Cardiac Catheterization

Indications:

o This should be performed for coronary angiography studies before AVR in patients at risk for CAD, including men older than 35 years, premenopausal women older than 35 years with coronary risk factors, and postmenopausal women.
o It can be used to assess the severity of regurgitation when noninvasive test results are inconclusive or discordant with clinical findings regarding the severity of regurgitation or the need for surgery.
o Use cardiac catheterization to assess LV function when noninvasive test results are inconclusive or discordant with clinical findings LV dysfuncation and the need for surgery in patients with severe AR.

Qualitative assessment (Aortic Angiogram):

o In mild AR (1+), a small amount of contrast enters the left ventricle during diastole and clears with each systole.
o In moderate AR (2+), more contrast enters with each diastole, and faint opacification of the entire LV chamber occurs.
o In moderately severe AR (3+), the LV chamber is well opacified and equal in density when compared with the ascending aorta.
o In severe AR (4+), complete dense opacification of the LV chamber occurs on the first beat and the left ventricle is more densely opacified than the ascending aorta.

Simultaneous aortic and LV pressure tracing (signs of severe AR):

o Wide pulse pressure may be present.
o LV diastolic pressure increases rapidly.
o Near quilibration of aortic and LV pressure occurs at diastole.

Imaging Studies:

M-mode features of AR include the following.

o Diastolic flutter of the mitral valve (can be both anterior and posterior mitral valve leaftlet)
o Diastolic flutter of the aortic valve
o Premature closure of the mitral valve (severe AR)
o Premature opening of the aortic valve (severe elevated LV end-diastolic pressure)
o Diastolic LV septal fluttering
o LV volume overload (hyperkinesis of the LV walls LV dilation)
o LVESD (>55mm indicates poorer surgical outcome)

On 2 Dimensional echocardiography, look for the following features:

o Flail aortic aneurysm.
o Dilatation of the sinuses of Valsalva (particularly in patients with Marfan syndrome or bicuspid aortic valve problem).
o Ascending aortic aneurysm.
o Incomplete closure of the aortic valve cusps on the parasternal short axis view of the aortic valve.
o High frequency diastolic fluttering of the anterior leafleft of the mitral valve during diastole.
o Reverse doming of the anterior mitral valve leafleft.
o LV volume overload pattern.
o Measurements of LV end diastolic and end-systolic dimensions and volumes. Shortening fractions and EFs - Criticall in determining the optimal time for valve replacement.
o Measurement of aortic regurgitant fraction, reguirgitant orifice size, and regurgitant volumes – Now available with Doppler echocardiography.

Dr. D.S. Merchant is a Gold Medalist in (Anatomy & Histology) Resident AKU has written articles on Cardiac Catheterization, Aortic Regurgitation, Pulmonary Sarcoidosis, Tuberculosis, Viral Hemorrhagic Fever, VHF Solutions, Hypertensive Disorders. Please leave the links intact if you wish to reprint this article.

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