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Simultaneous recording of oscillographic and radiologic events on cine film
New Methods Simultaneous Recording of Oscillographic and Radiologic Events on Cine Film Applications
of the Cmetrace
During Cardiac Catheterization*
S DAVID ROCKOFF, M D , EUGENE BRAUN~YALD, M D , F 4 c c , JOHN Ross, JR , II PETER L FROMMLR, M D , DEAN T MASON, u D and JAMES H GUJLT, M D Bethesda,
D ,
Maryland
right lower quadrant of the film, where it occupies one-ninth of the area of the 35 mm cme film The termmal portions of each oscllloscop~ trace lme correspond m time to the radlologlc data on the same cme frame The x-ray eqmpment consists of a Westinghouse 9-mch Televex Image Orthlcon System A 35 mm Photomechamsms camera unit IS employed, which 1s capable of recording cme film at 7 5, 15, 30 or 60 frames/set , televlslon monitors permit vlewmg of the fluoroscoplc Image during cme recording The use of a densttometer, which records the light from the output phosphor and IS an mtrmslc part of the Televex system, allows the cme exposures to be made directly without prehmmary scout studies Thejiberopttc catheter system which was employed as a catheter-tip oxlmeter m conJunction with the Cmetrace has been described m greater detail elsewhere 2 In brief, a light beam IS transmltted through one bundle of glass fibers and 1s reflected bv the red blood cells onto a second bundle which carnes It to the The spectral dlstlloutlon of this light 1s detector dependent on the 02 saturation of the hemoglobm _4fter passage through a light chopper and appropriate filters, the light lmpmges on a phototube, and the final output of the instrument 13 a lineal function of O1 saturation RESULTS AND DISCUSSION The Cmetrace has been employed during cardiac catheterization m more than 200 paThe precise temporal correlation betlents tween events recorded radlologlcally and osclllographlcally has proved to be quite helpful m a variety of clinical circumstances
URING the past two decades thele has been steady improvement in the mstrumentatlon for recordmg mformatlon obtained at cardiac catheterization With the development of effective methods for image mtenslficatlon, the Improved fluoroscoplc image greatly facilitated catheter marnpulatlon, and cmeradlography and cmeangmcardlography became practical clmlcal technics Concurrently, the perfectlon of catheter-tip manometers and catheter-tip microphones and oxlmeters has expanded and refined the data that can be recorded oscdlographlcally It has not been convenient, however, to make precise temporal correlations between the radlographlc image recorded on the cme film, and data displayed osclllographically such as the electrocardiogram and The present the intracardiac pressure pulses report describes the apphcatlons of a new device, termed the Cmetrace, which permits the simultaneous recording of osclllographlc and McIntosh et al l radlologlc data on cme film have recently described some of the technical features of this instrument
D
METHOD The Ctnetrace (Electromcs for Medlcme) IS designed to superimpose the data displayed on a cathode-ray This 1s oscilloscope on one corner of the cme film accomphshed by means of a slave momtor which has an independent sweep and projects the osclllo~~opl~ signals through the back of any standard type of cme film The camera magazme IS modified so that the slave momtor Image, which flashes on and off m synchrony with the frame rate, IS proJected onto the
LOCAL124TION OF OBSTRUCTION Left Ventrdar OutJow Obstruction obstruction to blood flow may be
* From the Dlagnostlc X-ray Department, Clmlcal Center, Natlonal Institutes of Health, and Branch, Natlonal Heart Institute, Bethesda, Md 708
THE
AMERICAN
JOURNAL
the
Areas of locahzed Cardiology
OF C4RDlOLOGY
Applications
70’1
of the Cinetrace
FIG. 1.
CiuPjlms exfxmd in n patientwith congenital aol-tic ualvular stenosis showing position of the catheter tip, the simultaneously rrcorded electrocardiogram and pressure pulse from the catheter tip as it was withdrawn from the left ventricular outflow rract i .\) into the aorta iust above the stenotic aortic valve (B). This and all other figurrs have been retouched for qreatcr clarity.
the catheter across the obprecisely 1,~ moving struction and recording the position of the catheter tip at the instant of pressure change. Figure 1 delineates the position of the aortic valve in a 15 year old patient with congenital aortic stenosis. A left ventricular pressure pulse was being recorded from the catheter tip, which was located quite high in the cardiac silhouette (Fig. 1A). However, when the catheter was withdrawn 1.5 cm., its tip passed across the aortic valve into the ascending aorta, as is clearly evident in the aortic pressure pulse recorded for one and a half cardiac cycles in Figure 1B. A peak systolic pressure gradient of 35 mm. Hg across the valve was present. In contrast, Figure 2 shows three separate frames of the cineradiogram of a patient with idiopathic hypertrophic subaortic stenosis. In panel A the tip of the catheter was positioned low in the left ventricular cavity and recorded a peak systolic pressure of 165 mm. Hg. The catheter was then gradually withdrawn, and panel B shows its position at the instant of the first cardiac cycle after its tip had crossed the obstruction. It is of interest that the tip of the catheter was still relatively low in the cardiac The relative positions of the intrasilhouette. ventricular obstruction and the aortic valve are made clear by comparing panels B and C. The latter frame was exposed after the catheter had been withdrawn another 3 cm. and its tip had just crossed the aortic valve, shown by the single aortic pressure pulse on the Cinetrace. VOLUME
16,
NOVEMBER
1965
The positions of these two types of obstruction to left ventricular outflow could be determined and recorded precisely by the Cinetrace, reducing the need for additional angiocardiographic examinations. The Right Ventricular OutJow Obstruction: usefulness of the Cinetrace in locating the obstruction to right ventricular outflow in 2 patients is illustrated in Figures 3 and 4. The position of the stenotic area in a patient with valvular pulmonic stenosis is clearly shown in Figure 3. Panel A shows the tip of the catheter while a pulmonary artery pressure of 10/3 mm. Hg was recorded from it; and panel B, recorded after the catheter had been withdrawn 2 cm., clearly shows the position of the catheter tip during the first ventricular systole after it had traversed the stenotic valve and recorded a peak systolic ventricular pressure of 90 mm. Hg. In another patient the tip of the catheter lay just within the cardiac silhouette in the ventricle, and a peak ventricular systolic pressure of 30 mm. Hg was recorded from it (Fig. 4A). Upon withdrawal of the catheter tip into the body of the right ventricle (Fig. 4B), the systolic pressure suddenly increased to 85 mm. Hg, revealing the exact position of a subvalvular obstruction. The Cinetrace has also been employed in a similar manner for delineating the sites of supravalvular aortic and pulmonic obstructions. LOCALIZATION
Patent
OF SITES
Foramen
OF CIRCULATORY
Ovale:
Recently,
the
SHUNTS
Cine-
Rockoff et al.
trace has been employed in conjunction with a and an fiberoptic catheter tip oximeter,2 example of how these systems can be used to relate the position of the catheter tip to the instantaneous intracardiac 02 saturation is shown in Figure 5. In this patient with a patent foramen ovale, the tip of the fiberoptic catheter was manipulated into the left atrium, from which an 02 saturation of 98 per cent was the catheter was then recorded (Fig. 5A); withdrawn so that its tip lay within the right atrium (Fig. 5B). The saturation of the blood had fallen to 60 per cent within this chamber. Left to Right Cardiac Shunt: The usefulness of combining the fiberoptic catheter with the Cinetrace in locating a left to right cardiac shunt is demonstrated in Figure 6. In this
patient, anomalous pulmonary venous drainage was not suspected until the relation between the 02 saturation and the position of the fiberoptic In panel A the cathcatheter was determined. eter tip is in the right innominate vein, in which Panel B is the 0s saturation was 63 per cent. a frame exposed four cardiac cycles later, when the catheter tip had been withdrawn to the junction of the two innominate veins. The 02 saturation was then 75 per cent as a result of the admixture of oxygenated blood from the pulmonary vein which drained into the left innominate vein. The catheter was withdrawn further, and the 02 saturation declined when it reached the right atrium (Fig. 6C) due to the mixture of unoxygenated blood from the inferior vena cava. THE AMERICAN
JOURNAL
OF
CARDIOLOGY
Applications
FIG. 3.
Cinejlms
711
of the Cinetrace
in a patient with congenital ~ralvularpulmonic stenosis showing the position of the catheter
in th? main pulmonary
artery (A), and just proximal
to the stenotic pulmonic
FIG. 4. Cinefilms in apatient with congenital infundibularpulmonic stenosis showing the Cinetrace recording of the catheter tip when it was in the right ventricular outflow tract distal to the area of obstruction right ventricular cavity proximal to the obstruction (B).
STUDY
OF
THE
AND HEART
ORIGIN
OF INTRACARDIAC
MURMURS
SOUNDS
Murmurs: The Cinetrace has been found particularly helpful in locating the position of intracardiac murmurs. Figure 7 shows a introduced in a retrograde phonocatheter, manner into the left ventricle of a patient with idiopathic hypertrophic subaortic stenosis ; the electrocardiogram, brachial artery pressure, and the intracardiac sound were recorded by VOLUME
16,
NOVEMBER
1965
tip when it was
valve (B).
and the position (,.I). and in the
the Cinetrace. As the catheter was gradually withdrawn it traversed a point, deep within the left ventricular cavity, at which the systolic murmur reached maximal intensity. By superimposing this point onto the left ventricular angiocardiogram, it was possible to show that the murmur originated near the lower end of the hypertrophic obstruction in the left ventricular outflow tract. Heart Sounds: The application of the Cine-
712
Rockoff
et al.
FIG. 5. Cinefilms in a patient with a patent foramen ouale showing the position of the tip of the fiberoptic catheter during recording of oxygen saturation (top line on the Cinetrace). A saturation of 98 per cent was recorded in the left atrium (A), and it dropped to 60 per cent when the catheter crossed the septum into the right atrium (B). The brachial arterial pressure pulse is also recorded on the Cinetrace.
FIG. 6. Cine jilms in a patient with a pulmonary vein draining into the left innominate zxin. On the Cinetrace are shown the 02 saturation determined with the fiberoptic catheter (center tracing), the electrocardiogram (top tracing), and the brachial arterial pressure pulse (bottom tracing). A, fiberoptic catheter in right innominate vein. B, catheter tip at junction of right and left innominate veins. C, catheter tip near top of right atrium.
THE
AMERICAN
JOURNAL
OF
CARDIOLOGY
Applications trace in elucidating the origin of heart sounds is illustrated in Figure 8, which shows a series of tine films in a patient with rheumatic heart disease and atria1 fibrillation in whom both the mitral and aortic valves had been replaced with Starr-Edwards prostheses. An external phonocardiogram and the electrocardiogram were recorded on the Cinetrace, together with the left ventricular and brachial arterial pressure pulses. Panel A, recorded during diastole, shows the aortic valve seated in the closed position, while the mitral valve was open. Panel B is a frame exposed toward the completion of the next QRS complex. The first component of the first heart sound was recorded just as the left ventricular pressiue began to rise and as the mitral ball seated. In panel C, the second component of the first sound was recorded as the left ventricular pressure began to exceed the arterial and the aortic ball impinged upon the top of its cage. Panel D, recorded early in diastole, shows that the aortic ball had begun to descend, and as it seated in the cage (E), the first component of the second heart sound was recorded. Finally, in panel F, the mitral ball has descended to the bottom of its cage and the second component of the second sound is shown to originate from the contact of the ball with the top of its cage. DIAGNOSIS
OF EBSTEIN’S
ANOMALY
The definitive diagnosis of Ebstein’s anomaly of the tricuspid valve is generally established by a combination of electrocardiographic, hemodynamic and angiocardiographic findings. In particular, this diagnosis is strongly suggested when a right atria1 pressure pulse is recorded together with right ventricular endocardial potentials in the region which lies just to the right of the displaced tricuspid valve. The Cinetrace makes it possible to determine precisely the relation between the position of the displaced tricuspid valve and the junction between atria1 and ventricular tissue (Fig. 9). Panel A shows the tip of the catheter in the right ventricular outflow tract, where right ventricular pressure and right ventricular endocardial potentials were being recorded ; panels B and C show the position of the catheter proximal and distal to the change from a right ventricular to a right atria1 pressure pulse; panel D shows the characteristic right atria1 pressure pulseoccurring together with the I ight ventricu1a.r ; panel E shows how far to electrocardiogram the right the ventricular tissue extends. Any VOLUME 16, NOVEMBER 1965
713
of the Cinetrace
FIG. 7. Cine Jilm in a patient with idiopathic lzypertrophic stenoszs showing the position of the intracardiac phonocatheter at the instant was recorded.
at which the ma\-imal murmur
further withdrawal, however, atria1 electrocardiogram (F). OTHER
resulted
in
an
APPLICATIONS
Detachment of Valve Prosthesis: The films and Cinetraces reproduced in Figure 10 were obtained from a patient in whom the acrtic valve had been replaced with a Starr-Edwards prosthesis, but in whom the development of bacterial endocarditis had resulted in loosening the attachments of the prosthesis. Panel A is a frame of the film exposed during diastole, as shown by the electrocardiogram, by the arterial pressure pulse, and the position of the ball. Panel B, exposed during the next ventricular ejection, shows that the entire base of the valve has been swung anterosuperiorly, the force of the systolic .jet displacing the loose prosthesis. The correlation between the arterial pressure pulse recorded on the Cinetrace and the changes in the position of the prosthetic valve facilitated analysis of this unusual fluoroscopic and cineradiographic finding. Interpretatzon of Cineangiocardiograms: The Cinetrace is helpful in the interpretation of cineangiocardiograms. For example, it is well known that alterations in cardiac rhythm may affect the competency of the atrioventricular valves. The Cinetrace makes it possible to determine the exact instant in the cardiac cycle during which the regurgitation takes place, and whether or not it occurs only during ventricular contractions which are not preceded by a normal
Rockoff
et al.
FIG. 8. Cinejlm in a patient with replacement of the aortic and mitral values with Starr-Edwards prostheses showing the origin of the externally recorded heart sounds. A, the aortic valve (A.V.) is closed and the mitral valve (M.V.) is open. P = external microphone. B, the first component of the first heart sound corresponds to the seating of the mitral ball prosthesis. The second component of the first heart sound occurs due to the opening of the aortic prosthesis (C). As diastole begins, the ball of the aortic prosthesis begins to descend (D) and, as it seats, causes the first component of the second heart sound (E). Opening of the mitral valve causes the second component of the second sound (F). E.C.G. = electrocardiogram, P.C.G. = phonocardiogram, Ba.P. = brachial arterial pressure, and L.V.P. = left ventricular pressure.
atria1 systole. In this manner the system permits a meaningful interpretation of the radiologic finding of ventriculo-atria1 regurgitation. The Cinetrace has also been applied in angiocardiographic studies on the volumes of cardiac chambers. It makes possible a precise temporal correlation between the intracardiac pressures In addiand the dimensions of the chamber. tion, the system has greatly faciliated the analysis of changes in ventricular dimensions by means of radiopaque markers sutured to the epicardium at operation3 since the motion of these markers can now be easily related to the
simultaneously occurring dynamic events.
electrical
and
hemo-
CONCLUSIONS The Cinetrace allows an extremely precise temporal correlation between electrocardiographic and hemodynamic events, recorded oscillographically, and the cineradiogram. It is common practice to record an electrocardiogram and an arterial pressure pulse during angiocardiography, since knowledge of the alterations in cardiac rhythm and arterial pressure induced by the injection of the contrast THE
AMERICAN
JOURNAL
OF
CARDIOLOGY
Applications
of the Cinetrace
715
Catheter tip in right vmtrizle iA) and (B). at FIG. 0. Cinr films in n pntirnt rei/h Ehst&n’s anomaly of the t,-icuspid mlw. right atrium (D). at junction of atria1 and ventrirular myocardium displacctl tricuspid val\,e CC:),in “\eiltricularized” I.C.E.C.G. intracardiac rlectrocardiqxn. P = prcssurc. (E). a11d ,\ithin ri,ght atrium proper (F).
Cinp,film in a patient with bacterial endocarditis of a ,fwosthetic aortic oalue, which has caused the valve to become FIG. 10. B, its position during systole, movement of the A, position of the prosthesis during diastole. partially detached. entire \ al\ e having occurred.
substance are often essential to the proper interpretation of the study. It may be difficult, h owever, to correlate a specific film or frame with these simultaneously occurring electroThe cardiographic or hemodynamic events. Cinetrace greatly facilitates this type of analysis during cineangiography, and does not diminish the size or quality of the radiologic image or increase the patient’s radiation exposure. In VOLUME
16,
NOVEMBER
1965
addition, the Cinetrace can also improve diagnostic accuracy when contrast substance is not in,jected by providing a record of the exact sites at which intracardiac or intravascular pressures, oxygen saturations? heart sounds, or electrocardiograms change as the catheter is moved In this within the heart and great vessels. manner the areas within the cardiac silhouette which correspond to the position of the cardiac
716
Rockoff
valves, the sites of entry of left to right shunts, or the locations of obstruction to blood flow can be defined In many instances such records provide sufficient mformatlon to reduce or ehmmate the need for additional anglocardlographlc studies In addltlon, the Cmetrace system also provides a useful method for mstructlon m cardiac catheterlzatlon technics It appears feanble to record both the oscllloscoplc and radiologic images simultaneously on vldeotape, wlthout exposing cme films, and thereby greatly reduce the I adlatlon exposure This approach 1s currently under mvestlgatlon.
et al REFERENCES 1 MCINTOSH, H D, SCHEINER, M L and ~YHALEN, R E A method for recordmg eight physlologlc events on the cmefluorogram Am J Cardwl , 15 668, 1965 2
FROMMER, P L, Ross, J,JR, MASON,D T,GwLT, J H and BRAUNWALD, E Chmcal apphcatlons of an improved, rapidly respondmg fiberoptic catheter Am J Cardtol , 15 672, 1965
3
HARRISON,D C,GOLDBLATT,A ~~~BRAUN~ALD, E Studies on cardiac dlmermons m mtact, unanestheI A description of techniques and wed man 13 448, thew vahdatlon Cwculatton Res , 1963
THF, AMERICANJOURNALOF
CARDIOLOGY
of the Cmetrace
During Cardiac Catheterization*
S DAVID ROCKOFF, M D , EUGENE BRAUN~YALD, M D , F 4 c c , JOHN Ross, JR , II PETER L FROMMLR, M D , DEAN T MASON, u D and JAMES H GUJLT, M D Bethesda,
D ,
Maryland
right lower quadrant of the film, where it occupies one-ninth of the area of the 35 mm cme film The termmal portions of each oscllloscop~ trace lme correspond m time to the radlologlc data on the same cme frame The x-ray eqmpment consists of a Westinghouse 9-mch Televex Image Orthlcon System A 35 mm Photomechamsms camera unit IS employed, which 1s capable of recording cme film at 7 5, 15, 30 or 60 frames/set , televlslon monitors permit vlewmg of the fluoroscoplc Image during cme recording The use of a densttometer, which records the light from the output phosphor and IS an mtrmslc part of the Televex system, allows the cme exposures to be made directly without prehmmary scout studies Thejiberopttc catheter system which was employed as a catheter-tip oxlmeter m conJunction with the Cmetrace has been described m greater detail elsewhere 2 In brief, a light beam IS transmltted through one bundle of glass fibers and 1s reflected bv the red blood cells onto a second bundle which carnes It to the The spectral dlstlloutlon of this light 1s detector dependent on the 02 saturation of the hemoglobm _4fter passage through a light chopper and appropriate filters, the light lmpmges on a phototube, and the final output of the instrument 13 a lineal function of O1 saturation RESULTS AND DISCUSSION The Cmetrace has been employed during cardiac catheterization m more than 200 paThe precise temporal correlation betlents tween events recorded radlologlcally and osclllographlcally has proved to be quite helpful m a variety of clinical circumstances
URING the past two decades thele has been steady improvement in the mstrumentatlon for recordmg mformatlon obtained at cardiac catheterization With the development of effective methods for image mtenslficatlon, the Improved fluoroscoplc image greatly facilitated catheter marnpulatlon, and cmeradlography and cmeangmcardlography became practical clmlcal technics Concurrently, the perfectlon of catheter-tip manometers and catheter-tip microphones and oxlmeters has expanded and refined the data that can be recorded oscdlographlcally It has not been convenient, however, to make precise temporal correlations between the radlographlc image recorded on the cme film, and data displayed osclllographically such as the electrocardiogram and The present the intracardiac pressure pulses report describes the apphcatlons of a new device, termed the Cmetrace, which permits the simultaneous recording of osclllographlc and McIntosh et al l radlologlc data on cme film have recently described some of the technical features of this instrument
D
METHOD The Ctnetrace (Electromcs for Medlcme) IS designed to superimpose the data displayed on a cathode-ray This 1s oscilloscope on one corner of the cme film accomphshed by means of a slave momtor which has an independent sweep and projects the osclllo~~opl~ signals through the back of any standard type of cme film The camera magazme IS modified so that the slave momtor Image, which flashes on and off m synchrony with the frame rate, IS proJected onto the
LOCAL124TION OF OBSTRUCTION Left Ventrdar OutJow Obstruction obstruction to blood flow may be
* From the Dlagnostlc X-ray Department, Clmlcal Center, Natlonal Institutes of Health, and Branch, Natlonal Heart Institute, Bethesda, Md 708
THE
AMERICAN
JOURNAL
the
Areas of locahzed Cardiology
OF C4RDlOLOGY
Applications
70’1
of the Cinetrace
FIG. 1.
CiuPjlms exfxmd in n patientwith congenital aol-tic ualvular stenosis showing position of the catheter tip, the simultaneously rrcorded electrocardiogram and pressure pulse from the catheter tip as it was withdrawn from the left ventricular outflow rract i .\) into the aorta iust above the stenotic aortic valve (B). This and all other figurrs have been retouched for qreatcr clarity.
the catheter across the obprecisely 1,~ moving struction and recording the position of the catheter tip at the instant of pressure change. Figure 1 delineates the position of the aortic valve in a 15 year old patient with congenital aortic stenosis. A left ventricular pressure pulse was being recorded from the catheter tip, which was located quite high in the cardiac silhouette (Fig. 1A). However, when the catheter was withdrawn 1.5 cm., its tip passed across the aortic valve into the ascending aorta, as is clearly evident in the aortic pressure pulse recorded for one and a half cardiac cycles in Figure 1B. A peak systolic pressure gradient of 35 mm. Hg across the valve was present. In contrast, Figure 2 shows three separate frames of the cineradiogram of a patient with idiopathic hypertrophic subaortic stenosis. In panel A the tip of the catheter was positioned low in the left ventricular cavity and recorded a peak systolic pressure of 165 mm. Hg. The catheter was then gradually withdrawn, and panel B shows its position at the instant of the first cardiac cycle after its tip had crossed the obstruction. It is of interest that the tip of the catheter was still relatively low in the cardiac The relative positions of the intrasilhouette. ventricular obstruction and the aortic valve are made clear by comparing panels B and C. The latter frame was exposed after the catheter had been withdrawn another 3 cm. and its tip had just crossed the aortic valve, shown by the single aortic pressure pulse on the Cinetrace. VOLUME
16,
NOVEMBER
1965
The positions of these two types of obstruction to left ventricular outflow could be determined and recorded precisely by the Cinetrace, reducing the need for additional angiocardiographic examinations. The Right Ventricular OutJow Obstruction: usefulness of the Cinetrace in locating the obstruction to right ventricular outflow in 2 patients is illustrated in Figures 3 and 4. The position of the stenotic area in a patient with valvular pulmonic stenosis is clearly shown in Figure 3. Panel A shows the tip of the catheter while a pulmonary artery pressure of 10/3 mm. Hg was recorded from it; and panel B, recorded after the catheter had been withdrawn 2 cm., clearly shows the position of the catheter tip during the first ventricular systole after it had traversed the stenotic valve and recorded a peak systolic ventricular pressure of 90 mm. Hg. In another patient the tip of the catheter lay just within the cardiac silhouette in the ventricle, and a peak ventricular systolic pressure of 30 mm. Hg was recorded from it (Fig. 4A). Upon withdrawal of the catheter tip into the body of the right ventricle (Fig. 4B), the systolic pressure suddenly increased to 85 mm. Hg, revealing the exact position of a subvalvular obstruction. The Cinetrace has also been employed in a similar manner for delineating the sites of supravalvular aortic and pulmonic obstructions. LOCALIZATION
Patent
OF SITES
Foramen
OF CIRCULATORY
Ovale:
Recently,
the
SHUNTS
Cine-
Rockoff et al.
trace has been employed in conjunction with a and an fiberoptic catheter tip oximeter,2 example of how these systems can be used to relate the position of the catheter tip to the instantaneous intracardiac 02 saturation is shown in Figure 5. In this patient with a patent foramen ovale, the tip of the fiberoptic catheter was manipulated into the left atrium, from which an 02 saturation of 98 per cent was the catheter was then recorded (Fig. 5A); withdrawn so that its tip lay within the right atrium (Fig. 5B). The saturation of the blood had fallen to 60 per cent within this chamber. Left to Right Cardiac Shunt: The usefulness of combining the fiberoptic catheter with the Cinetrace in locating a left to right cardiac shunt is demonstrated in Figure 6. In this
patient, anomalous pulmonary venous drainage was not suspected until the relation between the 02 saturation and the position of the fiberoptic In panel A the cathcatheter was determined. eter tip is in the right innominate vein, in which Panel B is the 0s saturation was 63 per cent. a frame exposed four cardiac cycles later, when the catheter tip had been withdrawn to the junction of the two innominate veins. The 02 saturation was then 75 per cent as a result of the admixture of oxygenated blood from the pulmonary vein which drained into the left innominate vein. The catheter was withdrawn further, and the 02 saturation declined when it reached the right atrium (Fig. 6C) due to the mixture of unoxygenated blood from the inferior vena cava. THE AMERICAN
JOURNAL
OF
CARDIOLOGY
Applications
FIG. 3.
Cinejlms
711
of the Cinetrace
in a patient with congenital ~ralvularpulmonic stenosis showing the position of the catheter
in th? main pulmonary
artery (A), and just proximal
to the stenotic pulmonic
FIG. 4. Cinefilms in apatient with congenital infundibularpulmonic stenosis showing the Cinetrace recording of the catheter tip when it was in the right ventricular outflow tract distal to the area of obstruction right ventricular cavity proximal to the obstruction (B).
STUDY
OF
THE
AND HEART
ORIGIN
OF INTRACARDIAC
MURMURS
SOUNDS
Murmurs: The Cinetrace has been found particularly helpful in locating the position of intracardiac murmurs. Figure 7 shows a introduced in a retrograde phonocatheter, manner into the left ventricle of a patient with idiopathic hypertrophic subaortic stenosis ; the electrocardiogram, brachial artery pressure, and the intracardiac sound were recorded by VOLUME
16,
NOVEMBER
1965
tip when it was
valve (B).
and the position (,.I). and in the
the Cinetrace. As the catheter was gradually withdrawn it traversed a point, deep within the left ventricular cavity, at which the systolic murmur reached maximal intensity. By superimposing this point onto the left ventricular angiocardiogram, it was possible to show that the murmur originated near the lower end of the hypertrophic obstruction in the left ventricular outflow tract. Heart Sounds: The application of the Cine-
712
Rockoff
et al.
FIG. 5. Cinefilms in a patient with a patent foramen ouale showing the position of the tip of the fiberoptic catheter during recording of oxygen saturation (top line on the Cinetrace). A saturation of 98 per cent was recorded in the left atrium (A), and it dropped to 60 per cent when the catheter crossed the septum into the right atrium (B). The brachial arterial pressure pulse is also recorded on the Cinetrace.
FIG. 6. Cine jilms in a patient with a pulmonary vein draining into the left innominate zxin. On the Cinetrace are shown the 02 saturation determined with the fiberoptic catheter (center tracing), the electrocardiogram (top tracing), and the brachial arterial pressure pulse (bottom tracing). A, fiberoptic catheter in right innominate vein. B, catheter tip at junction of right and left innominate veins. C, catheter tip near top of right atrium.
THE
AMERICAN
JOURNAL
OF
CARDIOLOGY
Applications trace in elucidating the origin of heart sounds is illustrated in Figure 8, which shows a series of tine films in a patient with rheumatic heart disease and atria1 fibrillation in whom both the mitral and aortic valves had been replaced with Starr-Edwards prostheses. An external phonocardiogram and the electrocardiogram were recorded on the Cinetrace, together with the left ventricular and brachial arterial pressure pulses. Panel A, recorded during diastole, shows the aortic valve seated in the closed position, while the mitral valve was open. Panel B is a frame exposed toward the completion of the next QRS complex. The first component of the first heart sound was recorded just as the left ventricular pressiue began to rise and as the mitral ball seated. In panel C, the second component of the first sound was recorded as the left ventricular pressure began to exceed the arterial and the aortic ball impinged upon the top of its cage. Panel D, recorded early in diastole, shows that the aortic ball had begun to descend, and as it seated in the cage (E), the first component of the second heart sound was recorded. Finally, in panel F, the mitral ball has descended to the bottom of its cage and the second component of the second sound is shown to originate from the contact of the ball with the top of its cage. DIAGNOSIS
OF EBSTEIN’S
ANOMALY
The definitive diagnosis of Ebstein’s anomaly of the tricuspid valve is generally established by a combination of electrocardiographic, hemodynamic and angiocardiographic findings. In particular, this diagnosis is strongly suggested when a right atria1 pressure pulse is recorded together with right ventricular endocardial potentials in the region which lies just to the right of the displaced tricuspid valve. The Cinetrace makes it possible to determine precisely the relation between the position of the displaced tricuspid valve and the junction between atria1 and ventricular tissue (Fig. 9). Panel A shows the tip of the catheter in the right ventricular outflow tract, where right ventricular pressure and right ventricular endocardial potentials were being recorded ; panels B and C show the position of the catheter proximal and distal to the change from a right ventricular to a right atria1 pressure pulse; panel D shows the characteristic right atria1 pressure pulseoccurring together with the I ight ventricu1a.r ; panel E shows how far to electrocardiogram the right the ventricular tissue extends. Any VOLUME 16, NOVEMBER 1965
713
of the Cinetrace
FIG. 7. Cine Jilm in a patient with idiopathic lzypertrophic stenoszs showing the position of the intracardiac phonocatheter at the instant was recorded.
at which the ma\-imal murmur
further withdrawal, however, atria1 electrocardiogram (F). OTHER
resulted
in
an
APPLICATIONS
Detachment of Valve Prosthesis: The films and Cinetraces reproduced in Figure 10 were obtained from a patient in whom the acrtic valve had been replaced with a Starr-Edwards prosthesis, but in whom the development of bacterial endocarditis had resulted in loosening the attachments of the prosthesis. Panel A is a frame of the film exposed during diastole, as shown by the electrocardiogram, by the arterial pressure pulse, and the position of the ball. Panel B, exposed during the next ventricular ejection, shows that the entire base of the valve has been swung anterosuperiorly, the force of the systolic .jet displacing the loose prosthesis. The correlation between the arterial pressure pulse recorded on the Cinetrace and the changes in the position of the prosthetic valve facilitated analysis of this unusual fluoroscopic and cineradiographic finding. Interpretatzon of Cineangiocardiograms: The Cinetrace is helpful in the interpretation of cineangiocardiograms. For example, it is well known that alterations in cardiac rhythm may affect the competency of the atrioventricular valves. The Cinetrace makes it possible to determine the exact instant in the cardiac cycle during which the regurgitation takes place, and whether or not it occurs only during ventricular contractions which are not preceded by a normal
Rockoff
et al.
FIG. 8. Cinejlm in a patient with replacement of the aortic and mitral values with Starr-Edwards prostheses showing the origin of the externally recorded heart sounds. A, the aortic valve (A.V.) is closed and the mitral valve (M.V.) is open. P = external microphone. B, the first component of the first heart sound corresponds to the seating of the mitral ball prosthesis. The second component of the first heart sound occurs due to the opening of the aortic prosthesis (C). As diastole begins, the ball of the aortic prosthesis begins to descend (D) and, as it seats, causes the first component of the second heart sound (E). Opening of the mitral valve causes the second component of the second sound (F). E.C.G. = electrocardiogram, P.C.G. = phonocardiogram, Ba.P. = brachial arterial pressure, and L.V.P. = left ventricular pressure.
atria1 systole. In this manner the system permits a meaningful interpretation of the radiologic finding of ventriculo-atria1 regurgitation. The Cinetrace has also been applied in angiocardiographic studies on the volumes of cardiac chambers. It makes possible a precise temporal correlation between the intracardiac pressures In addiand the dimensions of the chamber. tion, the system has greatly faciliated the analysis of changes in ventricular dimensions by means of radiopaque markers sutured to the epicardium at operation3 since the motion of these markers can now be easily related to the
simultaneously occurring dynamic events.
electrical
and
hemo-
CONCLUSIONS The Cinetrace allows an extremely precise temporal correlation between electrocardiographic and hemodynamic events, recorded oscillographically, and the cineradiogram. It is common practice to record an electrocardiogram and an arterial pressure pulse during angiocardiography, since knowledge of the alterations in cardiac rhythm and arterial pressure induced by the injection of the contrast THE
AMERICAN
JOURNAL
OF
CARDIOLOGY
Applications
of the Cinetrace
715
Catheter tip in right vmtrizle iA) and (B). at FIG. 0. Cinr films in n pntirnt rei/h Ehst&n’s anomaly of the t,-icuspid mlw. right atrium (D). at junction of atria1 and ventrirular myocardium displacctl tricuspid val\,e CC:),in “\eiltricularized” I.C.E.C.G. intracardiac rlectrocardiqxn. P = prcssurc. (E). a11d ,\ithin ri,ght atrium proper (F).
Cinp,film in a patient with bacterial endocarditis of a ,fwosthetic aortic oalue, which has caused the valve to become FIG. 10. B, its position during systole, movement of the A, position of the prosthesis during diastole. partially detached. entire \ al\ e having occurred.
substance are often essential to the proper interpretation of the study. It may be difficult, h owever, to correlate a specific film or frame with these simultaneously occurring electroThe cardiographic or hemodynamic events. Cinetrace greatly facilitates this type of analysis during cineangiography, and does not diminish the size or quality of the radiologic image or increase the patient’s radiation exposure. In VOLUME
16,
NOVEMBER
1965
addition, the Cinetrace can also improve diagnostic accuracy when contrast substance is not in,jected by providing a record of the exact sites at which intracardiac or intravascular pressures, oxygen saturations? heart sounds, or electrocardiograms change as the catheter is moved In this within the heart and great vessels. manner the areas within the cardiac silhouette which correspond to the position of the cardiac
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valves, the sites of entry of left to right shunts, or the locations of obstruction to blood flow can be defined In many instances such records provide sufficient mformatlon to reduce or ehmmate the need for additional anglocardlographlc studies In addltlon, the Cmetrace system also provides a useful method for mstructlon m cardiac catheterlzatlon technics It appears feanble to record both the oscllloscoplc and radiologic images simultaneously on vldeotape, wlthout exposing cme films, and thereby greatly reduce the I adlatlon exposure This approach 1s currently under mvestlgatlon.
et al REFERENCES 1 MCINTOSH, H D, SCHEINER, M L and ~YHALEN, R E A method for recordmg eight physlologlc events on the cmefluorogram Am J Cardwl , 15 668, 1965 2
FROMMER, P L, Ross, J,JR, MASON,D T,GwLT, J H and BRAUNWALD, E Chmcal apphcatlons of an improved, rapidly respondmg fiberoptic catheter Am J Cardtol , 15 672, 1965
3
HARRISON,D C,GOLDBLATT,A ~~~BRAUN~ALD, E Studies on cardiac dlmermons m mtact, unanestheI A description of techniques and wed man 13 448, thew vahdatlon Cwculatton Res , 1963
THF, AMERICANJOURNALOF
CARDIOLOGY