systolic. · cardiogram showed right axis deviation. the red cell count was 8.2 million, the...

STUDIES OF CONGENITALHEARTDISEASE. III. VENOUSCATHETERIZATION AS A DIAGNOSTIC AID IN PATENT

DUCTUSARTERIOSUS, TETRALOGYOF FALLOT,*VENTRICULAR SEPTAL DEFECT, AND AU-

RICULAR SEPTAL DEFECT'

By L. DEXTER, F. W. HAYNES, C. S. BURWELL, E. C. EPPINGER, M. C. SOSMAN,AND J. M. EVANS

(From the Medical Clinic and the Department of Radiology, Peter Bent Brigham Hospital, anldthe Departments of Medicine and Radiology, Harvard Medical School)

(Received for publication January 5, 1947)

Previous communications have outlined thetechnique of cardiac catheterization as applied tothe study of congenital heart disease and definedthe variations in pressures and oxygen contentobserved in a group of control patients (1, 2).This paper sets forth the results of study in 6patients with 4 varieties of congenital heart diseaseas examples of the type of information which canbe acquired' by the catheter technique in suchpatients.

OBSERVATIONS

Patent ductus arteriosusPatent ductus arteriosus is a persistence after

birth of the vascular anastomosis between thepulmonary artery and the aorta. While in thefetus blood flows from the pulmonary artery tothe aorta, the flow is from the aorta to the pulmo-nary artery after birth, as Eppinger, Burwell, andGross (3) have demonstrated.

Case 1. I. G. was a 26-year-old woman. In early in-fancy she was found to have a heart murmur. She de-veloped normally but was subject to palpitation, dyspnea,and fatigue on exertion. On physical examination, shewas a well-developed woman without cyanosis or club-bing. Arterial blood pressure was 125/65 mm. Hg. Theheart was enlarged to the left. There was a machinerymurmur in the pulmonic region. The first sound at theapex and the second sound at the pulmonic area were ac-centuated. The lungs were clear, the liver was not en-larged, and no edema was apparent. X-ray of the heart(Figure 1) showed it to be about 20 per cent enlargedwith prominence in the region of the pulmonary arteryand with hilar engorgement. An electrocardiogram wasnormal.

Venotus catheterization was performed, and Ta-ble I records the pressures and oxygen contents of

'This investigation was aided in part by a grant fromthe John and Mary R. Markle Foundation, and from theProctor Fund of the Harvard Medical School.

blood samples obtained from the various pointsshown in Figure 1. It will be noted that the oxy-gen content of blood in the pulmonary artery was2.2 volumes per cent higher than of that from theright ventricle. This is taken as indicating theentrance of arterial blood into the pulmonary ar-tery. Arterial shunts, other than patent ductusarteriosus, are exceedingly. rare in this region.The systolic. pressures in ,the pulmonary artery andright ventricle were elevated. The shunt wascalculated to be 7.6 1. per min.

A few days later, Dr. Robert E. Gross ligatedand divided a patent ductus arteriosus. Twoweeks later, venous catheterization was repeated,at which time the patient was weak an4 moder-ately anemic (hemoglobin 9.9 grams). Results

TABLE I

I. G. Age 26. Patent ductus arteriosus

Sample Oxygen Pres-content sure

ml. pert. mm. HgLeft pulmonary artery (near bifurcation) 151 63/3Right pulmonary artery (near bifurcation) 151

Right ventricle (near pulmonary valve) 129 63/6Right ventricle (mid-portion) 125

Right auricle (near tricuspid valve) 130 6Right auricle (upper portion) 119

Systemic artery 167 125/65(97 percent)

A-P diameter of chestOxygen consumptionBody surface areaPulmonary arteriovenous

oxygen differencePeripheral arteriovenous

oxygen differencePulmonary blood flowPeripheral blood flowFlow through shunt

17 cm.201 ml. per min.

1.53 sq. m.16 ml. per 1.

40 ml. per 1.

12.6 1. per min.5.0 1. per min.7.6 1. per min.

561

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,of the catheterization are presented in Figure 2and Table II. The oxygen values of bloods fromthe 3 chambers were in good agreement andshowed no deviation from the normal. The pres-sures in the pulmonary artery and right ventriclewere still elevated.

TABLE II

I. G. Age 26. 14 days after'division ofpatent ductus arteriosus


ml. per 1. mm. HgRight pulmonary artery (mid-portion) 91 80/4Right pulmonary artery (near bifurcation) 92 /45

Right ventricle (near pulmonary valve) 92Right ventricle (mid-portion) 88 80/-3Right ventricle (near tricuspid valve) 88



A-P diameter of chestOxygen consumptionBody surface areaArteriovenous oxygen

differenceCardiac outputCardiac index


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7.6 1. per min.5.1

Discussion: Calculation of the volume of flowthrough the ductus was made first by Eppinger,Burwell, and Gross (3) on the basis of bloodsamples obtained from the pulmonary artery atthe time of operation. Blood samples withdrawnthrough the intracardiac catheter have the greatadvantage of being obtained with the patient in a

relatively basal state. An oxygen content of bloodin the pulmonary artery significantly higher thanthat in the right ventricle has been found regularlyby venous catheterization in patients with patentductus arteriosus.

In a previous study with the catheter in a con-

trol series of patients (2), it was observed thatthe greatest variation between the highest oxygen

content of blood in the right ventricle and that inthe pulmonary artery was 0.5 volume per cent.On this basis, it is believed that flows through theductus of less than 0.5 1. per min., and possibly as

high as 1.0 1. per min., are probably not detectableby the venous catheter method unless the tip of thecatheter can be placed in the stream of arterial

blood flowing into the pulmonary artery throughthe ductus, in which case smaller defects may bedetectable.

Some patients with patent ductus have shown anelevation of pressure in the pulmonary artery andright ventricle, as in the example cited. In themajority of patients, however, the pressures havebeen normal.

The diagnosis of patent ductus arteriosus hasbeen confirmed by venous catheterization in 7 pa-tients to date and has been proved subsequentlyat the time of operation in each.

Tetralogy of Fallot

The tetralogy of Fallot consists of pulmonarystenosis, interventricular septal defect, dextro-position of the aorta, and right ventricular hyper-trophy. There is a diminished blood flow to thelung. A shunting of blood from the right ventricleinto the aorta produces cyanosis.

Case 2. P. B. was 22 years old and had been a "bluebaby." All his life he had been subject to periodic attacksof intense cyanosis and syncope, and his activities had al-ways been restricted. On physical examination, he wastall and well-developed with moderate cyanosis of lipsand nails and pronounced clubbing of fingers and toes.The blood pressure was 103/84 mm. Hg. Therewas a harsh systolic murmur in the second left in-tercostal space transmitted widely over the precordiumwithout thrill or diastolic component. There were nosigns of congestive heart failure. X-ray of the heart(Figure 3) showed enlargement to the left. The apex ap-peared to be lifted above the diaphragm. An electro-cardiogram showed right axis deviation. The red cellcount was 8.2 million, the hemoglobin was 27.4 grams,and the hematocrit was 75.

The results of venous catheterization are shownin Figure 3 and Table III. It will be noted that8 samples of blood from the right auricle, rightventricle, and pulmonary artery checked well asto oxygen content. The high systolic pressure inthe right ventricle with a low pressure and narrowpulse pressure in the pulmonary artery indicatedpulmonic stenosis (see Figure 4). Simultaneouspressures were not obtained from right ventricleand femoral artery, and hence the identity of thesesystolic pressures could not be tested. The sys-tolic arterial blood showed a moderate degree ofunsaturation. It was concluded that the patienthad pulmonary stenosis and ventricular septaldefect.

564

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TABLE III

P. B. Age 22. Tetralogy of Fallot


ml. per l. mm. Hg

Right pulmonary artery 242 8/4Right pulmonary artery 243 /

Right ventricle (near pulmonary valve) 248Right ventricle (mid-portion) 248 98/0Right ventricle (near tricuspid valve) 248RRight auricle (lower portion) 255Right auricle (mid-portion) 253 0Right auricle (upper portion) 250

Systemic artery 295 103/80*(85 percent)


oxygen difference (assum-ing 95 per cent saturationfor pulmonary venousblood)

Peripheral arteriovenousoxygen difference

Pulmonary artery blood flowPeripheral blood flowFlow through defect

Right to leftLeft to right

* Not recorded simultaneouslytricle.

19.0 cm.220 ml. per min.

1.71 sq. m.89 ml. per 1.

43 ml. per 1.

2.5 1. per min.5.1 1. per min.

2.6 1. per min.none

with that of right ven-

Flow calculations indicated only a moderate re-duction of pulmonary blood flow. Bing (4) hasstudied cases of tetralogy of Fallot in considerabledetail by means of the venous catheter and by ex-ercise and respiratory tests, and has evidence, bothphysiological and morphological, that these indi-viduals frequently develop a collateral circulationfrom systemic arteries to pulmonary artery whichis not revealed by application of the direct Fickprinciple with the venous catheter. In view ofhis findings, it is probably more accurate to defineour flow calculations as pulmonary artery flowrather than pulmonary blood flow -since we are inagreement with Bing that the method as describedin this report will not reveal the collateral circula-tion to the lung.

Following a subsequent operation, the patientexpired. Post-mortem examination revealed thatthe orifice of the pulmonary valve was only 0.5cm. in diameter (Figure 5). A 1.5 cm. defectwas present in the upper part of the interventricu-

lar septum. The right ventricular wall measured15 mm. in thickness, and that of the left ventricle,12 mm. There was dextroposition of the aorta.

Case 3. H. S. was a 10-year-old boy who at the ageof 6 weeks was found to have a heart murmur. He hadnever been as active as his playmates and had had a con-stant cyanotic tinge to his nails and lips. He had alwayshad dyspnea on climbing one flight of stairs, but this hadnot been progressive. On physical examination, he waswell-developed and well-nourished. The lips and nailbeds were slightly bluish. No clubbing was present. Theheart was enlarged to percussion. The only murmurheard was a loud machinery murmur, maximal in theaortic region but audible over the entire precordium.There was no thrill. The blood pressure was 110/70 mm.Hg. There were no signs of cardiac failure. The hemo-globin was 17.3 grams, and the hematocrit was 49. Circu-lation time with magnesium sulfate was 8 seconds. Anelectrocardiogram showed right axis deviation. X-ray(Figure 6) and fluoroscopy of the heart showed it to beenlarged to the left with dilated engorged hilar vessels.The aortic knob projected to the right.

On venous catheterization the catheter passedinto the right ventricle and thence into the aorticarch and the descending aorta (Figure 6). Thisdemonstrated the existence of an over-riding aortaor a ventricular septal defect and also of a right-arched aorta. Oxygeti and- pressure data are

TABLE IV

H. S. Age 10. Tetralogy of Fallot andpatent ductus arteriosus

Sample ~~~~Oxygen Pres-Sample content sure

mi. per 1. mm. Hg

Aorta 187 110/70(84 per

Owqils~j~y,9. -,,,' cent)

Right ventricle (neadpulfnionary valve) 173 110/4Right ventricle (near tricuspid valve) 140

Right auricle (mid-portion) 130 4Right auricle (upper portion) 120

A-P diameter of chestOxygen consumptionBody surface areaPulmonary arteriovenous oxy-

gen difference (assumingpatent ductus arteriosus asonly source and 95 per centoxygen saturation of pulmo-nary venous blood)


Pulmonary blood flow(through patent ductus ar-

teriosus assuming pulmon-ary atresia)

Peripheral blood flow


1.22 sq. m.25 ml. per 1.

62 ml. per 1.

6.7 1. per min.

2.7 1. per min.

566

567VENOUSCATHETERIZATION IN STUDY OF CONGENITAL HEART DISEASE

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A continuous pressure was obtained as the catheter was withdrawn from the pulmonary arteryto the right ventricle. Note the high systolic pressure in the right ventricle as compared withthat in the pulmonary artery indicative of pulmonic stenosis.

FIG. 5. HEART AT POST-MORTEMOF CASE 2On the left, the arrow points to the stenotic pulmonary valve. On the right, the aorta is at A and the .

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shown in Table IV. The systolic pressures inright ventricle and aorta were identical (see Fig-ure 7). The peripheral blood flow was small. Itwas assumed that most of the blood flow throughthe pulmonary artery entered by way of a patentductus arteriosus, as indicated by the typical mur-mur. The presence of a right-arched aorta per-haps explained the localization of the machinerymurmur at the aortic rather than at the pulmonicarea. Assuming that all of the blood entering thelung entered by way of a patent ductus arteriosus,pulmonary blood flow was calculated to be 6.71. per min. It should be pointed out that this cal-culation represents a maximal estimate and thatthe methods utilized by Bing (4) for calculationof pulmonary blood flow in these cases are morereliable.

Discussion: It is not to be expected that thetetralogy of Fallot could be recognized in its en-tirety by study with the venous catheter. Rightventricular hypertrophy is perhaps best indicatedby the electrocardiogram. Dextroposition of theaorta is largely a morphological diagnosis and isfunctionally indistinguishable from a ventricularseptal defect in studies with the venous catheter.

In the discussion to follow, the two will be in-cluded under the term, "ventricular septal defect."

The venous catheter may pass from the rightventricle through the stenotic pulmonary valveinto the pulmonary artery (Patient 2). In thiscase, pulmonary stenosis may be recognized bythe presence of a higher systolic pressure in theright ventricle than in the pulmonary artery (seeFigure 4). A ventricular septal defect has beenassumed to exist by the presence of diminishedoxygen saturation of the systemic arterial blood inassociation with pulmonary stenosis.

In other cases, the catheter may pass from theright ventricle, through the septal defect, and intothe aorta (Patient 3). In this case, ventricularseptal defect is demonstrated by the course fol-lowed by the catheter. Pulmonary stenosis hasbeen assumed to exist if the systolic pressures inthe aorta and right ventricle are identical.

The tetralogy of Fallot has been confirmed atautopsy in 2 patients. In one, the catheter hadbeen introduced into the pulmonary artery (Pa-tient 2), and in the other, not described here be-cause of clotting of blood samples, the catheter hadentered the aorta.

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In no case as yet has the catheter been intro-duced into both the aorta and the pulmonary arteryin the same patient.

Interventricular septal defect (Roger's disease)

Defects in the ventricular septum vary in sizeand are most commonly located at the base of theheart just below the aortic valve. Since the pres-sure in the left ventricle is higher than that in theright ventricle, the shunt is from the left to theright side of the heart except under certain specialconditions.

Case 4. J. H. was a 6-year-old boy who had had aknown murmur since the age of 11 months but had neverhad any limitation of activity. Physical examination re-vealed a healthy-looking active boy of normal develop-ment. There was no cyanosis or clubbing. Cardiac find-ings included a blood pressure of 105/45 mm. Hg, a heartenlarged to left and right, and an extremely loud andharsh systolic murmur heard maximally at the third leftintercostal space and transmitted over the entire pre-cordium. This murmur was accompanied by a thrill.A soft early diastolic murmur was heard along the leftborder of the sternum. X-ray (Figure 8) and fluoroscopyof the heart showed marked enlargement, especially in theregion of the left ventricle, a dilated left auricle posteri-orly, and enlargement of the pulmonary artery. Hilarvessels were engorged but could not be demonstrated topulsate. An electrocardiogram was normal.

Venous catheterization was performed as shownin Figure 8, and the results are tabulated in TableV. It is apparent that a considerable amount ofarterial blood entered the right ventricle, suggest-ing the presence of a defect in the ventricular sep-tum. The recorded pressures were normal.Catheterization did not explain the low diastolicpressure or the diastolic murmur. There was noevidence of a concomitant patent ductus arteriosuswith pulmonary insufficiency. It was believed thatthis patient probably had an aortic insufficiency inaddition to an interventricular septal defect.

Discussion: The recognition of interventricularseptal defect by venous catheterization should de-pend upon finding a significant increase in theamount of oxygen in the right ventricle as com-pared with that from the right auricle. Two suchcases have been described by Baldwin, Moore, andNoble (5). A significantly elevated oxygen con-tent of blood in the right ventricle may reflect thepresence of an interventricular septal defect or,theoretically, -of a patent ductus arteriosus with an

TABLE V

J. H. Age 6. Ventricular septal defect,aortic insufficiency


ml. per 1. mm

Right pulmonary artery (mid-portion) 160 29/12Pulmonary artery (at bifurcation) 154

Right ventricle (near pulmonary valve) 158Right ventricle (mid-portion) 155 29/4Right ventricle (near tricuspid valve) 156


Superior vena cava 128

Systemic artery 177(100 per

cent)


oxygen differencePeripheral arteriovenous

oxygen differencePulmonary blood flowPeripheral blood flowFlow through shunt


0.82 sq. m.20 ml. per l.

52 ml. per l.

7.9 1. per min.3.4 1. per min.4.5 1. per min.

associated pulmonic insufficiency. Three in-stances of the latter have been suspected, in oneof whom division of the ductus eradicated allmurmurs and subsequent venous catheterizationfailed to reveal any significant variations of oxy-gen in the right auricle, right ventricle, or pulmo-nary artery. It is believed, therefore, that a diag-nosis of interventricular septal defect in the pres-ence of a patent ductus arteriosus should be madewith caution.

In our control studies (2), the greatest vari-ation between maximal oxygen values in rightauricle and right ventricle was 0.9 volume percent. It is believed, therefore, that variationsgreater than 1.0 volume per cent are abnormal.This, in the average patient, corresponds to ashunt of 1.5 to 2.0 1. per min. Obviously, if. thetip of the catheter can be placed in the arterialstream coming througlhthe defect, smaller shunts.can be demonstrated.

Wehave not been successful in introducing thecatheter through a ventricular septal defect in theabsence of an associated pulmonary stenosis. Inthe absence of pulmonary stenosis or cardiac fail-

5711

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Interauricular septal defect

Defects in the interauricular septum vary con-siderably in size. The flow of blood is predomi-nantly from the left auricle to the right auricle(6). If the defect is large or if pressure in theright auricle becomes elevated, a right-to-left shuntmay likewise be present (7).

Two patients will be described to illustrate 2different ways in which venous catheterizationmay aid in the recognition of auricular septaldefects.

Introduction of catheter through the defect: Case 5.E. M. was a 25-year-old woman who had been found tohave a heart murmur in grade school. She had alwaysexperienced fatigue rather than dyspnea on exertion.For 5 years she had had cyanosis on exposure to cold andon exertion. She was slender and there was no clubbing,but the fingers and lips were perceptibly cyanotic. Theheart was overactive, and there was a harsh diastolicmurmur without thrill at the fourth intercostal space.The blood pressure was 108/76 mm. Hg. X-ray (Figure9) and fluoroscopy of the heart revealed it to be markedlyenlarged with a huge pulmonary artery. An electro-cardiogram showed right axis deviation.

Venous catheterization was incomplete in thispatient. The catheter entered the right auricle(Figure 9), and followed a course acutely up-wards and to the left so that the tip lay outside thecardiac shadow. Blood obtained from this pointwas 97 per cent saturated with oxygen (see TableVI). It was concluded that the catheter hadpassed through an auricular septal defect into theleft auricle and into one of the pulmonary veins.-Attempts to introduce the catheter into the pulmo-nary artery were unsuccessful.

Left-to-right shunt: Case 6. H. C. was a 56-year-oldman who denied ever having had any symptoms referableto the heart. On admission to the hospital for carcinomaof the bladder, it was noted that his heart was enlargedto left and right, that the rate was rapid, and that therewas a harsh systolic murmur without a thrill maximal atthe third left intercostal space and widely transmitted overthe precordium and back. No diastolic murmurs wereheard. The pulmonic second sound was accentuated.Cyanosis and clubbing were absent. There were no signsof congestive failure. The hemoglobin and hematocritwere normal. X-ray (Figure 10) and fluoroscopy of theheart showed it to be considerably enlarged, especiallyto the left, with hilar engorgement. An electrocardiogramdemonstrated no abnormalities.

TABLE VI

E. M. Age 25. Auricular septal defect

Oxygen Oxygen Pres-Sample content satura- suretion

ml. per 1. per cent mm. HgSuperior vena cava 130 60 -

Inferior vena cava 156 72

Right auricle (along right wall) 142 66 6

Left auricle 196 91 10

Pulmonary vein 212 97 14

Systemic artery 187 89 108/76

Venous catheterization (Figure 10 and TableVII) revealed a large increase of oxygenatedblood in the right auricle as compared with thatin the superior vena cava, as well as a value inone of the samples from the right auricle practi-cally identical with that found in the femoral ar-tery. On the basis of these findings, the diagnosisof an auricular septal defect seemed justified.There was no evidence of other cardiac defects.

TABLE VII

H. C. Age 56. Auricular septal defect


ml. per 1. mm. HgRight pulmonary artery 146Left pulmonary artery 145 35/10Left pulmonary artery 140

Right ventricle (near pulmonary valve) 142 2Right ventricle (mid-portion) 142 35/

Right auricle (near tricuspid valve) 113Right auricle (mid-portion) 147 2Right auricle (upper portion) 156

Superior vena cava 107Superior vena cava 130



oxygen difference (assum-ing 95 per cent oxygen satu-ration in pulmonary vein)


Pulmonary blood flowPeripheral blood flowFlow through shunt


1.83 sq. m.14 ml. per 1.

39 ml. per l.

20.0 1. per min.7.2 1. per min.

1 2.8 1. per min.

573

DEXTER, HAYNES, BURWELL, EPPINGER, SOSMAN, AND EVANS574

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Discussion: Two methods, as described byBrannon, Weens, and Warren (9), can be utilizedwith the venous catheter to assist in the diagnosisof auricular septal defect: (a) Introducing thecatheter through the defect (Patient 5), and (b)finding a significant increase in the oxygen contentof blood in the right auricle (left-to-right shunt)(Patient 6).

Attempts to introduce the venous catheterthrough a defect in the auricular septum have beenunsuccessful in the majority of cases. Anatomi-cally, there appears to be no reason that, with ex-

perience, it could not be done with fair regularity.A significant increase of oxygen content of blood

in the right auricle may be present as the result ofan interauricular septal defect with a left-to-rightshunt, of an anomalous pulmonary vein emptyinginto the right auricle (7, 10), or of tricuspid in-sufficiency associated with interventricular septaldefect. Baldwin, Moore, and Noble (5) have ob-served an instance of the latter and recognizedtricuspid insufficiency by analysis of the auricularand ventricular pressure tracings as described byCournand and associates (11). The recognitionof a pulmonary vein emptying into the right auricleis practically impossible with our present knowl-edge. Statistically, auricular septal defect is muchcommoner than anomalous pulmonary veins emp-

tying into the right auricle or tricuspid insuffi-ciency associated with a ventricular septal defect.In control patients, the oxygen content of theright auricle has been observed to be as much as

1.9 volumes per cent higher than that of the supe-

rior vena cava (2). It is apparent that sizableauricular septal defects can be easily overlookedunless the catheter can be placed in the stream ofarterial blood flowing from left auricle to rightauricle.

DISCUSSION

Venous catheterization has opened new possi-bilities for the recognition of many congenital de-fects, for elucidating the hemodynamic changes,and for assisting in rendering a prognosis by de-fining the nature and physiological magnitude ofthe defects. As with other methods, it has itslimitations and these we have tried to point out.The tetralogy of Fallot may be recognized with a

high degree of accuracy if the assumptions on

which the interpretations of pulmonary stenosis

and ventricular septal defect were made are ac-cepted. Patent ductus arteriosus can be detectedin most instances where the defect is of sufficientsize to produce symptoms or signs. Defects inthe auricular and ventricular septa offer greaterdifficulties in diagnosis than the other 2 lesions.The diagnostic accuracy of the method in septaldefects depends upon the success with which thetip of the catheter can be placed in the stream ofarterial blood flowing into the right side of theheart from the left.

The necessity of obtaining multiple samplesfrom each chamber is apparent, and a prerequisiteof successful venous catheterization in patientswith congenital cardiac defects is the gathering ofas much information as possible by history, physi-cal examination, x-ray, and fluoroscopy beforecatheterization is performed. Although we havenot as yet used the method of Robb and Steinberg(12) of visualization of the cardiac chambers andgreat vessels with diodrast, information derivedfrom this procedure should serve as a valuableadjunct to venous catheterization.

Finally, the increase of knowledge of hemody-namics acquired by techniques such as this willlead to increasing ease of diagnosis by simplermethods. Since certain varieties of congenitalheart disease can be relieved or cured by surgery,precise diagnosis is of such importance that alldoubtful cases should be studied with all availablediagnostic techniques.

SUMMARY

1. Venous catheterization has been applied as adiagnostic measure and as a method of studyingthe hemodynamics of various types of congenitalheart disease.

2. In patent ductus arteriosus, blood in the pul-monary artery is more highly oxygenated thanthat in the right ventricle.

3. In interventricular septal defect, blood in theright ventricle is more highly oxygenated than thatin the right auricle.

4. In the tetralogy of Fallot, pulmonary stenosisis identified by finding a higher systolic pressurein the right ventricle than in the pulmonary ar-tery. In some instances, the catheter may be in-troduced through the ventricular septal defect intothe aorta. Other aspects of the diagnosis arediscussed.

575


5. Auricular septal defect may be recognized byintroducing the catheter through the defect intothe left auricle, or by finding arterial blood in theright auricle in cases with a left-to-right shunt.

6. The limitations and potentialities of themethod are discussed.

The authors are indebted to Dr. Samuel A. Levinefor his help and encouragement in this study. Patients1, 3, and 4 were referred by him for evaluation by venouscatheterization, and Dr. Paul D. White sent us patient 5.

The authors wish to express their appreciation to MissBarbara Jacobs for her technical assistance.

BIBLIOGRAPHY

1. Dexter, L., Haynes, F. W., Burwell, C. S., Eppinger,E. C., Seibel, R. E., and Evans, J. M., Studies ofcongenital heart disease. I. Technique of venouscatheterization as a diagnostic procedure. J. Clin.Invest., 1947, 26, 547.

2. Dexter, L., Haynes, F. W., Burwell, C. S., Eppinger,E. C., Sagerson, R. P., and Evans, J. M., Studiesof congenital heart disease. II. The pressure andoxygen content of blood in the right auricle, rightventricle, and pulmonary artery in control patients,with observations on the oxygen saturation andsource of pulmonary "capillary" blood. J. Clin.Invest., 1947, 26, 554.

3. Eppinger, E. C., Burwell, C. S., and Gross, R. E., Theeffects of the patent ductus arteriosus on the cir-culation. J. Clin. Invest., 1941, 20, 127.

4. Bing, R. J., Vandam, L. D., and Gray, F. D., Jr.,Physiological studies in congenital heart disease.II. Results of preoperative studies in patients withtetralogy of Fallot. Bull. Johns Hopkins Hosp.,1947, 80, 121.

5. Baldwin, E. deF., Moore, L. V., and Noble, R. P.,The demonstration of ventricular septal defect bymeans of right heart catheterization. Am. Heart J.,1946, 32, 152.

6. Bedford, D. E., Papp, C., and Parkinson, J., Atrialseptal defect. Brit. Heart J., 1941, 3, 37.

7. Abbott, M. E., Atlas of Congenital Heart Disease.New York, Am. Heart Assoc., 1936.

8. Adams, W. E., Thornton, T. F., Jr., and Eichelberger,L., Cavernous hemangioma of the lung (arterio-venous fistula). Report of a case with successfultreatment by pneumonectomy. Arch. Surg., 1944,49, 51.

9. Brannon, E. S., Weens, H. S., and Warren, J. V.,Atrial septal defect. Study of hemodynamics by thetechnique of right heart catheterization. Am. J. M.Sc., 1945, 210, 480.

10. Brody, H., Drainage of pulmonary veins into rightside of heart. Arch. Path., 1942, 33, 221.

11. Cournand, A., Lauson, H. D., Bloomfield, R. A.,Breed, E. S., and Baldwin, E. deF., Recording ofright heart pressures in man. Proc. Soc. Exper.Biol. & Med., 1944, 55, 34.

12. Robb, G. P., and Steinberg, I., A practical method ofvisualization of the chambers of the heart, thepulmonary circulation, and the great blood vesselsin man. J. Clin. Invest., 1938, 17, 507.

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systolic. · cardiogram showed right axis deviation. the red cell count was 8.2 million, the...

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