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Coronary Angiography and Ventriculography 143
at the mid septum, the initial portion of the CFX artery courses
toward the aorta (the normal position of the proximal LAD), and
the LAD artery is relatively short (i.e., only the mid and distal LAD
are present). During RAO ventriculography, aortography, or coronary angiography, the LMCA and the CFX artery form an ellipse
(“eye”) to the left of the aorta, with the LMCA forming the superior
portion and the CFX forming the inferior portion.
3. Retroaortic course (benign): The LMCA passes posteriorly around
the aortic root to its normal position on the anterior surface of the
heart (Fig. 3-32). It divides into LAD and CFX arteries at the normal
point and gives rise to LAD and CFX coronary arteries of normal
length and course. During RAO ventriculography, aortography,
or coronary angiography, the LMCA is seen “on end,” posterior to
the aorta, and appears as a radiopaque dot, which signifies a
Posterior
“dot”
A
M
C
L
B
Figure 3-32 A, Diagram of retroaortic course of anomalous lef t coronar y
artery (LCA). C, Circumflex; L, left anterior descending ar tery; M, lef t main.
B, Intraseptal course of left main coronary ar tery (LMCA) from right sinus.
The LMCA, when it originates within the right sinus of Valsalva or from the
proximal right coronary artery (RCA), may take an inferior and intraseptal
course, a superior course anterior to the pulmonary artery, or a serpentine
course between the great arteries (which carries a risk of sudden death).
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Anterior
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posteriorly coursing anomalous vessel. (It is also seen with anomalous origin of CFX from the right sinus.)
cardial ischemia has been reported in only a few individuals.
4. Interarterial course (malignant): The LMCA courses between the
aorta and PA to its normal position on the anterior surface of the
heart (Fig. 3-33, only top part). It divides into LAD and CFX arteries
at the normal point and gives rise to LAD and CFX coronary arteries
of normal length and course. During RAO ventriculography, aortography, or coronary angiography, the LMCA is seen “on end,” anterior
to the aorta, and appears as a radiopaque dot to the left of the aortic
root. This variant is considered malignant and coronary revascularization with translocation is indicated in patients with myocardial ischemia. The need for revascularization in older patients with
this anomaly is less clear. A decision for revascularization should
be based on the severity of concomitant obstructive coronar y
disease and inducible myocardial ischemia.
Coronary Angiography and Ventriculography
Note: This variant is considered benign, and evidence of myo-
Anomalous Origin of the Right Coronary
Artery from the Left Sinus of Valsalva
(Malignant)
When the RCA arises from the left coronary cusp or the proximal
LMCA, it generally follows only one path, although other courses are
theoretically possible and have been reported. The RCA generally
courses between the aorta and PA to its normal position. During RAO
ventriculography (Fig. 3-34), the anomalous RCA (ARCA) is seen “on
end,” anterior to the aorta, and appears as a radiopaque dot. This coronary anomaly has been associated with symptoms of myocardial
ischemia, particularly when the RCA is dominant. Coronary revascularization should be considered when this anomaly is associated with
symptoms of myocardial ischemia. When the ARCA arises from an
anterior location or high above the sinus of Valsalva, an aortic root
injection will help locate the ostium for subselective catheter engagement using AL2 or MP catheters.
Anomalous Right Coronary Artery Above the
Sinus of Valsalva or from the Anterior
Aortic Wall (Benign)
The RCA may arise from an anterior location or high above the sinus
of Valsalva. Aortic root flush injection helps locate the ostium
for proper, subselective catheter selection (using AL2 or MP catheters,
for example).
“dot”
Figure 3-33 Intraarterial course of left main coronary arter y (LMCA) from
right sinus. C, Circumflex; L, left anterior descending ar tery; M, left main.
C
M
L
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Posterior
“dot”
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Coronary Angiography and Ventriculography 145
CFX
A
B
Figure 3-34 A, Diagram of retroaor tic course of circumflex (CFX) from the
left coronary cusp. B, The anomalous circumflex (CFX) arter y usually originates from the right sinus of Valsalva with a separate ostium or from the
proximal right coronary artery (RCA). The typical course of this benign
anomaly is retroaortic as it travels to the lateral surface of the lef t ventricle
(LV). The right anterior oblique (R AO) view shows a “dot” of the anomalous
retroaortic course of the CFX.
Anomalous Origin of the Left Anterior
Descending Coronary Artery from the Right
Sinus of Valsalva (Benign)
When the LAD artery arises from the right aortic cusp or the proximal
RCA, it generally follows one of two pathways, although other courses
are possible.
1. Anterior free wall course: The LAD coronary artery crosses the
anterior free wall of the right ventricle and then at the mid septum
turns toward the apex. During RAO ventriculography, aortography,
or coronar y angiography, the LAD artery is seen as passing to the
left and upward before turning toward the apex. This coronary
anomaly is benign.
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2. Septal course: The LAD coronary artery runs an intramuscular
course through the septum, along the floor of the RVOT. It then
surfaces in the mid septum and turns toward the apex. During RAO
ventriculography, aortography, or coronary angiography, the LAD
artery is seen as passing to the left and downward before turning
toward the apex. This anomaly is benign.
Coronary Angiography and Ventriculography
Ventriculography
The left ventriculogram is an integral part of every coronary arteriographic study and provides information about LV wall motion and
overall function of the heart. Figure 3-35 shows the LV in systole and
diastole in RAO and LAO projections. In the RAO view, from the 1
o’clock position, LV segments are the anterior base, anterior, apical,
inferior, and inferior base. The lateral wall cannot be seen in the RAO
projection. In the LAO view, the LV segments, moving from 12 o’clock
clockwise, are the high lateral, lateral, apical, septal, and base (see
Fig. 3-3).
Abnormal wall motion indicates the presence of coronary ischemia, infarction, aneurysm, or hypertrophy. Left ventriculography also
provides quantitative information, such as the ventricular volumes
during systole and diastole, ejection fraction (EF), rate of ejection,
quality of contractility, presence of hyperdynamic hypertrophic contraction, and valvular regurgitation. Ventricular function in general
and EF in particular predict the long-term outcome of patients
with CAD.
Ventriculography may be performed before or after coronary
angiography. Coronary angiography is routinely performed first
because ventricular function can be obtained through noninvasive
methods in case of complications that terminate the study prema-
A B
C D
Figure 3-35 A, Left ventriculographic frame 30 -degree right anterior
oblique (RAO) projection in diastolic. B, In systole. C and D, Left ventriculographic frame in diastole and systole, respectively.
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Coronary Angiography and Ventriculography 147
Box 3-2 Indications and Complications of Left
Ventriculography
Indications
1. Identification of LV function for patients with CAD, myopathy, or valvular
heart disease
2. Identification of VSD
3. Quantitation of the degree of mitral regurgitation
4. Quantitation of the mass of myocardium for regression of hypertrophy
or other similar research studies
Indications for Right Ventriculography
1. Documentation of tricuspid regurgitation
2. Assessment of RV dysplasia for arrhy thmias
3. Assessment of pulmonary stenosis
4. Assessment of abnormalities of pulmonar y outflow tract
5. Assessment of right-to-left ventricular shunts
Complications
1. Cardiac arrhythmias, especially nonsustained brief V T, do not require
treatment; sustained VT and ventricular fibrillation require immediate
cardioversion (Note: Arrhy thmias and staining are more common with
the use of end-hole catheters than with any other pigtail catheters.)
2. Intramyocardial contrast media “staining” during power injec tion
(generally transient and of no clinical imp ortance unless it is deep or
perforating producing tamponade)
3. Embolism (thrombi or air)
4. Contrast- related complications
5. Transient hypotension (<15 to 30 seconds) was common with ionic
high-osmolar contrast media
CAD, Coronar y arter y disease; LV, lef t ventricular; RV, right ventr icular; VSD,
ventricular septal defec t; V T, ventr icular tachycardia.
turely. The indications, contraindications, and complications for ventriculography are shown in Box 3-2.
Technical Notes for Ventriculography
Catheter Selection: End of the End-Hole Left
Ventricle Catheter
Left ventriculography, once an integral part of every cardiac angiographic procedure, has been reconsidered as often unnecessar y in
light of high-quality echocardiography for LV functional assessment.
In the 1980s, end-hole catheter ventriculography with an MP or Sonestype catheter was in decline and was ultimately replaced by the pigtail
multiside hole catheter because of increased safety with less ventricular ectopy and near absence of LV perforation. However, the practice
of end-hole ventriculography often performed through a JR catheter
with a hand injection for operator convenience has come under scrutiny as an inappropriate catheterization laboratory technique that
should be abandoned.
End-hole LV catheter angiography can cause serious harm with
poor catheter positioning. An operator can cause LV perforation with
an end-hole catheter (e.g., an MP catheter) when the tip is against the
LV wall and contrast is injected directly into or through the myocardium, followed by tamponade and cardiac arrest.
Another practice to be discouraged is the use of hand injection
for left ventriculograms. Hand delivery of a large contrast bolus to
adequately opacify the LV more often than not results in an inadequate
and nondiagnostic study. If one cannot perform a good LV study, get
an ECG. Although some operators perform hand injections to reduce
contrast use (e.g., in patients with chronic kidney disease at risk of
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contrast nephropathy), these images are nearly always suboptimal
and indeed may be misleading because too little contrast may not
identify hypokinetic LV segments. It goes without saying that one
should not bill for a “non-LV gram.” Quantitative left ventricular ejection fraction (LVEF) and wall motion assessment are optimal, but they
have been reserved generally for research studies. The visual estimate
of the LVEF is acceptable. Grading LVEF by 10% variance is probably
common (i.e., <20%, 20% to 30%, 30% to 40%, 40% to 50%, etc.).
both routine and emergency catheterizations. Cited reasons include
(1) preference for echo assessment, (2) concern for extra contrast
load, (3) fear of hypotension or complications of ventriculography,
and (4) extra time needed to perform the left ventriculogram. These
fears arise from a dated experience wherein the left ventriculogram,
performed with ionic, hyperosmolar contrast media, was associated
with worsening congestive heart failure (CHF), hypotension, arrhythmias, and death. These events do not occur with modern low-osmolar
or nonionic low-osmolar contrast media (LOCM). A left ventriculogram at the time of catheterization provides an accurate prediction of
the patient’s outcome relative to his or her coronary status. A lowvolume left ventriculogram (20 to 25 mL) has a very remote chance of
complication and will be immediately available for review in the catheterization laboratory at the time of surgical consultation for a onestop visit with full disclosure. Hence, in most patients the benefits of
ventriculography far outweigh the risks.
not responding to conventional medical treatment for heart failure
(i.e., with LV end-diastolic pressure >
with chronic kidney disease or those at higher risk for contrast-induced
nephropathy (diabetics, patients with proteinuria, or dehydrated/
hypotensive patients) to limit contrast exposure.
Coronary Angiography and Ventriculography
Some operators prefer to omit left ventriculography from
Left ventriculography should be omitted in compromised patients
35 mm Hg) as well as in patients
Operator Technique
During contrast injection, the physician performing the ventriculogram should be holding the catheter with the right hand and the
sheath with the left, preparing to withdraw the catheter if necessary,
observing the physiologic monitor, and looking for problems, such as
myocardial contrast staining, VT, or sudden hypotension. Rapid catheter withdrawal may be required. A pull back distance of 10 to 15 cm
from the femoral approach or 5 to 10 cm from the arm is needed to
take out the slack before the end of the catheter moves out of the
ventricle. Small-diameter (e.g., 4 F to 5 F) catheters require high injection pressures and do not allow flow rates >
nections to the manifold or direct connection to the catheter must be
secured so that inadvertent catheter-injector tubing separation does
not spray the operator, patient, and laboratory with contrast media.
Patients should be forewarned about the sudden warm sensation they
will feel during ventriculography. This will last for 30 to 60 seconds
and usually passes without incident.
13 mL/sec. Injector con-
Ventriculography Views
Standard left ventriculographic views are (1) a 30-degree RAO that
visualizes the high lateral, anterior, apical, and inferior LV walls and
(2) a 45- to 60-degree LAO, 20-degree cranial angulation that best
identifies the lateral and septal LV walls. The LAO with cranial angulation provides a view of the interventricular septum, projected on edge
and tilted downward to give the best view of ventricular septal defects
and septal wall motion. Biplane ventriculography, sometimes available
in some catheterization laboratories, involves increased radiation and
more time spent positioning equipment. These considerations are
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Table 3 -3
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Coronary Angiography and Ventriculography 149
Recommended Sites of Injection and Angiographic
Projections in the Evaluation of Valvular Regurgitation
and Shunts
Filming Projections Site of Injection
Type of Valvular Regurgitation
Aortic LAO, R AO Aortic root
Mitral RAO cranial, LAO (lateral) LV
Tricuspid R AO (shallow, lateral) RV
Pulmonic RAO, LAO, AP Main PA
Type of Cardiac Shunt
ASD LAO cranial PA
VSD LAO cranial LV
PDA AP cranial Aorta
AP, Anterior-p osterior; ASD, atrial septal defect; LAO, left anterior o blique; LV, left
ventricle; PA, pulmonary artery; PDA, patent duc tus ar teriosus; RAO, right anterior
oblique; RV, right ventricle; VSD, ventricular septal defect.
Table 3 -4
Angiographic Quantitation of Valvular Regurgitation
Mitral Regurgitation Aortic Regurgitation
+ Mild LA opacification; clears
rapidly; of ten jetlike
++ Moderate LA opacification < LV ++ Regurgitant jet faintly opacifies
+++ Diffuse contrast regur gitant;
LA opacification = LV; LA
significantly enlarged*
++++ LA opacification > LV,
persistent; systolic pulmonary
vein opacification may occur;
often marked LV enlargement*
+, 1; ++, 2+; +++, 3+; ++++, 4+; LA , lef t atrium; LV, left ventricle.
*Chronic regurgitation.
+ Small regurgitant jet only; LV
ejects contrast each systole
LV cavity; not cleared each systole
+++ Persistent LV opacification =
aortic root density; LV
enlargement*
++++ Persistent LV opacification >
aortic root concentration; often
marked LV enlargement*
offset by providing more information with less contrast media, which
is often important, especially in children and patients with renal
failure. If no biplane system is available, patients with coronary disease
affecting the lateral wall should have a second left ventriculogram in
a 60-degree LAO, 20 -degree cranial view. Almost every such patient
with normal renal function can tolerate an additional 30 to 40 mL of
contrast material.
Historically, cineangiographic frame rates have been 30 to
60 frames/sec depending on heart rate (30 frames/sec for rates of
<95 beats/min). Recent information suggests that 7.5 frames/sec will
produce satisfactory images with markedly reduced radiation. A
10-inch image field is routine, and collimating should be used to limit
radiation scatter. Recommended views for valvular regurgitation are
shown in Table 3-3. The angiographic quantitation of valvular regurgitation is shown in Table 3- 4.
Regional Left Ventricle Wall Motion
The normal pattern of LV contraction has been defined as a uniform,
concentric, inward motion of all points along the ventricular inner
surface during systole. Uniform wall motion depends on the cooperative and sequential contraction of the heart muscle, producing
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maximal effective work at minimal energy costs. This coordinated
contraction is called synchrony. Uncoordinated contractions of LV wall
motion are given names according to the severity of asynergy. Abnormal LV wall motion is particularly obvious in patients with severe CAD
or cardiomyopathy. Several methods exist to analyze LV wall motion
(Fig. 3-36). In general, individual segments are evaluated and reported
to have normal contraction, hypokinesis (sluggish or slowed contraction), akinesis (lack of contraction), or dyskinesis (movement of the
segment outward during systole and suggestive of a ventricular
aneurysm).
Coronary Angiography and Ventriculography
Contrast Volumes
Adequate visualization and opacification of the ventricular chambers
are accomplished by delivery of a large bolus (20 to 50 mL) of x-ray
contrast medium over a short period (1 to 3 seconds). For best quality,
a powered injection technique should be used. Typical power injector
settings for an average adult are total volume 20 to 50 mL at 10 to
15 mL/sec. The rate of rise to maximal pressure is also a variable that
can be set for smoother contrast delivery, typically a 0.5-second rise
time. With the catheter in the far apical position, a lower rate and
AA
Figure 3-36 Lef t ventriculographic wall motion analysis. A, Normal left
ventricle (LV) wall motion shows concentric inward motion of all LV wall segments. Bottom panel, Chords and deviation from midline.
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Coronary Angiography and Ventriculography 151
BB
Figure 3-36, cont’d
gram. Note failure of the LV to move inward on inferior wall. Bottom panel,
Abnormal chords above mean values. The centerline method of regional wall
motion analysis uses end-diastolic and end- systolic LV endocardial contours. Lower panels show how a centerline is constructed by the computer
midway bet ween the two contours. Motion is measured along 100 chords
constructed perpendicular to the centerline. Motion at each chord is normalized by the end -diastolic perimeter to yield a shortening fraction. Motion
along each chord is plotted for the patient (dark line). The mean motion in
the normal ventriculogram group (thin line) and 1 standard deviation (SD)
above and below the mean (dotted line) are shown for comparison. Wall
motion also is plotted as the difference in units of SDs from the normal
mean (right panel). Horizontal zero line, Normal ventriculogram group mean.
volume can be used (e.g., 10 mL/sec for 20 to 25 mL). Lower-volume
LV grams can be obtained with operator-controlled power injections
that are stopped when the ventricle is satisfactorily opacified. Hand
injection for ventriculography often produces suboptimal chamber
opacification, may be misleading, and should be discouraged.
B, Inferior wall motion abnormality on lef t ventriculo-
Setup of Contrast Medial Power
(High-Pressure) Injectors
Because contrast media is viscous and great force is necessary to
inject contrast rapidly through small catheters, power injectors are
always used to deliver a preset contrast volume over a brief period.
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Three steps are critical to safe ventriculography: (1) contrast loading,
(2) air bubble clearing from the injection syringe and high-pressure
connecting tubing, and (3) correct injector settings.
from the transparent pressure injection syringe and tubing before
any injection. This is an obligation of all physicians and nurses in the
laboratory. There is no excuse for injection of air during contrast
ventriculography.
follows:
1. Flow rate (10 to 15 mL/sec)
2. Total volume (20 to 50 mL)
3. Pressure limit (900 to 1200 psi)
4. Rise time (0.2 to 0.5 sec)
Coronary Angiography and Ventriculography
The most important step of the setup is to clear all air and bubbles
Typical injection pressure settings for ventriculography are as
Catheter Position
The optimal catheter position for left ventriculography is one that
avoids contact with the papillary muscles and is not positioned too
close to the mitral valve, so that mitral regurgitation is not produced
artificially. For most catheters, a mid-cavity position seems best
because contrast material fills most of the LV chamber and apex, and
the catheter during injection does not interfere with mitral valve function. In this position, pigtail catheter side holes are well below the
aortic valve, which improves chamber opacification. Angled (145
degrees) pigtail catheters and helical tip designs (Halo catheter; see
Fig. 3-5) may provide better quality ventriculography with less induced
ectopy and mitral regurgitation.
The pigtail loop of the catheter may be coiled upward or downward in front of the mitral valve in the RAO plane as long as it does
not interfere with mitral valve apparatus and produce ectopy. Twisting
and opening of the pigtail loop with each beat indicates interference
with the mitral valve apparatus. When the position of the catheter is
in question, a test injection of 5 to 8 mL of contrast material confirms
proper catheter position (i.e., catheter is not entrapped in the valve
structures or trabeculae).
For right ventriculography, a 7-F Berman balloon-tipped catheter
(with no end hole and side holes proximal to balloon) produces excellent opacification. The angiographic projection of right ventriculography is not standardized. An AP-cranial or -lateral projection is
commonly used to visualize the septum and RVOT. Injection rates
range from 8 to 10 mL/sec for volumes of 20 to 30 mL.
Ventricular Ectopy
Ventricular ectopy during powerful contrast material injection is
common and generally does not require antiarrhythmic medications.
A stable rhythm should be maintained before contrast material injection by careful catheter positioning between the papillary muscles and
the inferior LV wall. Ventricular ectopy is commonly produced by use
of end-hole (e.g., MP) catheters. A pigtail shape is safer. A Halo catheter is an out-of-plane pigtail loop with all holes directed into the
center of the loop and produces LV grams with nearly no ectopy.
Measurements of Left Ventricle Contractility
The most common measures of LV function are the EF and stroke
volume (SV). The EF (%) is calculated as:
EDV ESV
EF
=
EDV
SV EDV ESV= −
−
×100
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