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The preoperative detection of atrial thrombi by selective left atriography
The preoperative detection of atrial thrombi by selective left atriography Don L. Fisher, M.D.* (by invitation), Lawrence B. Brent, M.D. (by invitation), Edward M. Kent, M.D., and George J. Magovern, M.D., Pittsburgh, Pa.
X_/mbolization from a left atrial thrombus is an important potential hazard of sur gery in mitral stenosis, with sequelae which include death, stroke, saddle embolus, and infarction of viscera. Although embolization may occur at random during the pre- and postoperative periods, during operation it must be attributed to the surgeon's manipu lations. Prophylactic measures have been only partially successful. These measures have included anticoagulant drugs and stabiliza tion of rhythm pre- and postoperatively, cautious cleansing of the left atrial appen dage, and temporary carotid artery occlusion by tourniquet during the closed type of mitral repair, and the temporary insertion of a retaining sponge or sieve below the mitral valve during clot removal, in open mitral repair methods. Improved atrial flow after valve repair is thought to prevent thrombosis, and ligation of the left atrial appendage has been applied prophylactically against thrombosis. In the present study, left atriography by direct injection was used as a primary diag nostic method, aimed toward better underThis study was supported by a grant from the Tri-County Heart Association of Pennsylvania. Read at the Forty-fifth Annual Meeting of The American Association for Thoracic Surgery, New Orleans, La., March 29-31, 1965. •Address: Allegheny General Hospital, 320 E. North Avenue, Pittsburgh 12, Pa.
standing of the embolie hazard, with the hope of preventing more emboli than would be provoked by the test. Methods Left atriography was performed by direct injection during the course of transatrial septal left heart catheterization in 478 pa tients. In 4 additional patients, left atrial needles were placed for similar injection by the posterior percutaneous (transthoracic) method. 1 ' 2 Most of the subjects had been hospitalized for preoperative diagnostic study of chronic rheumatic valvular disease, or for related studies. Preparations for the tests included anticongestive treatment, stabilization of heart rate, and thyroid tests, where indicated. An explanation of the procedure was given to the patient in a confident and reassuring manner. The usual premedication was secobarbital, 0.1 Gm. and promethazine, 25 or 50 mg. orally. Transatrial septal left heart catheteriza tion was performed by a modification3 of the methods of Ross4' 5 · G and Cope.7 After skin puncture with a No. 11 scalpel point, 7 cm. distal to the right inguinal fold, a gauge 16T BD needle, No. T479LNR or No. 01-001,* was inserted cephalad, with en trance of the right femoral vein at a 45 de gree angle. A Seldinger flexible metal leader, •Becton, Dickinson Company, Rutherford, N. J.
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80.5 CM
<=co erfEH
Fig. 1. Instruments for transatrial septal left heart catheterization. A, Blunt stylet for needle. B, Needle, gauge 18T. C, Pre-formed catheter, radiopaque polyethylene (7-9F, 2.3-3.0 mm. outer diameter).
BD No. 01-0017, was inserted,8 and then the needle was replaced by an 8V2-9 Fr., 80 cm., K3, yellow, radiopaque, polyethylene Kifa catheter.* The tip end is tapered and has a pre-formed curve, 2.5 to 5 cm. in radius. An optional catheter is an 8F-radiopaque Teflon, No. LB-8-2.5-80.f After right heart catheterization measurements, a gauge 18T needle, 80.5 cm. long, with curved tip was inserted through the catheter with the help of a blunt stylet (Fig. 1). Starting at the superior vena cava, the needle-catheter assembly is drawn caudalward while the atrial septum is palpated with the tip. Normally, the tip drops into the shallow fossa ovalis about halfway between the superior and the inferior venae cavae (Fig. 2, A ) ; but in mitral valve disease, the septum usually is distended as a convex dome protruding into the right atrium (Fig. 2, B). With the needle point extended be yond the catheter tip and blunt stylet drawn back 12 cm., the assembly is pushed through the atrial septum at a point just caudal to the summit of the dome. The curved needle point is directed posteriorly and to the left. Care is taken not to glide up and over the dome to engage the aorta, which lies cephalad and anteriorly, or the pulmonary ar tery, farther anteriorly. Aneurysmal dilata•Schick X-ray Corp., 205 W. Wacker Drive, Chicago 6, 111. tCook, Inc., 300 South Swain Avenue, Bloomington, Ind.
tion of the aortic base is a special hazard. If the aorta be entered inadvertently, the pericardium must be vented externally to prevent pericardial tamponade, which can be fatal within 10 seconds after withdrawal of the catheter. Once the catheter has entered the left atrium, the blunt stylet is replaced, and the catheter alone is advanced; its pre-formed tip curve aids its insertion through the mitral valve. The blunt stylet-needle assembly may be used for support of the catheter in the maneuvers. An additional reverse curve at the tip of the catheter (shepherd's crook) will aid placement through the mitral valve in difficult cases. From the left ventricle, access to the aorta can be gained by inser tion of a small coaxial catheter (PE50, PE60, or size 4 Fr.) through the larger K3 catheter. A coaxial fitting is used for the dual fluid connection (BD No. 615A) and a wire stylet may support the manipulation ( B D N o . 01-0041). After left heart pressure measurements, the 8 Vi Fr. K3 catheter is withdrawn to the left atrium for left atriography. Twenty-one milliliters of sodium iothalamate (80 per cent)* is injected in IVi seconds or less, with the use of a special hand syringe (BD No. 20SLC) or a powered injector. A single y30 second, posteroanterior view, 10 x 12 »Angioconray, Mallinckrodt Chemical Works, St. Louis, Mo.
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Fig. 2A. Frontal section of normal heart through the right atrium. Transatrial septal passage is made through upper portion of fossa ovale, slightly to the left of the midpoint between su perior and inferior venae cavae. The curved point of the needle is directed diagonally posteriorly and to the left to reach the left atrium, avoiding the aorta and pulmonary artery, which lie cephalad and anteriorly. (Modified from Pernkopf's "Atlas of Topographical and Applied Human Anatomy, Philadelphia, 1964, W. B. Saunders Co.)
inch x-ray, spot film exposure is taken ex actly at the end of injection, with the use of a grid cassette. An additional injection for a right anterior oblique view is usually done (see Fig. 3, G ) . The use of a rapid film changer for multiple films is op tional. Thirty-five millimeter cinecardiographic films9 do not give satisfactory detail for the study of smaller filling defects. The criterion for the diagnosis of a throm bus was the presence of any definite filling defect that was not obviously an artifact. Artifacts may be caused by inflow at a pul monary vein orifice, occlusion or amputa tion of the appendage by previous surgery, inadequate injection of contrast material, or improper timing of film exposure. Mitral stenosis was judged to be present as a predisposing factor when a mean diastolic filling gradient of at least 3 mm. Hg
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Fig. 2B. Interior of right atrium in mitral valve disease shows eversion of fossa ovale. Transatrial septal needle entry to the left atrium is made on the caudalward slope of the dome, avoiding any tendency to glide over the prominence anteriorly and cephalad, into the aorta.
was present, and when the calculated mitral valve area was reduced by at least 25 per cent from the normal. The presence of atrial fibrillation was demonstrated by standard electrocardiographic criteria. Results In the 482 tests, 107 (22 per cent) showed definite filling defects diagnostic of left atrial thrombi (Table I ) . These were found as often in the main chamber as in the appendage alone. In this series of pa tients, thrombi were found only in the pres ence of atrial fibrillation or mitral stenosis, and with greatly increased incidence (48 per cent) when both factors were present (Table I I ) . Only two small thrombi were detected in patients having predominant mitral insufficiency. The diagnosis of thrombi as the true cause of the filling defects on the left atriograms was investigated at surgical operation in 128 cases (Table III). By means of the closed method of mitral valve repair, the
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Table I. Incidence of thrombi in preoperative left atriograms | Number Per cent Total tests Thrombi found (filling defects) Location a. Appendage only b. Main chamber
482 107
100 22
51 56
11 11
Table II. Occurrence of left atrial thrombi in relation to mitral stenosis and atrial fibrillation Num ber
Per cent
128 14
100 11
16 3
100 19
C. Patients with both mitral stenosis and atrial fibrillation Incidence of Thrombi
187 90
100 48
D. Patients with neither mitral ste nosis nor atrial fibrillation Incidence of thrombi
151 0
100 0
A. Patients with mitral stenosis Incidence of thrombi B. Patients with atrial fibrillation Incidence of thrombi
Table III. Surgical treatment of tested patients
Patients without thrombi Patients with thrombi Left atrium, main chamber Left atrial appendage only
Closed mitral valve repair
Openheart mitral repair
66 37 (23) (14)
18 7 (6) (1)
mitral stenosis and atrial fibrillation, a small preoperative thrombus was faintly outlined, within the main chamber and just medial to the appendage. However, it went unno ticed until the patient had hemiplegia during closed mitral valve repair; then a review of the x-ray film disclosed the omission in in terpretation. Another error in interpretation occurred in the first massive thrombus of the series by failure to recognize as a filling defect the lack of the usual rounded borders of the left atrium (for example, compare Figs. 3, A and 3, C ) . Exploration at open-heart mitral repair disclosed the large mural thrombus. Complications of the test series were relatively few. In 1 patient, one of the four left atrial thrombi migrated during the test to occlude the left carotid artery, and the patient later died. In 4 patients, various palsies or paresthesias were transiently noted within 3 hours after the tests, but there was complete recovery. Other episodes in the series, occurring on later days, were not attributed to the test, since the past history in each case revealed previous embolism. In 4 patients, the needle-catheter assembly was inadvertently directed through the right atrial wall and into the pericardium. No complications of such pericardial entry re sulted except in the 1 patient having an elevated right atrial pressure; in this case there was transient hypotension suggesting mild tamponade, and blood-stained peri cardial fluid was found later at elective mitral valve operation. Discussion
presence or absence of appendage thrombi was confirmed in 103 cases, with no dis agreements, but the thrombi detected radiographically in the main chamber could not safely be investigated. At the 25 open re pairs, both locations were explored, with close agreement. Embolization from the left atrium occurred in 3 of the closed and 1 of the open repairs. Initially, errors in film interpretation oc curred. In one 57-year-old patient with
The detailed demonstration of the parent thrombi is an approach to the study of the embolie hazard. However, the thrombi of this study showed surprisingly little tendency to break free, being perforated by needle and catheter in several cases (Figs. 3, A-F), and even tolerated forcible injections through channels in their substance (Figs. 3, A B, and D) without embolism. One such patient (Fig. 3, B), refusing mitral stenosis repair, has been kept on continuous
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Selective left atriography
Fig. 3. Massive left atrial thrombosis. A, Multiple thrombi, confirmed at open heart explora tion. Two thrombi in superior portion, 1 in appendage. B, Massive thrombus occupies superior half of left atrium. The patient refused operation, and has been free of emboli during VA years on oral anticoagulants. Note injection channel.
Fig. 3. Cont'd. C, Massive thrombus occupyies septal half of left atrium. Atrial wall is partially calcified. D, Massive thrombus occupies septal half of left atrium. Arrow indicates tip-end of catheter, with jet extending through a channel of the thrombus. The thrombus was com pletely removed at open repair of mitral valve. No embolism occurred subsequently.
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Fig. 3. Cont'd. E, Thrombus fills large left atrium, except supravalvular portion. Atrial wall is partially calcified. F, Thrombus covers superior and septal walls of the left atrium. Three separate thrombi were removed from the large appendage at closed mitral valve operation. No embolism occurred thereafter.
Fig. 3. Cont'd. G, Right anterior oblique view. Large ball thrombus lies against mitral valve, below appendage. No embolism occurred after thrombus removal and open-heart mitral valve repair. H, Posterior percutaneous (transthoracic) puncture for left atriography in mitral stenosis^ prone position. No thrombi were diagnosed, and none were found at open repair. The left atrium is displaced by severe right atrial enlargement, due to tricuspid stenosis and insufficiency.
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oral anticoagulant treatment for IVi years without embolism. Apparently the thrombi encountered were predominantly organized and well-attached to the atrial wall, rather than "fresh,"10 although one fatal embolus occurred on left atrial catheter insertion. A single, non-fatal cerebral embolus sim ilarly occurred in the series of Criley, Lewis, and Ross9 (109 patients). The well-known association of left atrial thromboembolism with the combined fac tors of mitral stenosis and atrial fibrillation is confirmed by our results (see Table I I ) . Therefore, it is suspected that patients in regular rhythm who have had emboli, also may have undiagnosed bouts of paroxysmal atrial fibrillation (Table I V ) . This diagnosis would probably be confirmed by the study of long-term continuous electrocardiographic tape recordings. The relative stability of most of the thrombi may encourage the use of direct Table IV. The formation and ejection of left atrial
thrombi
A. Probable factors in deposition of left atrial thrombi in mitral stenosis and atrial fibrillation 1. Decreased velocity of blood flow, both mean and maximum, due to a. subnormal cardiac output, in mitral ste nosis, atrial fibrillation; or b. dilatation of left atrium and appendage 2. Decreased emptying of left atrium, due to a. absence of atrial systole in atrial fibrilla tion; or b. dilatation of left atrium and appendage 3. Local injury to left atrial wall, due to a. rheumatic myocarditis b. chronic calcific deposits 4. Possible increased clotting tendencies of the blood due to variations of chemical blood factors B. Probable factors in dislodgement of left atrial thrombi in mitral stenosis and atrial fibrilla tion 1. Abrupt reversal of the above-listed factors for deposition of thrombi, especially rever sion of atrial fibrillation to regular sinus rhythm 2. Surgical manipulations of the left atrium and its appendage, including catheterization maneuvers
left atrial catheterization and atriographic injections,11 rather than the use of pulmo nary artery wedge pressures and pulmo nary artery injections.12' 13 The continued use of closed mitral valve repair may also be considered optional in left atrial throm bosis,14 rather than open repair for a man datory cleansing of the left atrium.15 It remains to be proved whether regression of such organized thrombi occurs with im provement of mitral valve function. A grad ual process of recanalization might be pos sible, without clinical embolization. Conclusions 1. Direct left atriographic injections were made in 482 patients, during the course of transatrial septal left heart catheterization, for the study of left atrial thrombi in rheu matic valve disease. 2. Diagnostic results were accurate, com pared with findings at later surgical ex plorations. Atriographic details may there fore be used reliably to aid in the choice of surgical techniques. 3. Most of the left atrial thrombi seemed to be well attached, organized rather than fresh, but 1 patient died of an embolus to the left carotid artery during the test. Other complications of the series were minor. 4. The advantage of increased diagnostic detail obtained by direct left atrial injec tions probably outweighs the relatively greater safety of distant angiocardiographic injections. REFERENCES 1 Fisher, D. L.: The Use of Pressure Recordings Obtained at Transthoracic Left Heart Cathe terization in the Diagnosis of Valvular Heart Disease, J. THORACIC SURG. 30: 379,
1955.
2 Fisher, D. L.: Catheterization of the Left Heart in Zimmerman, H. A., editor, Intravascular Catheterization, Springfield, 111., 1959, Charles C Thomas, Publisher. 3 Fisher, D. L., Logsdon, G. R., and McCaffrey, M. H.: Use of a Sharp Stylet for Interatrial Septal Passage of the Radiopaque Right Heart Catheter Into the Left Heart, Circulation 22: 4:749, 1960. 4 Ross, J., Ir., Braunwald, E., and Morrow, A. G.: Transseptal Left Atrial Puncture: New
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Technique for the Measurement of Left Atrial Pressure in Man, Am. J. Cardiol. 3: 653, 1959. 5 Ross, J., Jr.: Transseptal Heart Catheterization: A New Method of Left Atrial Puncture, Ann. Surg. 149: 395, 1959. 6 Brockenbrough, E. C , Braunwald, E., and Ross, J.: Transseptal Left Heart Catheterization: A Review of 450 Studies and Description of an Improved Technique, Circulation 25: 15, 1962. 7 Cope, C: Technique for Transseptal Catheterization of the Left Atrium: Preliminary Re port, J. THORACIC SURG. 37: 482,
1959.
8 Seidinger, S. I.: Catheter Replacement of the Needle in Percutaneous Arteriography, Acta Radiol. 39: 368, 1953. 9 Criley, J. M., Lewis, K. B., and Ross, R. S.: Detection of Left Atrial Thrombus by Cineangiocardiography, Circulation 30: 64, 1964 (Suppl. III). 10 Uglov, F. G., and Potashov, L. V.: The Pro phylaxis of Thromboembolic Complications in Surgery for Mitral Stenosis, J. THORACIC & CARDIOVAS. SURG. 44: 408,
1962.
11 Huston, J. H.: Left Atrial Angiocardiography in Left Atrial Thrombosis, Circulation 24: 963, 1961. 12 Soloff, L. A., and Zatuchni, J.: The Angiocardiographic Diagnosis of Left Atrial Throm bosis, Circulation 14: 25, 1956. 13 Ormons, R. S., Drake, E. H., and Gale, H. H.: Angiographie Study of the Left Atrium in Mitral Stenosis, Radiology 83: 277, 1964. 14 Vargas, L. L., and Corvese, W. P.: Occluding Thrombi of the Left Atrium: Report of Four Cases Treated Surgically, Dis. Chest 40: 313321, 1961. 15 Nichols, H. T., Blanco, G., Morse, D. P., Adam, A., and Baltazar, N.: Open Mitral Commissurotomy: Experience With 200 Con secutive Cases, J. A. M. A. 182: 268, 1962.
Discussion DR. OSLER ABBOTT Atlanta
Ca.
This presentation by Dr. Fisher and his group is most interesting and instructive. I rise to bring up two basic points. First, I believe there has been some misunder standing. I know of instances in our own institu tion (and, I gather, in others) in which a pre sumptive diagnosis has been made of left atrial thrombus with extension into pulmonary veins, because of delayed emptying of the pulmonary arterial circulation on one side during a pulmo nary angiogram. We have made a detailed study of pulmonary angiography the past 6 years, per forming 300 or more procedures, many on an experimental basis. Quite a few of the patient
studies were performed prior to and weeks or months after a thoracotomy. We learned from this study that thoracotomy, per se, delays circulation time on the side of the thoracotomy for as long as 4 months or more. In a recent case, left atrial thrombosis was sus pected because of delayed emptying time of the right pulmonary arteries. When we reviewed the findings in light of our above studies, the diag nosis was selective delay of pulmonary blood flow, due to a right thoracotomy 4 months pre viously. Subsequent slow progressive improvement occurred. This would suggest further reason for the application of Dr. Fisher's method. Second, I want to describe two left atrial per forations that have occurred as a result of trans septal catheterization, which is a very low com plication rate considering the frequency of this procedure. These perforations seem to have a predilection for perforating the posterior surface of the left auricle. In both instances, this com plication occurred in patients with high left atrial pressures due to mitral stenosis. Immediate surgi cal management would have required bypass tech niques and transatrial closure of the perforation. Because, in the first instance, of the fact that the pump was not immediately available, we elected to treat the patient by multiple pericardicenteses. The second patient was similarly treated. In the first one, nine pericardicenteses were required in the first 48 hours, and in the second case five. The patients both survived and subsequently had correction of their lesion. I appreciate the fact that the perforations re ported by Dr. Fisher involved the right atrium, and were more easily accessible for repair. It was surprising that left atrial perforations prox imal to mitral valve obstruction would respond to conservative therapy. In the future, we would prefer to manage such a problem by immediate open-heart surgery and concomitant repair of the atrial injury and mitral valve reconstruction or replacement. DR. CONRAD LAM Detroit,
Mich.
Our group would agree with Dr. Fisher that it is wise to find out about the presence of clots in the left atrium before doing a closed commis surotomy. With open commissurotomy, it makes no difference what one finds, and, in the patients, with atrial fibrillation, one would not be surprised to find a clot and would be able to take care of it. We still do some closed commissurotomies, and our policy is to do special studies on every case of atrial fibrillation. Dr. Drake and Dr. Gales used various puncture techniques, first going through the back and later with the Ross needle, and for reasons best known to them, they have abandoned both of these methods, and give us
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our information by routine right heart catheterization and, if indicated, a retrograde left heart catheterization. While they are doing the right side, they in ject dye into the pulmonary artery and get re markably good cine pictures. It is impossible to show without the cine how clearly some of these delineate the left atrium, but I do have a single frame. [Slide] One sees the catheter in the pulmonary artery. We have chosen a frame where recircu lation has taken, showing the pulmonary veins and a large filling defect. [Slide] This slide shows the clots that were removed at operation. This patient might have been accepted for a closed commisurotomy if it had not been for this study. The next point I would like to make is that we would be afraid to carry out manipulations in the presence of thrombosis by a closed tech nique. We think even a small clot in the atrium is very dangerous; and if we have the slightest suspicion that there is a clot anywhere other than in the tip of the appendage, we will plan an open operation. DR. DONALD KAHN Ann Arbor,
Mich,
A history of embolization in patients with mitral stenosis appeared to have little relation ship as to whether clots will be found in the left atrium. It has been our policy to do an "open" operation for pure mitral stenosis if there is a history of emboli. Of 7 patients operated upon with extracorporeal circulation for this reason, only one had clots in the left atrium. During the same period of time, unsuspected atrial clots were found in 15 per cent of the patients having a mitral valvulotomy with the use of the transven-
tricular dilator. These findings suggest that, if the "closed" technique for mitral stenosis is to be used, visualization of the left atrium preoperatively may be worth while. DR. FISHER (Closing) I would like to thank the discussers, Drs. Ab bott, Lam, and Kahn. There are several artifacts to recognize or avoid in producing left atriograms: the negative shadows of pulmonary venous inflow, poor filling due to delayed or too early timing of the exposure in relation to the injection, and the surgical ligation of the appendage. Whatever x-ray technique pro duces very good film detail will be useful; but in our experience we need the utmost detail we can get. This means a rapid direct injection into the left atrium and a large-sized x-ray film. As you have heard, anyone wiith both mitral stenosis and atrial fibrillation has at least an even chance of having thrombi in the left atrium. There are good clots and bad clots. The good ones are the organized thrombi; the bad ones are the transient or fresh thrombi. Unfortunately none comes with a label; and even though we see the thrombus clearly there is no direct way of dis tinguishing the two types. Nevertheless, organized thrombi can be very firmly attached, and in my opinion there is some times justification for leaving them in place, choosing closed mitral valve repair and optional use of the valve dilating instrument. A current project is the investigation of whether large thrombi can regress after closed mitral valve repair or anticoagulant treatment, without peripheral embolization. Perhaps this can occur, by means of a more gradual erosion process or recanalization.
X_/mbolization from a left atrial thrombus is an important potential hazard of sur gery in mitral stenosis, with sequelae which include death, stroke, saddle embolus, and infarction of viscera. Although embolization may occur at random during the pre- and postoperative periods, during operation it must be attributed to the surgeon's manipu lations. Prophylactic measures have been only partially successful. These measures have included anticoagulant drugs and stabiliza tion of rhythm pre- and postoperatively, cautious cleansing of the left atrial appen dage, and temporary carotid artery occlusion by tourniquet during the closed type of mitral repair, and the temporary insertion of a retaining sponge or sieve below the mitral valve during clot removal, in open mitral repair methods. Improved atrial flow after valve repair is thought to prevent thrombosis, and ligation of the left atrial appendage has been applied prophylactically against thrombosis. In the present study, left atriography by direct injection was used as a primary diag nostic method, aimed toward better underThis study was supported by a grant from the Tri-County Heart Association of Pennsylvania. Read at the Forty-fifth Annual Meeting of The American Association for Thoracic Surgery, New Orleans, La., March 29-31, 1965. •Address: Allegheny General Hospital, 320 E. North Avenue, Pittsburgh 12, Pa.
standing of the embolie hazard, with the hope of preventing more emboli than would be provoked by the test. Methods Left atriography was performed by direct injection during the course of transatrial septal left heart catheterization in 478 pa tients. In 4 additional patients, left atrial needles were placed for similar injection by the posterior percutaneous (transthoracic) method. 1 ' 2 Most of the subjects had been hospitalized for preoperative diagnostic study of chronic rheumatic valvular disease, or for related studies. Preparations for the tests included anticongestive treatment, stabilization of heart rate, and thyroid tests, where indicated. An explanation of the procedure was given to the patient in a confident and reassuring manner. The usual premedication was secobarbital, 0.1 Gm. and promethazine, 25 or 50 mg. orally. Transatrial septal left heart catheteriza tion was performed by a modification3 of the methods of Ross4' 5 · G and Cope.7 After skin puncture with a No. 11 scalpel point, 7 cm. distal to the right inguinal fold, a gauge 16T BD needle, No. T479LNR or No. 01-001,* was inserted cephalad, with en trance of the right femoral vein at a 45 de gree angle. A Seldinger flexible metal leader, •Becton, Dickinson Company, Rutherford, N. J.
473
Journal of
474
Fisher et al.
Thoracic and Cardiovascular Surgery
80.5 CM
<=co erfEH
Fig. 1. Instruments for transatrial septal left heart catheterization. A, Blunt stylet for needle. B, Needle, gauge 18T. C, Pre-formed catheter, radiopaque polyethylene (7-9F, 2.3-3.0 mm. outer diameter).
BD No. 01-0017, was inserted,8 and then the needle was replaced by an 8V2-9 Fr., 80 cm., K3, yellow, radiopaque, polyethylene Kifa catheter.* The tip end is tapered and has a pre-formed curve, 2.5 to 5 cm. in radius. An optional catheter is an 8F-radiopaque Teflon, No. LB-8-2.5-80.f After right heart catheterization measurements, a gauge 18T needle, 80.5 cm. long, with curved tip was inserted through the catheter with the help of a blunt stylet (Fig. 1). Starting at the superior vena cava, the needle-catheter assembly is drawn caudalward while the atrial septum is palpated with the tip. Normally, the tip drops into the shallow fossa ovalis about halfway between the superior and the inferior venae cavae (Fig. 2, A ) ; but in mitral valve disease, the septum usually is distended as a convex dome protruding into the right atrium (Fig. 2, B). With the needle point extended be yond the catheter tip and blunt stylet drawn back 12 cm., the assembly is pushed through the atrial septum at a point just caudal to the summit of the dome. The curved needle point is directed posteriorly and to the left. Care is taken not to glide up and over the dome to engage the aorta, which lies cephalad and anteriorly, or the pulmonary ar tery, farther anteriorly. Aneurysmal dilata•Schick X-ray Corp., 205 W. Wacker Drive, Chicago 6, 111. tCook, Inc., 300 South Swain Avenue, Bloomington, Ind.
tion of the aortic base is a special hazard. If the aorta be entered inadvertently, the pericardium must be vented externally to prevent pericardial tamponade, which can be fatal within 10 seconds after withdrawal of the catheter. Once the catheter has entered the left atrium, the blunt stylet is replaced, and the catheter alone is advanced; its pre-formed tip curve aids its insertion through the mitral valve. The blunt stylet-needle assembly may be used for support of the catheter in the maneuvers. An additional reverse curve at the tip of the catheter (shepherd's crook) will aid placement through the mitral valve in difficult cases. From the left ventricle, access to the aorta can be gained by inser tion of a small coaxial catheter (PE50, PE60, or size 4 Fr.) through the larger K3 catheter. A coaxial fitting is used for the dual fluid connection (BD No. 615A) and a wire stylet may support the manipulation ( B D N o . 01-0041). After left heart pressure measurements, the 8 Vi Fr. K3 catheter is withdrawn to the left atrium for left atriography. Twenty-one milliliters of sodium iothalamate (80 per cent)* is injected in IVi seconds or less, with the use of a special hand syringe (BD No. 20SLC) or a powered injector. A single y30 second, posteroanterior view, 10 x 12 »Angioconray, Mallinckrodt Chemical Works, St. Louis, Mo.
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Fig. 2A. Frontal section of normal heart through the right atrium. Transatrial septal passage is made through upper portion of fossa ovale, slightly to the left of the midpoint between su perior and inferior venae cavae. The curved point of the needle is directed diagonally posteriorly and to the left to reach the left atrium, avoiding the aorta and pulmonary artery, which lie cephalad and anteriorly. (Modified from Pernkopf's "Atlas of Topographical and Applied Human Anatomy, Philadelphia, 1964, W. B. Saunders Co.)
inch x-ray, spot film exposure is taken ex actly at the end of injection, with the use of a grid cassette. An additional injection for a right anterior oblique view is usually done (see Fig. 3, G ) . The use of a rapid film changer for multiple films is op tional. Thirty-five millimeter cinecardiographic films9 do not give satisfactory detail for the study of smaller filling defects. The criterion for the diagnosis of a throm bus was the presence of any definite filling defect that was not obviously an artifact. Artifacts may be caused by inflow at a pul monary vein orifice, occlusion or amputa tion of the appendage by previous surgery, inadequate injection of contrast material, or improper timing of film exposure. Mitral stenosis was judged to be present as a predisposing factor when a mean diastolic filling gradient of at least 3 mm. Hg
475
Fig. 2B. Interior of right atrium in mitral valve disease shows eversion of fossa ovale. Transatrial septal needle entry to the left atrium is made on the caudalward slope of the dome, avoiding any tendency to glide over the prominence anteriorly and cephalad, into the aorta.
was present, and when the calculated mitral valve area was reduced by at least 25 per cent from the normal. The presence of atrial fibrillation was demonstrated by standard electrocardiographic criteria. Results In the 482 tests, 107 (22 per cent) showed definite filling defects diagnostic of left atrial thrombi (Table I ) . These were found as often in the main chamber as in the appendage alone. In this series of pa tients, thrombi were found only in the pres ence of atrial fibrillation or mitral stenosis, and with greatly increased incidence (48 per cent) when both factors were present (Table I I ) . Only two small thrombi were detected in patients having predominant mitral insufficiency. The diagnosis of thrombi as the true cause of the filling defects on the left atriograms was investigated at surgical operation in 128 cases (Table III). By means of the closed method of mitral valve repair, the
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Table I. Incidence of thrombi in preoperative left atriograms | Number Per cent Total tests Thrombi found (filling defects) Location a. Appendage only b. Main chamber
482 107
100 22
51 56
11 11
Table II. Occurrence of left atrial thrombi in relation to mitral stenosis and atrial fibrillation Num ber
Per cent
128 14
100 11
16 3
100 19
C. Patients with both mitral stenosis and atrial fibrillation Incidence of Thrombi
187 90
100 48
D. Patients with neither mitral ste nosis nor atrial fibrillation Incidence of thrombi
151 0
100 0
A. Patients with mitral stenosis Incidence of thrombi B. Patients with atrial fibrillation Incidence of thrombi
Table III. Surgical treatment of tested patients
Patients without thrombi Patients with thrombi Left atrium, main chamber Left atrial appendage only
Closed mitral valve repair
Openheart mitral repair
66 37 (23) (14)
18 7 (6) (1)
mitral stenosis and atrial fibrillation, a small preoperative thrombus was faintly outlined, within the main chamber and just medial to the appendage. However, it went unno ticed until the patient had hemiplegia during closed mitral valve repair; then a review of the x-ray film disclosed the omission in in terpretation. Another error in interpretation occurred in the first massive thrombus of the series by failure to recognize as a filling defect the lack of the usual rounded borders of the left atrium (for example, compare Figs. 3, A and 3, C ) . Exploration at open-heart mitral repair disclosed the large mural thrombus. Complications of the test series were relatively few. In 1 patient, one of the four left atrial thrombi migrated during the test to occlude the left carotid artery, and the patient later died. In 4 patients, various palsies or paresthesias were transiently noted within 3 hours after the tests, but there was complete recovery. Other episodes in the series, occurring on later days, were not attributed to the test, since the past history in each case revealed previous embolism. In 4 patients, the needle-catheter assembly was inadvertently directed through the right atrial wall and into the pericardium. No complications of such pericardial entry re sulted except in the 1 patient having an elevated right atrial pressure; in this case there was transient hypotension suggesting mild tamponade, and blood-stained peri cardial fluid was found later at elective mitral valve operation. Discussion
presence or absence of appendage thrombi was confirmed in 103 cases, with no dis agreements, but the thrombi detected radiographically in the main chamber could not safely be investigated. At the 25 open re pairs, both locations were explored, with close agreement. Embolization from the left atrium occurred in 3 of the closed and 1 of the open repairs. Initially, errors in film interpretation oc curred. In one 57-year-old patient with
The detailed demonstration of the parent thrombi is an approach to the study of the embolie hazard. However, the thrombi of this study showed surprisingly little tendency to break free, being perforated by needle and catheter in several cases (Figs. 3, A-F), and even tolerated forcible injections through channels in their substance (Figs. 3, A B, and D) without embolism. One such patient (Fig. 3, B), refusing mitral stenosis repair, has been kept on continuous
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Fig. 3. Massive left atrial thrombosis. A, Multiple thrombi, confirmed at open heart explora tion. Two thrombi in superior portion, 1 in appendage. B, Massive thrombus occupies superior half of left atrium. The patient refused operation, and has been free of emboli during VA years on oral anticoagulants. Note injection channel.
Fig. 3. Cont'd. C, Massive thrombus occupyies septal half of left atrium. Atrial wall is partially calcified. D, Massive thrombus occupies septal half of left atrium. Arrow indicates tip-end of catheter, with jet extending through a channel of the thrombus. The thrombus was com pletely removed at open repair of mitral valve. No embolism occurred subsequently.
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Fig. 3. Cont'd. E, Thrombus fills large left atrium, except supravalvular portion. Atrial wall is partially calcified. F, Thrombus covers superior and septal walls of the left atrium. Three separate thrombi were removed from the large appendage at closed mitral valve operation. No embolism occurred thereafter.
Fig. 3. Cont'd. G, Right anterior oblique view. Large ball thrombus lies against mitral valve, below appendage. No embolism occurred after thrombus removal and open-heart mitral valve repair. H, Posterior percutaneous (transthoracic) puncture for left atriography in mitral stenosis^ prone position. No thrombi were diagnosed, and none were found at open repair. The left atrium is displaced by severe right atrial enlargement, due to tricuspid stenosis and insufficiency.
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oral anticoagulant treatment for IVi years without embolism. Apparently the thrombi encountered were predominantly organized and well-attached to the atrial wall, rather than "fresh,"10 although one fatal embolus occurred on left atrial catheter insertion. A single, non-fatal cerebral embolus sim ilarly occurred in the series of Criley, Lewis, and Ross9 (109 patients). The well-known association of left atrial thromboembolism with the combined fac tors of mitral stenosis and atrial fibrillation is confirmed by our results (see Table I I ) . Therefore, it is suspected that patients in regular rhythm who have had emboli, also may have undiagnosed bouts of paroxysmal atrial fibrillation (Table I V ) . This diagnosis would probably be confirmed by the study of long-term continuous electrocardiographic tape recordings. The relative stability of most of the thrombi may encourage the use of direct Table IV. The formation and ejection of left atrial
thrombi
A. Probable factors in deposition of left atrial thrombi in mitral stenosis and atrial fibrillation 1. Decreased velocity of blood flow, both mean and maximum, due to a. subnormal cardiac output, in mitral ste nosis, atrial fibrillation; or b. dilatation of left atrium and appendage 2. Decreased emptying of left atrium, due to a. absence of atrial systole in atrial fibrilla tion; or b. dilatation of left atrium and appendage 3. Local injury to left atrial wall, due to a. rheumatic myocarditis b. chronic calcific deposits 4. Possible increased clotting tendencies of the blood due to variations of chemical blood factors B. Probable factors in dislodgement of left atrial thrombi in mitral stenosis and atrial fibrilla tion 1. Abrupt reversal of the above-listed factors for deposition of thrombi, especially rever sion of atrial fibrillation to regular sinus rhythm 2. Surgical manipulations of the left atrium and its appendage, including catheterization maneuvers
left atrial catheterization and atriographic injections,11 rather than the use of pulmo nary artery wedge pressures and pulmo nary artery injections.12' 13 The continued use of closed mitral valve repair may also be considered optional in left atrial throm bosis,14 rather than open repair for a man datory cleansing of the left atrium.15 It remains to be proved whether regression of such organized thrombi occurs with im provement of mitral valve function. A grad ual process of recanalization might be pos sible, without clinical embolization. Conclusions 1. Direct left atriographic injections were made in 482 patients, during the course of transatrial septal left heart catheterization, for the study of left atrial thrombi in rheu matic valve disease. 2. Diagnostic results were accurate, com pared with findings at later surgical ex plorations. Atriographic details may there fore be used reliably to aid in the choice of surgical techniques. 3. Most of the left atrial thrombi seemed to be well attached, organized rather than fresh, but 1 patient died of an embolus to the left carotid artery during the test. Other complications of the series were minor. 4. The advantage of increased diagnostic detail obtained by direct left atrial injec tions probably outweighs the relatively greater safety of distant angiocardiographic injections. REFERENCES 1 Fisher, D. L.: The Use of Pressure Recordings Obtained at Transthoracic Left Heart Cathe terization in the Diagnosis of Valvular Heart Disease, J. THORACIC SURG. 30: 379,
1955.
2 Fisher, D. L.: Catheterization of the Left Heart in Zimmerman, H. A., editor, Intravascular Catheterization, Springfield, 111., 1959, Charles C Thomas, Publisher. 3 Fisher, D. L., Logsdon, G. R., and McCaffrey, M. H.: Use of a Sharp Stylet for Interatrial Septal Passage of the Radiopaque Right Heart Catheter Into the Left Heart, Circulation 22: 4:749, 1960. 4 Ross, J., Ir., Braunwald, E., and Morrow, A. G.: Transseptal Left Atrial Puncture: New
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Technique for the Measurement of Left Atrial Pressure in Man, Am. J. Cardiol. 3: 653, 1959. 5 Ross, J., Jr.: Transseptal Heart Catheterization: A New Method of Left Atrial Puncture, Ann. Surg. 149: 395, 1959. 6 Brockenbrough, E. C , Braunwald, E., and Ross, J.: Transseptal Left Heart Catheterization: A Review of 450 Studies and Description of an Improved Technique, Circulation 25: 15, 1962. 7 Cope, C: Technique for Transseptal Catheterization of the Left Atrium: Preliminary Re port, J. THORACIC SURG. 37: 482,
1959.
8 Seidinger, S. I.: Catheter Replacement of the Needle in Percutaneous Arteriography, Acta Radiol. 39: 368, 1953. 9 Criley, J. M., Lewis, K. B., and Ross, R. S.: Detection of Left Atrial Thrombus by Cineangiocardiography, Circulation 30: 64, 1964 (Suppl. III). 10 Uglov, F. G., and Potashov, L. V.: The Pro phylaxis of Thromboembolic Complications in Surgery for Mitral Stenosis, J. THORACIC & CARDIOVAS. SURG. 44: 408,
1962.
11 Huston, J. H.: Left Atrial Angiocardiography in Left Atrial Thrombosis, Circulation 24: 963, 1961. 12 Soloff, L. A., and Zatuchni, J.: The Angiocardiographic Diagnosis of Left Atrial Throm bosis, Circulation 14: 25, 1956. 13 Ormons, R. S., Drake, E. H., and Gale, H. H.: Angiographie Study of the Left Atrium in Mitral Stenosis, Radiology 83: 277, 1964. 14 Vargas, L. L., and Corvese, W. P.: Occluding Thrombi of the Left Atrium: Report of Four Cases Treated Surgically, Dis. Chest 40: 313321, 1961. 15 Nichols, H. T., Blanco, G., Morse, D. P., Adam, A., and Baltazar, N.: Open Mitral Commissurotomy: Experience With 200 Con secutive Cases, J. A. M. A. 182: 268, 1962.
Discussion DR. OSLER ABBOTT Atlanta
Ca.
This presentation by Dr. Fisher and his group is most interesting and instructive. I rise to bring up two basic points. First, I believe there has been some misunder standing. I know of instances in our own institu tion (and, I gather, in others) in which a pre sumptive diagnosis has been made of left atrial thrombus with extension into pulmonary veins, because of delayed emptying of the pulmonary arterial circulation on one side during a pulmo nary angiogram. We have made a detailed study of pulmonary angiography the past 6 years, per forming 300 or more procedures, many on an experimental basis. Quite a few of the patient
studies were performed prior to and weeks or months after a thoracotomy. We learned from this study that thoracotomy, per se, delays circulation time on the side of the thoracotomy for as long as 4 months or more. In a recent case, left atrial thrombosis was sus pected because of delayed emptying time of the right pulmonary arteries. When we reviewed the findings in light of our above studies, the diag nosis was selective delay of pulmonary blood flow, due to a right thoracotomy 4 months pre viously. Subsequent slow progressive improvement occurred. This would suggest further reason for the application of Dr. Fisher's method. Second, I want to describe two left atrial per forations that have occurred as a result of trans septal catheterization, which is a very low com plication rate considering the frequency of this procedure. These perforations seem to have a predilection for perforating the posterior surface of the left auricle. In both instances, this com plication occurred in patients with high left atrial pressures due to mitral stenosis. Immediate surgi cal management would have required bypass tech niques and transatrial closure of the perforation. Because, in the first instance, of the fact that the pump was not immediately available, we elected to treat the patient by multiple pericardicenteses. The second patient was similarly treated. In the first one, nine pericardicenteses were required in the first 48 hours, and in the second case five. The patients both survived and subsequently had correction of their lesion. I appreciate the fact that the perforations re ported by Dr. Fisher involved the right atrium, and were more easily accessible for repair. It was surprising that left atrial perforations prox imal to mitral valve obstruction would respond to conservative therapy. In the future, we would prefer to manage such a problem by immediate open-heart surgery and concomitant repair of the atrial injury and mitral valve reconstruction or replacement. DR. CONRAD LAM Detroit,
Mich.
Our group would agree with Dr. Fisher that it is wise to find out about the presence of clots in the left atrium before doing a closed commis surotomy. With open commissurotomy, it makes no difference what one finds, and, in the patients, with atrial fibrillation, one would not be surprised to find a clot and would be able to take care of it. We still do some closed commissurotomies, and our policy is to do special studies on every case of atrial fibrillation. Dr. Drake and Dr. Gales used various puncture techniques, first going through the back and later with the Ross needle, and for reasons best known to them, they have abandoned both of these methods, and give us
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our information by routine right heart catheterization and, if indicated, a retrograde left heart catheterization. While they are doing the right side, they in ject dye into the pulmonary artery and get re markably good cine pictures. It is impossible to show without the cine how clearly some of these delineate the left atrium, but I do have a single frame. [Slide] One sees the catheter in the pulmonary artery. We have chosen a frame where recircu lation has taken, showing the pulmonary veins and a large filling defect. [Slide] This slide shows the clots that were removed at operation. This patient might have been accepted for a closed commisurotomy if it had not been for this study. The next point I would like to make is that we would be afraid to carry out manipulations in the presence of thrombosis by a closed tech nique. We think even a small clot in the atrium is very dangerous; and if we have the slightest suspicion that there is a clot anywhere other than in the tip of the appendage, we will plan an open operation. DR. DONALD KAHN Ann Arbor,
Mich,
A history of embolization in patients with mitral stenosis appeared to have little relation ship as to whether clots will be found in the left atrium. It has been our policy to do an "open" operation for pure mitral stenosis if there is a history of emboli. Of 7 patients operated upon with extracorporeal circulation for this reason, only one had clots in the left atrium. During the same period of time, unsuspected atrial clots were found in 15 per cent of the patients having a mitral valvulotomy with the use of the transven-
tricular dilator. These findings suggest that, if the "closed" technique for mitral stenosis is to be used, visualization of the left atrium preoperatively may be worth while. DR. FISHER (Closing) I would like to thank the discussers, Drs. Ab bott, Lam, and Kahn. There are several artifacts to recognize or avoid in producing left atriograms: the negative shadows of pulmonary venous inflow, poor filling due to delayed or too early timing of the exposure in relation to the injection, and the surgical ligation of the appendage. Whatever x-ray technique pro duces very good film detail will be useful; but in our experience we need the utmost detail we can get. This means a rapid direct injection into the left atrium and a large-sized x-ray film. As you have heard, anyone wiith both mitral stenosis and atrial fibrillation has at least an even chance of having thrombi in the left atrium. There are good clots and bad clots. The good ones are the organized thrombi; the bad ones are the transient or fresh thrombi. Unfortunately none comes with a label; and even though we see the thrombus clearly there is no direct way of dis tinguishing the two types. Nevertheless, organized thrombi can be very firmly attached, and in my opinion there is some times justification for leaving them in place, choosing closed mitral valve repair and optional use of the valve dilating instrument. A current project is the investigation of whether large thrombi can regress after closed mitral valve repair or anticoagulant treatment, without peripheral embolization. Perhaps this can occur, by means of a more gradual erosion process or recanalization.