Complications of ventriculography
Arrhythmias
* Caused by mechanical stimulation of ventricular myocardium by KT/contrast jet
* Eliminated/minimized by replacing KT
* Rarely, can be sustained after removal of KT → treated w IV lidocaine bolus
Intramyocardial injections
* Deposition of contrast material w/I endocardium/myocardium
o Small stain usually benign
o Large stain → can lead to refractory ventricular arrhythmias (Vtach/fib)
Ventricular perforation
* Leakage of blood/contrast in pericardial space → cardiac tamponade
o Emergency pericardiocentesis
o Cardiothoracic surgeon
Fascicular block
* Transient L anterior fascicular block can occur during retrograde LV KT
o Proximity of anterior fascicle to LVOT
o Usually resolve in 12-24h
Embolism
* Injection of air or thrombus
* Minimized by frequent flushing w heparinized solution
What causes intramyocardial injections
improper positioning of KT
o Under papillary muscle
o Side hole lies firmly against ventricular wall
How to avoid endocardial staining
o Use KT with side holes + closed/tightly curved tip (NIH, Berma, Lehman’s, Pigtail)
Allows for
* Better contrast dispersion
* Stabilization of KT tip
* Lack of recoil
o Avoid positioning under papillary muscle
o Avoid pressing against myocardium
Appropriate settings for pressure injection during ventriculography
- Set to deliver a preset contrast volume over a brief period
- High pressure for small diameter KT
- Avoid air
- Settings
o Flow rate 10-15ml/s
o Total volume 20-50ml
o Pressure limit 900-1200psi: 6Fr = 900psi, 4Fr = 1200psi
o Rise time 0.2-0.5s
Time for contrast injection determined by
KT type, size, flow rate, distance, volume, pressure
Best injection site
injection of contrast directly into ventricular chamber
o LV: optimal position is mid cavity
Adequate delivery of contrast material in chamber’s body/apex
No interference w MV function
Position of end hole away from ventricular trabeculae
o R heart:
Usually pigtails or balloon tipped
* Straighten pigtails w guidewire before removal since can stay trapped in trabeculae
* Balloon: assisted by blood flow into RA → TV → RV → PA
o Deflate before removal
What to do if ventricular ectopy during injection
reposition KT in ventricular inflow tract → in front of MV posterior leaflet
What to do if vigorous ventricular contraction
no stable position found
o Can use pigtail → advanced to be in continuous contact w apex
Injection rate and volume depends on
o Type and size of KT
o Size of ventricular chamber
o Ventricular SV
o Pre ventriculography hemodynamics
If filling pressures are ↑ → LV ventriculography should be performed after nitroprusside
Time for contrast injection depend on
o Length/radius of KT
o Pressure used to inject
o Rate of contrast injection
Most common volume for contrast and preferred method of delivery
- Most cases: 1ml/kg
o Side holes: 10-12ml/s
o End hole: <7-10ml/s to ↓ recoil/staining - Power injector: rapid delivery of adequate amount of contrast
o Max pressure roughly 1000psi to avoid KT burst
Contrast agents
- Iodine based
o High atomic weight (↑radiodensity) → degree of opacity α to total amount of iodine in image
o 1st generation: Salts of triiodinated benzoic acid
High osmolality: 5-8x blood
o 2nd generation: Non ionic monomers
No dissolution in solution → less adverse rx
Low osmolar agents: 2-3x blood
o 3rd generation: Iodixanol
Iso-osmolar dimer → not dissociate in solution
Same osmolality of blood
What property of contrast agent affects flow rate
Viscosity
o Warming contrast ↓ viscosity
How does one distinguish significant TR from that caused by technical issues related to contrast injection during right ventriculography?
- RV angiography
o Artificial TR from KT across TV: mild
Small amount
Clearance between beats
Scale to classify TR severity
- Scale of +1 to +4 similar to MR assessment
o +1 mild: clears in 1 beat, do not opacify entire RA
o +2 moderate: not clear in 1 beat, faintly opacify entire RA
o +3 moderately severe: RA completely opacified, equal opacification as RV
o +4 severe: opacification become more dense after several beats, reflux in VC
Causes of TR
- TR can functional or organic
o Functional TR: RV dilation/failure from ↑Rv afterload
PH, MV stenosis, CM
o Organic TR: dz of TV/apparatus
Bacterial endocarditis, rheumatic, RV infarction
Hemodynamic assessment of TR
- RA pressure tracing: large systolic wave (v)
- Jugular venous tracing: s wave present
- Systolic wave: precedes/blend with normal venous filling (v) wave
o Severe TR: s and v are fused forming one single regurgitant wave - Distinction of organic vs functional: difficult
o If systolic RVP >60mmHg → functional TR
o If systolic RVP = 40mmHg → significant organic component
