Aortic Valvulography and Ascending Aortography

In our institution (Ohio State University) there has been an increasing awareness of the fact that patients who undergo mitral commissurotomy for mitral stenosis occasionally do very poorly if there is a co-existing aortic valve lesion. Moreover, it is recognized that in a small number of patients it is quite difficult, if not impossible, to differentiate clinically between the diastolic murmurs of aortic insufficiency and pulmonary valvular insufficiency (Graham Steell murmur). It is the purpose of this paper to report on the development of a method of thoracic aortography which is well suited for the evaluation of aortic valvular function (aortic “valvulography”) in that relatively small group of patients with confusing diastolic murmurs. It is hoped that the information gained regarding the function of the aortic valves will be useful in future analyses of the results of mitral valvulotomy. The method to be described is also of value in the study of lesions of the ascending aorta and coronary arteries, structures which are not consistently well visualized by other methods of thoracic aortography. It is our opinion that the accurate differential diagnosis between the murmurs of pulmonary valvular insufficiency and aortic valvular insufficiency is important if mitral commissurotomy is being considered, since patients with pulmonary valvular insufficiency (Graham Steell murmur) due to mitral stenosis should, and usually do, benefit greatly from the operation, whereas this expected improvement is sometimes not seen in patients with coexisting aortic insufficiency. The only previous mention of the unsatisfactory postoperative clinical course following mitral commissurotomy in patients with coexisting aortic valve disease is that by Uricchio and Likoff (1). In January 1957, they reported 3 cases with aortic stenosis and insufficiency in which “mitral commissurotomy was succeeded by unmistakable evidence of an increase in the severity of the coexisting uncorrected aortic valve defects,” with progressively increasing heart failure and death. The problem of accurate differential diagnosis in those patients with a diastolic murmur which could be due to either aortic insufficiency or pulmonic valvular insufficiency seemed amenable to a radiological solution, and we accordingly started our investigations in 1955. It was apparent that it would be necessary to inject contrast material near the aortic valve region in concentrations adequate for accurate radiographic evaluation of pathological regurgitation through the aortic valves into the left ventricle. Furthermore, since all previously described methods of injection against the rapidly moving blood flow in the aorta necessitated high pressures, it was postulated that the resultant rapidly moving jet of contrast material directed against the valve orifice might result in factitious regurgitation through normal valves.