Left atrial function in ischemic heart disease assessed by intravenous digital subtraction angiography.

To investigate changes in left atrial morphology and dimensions during the cardiac cycle, the atrium was visualized by intravenous digital subtraction angiography (DSA). The study subjects consisted of 22 male patients whose average age was 54.5 +/- 8.6 years. They had ischemic heart disease without mitral valve disease and were in sinus rhythm. They were 11 patients with old myocardial infarction (OMI group) and 11 who had chest pain without evidence of infarction (AP group). DSA was performed in the continuous mode. Contrast material (35 ml) was injected at a rate of 18 ml/sec via a catheter in the superior vena cava and subtraction images were obtained at a speed of 30 frames/sec in the right anterior oblique projection. The left atrial and left ventricular margins were traced manually, their areas were calculated, and fractional changes in area were analyzed. The left ventricular ejection fraction (LVEF) was calculated by densitometry. Cardiac catheterization was performed in 16 patients and the left ventricular end-diastolic pressure (LVEDP) and mean pulmonary arterial wedge pressure (PAWP) were measured. The entire left atrium was clearly imaged using DSA. Phase analysis of the time-area curves in the right anterior oblique projection revealed that the left atrial area was maximal during left ventricular end-systole (%LA1 = 100%), it decreased during early left ventricular diastole (%LA2), and then increased slightly again during mid-diastole (%LA3). After left atrial contraction, the minimum area was obtained (%LA4). The left atrium showed a two-stage decrease in the area due to passive emptying and active contraction during left ventricular diastole. Passive emptying (%LA1-%LA2) was significantly less in the OMI group than in the AP group (6.3 +/- 3.6 vs 13.3 +/- 4.8%, p < 0.01, respectively). In all 22 subjects, passive emptying correlated with LVEF (r = 0.70, p < 0.001) and LVEDP (r = -0.58, p < 0.05). There was no difference in active contraction (%LA3-%LA4) between the 2 groups (26.0 +/- 5.7% in the OMI group, 28.2 +/- 8.4% in the AP group), and it did not correlate with LVEF or LVEDP. The ratio of passive emptying to active contraction [(%LA1-%LA2)/(%LA3-%LA4)] correlated with LVEF (r = 0.63, p < 0.01). These findings suggested that impaired left ventricular diastolic function and a relative increase in atrial contraction were present in patients with a lower LVEF. The %LA4 correlated with LVEDP and PAWP (r = 0.65, r = 0.63, p < 0.01, respectively). In conclusion, DSA proved to be a useful method for investigating left atrial morphology and function.     

Left ventricular imaging by digital subtraction angiography

Summary Digital radiography is a rapidly developing new approach to cardiovascular imaging that converts radiographic and fluoroscopic video images into digital format for subsequent image enhancement analysis, and storage. Left ventriculography can be performed by this method using either intravenous or low-dose intraventricular contrast administration. Advantages over standard radiography include reduced radiation and contrast medium burden, visualization of very low contrast medium concentrations, and an image format that can be directly analyzed by quantitative techniques. As these cardiac applications are developed and improved archiving is implemented, it is likely that the digital left ventriculography will replace standard cardiac angiography.     

Left atrial myxoma: radioisotopic diagnosis

A case of left atrial Myxoma shown on an equilibrium radionuclide ventriculography is presented. The finding were consistent with the ecocardiographic patterns and the gross anatomy of the tumour. The analysis of various parameters obtained with gated radionuclide cardiac blood pool scan shows that the Fourier phase image is another method to detect and study this disease.     

Tricuspid regurgitation diagnosed by intravenous digital subtraction angiography

In spite of numerous available diagnostic methods, controversies concerning the precise diagnosis of tricuspid regurgitation (TR) still remain. In right ventriculography, catheter placement may modify tricuspid valvular function. Though noninvasive Doppler echocardiography is a useful method, it is sometimes too sensitive for clinical use. Furthermore, it is not applicable to cases in which ultrasound penetration is limited. In this study, we evaluated TR using intravenous digital subtraction angiography (DSA), which can provide good images even in cases with poorly recorded echocardiograms. For this study, we placed a catheter in the superior vena cava. Cardiac DSA examinations were performed in one hundred and one patients with heart disease. We injected 35 ml of contrast medium at a speed of 18 ml/sec via a catheter introduced in the superior vena cava. DSA images by continuous mode were obtained in the RAO projection for 15-20 sec. Sequential DSA images were observed and analyzed by time-density curves of the regions of interest (ROI) which were placed in the right ventricle (RV) and inferior vena cava (IVC). Doppler echocardiography was performed for 16 cases in which TR was suspected. Of these, phonocardiography with jugular pulse tracing was recorded for 14 and contrast echocardiography were performed for six, respectively. In cases without evidence of TR, regurgitation of contrast medium into the IVC during RV systole was not recorded by the DSA method. In cases of clinically-proven TR, regurgitation into the IVC during RV systole was observed. Thus, this was considered a diagnostic feature of positive TR using the DSA method, and 13 of the 16 cases undergoing Doppler echocardiography were diagnosed as having TR using the DSA method. The severity of TR was categorized as mild, moderate and severe according to analyses of time-density curves. The severity established by the DSA method showed a close correlation with the clinical severity of TR. Doppler echocardiography was negative for TR in two of the 13 cases, but positive for TR in two of the 16 suspected cases only by the Doppler method. In cases of moderate to severe TR diagnosed by the DSA method, jugular pulse tracings showed a regurgitant wave. By contrast echocardiography, TR was evident only in cases of severe TR diagnosed by the DSA method. In conclusion, the DSA method proved useful for diagnosing TR.     

Left ventricular dual-energy digital subtraction angiography: a motion immune digital subtraction technique

Digital subtraction angiography (DSA) allows quantitative analysis of ventricular function via densitometric and parametric imaging techniques. However, DSA is limited by the artifacts in temporal subtraction images that result from patient and cardiac motion. Dual-energy subtraction imaging is insensitive to motion. This study evaluated the initial application of dual-energy subtraction in cardiac patients. The image quality of dual-energy subtraction left ventriculograms obtained from a pulmonary artery injection of contrast was assessed in 13 patients, ranging in weight from 54 to 100 kg. The dual-energy images were compared with left ventricular images obtained using standard left ventricular injection cine angiography. End-systolic and end-diastolic ventricular volumes calculated from the cine (C) and dual-energy (DE) images using the Area-Length method were compared. The resulting regression line was DE=0.98 C + 7.0 ml, and the r value was 0.987. Dual-energy subtraction provided good left ventricular visualization, free from misregistration artifacts, even during patient motion.     

Imaging of aortocoronary bypasses with intravenous digital subtraction angiography

We examined 24 patients with 52 coronary bypass grafts, an average of 18 months after their respective operations. During the course of 1 week, a coronary angiography and a digital subtraction angiography (DSA) incorporating an intravenous injection of contrast medium were performed. Conventional coronary angiograms showed 40 bypasses as being open, ten as being occluded, and two could not be displayed at all. With the aid of digital angiography, 50 out of 52 bypasses could be classified as either open or occluded. In 44 out of 52 bypasses, DSA and coronary angiogram results were identical. Using DSA, three out of ten angiographically occluded bypasses were falsely diagnosed as being open and three out of 40 open bypasses as occluded. Two bypasses could not be interpreted due to poor picture quality. In the diagnosis "open bypass" the degree of both sensitivity and specificity subsequently amounted to 92.5%, and 70% in the diagnosis "occluded bypass". The distal part of the bypasses, as well as the proximal and distal part of the anastomoses, could not be evaluated for the most part. Furthermore, on account of the comparatively inferior quality of the pictures, detection of bypass stenosis is not reliable using digital subtraction angiography. Intravenous digital subtraction angiography may therefore serve as a screening method in the evaluation of coronary bypass grafts.     

Pericardiac extravasation during intravenous digital subtraction angiography: a case report

The authors reported a case, pericardiac extravasation of contract medium during an intravenous angiographic (IV DSA) procedure. To their knowledge this is the first such case in the literature. They suggest modifications of the IV DSA method to avoid this complication.     

Left atrial myxoma]

Left-atrial myxomas produce a broad array of clinical symptoms depending on their location, size, and morphology. The clinical presentation is characterized by obstruction of blood flow, systemic embolism, and unspecific systemic effects. Within 6 weeks, three patients presented in our clinic with left-atrial myxomas. Primary differential diagnoses were infective endocarditis, circulatory collapse, and transient ischemic attack of unknown origin. In all cases diagnosis was made with echocardiography (m-mode, 2D, TEE). In this review the etiology, epidemiology, and pathology are reported briefly. The variety of clinical symptoms with the corresponding differential diagnosis is presented systematically and discussed with our patients. Diagnostic, therapeutic, and prognostic aspects are summarized.     

Left atrial myxoma: Demonstration by stop-action cardiac ultrasonography

A case of left atrial myxoma masquerading as a cardiomyopathy is presented; the unsuspected tumor was diagnosed by stop-action cardiac ultrasonography and echocardiography. The stop-action technique complements standard echocardiography by enhancing the delineation of anatomic and spatial orientation. It has previously been applied to congenital cardiac lesions and should prove to be a valuable noninvasive technique in the precatheterization evaluation of acquired heart disease as well.     

Demonstration of the ascending aorta in infective endocarditis by intravenous digital subtraction angiography

Four patients with infective endocarditis were examined by digital subtraction angiography immediately before operation. In three a root abscess was suspected and the remaining patient was believed to have a false aneurysm at an infected aortic cannulation site. In all the cases digital subtraction angiography showed the structure in several projections and confirmed the presence of a cavity. Subsequent operation confirmed the site and nature of the lesions.     

Evaluation of aortic aneurysms and dissection of aorta by intravenous digital subtraction angiography

Intravenous (IV) digital subtraction angiography (DSA) was performed in 12 patients with suspected aortic aneurysm/dissection. Bolus injection of 30-40 ml of contrast in mid right atrium/main pulmonary artery at a flow rate of 18-20 ml/sec. during DSA accurately localised the site and extent in all 7 patients of aortic aneurysm and in 4 patients of aortic dissection. In one patient, radiological opacity was unrelated to aorta. There were no complications. IV-DSA should be the preferred mode of evaluation for aortic aneurysm and dissection of aorta.     

Left atrial mass: thrombus mimicking myxoma

A 31-year-old woman underwent elective transthoracic echocardiography for paroxysmal atrial fibrillation, which showed a large left atrial mass. A two-dimensional echocardiogram showed a large left atrium mass. Subsequent transesophageal echocardiography showed a 3 cm x 3 cm circular mass with smooth contours. The differential diagnosis included myxoma versus thrombus, but because of morphology and mobility of the mass, it was difficult to differentiate one from the other. The patient had been on chronic coumadin therapy for paroxysmal atrial fibrillation. An operation was performed and the intracardiac mass resected. On pathologic examination the mass was diagnosed as an organized thrombus. A brief review of the literature has been presented to discuss the differential diagnosis of the mass in the left atrium.     

Left atrial myxoma: three-dimensional echocardiographic assessment

The patient was a 70-year-old female with antecedents of diabetes mellitus and hypertension, being followed up in the outpatient care clinic due to chronic anemia after corrective surgery for angiodysplasia of the proximal jejunum, in whom an image suggestive of left atrial myxoma was found on routine transthoracic echocardiography. Then multiplanar transesophageal echocardiography and 3-dimensional echocardiography were performed, showing the latter better anatomical details of the tumor. The patient underwent exeresis of the mass with anatomicopathological confirmation of the tumor. Three-dimensional echocardiography proved to be a technique that can provide additional contributions to the diagnostic investigation of structural heart diseases.