Aortic insufficiency cardiac catheterization

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2], Varun Kumar, M.B.B.S., Lakshmi Gopalakrishnan, M.B.B.S.

Overview

Although echocardiography is now the primary imaging modality used to evaluate aortic insufficiency, cardiac catheterization is often performed in the patient with aortic insufficiency primarily to assess for the presence of epicardial coronary artery disease prior to surgical aortic valve replacement. Aortography can also be performed to assess the severity of aortic insufficiency. The presence or absence of an aortic dissection can be evaluated. Left ventricular function (hemodynamics), size and systolic function (ejection fraction) can also be evaluated.

Performance of Aortography

The pigtail catheter is placed a few centimeters above the aortic root. The image intensifier is place in the 45 degree left anterior oblique view with no cranial or caudal angulation. Usually a total of 40 to 50 cc of dye is injected with approximately 20 cc administered every second. You should tell the patient that they can expect a warm feeling throughout their body.

Grading Aortic Insufficiency

The grade of aortic insufficiency is based on the opacification of the left ventricle 2 complete cardiac cycles after injection compared to that of the aortic root.

Grade 1

Brief and incomplete ventricular opacification. Clears rapidly.

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Grade 2

Moderate opacification of the ventricle that clears in less that 2 cycles. Never greater than aortic root opacification.

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Grade 3

Opacification of the ventricle equal to aortic root opacification within 2 cycles. Delayed clearing of ventricle over several cycles.

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Grade 4

Opacification of the ventricle almost immediately that is greater than that of the aortic root with delayed clearing of the ventricle.

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Coronary Angiography in the Patient with Aortic Insufficiency

As a result of the regurgitant flow into the left ventricle, there is greater than normal flow in the coronary arteries that tends to dilute the contrast. It can be quite difficult to fill the coronary arteries during a standard injection.

2008 and Incorporated 2006 ACC/AHA Guidelines for the Management of Patients with Valvular Heart Disease (DO NOT EDIT)

Cardiac Catheterization Indications (DO NOT EDIT)

Class I

"1. Cardiac catheterization with aortic root angiography and measurement of LV pressure is indicated for assessment of severity of regurgitation, LV function, or aortic root size when noninvasive tests are inconclusive or discordant with clinical findings in patients with AR. (Level of Evidence: B)"

"2. Coronary angiography is indicated before AVR in patients at risk for CAD. (Level of Evidence: C)"

Class III

"1. Cardiac catheterization with aortic root angiography and measurement of LV pressure is not indicated for assessment of LV function, aortic root size, or severity of regurgitation before AVR when noninvasive tests are adequate and concordant with clinical findings and coronary angiography is not needed. (Level of Evidence: C)"

"2. Cardiac catheterization with aortic root angiography and measurement of LV pressure is not indicated for assessment of LV function and severity of regurgitation in asymptomatic patients when noninvasive tests are adequate. (Level of Evidence: C)"

Sources

• 2008 Focused Update Incorporated Into the ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease