How to Perform Right Ventricular Angiography in ARVCD

The following recommendations have been proposed by Wichter et al. [12] for the core laboratory of RV angiography within the NIH-funded North American "Multidisciplinary Study of ARVD" [13] and the EU-funded "European Registry of ARVC/D" [14]. The protocol was designed to perform RV an-giograms of best quality to assess structural and functional RV abnormalities in ARVC/D and to allow quantitative measurements of RV volumes, ejection fraction, and regional contraction and relaxation.

Right Heart Catheterization

After local anesthesia and venous puncture, a sheath is inserted at the venous puncture site using Seldinger's technique. Transfemoral or transjugular routes are most commonly used. Right heart catheterization should be performed prior to RV angiography to as sess RV and pulmonary vascular hemodynamics. Pressures are recorded in the wedge position, pulmonary artery, RV, and right atrium. Cardiac output can be measured by oximetry and/or thermodilution. Cardiac index, stroke volume, and pulmonary vascular resistance are calculated from these measures. RV endomyocardial biopsy may be performed for histological, ultrastructural, or molecular biology investigations if clinically indicated or part of a research program.

Calibration Reference

Volume calculations from RV angiograms require calibration for reference. A metal ball with defined diameter or a ruler with defined distances may be used as tools for calibration reference (Fig. 16.3).

b) Metal ball with defined diameter (5 cm)
Fig. 16.3 • Examples of calibration reference for right ventricular angiography. A conventional ruler with staples placed at defined distances (i.e., 2 cm) (panel a) or a metal ball with a defined diameter (i.e., 5 cm) (panel b) may be used as simple tools for calibration

A simple way is to use a 20 cm ruler with staples at 2 cm distance. The calibration reference tool should be placed 10 cm below and horizontal to the amplifier tube and filmed by cine. The height of the table and the distance of the amplifier tube to the patient chest should not be changed during the following angiograms.

Right Ventricular Contrast Cine Angiography

For selective RV angiography, a pigtail catheter (5F or larger) or a Berman catheter (6F or 7F) may be used for contrast injection. The catheter should be positioned approximately 1cm above the midinferior RV wall (RAO or PA view), without direct contact with the RV wall or trabeculae to avoid extrasystoles and to allow homogeneous opacification of the RV cavity during contrast injection. Four standard projections are recommended: [1] 30° RAO, [2] 60° LAO, [3] anteroposterior (AP), [4] straight lateral (sagittal) view (LAT). Biplane angiography using two orthogonal views is the favored technique. An additional caudocranial 30° RAO angulation may be used to visualize wall motion abnormalities confined to the inferior and inferobasal walls.

Cineangiograms should be acquired during deep inspiration and breath-hold and recorded at 25 or 30 images per second. It is useful to film a long sequence to allow analysis of regional dye persistence, lung passage, as well as left atrial and LV size and function. Depending on the global size of the RV, 40-50 ml of low toxicity contrast medium should be injected with a flow rate (velocity) of 12-15 ml/sec.

Optimizing Image Quality

To optimize image quality of RV cine angiograms, care should be taken to avoid ECG cables, connectors, etc., in the field of view. The investigator should make sure that the entire RV is depicted in the field of view during breathhold in all projections during diastole and systole. No additional image magnification should be used and table movement should be avoided during contrast injection.

Frequent extrasystoles during dye injection make visual and quantitative assessment of RV motion and volumes difficult if not impossible. Therefore, extrasystoles should be avoided if possible by optimal catheter position and limitation of dye injection velocity. Artificial tricuspid regurgitation can be excluded by smooth passage of the tricuspid valve. Similarly, avoiding contact and pressure of the catheter against the RV wall is essential to prevent artificial wall motion abnormalities.

In case of poor quality due to incomplete RV coverage, extensive table movement, breathing, or frequent extrasystoles, the RV angiogram should be repeated under optimized conditions.

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