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CARDIO-VASCULAR DIAGNOSTIC WORKSHOP: SPECIAL EXAMINATIONS: CORONARY ANGIOGRAPHY

Dr. Werner Forssmann made it possible to gain more information from X-rays of the heart when he developed a method of inserting a thin catheter into the vein of the arm and pushing it toward the heart. He experimented on himself in 1929 and received the Nobel Prize in 1946 for this method. It is feasible to observe more details in the X-ray films made by this method because a contrast fluid can be injected through the catheter and into the coronary vessels of the heart (a process called coronary angiography). Thus, coronary artery blockages could be identified and it could be determined how well the blood flows through the coronaries. Great advances have been made since 1970 in developing so-called invasive diagnosis, especially in coronary angiography, to evaluate the function of the heart muscle and the coronary arteries. It is now regarded as merely a routine procedure, which has passed successfully through the experimental stage and is used in most large hospitals.

Coronary angiography is used more frequently as, for example, to determine whether surgery is required in the case of a patient who experiences intense pain caused by angina pectoris which cannot be alleviated through medication. In such cases it is often possible to relieve the chest pain by performing a by-pass operation.

These drawings show how coronary vessels filled with contrast medium appear on an X-ray. The arrows point to vessel changes.

But is a coronary angiography not harmful to a patient with a damaged heart? Of course, such invasive diagnostic procedures can cause undesirable side effects but usually only one out of two thousand patients develops such complications in cardiology departments with experienced personnel. Since it is virtually impossible to obtain the vital information on the condition of the

coronary vessels by any other means (an EKG yields only indirect information), we must rely upon angiography even though it involves relatively small risks.

If you are a patient before or after a heart attack you will probably respond with mixed feelings to the news that this procedure needs to be carried out. The thought of coronary angiography will probably make you uneasy or perhaps afraid, feelings which are to be expected. But what is involved in this procedure? What will you actually feel? In our experience, a conversation with someone who has already undergone angiography is much more valuable than any written explanatory statement by a physician. Do you know such a patient personally? If not, you could ask your physician to acquaint you with someone who has experienced a coronary angiography. If you are uneasy or afraid, you can also request special medication to ease discomfort.

The procedure is as follows. The point at which the catheter will be inserted is either in the main artery on the inside of the thigh or the artery inside the elbow. This point of entry is usually anesthetized, and if the injection into the large vessel causes discomfort, you can request another local anesthetic, as you would ask a dentist during tooth work. A special catheter is inserted via the artery into the aorta and to the heart. An X-ray contrast medium is then injected through the catheter into the right and left coronary arteries. This part of the process is completely painless and the angiogram is recorded on film. The film will yield important information about the blood supply to the heart and the condition of the coronary vessels. Thereafter, more contrast fluid is injected into the ventricle (ventriculography) to determine the size and functioning of the heart and how well it contracts. Finally the catheter is removed and a compression bandage is placed over the point at which the catheter was introduced. The less bleeding occurs, the smaller will be a bruise mark in the thigh or arm, depending on the insertion location. After reading the films, three possible results may be discussed with the patient.

It may be decided that an aorta-coronary by-pass operation (involving the aorta and coronary vessels) is unnecessary. In this case, you will certainly be relieved. This will be the case if the coronary arteries are completely free of blockages or if it is only a matter of the normal aging process. Or it may be that certain changes have taken place in the vessel walls but that they cause the patient no discomfort, so an operation is unwarranted. As a matter of fact, half of the persons between ages fifty and sixty develop certain coronary atherosclerotic changes, but the narrowing of the vessels is not always sufficiently significant to require surgery.

The cardiologist recommends surgery, because coronary angiography has revealed a critical narrowing, for example, in the main trunk of the left coronary artery. It is the opinion of most surgeons that the survival rate of such patients with surgery is higher than that of those who do not receive an operation. In this case the patient must consider whether he should eliminate his risk by having the operation done, even if he does not experience great discomfort at that time. If, however, the patient does experience great chest pain from angina pectoris, then the cardiologist and cardiac surgeon may share the opinion that surgery will relieve the pain more quickly than would prolonged drug therapy. The cardiologist will then explain to the patient whether a one, two or three vessel by-pass is indicated. The patient may have little choice but to accept the surgery, because if he delays too long, a second coronary angiography may become necessary.

Another type of surgery may be indicated after a heart attack. Ventriculography (which reveals the capacity of the heart to pump blood) may show a disrupted movement of the walls of the ventricles, usually caused by scar tissue from a previous heart attack. Some patients do not remember that they have sustained a heart attack, but the disrupted movement of the ventricular walls shows evidence of myocardial infarction.

In the scar area, an aneurysm or sac, formed by local softening and thinning of the arterial wall, may develop. This certainly interferes with the normal cardiac rhythm or may cause complications leading to heart failure and formation of blood clots. It is extremely rare that such an aneurysm will burst. If an aneurysm has developed, then a bulge in the vessel wall will be visible during ventriculography. In the contraction or systolic phase, the shadow of the injected contrasting material is greater in the area of the aneurysm, while this usually decreases in a healthy heart. In such cases, surgery is often recommended to remove the aneurysm.

The third possibility is that heart surgery at its present stage may be judged to be of no greater benefit than prolonged drug treatment. If the narrowing of the vessel wall is in the periphery of the myocardium, the vessels are too small for surgery. Very small, thin by-passes do not remain open for very long, so the operation would have no long-term success. However, it is very likely that such technical problems will be resolved in the near future.

It is known that by-pass operations can alleviate the chest pain resulting from angina, but researchers are not certain whether they increase the length of life. A patient who expects miraculous results from surgery in this age of technology, instead of making small preventive efforts, can often be disappointed. The patient who tends to overrate surgery, underestimate non-surgical procedures, and who counts on the immediate success of surgery is equally dismayed. Although we can sympathize with such disappointment, we cannot share it, since there are many non-surgical procedures described in this book which can help resolve many problems. Even a successful by-pass operation is only a small part of a comprehensive plan for treatment. Although surgery enriches the possibilities for treatment of chronic heart disease, it is certainly not a universal remedy.

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