Retrograde Left Cardioangiography as a Test of Valvular Competence

To the present time there has been no simple or reliable method for differentiating mitral stenosis from mitral insufficiency. The correct diagnosis has great practical importance to the surgeon, who must decide whether open or closed heart surgery should be employed to correct the defect. Left heart catheterization with pressure and flow measurements has proved valuable in purely stenotic mitral lesions. In the presence of insufficiency, atrial fibrillation, or failure, however, the interpretation of these curves has been complicated and often disappointing. A practical technic of left cardioangiography has been developed to evaluate the degree of mitral and aortic insufficiency. Technic. The femoral artery is explored and a wide-lumen polyethylene catheter with a special soft teflonized spring wire stylet is introduced into the ascending portion of the arch of the aorta. The stylet itself is advanced about 2 inches beyond the tip of the catheter, which has a double curvature directing the spring toward the aortic valve. The soft wire spring is gently brought in contact with the aortic leaflets. At the end of systole the spring spontaneously slips between the valvular leaflets into the left ventricle. The double curvature at the tip of the catheter usually makes it possible to introduce the wire stylet even into tightly stenotic valves without injury. After the spring stylet has passed into the left ventricle, the catheter is advanced and placed in the apex of the left ventricle to minimize the occurrence of extrasystoles. The injection of 35–50 c.c. of opaque medium is made slowly during a period of at least four consecutive ventricular systoles. This slow injection through a wide lumen, six-hole catheter lessens the tendency to produce extrasystoles and does not affect the pressure in the left ventricle. Anteroposterior and lateral film studies are made, with four or five exposures per second, commencing at the onset of injection. After the roentgenograms are completed, the pressure of the left ventricle and pressure changes across the aortic valve are measured to determine the presence of aortic stenosis. To exclude aortic insufficiency, an additional injection of 25 to 30 c.c. with an end-hole closed catheter is made just above the sinus of Valsalva. Interpretation. In several cases of pure mitral stenosis there was no opacification of the left atrium. In cases of mitral insufficiency the opaque medium accumulated in the left atrium, staining it more densely than the left ventricle and aorta. Some of these diagnoses have been proved at surgery. We feel that the degree of opacification of the left atrium correlates directly with the degree of mitral insufficiency present. This procedure also has the advantage of showing the actual size of the left ventricle. Animals having artificially created mitral lesions were used for the initial studies.