Recommendations spell out optimal use for left ventriculography

Sometimes, as with left ventriculography, old techniques may lose prevalence but not relevance. This was the heart of a consensus statement published online Nov. 4 in Catheterization and Cardiovascular Interventions.

The Society for Cardiovascular Angiography and Interventions (SCAI) released the statement to shed light on the old imaging procedure, largely left out of current guidelines. Most guidelines discuss appropriate use of newer imaging technology but do not address left ventriculography, a procedure that has been in use since the 1960s, but has fallen out of favor among some professionals.

With a lack of oversight or society recommendations where the procedure still is performed, little if any standards have been made on optimal use. Left ventriculography use, as noted the consensus team, varied by region and hospital. Some concerns were raised that the procedure in some cases was used for financial gain rather than patient well-being.

Recognizing the gap, Osvaldo S. Gigliotti, MD, from the Seton Heart Institute in Austin, Texas, and SCAI colleagues issued the statement, along with recommendations on appropriate use.

Through left ventriculography, ejection fraction, defects in heart wall or valves, aneurysms in the left ventricle and ventricular volume can be identified, Gigliotti et al wrote. They noted the procedure was also useful for identifying septal defects. Left ventriculography, they argued, still had relevance among adult and pediatric patients, particularly those with septal defects and significant vessel abnormalities, when a catheter-based device is also employed.

While alternate imaging techniques may be more common and have fewer risks, they noted, there is still a place for this method. In a press release, Gigliotti stated, “when compared to other imaging options, left ventriculography should be performed selectively and avoided when adequate alternatives are available.” However, Gigliotti noted, “There are cases where left ventriculography is essential, such as when a catheter-based device is used to close a septal defect."

Gigliotti et al noted that one advantage left ventriculography had over other imaging modalities is low cost and convenience, adding a few extra minutes to a cardiac catheterization procedure, while costing two to five times less than other imaging procedures.

Complications do exist, they warned, and they advised physicians to proceed with caution.

Recommendations included:

• Consideration of left ventriculography when left ventricular function is unknown;
• Selective use of left ventriculography and avoiding it when adequate alternatives have already been performed;
• Avoidance of the procedure when it places patients at risk, including those with renal insufficiency, elevated diastolic pressure, left ventricular mural thrombus, aortic valvular vegetation or in patients with already high radiation exposures;
• The development of best practices to avoid wide individual variation in procedure performance, as is currently seen;
• Review of techniques and indications as part of case reviews to improve comprehensive catheterization quality programs;
• When performed, operators should ensure adequate contrast volumes, use a multi-sidehole catheter and deliver contrast dye by power injection.  

The consensus group further recommended clinical research studies, noting that the suggestions outlined in the document would be considered level of evidence C if formalized as guidelines.