Levophase of coronary angiogram

Levophase of coronary angiogram

Levophase of coronary angiogram showing tributaries of coronary sinus
Levophase of coronary angiogram showing tributaries of coronary sinus

Levophase of left coronary angiogram showing the coronary sinus and its tributaries. Levophase of the angiogram is obtained when you continue the cine recording till the contrast passes from the arterial tree through the capillaries to the venous system. Alternatively, you may start recording a little late after the coronary injection to approximately time for the levophase. But in this situation there is chance of missing the initial part of the levophase. Levophase angiogram gives an outline of the coronary sinus and its major tributaries. But it will not be enough for an excellent visualisation of the venous anatomy for left ventricular lead placement for cardiac resynchronization therapy (CRT). While planning to locate a good vein for CRT, coronary sinus angiography is directly performed by retrograde cannulation of the coronary sinus ostium from the right atrium. Care is needed to avoid dissection of the coronary sinus or its tributaries which are thin walled structures compared to the coronary arteries. Since the flow in the venous system is against the direction of contrast injection, proximal balloon occlusion is needed for good visualisation of the tributaries of the coronary sinus. The tributaries seen here are the middle cardiac vein (Middle cardiac V) and the lateral marginal vein (Lateral marginal V). The catheter tip of left Judkins catheter introduced via the transfemoral route is engaging the ostium of the left main coronary artery (LMCA).

Hyperemic venous return angiography (levophase) has been used to study the coronary venous anatomy [1]. Here the levophase recordings are taken after inducing hyperemia with intracoronary nitroglycerine or adenosine. In the study of 200 patients, sufficient anatomic information needed for cardiac resynchronization therapy was obtained in 99.5% patients. There was no significant different between hyperemic venous return angiography and occlusive retrograde venography in utility. Visibility scores were slightly higher for coronary sinus and lateral vein of the left ventricle with occlusive retrograde venography. But middle cardiac vein and anterior interventricular vein could be visualized better using venous return angiography. There were no complications with venous return angiography. Dissection of great cardiac vein occurred in three patients with occlusive venous angiography, but this did not prevent electrode implantation.

Reference

  1. Arbelo E, García-Quintana A, Caballero E, Hernández E, Caballero-Hidalgo A, Amador C, de Lezo JS, Medina A. Usefulness of hyperemic venous return angiography for studying coronary venous anatomy prior to cardiac resynchronization device implantation. Rev Esp Cardiol. 2008 Sep;61(9):936-44.