DIAGNOSTIC METHODSVENTRICULAR PERFORMANCE

Measurement of regional wall motion from biplanecontrast ventriculograms: a comparison of the 30degree right anterior oblique and 60 degree leftanterior oblique projections in patients withacute myocardial infarctionFLORENCE H. SHEEHAN, M.D., JOACHIM SCHOFER, M.D., DETLEF G. MATHEY, M.D.,MIRLE A. KELLETT, M.D., HUGH SMITH, M.D., EDWARD L. BOLSON, M.S.,AND HAROLD T. DODGE, M.D.

With the technical assistance of Suzanne Mitten and Jane Wygant

ABSTRACT The value of performing biplane vs single plane analysis of regional wall motion fromcontrast ventriculograms was determined in 102 patients who received thrombolytic therapy and whounderwent biplane ventriculography during acute myocardial infarction (n = 67), at follow-up more

than 2 weeks later (n - 80), or both (n = 45). Hypokinesis in the infarct region and hyperkinesis in thenoninfarct region were measured by the centerline method in the respective artery territories, whichwere defined from the data of 62 patients with single-vessel disease and were expressed in units ofstandard deviations from the mean of 32 normal subjects. Hypokinesis was more severe and extendedover a longer segment of the left ventricular contour when measured in the right anterior oblique (RAO)projection in thrombosis of the left anterior descending coronary artery (LAD) but more severe andextensive in the left anterior oblique (LAO) projection in circumflex stenosis. Hyperkinesis oppositethe LAD or the circumflex was greater in the LAO projection. In patients with thrombosis of the rightcoronary artery, wall motion abnormalities were similar in the two projections. Thus the evaluation ofhypokinesis caused by acute coronary thrombosis and of the effect of therapeutic interventions insalvaging function can be adequately evaluated from single-plane 30 degree RAO ventriculograms,except in the small minority of patients with circumflex thrombosis.Circulation 74, No. 4, 796-804, 1986.

THE OBSERVATION that coronary artery occlusioncauses regional ventricular dysfunction was made 50years ago by Tennant and Wiggers. ' However, quanti-tative methods for evaluating regional wall motion ab-normalities have only recently been developed. Thesemethods have been particularly useful in evaluating theefficacy of interventions such as thrombolytic therapyin salvaging myocardial function in patients with acute

From the Cardiovascular Research and Training Center, Universityof Washington, Seattle; University Hospital Eppendorf, Hamburg,West Germany; Boston University Medical Center, Boston; and theMayo Foundation, Rochester, MN.

Supported in part by grants from the R. J. Reynolds Foundation,Winston-Salem, NC, from the NHLBI (grants HL-27819 and HL-19451), and from Dr. Werner Otto-Stiftung, Hamburg.Address for correspondence: Florence H. Sheehan, M.D., University

of Washington RG-22, Seattle, WA 98195.Received June 11, 1986; accepted July 10, 1986.

infarction, especially because recent studies haveshown that variables of global ventricular functionsuch as the ejection fraction may not sensitively reflectthe severity of hypokinesis in the infarct site because ofthe influence of compensatory hyperkinesis in nonin-farct regions 2'3One of the issues that remains unresolved is the need

for biplane analysis. Previous studies have reportedeither no difference between the abnormalities mea-sured in the 30 degree right anterior oblique (RAO)and 60 degree left anterior oblique (LAO) projectionsor frequent underestimation in the LAO projection ofhypokinesis or even akinesis visible in the RAO pro-jection.4' 5However, hypokinesis may be better detect-ed in the LAO projection in certain subgroups, such aspatients with circumflex thrombosis in whom hypoki-

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nesis measured in the RAO is significantly less severethan that of patients with thrombosis of the left anteriordescending artery (LAD) or right coronary artery(RCA).6 Also, the magnitude of compensatory hyper-kinesis in the septal and posterior walls visualized inthe LAO projection has not been measured or com-pared with hyperkinesis in the RAO projection.

Therefore the present study was performed to com-pare the magnitude and extent of wall motion abnor-malities measured in the 30 degree RAO and 60 degreeLAO projections in patients studied during and afteracute thrombosis of the LAD, RCA, and circumflexcoronary artery.

Methods

Patients. The study population consisted of 102 patients whowere admitted within 5 hr after the onset of acute myocardialinfarction and who underwent cardiac catheterization in thecourse of receiving thrombolytic therapy with either intracoro-nary streptokinase or intravenous urokinase between October1979 and April 1984.2 " All patients were treated at the Univer-sity Hospital Eppendorf in Hamburg, West Germany, by two ofus (D. G. M. and-J. S.). Of the 102 patients, 67 had biplane datain the acute study, 80 had biplane data at follow-up, and 45patients had serial biplane data (table 1).The normal mean and standard deviation for wall motion in

both the RAO and LAO projections were defined from the dataof 32 patients who underwent diagnostic cardiac catheterizationbut were found to have normal cardiac anatomy and functionand who had biplane ventriculograms of adequate contrast forquantitative analysis.The region of the left ventricle in the LAO projection that is

considered the territory of each coronary artery was definedfrom the data of 62 patients with isolated stenosis of the LAD (n= 31), RCA (n = 16), or circumflex artery (n = 15) andbiplane ventriculograms.The number of patients with biplane ventriculograms was

smaller than the number of patients with single-plane ventricu-lograms (previously described2) whose data were used to definethe arterial territories in the 30 degree RAO projection. There-fore, the arterial territories in the LAO projection were definedusing only patients with single-vessel disease who had had aprevious infarction. This yielded arterial territories in the RAOprojection similar to those previously defined from single-planedata (table 2).8The ventriculograms of normal patients and patients with

single-vessel disease were obtained from (1) the University ofWashington or Seattle Veterans Administration Hospital bydata base search, (2) Boston University (M. K.), (3) MayoFoundation (H. S.), or (4) University Hospital Eppendorf.(J. S.).

Ventriculographic analysis. Biplane contrast ventriculog-raphy was perforned in the 30 degree RAO and 60 degree LAOprojections and recorded at 50 or 60 frames/sec. The cine filmswere analyzed at the University of Washington in Seattle. Theend-diastolic and end-systolic endocardial contours were pro-jected and traced from the frames with maximum and minimumvolume, respectively, from a normal, non-postpremature sinusbeat. Wall motion was measured by the centerline method8' 9along 100 chords constructed perpendicular to a centerlinedrawn midway between the end-diastolic and end-systolic con-tours (figure 1) and normalized by the end-diastolic perimeter.

TABLE 1Biplane data set

Acute Follow-upStatus of ventriculographic data study study

No ventriculogram performed 9 14Single-plane RAO ventriculogram only 13 6Biplane ventriculogram not analyzableA 13 2Biplane ventriculogram-analyzed 67 80Total no. of patients 102 102

Aln most cases, inability to analyze a ventriculogram is due to ventric-ular irritability resulting in arrhythmia.

Abnormality in chord motion at the infarct site was expressed inunits of standard deviations (SDS) from the mean wall motionof 32 normal patients with biplane ventriculograms. Hypokine-sis is indicated by negative values, hyperkinesis by positivevalues. Regional wall motion was calculated as the mean mo-tion of chords lying in the most hypocontractile half of theinfarct-related artery territory. Hyperkinesis was calculated inthe most hyperkinetic half of the territory on the wall oppositethe site of infarction.2 Both were expressed in SDs per chord.The derivation and application of this method have been pre-viously described. 10

Because the highly variable degree of foreshortening in theLAO view affects its projected length, the aortic root is ex-cluded from the contour.11' 12 Otherwise, motion in the LAOprojection was analyzed in the same way as for the RAO. Theterritory of each coronary artery in the LAO contour was de-fined as the set of contiguous chords whose motion, in patientswith isolated stenosis of that artery, was significantly depressedcompared with motion in the normal group. As in the RAO,hypokinesis in the infarct site was calculated as the mean motionof chords lying in the most hypocontractile half of the infarct-related artery territory. In patients with LAD thrombosis, whichresults in a binodal abnormality (figure 2), mean chord motionin the most hypokinetic half of the septal and apical regions wascalculated and these means were then averaged to yield anoverall measure of hypokinesis in the LAD territory. This vari-able better distinguishes the motion in normal patients from thatin patients with isolated LAD stenosis than measures of septalmotion alone, apical motion alone, or the more abnormal of thetwo.12 Hyperkinesis was similarly calculated as mean chordmotion in the most hypercontractile half of the territory oppositethe infarct. The severity of hypokinesis and the magnitude ofhyperkinesis are expressed in SDs per chord.

TABLE 2Coronary artery territories

Chord No. delimiting territory

Coronary artery 300 RAOA 30° RAOB 600 LAO

LAD 12-68 10-67 50-100RCA 52-84 51-80 38-74Circumflex c 19-67

ATenitories defined in present study by biplane data.BTerritories defined in previous studies2' 10 by data of patients with

single-plane ventriculograms.CPatients with left dominance are analyzed as having RCA disease;

patients with rght dominance are analyzed as having LAD disease.

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FIGURE 1. Centerline method of regional wall motion analysis. A, End-diastolic and end-systolic left ventricular endocardialcontours and centerline constructed by the computer midway between the two contours. B, Motion is measured along 100 chordsconstructed perpendicular to the centerline. C, Motion at each chord is normalized by the end-diastolic perimeter to yield ashortening fraction. Motion along each chord is plotted for the patient (solid line). The mean motion in the normal ventriculogramgroup (dashed line) and 1 SD above and below the mean (dotted lines) are shown for comparison. D, Standardized motion. Wallmotion is now plotted in units of SDs from the normal mean (dotted line). The normal ventriculogram group mean is representedby the horizontal zero line.

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Artery territories in the 60 degree LAO projection. Fig-,.o ure 2 illustrates the territories of the coronary arteries

-1.S - - L / in the 60 degree LAO projection as defined by the data-z.- . of the reference patients with chronic single-vessel-3.0 ...... disease and prior infarction. The lengths of the arterial-4.0 territories were similar in the RAO and LAO projec-

0 20 40 60 80 100 tions (table 2) for the LAD (58 and 51 chords, respec-4. tively) and RCA (30 and 37 chords).

:::t RCA | In the LAO projection, the territories of the RCAand circumflex were similar. Both overlapped exten-

.0. . ...... |- sively with the LAD territory. As a result, in patientswith multivessel disease, hypokinesis caused by sig-

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0 20 40 60 80 1030 nesis caused by the acute infarction.4 .0 _______________________________________ Wall motion abnormality in acute myocardial infarction.

3.0 - LIRD Hypokinesis in the infarct region was significantly2.0 more severe when measured in the RAO projection1.0 than in the LAO projection for the study population as

et0I.a whole and for patients with LAD thrombosis (table-20 t3). Hypokinesis was similar in the two projections in

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right dominant coronary artery anatomy was hypoki-0 20 40 60 80 100 nesis more severe in the LAO projection. The differ-

CHORD NUMBER ence was not significant, however, because of thesmall number of cases. Hypokinesis caused by throm-

URE 2. Coronary artery territories in the 60 degree LAO projec- . .H

Hypokinesis in patients with infarction due to LAD occlusion bosis of a left dominant circumflex artery was equallyws a binodal distribution. CFX = circumflex. well detected in both projections.

Hyperkinesis opposite the site of acute infarctionwas significantly greater in the walls visualized in the

ie circumferential extent of hypokinesis more depressed LAO projection in patients with thrombosis of the1 SD below normal was calculated as the number of contig- .

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chords with motion below that threshold within the artery's Limum territory and expressed as a percentage of endocardial those with RCA thrombosis, hyperkinesis was theaur length. The maximum territory excludes the paravalvu- same in the two projections (table 3)..gions and delimits the maximum extent of hypokinesis in The relationship between hypokinesis measured innts with acute coronary thrombosis and single-vessel dis-in our experience. In the RAO projection, the maximum the RAO and LAO projections is illustrated in figure 3.;ory spans chords 5 to 85 for the LAD and chords 25 to 85 Change in wall motion abnormality in infarct and nonin-he RCA; the circumflex is handled as an LAD in patients farct regions. As seen in the acute study recovery ofright-dominant coronary anatomy or as an RCA in those . . 'left-dominant anatomy. For patients with multivessel dis- wall motion after thrombolytic therapy was signifi-the circumferential extent of hypokinesis or akinesis was cantly underestimated when measured in the LAO asured within a range restricted by the statistically deter- compared with the RAO projection in patients withd territory (table 1): chords 5 to 67 for the LAD and chords

Z 85fortheRCAIntheLAOproecton,themaxmum LAD thrombosis (table 4; figure 3). In RCA thrombo-85 for the RCA. In the LAO projection, the maximum-ory of the RCA and circumflex spans chords 1 to 80, and sis, the change measured in the RAO and LAO projec-of the LAD spans chords 15 to 100. The circumferential tions was similar and correlated highly (r = .81). Init of hypokinesis more than 2 SDs below normal was also contrast improvement tended to be greater when mea-mined, and the extent of akinesis was calculated as the cnratimproe ment tento be gatie wihe mea-ber of chords with absolute motion of 0 or less. sured in the LAO projection in patients with circum-;atistical analysis. Motion measured in the RAO and LAO flex thrombosis.ctions and the change in motion between short-term and Change in the magnitude of hyperkinesis oppositetw-up studies were compared by paired t test. Motion inial subjects and patients with single-vessel disease was the infarction between short-term and follow-up stud-pared by one-way analysis of variance. ies tended to be greater in the walls visualized by the

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TABLE 3Comparison of wall motion abnormality during acute myocardialinfarction in the RAO and LAO projections

n 300 RAO 60° LAO p value

Infarct regionAll patients 67 -2.5 1.1 -2.1±+ 0.9 .001LAD 36 -2.9+0.9 -2.0+0.8 .001RCA 21 -2.2+1.0 -2.1 1.0 NSCFX 10 - 1.7 1.2 - 2.2± 0.8 NS

Right dominance 3 -0.9 1.3 - 2.4 0.8 NSLeft dominance 7 - 2.1 ±+1.1 - 2.1 0.8 NS

Noninfarct regionAll patients 67 0.2±1.0 0.8+1.1 .001LAD 36 0.3 1.2 1.1 1.1 .001RCA 21 0.4±0.7 0.4±1.0 NSCFX 10 -0.1±0.8 0.6+1.1 .034

Right dominance 3 -0.2 ±0.6 0.8 + 1.6 NSLeft dominance 7 0.0 ±0.9 0.5 ± 1.0 .036

Data expressed as SD/chord (standard deviations from the normalmean). Negative values indicate hypokinesis. positive values indicatehyperkinesis. Values are mean + 1 SD.CFX = circumflex coronary artery.

LAO projection than in those visualized by the RAOprojection. The exception was motion opposite cir-cumflex thrombosis, which did not change significant-ly in either projection.To investigate the lack of improvement seen in the

LAO projection in patients with LAD thrombosis, weexamined their motion individually. In five of 26cases, motion in the apical section changed in the samedirection as motion in the noninfarct region, ratherthan paralleling the change in the septal region (figure4). This type of intraterritorial discordance was notseen in the RAO projection. Tethering between theinfarct and noninfarct regions was also a phenomenon

primarily of the LAO projection (table 5), i.e., changein the motion of the infarct region correlated signifi-cantly with change in the motion of the noninfarctregion in patients with LAD thrombosis. In contrast,this was not seen in the RAO projection except inpatients with circumflex thrombosis.

Circumferential extent of hypokinesis and akinesis. Theresults of measuring the circumferential extent of hy-pokinesis and akinesis paralleled the results of measur-ing the severity of hypokinesis within the infarct site(table 6). That is, in general, hypokinesis was more

extensive in the RAO projection in patients with LADthrombosis and more extensive in the LAO projectionin patients with circumflex thrombosis. Since the cir-cumferential extent of hypokinesis caused by the acuteinfarction cannot be accurately distinguished from hy-pokinesis caused by disease of the noninfarct arteriesor prior infarction, even in the RAO projection with itslesser arterial territory overlap, the analysis was re-

peated in the subgroup with single-vessel disease. Theresults were similar and significant despite the smallernumber of patients: the hypokinetic region was longerin the RAO projection in patients with LAD thrombo-sis and longer in the LAO projection in those withcircumflex thrombosis.

Differences between the two projections were lesssignificant for measurement of the circumferential ex-

tent of hypokinesis than for measurement of the sever-

ity of hypokinesis (tables 3 and 4). This was probablydue to the greater variability of the former variable, as

indicated by the magnitude of the standard deviation.Measurements of the circumferential extent of hy-

perkinesis more than I SD above normal were alsoconcordant with measurements of the magnitude ofhyperkinesis opposite the infarct site.

TABLE 4Change in wall motion after acute myocardial infarction

n 30° RAO pA 60° LAO pA pB

Infarct regionAll patients 45 0.3+ 1.0 .03 0.2 ±+0.9 .089 NSLAD 26 0.4 +1.l .094 -0.0 ±+0.9 NS .014RCA 12 0.3 0.5 .064 0.5 0.8 .04 NSCFX 7 0.2 1.1 NS 0.7+0.8 .051 NS

Noninfarct regionAll patients 45 - 0.3+ 1.4 NS - 0.6 +1.1 .001 NSLAD 26 -0.4 1.4 .074 -0.6 1.2 .01 NSRCA 12 -0.2± 1.4 NS -0.6 +0.7 .014 NSCFX 7 0.2 1. 4 NS -0.3 1.3 NS NS

Data expressed as SD/chord (see table 3). Values are mean + 1 SD.APaired t test, acute vs follow-up.BPaired t test, change in motion (follow-up-acute) in RAO vs change in LAO.

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FIGURE 3. Relationship between wall motion abnormality measured in the 30 degree RAO and 60 degree LAO projections.Hypokinesis in the infarct artery territories and change in hypokinesis between acute infarction and followup are shown for eachcoronary artery. CFX - circumflex.

DiscussionMeasurement of wall motion in the 60 degree LAO pro-

jection. Measurement of regional left ventricular wallmotion in the 60 degree LAO projection is complicatedby the variable degree of foreshortening of the cham-ber's long axis. This foreshortening may explain whymeasurement of left ventricular chamber volume from

Vol. 74, No. 4, October 1986

30 degree RAOI60 degree LAO biplane ventriculo-grams is less accurate and has a greater standard errorof the estimate than estimation of volume from the 30degree RAO projection alone."3 The foreshorteningmay be avoided by angulating the camera cranially toobtain a full-length image,1' but this results in poorervisualization of the apex because of the increased over-

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PCUTE STUDY

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FIGURE 4. Example of intraterritorial discordanceMotion in the apical region of the LAD territory chardirection as motion in the noninfarct region rather thamotion change in the septal region.

lap between the apex and the diaphragmin this study the centerline method wa,the image obtained in the straight 60projection.

Variability in normal motion is higherprojection than in the RAO.'2 The variab

TABLE 5Correlation between change in hypokinesis in the infchange in hyperkinesis in the noninfarct region

Correlation with change in noni]

Infarct region n RAO p L

LAD 26 -.14 NSApical sectionSeptal section

RCA 12 -.03 NSCircumflex 7 .59 NSA

AInclusion of patients enrolled in the same thrombolyhad only single-plane RAO ventriculograms yields theof .588 but achieves significance because of the lapatients. 15

802

duced by excluding the aortic outflow tract, whoseprojected length was affected by the degree of fore-shortening.'" This reduced the variability, but not to

RRIToRY the level of the RAO projection. Since the centerlinemethod expresses motion abnormality in terms of stan-

-. .------ dard deviations from the normal mean, the higher vari-ability of normal motion in the LAO decreases thesensitivity with which abnormality can be detected inthat projection.14

80 100 Comparison of 30 degree RAO and 60 degree LAO pro-jections. Regardless of whether the severity of wallmotion abnormality, or its circumferential extent, wasmeasured, the same results were consistently obtained.Hypokinesis was significantly more severe in the RAOprojection in patients with LAD thrombosis and moresevere in the LAO projection for circumflex thrombo-sis. Hyperkinesis was greater in the LAO projectionfor LAD and circumflex disease. In patients with RCAthrombosis, evaluation in the two projections yieldedsimilar results. These findings confirm and extend theresults of previous studies by specifically examiningpatients with circumflex thrombosis, the only group inwhich hypokinesis is better detected in the LAO pro-jection, and by performing quantitative analysis of

80 100 both the extent and the severity of wall motion abnor-SEPTPL malities. Rigaud et al.4 reported that the akinetic (or

dyskinetic) segment length did not differ significantlyin wall motion. between biplane and single-plane determinations. Ourlged in the same data also show no difference between measurements in.n paralleling the

the RAO and LAO projections of the extent of akine-sis, but this variable suffers from low sensitivity.2

I. Therefore, Cohn et al.5 also found that the LAO projection oftens applied to underestimated abnormalities seen in the RAO in adegree LAO variety of locations. However, the converse was not

true: all patients with normal motion in the RAO hadin the LAO normal motion in the LAO, and all five patients withility was re- posterolateral wall asynergy caused by circumflex ste-

nosis had asynergy in the RAO projection. However,these investigators could not compare the severity of

rarct region and asynergy seen in the two projections because motionwas assessed qualitatively.

nfarct region Our observations can be related to the coronaryAO p anatomy as visualized in the two projections. The

paths of the LAD and RCA follow the ventricular.46 .05 contours in the 30 degree RAO projection. As a result,

.04 NS the overlap between the LAD and RCA territories is-.53 NS only 16 chords in the RAO projection and is easily.01 NS handled by dividing the overlap evenly beween the two

territories. This improves the correlation between theZsis trial but whosame crrelabutihon severity of coronary artery stenosis and regional hypo-same correlaftonirger number of kinesis in the stenosed artery's terTitory. 15 In the 60

degree LAO projection, foreshortening shifts the ap-

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TABLE 6Circumferential extent of hypokinesis and akinesis

Percent of LV contour with motion below threshold

Threshold RAO LAO n p

Acute infarctionInfarct artery

All patients - 1 SD 37± 19 37± 18 67 NS-2 SD 24±19 25±19. 67 NSAkinesis 11 ± 13 8 ± 14 67 NS

LAD -I SD 47±17 36±16 36 .001-2 SD 33 10 28 ± 19 36 NSAkinesis 18 14 13 ± 16 36 NS

RCA -1 SD 26+12 35±20 21 .022-2 SD 16±12 18±17 21 NSAkinesis 3±7 3±9 21 NS

Circumflex -1 SD 23± 15 42±22 10 .004-2 SD 11±8 26±20 10 .006Akinesis 2± 5 3 ± 6 10 NS

Change in motion (follow-up-short-term)Infarct artery

All patients -1 SD -2± 18 -4± 19 45 NSLAD -1 SD -2±22 2±18 26 NSRCA -1 SD -3±6 -9±18 12 NSCircumflex -1SD 1±18 -15±17 7 NS

parent "apex" inferiorly to myocardium supplied bythe RCA or circumflex. This is the probable explana-tion for (1) the overlap between the three arterial terri-tories at the "apex," (2) the correlation indicating teth-ering between the motion of the "apex" and that of thenoninfarct region (posterior wall) in patients with LADthrombosis, and (3) the lesser severity of hypokinesismeasured in the LAO projection in these patients.The opposite is true for circumflex thrombosis: its

course is midfield in the 30 degree RAO projection butsupplies much of the myocardium visualized in the 60degree LAO projection. For the RCA, the RAO pro-jection probably presents the best view. The artery'sinfluence on the "apex" of the LAO projection is alsostrong but may be attenuated by the hyperkinesis innoninfarct regions because of territory overlap.

Measurement of the circumferential extent of wall mo-

tion abnormality. Our results show that the circumferen-tial extent of hypokinesis resulting from thrombosis ofeach coronary artery is highly variable, as indicated bythe large standard deviation. For this reason, the evalu-ation of the percentage of the ventricular contour hav-ing abnormal motion is valid only in patients withsingle-vessel disease. Even within this subgroup, how-ever, variability remained high, particularly for mea-suring change between acute and follow-up studies.This reduced the sensitivity for detecting differencesbetween projections.

Clinical implications. The results of the present study

Vol. 74, No. 4, October 1986

indicate that the severity of hypokinesis caused byacute coronary artery thrombosis and the efficacy oftherapeutic interventions in salvaging ventricular func-tion can be adequately evaluated from single-plane 30degree RAO ventriculograms. Performance of biplaneventriculography is indicated primarily for patientswith circumflex thrombosis who form a small minorityof patients presenting with acute infarction (16% of the102 patients in the present study, 12% in the NIH-sponsored trial of Thrombolysis in Myocardial Infarc-tion, 8% in the Western Washington IntracoronaryStreptokinase Trial'6). Although the magnitude of hy-perkinesis in the noninfarct region is also better detect-ed in the LAO projection, the clinical significance ofhyperkinesis has not yet been determined.

References1. Tennant R, Wiggers CJ: Effect of coronary occlusion on myocardi-

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F H Sheehan, J Schofer, D G Mathey, M A Kellett, H Smith, E L Bolson and H T Dodgeprojections in patients with acute myocardial infarction.

comparison of the 30 degree right anterior oblique and 60 degree left anterior oblique Measurement of regional wall motion from biplane contrast ventriculograms: a

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