients (17%) developed left-sided regurgitation after exercise. These findings indicate that wall motion abnormalities and abnormal RVEF and LVEF responses to exercise occur in symptomatic MVP patients. In addition, 26/29 (89.6%) had left-sided regurgitation after exercise. Since the presence of a murmur did not correlate with the presence of mitral regurgitation by RNA, then symptomatic patients with MVP should have first-pass exercise RNA to assess the presence of regurgitation at rest and after exercise. Antibiotic prophylaxis is recommended in MVP patients with systolic murmurs or with regurgitation. Since patients without murmurs can have regurgitation, further study is necessary to determine the need for endocarditis prophylaxis in these patients.