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Retrograde left atrial catheterization in children with congenital heart disease
Retrograde left atrial catheterization in children with congenital heart disease Geoffrey W. Morrison, M.B., M.R.C.P. (U.K.) Olive Scott, M.D., F.R.C.P. 17 „ „
T
TV /r
J
X c i g u o o. ±yXci\^a.iijiicy, Leeds, England
"R*"!-*
-RiTT^y-^T^
i v i . i j . , iVl.XV.O.IT.
Entry into the left atrium during cardiac catheterization is essential in some patients for the accurate measurement of pulmonary blood flow and pulmonary vascular resistance, for the measurement of a mitral valve gradient or premitral obstruction. The majority of infants and children with congenital heart disease have a patent foramen ovale or atrial septal defect, thus making entry to the left atrium from the right relatively straightforward.' In the remaining patients an alternative route must be used. Needle puncture of the left atrium, either percutaneously (direct^" or via the left ventricle' "), or by the transbronchial approach,- is not suitable for use in children. Transseptal puncture through a closed fossa ovalis"'- is less hazardous but there are few reports of the use of this technique in children.' "• '^ Entry into the left atrium during retrograde transaortic left heart catheterization in children was reported by Vlad and colleagues."'' Shirey and Sones'" described a tapered catheter specifically designed for retrograde left atrial catheterization primarily in adults and our experience since then has permitted us to assess objectively, for the first time (as far as we are aware) the reliability and hazards of the method in children. Material and methods
Over the past five years 1,300 cardiac catheterizations have been performed in this laboratory in patients with congenital heart disease. RetroFrom The Department of Paediatric Cardiology, Killingbeck Hospital, Leeds, England. Received for publication Feb. 2, 1976. Accepted for publication March 8, 1976. Reprint requests: Dr. G.W. Morrison, Killingbeck Hospital, York Road, Leeds LS14 6UQ, England.
September, 1977, Vol. 94, No. 3, pp. 333-335
grade catheterization of the left atrium was attempted only if attempts to cross a foramen ovale had failed and it was felt that entry to the left atrium would provide information essential for the management of the individual patient. It was, therefore, only attempted in 39 patients (3.1 per cent of all catheterizations). Each time a retrograde catheterization was attempted a careful note was made of the procedure, indications, and complications. Thus a simple prospective study was set up. The Shirey catheter was used as the method of first choice for this purpose. In several patients, however, other catheters, which were already in the left (pulmonary venous) ventricle for other reasons, were successfully manipulated into the left atrium. A right axillary arteriotomy was performed under local anaesthesia after whole body heparinization (100 units/Kg of body weight). The catheter was advanced to the ascending aorta and across the aortic valve either directly or by forming a catheter loop." In patients with complete transposition and ventricular septal defect (V.S.D.) or double outlet right ventricle, the catheter was then passed across the V.S.D. Once the catheter tip was in the pulmonary venous ventricle, a loop was made and by careful rotation of the loop the catheter tip was placed posteriorly and advanced through the left atrioventricular (A/V) valve. Catheter tip pressure was monitored continuously and entry into the left atrium was signalled by a sudden drop in pressure in a zone of high oxygen saturation. In three of our patients a common ventricle was entered transvenously rather than transarterially, but essentially the same technique was used to enter the left atrium.
American Heart Journal
333
Morrison, Scott, and Macartney Table I. Retrograde catheterization of the left atrium Discordant ("corrected") TGA
NCGA Intact IVS Successful Unsuccessful
3 1
VSD 14* 6*
Intact IVS 1 0
VSD
Concordant ("complete") TGA with VSD
4t
1 0
3
Single (Primitive) ventricle
Total
7 3
30 13
Abbreviations; NCGA = normally connected great arteries, TGA = transposition of great arteries, IVS = inter-ventricular septum, VSD = ventricular septal defect. •Includes one patient with double outlet right ventricle and 1-malposition. flncludes one patient with persistent truncus arteriosus.
Results
Deliberate attempts to enter the left atrium retrogradely were made in 39 patients with success in 26 (67 per cent). Unintentional entry occurred on 4 other occasions, making a total of 30 retrograde left atrial catheterizations in all. In 80 per cent of patients the indication for attempted left atrial catheterization was the suspected presence of severe pulmonary vascular disease. All patients were aged 15 years or less. The median weight of patients in whom the left atrium was entered was 17.0 Kg. (range 5.4 to 42 Kg.), compared with 13.7 Kg. (range 7.1 to 32 Kg.) in the unsuccessful group. This difference is not statistically significant. The catheters used successfully to enter the left atrium retrogradely were: Shirey (X17), NIH (XlO), Sones Positrol (X3). Catheters which failed to enter the left atrium were: Shirey (X11), NIH (X7), Sones Positrol (X3), Goodale-Lubin ( X I ) and Eppendorf ( X1). On only one occasion did a different type of catheter enter the left atrium retrogradely after a Shirey had failed to do so. Table I shows the basic diagnoses of the patients involved. Left A/V valve abnormalities were present in 13 patients, with stenosis present in four (successful left atrial catheterization in 1), and regurgitation in seven (successful left atrial catheterization in six). In the first patient in whom the technique was tried sudden severe bradycardia occurred during manipulation in the left ventricle, followed by ventricular fibrillation and, although DC shock restored normal rhythm, she died four hours later. There was no evidence of cardiac trauma at autopsy which confirmed the catheterization diagnosis of persistent truncus arteriosus, inop-
334
erable because of severe pulmonary vascular disease. Subsequently, manipulation was carried out with much greater caution, and although short runs of premature ventricular contractions were invaria,bly produced, no other serious complications resulted. On no occasion has it been necessary to administer atropine for a bradycardia. Discussion
Retrograde left atrial catheterization is indicated when simpler means of entering the left atrium have failed and it is essential to know accurately both the pulmonary venous oxygen saturation, for determination of pulmonary blood flow by the Fick method in the presence of a right-to-left shunt, and the left atrial pressure, for the determination of the pulmonary arteriolar resistance. This is particularly important in the presence of pulmonary vascular disease when the capillary wedge pressure may be unreliable.'- '" There are several factors which might determine the ease of retrograde left atrial catheterization. Origin of the aorta from sites other than the left ventricle complicates the procedure but does not lessen the chance of success. T h e smaller size of the infant heart does not seem to make manipulation more difficult, but left A/V valve stenosis may lessen the likelihood of success. The best available alternative to retrograde left atrial catheterization is transseptal puncture, which has been used in children with an 85 per cent incidence of success," although the children reported in that study had weights significantly (p < 0.001) greater than those in this present study. Our own experience confirms that retrograde left atrial catheterization is not without risk,'" but then neither is transseptal punc-
September, 1977, Vol. 94, No. 3
Retrograde
ture.'- '^ In our hands closure of the axillary arteriotomy is followed by diminished or absent distal arterial pulsation in about ten per cent of cases over-all. This occurs most often in small infants, and is unusual in children of the size described in this paper. In no case has absence of the distal arterial pulse been accompanied by symptoms or evidence of retarded growth of the limb. Retrograde left atrial catheterization appears, therefore, to be a useful alternative to transseptal puncture, particularly in smaller children. Because the retrograde approach is also of value in entering the pulmonary artery in complete transposition with ventricular septal defect'-' -" and single primitive ventricle,-' there need be no shortage of opportunities for perfecting the delicate intraventricular manipulation required. Summary
Entry into the left atrium during cardiac catheterization may be essential for full assessment of the hemodynamic situation, particularly for the accurate calculation of pulmonary blood flow and pulmonary arteriolar resistance. The retrograde transaortic transmitral technique of left atrial catheterization has been described in adults but no detailed reports are available for the pediatric age group. Experience of this technique in 43 children with congenital heart disease is now presented, with a success rate of 67 per cent and a low incidence of comphcations. This method compares favorably with other methods of left atrial catheterization when the interatrial septum is intact. The authors would like to express their gratitude to Miss Jane Artie and Mrs. June Fisher for technical assistance in preparing the manuscript.
4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
15. 16. 17. 18.
19.
REFERENCES 1. Coumand, A., Motley, H. L., Himmelstein, A., Dresdale, D., and Baldwin, J.: Recording of blood pressure from the left auricle and the pulmonary veins in human subjects with interauricular septal defect, Am. J. Physiol. 150:267, 1947. 2. Allison, P. R., and Linden, R. J.: The bronchoscopic measurement of left auricular pressure, Circulation 7:669, 1953. 3. Morrow, A. G., Braunwald, E., and Ross, J., Jr.: Left
American Heart Journal
20.
21.
LA catheterization
in
children
heart catheterization. An appraisal of techniques and their apphcations in cardiovascular diagnosis, Arch. Intern. Med. 105:645, 1960. Bjork, V. O., Malmstrom, G., and Uggla, L. C : Left auricular pressure measurements in man, Ann. Surg. 138:718, 1953. Radner, S.: Extended suprasternal puncture technique. Acta Med. Scand. 151:223, 1955. Fisher, D. L.: The use of pressure recordings obtained at transthoracic left heart catheterization in the diagnosis of valvular heart disease, J. Thorac. Surg. 30:379, 1955. Brock, R., Milstein, B. B., and Ross, D. N.: Percutaneous left ventricular puncture in the assessment of aortic stenosis, Thorax 11:163, 1956. Levy, M. J., and Lillehei, C. W.: Percutaneous direct cardiac catheterization. A new method, with results in 122 patients, N. Engl. J. Med. 271:273, 1964. Ross, J., Jr.: Transseptal left heart catheterization. A new method of left atrial puncture, Ann. Surg. 149:395, 1959. Ross, J., Jr., Braunwald, E., and Morrow, A. G.: Transseptal left atrial puncture. Am. J. Cardiol. 31:653, 1959. Cope, C : Technique for transseptal catheterization of the left atrium. Preliminary report, J. Thorac. Surg. 37:482, 1959. Nixon, P. G. F., and Ikram, H.: Left heart catheterization with special reference to the transseptal method, Br. Heart J. 28:835, 1966. Roveti, G. C , Ross, R. S., and Bahnson, H. T.: Transseptal left heart catheterization in the pediatric age group, J. Pediatr. 61:855, 1962. Brockenbrough, E. C , Braunwald, E., and Ross, J., Jr.: Transseptal left heart catheterization, a review of 450 studies and description of an improved technic, Circulation 25:15, 1962. Vlad, P., Hohn, A., and Lambert, E. C : Retrograde arterial catheterization of the left heart. Experience with 500 infants and children. Circulation 29:787, 1964. Shirey, E. K., and Sones, F. M., Jr.: Retrograde transaortic and mitral valve catheterization. Am. J. Cardiol. 18:745, 1966. Zimmerman, H. A., Scott, R. W., and Becker, N. O.: Catheterization of the left side of the heart in man. Circulation 5:357, 1950. Hellems, H. K., Haynes, F. W., Dexter, L., and Kinney, I. D.: Pulmonary capillary pressure in animals estimated by venous and arterial catheterization. Am. J. Physiol. 155:98, 1948. Mullins, C. E., Neches, W. H., Reitman, M. J., El-Said, G., and Riopel, D. A.: Retrograde technique for catheterization of the pulmonary artery in transposition of the great arteries with ventricular septal defect. Am. J. Cardiol. 30:385, 1972. Macartney, F. J., Scott, 0., Deverall, P. B., and Hepburn, F.: New preformed catheter for entry into the pulmonary artery in complete transposition of great arteries, Br. Heart J. 37:525, 1975. Macartney, F. J., Partridge, J. B., Scott, O., and Deverall, P. B.: Common or single ventricle. An angiocardiographic and hemodynamic study of 42 patients. Circulation 53:543, 1976.
335
T
TV /r
J
X c i g u o o. ±yXci\^a.iijiicy, Leeds, England
"R*"!-*
-RiTT^y-^T^
i v i . i j . , iVl.XV.O.IT.
Entry into the left atrium during cardiac catheterization is essential in some patients for the accurate measurement of pulmonary blood flow and pulmonary vascular resistance, for the measurement of a mitral valve gradient or premitral obstruction. The majority of infants and children with congenital heart disease have a patent foramen ovale or atrial septal defect, thus making entry to the left atrium from the right relatively straightforward.' In the remaining patients an alternative route must be used. Needle puncture of the left atrium, either percutaneously (direct^" or via the left ventricle' "), or by the transbronchial approach,- is not suitable for use in children. Transseptal puncture through a closed fossa ovalis"'- is less hazardous but there are few reports of the use of this technique in children.' "• '^ Entry into the left atrium during retrograde transaortic left heart catheterization in children was reported by Vlad and colleagues."'' Shirey and Sones'" described a tapered catheter specifically designed for retrograde left atrial catheterization primarily in adults and our experience since then has permitted us to assess objectively, for the first time (as far as we are aware) the reliability and hazards of the method in children. Material and methods
Over the past five years 1,300 cardiac catheterizations have been performed in this laboratory in patients with congenital heart disease. RetroFrom The Department of Paediatric Cardiology, Killingbeck Hospital, Leeds, England. Received for publication Feb. 2, 1976. Accepted for publication March 8, 1976. Reprint requests: Dr. G.W. Morrison, Killingbeck Hospital, York Road, Leeds LS14 6UQ, England.
September, 1977, Vol. 94, No. 3, pp. 333-335
grade catheterization of the left atrium was attempted only if attempts to cross a foramen ovale had failed and it was felt that entry to the left atrium would provide information essential for the management of the individual patient. It was, therefore, only attempted in 39 patients (3.1 per cent of all catheterizations). Each time a retrograde catheterization was attempted a careful note was made of the procedure, indications, and complications. Thus a simple prospective study was set up. The Shirey catheter was used as the method of first choice for this purpose. In several patients, however, other catheters, which were already in the left (pulmonary venous) ventricle for other reasons, were successfully manipulated into the left atrium. A right axillary arteriotomy was performed under local anaesthesia after whole body heparinization (100 units/Kg of body weight). The catheter was advanced to the ascending aorta and across the aortic valve either directly or by forming a catheter loop." In patients with complete transposition and ventricular septal defect (V.S.D.) or double outlet right ventricle, the catheter was then passed across the V.S.D. Once the catheter tip was in the pulmonary venous ventricle, a loop was made and by careful rotation of the loop the catheter tip was placed posteriorly and advanced through the left atrioventricular (A/V) valve. Catheter tip pressure was monitored continuously and entry into the left atrium was signalled by a sudden drop in pressure in a zone of high oxygen saturation. In three of our patients a common ventricle was entered transvenously rather than transarterially, but essentially the same technique was used to enter the left atrium.
American Heart Journal
333
Morrison, Scott, and Macartney Table I. Retrograde catheterization of the left atrium Discordant ("corrected") TGA
NCGA Intact IVS Successful Unsuccessful
3 1
VSD 14* 6*
Intact IVS 1 0
VSD
Concordant ("complete") TGA with VSD
4t
1 0
3
Single (Primitive) ventricle
Total
7 3
30 13
Abbreviations; NCGA = normally connected great arteries, TGA = transposition of great arteries, IVS = inter-ventricular septum, VSD = ventricular septal defect. •Includes one patient with double outlet right ventricle and 1-malposition. flncludes one patient with persistent truncus arteriosus.
Results
Deliberate attempts to enter the left atrium retrogradely were made in 39 patients with success in 26 (67 per cent). Unintentional entry occurred on 4 other occasions, making a total of 30 retrograde left atrial catheterizations in all. In 80 per cent of patients the indication for attempted left atrial catheterization was the suspected presence of severe pulmonary vascular disease. All patients were aged 15 years or less. The median weight of patients in whom the left atrium was entered was 17.0 Kg. (range 5.4 to 42 Kg.), compared with 13.7 Kg. (range 7.1 to 32 Kg.) in the unsuccessful group. This difference is not statistically significant. The catheters used successfully to enter the left atrium retrogradely were: Shirey (X17), NIH (XlO), Sones Positrol (X3). Catheters which failed to enter the left atrium were: Shirey (X11), NIH (X7), Sones Positrol (X3), Goodale-Lubin ( X I ) and Eppendorf ( X1). On only one occasion did a different type of catheter enter the left atrium retrogradely after a Shirey had failed to do so. Table I shows the basic diagnoses of the patients involved. Left A/V valve abnormalities were present in 13 patients, with stenosis present in four (successful left atrial catheterization in 1), and regurgitation in seven (successful left atrial catheterization in six). In the first patient in whom the technique was tried sudden severe bradycardia occurred during manipulation in the left ventricle, followed by ventricular fibrillation and, although DC shock restored normal rhythm, she died four hours later. There was no evidence of cardiac trauma at autopsy which confirmed the catheterization diagnosis of persistent truncus arteriosus, inop-
334
erable because of severe pulmonary vascular disease. Subsequently, manipulation was carried out with much greater caution, and although short runs of premature ventricular contractions were invaria,bly produced, no other serious complications resulted. On no occasion has it been necessary to administer atropine for a bradycardia. Discussion
Retrograde left atrial catheterization is indicated when simpler means of entering the left atrium have failed and it is essential to know accurately both the pulmonary venous oxygen saturation, for determination of pulmonary blood flow by the Fick method in the presence of a right-to-left shunt, and the left atrial pressure, for the determination of the pulmonary arteriolar resistance. This is particularly important in the presence of pulmonary vascular disease when the capillary wedge pressure may be unreliable.'- '" There are several factors which might determine the ease of retrograde left atrial catheterization. Origin of the aorta from sites other than the left ventricle complicates the procedure but does not lessen the chance of success. T h e smaller size of the infant heart does not seem to make manipulation more difficult, but left A/V valve stenosis may lessen the likelihood of success. The best available alternative to retrograde left atrial catheterization is transseptal puncture, which has been used in children with an 85 per cent incidence of success," although the children reported in that study had weights significantly (p < 0.001) greater than those in this present study. Our own experience confirms that retrograde left atrial catheterization is not without risk,'" but then neither is transseptal punc-
September, 1977, Vol. 94, No. 3
Retrograde
ture.'- '^ In our hands closure of the axillary arteriotomy is followed by diminished or absent distal arterial pulsation in about ten per cent of cases over-all. This occurs most often in small infants, and is unusual in children of the size described in this paper. In no case has absence of the distal arterial pulse been accompanied by symptoms or evidence of retarded growth of the limb. Retrograde left atrial catheterization appears, therefore, to be a useful alternative to transseptal puncture, particularly in smaller children. Because the retrograde approach is also of value in entering the pulmonary artery in complete transposition with ventricular septal defect'-' -" and single primitive ventricle,-' there need be no shortage of opportunities for perfecting the delicate intraventricular manipulation required. Summary
Entry into the left atrium during cardiac catheterization may be essential for full assessment of the hemodynamic situation, particularly for the accurate calculation of pulmonary blood flow and pulmonary arteriolar resistance. The retrograde transaortic transmitral technique of left atrial catheterization has been described in adults but no detailed reports are available for the pediatric age group. Experience of this technique in 43 children with congenital heart disease is now presented, with a success rate of 67 per cent and a low incidence of comphcations. This method compares favorably with other methods of left atrial catheterization when the interatrial septum is intact. The authors would like to express their gratitude to Miss Jane Artie and Mrs. June Fisher for technical assistance in preparing the manuscript.
4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
15. 16. 17. 18.
19.
REFERENCES 1. Coumand, A., Motley, H. L., Himmelstein, A., Dresdale, D., and Baldwin, J.: Recording of blood pressure from the left auricle and the pulmonary veins in human subjects with interauricular septal defect, Am. J. Physiol. 150:267, 1947. 2. Allison, P. R., and Linden, R. J.: The bronchoscopic measurement of left auricular pressure, Circulation 7:669, 1953. 3. Morrow, A. G., Braunwald, E., and Ross, J., Jr.: Left
American Heart Journal
20.
21.
LA catheterization
in
children
heart catheterization. An appraisal of techniques and their apphcations in cardiovascular diagnosis, Arch. Intern. Med. 105:645, 1960. Bjork, V. O., Malmstrom, G., and Uggla, L. C : Left auricular pressure measurements in man, Ann. Surg. 138:718, 1953. Radner, S.: Extended suprasternal puncture technique. Acta Med. Scand. 151:223, 1955. Fisher, D. L.: The use of pressure recordings obtained at transthoracic left heart catheterization in the diagnosis of valvular heart disease, J. Thorac. Surg. 30:379, 1955. Brock, R., Milstein, B. B., and Ross, D. N.: Percutaneous left ventricular puncture in the assessment of aortic stenosis, Thorax 11:163, 1956. Levy, M. J., and Lillehei, C. W.: Percutaneous direct cardiac catheterization. A new method, with results in 122 patients, N. Engl. J. Med. 271:273, 1964. Ross, J., Jr.: Transseptal left heart catheterization. A new method of left atrial puncture, Ann. Surg. 149:395, 1959. Ross, J., Jr., Braunwald, E., and Morrow, A. G.: Transseptal left atrial puncture. Am. J. Cardiol. 31:653, 1959. Cope, C : Technique for transseptal catheterization of the left atrium. Preliminary report, J. Thorac. Surg. 37:482, 1959. Nixon, P. G. F., and Ikram, H.: Left heart catheterization with special reference to the transseptal method, Br. Heart J. 28:835, 1966. Roveti, G. C , Ross, R. S., and Bahnson, H. T.: Transseptal left heart catheterization in the pediatric age group, J. Pediatr. 61:855, 1962. Brockenbrough, E. C , Braunwald, E., and Ross, J., Jr.: Transseptal left heart catheterization, a review of 450 studies and description of an improved technic, Circulation 25:15, 1962. Vlad, P., Hohn, A., and Lambert, E. C : Retrograde arterial catheterization of the left heart. Experience with 500 infants and children. Circulation 29:787, 1964. Shirey, E. K., and Sones, F. M., Jr.: Retrograde transaortic and mitral valve catheterization. Am. J. Cardiol. 18:745, 1966. Zimmerman, H. A., Scott, R. W., and Becker, N. O.: Catheterization of the left side of the heart in man. Circulation 5:357, 1950. Hellems, H. K., Haynes, F. W., Dexter, L., and Kinney, I. D.: Pulmonary capillary pressure in animals estimated by venous and arterial catheterization. Am. J. Physiol. 155:98, 1948. Mullins, C. E., Neches, W. H., Reitman, M. J., El-Said, G., and Riopel, D. A.: Retrograde technique for catheterization of the pulmonary artery in transposition of the great arteries with ventricular septal defect. Am. J. Cardiol. 30:385, 1972. Macartney, F. J., Scott, 0., Deverall, P. B., and Hepburn, F.: New preformed catheter for entry into the pulmonary artery in complete transposition of great arteries, Br. Heart J. 37:525, 1975. Macartney, F. J., Partridge, J. B., Scott, O., and Deverall, P. B.: Common or single ventricle. An angiocardiographic and hemodynamic study of 42 patients. Circulation 53:543, 1976.
335