Usefulness of right-sided cardiac catheterization during “routine” coronary angiography

Usefulness of right-sided cardiac catheterization during “routine” coronary angiography

95%;47 (42%) werenarrowed 51 to 75%;25 (22%), 26 to SO%,and 28 (25%), 125%. A thrombus wasfound in a major epicardial coronary artery in 4 patients. T...

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95%;47 (42%) werenarrowed 51 to 75%;25 (22%), 26 to SO%,and 28 (25%), 125%. A thrombus wasfound in a major epicardial coronary artery in 4 patients. The presenceof fairly large depositsof blood (hematoma) in the subepicardialadiposetissueand a tear in the left ventricular myocardial wall in eachof the aforementioned 7 patients indicate that a through-and-through rupture had occurred in the myocardial wall of the left ventricle. The absenceof blood in the pericardial sac indicates that the epicardium had not ruptured. The result was a complete myocardial rupture and an incomplete epicardial rupture. In all 7 patients the amount of subepicardialadiposetissue was excessive.Had not a lot of fat coveredportions of ventricular wall, the myccardial seclionofcadlac FIGURE 2. (Patient 3, Table I). Trabtnwse tear would likely have led to hemopericardium. venbWe8 showlng a posbior wall aa& my&al infarct Despite the absenceof hemopericardium,eachof the wlthwphue(armwjhtotheepicadd~tissUekn 7 patients had clinical featuresconsistentwith a throughwRhoullllplweoftiw~.vs=v-raphm. and-through rupture of both myocardium and epicardidialfibrous adhesions.The hearts in the 3 men weighed um with fatal hemopericardium and tamponade:4 had 527 f 68 g, and in the 4 women, 485 f 110 g. The left sudden fatal cardiac arrest not preceded by shock or ventricular infarct involved the posterior wall in 4 pa- evidenceof congestiveheart failure and the other 3 had tients and the anterior wall in 3. In all 7 patients the suddencardiac arrest precededby failure or hypotension. To my knowledge, rupture through the entire thicksubepicardial adipose tissue was excessive (Figures I and 2). In all 7 patients blood had dissected into the nessof the myocardial wall of left ventricle during acute subepicardial fat but no tears or rupture sites involving myocardial infarction unassociatedwith either hemoperithe epicardium werefound. In addition to the left ven- cardium or false left ventricular aneurysm has been retricular free wall rupture in all 7 patients, 2 patients ported only once previously.3Edwards3described“sub(nos. 2 and 6) also had a partially ruptured posterome- total” left ventricular free wall rupture in a 69-year-old woman who had severevalvular aortic stenosisand died 7 dial papillary muscle. The 4 major epicardial coronary arteries were avail- days after onset of acute myocardial infarction. able for examination in 6 patients: a single artery was 1. Mann JM, Roberts WC. Rupture of the left ventricular free wall during acute narrowed >75% in cross-sectionalarea by atherosclerot- myocardial infarction: analysisof I38 necropsypatientsand comparisonwith 50 ic plaque in 3 patients, 2 arteries were so narrowed in 2 necropsypatientswith acutemyocardial infarction without rupture. Am J Cardiol patients, and 3 arteries in I patient. In 3patients, eachof 1988,62:847-859. 2. Reddy SG, Roberts WC. Frequencyof rupture of the left ventricular free wall the 4 major epicardial coronary arteries wasdivided into or ventricular septumamongnecropsycasesof fatal acute myocardial infarction 5-mm segmentsand a histologic section was prepared since introduction of coronary care units. Am J Cardiol 1989,63;906-911. and examinedfrom each segment.Of the 113 segments 3. Edwards JE. An Atlas of Acquired Diseasesof the Heart and Great Vessels. Volume II. Coronary Arterial Disease,Systemic Hypertension, Myocardiop studied, only 1 was narrowed >95% in cross-sectional athiea,the Heart in SystemicDisease,and Car Pulmonale,Acute and Chronic. area by plaque alone; 12 (I 1%) were narrowed 76 to Philadelphia: WB Saunders, 1961:578.

Usefulness of Right-Sided Cardiac Catheterization Coronary Angiography

During “Routine”

Alan D. Kogan, MD, Jose Ballesteros, MD, Ahmed U. Jamaluddin, MD, and Alfred J. Anderson, MS n the absenceof a specific indication, the performance of right-sided cardiac catheterization during coronary Iangiography has always been controversial.1Proponents justify it basedon the needfor a completecardiac evaluation in each patient and its “training value,” * while the potential increasedmorbidity and radiation exposureinvolved in the procedure are often cited as factors that mitigate against its routine usee3In this era of medical cost containment, the added cost of right-sided heart cathetersand physicians’ feesfurther aggravatethis controversy. In a recent seriesof 219 patients who underwent From St. Francis Hospital, 800 Austin, Suite 602, Evanston, Illinois 60202, and Milwaukee Cardiovascular Data Registry, Milwaukee, Wisconsin. Manuscript received August 1, 1989; revised manuscript receivedDecember 12, 1989,and acceptedDecember 13.

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THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 65

coronary angiography and right-sided cardiac catheterization, Shaneset al4 argued against its routine use.One third of their patients had abnormal right pressuresbut the presenceof pulmonary hypertensiondid not appearto influence the diagnosisor therapeutic recommendations. Thesefindings and conclusionswerecontradicted by Barron et a1,5who reported on 2,178 coronary angiography patients who had no signsor symptomsof valvular disease or congestiveheart failure but in whom there wasa 14.5% incidence of unsuspectedand significant abnormalities diagnosed by right-sided cardiac catheterization. To identify more clearly both the incidence of pulmonary hypertension in the catheterization laboratory of a community hospital and its possibleeffect on the treatment and mortality rates of patients with symptomatic coronary artery disease,we undertook the following study.

During a recent 18-month period, 3,095 cardiac catheterizations were performed in the Galvin Heart Center of St. Francis Hospital. Of these, 2,582 right-sided cardiac catheterizations were performed at the time of leftsided heart catheterization and coronary angiography. Right-sided heart pressures were measured using a variety of right-sided heart catheters, most commonly a 7Fr flow-directed catheter, and Spectramed DTX transducers. Pressures were recorded and analyzed on a HewlettPackard catheterization data analysis system. All patients undergoing cardiac catheterization and cardiac surgery were enrolled in the Milwaukee Cardiovascular Registry.6 Following previously established guidelines,4 mild, moderate and severe pulmonary hypertension were defined as pulmonary artery systolic pressures of 31 to 40,41 to 50 and >50 mm Hg, respectively. Not all patients catheterized at our hospital underwent cardiac surgery and some patients who had surgery were catheterized at other institutions. For the same time period, combined surgical and hemodynamic data were available for 2,512 patients. Surgical mortality was defined as peri- or postoperative death occurring before hospital discharge. The impact of cardiac pressures and of other patient parameters on hospital mortality was analyzed using the SAS statistical software package. Mean levels of pulmonary artery systolic pressure, left ventricular end-diastolic pressure, left ventricular ejection fraction, body mass index (weight [in kg] divided by height [in m*]) and age were compared using 2-sample t tests. Percentagesfor reoperation, left ventricular aneurysm and number of vessels with 275% occlusion were compared by use of the chi-square test. Significant differences are indicatedfor either the 0.05 or the 0.01 levelfor 2-tailed tests. In addition, pulmonary artery systolic pressure, left ventricular end-diastolic pressure and ejection fraction were divided into 3 levels compared to normal levels. The combined predictive power for all of the variables was determined using stepwise multiple logistic regression with p CO.05 neededfor inclusion into the equation. The relative risk for the significant variables, from the logistic regression, was calculated to quantify the additional risk of a hospital death for those patients with abnormal levels of each variable. Pulmonary hypertension was detected in 1,I 78 (46%) of 2,582 routine right-sided cardiac catheterizations performed during coronary angiography (Figure 1).

TABLE I Catheterization Gender

and Angiographic Variables by Female

No. Age Ws) BMI W&!/m*) PASP (mm Hg) LVEDP (mm Hg) LVEF (%) LV aneurysm Reoperation No. of coronary arteries narrowed: 1 2 3 4 PASP (mm Hg) <31 31 to 50 >50 LVEDP (mm Hg) <15 15to24 >24 LVEF (%) >54 35 to 54 <35 Surgical mortality

551 65 f 27 f 30f 15f8 64f 2 3

Male 1,961 6049+ 27 f 5 29i 12* 14*7* 61 f 16+ 2 3

9 6 12 16

4 20 40 36

4 21 40 35

66 30 4

71 27’ 2

52 34 14

58 33+ 9

75 20 5 5

69 24+ 7 2+

All + data are mea” f standard deviation; all other data are percentages. * p <0.05; +p
Mild pulmonary hypertension occurred in 734 patients (62%), moderate in 258patients (22%) and severe in 186 patients (16%). In the consecutive surgical cohort of 2,512 patients, the ratio of men to women was 3.6:1 (Table I). Women tended to be slightly older (65 us 60 years) and have slightly higher ejection fractions (64 us 61%) than men. Surgical mortality was significantly higherfor women (4.7 us 1.6%,p
*were

16%

‘50 moderate

22%

41-50 FIGURE 1. lncideme ol pulmonary hyperlenslen and distribution of pulmonary arkry systelic pressures in 2,582 consecutive cardiac cath&&ations.

mlla

62*

31-40 -~~

mmHg

Total THE AMERICAN

Pulmonary JOURNAL

OF CARDIOLOGY

Hypertension APRIL 15. 1990

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TABLE II Surgical Mortality by Catheterization and Angiographic Variables Female

No.

Age (yrs) BMI OWm2) PASP (mm Hg) LVEDP (mm Hg) LVEF (%) LV aneurysm Reoparation No. of coronary arteries narrowed:

1 2 3 4 PASP (mm Hg) <31

31 to50 >5C LVEDP (mm Hg) <15

15to24 Z-24 LVEF (%) X34

35to54 <35

Male

Survived

Died

Survived

Died

525 65f9 27f6 30f12

26 67zk9 26*6 31fll

1,930 6Ok9 27f5 29f12

31 64f9* 27 f 5 36f 17+

15f8 64f16

16&8 61 f 14

14f7 61f16

15f8

50f 19+ 13+ 13+

2 3

0 8

3 3

5 20 41 34

4* 15 19 62

4 21 40 35

0 23 29 48

66 30 4

69 23 8

71 27 2

52+ 32 16

52 34 14

46 39 15

58 33 9

52 32 16

75 20 5

73 23 4

69 24 7

39 42 19’

All f data are mean f standard deviation; all other data are percentages. * p <0.05 swvivad w died: + p
and the presence of a left ventricular aneurysm were signiificant predictors of hospital mortality in men (Table II). Using multiple logistic analysis, women with >3vesseldiseasehad 3 times the risk of death than women with I - or 2-vessel disease (p X0.01). For men, severe pulmonary hypertension was the bestpredictor of hospital mortality. Men with pulmonary artery systolic pressures >50 mm Hg had a 7 times greater risk of death when compared to men with lower pulmonary pressures (p 65 years, presenceof a left ventricular aneurysm and reoperation each independently increased the risk of death with relative risks of 2.0 (p <0.05), 5.0 (p
THE AMERICANJOURNALOF CARDIOLOGY VOLUME65

hypertensionfrom the history and physical examination, chest x-ray, electrocardiogram,arterial blood gas or hemoglobin level, but none of theseparametersproved reliable. It thus becomesimperative to determine right-sided heart pressuresto screenfor pulmonary hypertension at the time of diagnostic coronary angiography. In addition to the important prognosticvalue of rightsided cardiac catheterization during “routine” coronary angiography, the training value of this procedureshould not be overlooked.The Task Force for Training in Cardiac Catheterizationlo recommendedthat all cardiology trainees becomeproficient in the insertion of pulmonary artery cathetersand that they must participate in at least 100catheterizations.Traineeswho plan to pursuecareers as invasive cardiologists were recommendedto participate in at least 300 catheterizations.During the courseof a 3-year cardiology fellowship training program, an institution would need to provide 33 or 100 proceduresper noninvasive or invasive trainee per year to meet these recommendedgoals. A program with 10 trainees would need to provide 330 to 3,000 annual procedures.By restricting the performanceof right-sided cardiac catheterization during coronary angiography to only those patients with obvious clinical pulmonary hypertension, these training goals would only rarely be met. 1. Sibbald WJ, Sprung C. The pulmonary artery catheter. The debate continues. Chest 1988,94:899-901.

2. &met P. The completecardiac catheterization (editorial). Cathet Cardiwasc Diagn 1984;10:431-432.

3. Green JX?. Right heart catheterization and temporary pacemakerinsertion during coronary arteriography for suspectedcoronary artery disease.Cathet Cardiovax

Diagn 1984:10:429-430.

4. Shanes JG, Stein heart catheterization

uber den zusammenhang zwischen risikofaktoren and letalitat bei aorto-koronaren venenbypass-operationen. Anoesfhesist 1986:35:184-186. 8. Kennedy JW. Kaiser CC, Fisher LD. Fritz JK, Myers W, Mudd JG, Ryan TJ. Clinical and angiographic predictors of operative mortality from the collaborative Circulation /98/,63:793-802. study in Coronary Artery Surgery (CA%). 9. Tobias J, Danahy D, Aronow W, Chetty K, Glauser F. Comparison of noninvasive with hemodynamic data in patients with pulmonary hypertension due to chronic obstructive pulmonary disease. Am J Med Sci /979;278;/9-25. 10. Conti R. Faxon D. Gruentzig A, Gunnar R, Lesch M, Reeves J. Task Force Ill: training in cardiac catheterization. JACC /986;7:/205-1206.

MA, Dierenfeldt BJ, Kondos GT. The value of routine right in patients undergoing coronary arteriography. Am Heart J

1987;113:1261-1263. 5. Barron JT, Rug&e N, Uretz E, Messer JV. Findings on routine right heart catheterization in patients with suspected coronary artery disease. Am Heart J

1988:115:l193-1198. 6. Dorros G, L&n

RF, Daley P, Assa J. Coronary artery bypass surgery in patients over age 70 years: report from the Milwaukee Cardiovascular Data Clin Cardiol 1987;10:377-382. Registry. 7. Krumholz W, Kling D, Boldt J, Muller H, Hempclmann G. Untersuchung

Electrophysiologic

Effects of Oral Theophylline

Paolo Alboni, MD, Paolo Rossi, and Gian Enrico Antonioli, MD

MD,

Benedetto Ratto,

heophylline is commonly used in the treatment of bronchial obstruction. In experimental studies the drug showed positive chronotropic effects.l,* During long-term therapy, oral theophylline suppressedsymptoms in young patients with paroxysmal bradyarrhythmias3;moreover,it diminished the frequency and severity of bradycardia in newborn infants with apnea-bradycardia.4 In someelectrophysiologicstudies intravenous theophylline showedimprovement in sinusnodal function.3,5 The mechanismby which the drug exertspositivechronotropic action is controversial. One study suggeststhat the primary effect of theophylline at therapeutic concentrations is antagonism of adenosinereceptors6 An increase in plasma catecholaminesin both normal subjects and patients with chronic obstructive pulmonary diseasehas also been shown after intravenous administration5; however, this investigation, to our knowledge, has not been carried out after oral therapy. The present study evaluates the effects of oral theophylline on sinus nodal function in patients with sinus bradycardia, and defines whether drug-induced improvement of sinus nodal function could be related to direct effects(or effectsmediated by nonautonomic receptors) or by autonomic actions. T

Electrophysiologic studies were performed in 15 patients (ages 67 f 10 years) with sinus brudycurdiu (sinus rate <50 beats/mm not induced by drugs and present constantly on several resting electrocardiograms recorded diurnally). Nine patients had organic heart disease (6 hypertensive cardiovascular disease and 3 coronary artery disease) and the remaining 6 did not show signs of underlying heart disease. Thirteen patients had dizziness From the Divisions of Cardiology, S. Anna Hospital, 44100 Ferrara, Italy, and S. Martin0 Hospital, Genova. Manuscript received August 14,1989;revisedmanuscriptreceivedand acceptedDecember18,1989. FlGUl?El.Studyde&n.lnthefirst~~~6inu8nodom8a6lu6-

1

st

MD,

in Sinus Bradycardia

Paolo Pedroni,

MD,

Emilio Gatto,

MD,

or syncope and 3 had marked astenia. No patient was takingcardioactive medications or drugs known to interfere with the autonomic system or adenosine metabolism (dipyridamole or diazepam). Informed consent was obtained from each patient. To investigate the different modes of action of an antiarrhythmic drug in man,‘y8 we used a protocol that we previously adapted (Figure 1). Transesophageal pacing was used for electrophysiologic investigation. The studies were performed in the postabsorptive, nomedated state. Transesophageal pacing was performed in the catheterization room. A quadripolar catheter (Toec 4) with electrodes spaced at 25 mm was passed through the nares into the distal esophagus; the 2 distal poles were used for stimulation and the 2 proximal poles for recording the atria1 electrogram. The catheter was usually positioned so that the bipolar electrogram (filtered from 1 to 50 Hz) showed the greatest amplitude. Transesophageal stimulation was performed using a programmable stimulator (Medico 843/C) capable of delivering constant current square-wave pulses of 2 to 30 ms in duration and 1 to 40 mV. Ten minutes after the introduction of the catheter, the mean sinus cycle length (XL) was measured by averaging IO consecutive sinus cycles. The maximum-corrected sinus node recovery time was calculated by the method described by Narula et ala9 Total sinoatrial conduction time was estimated by the continuous pacing method described by Narula et al.‘O The pauses after pacing were defined as the interval from the last paced beat to the beginning of the succeeding spontaneous P wave because the esophageal electrogram always followed the beginning of P wave. Autonomic blockade was achieved by intravenous administration of propranolol 0.2 mglkg and atropine 2

Electrophysiologic

nd

Electrophysiologic

study

study

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state

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state

OVERALL EFFECTS

Autonomic blockade

Autonomic

DIRECT EFFECTS (OR EFFECTS MEDIATED BY NON AUTONOMIC RECEPTORS)

blockade

THE AMERICAN JOURNAL OF CARDIOLOGY APRIL 15. 1990

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