Usefulness of right ventriculography compared with computed tomography for ruling out the possibility of lead perforation before lead extraction.

PURPOSE: High-risk patients can be identified by preprocedural computed tomography (CT) before lead extraction. However, CT evaluation may be difficult especially for lead tip identification due to artifacts in the leads. Selective right ventriculography (RVG) may enable preprocedural evaluation of lead perforation. We investigated the efficacy of RVG for identifying right ventricular (RV) lead perforation compared with CT in patients who underwent lead extraction. METHODS: Ninety-five consecutive patients who were examined by thin-section non-ECG-gated multidetector CT and RVG before lead extraction were investigated retrospectively. Newly recognized pericardial effusion after lead extraction was used as a reference standard for lead perforation. We analyzed the prevalence of RV lead perforation diagnosed by each method. The difference in the detection rates of lead perforation by RVG and CT was evaluated. RESULTS: Of the 115 RV leads in the 95 patients, lead perforation was diagnosed for 35 leads using CT, but the leads for 29 (83%) of those 35 leads diagnosed as lead perforation by CT were shown to be within the right ventricle by RVG. Three patients with 5 leads could not be evaluated by CT due to motion artifacts. The diagnostic accuracies of RVG and CT were significantly different (p < 0.001). There was no complication of pericardial effusion caused by RV lead extraction. CONCLUSION: RVG for identification of RV lead perforation leads to fewer false-positives compared to non-ECG-gated CT. However, even in cases in which lead perforation is diagnosed, most leads may be safely extracted by transvenous lead extraction.

Optimal use of left ventriculography at the time of cardiac catheterization: a consensus statement from the Society for Cardiovascular Angiography and Interventions.

The rationale to perform left ventriculography at the time of cardiac catheterization has been little studied. The technique and frequency of use of left ventriculography vary by geographic regions, institutions, and individuals. Despite the recent publication of guidelines and appropriate use criteria for coronary angiography, revascularization, and noninvasive imaging, to date there have been no specific guidelines on the performance of left ventriculography. When left ventriculography is performed, proper technique must be used to generate high quality data which can direct patient management. The decision to perform left ventriculography in place of, or in addition to, other forms of ventricular assessment should be made taking into account the clinical context and the type of information each study provides. This paper attempts to show the role of left ventriculography at the time of coronary angiography or left heart catheterization. The recommendations in this document are not formal guidelines but are based on the consensus of this writing group. These recommendations should be tested through clinical research studies. Until such studies are performed, the writing group believes that adoption of these recommendations will lead to a more standardized application of ventriculography and improve the quality of care provided to cardiac patients. © 2014 Wiley Periodicals, Inc.

Clinical validation of the planar radionuclide ventriculography in patients with right ventricular dysfunction

Objetivos: La ventriculografía con radionúclidos (RNV) se puede utilizar para la evaluación de la función ventricular derecha, pero debe ser validada clínicamente en pacientes con patología específica del ventrículo derecho (RV) y con posible interacción del ventrículo izquierdo (LV). Métodos: Tres grupos de 15 pacientes cada uno, con diagnóstico de displasia arritmogénica del ventrículo derecho (ARVD), hipertensión arterial pulmonar (PAH) o defecto del septum auricular (ASD) se comparan con un grupo de sujetos normales. Se valoran parámetros de ambos ventrículos por separado (fracción de eyección: LVEF, RVEF y sincronismo intraventricular, cuantificado como la desviación estándar de la fase: LVPSD y RVPSD) así como la relación o interdependencia del RV con el LV (RV/LV volumen, LV/RV fracción de eyección y sincronismo interventricular). Se analizaron también todas las variables en conjunto para identificar grupos de pacientes según su comportamiento funcional. Resultados: Se encontraron diferencias significativas entre los pacientes y el grupo control para la función del RV mientras que la del LV se mantiene dentro de los límites normales. Cuando se considera la función del RV, el grupo control y los pacientes con ASD muestran diferencia con los pacientes ARVD y PAH. Cuando se valora la relación RV/LV hay diferencia entre el grupo control y el grupo ASD. En el grupo de PAH, la función del LV muestra diferencias con el resto de los grupos. Conclusión: La RNV es una herramienta clínica fiable para valorar la función del RV en pacientes con patología del RV (AU)

Objectives. Gated radionuclide ventriculography (RNV) may be used for the evaluation of the right ventricular function. However, the accuracy of the method should be clinically validated in patients suffering from diseases with specific pathology of the right ventricle (RV) and with possible left ventricular (LV) interaction. Methods. Three groups of 15 patients each, diagnosed with arrhythmogenic right ventricular dysplasia (ARVD), pulmonary artery hypertension (PAH) or atrial septal defect (ASD) were compared to a group of normal subjects. The parameters for both ventricles were evaluated separately (ejection fractions: LVEF and RVEF, and intraventricular synchronism quantified as phase standard deviation: LVPSD and RVPSD) as well as the relation or interdependence of the right to left ventricle (RV/LV volume ratio, LV/RV ejection fraction and stroke volume ratios, and interventricular synchronism). All the variables as a whole were analyzed to identify groups of patients according to their functional behaviour. Results. Significant differences were found between the patients and control group for the RV function while the LV function remained mostly within normal limits. When the RV function was considered, the control group and ASD patient group showed differences regarding the ARVD and PAH patients. On evaluating the RV/LV ratios, differences were found between the control group and the ASD group. In the PAH patients, LV function showed differences in relation to the rest of the groups. Conclusion. RNV is a reliable clinical tool to evaluate RV function in patients with RV abnormality (AU)

Angiographic core laboratory reproducibility analyses: implications for planning clinical trials using coronary angiography and left ventriculography end-points.

OBJECTIVES: To assess reproducibility of core laboratory performance and impact on sample size calculations. BACKGROUND: Little information exists about overall reproducibility of core laboratories in contradistinction to performance of individual technicians. Also, qualitative parameters are being adjudicated increasingly as either primary or secondary end-points. The comparative impact of using diverse indexes on sample sizes has not been previously reported. METHODS: We compared initial and repeat assessments of five quantitative parameters [e.g., minimum lumen diameter (MLD), ejection fraction (EF), etc.] and six qualitative parameters [e.g., TIMI myocardial perfusion grade (TMPG) or thrombus grade (TTG), etc.], as performed by differing technicians and separated by a year or more. Sample sizes were calculated from these results. TMPG and TTG were also adjudicated by a second core laboratory. RESULTS: MLD and EF were the most reproducible, yielding the smallest sample size calculations, whereas percent diameter stenosis and centerline wall motion require substantially larger trials. Of the qualitative parameters, all except TIMI flow grade gave reproducibility characteristics yielding sample sizes of many 100's of patients. Reproducibility of TMPG and TTG was only moderately good both within and between core laboratories, underscoring an intrinsic difficulty in assessing these. CONCLUSIONS: Core laboratories can be shown to provide reproducibility performance that is comparable to performance commonly ascribed to individual technicians. The differences in reproducibility yield huge differences in sample size when comparing quantitative and qualitative parameters. TMPG and TTG are intrinsically difficult to assess and conclusions based on these parameters should arise only from very large trials.

A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery.

OBJECTIVE: To evaluate the discriminatory value and compare the predictive performance of six non-invasive tests used for perioperative cardiac risk stratification in patients undergoing major vascular surgery. DESIGN: Meta-analysis of published reports. METHODS: Eight studies on ambulatory electrocardiography, seven on exercise electrocardiography, eight on radionuclide ventriculography, 23 on myocardial perfusion scintigraphy, eight on dobutamine stress echocardiography, and four on dipyridamole stress echocardiography were selected, using a systematic review of published reports on preoperative non-invasive tests from the Medline database (January 1975 and April 2001). Random effects models were used to calculate weighted sensitivity and specificity from the published results. Summary receiver operating characteristic (SROC) curve analysis was used to evaluate and compare the prognostic accuracy of each test. The relative diagnostic odds ratio was used to study the differences in diagnostic performance of the tests. RESULTS: In all, 8119 patients participated in the studies selected. Dobutamine stress echocardiography had the highest weighted sensitivity of 85% (95% confidence interval (CI) 74% to 97%) and a reasonable specificity of 70% (95% CI 62% to 79%) for predicting perioperative cardiac death and non-fatal myocardial infarction. On SROC analysis, there was a trend for dobutamine stress echocardiography to perform better than the other tests, but this only reached significance against myocardial perfusion scintigraphy (relative diagnostic odds ratio 5.5, 95% CI 2.0 to 14.9). CONCLUSIONS: On meta-analysis of six non-invasive tests, dobutamine stress echocardiography showed a positive trend towards better diagnostic performance than the other tests, but this was only significant in the comparison with myocardial perfusion scintigraphy. However, dobutamine stress echocardiography may be the favoured test in situations where there is valvar or left ventricular dysfunction.

A prospective comparison of echocardiographic wall motion score index and radionuclide ejection fraction in predicting outcome following acute myocardial infarction.

OBJECTIVE: To characterise echocardiographic wall motion score index (WMSI) as a surrogate measure of left ventricular ejection fraction (EF) following acute myocardial infarction (AMI) and to compare its prognostic value with that of EF measured by radionuclide ventriculography (RNV). DESIGN: A prospective study to compare baseline echocardiographic WMSI with RNV EF in consecutive patients thrombolysed for AMI, both performed on the same day before discharge, and their relative prognostic values in predicting cardiac events. SETTING: District general hospital coronary care unit and cardiology department. PATIENTS: 120 consecutive patients free of exclusion criteria thrombolysed for AMI and followed up for a mean (SD) of 13 (10) months. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Correlation coefficients and receiver operating characteristic curve analyses plus cardiac event rates at follow up between RNV EF and echocardiographic WMSI. RESULTS: WMSI correlated well with RNV EF. The best corresponding WMSIs for EFs 45%, 40%, and 35% were 0.6, 0.8, and 1.1, respectively. There were 42 cardiac events during follow up. Although both RNV EF and WMSI were strong univariate predictors of cardiac events, only WMSI independently predicted outcome in a multivariate model. All three WMSI cut offs significantly predicted events, while an RNV EF cut off of 45% failed to reach significance. CONCLUSIONS: Although both RNV and echocardiographic WMSI strongly predicted cardiac outcome, WMSI, a cheaper and more readily available technique, is more discriminatory, especially in cases of mild left ventricular dysfunction following AMI.

Assessment of viable myocardium and prediction of postoperative improvement in left ventricular function in patients with severe left ventricular dysfunction by quantitative planar stress-redistribution-reinjection 201-T1 imaging.

A noninvasive approach to determine viable but asynergic myocardium will be clinically significant in identifying patients with coronary artery disease and severe left ventricular dysfunction who will benefit most from coronary bypass surgery. Accordingly, 12 patients (mean ejection fraction 0.32 +/- 0.03) underwent quantitative planar stress-redistribution-reinjection thallium scintigraphy and radionuclide ventriculography before and 8 weeks after revascularization for viability and segmental and global left ventricular function assessment, respectively. Reinjection scan showed new fill-in in 63% of segments without redistribution. Postoperative improvement in perfusion and function of asynergic segments were significantly better in viable compared to nonviable segments (P < 0.001, P < 0.01, respectively) with a strong correlation between improvement in 201-T1 uptake and function (P < 0.001). When adequacy of revascularization was considered, the predictive value of a positive preoperative viability test for functional improvement was 83%. Finally, mean ejection fraction and global wall motion score increased significantly after revascularization for the group as a whole (0.32 +/- 0.03 to 0.44 +/- 0.04, P < 0.001 and 24.08 +/- 2.90 to 33.16 +/- 3.32, P < 0.001, respectively). Thus, preoperative quantitative planar stress-redistribution-reinjection thallium imaging detects viable but asynergic segments which improve function postoperatively and may be valuable in selection of patients with severe left ventricular dysfunction for revascularization.

Lack of agreement between measurement of ejection fraction by impedance cardiography versus radionuclide ventriculography.

OBJECTIVE: To determine the limits of agreement between left ventricular ejection fraction estimated using systolic time intervals from impedance cardiography and left ventricular ejection fraction estimated by radionuclide ventriculography. DESIGN: A prospective study for diagnostic tests using radionuclide ventriculography as the criterion standard. SETTING: A large military teaching hospital. PATIENTS: Twenty ambulatory adults scheduled for radionuclide ventriculography. MEASUREMENTS AND MAIN RESULTS: A regression equation to estimate ejection fraction from systolic time intervals is available in a widely used impedance-based cardiac monitoring device. The estimated ejection fraction is then used in an equation with stroke volume estimated by the same device to calculate an end-diastolic volume. We studied the agreement of the ejection fraction as estimated by this device with the ejection fraction estimated by radionuclide ventriculography by obtaining simultaneous estimates of ejection fraction over a broad range of adult patients. Twenty ejection fraction pairs were analyzed. The correlation of ejection fraction by impedance cardiography to ejection fraction by radionuclide ventriculography was significant (r2 = .55; p < .002). However, the mean difference between the technologies was -8.85%, with a standard deviation of the differences of 7.15%, resulting in a 95% confidence range for agreement of -23.2% to +5.5%. CONCLUSIONS: The 95% confidence range defining the limits of agreement between ejection fraction by impedance cardiography and ejection fraction by radionuclide ventriculography is not clinically acceptable. In the opinion of the authors impedance cardiography should not be used in place of radionuclide ventriculography for the assessment of ejection fraction at this time.

Subjective visual echocardiographic estimate of left ventricular ejection fraction as an alternative to conventional echocardiographic methods: comparison with contrast angiography.

Left ventricular ejection fraction (LVEF) is a measure of ventricular function with clinical and prognostic significance and can be reliably calculated with various M-mode and two-dimensional echocardiographic formulas in selected, good quality echocardiograms. Subjective visual echocardiographic estimate of LVEF is a potentially less time consuming and more widely applicable method. In order to test its reliability, we performed a prospective blind trial in 40 consecutive patients undergoing biplane contrast ventriculography (BCV), to compare the visual estimate of LVEF during a complete echocardiogram of three independent observers with (1) cubed M-mode formula, (2) Teichholz M-mode formula, (3) length-area method from the four-chamber view, and (4) Simpson's single plane formula. BCV was the reference method. The best correlation with BCV was obtained by visual estimate [r of the three observers, respectively = 0.75; 0.84; 0.81] and M-mode measurements [r (1) = 0.8; r (2) = 0.8], but the most sophisticated methods provided the poorest estimate [r (3) = 0.54; r (4) = 0.49]. All correlation coefficients improved when good studies, defined as a definition of the endocardial surface of more than 75%, were selected (n = 23), but the differences persisted. One observer systematically estimated higher values than the other two (Friedman's test, p less than 0.01) and this interobserver variability suggests that each echocardiographer should test himself against BCV in his lab in order to apply the visual estimate method reliably.

The role of preoperative radionuclide ventriculography in defining outcome after revascularization of the extremity.

Revascularization of the extremity was performed upon 110 patients after preoperative radionuclide ventriculography (RNVG). Mean ejection fraction (EF) was 50 +/- 13 per cent. Ventricular wall motion abnormalities were present in 46 per cent. Revascularization included inflow procedures, such as aortofemoral (n = 25) or extraanatomic bypass (axillofemoral or femorofemoral, n = 11); infrainguinal reconstruction, including femoropopliteal or distal bypass (n = 43), and other procedures to improve perfusion of the limb or correct complications after previous vascular reconstruction upon the extremity (n = 31). Perioperative (30 days) mortality rate was 0.9 per cent and 97.0 per cent of the patients were discharged alive from the hospital. Myocardial infarction (MI) occurred in 3.6 per cent, new ventricular arrhythmia in 1.8 per cent and congestive heart failure in 6.4 per cent of the patients during the perioperative period. During follow-up study (607 +/- 363 days), 7.3 per cent required major amputation, ipsilateral to reconstruction, 5.5 per cent required surgical or angiographic revision for hemodynamic failure of the reconstruction prior to thrombosis and 12.7 per cent thrombosed part or all of the reconstruction. Revascularization failure did not appear to be related to the level of cardiac function. Those with normal (greater than 50 per cent) EF had greater over-all survival by life table analysis than those with EF less than or equal to 50 per cent (p = 0.0006, Mantel-Cox test). Ventricular wall motion abnormalities were associated with reduced over-all survival (p = 0.008, Mantel-Cox test). The presence of angina or previous MI, singularly or in combination, did not have an adverse effect on over-all survival, whereas diabetes (p = 0.0058, Mantel-Cox test) and cigarette smoking (p = 0.0137, Breslow test) were associated with significantly diminished over-all survival. Preoperative RNVG can identify subgroups at a survival disadvantage after revascularization of the extremity in a population in which the presence of angina or previous MI does not predict survival.