DIAGNOSTIC METHODS
VENTRICULAR PERFORMANCE
Measurement of regional wall motion from biplane
contrast ventriculograms: a comparison of the 30
degree right anterior oblique and 60 degree left
anterior oblique projections in patients with
acute myocardial infarction
FLORENCE 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.
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With the technical assistance of Suzanne Mitten and Jane Wygant
ABSTRACT The value of performing biplane vs single plane analysis of regional wall motion from
ventriculograms was determined in 102 patients who received thrombolytic therapy and who
underwent 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 the
noninfarct region were measured by the centerline method in the respective artery territories, which
were defined from the data of 62 patients with single-vessel disease and were expressed in units of
standard deviations from the mean of 32 normal subjects. Hypokinesis was more severe and extended
over 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 and
extensive in the left anterior oblique (LAO) projection in circumflex stenosis. Hyperkinesis opposite
the LAD or the circumflex was greater in the LAO projection. In patients with thrombosis of the right
coronary artery, wall motion abnormalities were similar in the two projections. Thus the evaluation of
hypokinesis caused by acute coronary thrombosis and of the effect of therapeutic interventions in
salvaging 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.
contrast
THE OBSERVATION that coronary artery occlusion
causes regional ventricular dysfunction was made 50
years ago by Tennant and Wiggers. ' However, quantitative methods for evaluating regional wall motion abnormalities have only recently been developed. These
methods have been particularly useful in evaluating the
efficacy of interventions such as thrombolytic therapy
in salvaging myocardial function in patients with acute
From the Cardiovascular Research and Training Center, University
of Washington, Seattle; University Hospital Eppendorf, Hamburg,
West Germany; Boston University Medical Center, Boston; and the
Mayo Foundation, Rochester, MN.
Supported in part by grants from the R. J. Reynolds Foundation,
Winston-Salem, NC, from the NHLBI (grants HL-27819 and HL19451), 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.
796
infarction, especially because recent studies have
shown that variables of global ventricular function
such as the ejection fraction may not sensitively reflect
the severity of hypokinesis in the infarct site because of
the influence of compensatory hyperkinesis in noninfarct regions 2'3
One of the issues that remains unresolved is the need
for biplane analysis. Previous studies have reported
either no difference between the abnormalities measured in the 30 degree right anterior oblique (RAO)
and 60 degree left anterior oblique (LAO) projections
or frequent underestimation in the LAO projection of
hypokinesis or even akinesis visible in the RAO projection.4' 5However, hypokinesis may be better detected in the LAO projection in certain subgroups, such as
patients with circumflex thrombosis in whom hypokiCIRCULATION
DIAGNOSTIC METHODS-VENTRICULAR PERFORMANCE
nesis measured in the RAO is significantly less severe
than that of patients with thrombosis of the left anterior
descending artery (LAD) or right coronary artery
(RCA).6 Also, the magnitude of compensatory hyperkinesis in the septal and posterior walls visualized in
the LAO projection has not been measured or compared with hyperkinesis in the RAO projection.
Therefore the present study was performed to compare the magnitude and extent of wall motion abnormalities measured in the 30 degree RAO and 60 degree
LAO projections in patients studied during and after
acute thrombosis of the LAD, RCA, and circumflex
coronary artery.
Methods
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
Patients. The study population consisted of 102 patients who
were admitted within 5 hr after the onset of acute myocardial
infarction and who underwent cardiac catheterization in the
course of receiving thrombolytic therapy with either intracoronary streptokinase or intravenous urokinase between October
1979 and April 1984.2 " All patients were treated at the University Hospital Eppendorf in Hamburg, West Germany, by two of
us (D. G. M. and-J. S.). Of the 102 patients, 67 had biplane data
in the acute study, 80 had biplane data at follow-up, and 45
patients 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 data
of 32 patients who underwent diagnostic cardiac catheterization
but were found to have normal cardiac anatomy and function
and who had biplane ventriculograms of adequate contrast for
quantitative analysis.
The region of the left ventricle in the LAO projection that is
considered the territory of each coronary artery was defined
from the data of 62 patients with isolated stenosis of the LAD (n
= 31), RCA (n = 16), or circumflex artery (n = 15) and
biplane ventriculograms.
The number of patients with biplane ventriculograms was
smaller than the number of patients with single-plane ventriculograms (previously described2) whose data were used to define
the arterial territories in the 30 degree RAO projection. Therefore, the arterial territories in the LAO projection were defined
using only patients with single-vessel disease who had had a
previous infarction. This yielded arterial territories in the RAO
projection similar to those previously defined from single-plane
data (table 2).8
The ventriculograms of normal patients and patients with
single-vessel disease were obtained from (1) the University of
Washington or Seattle Veterans Administration Hospital by
data base search, (2) Boston University (M. K.), (3) Mayo
Foundation (H. S.), or (4) University Hospital Eppendorf.
(J. S.).
Ventriculographic analysis. Biplane contrast ventriculography was perforned in the 30 degree RAO and 60 degree LAO
projections and recorded at 50 or 60 frames/sec. The cine films
were analyzed at the University of Washington in Seattle. The
end-diastolic and end-systolic endocardial contours were projected and traced from the frames with maximum and minimum
volume, respectively, from a normal, non-postpremature sinus
beat. Wall motion was measured by the centerline method8' 9
along 100 chords constructed perpendicular to a centerline
drawn midway between the end-diastolic and end-systolic contours (figure 1) and normalized by the end-diastolic perimeter.
Vol. 74, No. 4, October 1986
TABLE 1
Biplane data set
Status of ventriculographic data
No ventriculogram performed
Single-plane RAO ventriculogram only
Biplane ventriculogram not analyzableA
Biplane ventriculogram-analyzed
Total no. of patients
Acute
study
Follow-up
study
9
13
13
67
102
14
6
2
80
102
Aln most cases, inability to analyze a ventriculogram is due to ventricular irritability resulting in arrhythmia.
Abnormality in chord motion at the infarct site was expressed in
units of standard deviations (SDS) from the mean wall motion
of 32 normal patients with biplane ventriculograms. Hypokinesis is indicated by negative values, hyperkinesis by positive
values. Regional wall motion was calculated as the mean motion of chords lying in the most hypocontractile half of the
infarct-related artery territory. Hyperkinesis was calculated in
the most hyperkinetic half of the territory on the wall opposite
the site of infarction.2 Both were expressed in SDs per chord.
The derivation and application of this method have been previously described. 10
Because the highly variable degree of foreshortening in the
LAO view affects its projected length, the aortic root is excluded from the contour.11' 12 Otherwise, motion in the LAO
projection was analyzed in the same way as for the RAO. The
territory of each coronary artery in the LAO contour was defined as the set of contiguous chords whose motion, in patients
with isolated stenosis of that artery, was significantly depressed
compared with motion in the normal group. As in the RAO,
hypokinesis in the infarct site was calculated as the mean motion
of chords lying in the most hypocontractile half of the infarctrelated artery territory. In patients with LAD thrombosis, which
results in a binodal abnormality (figure 2), mean chord motion
in the most hypokinetic half of the septal and apical regions was
calculated and these means were then averaged to yield an
overall measure of hypokinesis in the LAD territory. This variable better distinguishes the motion in normal patients from that
in patients with isolated LAD stenosis than measures of septal
motion alone, apical motion alone, or the more abnormal of the
two.12 Hyperkinesis was similarly calculated as mean chord
motion in the most hypercontractile half of the territory opposite
the infarct. The severity of hypokinesis and the magnitude of
hyperkinesis are expressed in SDs per chord.
TABLE 2
Coronary artery territories
Chord No. delimiting territory
Coronary artery
LAD
RCA
Circumflex
300 RAOA
30° RAOB
600 LAO
12-68
52-84
10-67
51-80
50-100
38-74
19-67
c
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.
797
SHEEHAN et al.
60` LPO
3'0 RPO
A
,10
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20
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a
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CHORD NUMBER
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-4.0
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20
40
60
80
100
CHORD NUMBER
FIGURE 1. Centerline method of regional wall motion analysis. A, End-diastolic and end-systolic left ventricular endocardial
contours and centerline constructed by the computer midway between the two contours. B, Motion is measured along 100 chords
constructed perpendicular to the centerline. C, Motion at each chord is normalized by the end-diastolic perimeter to yield a
shortening fraction. Motion along each chord is plotted for the patient (solid line). The mean motion in the normal ventriculogram
group (dashed line) and 1 SD above and below the mean (dotted lines) are shown for comparison. D, Standardized motion. Wall
motion is now plotted in units of SDs from the normal mean (dotted line). The normal ventriculogram group mean is represented
by the horizontal zero line.
798
CIRCULATION
DIAGNOSTIC METHODS-VENTRICULAR PERFORMANCE
4.0
3.0 -
Results
i.
CFX
2^ ,~ ~ ~1
,.o
-1.S -z.-
-
L
-4.0
c-
4.
z
0
/
.
-3.0
In
Artery territories in the 60 degree LAO projection. Fig-
......
20
0
40
60
.0.
|
.
|-
......
-2.0
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
In
100
RCA
:::t
c:
z
80
....
4 .0
80
1030
20
40
60
0
_______________________________________
3.0
-
LIRD
2.0
1.0
than in the LAO projection for the study population as
et0I.a whole and for patients with LAD thrombosis (table
t3). Hypokinesis was similar in the two projections in
-20
2.0
-3 .0
ure 2 illustrates the territories of the coronary arteries
in the 60 degree LAO projection as defined by the data
of the reference patients with chronic single-vessel
disease and prior infarction. The lengths of the arterial
territories were similar in the RAO and LAO projections (table 2) for the LAD (58 and 51 chords, respectively) and RCA (30 and 37 chords).
In the LAO projection, the territories of the RCA
and circumflex were similar. Both overlapped extensively with the LAD territory. As a result, in patients
with multivessel disease, hypokinesis caused by significant stenosis or prior infarction involving noninfarct arteries could not be distinguished from hypokinesis caused by the acute infarction.
Wall motion abnormality in acute myocardial infarction.
Hypokinesis in the infarct region was significantly
more severe when measured in the RAO projection
..---.
........
..--.-.-.
0
20
..-
..
40
60
CHORD NUMBER
80
100
RCA thrombosis. Only in circumflex thrombosis with
right dominant coronary artery anatomy was hypokinesis more severe in the LAO projection. The difference was not significant, however, because of the
small. number of cases. Hypokinesis caused by thromH
2. Coronary artery territories in the 60 degree LAO projection. Hypokinesis in patients with infarction due to LAD occlusion
follo ws a binodal distribution. CFX = circumflex.
FIGIURE
Thie circumferential extent of hypokinesis more depressed
than 1 SD below normal was calculated as the number of contiguous chords with motion below that threshold within the artery's
maxiimum territory and expressed as a percentage of endocardial
cont( aur length. The maximum territory excludes the paravalvular re.gions and delimits the maximum extent of hypokinesis in
patients with acute coronary thrombosis and single-vessel dis-
in our experience. In the RAO projection, the maximum
ease
territ;ory spans chords 5 to 85 for the LAD and chords 25 to 85
for tihe RCA; the circumflex is handled as an LAD in patients
with right-dominant coronary anatomy or as an RCA in those
with left-dominant anatomy. For patients with multivessel dis-
.
bosis of a left dominant circumflex
well detected in both projections.
artery was equally
Hyperkinesis opposite the site of acute infarction
was significantly greater in the walls visualized in the
LAO projection in patients with thrombosis of the
.
o
L
those with RCA thrombosis, hyperkinesis was the
same in the two projections (table 3).
The relationship between hypokinesis measured in
the RAO and LAO projections is illustrated in figure 3.
Change in wall motion abnormality in infarct and nonin-
farct regions. As seen in the acute study recovery of
.
wall
.
'
motion after thrombolytic therapy was signifi-
the circumferential extent of hypokinesis or akinesis was
within a range restricted by the statistically deter-
cantly underestimated when measured in the LAO as
compared with the RAO projection in patients with
mine d territory (table 1): chords 5 to 67 for the LAD and chords
InntheLAOproecton,themaxmum
RCA. I
the LAO projection, the maximum
51 te 85 forZ the
85fortheRCA
territ-ory of the RCA and circumflex spans chords 1 to 80, and
that (of the LAD spans chords 15 to 100. The circumferential
LAD thrombosis (table 4; figure 3). In RCA thrombosis, the change measured in the RAO and LAO projections was similar and correlated highly (r = .81). In
contrast improvement tended to be greater when meaimproe ment tento be gatie wihe meacnrat
sured in the LAO projection in patients with circumflex thrombosis.
Change in the magnitude of hyperkinesis opposite
ease,
meas ured
exterit of hypokinesis
more than 2 SDs below normal was also
determined, and the extent of akinesis was calculated as the
numi
ber of chords with absolute motion of 0 or less.
St:;atistical analysis. Motion measured in the RAO and LAO
proje ctions
and the change in motion between short-term and
follotw-up studies were compared by paired t test. Motion in
normial
comi
subjects and patients with single-vessel disease was
pared by one-way analysis of variance.
Vol. 74, No. 4, October 1986
the infarction between short-term and follow-up studies tended to be greater in the walls visualized by the
799
SHEEHAN et al.
TABLE 3
Comparison of wall motion abnormality during acute myocardial
infarction in the RAO and LAO projections
Infarct region
All patients
LAD
RCA
CFX
Right dominance
Left dominance
Noninfarct region
All patients
LAD
RCA
CFX
Right dominance
Left dominance
n
300 RAO
60° LAO
p value
67
36
21
10
3
7
-2.5 1.1
-2.9+0.9
-2.2+1.0
- 1.7 1.2
-0.9 1.3
- 2.1 ±+1.1
-2.1±+ 0.9
-2.0+0.8
-2.1 1.0
- 2.2± 0.8
- 2.4 0.8
- 2.1 0.8
.001
.001
NS
NS
NS
NS
67
36
21
10
3
7
0.2±1.0
0.3 1.2
0.4±0.7
-0.1±0.8
-0.2 ±0.6
0.0 ± 0.9
0.8+1.1
1.1 1.1
.001
.001
NS
.034
NS
.036
0.4±1.0
0.6+1.1
0.8 + 1.6
0.5 ± 1.0
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Data expressed as SD/chord (standard deviations from the normal
mean). Negative values indicate hypokinesis. positive values indicate
hyperkinesis. Values are mean + 1 SD.
CFX = circumflex coronary artery.
LAO projection than in those visualized by the RAO
projection. The exception was motion opposite circumflex thrombosis, which did not change significantly in either projection.
To investigate the lack of improvement seen in the
LAO projection in patients with LAD thrombosis, we
examined their motion individually. In five of 26
cases, motion in the apical section changed in the same
direction as motion in the noninfarct region, rather
than paralleling the change in the septal region (figure
4). This type of intraterritorial discordance was not
seen in the RAO projection. Tethering between the
infarct and noninfarct regions was also a phenomenon
primarily of the LAO projection (table 5), i.e., change
in the motion of the infarct region correlated significantly with change in the motion of the noninfarct
region in patients with LAD thrombosis. In contrast,
this was not seen in the RAO projection except in
patients with circumflex thrombosis.
Circumferential extent of hypokinesis and akinesis. The
results of measuring the circumferential extent of hypokinesis and akinesis paralleled the results of measuring 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 LAD
thrombosis and more extensive in the LAO projection
in patients with circumflex thrombosis. Since the circumferential extent of hypokinesis caused by the acute
infarction cannot be accurately distinguished from hypokinesis caused by disease of the noninfarct arteries
or prior infarction, even in the RAO projection with its
lesser arterial territory overlap, the analysis was repeated in the subgroup with single-vessel disease. The
results were similar and significant despite the smaller
number of patients: the hypokinetic region was longer
in the RAO projection in patients with LAD thrombosis and longer in the LAO projection in those with
circumflex thrombosis.
Differences between the two projections were less
significant for measurement of the circumferential extent of hypokinesis than for measurement of the severity of hypokinesis (tables 3 and 4). This was probably
due to the greater variability of the former variable, as
indicated by the magnitude of the standard deviation.
Measurements of the circumferential extent of hyperkinesis more than I SD above normal were also
concordant with measurements of the magnitude of
hyperkinesis opposite the infarct site.
TABLE 4
Change in wall motion after acute myocardial infarction
n
Infarct region
All patients
LAD
RCA
CFX
Noninfarct region
All patients
LAD
RCA
CFX
30° RAO
pA
60° LAO
pA
pB
45
26
12
7
0.3+ 1.0
0.4 +1.l
0.3 0.5
0.2 1.1
.03
.094
.064
NS
0.2 ±+0.9
-0.0 ±+0.9
0.5 0.8
0.7+0.8
.089
NS
.04
.051
NS
.014
NS
NS
45
26
12
7
- 0.3+ 1.4
-0.4 1.4
-0.2± 1.4
0.2 1. 4
NS
.074
NS
NS
- 0.6 +1.1
-0.6 1.2
-0.6 +0. 7
-0.3 1.3
.001
.01
.014
NS
NS
NS
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.
800
CIRCULATION
DIAGNOSTIC METHODS-VENTRICULAR PERFORMANCE
HYPOKINESIS
A
HYPOKINESIS
3
1.
2
0
cl
a
0
1
0
IL -I
o
LflD
LP
0
cl
0
I 2a
0
0
03
00
1
o
0
0
0~~~~~
~~~~0
0
0
0.
0
(o
0
a-3a
<I
'J
0
000
-1
0
G
2
0
_-4
- LINE OF IDENTIFY
-3 i
-S
-
-3
-4
-3
-2
-1
0
1
-3
-2
300 RPO0 SD/CHORD
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0
o
0
Ch
0
0
0
3
0
Q -2
-1
0
(0
0 ~
~
10
0
-4
-2
0
- LINE OF IDENTITY
-s
-3
-4
-
---NEl OF IDENTITY
-3
1
-5
tn
2
I0
/
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I -1
CX
1
SD/CHORD
Cl
ItD
0£14
a
0
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a
01.
0
00
-1
300
LINE OF IDENTIFY
-2
-1
1
6
0
-3
-
300 RPO* SD/CHORD
2
3
300° RAO . SD/CHORD
3
_i
G
_~~~
2
0
Cla
0
I
0
<)
0
0
0
00
o
0
-1
0
(0
0
0
-1.
0
-2
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- LINE OF IDENTITY
-LINE OF IDENTITY
-13
-5
-4
-3
-2
-1
0
300 RPO* SD/CHORD
I
-3
-
-
300
O2
3
RPO. SD/CHORD
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 each
coronary artery. CFX - circumflex.
Discussion
Measurement of wall motion in the 60 degree LAO pro-
jection. Measurement of regional left ventricular wall
motion in the 60 degree LAO projection is complicated
by the variable degree of foreshortening of the chamber's long axis. This foreshortening may explain why
measurement of left ventricular chamber volume from
Vol. 74, No. 4, October 1986
30 degree RAOI60 degree LAO biplane ventriculograms is less accurate and has a greater standard error
of the estimate than estimation of volume from the 30
degree RAO projection alone."3 The foreshortening
may be avoided by angulating the camera cranially to
obtain a full-length image,1' but this results in poorer
visualization of the apex because of the increased over801
SHEEHAN et al.
PCUTE STUDY
4.0
I-
HYPERKINESIS IN
NONINFPRCT RECION
2.0
CU
LPiD TE
RRIToRY
1 .0
-.
.------
-1 .0
z--2.0
um
-
3.0
.
-4.0
1
0
20
40
s0
80
100
CHORD NUMBER
FOLLOW-UP STUDY
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0
20
40
60
PPICPL
80
100
SEPTPL
CHORD NUMBER
FIGURE 4. Example of intraterritorial discordance in wall motion.
Motion in the apical region of the LAD territory charlged in the same
direction as motion in the noninfarct region rather tha.n paralleling the
motion change in the septal region.
lap between the apex and the diaphragmI. Therefore,
in this study the centerline method wa,s applied to
the image obtained in the straight 60 degree LAO
projection.
Variability in normal motion is higher in the LAO
projection than in the RAO.'2 The variab ility was reTABLE 5
Correlation between change in hypokinesis in the infrarct region and
change in hyperkinesis in the noninfarct region
Correlation with change in noni] nfarct
region
Infarct region
n
RAO
p
L AO
p
LAD
26
-.14
NS
.46
.05
Apical section
Septal section
RCA
Circumflex
.04
12
7
-.03
.59
NS
NSA
-.53
.01
NS
NS
NS
AInclusion of patients enrolled in the same thrombolyZsis trial but who
had only single-plane RAO ventriculograms yields the same correlafton
of .588 but achieves significance because of the lairger number of
patients. 15
same crrelabutihon
802
duced by excluding the aortic outflow tract, whose
projected length was affected by the degree of foreshortening.'" This reduced the variability, but not to
the level of the RAO projection. Since the centerline
method expresses motion abnormality in terms of standard deviations from the normal mean, the higher variability of normal motion in the LAO decreases the
sensitivity with which abnormality can be detected in
that projection.14
Comparison of 30 degree RAO and 60 degree LAO projections. Regardless of whether the severity of wall
motion abnormality, or its circumferential extent, was
measured, the same results were consistently obtained.
Hypokinesis was significantly more severe in the RAO
projection in patients with LAD thrombosis and more
severe in the LAO projection for circumflex thrombosis. Hyperkinesis was greater in the LAO projection
for LAD and circumflex disease. In patients with RCA
thrombosis, evaluation in the two projections yielded
similar results. These findings confirm and extend the
results of previous studies by specifically examining
patients with circumflex thrombosis, the only group in
which hypokinesis is better detected in the LAO projection, and by performing quantitative analysis of
both the extent and the severity of wall motion abnormalities. Rigaud et al.4 reported that the akinetic (or
dyskinetic) segment length did not differ significantly
between biplane and single-plane determinations. Our
data also show no difference between measurements in
the RAO and LAO projections of the extent of akinesis, but this variable suffers from low sensitivity.2
Cohn et al.5 also found that the LAO projection often
underestimated abnormalities seen in the RAO in a
variety of locations. However, the converse was not
true: all patients with normal motion in the RAO had
normal motion in the LAO, and all five patients with
posterolateral wall asynergy caused by circumflex stenosis had asynergy in the RAO projection. However,
these investigators could not compare the severity of
asynergy seen in the two projections because motion
was assessed qualitatively.
Our observations can be related to the coronary
anatomy as visualized in the two projections. The
paths of the LAD and RCA follow the ventricular
contours in the 30 degree RAO projection. As a result,
the overlap between the LAD and RCA territories is
only 16 chords in the RAO projection and is easily
handled by dividing the overlap evenly beween the two
territories. This improves the correlation between the
severity of coronary artery stenosis and regional hypokinesis in the stenosed artery's terTitory. 15 In the 60
degree LAO projection, foreshortening shifts the apCIRCULATION
DIAGNOSTIC METHODS-VENTRICULAR PERFORMANCE
TABLE 6
Circumferential extent of hypokinesis and akinesis
Percent of LV contour with motion below threshold
Threshold
RAO
LAO
n
p
1 SD
-2 SD
Akinesis
-I SD
-2 SD
Akinesis
-1 SD
-2 SD
Akinesis
-1 SD
-2 SD
Akinesis
37± 19
24±19
11 ± 13
47±17
33 10
18 14
26+12
16±12
3±7
23± 15
11±8
2± 5
37± 18
25±19.
8 ± 14
36±16
28 ± 19
13 ± 16
35±20
18±17
3±9
42±22
26±20
3±6
67
67
67
36
36
36
21
21
21
10
10
10
NS
NS
NS
.001
NS
NS
.022
NS
NS
.004
.006
NS
Change in motion (follow-up-short-term)
Infarct artery
All patients
-1 SD
LAD
-1 SD
RCA
-1 SD
Circumflex
- 1SD
-2± 18
-2±22
-3±6
1±18
45
26
12
7
NS
NS
NS
NS
Acute infarction
Infarct artery
All patients
LAD
RCA
Circumflex
-
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
-4± 19
2±18
-9±18
-15±17
parent "apex" inferiorly to myocardium supplied by
the RCA or circumflex. This is the probable explanation for (1) the overlap between the three arterial territories at the "apex," (2) the correlation indicating tethering between the motion of the "apex" and that of the
noninfarct region (posterior wall) in patients with LAD
thrombosis, and (3) the lesser severity of hypokinesis
measured in the LAO projection in these patients.
The opposite is true for circumflex thrombosis: its
course is midfield in the 30 degree RAO projection but
supplies much of the myocardium visualized in the 60
degree LAO projection. For the RCA, the RAO projection probably presents the best view. The artery's
influence on the "apex" of the LAO projection is also
strong but may be attenuated by the hyperkinesis in
noninfarct regions because of territory overlap.
indicate that the severity of hypokinesis caused by
acute coronary artery thrombosis and the efficacy of
therapeutic interventions in salvaging ventricular function can be adequately evaluated from single-plane 30
degree RAO ventriculograms. Performance of biplane
ventriculography is indicated primarily for patients
with circumflex thrombosis who form a small minority
of patients presenting with acute infarction (16% of the
102 patients in the present study, 12% in the NIHsponsored trial of Thrombolysis in Myocardial Infarction, 8% in the Western Washington Intracoronary
Streptokinase Trial'6). Although the magnitude of hyperkinesis in the noninfarct region is also better detected in the LAO projection, the clinical significance of
hyperkinesis has not yet been determined.
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804
CIRCULATION
Measurement of regional wall motion from biplane contrast ventriculograms: a
comparison of the 30 degree right anterior oblique and 60 degree left anterior oblique
projections in patients with acute myocardial infarction.
F H Sheehan, J Schofer, D G Mathey, M A Kellett, H Smith, E L Bolson and H T Dodge
Downloaded from http://circ.ahajournals.org/ by guest on June 17, 2017
Circulation. 1986;74:796-804
doi: 10.1161/01.CIR.74.4.796
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