Diagnosis of Pulmonary Regurgitation by a Dye Method

Abstract

Graham Steell (1888) first described a variable and at times indistinct diastolic murmur over and slightly below the pulmonary area: this he attributed to "pulmonary regurgitation ... occurring independently of disease or deformity of the valves, and as the result of long-continued excess of blood pressure in the pulmonary artery." He later (1895) reported 60 cases of mitral stenosis and considered that only one had the murmur of "high pressure" in the pulmonary artery. Kezdi et al. (1955) reviewed 95 cases of mitral stenosis and found only one that they considered had the functional murmur of pulmonary regurgitation. This incidence of pulmonary regurgitation is low and reflects the strict criteria that were applied in order to arrive at a certain diagnosis.In this department consideration of the diagnosis of pulmonary regurgitation seemed to arise more frequently, and there was often disagreement among observers about patients with early basal diastolic murmurs. This arose partly because some of these murmurs were soft and transient and partly because there was often little supporting evidence to distinguish pulmonary from aortic regurgitation. The question particularly came up in patients with rheumatic heart disease. For these reasons an attempt was made to demonstrate pulmonary regurgitation by a dye method in 9 patients undergoing cardiac catheterization. MATERIAL AND METHODThe nine patients investigated fell into three groups: Group A, three patients who were catheterized for routine purposes and were not thought to have a Graham Steell murmur; Group B, four patients in whom the presence of a Graham Steell murmur was debatable; and Group C, two patients in whom a Graham Steell murmur was clinically agreed to be present. The diagnosis of a Graham Steell murmur was made clinically on the basis of a blowing early diastolic murmur heard in the left 2nd and 3rd intercostal space in the absence of peripheral signs of aortic regurgitation and in the presence of a strong systolic pulsation over the area of the right ventricle, a palpable pulmonary artery impulse, an accentuated second sound in the pulmonary area, X-ray signs of pulmonary artery enlargement, and electrocardiographic evidence of right ventricular hypertrophy.At right heart catheterization a number 8 catheter was placed 1-2 cm. distal to the pulmonary valve, and a number 9 catheter with multiple perforations at the end (Goodale-Lubin tip) was placed in the right ventricle just below the pulmonary valve. In the first three studies (patients B4, B5, and B6), 2 ml. of Evans blue (T-1824) were injected into the pulmonary artery in less than 1 second, and at the same instant fractional collection of blood from the right ventricle was begun with a Cornwall double valved syringe at a rate of 2 ml. per second. This had the disadvantage that, with a single bolus of dye rapidly injected into the pulmonary artery, streaming from the tip of the catheter was great and regurgitant dye that appeared transiently might be missed with the interrupted method of samplin...