Left ventriculography became the gold standard for assessing left ventricle function decades ago, but newer imaging technologies like cardiac MRI, echocardiography, and cardiac CT angiography have led to less frequent use of this test. Studies have shown that left ventriculography use varies widely throughout the country and within hospitals. Decisions to perform left ventriculography are usually left to the discretion of the operator.
“Until recently, there have been no specific guidelines to help clinicians recognize when it’s appropriate to perform left ventriculography at the time of coronary angiography or left heart catheterization,” explains Osvaldo S. Gigliotti, MD, FSCAI. “Although use of left ventriculography has declined over time, there are instances when this test is a good option for some patients.”
Filling a Void on Optimal Uses for Left Ventriculography
The Society for Cardiovascular Angiography and Interventions (SCAI) has issued a consensus statement on optimal uses for left ventriculography based on currently available data. “The statement fills a void by guiding clinicians on when left ventriculography should and should not be used,” says Dr. Gigliotti, who was the consensus statement’s lead author. Several uses for the test are reviewed in the consensus statement, including measuring ejection fraction, identifying defects in motions of the heart wall, and measuring ventricle volume in patients with heart valve defects. Left ventriculography is also useful for identifying aneurysms in the left ventricle and septal defects.
Key Recommendations on Appropriate Use of Left Ventriculography
The SCAI document offers several key recommendations on using left ventriculography. These tests should be:
1. Considered when left ventricular function or wall motion is unknown, or when mechanical disruption is suspected and results of the study will help determine therapy.
2. Performed selectively and avoided when an adequate alternative left ventricular imaging study has been performed.
3. Avoided in patients for whom it creates significant risk, including patients with renal insufficiency, elevated end diastolic pressure levels, known or suspected left ventricular mural thrombus, and aortic valvular vegetation. It should also be avoided in people who have already received high levels of radiation exposure.
4. Performed with a multi-sidehole catheter using a power injector.
SCAI also recommends that clinicians develop local criteria for performing left ventriculography and that efforts are made to decrease variation in its performance among operators within individual catheterization laboratories. In addition, techniques and indications should be included in random case reviews as part of a comprehensive catheterization laboratory quality program.
“Our recommendations are based on consensus, but still need to be tested in clinical studies,” says Dr. Gigliotti. “We need more open discussions on the use of left ventriculography so we can push science forward. Until this research emerges, these recommendations can be used to help standardize the application of left ventriculography and improve quality of care.”
Gigliotti OS, Babb JD, Dieter RS, et al. Optimal use of left ventriculography at the time of cardiac catheterization: a consensus statement from the Society for Cardiovascular Angiography and Interventions. Catheter Cardiovasc Interv. 2014 Nov 4 [Epub ahead of print]. Available at: http://onlinelibrary.wiley.com/doi/10.1002/ccd.25642/abstract.
Witteles RM, Knowles JW, Perez M, et al. Use and overuse of left ventriculography. Am Heart J. 2012;163:617-623.
Joffe SW, Chalian A, Tighe DA, et al. Trends in the use of echocardiography and left ventriculography to assess left ventricular ejection fraction in patients hospitalized with acute myocardial infarction. Am Heart J. 2009;158:185-192.
Heidenreich PA, Lin S, Knowles JW, et al. Variation in use of left ventriculography in the Veterans Affairs Health Care System. Circ Cardiovasc Qual Outcomes. 2013;6:687-693.