In fairness to the interventionalist above, he was concerned that the additional contrast and the performance of an LV gram in this setting was unnecessary and possibly harmful. I disagree. From our subsequent discussions, it was apparent that in recent years operators have come to omit left ventriculography from both routine and emergency catheterizations for several reasons: 1) Prior echo assessment of the LV; 2) Concern for extra contrast load; 3) Fear of hypotension or other complications of ventriculography; 4) Extra time needed to perform the LV gram. With specific exceptions, I do not believe these are valid reasons to omit the LV gram from the cath procedure. In some centers, conventional wisdom has grown from the old days of the cardiac cath lab where the LV gram was associated with worsening congestive heart failure (CHF), hypotension, arrhythmias and death. These events were mostly related to ionic, hyperosmolar contrast media which we no longer use. It is a common fallacy to extend these adverse responses to modern ionic low-osmolar or non-ionic low osmolar contrast media (LOCM). Fear of the historical dangers of ventriculography appears to have been extended into daily practice in the minds of many operators. In most patients, the benefits of ventriculography far outweigh the risks.

The risk of death related to left ventriculography has been associated with two main clinical scenarios: First, the left main coronary stenosis, where any hemodynamic perturbation might cause hypotension with subsequent drop in the transstenotic coronary pressure and flow, resulting in a decrease of myocardial perfusion and initiating the downward spiral of myocardial ischemia, left ventricular dysfunction, further ischemia and death. The second scenario where left ventriculography might lead to death is in patients with aortic stenosis (AS). A post-LV gram hypotensive (and possible myocardial depressant) effect would produce reduced cardiac output, causing hypoperfusion of hypertrophic AS myocardium, resulting in myocardial dysfunction, further impaired perfusion, and setting up a death spiral of hypotension leading to cardiac arrest.

These concerns arise from a time when contrast media was of different type than we use today. I believe it is no longer a valid concern in 99% of our patients with these two scenarios. In the decades of the 70s, 80s and partly into the 90s, contrast media was of high osmotic and ionic composition, associated with vasodilation and hypotension, arrhythmias (mostly bradyarrhythmias when injecting coronary angiography of the right coronary artery) and myocardial depression. Ventriculography caused increases in LV end diastolic pressure (LVEDP). The osmotic load transiently expanded intravascular volume in some individuals, contributing to LV dysfunction and congestive heart failure in any compromised left ventricles studied. The drop in blood pressure and increase in congestive cardiac volumes would be especially detrimental to patients with either left main stenosis (LM) or AS. For this reason, left ventriculography was thought to be contraindicated in LM and AS. Because echocardiography is excellent for appreciating LV function, many individuals have extended their concerns to patients with critical CAD or even moderate AS and thus omit the left ventriculogram from their repertoire of diagnostic methods. This absence of left ventriculography at times leads to an incomplete diagnostic study, a delay in the appreciation of the LV function with delay in the institution of intraaortic balloon pumping or surgical intervention. The lack of an LV gram limits the complete prediction of patient's outcome based on cardiac function relative to their coronary status.

Given the marked improvement in the LOCM contrast media we use today, these concerns are generally not valid. Hypotension and myocardial depression after LOCM ventriculography are truly rare. In addition, a low-volume LV gram (20-25 ml) has even less potential adverse effects and with digital imaging can easily produce a quality diagnostic image. An LV gram available for review in the cath lab at the time of surgical consultation is not mandatory but it is certainly helpful to have a one-stop visit for full disclosure. In addition, it adds information to the interventionalist undertaking high-risk ad hoc intervention in selecting myocardial territories which may not benefit from revascularization.

However, there is a third scenario, the patients with marginal renal function (including diabetics and the dehydrated patient), in which there is a legitimate concern for performing ventriculography. In these patients, an extra contrast load may tip the balance of marginal renal function and produce contrast-induced nephropathy. The potential for frank renal failure climbs with increasing amounts of contrast given. With regard to renal function, although the increased amount of contrast may be detrimental, the exact threshold amount is unknown. A low-volume left ventriculogram be performed with 20-25 cc in a single bolus, and thus the LV information can be readily obtained without excessive risk to the patient.

It is my view that the value of left ventriculography is substantial and at times different from that obtained by echocardiography. Consider that the echo might have been obtained under other clinical circumstances which may erroneously be extrapolated to the patient on the cardiac cath lab table. This is especially true in the patient with acute myocardial infarction with critical CAD. LV function obtained either prior to or immediately after reperfusion for the acute myocardial infarction patient will provide substantial information on how we should manage this individual. Would an intraaortic balloon pump be helpful? Is there significant mitral regurgitation? What is the myocardial function adjacent to the infarct-related artery as well as the non-infarct related territory? This information is critical to good patient care. It is also my belief that we do not jeopardize the patient (using low osmolar nonionic contrast media) by performing low-volume ventriculography even in the most critically ill patients. This LV gram facilitates our understanding of the patient's complete clinical status. Even given the echocardiographic assessment of LV function, there is additional information to be gained. When working with such individuals, please consider the current nature of LOCM contrast media, which is very good and only minimally disturbing to our patient's hemodynamic status.