Letter to the editor
1
Catheterization and Cardiovascular Diagnosis 4:475-476 (1 978) Letter to the Editor TO THE EDITOR We read with interest the recent paper by Danahy [Cathet Cardiovasc Diagn 4: 19%205, 19781 on “Pseudosubaortic Stenosis - A Catheter Induced Artifact.” The author has elegantly illustrated a possible source of error in the study of aortic valve stenosis where an additional fictitious subaortic chamber is demonstrated by the use of a multihole catheter on withdrawal from the left ventricle to aorta. Certainly the cases of combined aortic valve and subvalvular stenosis described in the literature in the past need to be rescrutinized with this possibility in mind. To minimize this error, we routinely insist on obtaining a “pullback” tracing from the left ventricle into the aorta with an end hole catheter. For this purpose, we have found a Judkin right coronary catheter eminently suitable- enabling one to cross even the most stenosed and malaligned valves. Since the author does not mention his technique, we thought it might be useful to mention this practical point for the readers of this Journal. It should be also appreciated that an effort should be made to accomplish the pullback without the occurrence of premature beats. Interpretation of the pressure gradient in the outflow tract of the left ventricle can be extremely erroneous in the presence of premature beats. With these points in mind, the demonstration of a subaortic gradient is fairly reliable. Sudarshan Kumar, MD, Carl Tommaso, MD Northwestern Medical School, VA Lakeside Hospital, Chicago AUTHOR’S REPLY I wish to thank Doctors Kumar and Tommaso for their comments regarding the paper “Pseudo Subaortic Stenosis - A Catheter-Induced Artifact”. I have had no personal experi- ence using a Judkins right coronary catheter for crossing stenotic aortic valves and welcome this information regarding their technique. I have not routinely obtained left ventricular to aortic root pull-back pressure recordings with a single hole catheter in patients with valvular aortic stenosis. Since left ventriculog- raphy is important in assessing such patients, I have routinely used a multi-hole catheter to enter the left ventricle, record pressure and perform a left ventriculogram. Only in situations where other data raises a question regarding subvalvular obstruction does the additional use of a single hole catheter become crucial. I believe close scrutiny of the left ventriculogram and of the post-PVC pressure response are important in this regard. The post-PVC pressure response is helpful both in terms of measuring arterial pulse pressure (Brockenbrough response [I]) as well as measuring the left ventricular ejection time which shows a charac- teristic prolongation in the presence of dynamic subvalvular obstruction [21. 0098-6569/78/0404-0475$00.80 0 1978 Alan R. Liss, Inc.
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Transcript of Letter to the editor
Catheterization and Cardiovascular Diagnosis 4:475-476 (1 978)
Letter to the Editor
TO THE EDITOR
We read with interest the recent paper by Danahy [Cathet Cardiovasc Diagn 4: 19%205, 19781 on “Pseudosubaortic Stenosis - A Catheter Induced Artifact.”
The author has elegantly illustrated a possible source of error in the study of aortic valve stenosis where an additional fictitious subaortic chamber is demonstrated by the use of a multihole catheter on withdrawal from the left ventricle to aorta. Certainly the cases of combined aortic valve and subvalvular stenosis described in the literature in the past need to be rescrutinized with this possibility in mind. To minimize this error, we routinely insist on obtaining a “pullback” tracing from the left ventricle into the aorta with an end hole catheter. For this purpose, we have found a Judkin right coronary catheter eminently suitable- enabling one to cross even the most stenosed and malaligned valves. Since the author does not mention his technique, we thought it might be useful to mention this practical point for the readers of this Journal. It should be also appreciated that an effort should be made to accomplish the pullback without the occurrence of premature beats. Interpretation of the pressure gradient in the outflow tract of the left ventricle can be extremely erroneous in the presence of premature beats. With these points in mind, the demonstration of a subaortic gradient is fairly reliable.
Sudarshan Kumar, MD, Carl Tommaso, MD Northwestern Medical School, VA Lakeside Hospital, Chicago
AUTHOR’S REPLY
I wish to thank Doctors Kumar and Tommaso for their comments regarding the paper “Pseudo Subaortic Stenosis - A Catheter-Induced Artifact”. I have had no personal experi- ence using a Judkins right coronary catheter for crossing stenotic aortic valves and welcome this information regarding their technique.
I have not routinely obtained left ventricular to aortic root pull-back pressure recordings with a single hole catheter in patients with valvular aortic stenosis. Since left ventriculog- raphy is important in assessing such patients, I have routinely used a multi-hole catheter to enter the left ventricle, record pressure and perform a left ventriculogram. Only in situations where other data raises a question regarding subvalvular obstruction does the additional use of a single hole catheter become crucial. I believe close scrutiny of the left ventriculogram and of the post-PVC pressure response are important in this regard. The post-PVC pressure response is helpful both in terms of measuring arterial pulse pressure (Brockenbrough response [I]) as well as measuring the left ventricular ejection time which shows a charac- teristic prolongation in the presence of dynamic subvalvular obstruction [21.
0098-6569/78/0404-0475$00.80 0 1978 Alan R. Liss, Inc.
