Download Hemodynamic Consequences of the Injection of Radiopaque Material

Hemodynamic Consequences of the Injection of
Radiopaque Material
By G. C. FRIESINGER, M.D., JOCHEN SCHAFFER, M.D., J. MICHAEL CRILEY, M.D.,
ROBERT A. GAERTNER, M.D., AND RICHARD S. Ross, M.D.
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terials in-to the left heart and aorta in man can
be quite different from those following rightsided injection and have not been well documented." We have observed significant and
consistent changes in a variety of hemodynamic parameters as a consequence of the injection of radiopaque materials into the left
atrium, left ventricle and aorta in patients undergoing diagnostic cineangiocardiography.'2 These clinical observations, supplemented by related animal experiments,
form the subject of the current report.
ANGIOCARDIOGRAPHY and cineangiocardiography are employed with increasing frequency for the diagnosis of cardiovascular diseases. These commonplace technics
of cardiovascular radiology depend upon the
rapid injection of radiopaque materials into
the heart or central circulation. A wide variety
of substances are in use, but all are hypertonic
and some are considerably more viscous than
blood. A variety of studies are available to
indicate that the hemodynamic effects can be
related to chemical structure, -3 but as newer
and safer agents have become available it
seems clear that the pharmacodynamic effects
are related most importantly to the hypertonicity of these compounds. The effects of the
injection of oontrast media can therefore be
considered to be the effects of hypertonicity
on the circulation, and the study of these
effects assumes considerable practical importance.
Numerous reports are available that deal
with the effects of hypertonic (and radiopaque) materials injected into the right heart
and pulmonary circulation in animals,4-10 but
comparable systematic studies in man are not
available. The hemodynamic consequences associated with the injection of radiopaque ma-
Materials and Methods
The records of 101 patients undergoing cineangiographic studies have been analyzed. Al]
patients were studied by technics previously described.13-15 The electrocardiogram and intracardiac pressures were recorded before and after
the injection of radiopaque material in every case.
Left atrial pressure was recorded for at least 15
minutes after left atrial injections of contrast
material in 28 patients, and after left ventricular
or aortic injections, or both, in 21 patients. The
other patients had less prolonged or less systematic observation.
Sodium and methylglucamine diatrizoate (75
per cent or 90 per cent Hypaque) was the radiopaque material injected into all patients. The
dose was 30 to 50 ml., depending upon body
weight, heart size, and site of injection. Sodium
and methylglucamine diatrizoate (90 per cent)
contains 30 per cent sodium salt and 60 per cent
methylglucamine salt with edathamil calciumdisodium 1:10,000, and the pH is adjusted to
between 6.5 and 7.5. At body temperature, the
90 per cent solution has a viscosity approximately
four times that of water and an osmolality 10
times that of blood. The 75 per cent solution
is made up of 25 per cent sodium and 50 per
cent methlyglucamine salts. No qualitative or obvious quantitative difference in reactions to the
two concentrations was noted, and hence no distinction was made between the two in the analysis of results.
The Hypaque was injected by a power syringe
at a pressure of 8 to 10 Kg./cm.2 and delivered
From the Departments of Medicine, Surgery, and
Radiology, The Johns Hopkins University School of
Medicine and The Johns Hopkins Hospital, Baltimore,
Maryland.
Supported by Research Grant HE-05584 CV from
the National Heart Institute, U. S. Public Health
Service, and by Clinical Center Grant FR-35 from
the Division of General Medical Sciences.
This work done during Dr. Friesinger's tenure as
U. S. Public Health Service Research Fellow (1960-
62).
Presented in part to the Federation of American
Societies for Experimental Biology, Atlantic City,
April 1962.
730
Circulation, Volumse
XXXI, May 1965
T3 1
RADIOPAQUE MATERIAL7
mm
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ma
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-
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Figure 1
Left atrial pressure records obtained before and(c at 25 seconds, 6 minuttecs, anid 14 nintintcs
oifter inijection of radiopaq tic contrast material into the left atriumiii. ihcb electrocardiogrtant anid
phonocardlogranm have also beere recorded. All paramneters of thie left atrial pressure pulse
increasedl after thfe injietion witl the miost promninent increase in thie uv" icave. T'7he hieart
rcate is relativelyl unchanged (Ilurinig the period of observation. IbIis tracing tas obtained fr'ont1
a patient wvith puire miiitr'al stenosis.
in 1.5 to 3
seconds.
Pressure
imeasuremenits were
made xvith a p23A Statham strain-gage. Cardiac
ouitpult was measured with indocyanine green anid
the indicator-dilution currves were iniscribed withi a
Gilford 103 JR (lenisitometer aind a Harvard with-
delawal pump. Cardiac ouitpuit calculations wvere
per-formed as described by Hamilton.1"
Results
Observations in Patients Undergoing
Cineangiography
Left Atrial Pressuire
A typical record of left atrial pr-essure prior
to and after the injection of radiopaque material into the left atritum of a patient with
mitral stenosis is shown iu figure 1. The left
atrial mean pressuire ofteui increased by 100
per cent or more. The increase began Within
30 seconds after the injection and persisted
for as long as 1O minuites. The "v" wave regularly increased more thani the "a" xvave. Figure
2 shoxv s that there is nio evident relationship
betxveen the resting left atrial pressture and
the inicrease resultinig from the injection. Figuire 3 shoxvs the average pressu-res and time
sequence of changes in 28 patients. Similar
left atrial pressure changes were recorded
after injections inlto the aortic root as vell as
in patients with niormal mitral valves (although the changes xvere of lesser magni-
tu-ide).
Citzulaiion, Vol/iue XX\I, ALa 19(65
Left Ven1tricuilar J)iastolic Pressnine
Left ventricuilar end-diastolic pressure was
measured in 21 patieits before anid after in.jection of Hypaquie into the left ventricle or
ao-rtic root, anid the restults are shoxvn in figure
4. In all patients, the left ventricuilar enddiastolic pressure increased but there xvas
great variability in the magnitude of the inmm Hg
50
45
40
35
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30
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LAMP under
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v LAMP above
lSrn15mmHg
sobservatons otter
Hypaque injections
irito LA in 2Spaternts
with rnitral disease
0
2
3
4
5
minutes
Figure 2
Left cttrial mean pressure (LAMAIP) int 25 patients mvitli
mitral valve dlisease befor e anid after injections of
IIypaquce into the left a1triumw11 Ottfthe time scale, 0
is tite Otiontettt of itjictiont.
732
FRIESINGER ET AL.
Hg
HEARTRATE
140
130.
120
110 -
I
0
100
90
80
70
60
50
01
28 Patients
0
heartrate
**
v-wove
0 0 a-wave
* v LA mean pressure
LA diastolic pressure
A
mm Hg
45
40
35
30.
25
20.
5
0
5
peripheral ort. pressure
A
A
.
I
/,
I ' ,,,
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e
sixty
SECONDS
2
3
4
5
6 7 8 9 10
MINUTES
II
12
13
14 15
Figure 3
Mean values for peripheral artery pressure, heart rate, and left atrial pressure
from 28 patients with mitral valve disease who had pre-injection measurements recorded and serial measurements (at 1 or 2 minute intervals) for
12 to 15 minutes after injection of Hypaque into the left atrium.
maximal LVEDP
mm Hg
riseafter Hypaque
ir 21 patients
45
40
crease, which may be explained by the lack
of homogeneity of the patient population with
regard to type and severity of heart disease
present.
40
Left Atrial-Left Ventricular Pressure Gradient
35
=
30
25
20
15
;
10I
i_
*
.
0
1
2
3
4
5
minutes
Figure 4
Left ventricular end-diastolic pressure (LVEDP) before and at designated times after injection of Hypaque into left ventricle or aortic root in 21 patients.
0 on time scale indicates instant of injection.
In 21 patients with mitral valve disease, simultaneous left atrial-left ventricular pressures were obtained before and after the injection of Hypaque. An increase in diastolic
gradient always resulted. Figure 5a illustrates
the pressure tracing from a patient with pure
mitral stenosis (on the basis of clinical, cineangiographic, and operative findings). Figure
5b was obtained from a patient who has primarily mitral regurgitation (on the basis of
clinical and cineangiographic findings). The
left atrial pulse contour is similar in the
two patients following the injection although
the pre-injection pulse oontours are very different and the mitral valve lesions are dissimilar.
Cardiac Output
In six patients, cardiac output
was meas-
Circulation, Volume XXXI, May 1965
SIW-w 1R-mls l z_
RADIOPAQUE MATERIAL
BEFORE
M
.:
ROM
l
l
S
.
ECO
AFTER ROM
.IV
-
mmH
-5o-
-30-
-
A:v
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BEFORE R O Ml
I733
V~~~~~~~~~
AFTER ROM
ECG
mmHg
-30_.R
-20_
.k
111-Vt It
v
LAfi
,j-.A
I
4
I>
A,
.N
-10-
Li I
LV
i~~~~-0
Figure 5
Simiullltaineouis left atrial and left venitricular pressures im7lmedliately beforec andcl after inijectionI
of Ilypaque into the left atritum. A., upper. Tracings from a patient with pure mitral stenosis.
Thl'ere is elevation of left venitricular end-diastolic pressure, increase in gradient, atnd marked
inrcrease int "v' waves. The heart rate is niot changed. Postinijection tracitng was obtainied 3
mitiniutes after 40 ml. of IHypaque in1to the left atrium. B., lower. T'racings obtained before anid
5 minuites after the injection of 40 ml. of Hypaque into left atrium of a patient wcho blad
prumarily mitral regu4rgitation. "V" twave again has markedly increased icithi slightly increased
gradient. Heart rate has slowedl.
uired with indocyanine green before and within 10 minutes after injections of Hypaque into
the left heart. Cardiac output increased in
each case; the average increase was 21 per
cent. It was appreciated that indocyanine
green may not be measured accurately in
the presence of radiopaque material, but any
error introduced by optical inlterference of the
material would result in an underestimate of
the cardiac output.' I
Circulation, Volume XXXI, May 1965
Peripheral Artery Pressure
The changes in arterial pressure are illustrated in figure 3. During the first minute
after injection of Hypaque into the left heart,
a drop in peripheral artery pressure of 20
to 30 per cent occurred. This hypotension was
accompanied by a transient increase in heart
rate of 10 to 15 per cent. Both arterial pressure and heart rate returned to control values
within 3 or 4 minutes after the injection.
FRIESINGER ET AL.
734
Hematocrit Determinations
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In 11 patients, serial hematocrit determinations were made. The initial blood
sample was taken within the first minute
after injection of Hypaque and serial measurements were continued for a period of 10
to 15 minutes. All samples were obtained
from the free flow of an indwelling arterial
needle. A marked and sudden fall in hematocrit level occurred immediately after the injection, with return to control values in 10 to
15 minutes (fig. 6). No gross hemolysis was
detected in the plasma, and spectrophotometric analysis with correction for the interfering
effects of radiopaque material indicated that
hemolysis was absern or present only to a
minimal degree.
Supplementary Observations in Dogs and in
Vitro Studies
To supplement the observations made during cineangiography 24 mongrel dogs were
studied with a variety of preparations. Observations were made with use of hypertonic
solutions of siodium chloride and glucose, but
in general Hypaque was used, since the primary objective was a better understanding of
conditions that prevailed in patients undergoing cineangiography. The systematic study
of the effects of solutions of varying hyperdrop in hematocrnt after
injection of Hypaque in
11 patients
%tHct
y
100
0
0.~~~
0
90Q
:VPF
80
i
V
+
" t
i
i.
0
70 1
0
1
2
3
4
5 6 7
minutes
8
9
10 11
Figure 6
Serial hematocrit determinations in 11 patients who
had injections of Hypaque into the left atrium, left
ventricle, and aortic root. Control hematocrit level
is taken as 100 per cent.
tonicity was not attempted here. As hematocrit and spectrophotometric changes in the
blood occur with the injections of hypertonic
solution, and these alterations can influence
the flow measurements, it is important to emnphasize that similar flow changes were recorded whether dye-dilution, rotameter, or electromagnetic flow meter was utilized for the
cardiac output determination.
Hematocrit Valiue
In 14 dogs, serial hematocrit determinations
after injection of 50 per cent glucose showed
changes similar to those resulting from injections of Hypaque. Hematocrit changes occurring after a regional injection of the material were also studied. The femoral artery
was most frequently used as the site of injection and samples were withdrawn from the
accompanying vein. The drop in hematocrit
level in the first minute after injection wvas extreme, usually more than 50 per cent, sometimes as much as 70 to 80 per cent of the
control value.
The effect of hypertonic solutions on the
hematocrit level was studied in vitro by adding solutions to blood in a beaker. The addition of a volume of Hypaque equal to 2 per
cent of the volume of blood in the beaker resulted in a 10 per cent reduction in the
hematocrit level. Therefore, the drop observed
in vivo was at least in part the result of shrinkage of red blood cells due to the loss of red
cell water (fig. 7). Shrinkage and deformation of red cells could be observed by light
microscopy after the addition of radiopaque
material.
Observations on the Effects of Hypaque on the
Coronary Circulation
In five dogs, left coronary blood flow, left
ventricular diastolic (or left atrial) and peripheral artery pressures, myocardial contractile force, and multiple electrocardiographic
leads were recorded during the intracoronary
injection of S to 2 ml. of radiopaque or
other hypertonic media. The changes are illustrated in figure 8. There was an initial marked
drop in coronary blood flow, which may be
a-ttributed to the high viscosity of Hypaque
Circ?nlatioz, Vuoltme XXXI, May 1965
RADIOPAQUE MATERIAI7
-i J3
HUMAN BLOOD (in vitro)
% of
Control Hct
100
0
S
A
099%NoCI
5%NoCI
90%Hypaque
95
90
85
100
101 102 103 104
% of Control Volume
Figure 7
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An in vitiro study ncleiontistiratintig tlhat the early fall iii
1eieoiatoct'it mtutlst be nIne to loss of red cell water. A
(quantity of wchole b0lood in a beaiker- hlad its volumwlle
inicreadse by the addition of radiopaqute mnaterial in
the a(mlountts inidicateld annl serial hbemnatocrit valties
tere determnined, e.g., wchent 4 nil,. of 90 per cent
Hypay(ne Lucre aclddcnl to 100 ndl. whole blood tihe
hct,iiatocrit of thle sotiuttuin was oirily 85 per (cTit of thlc
control valne (40 and 34, rcspectively).
or may be dtue to the agglutinationl of red
l)lood cells and transient mechanical l)lockage
of the coronary vascuilar l)ed, and suibsequient-
ly a marked prolonged increase in coronaixl)lood flow. \Iyocardial conitractile force anti
peripheral arterv blood pressture fell transiently, while there was a ininmal elevation of
left ventricular end-diastolic or left atrial
pressures. Striking changes in the electrocardiogram have been observed following the
injectionii of I-Iypaq(e into the coronary arteries. These may be stummarized by stating
that the T-wave vector moves away from the
milass of myocardiunm 1eing perfused by the
hypertoniic' medIiuim. Isotonic soluitioni also
causes T-xxwave chaniges wheni inijected into
the coronary arteries, butt these are less
macrked acnd more transient. In txvo aniimals in
which the left coronary artery wxas cannuilated and supplied Nxxith blood from a perftusion bottle, the changes resuilting from left
heart injections of radiopaque material were
inot significantly altered. Hence, inijection of
Hypaquie into the coronary arteries does not
produce changes simnilar- to those occutirrinig
with iinjections into the left heart chambers
anid, excluding the coronai-ry circuilation, does
not motdify the effects of left heart inijections.
901%
I cc (LCA)
Hypoque
.Do#28
Figure 8
Tracing obtaiiiicel ni/c'n I nl. of 90 )er cent IHypaque ways iijectecl inito the left coronary
artery of a (log whose artery hladc l)Cen canttnlatedI withl a Gregg canr nula and flotw Imeasuired
wiillh arotaiuter. Myocaindial conltr'actile for'ce (top), femlor-al artcry 1pressure (middle), and
left atrinl p)rcssure (bottom) in anlndition to left coronary a rte-ry flowc atre shown. Siitmltancetos
o
electroc'iZ'(ardiographic moitor-ing1
(not Slimterl) sholced profond T-tLeave chan1ges th7at )crsisted
for o2 t 3 mintces of tcr thin injectioni.
(Circlation,
Volume
X/X,X
Slin 1965
736
F1IIESINGER ET AL.
"Artificial" Mitral Stenosis
By the technique of Davila,18 an umbilical
tal)e xvas passed around the AV ring and a
left ventricular-left atrial diastolic gradient
vas produced to simulate mitral stenosis in
four dogs. These animals shoved the same
pressure and flow changes as seen in patients.
In addition, contractile force was measured
vith a strain-gatuge arch placed on the veintricle. Although contractile force was decreased by the injection of Hypaque, the decrease was small (less than 25 per cent) and
transienit (iusually not longer than 10 to 12
seconds). An example of the pressure changes
produced in these dogs is illustrated in figuire 9.
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Comparison of Right- and Left-Sided Injections
In animals, sequential injections of Hypaqtue
and other hypertonic media into the right and
left side of the circulationi xvere possible. In
Control
mnmHg /
six animals, it was demonstrated that 1
ml./Kg.
of Hypaque into the right side of the circulation usually produiced outpult inicreases and
pressure alterations similar to changes described with left-side injections of the same
quantity of the material. However, injections
of larger quantities into the right side of
the cireulation (uip to 3 ml./Kg.) produiced
very different results. Again, peripheral artery
pressture fell but pulmonary artery pressure
rose sharply, cardiac output fell markedly and
cardiac arrhythmias frequtently occuirred. After several injections of these volumes of
flypaquie, tachyplhylaxis developed, which
likely vas due to the hypervolemia created.'9
Hence, a number of studies were performed
with use of hypertonic saline (18 per cent)
xvhich produced identical effects as the Hypaque but with lesser voluimes of injectate required. Figuire 10 is a record from an animal
LA INJECTION 90% HYPAQUE lOcc
2 seconds 3 seconds
23 seconds
%
50 seconds
'** fA,
v
--------- .4
(.
,
2501o00
~
~
V
20LV
15I
LA
go.
t
I
Figure 9
Serial excerpts from a continuous tracing fromtia dog teitl "mitrcal steniosis" created acutely by
passing umbilical tape about AV ring. Time designations are seconds after injection. Peripheral
artery pressure, left ventrictlar diastolic and left atrial pressure are shown. Cardiac output
was 1.6 L./min. at time of control pressure tracing antd teas 2.2 L./min. 1 mrinute after
injection. Note large "a" wave prior to injection and elevation of all aspects of left atrial pressure pulse injectionis. There is a marked drop in femoral artery pressuire with beginning
recovery at 50 seconds after injection, when left ventrictular-left atrial diastolic pressure
gradient is mutch increased over control. Note that the left ventricular end-diastolic pressure
(lid not significantly elevate in this instance and heart ralte is relatively con1stant throughou1t.
(The left ventricular-left atrial and femoral artery pressuires are on different amplification, anld
separate calibration scale.s are shown at left mnargin of figure.)
(irculation, Volumne XXY,J Mlay 1965
RADIOPAQUE MATERIAIL7
737
1
mmhig
14mt of
09"/,NaCt
NaCI
18l1
.z& DA
180/. NCt,
into LA
Into LA
i
t¶M
PA4f
50-
0
FA
mmNHg
160-
mi/ruin
Aortic Flow (mean)
5000-
mi/min
Aortic
Flow
(phasic)
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60-
ecods--
s
13.7kg
Figure 10
Sequential in jections of 0t9 011(I 18 petr cett NaCI icitli incasucmrients of pulmonarty aoItcry piessure", feinrot-al artery pressure, (lorttci mneant atI( phasic flowl (luit/i electoiroll-netic flonc probe
ab0otit aootie root). Note iniinial atid transicet (1litliIges cit/i (0.9) per ('en! NaCl. 1/lic flowc inl(reasc produced by t/hc intjection of lie1r'toic .solntioiis ill-t tow/c 1(:lft ofthiim is coniid(tI-bly
less thian tli(it uisuially prodiwted.
in xw hich sequential injectionls of hypertonic
saline were made into the righit anid left heart.
A control injection of isotoniic saline is also
shown. With larger volumeis of hypertonic
saline (1 m1. Kg.) injected directly into the
ptilmonary artery, peripheral artery pressure
and flox sometimes fell to zero and the animal died. The immediate drop in peripheral
artery pressrire (and rise in pulmonary artery
pressuire) xith right-sided injections must be
duie to mechanical blockage of the pulmonary
vaseilar bed by clumping of red cells as
posttulated by Read241 and noted by Wolcott's
group. 1-
Discussion
It xxas the recognition of the change in left
atrial pressure (most pronounced in patients
with mitral stenosis) after injection of radiopaquie material that stimulated this investigation. An inicrease in cardiac ouitptut is chiefly responsible for the changes, but a rise in
left ventricular enid-diastolic pressure also
contributes, and the elastic properties of the
left atritum must play a role.21 2
Circultrion, Volume XXXI, May 1965
It is important to niote that there is no evidence to indicate that an increase in the severity of mitral regurgitatioi or the developm-enit of this lesion is responsible for the
changes in puilse contour. MXlany of the patients witli
"pure mitral stenosis" showing the
increase in the "v xwave have beenr operated
iponlland no mitral insuifficiency has been
founiid; in others, mitral regurgitationi has not
becni seeni duiring left vxentricular angiograms.
Stuidies in dogs xxith suirgically produced "mitral steniosis" confirm the fact that iincreases
in stroke output accouint for the increase in
the "v" wx ave since mitral insufficiency cannot occuir in this preparation. Hence, it is
clear that the v'-wxxave inicrease is duie to increased atrial filling as a resuilt of the increase in cardiac ouitput.
The simutltaneous left atrial anid left veiltricular pressirecs obtained in patients after
inijection of Hypaque inito the left atrium,
vllich shoxx that the left xventricular end-diastolic pressuire rises, "v" wave inicreases, and
mitr al diastolic gradienit becormes greater,
738
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emphasize the potential inaccuracy of methods that attempt to evaluate the functional
status of the mitral valve by analysis of left
atrial pulse contour alone. This point has
been emphasized by Nixon.24
The decrease in peripheral artery pressure
after left-sided injection is the result of peripheral vascular dilatation, and, when considered
with the increase in cardiac output, indicates
that a marked fall in peripheral vascular resistance has occurred. The increase in cardiac
output is achieved by an increase in stroke
output, since tachycardia does not occur. This
"relative bradycardia" in face of an increased
output and decreased peripheral vascular resistance is difficult to explain. The effect of the
vagus nerve can probably be excluded as all
patients have received atropine prior to the
study, and, in dogs, sectioning of the vagi did
not alter the heart rate response. In the dog
experiments, the vagolytic effect of barbiturate
anesthesia may account for the failure of rate
to increase after vagotomy.25 It is also possible
that some direct effects of radiopaque material on the myocardium or on the neural
effector organs within the heart may account
for this peculiar rate response.
The profound and sudden drop in hematocrit level must be chiefly due to shrinkage
of red cells, but its persistence may be attributed to an increase in plasma volume due to
imbibition of extravascular fluid.26 Shrinkage
of red cells should be an'ticipated when they
are placed in solutions 3 to 4 times the osmolality of blood,27 and shrinkage was directly
demonstrated by the in vitro studies. Hemolysis was not detected in these studies and
therefore did not contribute to the decrease
in hematocrit level. The absence of hemolysis
is important from another point of view in
that some of the peripheral effects of Hypaque
might be explained by the liberation of potent vasodilatory agents known to be present
in red cells. The absence of hemolysis on
spectrophotometric examination makes this
unlikely, although minute amounts of hemolysis can be responsible for market hemodynamic changes.28-30
It seemed possible that some of the hemo-
FRIESINGER ET AL.
dynamic changes could be the result of a
high-pressure rapid injection, since the existence of pressor receptors in the left heart
chambers31 has been postulated. The failure
of injections of isotonic saline in dogs to elicit
significant hemodynamic changes rules out the
mechanical effect of injections as an important
contributor to the reaction.
Our observations on the effects of injection
of Hypaque directly into the coronary circulation, which agree with those of others,32 33
and the observation that exclusion of the coronary circulation does not alter the reaction
make it evident that entry of the material into
the coronary circulation is not necessary for
the changes reported here.
The many observations by other investigators,34-39 as well as measurements in this study,
indicate that a wide number of hypertonic
agents will dilate the peripheral vascular bed.
It must be this action of the Hypaque that is
primarily responsible for the reactions following left heart injections we have recorded.
Pressures and flow changes are readily accounted for as a consequence of this dilatation.
Other actions occur and modify the outcome,
among them the peculiar heart rate response
and direct myocardial and possible neural
effects of radiopaque material speculated upon
earlier.
The effects of the injection of hypertonic
media into the right side of the heart can be
different in many important ways from the
effects observed after left-sided injection. As
previously mentioned, the changes with the
right-sided injections are more variable than
those resulting from left-sided injections and
must be dependent on the amount as well as
the hypertonicity of the solutions delivered.
After right-sided injections, pressures rise in
the pulmonary artery and throughout the right
heart, systemic pressure falls, and cardiac output falls; bradyeardia and ectopic beats regularly occur. Numerous animal experiments4' 20 have led to the suggestion that
blockage of the pulmonary vascular bed by
aggregated red blood cells can be the explanation for the events that follow rightsided injection. The hematocrit changes demCirculation, Volume XXXI, May 1965
RADIOPAQUE MATERIAL
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onstrated in the current investigation are in
keeping with the hypothesis that sludging
and clumping of the red cells are occurring,
but indicate that the flow and pressor responses to this phenomenon are quite different in
the systemic and pulmonary circulations. In
the presence of pulmonary hypertension and
increased pulmonary vascular resistance, these
differences between right- and left-sided injections may be especially important when
considering the "toxic effects" of contrast material.
The changes resulting from the injection of
hypertonic radiopaque material into the central circulation in man are widespread and
dramatic. Awareness of these factors is important in the interpretations of data obtained
after angiography as well as in explaining
and avoiding untoward effects of radiopaque
material. Contrast media have become safer
in recent years, but hypertonicity will almost
certainly remain as a property of these agents,
and hence the effects described in this report
will continue to occur with such agents. The
relative safety of the injection of Hypaque into the heart or central circulation is illustrated
by the fact that more than 500 patients were
studied by cineangiography during the period
when the data for this report were accumulating, and no deaths occurred although many
patients had two or three injections. Significant reactions were few and chiefly limited to
transient periods of mild hypotension or arrhythmia.
Summary
The hemodynamic changes resulting from
injection of radiopaque material into the left
heart in a series of patients undergong cineangiographic studies have been reported. The
hypertonicity of radiopaque materials appears
to be responsible for much of the observed
reaction. The mechanism whereby hypertonic solutions produce the observed physiologic
changes remains unknown.
Changes observed in patients could be reproduced in experimental animals. The combined experimental and clinical data show
that left atrial pressure increases, left atrial
pulse contour alters, stroke output increases,
Circulation, Volume XXXI, May 1965
739
heart rate is much unchanged, peripheral artery pressure falls, hematocrit level falls, and
myocardial contractile force decreases mildly
and transiently.
The difference between the physiologic effects of injecting hypertonic media into the
right and left sides of the circulation is discussed.
Because the pressure changes are easy to
monitor and parallel the other features of the
hemodynamic reaction, it is good to wait until
pressures have returned to the pre-angiographic level before proceeding with the injection of more radiopaque material. This
usually requires 15 minutes.
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Circulation, Vohme XXXI, May 1965
Hemodynamic Consequences of the Injection of Radiopaque Material
G. C. FRIESINGER, JOCHEN SCHAFFER, J. MICHAEL CRILEY, ROBERT A.
GAERTNER and RICHARD S. ROSS
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Circulation. 1965;31:730-740
doi: 10.1161/01.CIR.31.5.730
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