Axial cineangiography in congenital heart disease. Section I. Concept, technical and anatomic considerations

Cineangiographic axial techniques were designed to overcome the limitations of conventional angiography in the diagnosis of congenital heart disease. Two basic patient (or equipment) maneuvers are involved; 1) long axis of the heart is aligned perpendicular to the X-ray beam, and 2) rotation of patient results in the heart being radiographically sectioned at 30 degree angles. To accomplish this with fixed vertical and horizontal X-ray tubes, three positions were developed: 1) "hepato-clavicular," "4 chamber," 2) "long axial oblique," 3) "anterior-posterior axial." A fourth, the "sitting-up" projection is discussed. The hepato-clavicular position profiles the posterior ventricular septum and atrial septum, separates the A-V valves, places the four cardiac chambers en face, and clarifies mitral valve-semilunar valve and outflow tract relationships. The long axial oblique profiles the anterior ventricular septum, left ventricular outflow tract, aortic valve-anterior mitral valve leaflet. The sitting-up view visualizes the bifurcation of the pulmonary trunk and separates true pulmonary arteries from systemic collaterals.

Chest pain and bilateral atrioventricular valve prolapse with normal coronary arteries in isolated corrected transposition of the great vessels. Clinical, angiographic and metabolic features

A man evaluated for disabling chest pain was found to have isolated anatomically corrected transposition of the great vessels. Angiography demonstrated right and left atrioventricular (A-V) valve prolapse and normal coronary arteries. Atrial pacing produced chest pain, ischemic electrocardiographic changes, abnormal myocardial lactate metabolism and marked elevation of the left ventricular end-diastolic pressure; all of these changes returned to normal on termination of pacing. The association of corrected transposition and bilateral A-V valve prolapse and the possible causes of myocardial ischemia in this patient are discussed.

Left ventricular size and function and heart size in the year following myocardial infarction

Interrelationships among left ventricular (LV) size, LV function, and heart size were investigated in 49 patients studied 2-12 months after myocardial infarction. LV end-diastolic volume (EDV) and ejection fraction (EF) were determined by biplane ventriculography. Heart size was estimated from chest films by the cardiothoracic ratio (CTR) and cardiac volume (CV) methods. Ventricular function (i.e., EF) was related to chamber size (i.e., EDV), but the correlation coefficient was not high ( r = 0.74); thus, chamber size was not an accurate predictor of EF. Because of the close linear relation that exists between LV end-systolic volume and EDV ( r = 0.98), a hyperbola describes the relation between EF and EDV. In general, EF was depressed (<0.50) when EDV exceeded 70 ml/m 2 , was <0.35 when EDV exceeded upper normal limits (110 ml/m 2 ), and was <0.25 with chamber size >150 ml/m 2 . Thus relatively small chamber size (<150 ml/m 2 ) was associated with a wide range in ventricular function, while large chamber size was associated with severe dysfunction (EF < 0.30). By either heart size method, cardiomegaly (CTR > 0.50 or CV > 540 ml/m 2 ) was not found consistently until EDV exceeded 150 ml/m 2 . Hence normal heart size was often associated with moderate EF depression (0.49-0.30), while cardiomegaly was often associated with severe dysfunction. Clinical heart failure (CHF) was usually accompanied by EF < 0.30, but chamber size ranged from 101 to 331 ml/m 2 . Primarily because of this variation in chamber size, both normal heart size and cardiomegaly were at times associated with CHF.

The poor correlations of EF with CTR ( r = –0.43) and CV ( r = –0.52) preclude use of the heart size indices as accurate predictors of LV function. When the data were analyzed according to the presence or absence of cardiomegaly, the following generalizations could be made regardless of the heart size method used. Cardiomegaly was a reasonable indicator of postinfarction LV function, being associated with depressed function and often with CHF. However normal heart size was associated with either normal LV function, or commonly, with depressed function, often not clinically apparent.

Surgical treatment of double-outlet left ventricle. Report of four cases

Four patients with double-outlet left ventricle and ventricular septal defect have been successfully corrected surgically. Three of the patients had pulmonary stenosis, and one did not. Three patients had d -position of the great arteries, and one patient had l -position with the aorta anterior and to the left. Surgical correction was accomplished by repairing the ventricular septal defect, closing the connection between left ventricle and pulmonary artery, and creating a conduit between right ventricle and pulmonary artery. The preferred conduit is a composite valved one.

Cardiac repair in anatomically corrected malposition of the great arteries

Anatomically corrected malposition of the great arteries is a congenital cardiac malformation in which the atria and ventricles are in concordant relation, as are the ventricles and great arteries, but the aorta is to the left of the pulmonary artery (1-position). The reported cases and our two patients have had situs solitus of viscera and atria. The aortic and pulmonary circulations are in series. We report successful surgical repair in 2 patients with associated large ventricular septal defects and pulmonary stenosis. In one the defect was posterior and in relation to the pulmonary artery which slightly overrode it. In the other the defect was anterior and the aorta overrode it. The developmental basis of these two examples of the same entity is probably different. An appropriate terminology and categorization that is useful surgically is presented.