Gotsman, M.S.

Quantrill, J.R.

van der Horst, R.L.

Winship, W.S.

English

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13 September 1969 S.A. TYDSKRIF VIR GE EESKUNDE 1141DIAGNOSTIC SELECTIVE CORONARY ARTERIOGRAPHY*M. S. GOTSMAN, M.D., M.R.C.P., M.R.C.P. (GLASG.), D.T.M. & H., W. S. WINSHIP, M.B .. CH.B., M.Mw.(PAW.), J. R. QUA TRILL, M.B., CH.B., D.P.H., D.M.R.D. AND R. L. VA DER HORST, M.B., CH.B.. M.Mw. (PAED.).Cardio-Thoracic Unit, Wentll'onh Hospital and The UniversiTy of aralNo. of casesTABLE 11. CLI ICAL MATERIAL - DIAG 'OSTlC CATEGORIESflure' film. Angiography was then repeated after sub-lingual administration of isorbide dinitrate. a potentcoronary vasodilator.RESL LTS A 'D DISCUSSIONThe clinical material is analysed in Table 11. Satisfactorycoronary arteriograms were obtained in all but one ofthe patients, and the ease of performing the procedure im-proved with experience. The patients had ECG changesimmediately after the injection of contrast medium, butthese returned rapidly to normal once the contrast mediumhad cleared. Serious bradycardia with hypotension occurredin 2 patients but was improved by an intravenous injectionof atropine. One patient developed intermittent claudicationof the right arm after arteriotomy and angiography showedthrombosis of the right brachial artery.I2I3I254225I2IInormalDiagnosis1. Occlusive coronary artery disease (atheroma)Ca) With angina pectoris only .Cb) With severe ischaemic fibrosis2. Aortic valve disease with severe anginaCa) With organic coronary artery diseaseCb) Without CA disease3. Idiopathic hypertrophic obstructive cardiomyo-pathy CHocum) (with angina)4. Cardiomyopathy in Whites5. Bantu patients with atypical symptomsChest painInfarct pattern on ECG .VPA + post-ectopic T-wave change.Hocum . .6. Young females with angina pectoris andcoronary arterial tree .7. Mitral stenosis with atypical angina(a) With organic coronary artery diseaseCb) Without coronary artery disease8. ASD with abnormal ECG .9. Congenital fistula between coronary artery andright ventricle . .10. Mitral incompetence with posterior leafletprolapseofl/wl Anatomy (Fig. I)"The left coronary artery arises from the upper part ofthe left coronary sinus of Valsalva. It has a short main stemof I - 2 cm. and then divides into 2 main branches. Theanterior descending branch runs down the anterior inter-ventricular septum, giving off diagonal branches whichsupply the anterior surface of the left ventricle. and 2 or3 perforating branches which supply the anterior portionof the inter-ventricular eptum. Often a terminal branchcurves round the apex of the ventricle.The circumflex branch of the left coronary artery is theother major branch and passes to the left in the atrio-ventricular groove supplying branches downwards to thefree wall of the left ventricle and up to the atrium. Alarge marginal branch passes down the obtu e margin ofthe left ventricle to supply it lateral urface. The circum-TABLE I. INDICATIONS FOR CORO ARY ARTERIOGRAPHYI. Clinical Corollary Artery Disease.Ca) To establish the diagnosis.Cb) To assess the type and extent of involvement.Cc) To assess LV function.Cd) Performed as a routine before surgery for:(i) Revascularization of myocardium CVinebergoperation).(ii) Coronary endarterectomy.(iii) Resection of ventricular aneurysm.2. Angilla Pectoris ill atl ATypical Clinical Sitllarion.3. ECG Illdicarillg Ischaemic Hearr Disease ill all UllusualPatiellT.4. Left Venrricular Disease with Angilla PeCToris.5. Before Cardiac Surgery: to exclude coronary artery diseasein a patient with angina pectoris.Selective coronary arteriography is an excellent techniqueto demonstrate the living anatomy and pathology of thecoronary vascular tree.""We have used this technique for the past year andthis paper will describe the indications, problems and valueof the procedure, with special reference to our unit inwhich a large portion of the patients are Bantu.PATIE TS AND METHODSCoronary arteriography was undertaken in patients inwhom coronary artery disease was suspected on clinicalor electrocardiographic criteria (Table 1).*D:ue recei\'~d: 21 Fehru3.ry 1969.Local anaesthesia was used, with 50 mg. pethidine asa sedative. The right brachial artery was exposed througha small cutdown immediately above the skin crease in theright antecubital fossa. Routine right- and left-heartcatheterization was then performed and the cardiac out-put was measured by the direct Fick principle. The end-diastolic pressure in the left ventricle was measured. Leftventricular function was also assessed by selective ven-triculography, and this was followed by aortography todemonstrate the aortic valve and root, and the ostia of thecoronary arteries. A o. 7 or 8F Sones coronary arterycatheter with a 1- or Jt-in. tip was then used for selectivecatheterization of each coronary orifice. A 4-way tapsystem permitted continuous monitoring of aortic pressure,flushing of the catheter and intermittent injection of 76 0 0Urografin which was used as a contrast medium. Thepatient was turned into each oblique position (600 rightand left anterior oblique positions) and each coronaryostium intubated in turn. A trial injection of 2 ml. ofUrografin confirmed that the catheter tip had entered thecoronary ostium. The patient was then asked to hold hisbreath in inspiration, and 6 ml. of U rografin was injectedrap;dly by hand under radiographic control. Two to threeinjections were made into each coronary artery in eachposition. Cinephotography was performed through a 9-in. Philips image intensifier using a 35-mm. Arriflexcamera, filming 32 frames per 5econd with Kodak 'Cine-1142 S.A. MEDICAL JOURNAL 13 September 1969flex branch can be identified easily: it follows the samecourse as the coronary inus which drains into the rightatrium.:.IFig. 1. Superimposed tracings of a selective left and ri~htcoronary arteriogram in the left antenor oblique positIOnto show the normal anatomy and atheroma (a) of theleft and right coronary arteries, with obstruction of theanterior descending (AD-ob) and circumflex (c) leftcoronary arteries with well-developed collateral ci rcula-tion (Co). LCA = left coronary artery; RCA = nghtcoronary artery; PI = posterior inter-ventricular artery;C = circumflex artery: M = marginal artery.The right coronary artery arises from the right sinusof Valsalva and has a long, undivided course in the atrio-ventricular groove between the right atrium and ventricle.It passes to the crux of the heart where a terminal branchfollows the left atrioventricular groove and another majorbranch passes down the posterior inter-ventricular groove.Major branches include a small ascending branch to thesino-atrial node, larger branches to the atrium, a largemarginal branch to the margin of the right ventricle.smaller right ventricular branches and perforating branchesin the posterior inter-ventricular septum. It also supplies asmall artery to the atrioventricular node.In the majority of patients, the right coronary artery is'dominant'-it supplies the crux of the heart and givesoff the posterior inter-ventricular artery. In 20 0 0 of patientsthis region is supplied by a left coronary artery which isthen regarded as 'dominant'. The artery to the crux of theheart usually gives off the artery to the atrioventricularnode. Occasionally the sinus node artery arises from theorigin of the circumflex left coronary artery.Technical Quality of AngiographyThree techniques of coronary arteriography give goodresults. Nordenstrom'O utilizes non-selective aortography.The procedure is undertaken under general anaesthesia andthe endo-bronchial pressure i raised to 2 atmospheres tostop the venous return to the heart. The cardiac output thenfalls and contr, st is selectively layered within the root of theaorta. Biplane serial roentgenography on 14 x 14-in. rollfilm at 6 exposures per second provides excellentanatomical details of the smaller vessels. This is a goodtechnique but requires general anaesthesia. Judkins" usesa catheter with a preformed tip inserted percutaneouslyinto the femoral artery and performs mUltiple injections indifferent positions. This procedure has great promise. TheSones technique is now employed in many centres."" It isa difficult technique and requires perfect radiography.Our X-ray equipment was not ideal and we could notobtain adequate magnification. A 6-in. image intensifierwith lOO-mm. focal-distance lens is needed for optimumradiographic quality. Despite these disadvantages our filmswere of adequate quality and resolution.Occlusive Coronary A rtery DiseaseSeven patients had atheroma of the coronary arteries.Two had obstruction of one artery with well-developedcollateral vessels and good left ventricular function; 5others had localized abnormalities of the pattern of ven-tricular contraction-akinesis, dyskinesis or aneurysmformation. Two of the latter group had obstruction of onevessel, 2 had obstruction of 2 vessels and I had obstructionof 3 vessels. In general, patients with severe clinical dis-ability and shortness of breath had more severe leftventricu'ar dysfunction and more extensive artery disease.One 33-year-old patient had severe angina pectoris andgood left ventricular function. His left internal mammaryartery was implanted into the anterior surface of the leftventricle. Surgery was not undertaken in the other 6patients: their angina was too mild or their left ventriculardysfunction too severe.In each patient, coronary arteriography was the onlyexact method to determine the anatomy of the coronaryartery obstruction and disease, and the extent to which thecollateral circulation had developed. The left ventriculo-gram identified the degree of left ventricular dysfunction.Aortic Valve Disease with Severe Angina PectorisPatients with aortic stenosis or incompetence oftenpresent with classical angina pectoris. Left ventricular hy-pertrophy increases the oxygen demand of the heart andeach lesion compromises coronary perfusion on a hae-modynamic basis. Thus, in aortic stenosis, the systolicpressure in the left ventricle exceeds aortic pressure, where-as in aortic incompetence the low aortic diastolic pressureis unable to maintain an adequate diastolic coronary bloodflow.Six older subjects presented with severe angina pectoris.Four had associated organic disease of the coronaryarteries. while 2 did not have coronary artery disease.Selective coronary arteriography, therefore, is mandatoryin patients with aortic valve disease associated with anginapectoris. Many of these patients are regarded as cases ofischaemic heart disease and their aortic systolic murmur isattributed to aortic valve sclerosis. Often the aortic stenosisis severe and responsible for the patient's symptoms.Idiopathic Hypertrophic Obstructive CardiomyopathyThree patients with this syndrome presented with severeangina pectoris: 2 were diagnosed and referred as casesof ischaemic heart disease. The correct diagnosis was con-firmed by catheterization and left ventriculography. and thecoronary arteries were demonstrated to be large, but normaland patent.13 September 1969 S.A. TYDSKRIF VIR OE EESKUNDE 1143A clinical diagnosis can be made if the diagnosis iskept in mind, but if the patient presents with severeangina pectoris or if the physical signs are slightly atypical,the diagnosis may be missed.Cardiomyopathy in White PatientsOne older subject with heart failure had electrocardio-graphic features of left ventricular damage. Coronaryarteriography was undertaken to exclude coronary arterydisease.Myocardial fibrosis, secondary to ischaemic heart dis-ease, and primary myocardial disease may resemble eachother if there is no history of angina pectoris. Coronaryarteriography is then the only method of arriving at thecorrect diagnosis.Bantu Patients with Atypical SymptomsIschaemic heart disease was suspected on clinicalgrounds in 5 patients. One young subject had typicalprecordial pain but had normal intracardiac dynamics andcoronary arteriograms. Two had an infarct pattern on theelectrocardiogram and a loud 3rd heart sound. Both hadlocalized, non-contractile segments of the left ventricle dueto localized cardiomyopathy without coronary artery dis-ease. Another patient had numerous ventricular prematuresystoles with post-ectopic T-wave changes and a loud 3rdheart sound. She also had primary myocardial disease. The5th patient had hypertrophic obstructive cardiomyopathy.In each case coronary arteriography demonstrated normalcoronary arteries.Angina ill Young FemalesTwo premenopausal women with typical anginapectoris had abnormal electrocardiographic patterns inkeeping with coronary artery disease. There was noevidence of diabetes or hypercholesterolaemia. Both hadnormal coronary arteriograms, thus excluding significantdisease of the large coronary arteries. These patients prob-ably have abnormalities of the coronary arteries-smallvessel angina."Mitral Stenosis with Atypical AnginaAngina pectoris also occurs in patients with mitral valvedisease and may be due to severe pulmonary hypertension,coronary artery embolism or associated organic atheros-clerotic coronary artery disease." Three patients with mitralvalve disease and severe pulmonary hypertension presentedBOEKE ONTVANGWhirby {/nd Bri((on's Disorders of rhe Blood. 10th ed. By e.J. e. Britton. M.D. (New Zealand), D.P.H., Fe. Path.Pp. viii + 860. Illustrated. n.1O.0. London: J. & A.Chu rchill. 1969.An !nrroducrion to Child Psychiarry. 2nd ed. By S. Chess,MD. Pp. viii + 263. $6.75. New York and London:Grune & Stratton. 1969.Operarive Surgery Revision. 2nd ed. By J. J. Shipman, M.S.(Lond.). FR.e.S. (Eng.). Pp. vii + 171. £1.15.0. London:H. K. Lewis. 1969.Pye's Surgical Handicrafr. 19th ed. Ed. by J. Kyle, M.Ch. (BelL),F.R.e.S. (I.), FR.e.S. (Eng.), FR.e.S. (Edin.). Pp. xii +820. Illustrated. £3.9.6. Bristol: John Wright & Sons. 1969.with atypical angina pectoris. One patient had organiccoronary artery disease and in the other 2 the coronaryarteries were normal.CONCLUSIONSCoronary arteriography is a simple, safe and reliableprocedure, provided it is undertaken by experienced per-sonnel who have facilities available for immediate re-suscitation when cardiovascular catastrophes such as ven-tricular fibrillation or complete heart block occur. Theindications for coronary arteriography have now crystal-lized and we perform the investigations in any patient withcoronary artery disease in whom surgery is contemplated.any patient with valvular heart disease who might be sub-ject to open heart surgery and who has a history of anginapectoris, and unusual patients with difficult diagnosticproblems in whom coronary artery disease is suspected.The last group includes Bantu patients who present withangina pectoris or an eiectrocardiographic pattern in keep-ing with myocardial infarction.SUMMARYSelective coronary arteriography was performed on 30 subjects.It was a simple, safe and reliable technique and was performedin patients with coronary artery disease awaiting surgery. inpatients awaiting cardiac surgery who also had anginapectoris, and in patients with angina' pectoris or atypicalheart disease in whom a confident diagnosis was needed.We wish to thank Dr S. Disler, Medical Superintendent ofWentworth Hospital, for permission to publish. and theEthical Drug Association Foundation for financial assistance.REFERE CESl. Son~s. F. M. jnr and Shirey. E. K. (1960): Circulation. 22. 81-.2. Sones, F. M. and Shirey. E. K. (1962): Mod. Cone. Cardiov. Di, ..3 I. 7353. Proud fit. W. L.. Shirey, E. K. and Sones. F. M. jnr (1966):Circulation. 33, 90l.4. Proudfit, W. L., Shirey, E. K. and Sones. F. M. (1967): Ihid .. 36.54.5. Proud fit, W. L., Shirey, E. K., Sheldon. W. C. and Sones, F. M.(968): Ihid .. 38. 947.6. Sewell, W. H. (1965): Amer. J. Roentgenol.. 95. 673.7. Cohen. L. S.. Elliot. W. S.. Klein, M. D. and Gorlin. R. 119661:Amer. J. Cardiol.. 17. 153.8. Elliol!. W. C. and Gorlin. R. (1966): Mod. Cone. Cardiov. Di, ..35. 117.9. Hultgren. H., Calciano. A., Pial!. F. and Abrams. H. (1967): Amer.J. Med .. 42. 228.10. 'ordenstrom. B. (1964): Radial. Ciin. N. Amer.. 2. 377.11. Judkins. M. P. (1967): Radiology. 89. 815.12. James. T. N. 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Diagnostic selective coronary arteriography

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Diagnostic selective coronary arteriography

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