age of longitudinal fibers would account for the reduced apex-to-base shortening and for the outward end-systolic curvature of the inferobasal wall in inferior myocardial infarction. The minor degree of wall motion alterations that has been observed in the inferior compared with the anterior infarct (even when the extent of anatomic lesion is the same) can be explained by considering the limitations of the methods frequently used to evaluate segmental wall motion. Most methods evaluate the movement of endocardium toward the ventricular cavity, overlooking the longitudinal component of inferior wall asynergy. As in previous studies,1-3 our results indicate that wall expansion is infrequent in the inferior infarct. The diastolic length of the inferior hemiperimeter was not sign& cantly different from that of normal subjects. A higher parietal stress due to the greater curvature radius of the anterolateral wall has been considered a factor leading to wall expansion in anterior myocardial infarction, with eventual development of anterior aneurysm.5v7The catenoid shape of the inferior wall at end-systole, lowering parietal stresses,19 may exert a protective action against wall stretching and thinning. In conclusion, the inferior wall in patients with an inferior wall myocardial infarction showed a decreased longitudinal shortening and a greater concavity than in normal subjects, which correlated with asynergy extension and pump function. The normal negative curvature of this wall may protect against aneurysm formation in this infarct location. 1. Eaton LW, Weiss JL, Bulkley BH, Garrison JB, Weisfeldt ML. Regional cardiac dilatation after acute myocardial infarction: recognition by twodimensional e&cardiography. N Engl J Med 1979;300:57-62. 2. Visser CA, Kan G, Meltxer RS, Koolen JJ, Dunning AJ. Incidence, timing and prognostic value of left ventricular aneurysm formation after myocardial infarction: a prospective, serial echocardiographic study of 158 patients. Am J Gvdiol 1986;57:729-732.
3. Horan JG, Flowers NC, Johnson JC. Significance of the diagnostic Q wave of myocardial infarction. Circuhtion 1971;43:426-436. 4. Picard MH, Wilkins GT, Gillam LD, Thomas JD, Weyman AE. Immediate regional endocardial surface expansion following coronary occlusion in the canine left ventricle: disproportionate effects of anterior versus inferior ischemia. Am Heart J 1991;121:753-762. 5. Benhorin J, Moss AJ, Oakes D, Marcus F, Greenberg H, Dwyer EM, Algeo S, Hahn E. The prognostic significance of first myocardial infarction type (Q wave versus non-Q wave) and Q wave location. The Multicenter Diltiaxem Post-Infarction Research Group. J Am Coli Cardiol 1990$1201-1207. 6. Miller RR, Olson HG, Vismara LA, Bogren HG, Amsterdam BA, Mason DT. Pump dysfunction after myocardial infarction: importance of location, extent and pattern of abnormal left ventricular segmental contraction. Am J Cardiol 1976;37:340-344. 7. Bulkley BH. Site and squelae of myocardial infarction. N Engl J Med 1981;305:337-338. B. Yang SS. Bentivoglio LG. Maranhao V, Goldberg H. From Cardiac Catheterization Data to Hemodynamic Parameters. 3rd ed. Philadelphia: FA Davis, 1988:73. 9. Chapman CB, Baker 0, Reynolds J, Bonte FJ. Use of biplane cinefluorography for measurement of ventricular volume. Circularion 1958;18:1105-1117. 10. Sheehan FH, Bolson EL, Dodge I-IT, Mathey Dg, Schafer J, Woo H. Advantages and applications of the centerline method for characterizing regional ventricular function. Circulation 1986;74:293-305. 11. Sheehan FH, Matley DG, Schoper J, Krebber H, Dodge HT. Effect of interventions in salvaging left ventricular function in acute myocardiil infarction: a study of intracoronary streptokinase. Am J Cardiol 1983;52:431-438. 12. Baroni M, Barletta G. Digital curvature estimation for left ventricular shape analysis. Image & Vision Comput 1992;10:485-494. 13. Kas DA, Trail1 TA, Altieri PI, Ma&am WL. Abnormalities of dynamic ventricular shape change in patients with aortic and mitral valvular regurgitation: assessment by Fourier shape analysis and global geometric indexes. Circ Res 1988;62:127-138. 14. Rigaud M, Rocha P, Boschat J, Farcot JC, Bardet J, Boudarias JP. Regional left ventricular function asses& by contrast angiography in acute myocardial infarction. Circulation 1979;60:130-139. 1% Sheehan FH, Schafer JM, Mathey DG, Kellett MA, Smith H, Bolson EL, Dodge HT. Measurement of regional wall motion by biplane contrast ventriculcgrams. Circulation 1986;74:796-804. 16. Mancini GBJ, DeBoe SF, Anselmo E, Simon SB, LeFree MT, Vogel RA. Quantitative regional curvature analysis: an application of shape determination for the assessment of segmental left ventricular function in man. Am Hew J 1987;113:326-334. 17. Greenbaum RA, Ho SY, Gibson DG, Becker AE, Anderson RH. Left ventricular Iibre architecture in man. Br Hear? J 1981;45:248-263. 18. Hoglund C, Alam M, Thorstrand M. Effects of acute myocardial infarction on the displacement of the at&ventricular plane: an echocardiographic study. J Intern Med 1989;226:251-256. 19. Hutchins GM, Bulldey BH, Moore GW, Piasio MA, Lohr FT. Shape of the human cardiac ventricles. Am J Cardiol 1978;41:646654.
Coronary Angiographywith Four FrenchCatheters Abhay K. Pande, MD, Bernhard Meier, MD, Philip Urban, MD, Vitali Verin, MD, Victor P. Moles, MD, Frarqois Chappuis, MD, and Vivek K. Mehan, MD n coronary angiography, there is a trend to use smaller Iandcatheters in order to avoid puncture site complications minimize hospital stay.1-4 It is a standard practice in our laboratory to perform routine coronary angiography with 6Fr catheters. Recently, 4Fr catheters have been introduced for angiography. This prospective randomized study addresses the performance of 4Fr catheters for diagnostic coronary angiography compared with 6Fr catheters. The study population comprised 200 consecutive unselected patients (168 men, mean age 61 f 10 years, range 31 to 82) undergoing diagnostic coronary angiography (excluding patients with pure valve disease). The From the Cardiology Center, University Hospital, 1211 Geneva 14, Switzerland. Manuscript received April 2, 1992; revised manuscript received and accepted May 28.1992.
angiography was performed through a femoral artery with a 4 and 6Fr sheath (puncture hole diameter 1.67 mm for 4Fr and 2.30 mm for 6Fr). In 36 patients in the 4Fr and 7 in the 6Fr group, the procedure was done without a sheath (puncture hole diameter I .35 mm for 4Fr and 2.00 mm for 6Fr). Cordis (Cordis Europa N.V., the Netherlands) catheters and 0.035 inch (0.89 mm) guidewires were used exclusively. The internal diameter of the 4Fr catheters used was 0.040 inch (1.02 mm) and of the 6Fr 0.050 inch (1.27 mm). The patients were randomized to 4 or 6Fr catheters in the catheterization laboratory using the sealed envelope system. Procedure duration and fluoroscopy time for coronary angiography, quantity of radiographic contrast medium used, length of cinefilm, quality of ventriculography (I = excellent, to 4 = bad), occurrence of streaming (incomplete opacification of arteries), ease of catheter manipulation BRIEF REPORTS
1085
TABLE I Technical Problems
Dislodgment from ostium Right coronary artery Left coronary artery Streaming Right coronary artery Left coronary artery
4 French (n = 1001
6 French (n = 1001
p Value
34 27
6 4
0.0001 0.0001
9 26
4 2
0.05 0.001
(1 = very easy, to 6 = impossible), torque control (I = excellent, to 4 = bad), time to achieve hemostasis at puncture site, and needfor different French size were analyzed. The quality of the tine film was assessedby the operator and an additional cardiologist. Nonionic contrast medium and premeditation with nitroglycerin were used in all cases.Heparin (2,500 U) was given according to the physician’s preferenceat the beginning of the procedure in 51 patients (51%) in the 4Fr group, and 56 (56%) in the 6Fr group. Statistical analysis was performed using the chi-square test and the unpaired t test. Valuesare expressedas meanf standard deviation. There wereno cardiac or puncture site complications and no significant problem with ostial wedging in either group. Adequate angiograms were obtained in 97% of patients. In the group with 4Fr catheters,a crosswer to another French size was required in 4 patients (4%) owing to difficulty in engagingthe coronary ostia versus 2 patients (2%) with 6Fr catheters (difference not sign.+ icant). No significant differences between 4 and 6Fr catheters (including time after crosswer to another French size) wereseenin total duration of the procedure (496 f 262 us475 f 383 seconds),jluoroscopytime (381 f 224 vs 420 f 557 seconds),quantity of contrast medium (91 f 30 us 97 f 47 ml), length of cinefilm (75 f 36 us 71 f 26 seconds),and number of cathetersper patient (3.1 in both groups including the pigtail catheter for ventriculography). The quality of ventnkulography was judged slightly better with 6Fr catheters(I .8 f 0.6 us2.0 f 0.8 with 4Fr, p = 0.05). There was a signijicantly higher incidenceof dislodgmentfrom the ostia with 4Fr catheters (31 us 5%, p = OJWO1)(Table I). The incidenceof streaming was also higher with 4Fr catheters (I8 us 3% p = 0.001). The technicalfacility wasjudged to be similar in both groups. Torque control was perceivedas slightly better with 4Fr catheters(1.6 f 0.6for right and 1.5 f 0.6for left coronary catheterswith 4Fr us 1.7 f 0.8for right and 1.7 f 0.7for left coronary catheters with 6Fr, p = 0.05). Compressiontime to achieve hemostasiswas 310 f 159 secondsfor 4Fr (75 patients) versus383 f 151 secondsfor6Fr (74patients,p = 0.01); the remaining 51 patients underwent immediate angioplasty and therefore were not included for the hemostasis analysis. There were no early or late puncture site complications. The reported incidence of local vascular complications with coronary angiography is 4 to 12%~.~,~ Smaller
1086
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
catheters are likely to reduce these complications.1>4 However, there are concernsabout the quality of angiography and technical difficulties with smaller catheters. This study addressestheseaspectsconcerningthe recently introduced 4Fr catheters. Adequate coronary angiograms were obtained with 4Fr cathetersin 96%of patientsversus98%with 6Fr. The high incidence of dislodgment of 4Fr catheters from the coronary ostia, becauseof their reducedstability and the increased velocity of the exiting contrast medium, resulted in streaming, particularly in the left coronary artery. Streaming did not occur with a stableposition of the 4Fr catheters,indicating that it wasnot a consequenceof limited flow. This technical difficulty did not impact on the length of procedure,the quantity of contrast medium used,or the length of tine film. None of the procedures had to be repeated becauseof inadequate quality for clinical decision making. An interesting finding wasthe superiority of 4Fr catheters in terms of torque control. This is explained by a novel shaft technology basedon a new material “Pellethane,” not yet implemented in 6Fr catheters used. The advantageof the small puncture hole with 4Fr catheters was evident from the significantly reduced time to achievehemostasis.Moreover, 4Fr catheterscan be easily introduced without the usual blade incision of the skin. Limitations of the 4Fr catheters are the need to stint the pigtail catheter with a guidewire to pass the aortic valve and the restriction to guidewires 10.035 inch (0.89 mm). Angiography with 4Fr comparedwith 6Fr catheters requires more skill, particularly in preventing dislodgment from the coronary ostia during contrast medium injection, which has to be done vigorously to achieve adequate flow. They should therefore be reserved for experiencedangiographers. In conclusion,4Fr catheterspermit an adequatediagnostic coronary angiography in 96% of patients. Compared with 6Fr catheters, there is a higher incidence of catheter dislodgmentleading to streaming.However,this can be corrected in most casesand doesnot compromise overall quality to a clinically significant degree. The smaller puncture hole reducescompressiontime and may ultimately allow for earlier ambulation, shorter hospital stay and reduction of puncture site complications. 1. Kern MJ, Cohen M, Talley JD, Litvack F, Serota H, Aguire F, Deligonul U, BashoreT. Early ambulationafter 5 Frenchdiagnosticcatheterization:resultsof a multicenter trial. J Am Co11Cardiol 1990,15:1475-1483. 2. Molajo AO, Ward C, Bray CL, DobsonD. Comparisonof the performanceof supcrflow (5F) and conventional8F cathetersfor &diic catheterization by the femoral route. Cathet Cardiarasc Diagn 1987;13:275-276. 3. Erlemeier HH. Bleifeld W. Decreasedin-natient bedresttime after coronarv angiography with’5 French catheters. Z K&diol 1990;79:641-646. 4. Hui WKK, Klnke WP, Kubac G, Talibi T. Comparison of 5F and 7/8F cathetersfor left ventricular and coronary angiography.Cafhet Cardiouasc Diagn 1990,19:84-86. 1. Wvman MR. Salian RD. Portwav V. Silkman JJ. M&w RG. Bairn D. Current compli&tions of diaBrmsticand therapeutic cardiac catheterization. J Am Co11 Cardiol 1988;12:140&1406.
6. Block PC, GckaneI, GoldbergRJ. A prospectiverandomizedtrial of outpatient versus inpatient cardiac catheterization. N Engl J Med 1988;319:1251-1255.
OCTOBER 15. 1992
3. Horan JG, Flowers NC, Johnson JC. Significance of the diagnostic Q wave of myocardial infarction. Circuhtion 1971;43:426-436. 4. Picard MH, Wilkins GT, Gillam LD, Thomas JD, Weyman AE. Immediate regional endocardial surface expansion following coronary occlusion in the canine left ventricle: disproportionate effects of anterior versus inferior ischemia. Am Heart J 1991;121:753-762. 5. Benhorin J, Moss AJ, Oakes D, Marcus F, Greenberg H, Dwyer EM, Algeo S, Hahn E. The prognostic significance of first myocardial infarction type (Q wave versus non-Q wave) and Q wave location. The Multicenter Diltiaxem Post-Infarction Research Group. J Am Coli Cardiol 1990$1201-1207. 6. Miller RR, Olson HG, Vismara LA, Bogren HG, Amsterdam BA, Mason DT. Pump dysfunction after myocardial infarction: importance of location, extent and pattern of abnormal left ventricular segmental contraction. Am J Cardiol 1976;37:340-344. 7. Bulkley BH. Site and squelae of myocardial infarction. N Engl J Med 1981;305:337-338. B. Yang SS. Bentivoglio LG. Maranhao V, Goldberg H. From Cardiac Catheterization Data to Hemodynamic Parameters. 3rd ed. Philadelphia: FA Davis, 1988:73. 9. Chapman CB, Baker 0, Reynolds J, Bonte FJ. Use of biplane cinefluorography for measurement of ventricular volume. Circularion 1958;18:1105-1117. 10. Sheehan FH, Bolson EL, Dodge I-IT, Mathey Dg, Schafer J, Woo H. Advantages and applications of the centerline method for characterizing regional ventricular function. Circulation 1986;74:293-305. 11. Sheehan FH, Matley DG, Schoper J, Krebber H, Dodge HT. Effect of interventions in salvaging left ventricular function in acute myocardiil infarction: a study of intracoronary streptokinase. Am J Cardiol 1983;52:431-438. 12. Baroni M, Barletta G. Digital curvature estimation for left ventricular shape analysis. Image & Vision Comput 1992;10:485-494. 13. Kas DA, Trail1 TA, Altieri PI, Ma&am WL. Abnormalities of dynamic ventricular shape change in patients with aortic and mitral valvular regurgitation: assessment by Fourier shape analysis and global geometric indexes. Circ Res 1988;62:127-138. 14. Rigaud M, Rocha P, Boschat J, Farcot JC, Bardet J, Boudarias JP. Regional left ventricular function asses& by contrast angiography in acute myocardial infarction. Circulation 1979;60:130-139. 1% Sheehan FH, Schafer JM, Mathey DG, Kellett MA, Smith H, Bolson EL, Dodge HT. Measurement of regional wall motion by biplane contrast ventriculcgrams. Circulation 1986;74:796-804. 16. Mancini GBJ, DeBoe SF, Anselmo E, Simon SB, LeFree MT, Vogel RA. Quantitative regional curvature analysis: an application of shape determination for the assessment of segmental left ventricular function in man. Am Hew J 1987;113:326-334. 17. Greenbaum RA, Ho SY, Gibson DG, Becker AE, Anderson RH. Left ventricular Iibre architecture in man. Br Hear? J 1981;45:248-263. 18. Hoglund C, Alam M, Thorstrand M. Effects of acute myocardial infarction on the displacement of the at&ventricular plane: an echocardiographic study. J Intern Med 1989;226:251-256. 19. Hutchins GM, Bulldey BH, Moore GW, Piasio MA, Lohr FT. Shape of the human cardiac ventricles. Am J Cardiol 1978;41:646654.
Coronary Angiographywith Four FrenchCatheters Abhay K. Pande, MD, Bernhard Meier, MD, Philip Urban, MD, Vitali Verin, MD, Victor P. Moles, MD, Frarqois Chappuis, MD, and Vivek K. Mehan, MD n coronary angiography, there is a trend to use smaller Iandcatheters in order to avoid puncture site complications minimize hospital stay.1-4 It is a standard practice in our laboratory to perform routine coronary angiography with 6Fr catheters. Recently, 4Fr catheters have been introduced for angiography. This prospective randomized study addresses the performance of 4Fr catheters for diagnostic coronary angiography compared with 6Fr catheters. The study population comprised 200 consecutive unselected patients (168 men, mean age 61 f 10 years, range 31 to 82) undergoing diagnostic coronary angiography (excluding patients with pure valve disease). The From the Cardiology Center, University Hospital, 1211 Geneva 14, Switzerland. Manuscript received April 2, 1992; revised manuscript received and accepted May 28.1992.
angiography was performed through a femoral artery with a 4 and 6Fr sheath (puncture hole diameter 1.67 mm for 4Fr and 2.30 mm for 6Fr). In 36 patients in the 4Fr and 7 in the 6Fr group, the procedure was done without a sheath (puncture hole diameter I .35 mm for 4Fr and 2.00 mm for 6Fr). Cordis (Cordis Europa N.V., the Netherlands) catheters and 0.035 inch (0.89 mm) guidewires were used exclusively. The internal diameter of the 4Fr catheters used was 0.040 inch (1.02 mm) and of the 6Fr 0.050 inch (1.27 mm). The patients were randomized to 4 or 6Fr catheters in the catheterization laboratory using the sealed envelope system. Procedure duration and fluoroscopy time for coronary angiography, quantity of radiographic contrast medium used, length of cinefilm, quality of ventriculography (I = excellent, to 4 = bad), occurrence of streaming (incomplete opacification of arteries), ease of catheter manipulation BRIEF REPORTS
1085
TABLE I Technical Problems
Dislodgment from ostium Right coronary artery Left coronary artery Streaming Right coronary artery Left coronary artery
4 French (n = 1001
6 French (n = 1001
p Value
34 27
6 4
0.0001 0.0001
9 26
4 2
0.05 0.001
(1 = very easy, to 6 = impossible), torque control (I = excellent, to 4 = bad), time to achieve hemostasis at puncture site, and needfor different French size were analyzed. The quality of the tine film was assessedby the operator and an additional cardiologist. Nonionic contrast medium and premeditation with nitroglycerin were used in all cases.Heparin (2,500 U) was given according to the physician’s preferenceat the beginning of the procedure in 51 patients (51%) in the 4Fr group, and 56 (56%) in the 6Fr group. Statistical analysis was performed using the chi-square test and the unpaired t test. Valuesare expressedas meanf standard deviation. There wereno cardiac or puncture site complications and no significant problem with ostial wedging in either group. Adequate angiograms were obtained in 97% of patients. In the group with 4Fr catheters,a crosswer to another French size was required in 4 patients (4%) owing to difficulty in engagingthe coronary ostia versus 2 patients (2%) with 6Fr catheters (difference not sign.+ icant). No significant differences between 4 and 6Fr catheters (including time after crosswer to another French size) wereseenin total duration of the procedure (496 f 262 us475 f 383 seconds),jluoroscopytime (381 f 224 vs 420 f 557 seconds),quantity of contrast medium (91 f 30 us 97 f 47 ml), length of cinefilm (75 f 36 us 71 f 26 seconds),and number of cathetersper patient (3.1 in both groups including the pigtail catheter for ventriculography). The quality of ventnkulography was judged slightly better with 6Fr catheters(I .8 f 0.6 us2.0 f 0.8 with 4Fr, p = 0.05). There was a signijicantly higher incidenceof dislodgmentfrom the ostia with 4Fr catheters (31 us 5%, p = OJWO1)(Table I). The incidenceof streaming was also higher with 4Fr catheters (I8 us 3% p = 0.001). The technicalfacility wasjudged to be similar in both groups. Torque control was perceivedas slightly better with 4Fr catheters(1.6 f 0.6for right and 1.5 f 0.6for left coronary catheterswith 4Fr us 1.7 f 0.8for right and 1.7 f 0.7for left coronary catheters with 6Fr, p = 0.05). Compressiontime to achieve hemostasiswas 310 f 159 secondsfor 4Fr (75 patients) versus383 f 151 secondsfor6Fr (74patients,p = 0.01); the remaining 51 patients underwent immediate angioplasty and therefore were not included for the hemostasis analysis. There were no early or late puncture site complications. The reported incidence of local vascular complications with coronary angiography is 4 to 12%~.~,~ Smaller
1086
THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 70
catheters are likely to reduce these complications.1>4 However, there are concernsabout the quality of angiography and technical difficulties with smaller catheters. This study addressestheseaspectsconcerningthe recently introduced 4Fr catheters. Adequate coronary angiograms were obtained with 4Fr cathetersin 96%of patientsversus98%with 6Fr. The high incidence of dislodgment of 4Fr catheters from the coronary ostia, becauseof their reducedstability and the increased velocity of the exiting contrast medium, resulted in streaming, particularly in the left coronary artery. Streaming did not occur with a stableposition of the 4Fr catheters,indicating that it wasnot a consequenceof limited flow. This technical difficulty did not impact on the length of procedure,the quantity of contrast medium used,or the length of tine film. None of the procedures had to be repeated becauseof inadequate quality for clinical decision making. An interesting finding wasthe superiority of 4Fr catheters in terms of torque control. This is explained by a novel shaft technology basedon a new material “Pellethane,” not yet implemented in 6Fr catheters used. The advantageof the small puncture hole with 4Fr catheters was evident from the significantly reduced time to achievehemostasis.Moreover, 4Fr catheterscan be easily introduced without the usual blade incision of the skin. Limitations of the 4Fr catheters are the need to stint the pigtail catheter with a guidewire to pass the aortic valve and the restriction to guidewires 10.035 inch (0.89 mm). Angiography with 4Fr comparedwith 6Fr catheters requires more skill, particularly in preventing dislodgment from the coronary ostia during contrast medium injection, which has to be done vigorously to achieve adequate flow. They should therefore be reserved for experiencedangiographers. In conclusion,4Fr catheterspermit an adequatediagnostic coronary angiography in 96% of patients. Compared with 6Fr catheters, there is a higher incidence of catheter dislodgmentleading to streaming.However,this can be corrected in most casesand doesnot compromise overall quality to a clinically significant degree. The smaller puncture hole reducescompressiontime and may ultimately allow for earlier ambulation, shorter hospital stay and reduction of puncture site complications. 1. Kern MJ, Cohen M, Talley JD, Litvack F, Serota H, Aguire F, Deligonul U, BashoreT. Early ambulationafter 5 Frenchdiagnosticcatheterization:resultsof a multicenter trial. J Am Co11Cardiol 1990,15:1475-1483. 2. Molajo AO, Ward C, Bray CL, DobsonD. Comparisonof the performanceof supcrflow (5F) and conventional8F cathetersfor &diic catheterization by the femoral route. Cathet Cardiarasc Diagn 1987;13:275-276. 3. Erlemeier HH. Bleifeld W. Decreasedin-natient bedresttime after coronarv angiography with’5 French catheters. Z K&diol 1990;79:641-646. 4. Hui WKK, Klnke WP, Kubac G, Talibi T. Comparison of 5F and 7/8F cathetersfor left ventricular and coronary angiography.Cafhet Cardiouasc Diagn 1990,19:84-86. 1. Wvman MR. Salian RD. Portwav V. Silkman JJ. M&w RG. Bairn D. Current compli&tions of diaBrmsticand therapeutic cardiac catheterization. J Am Co11 Cardiol 1988;12:140&1406.
6. Block PC, GckaneI, GoldbergRJ. A prospectiverandomizedtrial of outpatient versus inpatient cardiac catheterization. N Engl J Med 1988;319:1251-1255.
OCTOBER 15. 1992
