Kirk Lipscomb

Limitations of qualitative angiographic grading in aortic or mitral regurgitation

This study was performed to assess the accuracy of qualitative angiographic grading in persons with aortic regurgitation (AR) or mitral regurgitation (MR) and to determine the factors that may influence the reliability of such grading. In 230 patients (152 men, 78 women, aged 52 +/- 14 years) with AR or MR, forward cardiac index was measured by the Fick and indicator dilution techniques and left ventricular (LV) angiographic index by the area-length method, from which the regurgitant volume index was calculated. In 124 other patients (89 men, 35 women, aged 52 +/- 11 years) without regurgitation, there was good agreement between forward and angiographic cardiac indexes (r = 0.87, p less than 0.001). In the 83 patients with AR, the regurgitant volume indexes in those with 1+ (0.87 +/- 0.57 liters/min/m2) and 2+ (1.72 +/- 1.19 liters/min/m2) angiographic regurgitation were not significantly different from one another, but were significantly different from those with 3+ (3.0 +/- 1.42 liters/min/m2) and 4+ (4.80 +/- 2.25 liters/min/m2) regurgitation; at the same time, the regurgitant volume indexes of patients with 3+ and 4+ AR were not significantly different from one another. In the 147 patients with MR, the regurgitant volume indexes in patients with 1+ regurgitation (0.61 +/- 0.64 liters/min/m2) were significantly lower than other grades, but the regurgitant volume indexes of 2+ (1.14 +/- 0.85 liters/min/m2) vs 3+ (2.14 +/- 1.37 liters/min/m2) and of 3+ vs 4+ (4.60 +/- 2.31 liters/min/m2) were not significantly different. With AR and MR, regurgitant flow within each angiographic grade varied widely, especially in grades 3+ and 4+, and there was considerable overlap of regurgitant volume indexes between grades.(ABSTRACT TRUNCATED AT 250 WORDS)

Modified technique of transseptal left heart catheterization

Transseptal left heart catheterization was performed in 106 instances in 101 patients using right anterior oblique fluoroscopy to define septal boundaries during interatrial septal puncture, and using a preshaped guide wire to catheterize the left ventricle. By using these two modifications of the classic transseptal technique, the left atrium was entered in 105 instances (99%) and the left ventricle was catheterized in all 87 attempts (100%), including attempts in eight patients with mitral stenosis (valve area 1.29 +/- 0.39 cm2 [mean +/- standard deviation] ). No deaths occurred as a direct result of transseptal catheterization; nonfatal complications occurred in 2.8% of patients (hemopericardium in one patient, ventricular fibrillation in one patient and transient vagal reaction in one patient). The use of the right anterior oblique projection to adequately visualize both the interatrial septum and the intended point of puncture, the use of a pigtail catheter positioned in the ascending aorta to define the relation of the puncture site to the aorta in this projection and the utilization of a flexible preshaped guide wire to catheterize the left ventricle are the major factors contributing toward this improved success rate and low incidence of complications.

Early positive exercise test and extensive coronary disease: effect of antianginal therapy.

The effect of antianginal therapy on the incidence of an early positive exercise response as a screening tool for 3-vessel and left main (LM) coronary artery disease (CAD) was examined. Fifty-seven men with stable angina pectoris underwent bicycle ergometry before and after long-acting nitrate or calcium antagonist therapy was instituted. An early positive response was defined as signs of myocardial ischemia at low levels of myocardial and total body workload (corresponding to a workload of less than 300 kpm/min). Thirty-nine patients (68%) had an early positive response before therapy, compared with 14 (24%) after therapy. Of 24 patients undergoing coronary angiography, 12 had 3-vessel CAD (including 2 with LM), 5 had 2-vessel CAD, 6 had 1-vessel CAD and 1 patient had no CAD. The sensitivity and specificity of an early positive response in predicting 3-vessel/LM CAD changed from 92% and 58% before to 42% and 75% after therapy. The positive and negative predictive values changed from 69% and 88% before to 63% and 63% after therapy. It is concluded that antianginal therapy reduces the value of an exercise test as a screening tool for 3-vessel/LM CAD.

Measurement of aortic root size by biplane angiography before cardiac valve replacement

Aortic valve replacement (AVR) in the patient with a small aortic root demands special consideration because the hemodynamic function of artificial valves with a small external diameter is often poor. In this study, the internal diameter of the aortic root was measured from biplane ventriculography. This measured root diameter was then used to predict the external diameter of the artificial valve. Twelve patients underwent biplane ventriculography followed by AVR with Carpentier-Edwards bioprostheses. The artificial valve diameter was predicted with a correlation coefficient of 0.93, a standard error of estimate of 0.89 mm, and an average absolute difference between preoperative measurement and valve diameter of 0.69 mm. Therefore, the aortic root diameter can be accurately measured from the ventriculogram, thus detecting the patient with a small aortic root before surgery.