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Left atrial puncture in patients with rheumatic mitral valvular disease
left
atrial
patients
puncture with
in
rheumatic
mitral
valvular
disease
Mendel Wassermil, M.D. Donald L. Warkentin, M.D. N. Ba2four Slonim, M.D. Abe Ravin, M.D. Denver, Cola.
I
n spite of the advances made in surgical techniques, the correction of mitral regurgitation remains a difficult problem and is not entirely satisfactory. For this reason, careful judgment is required for correct selection of patients with combined mitral disease for surgical treatment. The diagnostic difficulty in determining the predominant mitral lesion is considerable. It was hoped that the addition of left atria1 puncture to our diagnostic armamentarium would greatly facilitate the differentiation of mitral regurgitation from mitral stenosis. Review of the literature disclosed, however, conflicting reports as to the value of left atria1 puncture in general, and the aualysis of left atria1 curves in particular, in the diagnosis of predominant mitral valvular disease. The present study was undertaken in order to clarify the conflicting views and to assess the value of left atria1 puncture in the diagnosis of lesions of the mitral valve. The investigation consists of three parts. The first part evaluates the results obtained from analysis of left atria1 pressures as compared with surgical findings; the second part deals with the morbidity connected with left atria1 puncture; and the third part tests the validity of pul-
monary arterial wedge pressure cator of left atria1 pressure.
as an indi-
Material The material for this investigation consisted of 50 patients who underwent a total of 52 left atria1 punctures. The patients were divided into two groups (Table I). The first group consisted of 25 patients and forms the basis for analysis and correlation of atria1 pressure curves with surgical find-
Table I Group I: Pafients 11 patients-Pure 4 patients-Mitral
operated on mitral stenosis stenosis and Grade 1 mitral regurgitation 7 patients-Mitral stenosis and Grade 2 mitral regurgitation 3 patients-Minimal mitral stenosis and Grade 3 mitral regurgitation
Group II: Patients 12 patients-Minimal
From the Department of Cardiology and the Cardiopulmonary Cola. This study was supported by the Colorado Heart Association, Inc., of New York. Received for publication Jan. 19. 1962.
not operated on mitral stenosis and dominant mitral regurgitation 7 patients-Predominant mitral stenosis 2 patients-Aortic involvement 4 patientsNo diagnosis
Laboratory, Denver,
General Cola..
Rose Memorial
and the John
Hospital,
A. Hartford
prc-
I)enver,
Foundation.
Left atria1 @nctuve in rheumatic mitrul valvular disease
ings. The patients in this group had a clinical diagnosis of predominant mitral stenosis (which was substantiated by catheterization data). Twenty-three patients were operated on by the same experienced surgeon; the cross-sectional area of his index finger was measured and was found to be 1.3 square centimeters. The surgeon estimated the area of the valve by palpation and determined the presence of regurgitation with his gloved index finger. The evaluation of regurgitation depended on the estimated size of the valve opening as well as the force and the distance at which the regurgitant jet could be felt. The regurgitant volume was assessed as l-plus through 4-plus. At operation, 11 of the 2.5 patients had pure mitral stenosis with a valve area which ranged from 0.5 to 1.5 CI~.~. The other 14 patients had moderate mitral stenosis with a valve area which ranged from 1 to 2 cm.‘. Of these 14 patients, 4 were considered to have l-plus regurgitation, 7 had 2-plus regurgitation, and 3 had predominant mitral insufficiency with 3-plus regurgitation. The second group consisted of the other 25 patients who for various reasons were not operated on (Table I). All 50 patients were included in the assessment of morbidity associated with left atria1 puncture, and correlation of left atria1 pressures with pulmonary arterial wedge pressure. Methods .A11 catheterizations, with two exceptions, consisted of catheterization of the right side of the heart and left atria1 puncture, which was performed by the method of Bjork as modified by Fisller.1-3 In 2 patients, only left atria1 puncture was performed. The patients were in the postabsorptive state and were premeditated with secobarbital alone or in combination with meperidine. Pressures were recorded on a Sanborn Poly-Viso, direct-writing, fourchannel recorder, employing Statham 23Db strain-gauge transducers. The zero reference level for both pulmonary arterial wedge pressures and the left atria1 pressure was 10 cm. above the level of the table. (‘ontinuous pressures were recorded as the PESO* polyethylene catheter was with*Available from Clay-Adams, Inc.. New York, diameter 0.023” and outside diameter 0.038”.
N.
Y.
Inside
593
drawn from the left ventricle into the left atrium. For the determination of the atrioventricular diastolic filling gradient the left atria1 and left ventricular pressure curves were superimposed as closely as possible in the same phase of respiration. In each case, at least two respiratory cycles were recorded and measured. The pressure tracing obtained through the PESO catheter was slightly damped as compared to that obtained directly through the needle. The difference between the two recordings was so negligible that for practical purposes these tracings might be considered to be identical. The frequency response of the hydraulic system of the No. 7 catheter used for catheterization of the right side of the heart and that of the 18-gauge needle used for left atria1 puncture were very similar. The individual left atria1 waves were measured and analyzed according to their relative height and for the duration of the y descent. The mean left atria1 pressures were determined by planimetry. The same measurements were made on pulmonary arterial wedge tracings. Pulmonary arterial wedge pressures were recorded according to the criteria of Rapaport and Dexter.’ The mean pulmonary arterial wedge pressure was compared with the mean left atria1 pressure. The v waves in both left atria1 and pulmonary arterial wedge pressures were analyzed and correlated. The terminology of MacKenzie and Wiggersm6 was used in describing the atria1 waves, which are both positive and negative. Of the positive waves, the a wave is caused by atria1 systole, the c wave is due to closure of the atrioventricular valves, and the v wave is related to atria1 filling. Two negative troughs are also described: the .L^ wave, which follows the c wave, is caused by a drop in atria1 pressure as the ventricles contract, and the y descent, which follows the peak of the v wave and ends in the y point, is due to lowering of the atria1 pressure as the blood flows into the ventricles during diastole. Results
Technicab d$cultirs. The left atrium could not be entered in 5 patients; in 2 of these there was pericardial effusion which had not been detected on the chest x-ray
594
Warkentin,
Wassermil,
Sbonim, and Kavin
V-
I
*. . .: .*:
: .
m LA
. . . . . .. .
:*
O.lRyl’d/mLA rnnl”[, se:
.::. .
..
.. : . :
. .
Fig. 1. Relationship between values derived from analysis of left atrial pressures and the degree of mitral regurgitation. The values obtained from the application of four formulas (see text) are plotted as ordinates, and the degree of mitral regurgitation (0-1) is plotted as abscissas. Note the failure to separate mitral stenosis from mitral regurgitation.
film. In the other 47 successful left atria1 punctures, the PESO catheter failed to enter the left ventricle in 10 patients. In 6 patients the “washout” phenomenon was encountered : the polyethylene tubing was washed back from the left ventricle into the left atrium by the regurgitant stream of blood during ventricular systole. In no case did knotting or accidental cutting of the PESO polyethylene catheter occur. Morbidity. Short periods of arrhythmia (consisting predominantly of premature ventricular beats and changes in rhythm) were encountered in about 60 per cent of the patients as the needle entered the left atrium. Discomfort in the form of pain was experienced by most patients. The over-all morbidity was significant, but no perma-
nent disability or death resulted from the 52 left atria1 punctures. The salient features of these complications are summarized in Table II. Pericardial tamponade occurred in one patient several hours after the procedure. The patient responded well to pericardiocentesis and recovered. Another patient had a pulmonary hemorrhage immediately after the removal of the intracardiac needle; this was due to puncture of lung parenchyma. Two patients developed small pneumothoraces. Another patient developed fever and signs of infiltration in the left lung, which were probably due to emboli that originated in the right atrium, which was inadvertently punctured. Two patients had severe precordial pain which resembled the postconl-
Left atria1 puncture in rheumatic mitral valvular disease
l’nblr IT. Morbidity
in 50 patients
Pericardial tamponade Pulmonary hemorrhage Pneumothorax Pulmonary infarction and fever Postcommissurotomy-like syndrome Asystole Pleuritic pain Signs of blood in pericardium at surgeq
(1) (v (height) x to x + (2) (v (height) x to x + 1 1 2 1 2 1 50
2 2 4 2 4 2 100
21
missurotomy syndrome; the pain abated after a few doses of aspirin. One patient had a period of asystole which lasted 5 seconds as the needle punctured the left atria1 wall. Most patients complained of pleuritic-type pain at some time during the 24 hours after the procedure. The pulmonary artery, aorta, right atrium, and right ventricle were sometimes inadvertently entered during attempts to puncture the left atrium. Fortunately, no untoward results occurred from the puncture of these structures. A small quantity of dark blood was found in the pericardium of 21 patients who underwent mitral commissurotomy shortly after the left atria1 puncture. Analysis of curves in the assessment of pvedomznant valvular disease. We analyzed the characteristic left atria1 waves in the tracings of 25 patients who underwent surgery. The most commonly used hemodynamic formulas which have been developed by various investigators to help separate mitral stenosis from mitral regurgitation were investigated and their value was assessed. These formulas are based on the relative height of the v wave and the rapidity of y descent, and are as follows: (1) rate of y descent during the first 0.1 second8,g; (2) height of v wave minus the height of c wave”; (3) the ratio of the height of v wave to the height of mean left atria1 pressure’“; (4) height of v wave minus mean left atria1 pressure” ; (5) absence of diastasis in mitral stenosis.g 111 addition to the afore-mentioned formulas, we developed in our laborator)‘, on the basis of the height and area of the v wave, two indices of mitral regurgitation. They consist of two formulas:
595
-
y) X (v (area) from 0.2 second) - x) X (v (area) from 0.2 second)
Of the criteria tested and previously reported to be valuable in the differentiation of mitral stenosis from mitral regurgitation, none adequately separated the two conditions. Fig. 1 shows graphically the random distribution of points when results analyzed according to each of the formulas mentioned above were plotted against our estimate at the time of operation. According to Braunwald, diastasis is absent in mitral stenosis. Diastasis is the rise in left atria1 pressure just before onset of the ac wave. It is due to a rise in ventricular pressure as the ventricle is filled with blood.g Of the 25 cases evaluated at the time of operation, diastasis was present in 5. Two patients had predominant mitral stenosis with Grade I and II regurgitation, and 3 patients had pure mitral stenosis. In the other 20 patients, diastasis was not denlonstrable. jiniong these there were 8 cases of pure mitral stenosis, 3 cases of nioderate niitral stenosis with Grade I regurgitation, 6 cases of Grade II regurgitation, and 3 cases of predominant niitral regurgitation (Grade III regurgitation). From this analysis, we concluded that absence of diastasis in our cases was not a
.
. .
l X
1
2
3
I
MI
Fig. 2. The values derived from the application of the mitral regurgitation index to left atria1 pressure curves are plotted as ordinates. The degree of mitral regurgitation (O-4) is plotted as abscissas. Note the failure to separate mitral regurgitation from mitral stenosis.
596
Wassermil, Warkentin,
Fig. 3. The Ieft ventricle
.lm Iirori .
Slonim, and Ravin
,\ 07 iinbci,
“washout phenomenon. ” The plastic catheter back into the left atrium during ventricular
Fig. 4. Ventricularization of left atria1 atrial curve. B shows the same pressure resulted in severe mitral regurgitation.
reliable criterion for the diagnosis of mitral stenosis. Examination of Fig. 1 discloses the lack of separation between predominant mitral stenosis and mitral regurgitation. None of the formulas tested separated the two conditions satisfactorily. The index of mitral regurgitation suggested by us (Fig. 2) likewise failed to separate the two conditions. Although the hemodynamic criteria derived from the analysis of left atria1 pressure curves proved to be disappointing, two phe-
pressure. A after mitral
is washed systole.
shows preoperative commissurotomy
from
1”0’
the
left which
nomena seemed to indicate predominant mitral regurgitation. One which has been reported previously’?-l4 is the catheter in which event the small poly“washout,” ethylene catheter enters the left ventricle in diastole but is immediately washed back into the left atrium by the regurgitant no\\of blood (luring ventricular systole (Fig. .~,I. We observed this phenomenon in all 3 patients who were found at operation to have predominant mitral regurgitation. The second persistent finding in predominant Illi-
Left atria1 punctlue i?z rheumatic mitral valvular disease
tral regurgitation was ventricularization of the left atria1 pressure curve (Fig. 41, indicating a common atrioventricular chamber. The mean atrioventricular gradient was determined in 19 of the 2.5 patients in Group I. For 7 patients with pure mitral stenosis it averaged 9.3 mm. Hg. For 6 patients with rilitral stenosis and Grade 2 mitral insufficiency it averaged 10.6 mm. Hg. In one patient with Grade 3 mitral insufficiency it was 9 mm. Hg. It is obvious that, although the gradient indicates the presence of some mitral stenosis, it does not help to differentiate pure mitral stenosis from mitral stenosis with significant mitral insufficiency.
597
correlation of the v waves. The coefficient of regression was 0.78. These results corroborate the findings of other investigators that pulmonary arterial wedge pressure is a good indicator of left atria1 pressure, not only in terms of mean pressure but also in terms of individual waves.15-23 In the 25 patients in whom the pulmonary arterial wedge pressure disclosed phasic variations, the mean left atria1 pressure varied between 11 and 34 mm. Hg. The height of left atria1 pressure, therefore, did not seem to influence the transmission of individual waves from the left atrium to the catheter wedged in a branch of the pulmonary artery.
Correlation of‘ left atria1 pressure with pulmonary arterial wedge presszue. Correla-
Discussion
tion of pulmonary arterial wedge pressure with left atria1 pressure was possible in 37 patients. In 12 patients the pulmonary arterial wedge pressure was nonphasic or damped, which made the identification of individual waves impossible. In the other 25 patients the individual waves were well recorded and could be compared with characteristic left atria1 pressure waves. Good correlation was obtained in the comparison of lx~lmonary arterial wedge pressure with left atria1 pressure (Fig. 5). The correlation coefficient for the mean left atria1 and mean pulmonary arterial wedge pressure was r = +0.68. A somewhat better figure of r = -j-O.72 was obtained for the
When the technique of left atria1 puncture was introduced, it was hoped that it would be helpful in differentiating mitral regurgitation from mitral stenosis in combined mitral lesions. In our series of 50 patients, left atria1 puncture was associated with considerable morbidity, and the analysis of left atria1 pressures has not consistently separated mitral stenosis from mitral regurgitation. The various hemodynamic formulas proposed for the detection of mitral regurgitation were not helpful in this study. Similar negative findings have also been reported by other investigators.24.26 The reasons for this are not enWedge v waw mm Hg
m Wedge mm Hg
-~ 10
20
30
40
m
I8
LA
28
18
LA V weve mm Hg
48
mm Hg
Fig. 5. Relationship between between mean pressures and
left atrial 21waves.
and
pulmonary
arterial
wedge
pressures.
Note
the
close
correlation
59x
Wassermil, Warkentin,
.ilnz. Heavt
Slonim, and Rnvin
tirely clear. One possibility is that we measure only the relative height of the different atria1 waves, without taking into consideration the pressure-volume relationship in the atrium and the elasticity of the left atria1 wa11.**“6,2’ The other possibility is that the assessment of regurgitation by the surgeon is not reliable. The finger in the left atrium may distort the valvular ring and cause a false impression of regurgitation. Left atria1 puncture is reliable in the diagnosis of significant mitral stenosis or pure mitral regurgitation. However, such a diagnosis may also be established with a high degree of accuracy by clinical tnethods alone. There are two groups of patients in whom left atria1 puncture is indicated. One group of patients consists of so-called silent mitrats. These patients have all the symptoms of mitral stenosis but lack the characteristic murmur. The demonstration of a significant atrioventricular gradient across the mitral valve by means of left atria1 puncture is of prime importance. The second group consists of patients with cottgestive heart failure and an enlarged left atrium without other diagnostic features. Catheterization of the right side of the heart usually demonstrates a high pulmonary arterial wedge pressure and a high right ventricular end-diastolic pressure. I,eft atria1 puncture will help to rule out mitral stenosis by the absence or presence of an atrioventricular gradient. In view of the relatively high morbidit> associated with this procedure and the uttreliable data obtained front the analysis of atria1 curves, this procedure should not be undertaken lightly. This impression is further strengthened by the fact that a good correlation was obtained from the comparison of left atria1 pressure with pulmonary arterial wedge pressure. On the basis of our findings, a properly recorded pulmonary arterial wedge pressure, both at rest and during exercise, provided sufficient diagnostic information. The presence of an atrioventricutar gradient is sometimes tnisleading, because ;t large gradient ma-) also exist in patients with combined tnitral lesions with sigllificant mitral regurgitation. Atrioventricutar gradients should, however, be determined during mitral commissurototny, before and after the opening of the mitral valve. Abo-
,l’mw&her,
I.
19h.z
lition of the atrioventricular gradient affords a quantitative tneasure of the successful relief of mitral stenosis. Mitral regurgitation may be best assessed by actual measurement of the volume of the regurgitant flow of blood. Recent advances in retrograde angiocardiographq ittdicate that this may be the best method in the future.28s2g It is proposed that, within the presettt means of analysis, left atria1 puncture affords few advantages in most cases, c~ttl emphasis should be placed ott clinical evaluation of the patient, combined if necessary with catheterization of the right side of the heart. Summary The value of percutaneous transthoracic left atria1 puncture in the diagnosis of predominant mitral regurgitation was studied itt 50 patients with combined lesions of the ntitral valve. The investigation was divided into three parts and consisted of: (1) assessment of morbidity associated with this procedure, (I) comparison of surgical findings with the results of analysis of left atria1 pressure curves, and (3) correlation of left atria1 pressure curves with the pulmonarp arterial wedge pressure-pulse contours. The results obtained indicate that percutaneous transthoracic left atria1 puncture was associated with significant morbidity. The analysis of left atria1 pressure curves did not consistently separate mitral regurgitation from mitral stenosis. Pulmonary arterial wedge pressure, on the other hand, correlated well with the left atria1 pressure curves. The results of this investigation are discussed and indicate that left atria1 puncture in most cases of combined mitral lesions affords few advantages. For this reason, emphasis should be placed on clinical evaluation of patients, combined, if necessary, with catheterization of the right side of the heart. 1.
2.
3.
REFERENCES BjBrk, V. O., MalmstrBm, G., and IJggla, I,. C;.: Left am+ular pressure measurements in man, Ann. Surg. 138:718, 1953. Fisher, D. L.: The use of pressure recordings obtained at transthoracic left heart catheterization in the diagnosis of valvular heart disease, J. Thoracic Surg. 30:379, 195.5. Kent, E. M., Ford, W. B., Fisher, D. L., and Childs, T. B. : The estimation of the severity of
Left atria1 puncture in rheumatic mitral valvular disease
mitral regurgitation, Ann. Surg. 141:47, 1955. MacKenzie, J.: The study of the pulse, arterial, venous and hepatic, and of the movements of the heart, London, 1902, Young J. Pentland, pp. 197.208. .5 . MacKenzie, J.: Diseases of the heart, ed. 4, London, 1955, Oxford University Press, pp. 461-476. 6. Wiggers, C. J.: The pressure pulse in the cardiovascular system, New York, 1928, Longmans, pp. 46-64. 7. Rapaport, E., and Dexter, L.: Pulmonary “capillary” pressure, in Methods in medical research, vol. 7, Chicago, 1958, Year Book Publishers, Inc., pp. 85-93. 8. Owen, S. G., and Wood, P.: A new method of determining the degree or absence of mitral obstruction: an analysis of the diastolic part of indirect left atrial pressure tracings, Brit. Heart J. 17:41, 195.5. A. G., Braunwald, E., Heller, J. A., Jr., 9. Morrow, and Sharp, E. H.: Left heart catheterization by the transbronchial route: technique and applications in physiologic and diagnostic investigations, Circulation 16:1033, 1956. 10. Fox, I. J., Wakai, C. S., Connolly, D. C., and Wood, E. H.: Left atria1 and ventricular pressure pulses in mitral valvular disease, Proc. Staff Meet. Mayo Clin. 31:126, 1956. 11. Connolly, D. C., and Wood, E. H.: Hemodynamic data during rest and exercise in patients with mitral valvular disease in relation to the differentiation of stenosis and insufficiency from the pulmonary artery wedge pressure pulse, J. Lab, & Clin.. Med. 49:526, 1957. V. 0.. and Malmstrijm. G.: The diastolic 12. Biork. pies&e gradient between the left atrium and the left ventricle in cases of mitral stenosis, AM. HEART J. 58:486, 1959. 13. Ross, J., Jr., Braunwald, E., and Morrow, A. G.: Clinical and hemodynamic observations in pure mitral insufficiency, Am. J. Cardiol. l:ll, 1958. J. E., and Shaffer, A. B.: Diagnostic 14. Neustadt, value of the Ieft atriai pressure pulse in mitral valvular disease, AM. HEART J. 58:675, 1959. 1.5. Hellems, H. K., Haynes, F. W., and Dexter, L.: Pulmonary “capillary” pressure in man, J. Appl. Physiol. 2:24, 1949. 16. Lagerlof, H., aJld Werko, L.: Studies OJI the circulation of blood in man. VI. The pulmonary capillary venous pressure pulse in man, Scandinav. J. Clin. & Lab. Invest. 6:147, 1949. L., Dow, J. W., Haynes, F. W., Whit17. Dexter, tenberger, J. L., Ferris, B. G., Goodale, W. ‘I., 4.
18.
19.
20.
21.
22.
23.
24.
2s.
26.
27.
28.
29.
599
and Hellems, H. K.: Studies of the pulmonary circulation in man at rest. Normal variations and the interrelations between increased pulmonary blood flow, elevated pulmonary arterial pressure, and high pulmonary “capillary” pressures, J. Clin, Invest. 29:602, 1950. Werko, L., Varnauskas, E., Eliasch, H., Lagerlof, H., Senning, A., and Thomasson, E.: Further evidence that the pulmonary capillary venous pressure pulse in man reflects cyclic pressure changes in the left atrium, Circulation lies. 1:337, 1953. Connolly, D. C., Tompkins, R. G., Lev, R., Kirklin, J. W., and Wood, E. H.: Pulmonaryartery wedge pressures in mitral valve disease; relationship to left atria1 pressures, Proc. Staff Meet. Mayo Clin. 28:72, 1953. Connolly, D. C., Kirklin, J. W., and Wood, E. H.: The relationship between pulmonary artery wedge pressure and left atria1 pressure in man, Circulation Res. 2:434, 1954. Connolly, D. C., and Wood, E. H.: The pulmonary vein wedge pressure in man, Circulation Res. 3:7, 1955. Epps, R. G., and Adler, R. H.: Left atrial and pulmonary capillary venous pressures in mitral stenosis, Brit. Heart J. 15:298, 19.53. Mueller. H., Gensini, G., Prevedel, A. E., and Blount, S. G.: Retrograde transmission of left atria1 pressure pulses across the pulmonary capillary bed in dogs, Circulation Res. 2:426, 1954. McCampbell, S. R.: Direct left atria1 pressure tracings and the degree of mitral obstruction, Brit. Heart J. 20:341, 1958. Wells, B. G.: The diagnosis of mitral incompetence from left atria1 pressure curves, Brit. Heart J. 20:321, 1958. Hamer. N. A.. and Dow. I. W.: The indications for mejsurement of left hgart pressures in mitral and aortic valvular disease, AM. HEART J. 62:344, 1961. Fairley, F. K.: The influence of atria1 size and elasticity on the left atria1 pressure tracing, Brit. Heart J. 23:512, 1961. Bjork, V. O., Lodin, H., and Malers, E.: The evaluation of the degree of mitral insufficiency bv selective left ventricular angiocardiographv. ,
I
atrial
patients
puncture with
in
rheumatic
mitral
valvular
disease
Mendel Wassermil, M.D. Donald L. Warkentin, M.D. N. Ba2four Slonim, M.D. Abe Ravin, M.D. Denver, Cola.
I
n spite of the advances made in surgical techniques, the correction of mitral regurgitation remains a difficult problem and is not entirely satisfactory. For this reason, careful judgment is required for correct selection of patients with combined mitral disease for surgical treatment. The diagnostic difficulty in determining the predominant mitral lesion is considerable. It was hoped that the addition of left atria1 puncture to our diagnostic armamentarium would greatly facilitate the differentiation of mitral regurgitation from mitral stenosis. Review of the literature disclosed, however, conflicting reports as to the value of left atria1 puncture in general, and the aualysis of left atria1 curves in particular, in the diagnosis of predominant mitral valvular disease. The present study was undertaken in order to clarify the conflicting views and to assess the value of left atria1 puncture in the diagnosis of lesions of the mitral valve. The investigation consists of three parts. The first part evaluates the results obtained from analysis of left atria1 pressures as compared with surgical findings; the second part deals with the morbidity connected with left atria1 puncture; and the third part tests the validity of pul-
monary arterial wedge pressure cator of left atria1 pressure.
as an indi-
Material The material for this investigation consisted of 50 patients who underwent a total of 52 left atria1 punctures. The patients were divided into two groups (Table I). The first group consisted of 25 patients and forms the basis for analysis and correlation of atria1 pressure curves with surgical find-
Table I Group I: Pafients 11 patients-Pure 4 patients-Mitral
operated on mitral stenosis stenosis and Grade 1 mitral regurgitation 7 patients-Mitral stenosis and Grade 2 mitral regurgitation 3 patients-Minimal mitral stenosis and Grade 3 mitral regurgitation
Group II: Patients 12 patients-Minimal
From the Department of Cardiology and the Cardiopulmonary Cola. This study was supported by the Colorado Heart Association, Inc., of New York. Received for publication Jan. 19. 1962.
not operated on mitral stenosis and dominant mitral regurgitation 7 patients-Predominant mitral stenosis 2 patients-Aortic involvement 4 patientsNo diagnosis
Laboratory, Denver,
General Cola..
Rose Memorial
and the John
Hospital,
A. Hartford
prc-
I)enver,
Foundation.
Left atria1 @nctuve in rheumatic mitrul valvular disease
ings. The patients in this group had a clinical diagnosis of predominant mitral stenosis (which was substantiated by catheterization data). Twenty-three patients were operated on by the same experienced surgeon; the cross-sectional area of his index finger was measured and was found to be 1.3 square centimeters. The surgeon estimated the area of the valve by palpation and determined the presence of regurgitation with his gloved index finger. The evaluation of regurgitation depended on the estimated size of the valve opening as well as the force and the distance at which the regurgitant jet could be felt. The regurgitant volume was assessed as l-plus through 4-plus. At operation, 11 of the 2.5 patients had pure mitral stenosis with a valve area which ranged from 0.5 to 1.5 CI~.~. The other 14 patients had moderate mitral stenosis with a valve area which ranged from 1 to 2 cm.‘. Of these 14 patients, 4 were considered to have l-plus regurgitation, 7 had 2-plus regurgitation, and 3 had predominant mitral insufficiency with 3-plus regurgitation. The second group consisted of the other 25 patients who for various reasons were not operated on (Table I). All 50 patients were included in the assessment of morbidity associated with left atria1 puncture, and correlation of left atria1 pressures with pulmonary arterial wedge pressure. Methods .A11 catheterizations, with two exceptions, consisted of catheterization of the right side of the heart and left atria1 puncture, which was performed by the method of Bjork as modified by Fisller.1-3 In 2 patients, only left atria1 puncture was performed. The patients were in the postabsorptive state and were premeditated with secobarbital alone or in combination with meperidine. Pressures were recorded on a Sanborn Poly-Viso, direct-writing, fourchannel recorder, employing Statham 23Db strain-gauge transducers. The zero reference level for both pulmonary arterial wedge pressures and the left atria1 pressure was 10 cm. above the level of the table. (‘ontinuous pressures were recorded as the PESO* polyethylene catheter was with*Available from Clay-Adams, Inc.. New York, diameter 0.023” and outside diameter 0.038”.
N.
Y.
Inside
593
drawn from the left ventricle into the left atrium. For the determination of the atrioventricular diastolic filling gradient the left atria1 and left ventricular pressure curves were superimposed as closely as possible in the same phase of respiration. In each case, at least two respiratory cycles were recorded and measured. The pressure tracing obtained through the PESO catheter was slightly damped as compared to that obtained directly through the needle. The difference between the two recordings was so negligible that for practical purposes these tracings might be considered to be identical. The frequency response of the hydraulic system of the No. 7 catheter used for catheterization of the right side of the heart and that of the 18-gauge needle used for left atria1 puncture were very similar. The individual left atria1 waves were measured and analyzed according to their relative height and for the duration of the y descent. The mean left atria1 pressures were determined by planimetry. The same measurements were made on pulmonary arterial wedge tracings. Pulmonary arterial wedge pressures were recorded according to the criteria of Rapaport and Dexter.’ The mean pulmonary arterial wedge pressure was compared with the mean left atria1 pressure. The v waves in both left atria1 and pulmonary arterial wedge pressures were analyzed and correlated. The terminology of MacKenzie and Wiggersm6 was used in describing the atria1 waves, which are both positive and negative. Of the positive waves, the a wave is caused by atria1 systole, the c wave is due to closure of the atrioventricular valves, and the v wave is related to atria1 filling. Two negative troughs are also described: the .L^ wave, which follows the c wave, is caused by a drop in atria1 pressure as the ventricles contract, and the y descent, which follows the peak of the v wave and ends in the y point, is due to lowering of the atria1 pressure as the blood flows into the ventricles during diastole. Results
Technicab d$cultirs. The left atrium could not be entered in 5 patients; in 2 of these there was pericardial effusion which had not been detected on the chest x-ray
594
Warkentin,
Wassermil,
Sbonim, and Kavin
V-
I
*. . .: .*:
: .
m LA
. . . . . .. .
:*
O.lRyl’d/mLA rnnl”[, se:
.::. .
..
.. : . :
. .
Fig. 1. Relationship between values derived from analysis of left atrial pressures and the degree of mitral regurgitation. The values obtained from the application of four formulas (see text) are plotted as ordinates, and the degree of mitral regurgitation (0-1) is plotted as abscissas. Note the failure to separate mitral stenosis from mitral regurgitation.
film. In the other 47 successful left atria1 punctures, the PESO catheter failed to enter the left ventricle in 10 patients. In 6 patients the “washout” phenomenon was encountered : the polyethylene tubing was washed back from the left ventricle into the left atrium by the regurgitant stream of blood during ventricular systole. In no case did knotting or accidental cutting of the PESO polyethylene catheter occur. Morbidity. Short periods of arrhythmia (consisting predominantly of premature ventricular beats and changes in rhythm) were encountered in about 60 per cent of the patients as the needle entered the left atrium. Discomfort in the form of pain was experienced by most patients. The over-all morbidity was significant, but no perma-
nent disability or death resulted from the 52 left atria1 punctures. The salient features of these complications are summarized in Table II. Pericardial tamponade occurred in one patient several hours after the procedure. The patient responded well to pericardiocentesis and recovered. Another patient had a pulmonary hemorrhage immediately after the removal of the intracardiac needle; this was due to puncture of lung parenchyma. Two patients developed small pneumothoraces. Another patient developed fever and signs of infiltration in the left lung, which were probably due to emboli that originated in the right atrium, which was inadvertently punctured. Two patients had severe precordial pain which resembled the postconl-
Left atria1 puncture in rheumatic mitral valvular disease
l’nblr IT. Morbidity
in 50 patients
Pericardial tamponade Pulmonary hemorrhage Pneumothorax Pulmonary infarction and fever Postcommissurotomy-like syndrome Asystole Pleuritic pain Signs of blood in pericardium at surgeq
(1) (v (height) x to x + (2) (v (height) x to x + 1 1 2 1 2 1 50
2 2 4 2 4 2 100
21
missurotomy syndrome; the pain abated after a few doses of aspirin. One patient had a period of asystole which lasted 5 seconds as the needle punctured the left atria1 wall. Most patients complained of pleuritic-type pain at some time during the 24 hours after the procedure. The pulmonary artery, aorta, right atrium, and right ventricle were sometimes inadvertently entered during attempts to puncture the left atrium. Fortunately, no untoward results occurred from the puncture of these structures. A small quantity of dark blood was found in the pericardium of 21 patients who underwent mitral commissurotomy shortly after the left atria1 puncture. Analysis of curves in the assessment of pvedomznant valvular disease. We analyzed the characteristic left atria1 waves in the tracings of 25 patients who underwent surgery. The most commonly used hemodynamic formulas which have been developed by various investigators to help separate mitral stenosis from mitral regurgitation were investigated and their value was assessed. These formulas are based on the relative height of the v wave and the rapidity of y descent, and are as follows: (1) rate of y descent during the first 0.1 second8,g; (2) height of v wave minus the height of c wave”; (3) the ratio of the height of v wave to the height of mean left atria1 pressure’“; (4) height of v wave minus mean left atria1 pressure” ; (5) absence of diastasis in mitral stenosis.g 111 addition to the afore-mentioned formulas, we developed in our laborator)‘, on the basis of the height and area of the v wave, two indices of mitral regurgitation. They consist of two formulas:
595
-
y) X (v (area) from 0.2 second) - x) X (v (area) from 0.2 second)
Of the criteria tested and previously reported to be valuable in the differentiation of mitral stenosis from mitral regurgitation, none adequately separated the two conditions. Fig. 1 shows graphically the random distribution of points when results analyzed according to each of the formulas mentioned above were plotted against our estimate at the time of operation. According to Braunwald, diastasis is absent in mitral stenosis. Diastasis is the rise in left atria1 pressure just before onset of the ac wave. It is due to a rise in ventricular pressure as the ventricle is filled with blood.g Of the 25 cases evaluated at the time of operation, diastasis was present in 5. Two patients had predominant mitral stenosis with Grade I and II regurgitation, and 3 patients had pure mitral stenosis. In the other 20 patients, diastasis was not denlonstrable. jiniong these there were 8 cases of pure mitral stenosis, 3 cases of nioderate niitral stenosis with Grade I regurgitation, 6 cases of Grade II regurgitation, and 3 cases of predominant niitral regurgitation (Grade III regurgitation). From this analysis, we concluded that absence of diastasis in our cases was not a
.
. .
l X
1
2
3
I
MI
Fig. 2. The values derived from the application of the mitral regurgitation index to left atria1 pressure curves are plotted as ordinates. The degree of mitral regurgitation (O-4) is plotted as abscissas. Note the failure to separate mitral regurgitation from mitral stenosis.
596
Wassermil, Warkentin,
Fig. 3. The Ieft ventricle
.lm Iirori .
Slonim, and Ravin
,\ 07 iinbci,
“washout phenomenon. ” The plastic catheter back into the left atrium during ventricular
Fig. 4. Ventricularization of left atria1 atrial curve. B shows the same pressure resulted in severe mitral regurgitation.
reliable criterion for the diagnosis of mitral stenosis. Examination of Fig. 1 discloses the lack of separation between predominant mitral stenosis and mitral regurgitation. None of the formulas tested separated the two conditions satisfactorily. The index of mitral regurgitation suggested by us (Fig. 2) likewise failed to separate the two conditions. Although the hemodynamic criteria derived from the analysis of left atria1 pressure curves proved to be disappointing, two phe-
pressure. A after mitral
is washed systole.
shows preoperative commissurotomy
from
1”0’
the
left which
nomena seemed to indicate predominant mitral regurgitation. One which has been reported previously’?-l4 is the catheter in which event the small poly“washout,” ethylene catheter enters the left ventricle in diastole but is immediately washed back into the left atrium by the regurgitant no\\of blood (luring ventricular systole (Fig. .~,I. We observed this phenomenon in all 3 patients who were found at operation to have predominant mitral regurgitation. The second persistent finding in predominant Illi-
Left atria1 punctlue i?z rheumatic mitral valvular disease
tral regurgitation was ventricularization of the left atria1 pressure curve (Fig. 41, indicating a common atrioventricular chamber. The mean atrioventricular gradient was determined in 19 of the 2.5 patients in Group I. For 7 patients with pure mitral stenosis it averaged 9.3 mm. Hg. For 6 patients with rilitral stenosis and Grade 2 mitral insufficiency it averaged 10.6 mm. Hg. In one patient with Grade 3 mitral insufficiency it was 9 mm. Hg. It is obvious that, although the gradient indicates the presence of some mitral stenosis, it does not help to differentiate pure mitral stenosis from mitral stenosis with significant mitral insufficiency.
597
correlation of the v waves. The coefficient of regression was 0.78. These results corroborate the findings of other investigators that pulmonary arterial wedge pressure is a good indicator of left atria1 pressure, not only in terms of mean pressure but also in terms of individual waves.15-23 In the 25 patients in whom the pulmonary arterial wedge pressure disclosed phasic variations, the mean left atria1 pressure varied between 11 and 34 mm. Hg. The height of left atria1 pressure, therefore, did not seem to influence the transmission of individual waves from the left atrium to the catheter wedged in a branch of the pulmonary artery.
Correlation of‘ left atria1 pressure with pulmonary arterial wedge presszue. Correla-
Discussion
tion of pulmonary arterial wedge pressure with left atria1 pressure was possible in 37 patients. In 12 patients the pulmonary arterial wedge pressure was nonphasic or damped, which made the identification of individual waves impossible. In the other 25 patients the individual waves were well recorded and could be compared with characteristic left atria1 pressure waves. Good correlation was obtained in the comparison of lx~lmonary arterial wedge pressure with left atria1 pressure (Fig. 5). The correlation coefficient for the mean left atria1 and mean pulmonary arterial wedge pressure was r = +0.68. A somewhat better figure of r = -j-O.72 was obtained for the
When the technique of left atria1 puncture was introduced, it was hoped that it would be helpful in differentiating mitral regurgitation from mitral stenosis in combined mitral lesions. In our series of 50 patients, left atria1 puncture was associated with considerable morbidity, and the analysis of left atria1 pressures has not consistently separated mitral stenosis from mitral regurgitation. The various hemodynamic formulas proposed for the detection of mitral regurgitation were not helpful in this study. Similar negative findings have also been reported by other investigators.24.26 The reasons for this are not enWedge v waw mm Hg
m Wedge mm Hg
-~ 10
20
30
40
m
I8
LA
28
18
LA V weve mm Hg
48
mm Hg
Fig. 5. Relationship between between mean pressures and
left atrial 21waves.
and
pulmonary
arterial
wedge
pressures.
Note
the
close
correlation
59x
Wassermil, Warkentin,
.ilnz. Heavt
Slonim, and Rnvin
tirely clear. One possibility is that we measure only the relative height of the different atria1 waves, without taking into consideration the pressure-volume relationship in the atrium and the elasticity of the left atria1 wa11.**“6,2’ The other possibility is that the assessment of regurgitation by the surgeon is not reliable. The finger in the left atrium may distort the valvular ring and cause a false impression of regurgitation. Left atria1 puncture is reliable in the diagnosis of significant mitral stenosis or pure mitral regurgitation. However, such a diagnosis may also be established with a high degree of accuracy by clinical tnethods alone. There are two groups of patients in whom left atria1 puncture is indicated. One group of patients consists of so-called silent mitrats. These patients have all the symptoms of mitral stenosis but lack the characteristic murmur. The demonstration of a significant atrioventricular gradient across the mitral valve by means of left atria1 puncture is of prime importance. The second group consists of patients with cottgestive heart failure and an enlarged left atrium without other diagnostic features. Catheterization of the right side of the heart usually demonstrates a high pulmonary arterial wedge pressure and a high right ventricular end-diastolic pressure. I,eft atria1 puncture will help to rule out mitral stenosis by the absence or presence of an atrioventricular gradient. In view of the relatively high morbidit> associated with this procedure and the uttreliable data obtained front the analysis of atria1 curves, this procedure should not be undertaken lightly. This impression is further strengthened by the fact that a good correlation was obtained from the comparison of left atria1 pressure with pulmonary arterial wedge pressure. On the basis of our findings, a properly recorded pulmonary arterial wedge pressure, both at rest and during exercise, provided sufficient diagnostic information. The presence of an atrioventricutar gradient is sometimes tnisleading, because ;t large gradient ma-) also exist in patients with combined tnitral lesions with sigllificant mitral regurgitation. Atrioventricutar gradients should, however, be determined during mitral commissurototny, before and after the opening of the mitral valve. Abo-
,l’mw&her,
I.
19h.z
lition of the atrioventricular gradient affords a quantitative tneasure of the successful relief of mitral stenosis. Mitral regurgitation may be best assessed by actual measurement of the volume of the regurgitant flow of blood. Recent advances in retrograde angiocardiographq ittdicate that this may be the best method in the future.28s2g It is proposed that, within the presettt means of analysis, left atria1 puncture affords few advantages in most cases, c~ttl emphasis should be placed ott clinical evaluation of the patient, combined if necessary with catheterization of the right side of the heart. Summary The value of percutaneous transthoracic left atria1 puncture in the diagnosis of predominant mitral regurgitation was studied itt 50 patients with combined lesions of the ntitral valve. The investigation was divided into three parts and consisted of: (1) assessment of morbidity associated with this procedure, (I) comparison of surgical findings with the results of analysis of left atria1 pressure curves, and (3) correlation of left atria1 pressure curves with the pulmonarp arterial wedge pressure-pulse contours. The results obtained indicate that percutaneous transthoracic left atria1 puncture was associated with significant morbidity. The analysis of left atria1 pressure curves did not consistently separate mitral regurgitation from mitral stenosis. Pulmonary arterial wedge pressure, on the other hand, correlated well with the left atria1 pressure curves. The results of this investigation are discussed and indicate that left atria1 puncture in most cases of combined mitral lesions affords few advantages. For this reason, emphasis should be placed on clinical evaluation of patients, combined, if necessary, with catheterization of the right side of the heart. 1.
2.
3.
REFERENCES BjBrk, V. O., MalmstrBm, G., and IJggla, I,. C;.: Left am+ular pressure measurements in man, Ann. Surg. 138:718, 1953. Fisher, D. L.: The use of pressure recordings obtained at transthoracic left heart catheterization in the diagnosis of valvular heart disease, J. Thoracic Surg. 30:379, 195.5. Kent, E. M., Ford, W. B., Fisher, D. L., and Childs, T. B. : The estimation of the severity of
Left atria1 puncture in rheumatic mitral valvular disease
mitral regurgitation, Ann. Surg. 141:47, 1955. MacKenzie, J.: The study of the pulse, arterial, venous and hepatic, and of the movements of the heart, London, 1902, Young J. Pentland, pp. 197.208. .5 . MacKenzie, J.: Diseases of the heart, ed. 4, London, 1955, Oxford University Press, pp. 461-476. 6. Wiggers, C. J.: The pressure pulse in the cardiovascular system, New York, 1928, Longmans, pp. 46-64. 7. Rapaport, E., and Dexter, L.: Pulmonary “capillary” pressure, in Methods in medical research, vol. 7, Chicago, 1958, Year Book Publishers, Inc., pp. 85-93. 8. Owen, S. G., and Wood, P.: A new method of determining the degree or absence of mitral obstruction: an analysis of the diastolic part of indirect left atrial pressure tracings, Brit. Heart J. 17:41, 195.5. A. G., Braunwald, E., Heller, J. A., Jr., 9. Morrow, and Sharp, E. H.: Left heart catheterization by the transbronchial route: technique and applications in physiologic and diagnostic investigations, Circulation 16:1033, 1956. 10. Fox, I. J., Wakai, C. S., Connolly, D. C., and Wood, E. H.: Left atria1 and ventricular pressure pulses in mitral valvular disease, Proc. Staff Meet. Mayo Clin. 31:126, 1956. 11. Connolly, D. C., and Wood, E. H.: Hemodynamic data during rest and exercise in patients with mitral valvular disease in relation to the differentiation of stenosis and insufficiency from the pulmonary artery wedge pressure pulse, J. Lab, & Clin.. Med. 49:526, 1957. V. 0.. and Malmstrijm. G.: The diastolic 12. Biork. pies&e gradient between the left atrium and the left ventricle in cases of mitral stenosis, AM. HEART J. 58:486, 1959. 13. Ross, J., Jr., Braunwald, E., and Morrow, A. G.: Clinical and hemodynamic observations in pure mitral insufficiency, Am. J. Cardiol. l:ll, 1958. J. E., and Shaffer, A. B.: Diagnostic 14. Neustadt, value of the Ieft atriai pressure pulse in mitral valvular disease, AM. HEART J. 58:675, 1959. 1.5. Hellems, H. K., Haynes, F. W., and Dexter, L.: Pulmonary “capillary” pressure in man, J. Appl. Physiol. 2:24, 1949. 16. Lagerlof, H., aJld Werko, L.: Studies OJI the circulation of blood in man. VI. The pulmonary capillary venous pressure pulse in man, Scandinav. J. Clin. & Lab. Invest. 6:147, 1949. L., Dow, J. W., Haynes, F. W., Whit17. Dexter, tenberger, J. L., Ferris, B. G., Goodale, W. ‘I., 4.
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and Hellems, H. K.: Studies of the pulmonary circulation in man at rest. Normal variations and the interrelations between increased pulmonary blood flow, elevated pulmonary arterial pressure, and high pulmonary “capillary” pressures, J. Clin, Invest. 29:602, 1950. Werko, L., Varnauskas, E., Eliasch, H., Lagerlof, H., Senning, A., and Thomasson, E.: Further evidence that the pulmonary capillary venous pressure pulse in man reflects cyclic pressure changes in the left atrium, Circulation lies. 1:337, 1953. Connolly, D. C., Tompkins, R. G., Lev, R., Kirklin, J. W., and Wood, E. H.: Pulmonaryartery wedge pressures in mitral valve disease; relationship to left atria1 pressures, Proc. Staff Meet. Mayo Clin. 28:72, 1953. Connolly, D. C., Kirklin, J. W., and Wood, E. H.: The relationship between pulmonary artery wedge pressure and left atria1 pressure in man, Circulation Res. 2:434, 1954. Connolly, D. C., and Wood, E. H.: The pulmonary vein wedge pressure in man, Circulation Res. 3:7, 1955. Epps, R. G., and Adler, R. H.: Left atrial and pulmonary capillary venous pressures in mitral stenosis, Brit. Heart J. 15:298, 19.53. Mueller. H., Gensini, G., Prevedel, A. E., and Blount, S. G.: Retrograde transmission of left atria1 pressure pulses across the pulmonary capillary bed in dogs, Circulation Res. 2:426, 1954. McCampbell, S. R.: Direct left atria1 pressure tracings and the degree of mitral obstruction, Brit. Heart J. 20:341, 1958. Wells, B. G.: The diagnosis of mitral incompetence from left atria1 pressure curves, Brit. Heart J. 20:321, 1958. Hamer. N. A.. and Dow. I. W.: The indications for mejsurement of left hgart pressures in mitral and aortic valvular disease, AM. HEART J. 62:344, 1961. Fairley, F. K.: The influence of atria1 size and elasticity on the left atria1 pressure tracing, Brit. Heart J. 23:512, 1961. Bjork, V. O., Lodin, H., and Malers, E.: The evaluation of the degree of mitral insufficiency bv selective left ventricular angiocardiographv. ,
I