Gunnar Malmström

On methods and complications in catheterization of heart and large vessels, with and without contrast injection☆

Abstract Experiences from 12 Swedish hospitals concerning catheterization of the heart and large vessels, with or without contrast injection, have been reviewed with respect to rate of fatal and nonfatal complications, indications and contra-indications, technique, and preventive measures. The rate of certain fatal complications due to right heart catheterization was 55,859; to completed or incomplete angiocardiography 92,451; and to completed or incomplete thoracic aortography 5340.

Technique and sequelae of catheterization of the left side of the heart.

Abstract Left heart catheterization is an investigation which has much to offer in the accurate diagnosis and study of mitral and aortic valvular disease. It is a practical procedure which carries a reasonably low risk. However, left heart catheterization has been connected with some complications, and several of these can be avoided. Some complications cannot be avoided. Therefore we only advise a left heart catheterization where its diagnostic help is found necessary for the decision of an eventual surgical exploration. We believe a chest surgeon should perform the puncture and he should be equipped to perform a thoracotomy and defibrillation. In our group of 150 cases of mitral stenosis major complications were observed in eleven cases or 7 per cent. No death occurred in this group and no patient had persistent sequelae. In our seventeen cases of aortic valvular disease there were three major complications. In such cases with a small left atrium the puncture may be performed with the aid of fluoroscopy. We have had the most severe complications in this group, i.e. cardiac tamponade with ventricular fibrillation. When angiocardiography is performed it is most important to have the patient well oxygenated during and after the anesthesia. The complications, which have occurred in this group seem to be more related to the anesthesia than to the actual injection of contrast media. The complication frequency could probably be lowered with a thinner needle. But, as we consider, it is essential to perform pressure measurements in the left ventricle and angiocardiography we will continue to use the technique outlined.

Left atrial and pulmonary "capillary" pressure curves during Valsalva's experiment.

Abstract Simultaneous measurements of the left atrial and pulmonary “capillary” pressures were made during the Valsalva maneuver in nine patients with mitral valve disease. 1. 1. The pulmonary “capillary” pressure curve paralleled the left atrial pressure curve both during and after the period of forced expiration. 2. 2. There was a decline in the pressure during the Valsalva maneuver. 3. 3. A pronounced decrease in the amplitude of peak 7 (representing opening of the mitral valve) during forced expiration was observed in all but one of the patients. In this patient mitral regurgitation was suspected and here the decrease in amplitude was less pronounced. 4. 4. After forced expiration was ended the pressures fell abruptly to below the resting values. This was followed by a rapid rise and overshoot above the normal levels. This overshoot phenomenon is attributed to the sudden increase in the pulmonary flow that follows release of the blood arrested in the venous system during the Valsalva maneuver.

The diagnosis of aortic stenosis

Abstract The application of left-heart catheterization is discussed and exemplified with a case of aortic stenosis. The withdrawal curve from the aorta (systolic pressure, 105 mm. Hg) to the left ventricle (systolic pressure, 222 mm. Hg) showed a pressure gradient of more than 100 mm. Hg across the aortic valves.

The diagnosis of mitral insufficiency

Abstract When the clinical findings and the left-heart catheterization suggest a dominating mitral insufficiency we can perform an angiocardiography by injection of contrast medium through the needle into the left atrium in order to visualize the mitral valves. By this method it is possible to prove the diagnosis of a mitral insufficiency and avoid an exploratory cardiotomy.

Comparison of the oxygen tension in blood from the left atrium and a systemic artery

Abstract 1. 1. The oxygen tension has been estimated in blood simultaneously collected from the left atrium, a systemic artery, and from the “pulmonary capillaries” in eleven patients with mitral valvular disease. 2. 2. The oxygen tension is on an average higher in the “pulmonary capillaries” as compared to the left atrium and higher in the left atrium than in a systemic artery. These differences are statistically significant. 3. 3. The difference in oxygen tension between blood from the “pulmonary capillaries” and the left atrium is larger than the difference between the left atrium and a systemic artery. 4. 4. The explanations for these differences in oxygen tension are discussed.

Simultaneous left and right atrial pressure curves during Valsalva's experiment

Abstract When a Valsalva experiment is performed during simultaneous pressure measurements in the left and right atrium a typical difference in the two curves will be found. The left atrial pressure level will slowly decrease during a Valsalva experiment due to a damming up of blood in the venous system. The pressure in the right atrium on the other hand will not decrease as much during the Valsalvas experiment, or it may even increase. The pressure in a thick-walled left atrium due to mitral stenosis will not increase as much as the pressure in the right atrium during a Valsalva experiment. In the poststraining period there is a more pronounced pressure overshoot in the left atrium in front of mitral stenosis than in the right atrium or in a normal left atrium.

Left Heart Catheterization

Direct puncture of the left atrium with a needle, through which a catheter can be passed, allows pressure measurements in atrium, left ventricle and aorta. This procedure is considered to be more helpful than right heart catheterization in evaluation of patients with mitral and aortic valvular lesions.

The diastolic pressure gradient between the left atrium and the left ventricle in cases of mitral stenosis

Abstract 1. 1. The end-diastolic pressure gradient between the left atrium and the left ventricle has been determined at rest in 63 patients with mitral valvular lesion. The diagnosis was verified at surgery in all cases. 2. 2. In all patients with a mitral stenosis, there was a positive end-diastolic pressure gradient between the left atrium and the left ventricle, varying between 36 and 1 mm. Hg. In 56 of these patients who had mitral lesions with a dominating mitral stenosis the pressure gradient averaged 10.5 mm. Hg. In 10 patients it was less than 5 mm. Hg. A corresponding pressure gradient could not be observed in 7 patients who had an aortic lesion without a mitral lesion. 3. 3. In 14 patients in whom the minute volume was determined during the measurement of the pressure gradient, there was a slight but probably significant correlation between these two factors. 4. 4. No correlation could be observed between the degree of the pressure gradient and the size of the orifice as measured by the surgeons observations. Furthermore, in this material no correlation could be found between the pressure gradient and the heart volume or the patients working capacity. 5. 5. A diastolic pressure gradient over the mitral orifice of at least 5 mm. Hg will indicate the presence of a stenotic component in the mitral valves. However, such a pressure gradient does not help to distinguish cases of pure mitral stenosis from those with a concomitant mitral regurgitation, nor to evaluate the degree of such mitral regurgitation.

Left auricular pressure curve before and during first degree atrioventricular block.

Abstract The left auricular pressure curve was recorded through a needle inserted into the left auricle in a case of mitral stenosis with regular sinus rhythm. After the injection of contrast medium into the auricle a transient prolongation of the atrioventricular conduction time appeared. This event made it possible to study the auricular contraction pressure peak without interference with the pressure waves caused by the closure of the atrioventricular valve and the systolic downward movement of the atrioventricular plane.