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The diagnosis of mitral insufficiency
THE
DIAGNOSIS
OF MITRAL
INSUFFICIENCE
\'IKING 0~07~ BJORK, M.D., SVEN ROLAND KJELLRERG, GWNNAR MALMSTR~M. M.D., AND ULF RuDHE,M.D.
M. .D.,
STOCKHOLM,SWEDEN
T
HE diagnosis of mitral insufficiency remains a difficult clinical problem in many patients. As surgery so far has very little to offer these cases, ever! effort should be made to achieve a correct preoperative diagnosis.
The and the pressure perform order to
left-heart catheterization with pressure measurement in the left atriurn left ventricule has opened new diagnostic possibilities. When the curve from the left atrium suggests a significant regurgitation, we can a selective angiocardiography through the needle in the left atrium in visualize the’mitral valves. METHOD
of a needle The technique has been described earlier’,? for the introduction of 1.0 mm. inner diameter (Stille, Stockholm) paravertebrally above the posterior end of the right ninth rib and then into the left atrium. ,4 fine plastic catheter of 0.5 mm. inner diameter is then introduced through the needle into the ventricle and out into the aorta. Pressure measurements are then made, while the catheter is slowlyL withdrawn from the aorta via the left ventricle to the left atrium. A WarburgLHansen capacitance manometer is used. Then the contrast medium is injected through the needle into the left atrium. The injection of 50 to 70 ml. contrast medium has in all cases been performed with an automatic pressure syringe (Gidlundj in 1 to 2 seconds. Due to the oblique position of the atrioventricular plane the patient is investigated in the right oblique position with the central beam directed 20 degrees toward th(s head of the patient. RESULTS The results obtained will be illustrated by the following case. ,4 25year-old woman had acute rheumatic fever in 1948. In 1953, she began to complain about precordial pain. There wasa harsh systolic murmur audible over the whole heart. A short diastolic murmur was heard over the apex. X-ray investigation showed an enlarged left atrium. The heart was slightly enlarged. Received
for publication
Nov.
30, 1954. 719
720
AMERICAN
HEART
JOURNAL
All VA1 ste
Vig. 2.--A, Angiocardiogram during ventricular systole with contrast injection ia the left atri urn. incomplete closure of the mitral leaflets is observed. B. Angiocardiogram during disstole 1vith ltrast injection in the left atrium. The posterior leaflet (lower arror) is now visible close to the ltrlcular wall. The anterior mitral leal?et (upper arrow) has only slightly changed its position. No nosis of the mitral orifice was thus found.
722
AMERICAN
HEART
JOURNAL
Electrocardi820 ml. corresponding to 520 ml. per square meter body surface. ography was normal with sinus rhythm. Electrokymography suggested mitral stenosis without signs of mitral insufficiency. Her working capacity was 500 kgm./min. The mean pressure in the pulmonary artery was 19 mm. Hg at rest and 2.5 mm. Hg during exercise. The mean pressure in the left atrium was increased, 11 mm. Hg. The contour of the left atria1 pressure curve was typical for a dominating mitra1 insufficiency with a high pressure peak at the second heart sound, Fig. 1. Selective angiocardiography through the needle in the left atrium was performed, Fig. 2,. A and B. The valvular plane is clearly outlined during ventricular systole (Fig. 2, A). The valves are sharply outlined against the left atrium except in the central portion where a funnel-shaped extension of contrast medium into the left ventricle demonstrates a defective closure of the valves. During diastole, Fig. 2, B, the posterior mitral leaflet is visible close to the ventricular wall (lower arrow) while the anterior mitral leaflet (upper arrow) has changed its position only slightly. Thus no stenosis of the mitral orifice was found. There was a regurgitation of contrast medium to the pulmonary veins from the enlarged left atrium. DISCUSSION
Angiocardiography with injection of contrast medium through a catheter in the pulmonary artery will clearly outline the left atria1 wall permitting the diagnosis of a mural thrombus or an intra-atria1 myxoma. To visualize the mitral leaflets clearly enough for the diagnosis of a mitral insufficiency a technique has been worked out by which the contrast medium is injected directly into the left atrium through a needle. We have tried the injection of contrast medium into the left ventricle through the plastic catheter. So far we have been without success as in every instance the catheter due to a recoil has been displaced back into the left atrium or into a pulmonary vein. Furthermore, it is necessary to use a larger needle and catheter which we do not recommend as we had to aspirate the pericardium for blood in two cases where this technique was used. So far the patients have had severe reactions after this x-ray and therefore we do not yet recommend it for routine clinical use.
investigation,
SUMMARY
When the clinical findings and the left-heart catheterization suggest a dominating mitral insufficiency we can perform an angiocardiography by injection of contrast medium through the needle into the left atrium in order to visualize the mitral valves. By this method it is possible to prove the diagnosis of a mitral insufficiency and avoid an exploratory cardiotomy.
RJiiRK
ET
AL.
SUMMARIO
:
MITRAL
IN
INSPFFICIENCY
INTERLINCI-X
Quando le constatationes clinic e le catheterisation sinistrocardiac surges v un dominante insufficientia mitral, il es possibile render le valvulas mitral ;lngictrardiographicamente visibile per injicer un substantia de contrasto via le ngull:~ Iste method0 permitte 1~ verification rlcl di;q-ww cltl iti:I in le atrio sinistre. sufficientia mitral sin cardiotomia exploratori.
KEFERENCI-5
1.
Rjiirk,
2.
Bjiirk,
.1.
Rjiirk.
1.. O., Malmstriim, G., and Uggla, L. G.: Left .\urictllar in Man, .Ann. Surg. 138:718, 1953. V. 0.: Direct Pressure Measurement in the Left .\trium. the Aorta, Acta chir. Scandinav. 107:466, 195%. \‘. O., and MalmstrGm, G.: Left Heart Cathrterizat ion, 1951.
Pressure the
Left
(‘irculation
Rleasuremen-s \.cntricle lies.
a.11~1 2:12 1,
DIAGNOSIS
OF MITRAL
INSUFFICIENCE
\'IKING 0~07~ BJORK, M.D., SVEN ROLAND KJELLRERG, GWNNAR MALMSTR~M. M.D., AND ULF RuDHE,M.D.
M. .D.,
STOCKHOLM,SWEDEN
T
HE diagnosis of mitral insufficiency remains a difficult clinical problem in many patients. As surgery so far has very little to offer these cases, ever! effort should be made to achieve a correct preoperative diagnosis.
The and the pressure perform order to
left-heart catheterization with pressure measurement in the left atriurn left ventricule has opened new diagnostic possibilities. When the curve from the left atrium suggests a significant regurgitation, we can a selective angiocardiography through the needle in the left atrium in visualize the’mitral valves. METHOD
of a needle The technique has been described earlier’,? for the introduction of 1.0 mm. inner diameter (Stille, Stockholm) paravertebrally above the posterior end of the right ninth rib and then into the left atrium. ,4 fine plastic catheter of 0.5 mm. inner diameter is then introduced through the needle into the ventricle and out into the aorta. Pressure measurements are then made, while the catheter is slowlyL withdrawn from the aorta via the left ventricle to the left atrium. A WarburgLHansen capacitance manometer is used. Then the contrast medium is injected through the needle into the left atrium. The injection of 50 to 70 ml. contrast medium has in all cases been performed with an automatic pressure syringe (Gidlundj in 1 to 2 seconds. Due to the oblique position of the atrioventricular plane the patient is investigated in the right oblique position with the central beam directed 20 degrees toward th(s head of the patient. RESULTS The results obtained will be illustrated by the following case. ,4 25year-old woman had acute rheumatic fever in 1948. In 1953, she began to complain about precordial pain. There wasa harsh systolic murmur audible over the whole heart. A short diastolic murmur was heard over the apex. X-ray investigation showed an enlarged left atrium. The heart was slightly enlarged. Received
for publication
Nov.
30, 1954. 719
720
AMERICAN
HEART
JOURNAL
All VA1 ste
Vig. 2.--A, Angiocardiogram during ventricular systole with contrast injection ia the left atri urn. incomplete closure of the mitral leaflets is observed. B. Angiocardiogram during disstole 1vith ltrast injection in the left atrium. The posterior leaflet (lower arror) is now visible close to the ltrlcular wall. The anterior mitral leal?et (upper arrow) has only slightly changed its position. No nosis of the mitral orifice was thus found.
722
AMERICAN
HEART
JOURNAL
Electrocardi820 ml. corresponding to 520 ml. per square meter body surface. ography was normal with sinus rhythm. Electrokymography suggested mitral stenosis without signs of mitral insufficiency. Her working capacity was 500 kgm./min. The mean pressure in the pulmonary artery was 19 mm. Hg at rest and 2.5 mm. Hg during exercise. The mean pressure in the left atrium was increased, 11 mm. Hg. The contour of the left atria1 pressure curve was typical for a dominating mitra1 insufficiency with a high pressure peak at the second heart sound, Fig. 1. Selective angiocardiography through the needle in the left atrium was performed, Fig. 2,. A and B. The valvular plane is clearly outlined during ventricular systole (Fig. 2, A). The valves are sharply outlined against the left atrium except in the central portion where a funnel-shaped extension of contrast medium into the left ventricle demonstrates a defective closure of the valves. During diastole, Fig. 2, B, the posterior mitral leaflet is visible close to the ventricular wall (lower arrow) while the anterior mitral leaflet (upper arrow) has changed its position only slightly. Thus no stenosis of the mitral orifice was found. There was a regurgitation of contrast medium to the pulmonary veins from the enlarged left atrium. DISCUSSION
Angiocardiography with injection of contrast medium through a catheter in the pulmonary artery will clearly outline the left atria1 wall permitting the diagnosis of a mural thrombus or an intra-atria1 myxoma. To visualize the mitral leaflets clearly enough for the diagnosis of a mitral insufficiency a technique has been worked out by which the contrast medium is injected directly into the left atrium through a needle. We have tried the injection of contrast medium into the left ventricle through the plastic catheter. So far we have been without success as in every instance the catheter due to a recoil has been displaced back into the left atrium or into a pulmonary vein. Furthermore, it is necessary to use a larger needle and catheter which we do not recommend as we had to aspirate the pericardium for blood in two cases where this technique was used. So far the patients have had severe reactions after this x-ray and therefore we do not yet recommend it for routine clinical use.
investigation,
SUMMARY
When the clinical findings and the left-heart catheterization suggest a dominating mitral insufficiency we can perform an angiocardiography by injection of contrast medium through the needle into the left atrium in order to visualize the mitral valves. By this method it is possible to prove the diagnosis of a mitral insufficiency and avoid an exploratory cardiotomy.
RJiiRK
ET
AL.
SUMMARIO
:
MITRAL
IN
INSPFFICIENCY
INTERLINCI-X
Quando le constatationes clinic e le catheterisation sinistrocardiac surges v un dominante insufficientia mitral, il es possibile render le valvulas mitral ;lngictrardiographicamente visibile per injicer un substantia de contrasto via le ngull:~ Iste method0 permitte 1~ verification rlcl di;q-ww cltl iti:I in le atrio sinistre. sufficientia mitral sin cardiotomia exploratori.
KEFERENCI-5
1.
Rjiirk,
2.
Bjiirk,
.1.
Rjiirk.
1.. O., Malmstriim, G., and Uggla, L. G.: Left .\urictllar in Man, .Ann. Surg. 138:718, 1953. V. 0.: Direct Pressure Measurement in the Left .\trium. the Aorta, Acta chir. Scandinav. 107:466, 195%. \‘. O., and MalmstrGm, G.: Left Heart Cathrterizat ion, 1951.
Pressure the
Left
(‘irculation
Rleasuremen-s \.cntricle lies.
a.11~1 2:12 1,