Use and overuse of left ventriculography

doi:10.1016/j.ahj.2011.12.018

American Heart Journal

Volume 163, Issue 4, April 2012, Pages 617-623.e1

https://doi.org/10.1016/j.ahj.2011.12.018 Get rights and content

Background

Left ventriculography provided the first imaging of left ventricular function and was historically performed as part of coronary angiography despite a small but significant risk of complications. Because modern noninvasive imaging techniques are more accurate and carry smaller risks, the routine use of left ventriculography is of questionable utility. We sought to analyze the frequency that left ventriculography was performed during coronary angiography in patients with and without a recent alternative assessment of left ventricular function.

Methods

We performed a retrospective analysis of insurance claims data from the Aetna health care benefits database including all adults who underwent coronary angiography in 2007. The primary outcome was the concomitant use of left ventriculography during coronary angiography.

Results

Of 96,235 patients who underwent coronary angiography, left ventriculography was performed in 78,705 (81.8%). Use of left ventriculography was high in all subgroups, with greatest use in younger patients, those with a diagnosis of coronary disease, and those in the Southern United States. In the population who had undergone a very recent ejection fraction assessment by another modality (within 30 days) and who had had no intervening diagnosis of new heart failure, myocardial infarction, hypotension, or shock (37,149 patients), left ventriculography was performed in 32,798 patients (88%)—a rate higher than in the overall cohort.

Conclusions

Left ventriculography was performed in most coronary angiography cases and often when an alternative imaging modality had been recently completed. New clinical practice guidelines should be considered to decrease the overuse of this invasive test.

Section snippets

Patient population

All adults enrolled in Aetna health benefits plans and undergoing cardiac catheterization from January 1 to December 31, 2007, were included (n = 96,235). Cardiac catheterization was defined as any of the following International Classification of Diseases, Ninth Edition (ICD-9) procedure codes (3722, 3723, and 8853-8858) or Current Procedural Terminology (CPT) codes (93510, 93511, 93555, 93543, 91920, 93539, 93540, 93545, 93556, and 93508). Stanford University Institutional Review Board

Results

A total of 96,235 patients underwent coronary angiography. The mean age was 62.0 ± 13 years, and 61% were male. Other baseline clinical characteristics are present in Table I. Out of all patients who underwent coronary angiography, left ventriculography was performed in 78,705 (81.8%). Most subgroups had >80% usage rates, including 64% of those with a prior history of renal failure (Table I).

Discussion

The primary finding from this study is that left ventriculography was performed as a routine “add-on” with most of the cardiac catheterizations and that the frequency of its use was actually increased when no new information was likely to be obtained. The findings raise concerns that there is substantial overuse of left ventriculography, with implications for cost of care and patient morbidity.

Summary

In an analysis of >96,000 patients undergoing cardiac catheterization in 2007, we found that left ventriculography was concomitantly performed 81.8% of the time. Left ventriculography was performed at an extremely high frequency regardless of patient characteristics and was performed even more often if an alternative imaging modality had been recently completed. New clinical practice guidelines should be considered to decrease the overuse of this invasive test.

Disclosures

Funding Sources: This work was funded by internal funds from Stanford, the Palo Alto VA Healthcare system, and Aetna. This was an investigator-initiated study proposed by Drs Witteles, Knowles, Perez, and Heidenreich to Aetna. Through Drs Spettell and Brennan and Mr Morris, Aetna did participate in some aspects of the collection, management, and analysis of the data. Dr Knowles was supported by an AHA Fellowship grant. Dr Heidenreich is supported by a grant from the Veteran Administration's

Acknowledgements

The authors would like to thank Dr Jerome P Kassirer for helpful initial discussions regarding the project and Drs Andrew Baskin (Aetna) and William Fearon (Stanford) for helpful comments on the final manuscript.

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It is supported by several complementary technologies allowing further characterization of plaque significance (eg, intravascular ultrasonography [US], fractional flow reserve) [32,33]. While concurrent LV ventriculography is dissuaded for LVEF determinations [34], direct hemodynamic measurements reflecting cardiac function maintain a distinct role in assessing a range of cardiovascular conditions in complicated clinical cases. The objective of stress testing is typically to evaluate the extent and adequacy of the hyperemic response, thereby assessing the ability of the coronary circulation to augment flow to meet increasing work demand (ie, coronary flow reserve) [35].
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Atherosclerosis is an ongoing process initiated by endothelial dysfunction and vessel-wall inflammation, ultimately resulting in endovascular lumen narrowing. Myocardial ischemia can result in abnormal cardiac function and increased risk for arrhythmias. Early signs of endothelial dysfunction and subclinical atherosclerosis can be detected by several noninvasive assessments in the microvasculature (laser Doppler imaging with iontophoresis of vasoactive agents) and in the large vessels (flow-mediated dilatation and intima-media thickness). Myocardial anatomy can be measured by other invasive and noninvasive diagnostic modalities such as coronary CT and coronary angiography. Many electrocardiographic tools have been proposed to predict the occurrence of ventricular and supraventricular arrhythmias, eg, T-wave abnormalities, QT variability index, heart-rate turbulence, signal-averaged electrocardiogram, and T-wave alternans. The aim of the current chapter is to review the battery of tests developed for inpatient and outpatient evaluation, for diagnosing clinical or subclinical coronary disease, cardiac structural and functional abnormalities, and for stratifying arrhythmic risk. Hence, this chapter offers a guide to clinicians using toolkits for cardiac testing in patients with either cardiac illnesses or systemic diseases with presumably cardiac involvements.
Procedural Variations in Performing Primary Percutaneous Coronary Intervention in Patients With ST-Elevation Myocardial Infarction
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Despite above-mentioned potential advantages, there exists a huge geographical and regional variation in utilization of LVgraphy all over the United States. While the rates are highest in Southern Atlantic region, surprisingly the other parts of New England, the Pacific, and West North Central regions have lowest reported rates.6 A study based on Veterans Affairs Health System also reported a decreasing trend of ventriculogram performance from 2000-2009.7
Multiple variations exist in performing a primary percutaneous coronary intervention (pPCI) in ST-segment elevation myocardial infarction (STEMI) among various cardiologists. These variations range from the choice of peripheral access artery (radial vs femoral), performance or time of complete angiography including left ventriculography, and nonculprit vessel angiography before or after intervening on the culprit vessel. The reasons for such variations include emphasis on door-to-balloon time, knowledge of cardiac anatomy before proceeding with pPCI, physician expertise, and the level of comfort with radial approach. Over the last 2 decades, the field of interventional cardiology has changed dynamically leading to marked improvements in the clinical outcomes of patients with STEMI. This includes upstreaming of pPCI along with technical advancements ranging from radial artery catheterization to culprit lesion–guided approach. Increased comfort with use of radial access approach by cardiologists and availability of multiuse guide catheters would both reduce door-to-balloon time and enable complete coronary angiography before performance of percutaneous coronary intervention. There are no clear guidelines or consensus dictating on cardiologists a correct sequence of action during STEMI, or even suggesting what the preferred approach is. Lack of guidelines results in a substantive variation in methodology. This review aims to highlight and to better understand the variations in the current practice, and to emphasize the advantages as well as the disadvantages of each approach. It is also perhaps a call out for guidelines that direct cardiologists to the best practice.
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Thus, we believe that strain can be estimated from the long-axis displacement at systole and diastole using any imaging modality. Based on data from the healthcare system, LVG is still reportedly performed during 60–80% of coronary angiographies (CAGs), and there is a wide variation in the views of invasive cardiologists regarding the utility of routine LVG [8,9]. To resolve a limitation of LVEF and a wide variety of views on using LVG, we propose the use of aortic annulus displacement (AAD), possibly representing LV long-axis shortening, as a marker of prognostic indicator in patients who undergo LVG.
We propose the use of aortic annulus displacement (AAD) detected on contrast left ventriculography (LVG) during invasive coronary angiography as a marker of left ventricular (LV) long-axis shortening. In the present study, we aimed to investigate whether AAD is associated with adverse events in patients who underwent coronary angiography because of suspected coronary artery disease.
In this retrospective study, we evaluated the medical records of 998 consecutive patients who underwent invasive coronary angiography and LVG. LV lengths were measured from the apex to the aortic valve insertion by using LVG images. AAD (%) was calculated as [(LV end-diastolic length − LV end-systolic length)/LV end-diastolic length] × 100.
The participants’ median age was 67 years. Ninety-six adverse events (composite events; all-cause death, 39; congestive heart failure, 21; late revascularization, 34; and myocardial infarction, 2) were observed during a median follow-up period of 3.1 years. In multivariate Cox regression analysis, adverse events were associated with lower AAD (hazard ratio, 0.703; p = 0.002), after adjusting for traditional risk factors and coronary artery stenosis. The area under the curve of AAD for predicting adverse events was greater than that of LV ejection fraction (0.656 vs. 0.541, p < 0.05).
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Left ventriculography was the first imaging tool to assess ventricular function and historically has been conducted as part of the diagnostic CA, even if it poses a small but significant risk of complications, and a higher dose of radiation and contrast volume [10,11]. Due to the fact that modern noninvasive imaging techniques are more accurate for the assessment of ventricular function and also lead to lower risks, the routine use of ventriculography is more than questionable [10,12]. However, even having proved this fact, in many centers “the custom” to perform left ventriculography as part of the diagnostic CA remains.
A reduction in radiation doses at the catheterization laboratory, maintaining the quality of procedures is essential. Our objective was to analyze the results of a simple radiation reduction protocol at a high-volume interventional cardiology unit.
We analyzed 1160 consecutive procedures: 580 performed before the implementation of the protocol and 580 after it. The protocol consisted in: the reduction of the number of ventriculographies and aortographies, the optimization of the collimation and the geometry of the X ray tube-patient-receptor, the use of low dose-rate fluoroscopy and the reduction of the number of cine sequences using the software “last fluoroscopy hold”.
There were no significant differences in clinical baseline features or in the procedural characteristics with the exception of a higher percentage of radial approach (30.7% vs 69.6%; p < 0.001) and of percutaneous coronary interventions of chronic total occlusions after the implementation of the protocol (2.1% vs 6.7%; p = 0,001). Angiographic success was similar during both periods (98.3% vs 99.2%; p = 0.2). There were no significant differences between both periods regarding the overall duration of the procedures (26.9 vs 29.6 min; p = 0.14), or the fluoroscopy time (13.3 vs 13.2 min; p = 0.8). We observed a reduction in the percentage of procedures with ventriculography (80.9% vs 7.1%; p < 0.0001) or aortography (15.4% vs 4.4%; p < 0.0001), the cine runs (21.8 vs 6.9; p < 0.0001) and the dose–area product (165 vs 71 Gyxcm²; p < 0.0001).
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The other limitations concern the volume of contrast used and the high rate of suboptimal diagnostic images according to rhythmic disorders during the procedure. Thus, we should consider whether each stage of our procedure is safe and essential; left ventricular angiography, which is actually used less frequently, should be successfully replaced by alternative imaging modalities.25 Finally, the importance of the operator volume also had an impact on the occurrence of ischemic stroke.
Stroke associated with left cardiac catheterization is a devastating complication, and its incidence has not changed over the decades.
We investigated the incidence, in-hospital outcomes and the modifiable and non-modifiable risk factors for periprocedural ischemic stroke.
Our retrospective cohort study included all patients experiencing periprocedural ischemic stroke among the 24,500 patients who underwent left cardiac catheterization between January 2003 and October 2010. The case group was compared with a group of control patients randomly selected among those who underwent the procedure during this period.
Ischemic cerebrovascular events attested by brain imaging occurred in 37 patients (0.15% of procedures), transient ischemic attack occurred in 9 cases, and persistent neurological deficit occurred in 28 cases.
Patients who developed strokes were more likely to be older and were more often female with a greater prevalence of comorbidities. Emergency and longer procedures were more frequent in patients in the case group who had more coronary complications.
A multivariate analysis identified diabetes mellitus (adjusted odds ratio (OR) 4.2; 95% CI 1.8-9.9; P < .001), chronic renal dysfunction (OR 2.4; 95% CI 1.1-5.4; P < .001), known cerebrovascular disease (OR 5.1; 95% CI 2.3-11.5; P < .001), emergency procedure (OR 3.1; 95% CI 1.4-9.2; P < .01) and recent congestive heart failure (OR 6.1; 95% CI 2.9-13; P < .001) as independent predictors for stroke. The independent modifiable predictive factors were represented by left ventricular angiography (OR 7.5; 95% CI 2.7-21; P < .001), and low operator volume (OR 3.1; 95% CI 1.3-7.4; P < .01).
Limiting the performance of left cardiac catheterization to high volume operators and avoiding unnecessary left ventricular angiography may reduce periprocedural ischemic stroke.

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: A. Michael Lincoff, MD, served as guest editor for this article.

^e: These authors contributed equally to this article.

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Clinical InvestigationIntervention CardiologyUse and overuse of left ventriculography

Background

Methods

Results

Conclusions

Section snippets

Patient population

Results

Discussion

Summary

Disclosures

Acknowledgements

Am Heart J

Am J Cardiol

Am Heart J

Int J Cardiol

Am Heart J

Am J Med

Am J Med

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Clinical Investigation
Intervention Cardiology
Use and overuse of left ventriculography