Thorax (1958), 13, 9 7.

PERCUTANEOUS LEFT VENTRICULAR PUNCTURE WITHCATHETERIZATION OF THE AORTA

BY

H. A. FLEMING, E. W. HANCOCK,* B. B. MILSTEIN, AND D. N. ROSSFrom Brompton Hospital and Guy's Hospital, London

(RECEIVED FOR PUBLICATION JANUARY 21, 1958)

The technique of percutaneous puncture of theleft ventricle for the assessment of patients withaortic stenosis was described by Brock, Milstein,and Ross (1956) and the results in the first 28cases were analysed by Fleming and Gibson(1957). This procedure has now been carried outin 115 patients at these two hospitals and thetechnique has been extended to include catheter-ization of the aorta via the left ventricular needle.This paper describes our experience with catheter-ization of the aorta by this method in the first 36attempts.

It is desirable to catheterize the aorta for tworeasons. First, pressure tracings recorded con-tinuously during the withdrawal of the cathetertip from the aorta to the left ventricle may revealsubvalvar stenosis undietectable by any othermethod short of surgical exploration (Brock andFleming, 1956). This is an important considera-tion in all patients with congenital aortic stenosisand in patients with severe left ventricular hyper-trophy due to aortic valve stenosis or to hyper-tension (Brock, 1957b). Second, the systolicpressure gradient across the aortic valve is calcu-lated more accurately from the aortic pressurepulse than from a peripheral arterial pulse.Although the difference between the central andperipheral pulse contours is usually small in aorticstenosis (Wright, Toscano-Barboza, and Branden-burg, 1956) the variability of this has not yet beenfully explored.

METHOD

The basic technique for percutaneous left ventricu-lar puncture remains as already described (Brock andothers, 1956). The use of the catheter requires alarger bore needle than previously used for left ventri-cular puncture alone in which a needle of 18 gauge(external diameter 1.1 mm.) is used. A 16-gaugeneedle (external diameter 1.5 mm.) allows easy passageof nylon (Portex No. 2) or polythene tubing of0.74 mm. internal diameter and 0.94 mm. external

* Research Fellow, American Heart Association.

H

diameter and has been found adequate for pressurerecordings of excellent quality (Figs. 2-7). Theneedle, catheter, and adaptor assembly are illustratedin Fig. 1. A sidearm on the needle and a rubber sealaround the catheter at its entrance into the needle hubcan be used to allow a continuous slow irrigation ofheparinized saline between the needle and thecatheter. This prevents the development of stickiness,which can sometimes impede the free movement ofthe catheter and also guards against clots or bubblebeing sucked into the ventricle in diastole. Thisrefinement has not been used in the present series. Avery slow drip of heparinized saline is also used inthe catheter to prevent the reflux and clotting ofblood.The junction of the shaft of the needle with the

butt may need some attention to permit the freemovement of the catheter. A coiled catheter is un-desirable and should be straightened out by hangingovernight with a weight on the end. Suchstraightened catheters enter the aorta readily if theneedle is properly directed along the outflow tract ofthe left ventricle and are also less apt to kink or snareoff when withdrawn over a sharp needle tip. Nylon israther more liable to kink and polythene more liableto snare, but the tendency in each case is slight. Ifthere is any suggestion of snaring no force must beused and the catheter and needle must be withdrawntogether from the chest and the puncture repeated.This has seldom been necessary.

RESULTSThe results of the first 36 attempts are sum-

marized in Table I. The catheter entered theaorta in 28 cases (78%), usually immediately andwithout ventricular irritability. In one case ofsuspected valvar and subvalvar stenosis (Case 26)only the subvalvar chamber could be entered. Thelevel of systolic pressure recorded from the needlein the femoral artery confirmed the presence ofboth valvar and subvalvar stenosis. In two casesof pure valvar stenosis (Cases 29 and 34) the aortacould not be entered and later at necropsy thevalve orifice was found to be tiny and situatedperipherally in a great. craggy mass of calcium.

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98 H. A. FLEMING, E. W. HANCOCK, B. B. MILSTEIN, and D. N. ROSS

TABLE IDETAILS OF CASES INVESTIGATED (AGE RANGE FROM

5 TO 63 YEARS)

CasePatient Age Sex Diagnosis Aorta StandardNo. Entered of Trace

1 D.F. 15 M AS Yes Poor2 M.B. 49 F AS-Al No -3 A.B. 34 M AS Yes Damped4 D.H. 15 M AS-Al No -5 C.F. 50 M AS-Al Yes Good6 W.M. 32 M AS to Damped7 B.W. 46 F AS o, Fair8 J.C. 22 M sub-AS ,, Good9 M.S. 16 F AS ,, Fair10 K.S. 27 M AS and coarct. ,, Good11 J.T. 36 M AS12 C.N. 63 M AS13 A.A. 60 M Aortic No

aneurysm14 J.G. 18 M AI+VSD Yes Good15 *H.M 47 M AS-Al 9 9

16 P.D. 21 F AS-AI , .,17 P.B. 6 M AS and coarct. ,, ,,18 T.H. 46 M AS19 R.B. 16 M AS20 R.B. 52 F AS-Al No .21 W.D. 31 M AS-Al VI)22 J.C. 50 M sub-AS and Yes Good

hypertn.23 t.W. 49 M AS24 E.G. 61 F Hypertn. and

isch.25 J.R. 24 F AS 9 .26 M.W. 11 M Severe AS Subvalvar chamber

and sub-AS entered, but notaorta

27 M.H. 39 F Coarct. Yes Good28 V.B. 56 F AS29 E.D. 33 M AS No. LV pressure

450 mm. Hg andtiny eccentric ori-fice

30 R.W. 17 M sub-AS Yes Good31 J.B. 5 M AS .,32 S.D. 54 M sub-AS 9

33 J.Br. 24 F AS-ai .. 7

34 R.T. 57 M AS No. Small eccen-tric orifice

35 G.E. 47 M AS-ai Yes Good36 R.B. 25 M AS-Al

* L.A. also entered and good withdrawal trace across mitral valveA.S.=aortic valve stenosis; A.I.=aortic valve incompetence;

sub-AS-subaortic stenosis; VSD=ventricular septal defect.

It would be fortunate if the orifice could beentered in these cases. Reference to TableI shows that in four of the remaining fivefailures there was a significant degree of aorticregurgitation. This is not thought to be of import-ance in the failure, which can be explained morereadily on other grounds. All these four casesoccurred at an early stage in the operators'experience.Although there were difficulties in the first cases,

the pressure tracings obtained in the last 30 caseshave been uniformly excellent. The ease of enter-ing the aorta is in contrast to our experience withleft atrial puncture (Bjork, Blakemore, and Malm-strom, 1954) where we have frequently failed andprolonged manipulations of the catheter tip withinthe left ventricle have given rise to severe arrhyth-mia. Figs. 2-7 show the minimal disturbance to

rhythm using the present method. Only in Fig. 6is there an ectopic beat. On this record the electro-cardiogram had failed.

In a normal aortic valve there is no systolicgradient and there is a clean change from aorticto left ventricular pulse (Fig. 2). In aortic valvestenosis there is a single systolic gradient and thetransition from aortic to ventricular pulse alsooccurs abruptly, without intermediate pulse forms(Fig. 3). Artefacts may occur when the tip of thecatheter is just at the valve. It is important tohave a simultaneously recorded electrocardiogramto ensure that these are not due to arrhythmia. Afalse appearance of subvalvar stenosis may be pro-duced by too slow a withdrawal, the catheter tipbeing flung into the aorta in systole and drawninto the ventricle in diastole. The resultant traceresembles that from an infundibular chamber.With experience a steady, slow rate of withdrawalcan be achieved and any questionable results canbe checked by repeating the withdrawal. Thepressure pulse from a brachial artery is recordedat the same time. In the event of failure to enterthe aorta, the systolic gradient across the aorticvalve can still be measured.

It is known that a diaphragmatic type ofstenosis, immediately below the valve, may appearvalvar on a withdrawal trace. Brock and Fleming(1956) report this as occurring at operation. Inthis series we have had one such case in which our

investigation indicated a stenosis at valve levelonly. This was confirmed by a withdrawal atoperation, but the valve was normal and thestenosis lay so immediately under the valve as tomake it likely that the valve cusps were in contactwith the stenosis in diastole.

In the present series five cases of subvalvarobstruction have been identified. None of thesehas yet come to operative confirmation. Twoexamples from this group are given later.

ILLUSTRATIVE CASES

CASE 18.-T. H., a man aged 46, was found to havea heart murmur at the age of 10 years. Nine monthsbefore admission he developed paroxysmal nocturnaldyspnoea and angina. He had an anacrotic pulse buta blood pressure of 160/120 mm. Hg. There was

clinical, electrocardiographic, and radiological evidenceof gross left ventricular hypertrophy. There was a

marked aortic systolic murmur and thrill and thesecond sound was single. There was gross calcifica-tion in the region of the aortic valve, but the level ofthe blood pressure was disturbing. A withdrawalrecord (Fig. 3) from the aorta to the left ventricleshowed a single pressure change and the valvarstenosis was confirmed at operation.

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PERCUTANEOUS LEFT VENTRICULAR PUNCTURE,,...FIG. 1.-The needle, catheter (cut short for illustration), and adaptor assembly used for left ventricular puncture and catheterization of the

aorta.

mm.Hg

200- -1 SEC7-:200-

50:0.- &

00-.'.'...,, A ,.

..../.:..

Withdrawal from Aorta to Le etVentricle

FIG. 2.-Example of a withdrawal record across anorin aortic valve. Case 27 with coarctation ofthe aorta and a falling blood pressuren.

mroHg

300-

250 _ _EC-A

Aorta Left Ventricle

FIG. 3.-Excample of a withdrawal record in Case 18 with systemic hypertension and moderate aortic stenosis. There is a systolic gradientof 70 mm. Hg at the aortic valve.

99

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100 H. A. FLEMING, E. W. HANCOCK, B. B. MILSTEJN, and D. N. ROSS

Aorta

- fSEC.--

Left Ventricle

K~ A.1

Brachial f\ !Artery%4I4\_i i _J

ECGX ~

FiG. 4.-Withdrawal record of Case 35 from aorta to left ventricle, with simlbrachial artery record, in a typical case of severe aortic stenosis. Thegradient is 100 mm. Hg and there is a slight pulsus alternans. The diff(pulse form between the aorta and the brachial artery is more markecusual in aortic stenosis.

CASE 35.--G. E. was a man of 46 with a six months' sharlhistory of angina pectoris and progressive breathless- heavness on exertion. There was a loud aortic systolic prae(murmur and thrill conducted into the carotids, a Electdelayed aortic second sound, and a slight aortic diastolic hypemurmur. Blood pressure was 130/60 mm. Hg. meniElectrocardiogram indicated extreme left ventri- vent]cular hypertrophy, and aortic valve calcium was shovclearly seen on fluoroscopy. Left ventricular withpuncture showed a systolic gradient of 100 mm. Hg valvwacross the aortic valve, and a withdrawal record cAshowed an abrupt change from aorta to left ventricle ecttypical of aortic valve stenosis (Fig. 4), which was ectverified at operation. and

Aorta

CASE 33.-J. Br. was a 24-year-old woman with angina pectoris

mm.Hg and cardiac failure. There was aloud aortic systolic murmur with

-200 a single second sound and a softaortic diastolic murmur. Bloodpressure was 130/90 mm. Hg. Elec-

-150 trocardiogram indicated left ventri-cular hypertrophy. Slight aortic

-100 valve calcification was shown bytomography. Left ventricularpuncture with catheterization of

-so the aorta showed a systolic pres-sure gradient of 130 mm. Hg, anda withdrawal record was typical of

-o aortic valve stenosis (Fig. 5) sub-sequently verified at operation.CASE 30.-R. W. was a 17-year-

esystolic old boy whose heart murmur was

erence in discovered at the age of 5 yearsd than is and who had a reduced exercise

tolerance because of fatigue andbreathlessness. The pulse was

p and full, there was a marked left ventricularve and a rough systolic murmur over the wholecordium. Blood pressure was 130/60 mm. Hg.trocardiogram indicated marked left ventricular-rtrophy. Fluoroscopy showed marked enlarge-t of the left ventricle and no valve calcium. Left:ricular puncture with catheterization of the aorta,ved a systolic gradient of 50 mm. Hg, and theidrawal record was characteristic of aortic sub-ar stenosis (Fig. 6). Operation was deferred.ASE 32.-S. D. was a man of 54 years with anginaonis, syncope, and progressive breathlessness ontion. There was a loud aortic systolic murmura single second sound. Electrocardiogram indi-

Left Ventricle

mm.Hg

-200

-150

-100Brachial

i_nArtery ~5

V w.~A __\ so

ECG~~~~~ "S,-wte;;>>t''is.., t<" ttl )t

'I

Phono ON;i_t * r *11t~A:.;

FIG. 5.-Withdrawal record of Case 33 from aorta to left ventricle, with simultaneous brachial artery record, in a case of severe aorticvalve stenosis (systolic gradient 130 mm. Hg) of presumed congenital origin.

M R -, -7T 11! -7 1 _vII

* .: ...I 'I - .:.

.,1:-

.I"

ECG

/i'ii

,

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PERCUTANEOUS LEFT VENTRICULAR PUNCTURE

cated considerable leftventricular hypertrophyand a t r i a 1 fibrillation.Radiology showedmarked left ventricularenlargement, b u t n ocalcification of the aorticvalve could be demon-strated. Left ventricularpuncture showed a sys-tolic gradient of 100mm. Hg, but a with-drawal record showedthat the obstruction wassubvalvar (Fig. 7). Thiscondition was consideredinoperable.

Aorta Subaortic Chamber Left Ventricle

mm.Hg

-I sEc.--

i~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~1\ .;:Brachial 100Artery IA 5

1 -50

- -o

FIG. 6.-Withdrawal record of Case 30 from aorta to left ventricle, with simultaneous brachial arteryrecord, showing the gradient (50 mm. Hg) to be localized to a subvalvar site in the left ven-tricle rather than at the valve.

COMPLICATIONSThere have been two deaths in this series. These

are the only deaths attributable to left ventricularpuncture in a total of 115 cases investigated atthese two hospitals.

CASE 24.-The first patient was a woman of 61 yearswith a history of hypertension. She was in intractablecongestive heart failure, had a low cardiac output(1.5 1./min.), extreme pulmonary vascular resistance(28 units), and features of aortic stenosis. Theprocedure was accomplished easily and there was noaortic gradient. Death occurred within four hoursfrom cardiac tamponade and blood loss, in spite ofaspiration and transfusion. Necropsy showed thatthe left ventricular puncture needle had traversed thescar of a small, healed apical myocardial infarct only3 mm. in thickness. It was from this site that thebleeding had occurred. There was severe coronaryatherosclerosis.CASE 34.-The second case was a man aged 57

years who had suffered for several years from anginapectoris, syncope, effort and nocturnal dyspnoea, and

congestive cardiac failure. He had the signs of cal-cific aortic stenosis. Left ventricular puncture waseasily accomplished, but the catheter could not beintroduced into the aorta. There was a fall in bloodpressure without other clinical signs of tamponade,but cardiac arrest occurred suddenly 20 minuteslater. Thoracotomy revealed a substantial haemo-pericardium. Resuscitation efforts failed andnecropsy revealed extreme aortic valve stenosis with atiny, eccentrically placed orifice.From this experience it is felt that patients with

any possibility of ischaemic heart disease ormyocardiopathy should not be submitted to leftventricular puncture. It will not always be easy toavoid such cases, but a preliminary arterial pulsetracing may be helpful in deciding whether aorticstenosis must still be seriously considered (Wood,1958) and further investigation necessary.The classical post-pericardiotomy syndrome

(Papp and Zion, 1956) has occurred in two cases.This has been similar in all respects to that occur-ring after cardiac operations and, when treatment

Subaortic Chamber

-I c.

Left Ventricle

mm HgA A_200

k.

N.J

-150

.i -100

-50

-0.V - 11;1- 1VI O .- 11-1% -. - '% '% 'k ..

~~~~~~~~~~~~~~~~~~~~~~~~~~~~

FIG. 7.-Withdrawal record of Case 32 from aorta to left ventricle, showing a subvalvar site of the pressure gradient (100 mm. Hg). The

same appearance was obtained on repeated withdrawal tracings. Operation has not been undertaken.

Aorta

l-S llul -S-

t 4 t it t i

101

i. r d,

.:.!'t 11.1

VI .

.1 j./,WI\ r-jlnoll-,.40...

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102 H. A. FLEMING, E. W. HANCOCK, B. B. MILSTEIN, and D. N. ROSS

was necessary, there has been a good response toprednisone. The recognition of this complication isimportant as, in these two cases, the onset wassudden and severe, some days after the puncture.There was considerable pain with transientcollapse, and myocardial infarction could havebeen diagnosed. The early appearance of a peri-cardial rub and the subsequent course made thetrue diagnosis evident.

A small number of patients have suffered fromsevere pericardial pain at the time of the punc-ture. This has been treated with intravenouspethidine and has not been accompanied by othersigns.

One patient, aged 5 years, had chest pain ofsudden onset four days after puncture (Case 31).The neck veins were distended and the pulse wasparadoxical. Cardiac tamponade was diagnosedbut subsided uneventfully without treatment.

DISCUSSION

The simplicity of the method and the excellentquality of the traces obtained are encouraging.However, the two deaths and the small number ofother complications have been confined to thepresent series. As experience in the surgery ofaortic stenosis (Brock, 1957a) has extended, moreand more seriously ill patients have come to thesehospitals for assessment, and the risk of any pro-cedure, however small, in such cases is consider-able. Nevertheless it cannot be denied that theuse of a larger and more rigid needle and theslightly longer time necessary for the manipulationmay make the procedure a more dangerous one inpoor-risk cases. It is therefore suggested that itsuse be confined to patients in whom congenitalsubaortic stenosis is suspected, those withoutcalcium in the valve, and those with a history ofsystemic hypertension.

SUMMARY AND CONCLUSIONSCatheterization of the aorta with a fine plastic

catheter is described as an addition to the tech-nique of percutaneous left ventricular puncture inthe diagnosis and assessment of aortic stenosis.The procedure has been successful in 28 of thefirst 36 attempts. Aortic pressure tracings andexcellent withdrawal records across the valve havebeen regularly obtained. Five cases of subvalvarstenosis have been identified and one missed bythis method. Two deaths have occurred, the onlydeaths in a total of 115 left ventricular punctures.It is suggested that this method is valuable, butthat in cases with a poor myocardium there is anincreased risk of haemorrhage. Its use shouldtherefore be confined to cases where it is par-ticularly indicated, and if the gradient alone is tobe measured the technique of left ventricular andbrachial artery puncture will give the information.

We wish to thank Sir Russell Brock for much helpand encouragement; Dr. Paul Wood, Dr. R. V.Gibson, Dr. C. Baker. and Sir Russell Brock underwhose care patients were investigated. Mr. M. Panethand Dr. A. M. Johnson have assisted in these investi-gations. The illustrations are the results of the workof the cardiological technicians and the photographicdepartments of both hospitals.

REFERENCES

Bjork, V. O., Blakemore, W. S., and Malmstrom, G. (1954). Amer.Heart J., 48, 197.

Brock, R. C. (1957a). Brit. med. J., 1, 1019.-- (1957b). Guy's Hosp. Rep., 106, 221.

and Fleming, P. R. (1956). Ibid., 105, 391.Milstein, B. B., and Ross, D. N. (1956). Thorax, 11, 163.

Fleming, P. R., and Gibson, R. V. (1957). Ibid., 12, 37.Papp, C., and Zion, M. M. (1956). Brit. Heart J., 18, 153.Wood, P. (1958). Anmer. J. Cardiol., 1, 553.Wright, J. L., Toscano-Barboza, E., and Brandenburg, R. 0. (1956).

Proc. Mayo Clin., 31, 120.

ADDENDUMSince this paper was submitted for publication a

further 43 patients at these two hospitals have hadleft ventricular puncture without complications.Of these, 23 also had the aorta catheterized.

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