Catheterization and Cardiovascular Diagnosis 2:309-312 (1976)

PULMONARY ARTERIOGRAPHY IN CONGENITAL HEART DISEASE Robert M. Freedom, M.D., and Peter M. Olley, M.D. Pulmonary outflow tract obstruction may occur at subvalve, valve, or pulmonary artery level. Selective ventriculography will usually define the intracardiac obstruction (whether valve, subvalve, or both) and may define pulmonary arterial abnormalities. Increasing experience in the surgical management of patients with tetralogy of Fallot and other conotruncal abnormalities characterized by significant pulmonary outflow tract obstruction suggests that preoperativerecognition of pulmonary arterial stenosis is essential to the successful operative management of these patients (14). Becauseof the anatomlcospacialrelationships of the pulmonary arteries in “simple” (tetralogy of Fallot) and complex conotruncal malformations, selective ventrlculography may not invariably provide sufficient detail about the morphologic state of the pulmonary arteries. Slmllarly, even selective pulmonary arteriography in the standard anterioposterior, lateral, and oblique views may not always allow accurate anatomic assessment of these vessels. Therefore, we wish to document a maneuver that has proved valuable in the assessment of pulmonary arteries during selective pulmonary arteriography. This maneuver was originally suggested to Peter M. Olley by Dr. L. M. Bargeron, Jr., and the surgical valve obtained from this angiographic view was stressed by Dr. John Klrklin Inhis John Keith lecture at the Canadian Cardiovascular Society (5). Although it is being used at some cardiovascular centers, we feel its application warrants this report. Key words: conotruncal anomalies, tetralogy of Fallot, pulmonary arterial stenoses, heart surgery, angiocardiography

MANEUVER

The patient’s chest is elevated from 30” to 45” from the supine. This is accomplished by placing the patient on a clear, plastic mold that can be elevated to the desired angle. Then, using only the AP camera, from 0.50 ml to 1.0 ml per kg of contrast material is injected at 200400 lb/inch2 with filming at 60 frameslsec.

From the Division of Paediatric Cardiology, The Hospital for Sick Children, and ,&partment of Paediatrics, The University of Toronto

Reprint requests to: Robert M. Freedom, M.D., The Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, Canada MSG 1x8 Received February 20, 1976; revision accepted April 10, 1976.

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Freedom and Olley

Fig. 1. Selective “headup” pulmonary arteriogram in a 3-year-old with tetralogy of Fallot.There is mild stenosis at the right pulmonary artery (RPA) -main pulmonary artery (MPA junction). There is mild poststenotic dilatation. This projection allows one to “look down” onto the pulmonary arteries. Note how well the left pulmonary artery (LPA) - MPA junction is visualized. Arrows in this and subsequent figures point to the stenotic area.

In the past 16 months, 62 patients, ranging in age from 3 days to 14 years, have undergone this “headup” pulmonary arteriography as part of their complete hemodynamic and angiographic catheter assessment. The majority of these patients had tetralogy of Fallot, but patients with tricuspid atresia, double outlet right, ventricle, and isolated peripheral pulmonary arterial stenosis have also been studied. Figures 1 through 5 are illustrative of this technique. DISCUSSION

Congenital or hemodynamically acquired malformations of the pulmonary arteries, including diffuse hypoplasia, unilateral or bilateral absence, unilateral or bilateral stenoses or coarctation, aberrant origin from the ascending aorta (hemitruncus), and discontinuity from the heart usually, but not invariably, occur in concert with conotruncal malformations. Their recognition is essential to the preoperative assessment of such patients. This headup maneuver has proved a most useful adjunct in the angiocardiographic evaluation of the patient with congenital heart disease. It allows us to “look down” upon the pulmonary arteries, and hence enables us to better visualize the caliber and morphologic variations of the main and branch pulmonary arteries, especially at their central bifurcations. Preoperative recognition of hemodynamically significant pulmonary arterial anomalies should help to minimize the surgical mortality and morbidity incurred at the time of total correction of patients with conotruncal anomalies and pulmonary outflow tract obstruction ( 5 ) .

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”Headup“ Pulmonary Arteriography

Fig. 2. Selective “headup” pulmonary arteriogram in a 15-month-old infant with severe tetralogy of Fallot. Note the severe stenosis in the midportion of the RPA. The origin of the RPA is also narrowed, but no stenosis of the LPA is appreciated.

Fig. 3. Selective “headup” pulmonary arteriogram in a 2%-year-old with severe tetralogy of Fallot There are rlgnificant bilateral branch stenoses: RPA MPA and left upper branch LPA.

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ACKNOWLEDGMENT

We wish to acknowledge the fact that Dr. L. Bargeron, Jr., of Birmingham, Alabama, originally drew our attention to the value of this angiographic technique. REFERENCES I . Kirklin J W and Karp RB: In, The Tetralogy of Fallot: From a Surgical Viewpoint. Philadelphia, W.B. Saunders Co., 1970. 2. Gregoratos-G, Jones RC. and Jahnke EJ, Jr: Unilateral peripheral pulmonic stenosis complicating tetralogy of Fallot: Diagnosis and therapeutic considerations. J Thorac Cardiovasc Surg 50:202. 1965. 3. Kirklin JW: The tetralogy of Fallot. Caldwell Lecture. 1967. Am J Roentgen 120:251, 1968. 4. Nagao GI. Daoud GI, McAdams AJ. Schwartz DC, and Kaplan S: Cardiovascular anomalies associated with tetralogy of Fallot. Am J Cardiol 20:206, 1967. 5. Kirklin JW: The John Keith Lecture, The Canadian Cardiovascular Society. Montreal, Canada. October 24, 1975.

Pulmonary arteriography in congenital heart disease.

Catheterization and Cardiovascular Diagnosis 2:309-312 (1976) PULMONARY ARTERIOGRAPHY IN CONGENITAL HEART DISEASE Robert M. Freedom, M.D., and Peter...
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