Clinical Radiology (1991) 44, 27-30
Comparison of Left Coronary and Laevo-Phase Pulmonary Angiograms in Detecting Left Atrial Thrombi in Rheumatic Mitral Stenosis S. SHARMA, M. V. KUMAR*, V. M. R E D D Y t , U. KAUL*, M. RAJANI and P. VENUGOPAL~ Departments of Cardiovascular Radiology, *Cardiology, and ~ Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute o f Medical Sciences, New Delhi, India We have compared the diagnostic accuracy of left coronary and laevo-phase pulmonary angiograms in detecting left atrial thrombi in 27 consecutive patients with rheumatic mitral stenosis who underwent both these procedures prior to open-heart surgery. In 10 patients, both procedures were 'positive' for thrombus, confirmed at subsequent surgery in all instances (true positive). Both procedures were negative for thrombus in 11 patients, and none of these patients showed thrombi at subsequent surgery (true negative). Left coronary angiography only was positive for thrombus in one patient in whom no thrombus was found at surgery. Laevo-phase pulmonary angiography only was positive for thrombus in five patients, two of whom had thrombus at subsequent surgery. The sensitivity, specificity and predictive accuracy of left coronary angiogram were 83.3% and 93.3% and 90.9% and that of laevo-phase pulmonary angiogram 100%, 80% and 80% respectively. Laevo-phase pulmonary angiograms showed higher sensitivity and left coronary angiograms showed higher specificity for angiographic diagnosis. However, the differences were found to be statistically insignificant. Angiography is a reliable method for detecting left atrial thrombi if both left coronary and pulmonary angiograms are performed and both procedures are positive or negative for thrombus. Sharma, S., Kumar, M.V., Reddy, V.M., Kaul, U., Rajani, M. & Venugopal, P. Clinical Radiology 44, 27-30. Comparison of Left Coronary and Laevo-Phase Pulmonary Angiograms in Detecting Left Atrial Thrombi in Rheumatic Mitral Stenosis
Thrombosis of the left atrium or its appendage is common in rheumatic mitral stenosis and is said to occur in 22% of patients at surgery (Nichols et al., 1962) and in 35.8% of patients at autopsy (Wallach et al., 1963). Most thrombi are small and occur in the vicinity of the appendage but occasionally a large thrombus may extend along the posterior wall of the left atrium (Matsuyama et al., 1983). Localization of the thrombus is important since its presence is a contraindication to percutaneous balloon mitral valvo-plasty and necessitates open-heart surgery. The need for an imaging technique with high sensitivity and specificity for detecting these thrombi is obvious. Conventional chest radiographs and fluoroscopy are unreliable in predicting left atrial thrombi (Arendt and Cardon, 1949; Matsuyama et al., 1983). Echocardiography has also been utilized for this purpose but is associated with low sensitivity and specificity (Spangler and Okin, 1975; Schweizer et al., 1981; Shrestha et al., t983) and is especially unreliable in detecting thrombi in the appendage which is the site of thrombus formation in as many as 84% of patients (Swanson and Steinberg, 1964; Schweizer et al., 1981; Shrestha et al., 1983). Transoesophageal echocardiography can readily visualize the atrial appendage and may prove helpful in detecting thrombi in it, especially in patients in whom conventional two-dimensional echocardiogram is not diagnostic (Shuaile, 1988). Recently, computed tomography and scintigraphy have also shown encouraging results in this regard but these investigations are not, as Correspondence to: Dr Sanjiv Sharma, Department of Radiodiagnosis,All India Instituteof MedicalSciences,AnsariNagar, New Delhi, India
yet, widely available (Nair et al., 1981; Tomoda et al., 1983; Yamada et al., 1984). Angiocardiography, therefore, remains a widely accepted investigation for detecting these thrombi. Various procedures including left atrial opacification either by direct left atrial injection or in the laevo-phase of pulmonary angiograms, and selective left coronary angiograms have been employed (Soloff and Zatuchni, 1956; Ormond et al., 1964; Swanson and Steinberg, 1964; Lewis et al., 1965; Parker et al., 1965; Baue et al., 1968; Cipriano and Guthaner, 1978; Colman et al., 1981; Eriksson et al., 1984; Hubbard et al., 1987). Previous studies reported conflicting results regarding the reliability of various angiographic procedures in detecting thrombi; in addition, these procedures have not been compared in the same patient. We planned this study in order to compare the predictive accuracy of laevo-phase pulmonary angiography and left coronary angiography in detecting left atrial thrombi in 27 consecutive patients with rheumatic mitral stenosis who underwent both procedures prior to open-heart surgery.
MATERIAL AND M E T H O D S DUring the last 4 years, 98 patients with rheumatic mitral stenosis (50 males, 48 females; age range 16 to 68 years, mean age 41.8 years) underwent pre-operative left coronary and/or laevo
Comparison of Left Coronary and Laevo-Phase Pulmonary Angiograms in Detecting Left Atrial Thrombi in Rheumatic Mitral Stenosis S. SHARMA, M. V. KUMAR*, V. M. R E D D Y t , U. KAUL*, M. RAJANI and P. VENUGOPAL~ Departments of Cardiovascular Radiology, *Cardiology, and ~ Cardiothoracic and Vascular Surgery, Cardiothoracic Centre, All India Institute o f Medical Sciences, New Delhi, India We have compared the diagnostic accuracy of left coronary and laevo-phase pulmonary angiograms in detecting left atrial thrombi in 27 consecutive patients with rheumatic mitral stenosis who underwent both these procedures prior to open-heart surgery. In 10 patients, both procedures were 'positive' for thrombus, confirmed at subsequent surgery in all instances (true positive). Both procedures were negative for thrombus in 11 patients, and none of these patients showed thrombi at subsequent surgery (true negative). Left coronary angiography only was positive for thrombus in one patient in whom no thrombus was found at surgery. Laevo-phase pulmonary angiography only was positive for thrombus in five patients, two of whom had thrombus at subsequent surgery. The sensitivity, specificity and predictive accuracy of left coronary angiogram were 83.3% and 93.3% and 90.9% and that of laevo-phase pulmonary angiogram 100%, 80% and 80% respectively. Laevo-phase pulmonary angiograms showed higher sensitivity and left coronary angiograms showed higher specificity for angiographic diagnosis. However, the differences were found to be statistically insignificant. Angiography is a reliable method for detecting left atrial thrombi if both left coronary and pulmonary angiograms are performed and both procedures are positive or negative for thrombus. Sharma, S., Kumar, M.V., Reddy, V.M., Kaul, U., Rajani, M. & Venugopal, P. Clinical Radiology 44, 27-30. Comparison of Left Coronary and Laevo-Phase Pulmonary Angiograms in Detecting Left Atrial Thrombi in Rheumatic Mitral Stenosis
Thrombosis of the left atrium or its appendage is common in rheumatic mitral stenosis and is said to occur in 22% of patients at surgery (Nichols et al., 1962) and in 35.8% of patients at autopsy (Wallach et al., 1963). Most thrombi are small and occur in the vicinity of the appendage but occasionally a large thrombus may extend along the posterior wall of the left atrium (Matsuyama et al., 1983). Localization of the thrombus is important since its presence is a contraindication to percutaneous balloon mitral valvo-plasty and necessitates open-heart surgery. The need for an imaging technique with high sensitivity and specificity for detecting these thrombi is obvious. Conventional chest radiographs and fluoroscopy are unreliable in predicting left atrial thrombi (Arendt and Cardon, 1949; Matsuyama et al., 1983). Echocardiography has also been utilized for this purpose but is associated with low sensitivity and specificity (Spangler and Okin, 1975; Schweizer et al., 1981; Shrestha et al., t983) and is especially unreliable in detecting thrombi in the appendage which is the site of thrombus formation in as many as 84% of patients (Swanson and Steinberg, 1964; Schweizer et al., 1981; Shrestha et al., 1983). Transoesophageal echocardiography can readily visualize the atrial appendage and may prove helpful in detecting thrombi in it, especially in patients in whom conventional two-dimensional echocardiogram is not diagnostic (Shuaile, 1988). Recently, computed tomography and scintigraphy have also shown encouraging results in this regard but these investigations are not, as Correspondence to: Dr Sanjiv Sharma, Department of Radiodiagnosis,All India Instituteof MedicalSciences,AnsariNagar, New Delhi, India
yet, widely available (Nair et al., 1981; Tomoda et al., 1983; Yamada et al., 1984). Angiocardiography, therefore, remains a widely accepted investigation for detecting these thrombi. Various procedures including left atrial opacification either by direct left atrial injection or in the laevo-phase of pulmonary angiograms, and selective left coronary angiograms have been employed (Soloff and Zatuchni, 1956; Ormond et al., 1964; Swanson and Steinberg, 1964; Lewis et al., 1965; Parker et al., 1965; Baue et al., 1968; Cipriano and Guthaner, 1978; Colman et al., 1981; Eriksson et al., 1984; Hubbard et al., 1987). Previous studies reported conflicting results regarding the reliability of various angiographic procedures in detecting thrombi; in addition, these procedures have not been compared in the same patient. We planned this study in order to compare the predictive accuracy of laevo-phase pulmonary angiography and left coronary angiography in detecting left atrial thrombi in 27 consecutive patients with rheumatic mitral stenosis who underwent both procedures prior to open-heart surgery.
MATERIAL AND M E T H O D S DUring the last 4 years, 98 patients with rheumatic mitral stenosis (50 males, 48 females; age range 16 to 68 years, mean age 41.8 years) underwent pre-operative left coronary and/or laevo
