\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,english]{babel}



\usepackage{float}








\begin{document}

\title{Useful Respiratory Maneuvers Aiding Left Heart Cardiac
Catheterization and Intervention. A Comprehensive Review}



\author[1]{Mohammad Reza Movahed}%
\affil[1]{Affiliation not available}%


\vspace{-1em}



  
  \date{June 11, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup








\sloppy


\textbf{Short title: Respiratory Maneuvers during Invasive Cardiac
Procedures}

\textbf{Mehrbod Vakhshoori MD\textsuperscript{1}, Mohammad Reza Movahed
MD, PhD} \textsuperscript{1,2}

University of Arizona Sarver Heart Center, Tucson,
Arizona\textsuperscript{1}

University of Arizona, College of Medicine, Phoenix,
Arizona\textsuperscript{2}

\textbf{Correspondence to:}

Mohammad Reza Movahed, MD, Ph.D., FACC, FSCAI, FACP

Clinical Professor of Medicine, University of Arizona

1501 N Campbell Ave,

Tucson, AZ 85724

Tel: 949 400 0091

Email: \emph{rmova@aol.com}

\textbf{Keywords:} Cardiac Catheterization; Coronary angiography; left
heart catheterization; Percutaneous coronary intervention; Stents;
Respiration; Inhalation; Exhalation

\textbf{Abstract:}Left heart catheterizations, coronary angiography, and
coronary interventions are important common cardiac procedures.
Performing a successful cardiac catheterization and intervention and
proper catheterization and device delivery is not always without
difficulties, especially in the context of calcification or vessel
tortuosity. Although there are some techniques to overcome this issue,
performing respiratory maneuvers (inspiration or expiration) can be
simply tried as the first step to increasing successful procedures which
is underreported and underutilized. The goal of this manuscript is to
review current literature regarding useful respiratory maneuvers that
can aid in successful left heart cardiac catheterization, coronary
angiography, and intervention for a successful
procedure.\textbf{~~~~~~~~~Introduction:}Left heart catheterization and
percutaneous coronary intervention (PCI) are very common cardiac
procedures performed in patients with valvular heart disease, suspected
coronary artery disease, or heart failure, patients. Although
significant advances have been done in terms of instrument designs and
improved technology to improve the success rate, respiratory maneuvers
are helpful to achieve higher success rates~(1, 2). In terms of PCI,
engaging coronary artery ostium and advancing balloons or stents can be
challenging.~~Stent delivery difficulties still occur with an incidence
of 2.7\% - 3.3\%~(3). Both inspiration and expiration could be utilized
to improve cardiac catheterization and device delivery during PCI due to
the mediastinal motion of the heart in each respiratory cycle. The goal
of this manuscript is to summarize respiratory maneuvers that can aid
physicians in improving diagnostic and interventional cardiac procedures
during a left heart catheterization, coronary angiography, and
intervention. This manuscript will not discuss respiratory maneuvers
that can be used during a right heart catheterization, structural heart
intervention, or electrophysiological studies.\textbf{~Respiratory
maneuvers that can aid during cardiac catheterization}Inspiration is
also a practical method to pass the brachiocephalic trunk and vertebral
artery as two critical points with probable catastrophic adverse events
including cerebral athero-embolic or thrombo-embolic complications. By
asking the patient to inspire deeply, the mediastinum and heart would be
caudally displaced leading to the strengthening of the aorta and
coronary arteries leading to facilitate passage of catheters or devices,
particularly during trans-radial catheterization. Engaging the ostium of
the right coronary artery (RCA) and certain left main take-offs can
improve with deep inspiratory maneuvers.~~Dahm and colleagues suggested
Amplatz~II catheter in the central position of ascending aorta adjacent
to the aortic valve can be successfully advanced by asking the patient
to take a deep breath and hold it and turning right the catheter into
the right sinus of Valsalva leading to the appropriate RCA cannulation
(Figure 1)~(4).~~The same~strengthening of the left main ostium can be
achieved but taking a deep breath particularly when the left main
take-off has a superior angle. This can not only aid Amlpatz catheters
but any catheters. Di Mario et al. indicated for proper RCA intubation,
breath-holding during deep inspiration can help cannulation after
appropriate engagement using 4.0 right Judkins catheter in left anterior
oblique view with rotation and slow pull-back catheter movement from a
right coronary sinus~(5).~The same maneuver can aid to engage the left
main when the catheter tip does not enter the left coronary cusp. In
difficult cases, deep inspiration can also facilitate pigtail catheter
advancement into the left ventricle for performing ventriculography.
After the advancement of the Pigtail catheter to the level of the aortic
valve and loop positioning to the left in the right anterior oblique
(RAO) projection and making a U shape by pushing the Pigtail catheter
against the aortic valve, deep inspiration can facilitate ventricular
entry.~By taking a deep breath, the heart will be displaced in a more
vertical position, making it easier to~advance~the Pigtail catheter~(6).
Respiratory maneuvers that are useful during the percutaneous coronary
intervention: Tortuosity is one of the most challenging anatomical
obstacles that can cause great difficulty during wire and stent
advancement~(7). Many techniques have been developed to overcome this
obstacle such as using buddy wire, stiffer wire, or extension catheters
with the deep sitting of the extension catheters. All the above methods
are other not mentioned complex interventions that are time and
cost-consuming and can cause vessel injury~(8-11). Simple respiratory
maneuvers such as inspiration or expiration can easily overcome this
obstacle in the majority of cases that should be attempted first before
proceeding with more advanced techniques due to ease of use without much
additional time or cost utilization. In the following paragraphs,
inspiratory and expiratory maneuvers are separated based on the vessels
that needed intervention. Native vessel tortuosity can be reduced by
deep inspiration while vein graft tortuosity can be reduced using
expiration. Detailed descriptions and reviews of cases are described in
the following two paragraphs.~\textbf{~Deep inspiratory maneuver to
overcome vessel tortuosity in native vessel coronary
intervention:}Inspiration has been reported to be a simple procedure
associated with a higher likelihood of stent delivery in tortuous
coronary vessels. Attaran et al. implemented this technique in four
cases with successful outcomes~(12). The first case was a 61-year-old
man with prior coronary artery bypass grafting (CABG) surgery of the
left internal mammary artery and saphenous vein to the left anterior
descending (LAD) and obtuse marginal (OM) branch, respectively. A 90\%
stenosis in the left circumflex (LCx) artery was found. After wiring,
and ballooning the lesion, the~2.5x18-mm
Endeavor\selectlanguage{ngerman}\textsuperscript{®}~stent could not be advanced due to the
presence of tortuosity. After performing deep inspiration by the
patient, successful stent advancement across the tortuosity was
achieved. (Figure 2). In another case, a 79-year-old man was admitted
with non-ST segment elevation myocardial infarction (NSTEMI)
with~~significant lesions found~~in the proximal and mid~~LAD. After
wiring and balloon dilatation, again stent could not be advanced until a
deep inspiratory maneuver was performed. (Figure 3 A \& B). In the third
case, a 61-year-old man presented with NSTEMI and 99\% stenosis in the
proximal first OM only after deep inspiration, the stent could be
advanced into the lesion. (Figure 3 C \& D). In their last
case,~~a~~90\% stenosis in the mid-distal RCA can only be stented after
deep inspiration.~~~(Figure 3 E \& F)~(12).~During inspiration, coronary
arteries move downward and this caudal movement is approximately equal
in both left and right coronary vessels~(13). Also, RCA and LAD, as two
anterior coronary arteries, move to the posterior position during
inspiration~(13, 14). This maneuver has been reported to decrease
coronary vessel tortuosity. Also, the heart and diaphragm move to a
vertical position during deep inspiration resulting in facilitated
device delivery~(12).~ ~ An expiratory maneuver that can facilitate
stent deliverability in tortuous vein grafts: In terms of expiration,
this respiratory maneuver has been associated with successful device
delivery in tortuous vein grafts. The so-called Reverse Movahed maneuver
was successfully published.~~The first~case reported a 61-year-old man
with prior CABG presenting with unstable angina. The OM graft had a
significant lesion requiring intervention. Several attempts failed to
advance a Promus stent (3.5x16 mm) (Boston Scientific). The patient was
instructed to perform a deep expiration leading to straightened
saphenous vein graft (SVG) and successful stent delivery (Figure
4)~(15). In~Figure 5, a schematic illustration of the ``Reverse Movahed
Maneuver'' is depicted~(16). A full expiration results in the upward
motion of the aorta and aortic arch containing the vein grafts
consequently causes strengthening the grafts and thereby facilitating
stent delivery while deep inspiration would have the opposite negative
effect.~~(15). Laramee et al. reported the effects of respiration on SVG
stenosis in two cases. The first patient was a 69-year-old man with
prior 11 years CABG history (SVG to LAD, OM branch of LCx, and posterior
descending branch of RCA with successful dilation of stenosis at
proximal anastomosis of the latter graft presented with unstable angina.
90\% tubular stenosis at the proximal anastomosis and 60\% stenosis at
the graft body were successfully dilated using appropriate balloon
catheters. However, a dynamic 80\% tubular narrowing adjacent to the
proximal segment was observed when the patient held his breath in full
inspiration. This narrowing was unrelated to the cardiac cycle and was
not affected by the administration of nitroglycerine or verapamil and
was just associated with the respiratory cycle (Figure 6 A \& B). The
second case was a 61-year-old man with prior 15 years of CABG history in
addition to previous PCI for stenosis in the SVG to RCA and native RCA
lesion distal to the graft site. Prior to angioplasty, 80\% tubular
obstruction was found adjacent to the proximal anastomosis of SVG to RCA
when the patient was inspired deeply. This dynamic obstruction
disappeared during exhalation and was not relieved either after
nitroglycerine intra-graft injection or balloon dilation (Figure 6 C \&
D). They suggested diaphragm descent during inspiration can produce
linear traction to a fixed area near the anastomosis in the context of
pre-existing pericardial adhesions or local scarring and fibrosis~(17).
In another case, a 52-year-old man presented with persistent exertional
chest pain. He had CABG two years prior to his current admission. Left
internal mammary artery was grafted to LAD and the saphenous vein was
anastomosed to diagonal and intermediate branches. Due to hemodynamic
instability, another vein graft was implemented in LAD distal to the
anastomosis of the left internal mammary artery with anastomosis of the
proximal end to the bypass supplying diagonal and intermediate branches
as well as another vein graft to RCA. Within two years of
post-operation, he was admitted two times for recurrent chest pain with
no identifiable causes. CAG in current admission revealed chronic
obstruction of bypass to the diagonal branch and left internal mammary
artery bypass. Interestingly, dynamic stenosis in the vein graft
supplying distal LAD was observed during deep inspiration but resolved
in expiration (Figure 7)~(18).\textbf{~Respiration associated
risks}Using this maneuver is not risk-free. Despite its rareness,
complications are reported in the literature. Biel et al. reported
coronary dissection during contrast injection in a 37-year-old man. The
patient underwent coronary intervention because of significant coronary
lesions. During contrast administration, the patient was inspired deeply
leading to the downward movement of the Amplatz catheter in the left
main coronary artery causing sub-intimal dissection. Fortunately, he
survived and was discharged from the hospital without
complications~(19). ~\textbf{Future perspective:}Performing a
respiratory maneuver (either inspiration or expiration) is a relatively
simple and inexpensive task that can be used in clinical settings to
increase device deliverability in difficult tortuous coronary vessels.
These maneuvers can reduce intervention time as well as radiation
exposure. However, some considerations should be made. The first and
most important issue is patient cooperation. Making deep inspiration
might not be practical, especially among patients sedated heavily. On
the other hand, the procedure itself must be taken into account.
Inspiration can be a useful technique for the intervention of naïve
coronary arteries. However, this maneuver can be associated with higher
failure rates when performing coronary interventions in vein grafts.
Thereby, the patient should be instructed to avoid a deep inspiration
and perform a gradual inhalation to prevent additional vessel kinking of
vein graft prior to full exhalation. Furthermore, extra caution should
be done during coronary interventions if the catheter tip moves
excessively and perform contrast injection after the completion of
inspiration, but not during the active phase of respiration, in order to
prevent a rare but significant complication, named arterial dissection.
It should be also kept in mind that the detection of vessel tortuosity
in vein grafts might not be completely obvious from two-dimensional
angiographic images. Thus, a high index of suspicion is required,
especially in terms of difficult device delivery in relatively normal
cine images.~ ~\textbf{Summary:}Cardiac catheterization and device
delivery during coronary interventions might not always be feasible,
especially in calcified lesions or tortuous vessels. Although several
techniques have been already proposed, they are associated with
complications and are invasive. However, performing inhalation or
exhalation during the procedure, as appropriate, and requested by the
interventionist might be associated with a higher successful balloon
and/or stent delivery and this simple and safe technique can be done at
the first step if a device delivery is encountered with
difficulties.~\textbf{Competing interests}: None\textbf{Abbreviations:}

\begin{itemize}
\tightlist
\item
  CABG: Coronary Artery Bypass Grafting
\item
  CAG: Coronary Angiography
\item
  LAD: Left Anterior Descending
\item
  LCx: Left Circumflex
\item
  NSTEMI: Non-ST segment Elevation Myocardial Infarction
\item
  OM: Obtuse Marginal
\item
  PCI: Percutaneous Coronary Intervention
\item
  RAO: Right Anterior Oblique
\item
  RCA: Right Coronary Artery
\item
  SVG: Saphenous Vein Graft
\end{itemize}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\selectlanguage{ngerman}\textbf{Figure 1. Right coronary artery (LAO 30°), Amplatz II located in
the central position of ascending aorta plus its tip in right sinus
Valsalva during deep inspiration while turning right to engage right
coronary artery, reported by Dahm et al. (4). (with permission from Herz
Journal)}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

\textbf{Figure 2. A: High grade lesion located in left circumflex
coronary artery and diaphragm position (white arrow) during expiration,
B: Small improvement in ostial angle of left circumflex coronary artery
and diaphragm position (white arrow) during inspiration, C: Successful
stent advancement through the target stenosis, D: Final angiographic
finding, reported by Attaran et al. (12). (with permission from Texas
Heart Institute Journal)}

\textbf{Figure 3. A: High grade lesion in mid-left anterior descending
coronary artery with slight lesion angle strengthening and diaphragm
position (white arrow) during inspiration, B: Successful stent
advancement through the target stenosis, C: High grade lesion located in
left circumflex coronary artery and slight lesion angle strengthening
and diaphragm position (white arrow) during inspiration, D: Successful
stent advancement through the target stenosis, E: High grade lesion
located in mid-to-distal right coronary artery and lesion angle
strengthening and diaphragm position (white arrow) during inspiration,
F: Successful stent advancement through the target stenosis, reported by
Attaran et al. (12). (with permission from Texas Heart Institute
Journal)}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image15/image15}

\end{center}
\end{figure}

\textbf{Figure 4. A: Two high grade lesions in saphenous vein graft
supplying obtuse marginal branch, B: Vein graft location during
expiration showing upward heart position and strengthening of vein graft
(black arrows), C: Vein graft location during inspiration showing
downward heart position and more tortuosity of vein graft (black
arrows), D: Final angiographic outcome, reported by Movahed (15). (with
permission from International Journal of Angiology)}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image16/image16}

\end{center}
\end{figure}

\textbf{Figure 5. Schematic illustration of Reverse Movahed Maneuver
showing upward moving of aorta and aortic arch during expiration
(straight line) results in vein graft strengthening and downward aorta
movement in inspiration (dashed line) leading to increased vein graft
tortuosity and kinking, reported by Movahed(15). (with permission from
International Journal of Angiology)}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image17/image17}

\end{center}
\end{figure}

\textbf{Figure 6. A: Coronary angiogram of vein graft to posterior
descending branch during expiration, B: Coronary angiogram of vein graft
to posterior descending branch during a full inspiration showing
inhalation induced narrowing (arrowhead), C: Coronary angiogram of vein
graft to distal right coronary artery showing 30\% narrowing as well as
diffuse narrowing after proximal anastomosis, D: Coronary angiogram of
vein graft during full inspiration showing remarkable focal narrowing in
the proximal vein graft (arrowhead), reported by Laramee et al. (17).
(with permission from Catheterization and Cardiovascular Diagnosis)}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image18/image18}

\end{center}
\end{figure}

\textbf{Figure 7. A: Coronary angiography image showing venous graft to
left anterior descending coronary artery in expiration, B: Coronary
angiography image showing dynamic obstruction of vein graft to left
anterior descending coronary artery during inspiration suggesting
respiratory dependent vein graft occlusion, reported by Wilhelm et al.
(18). (with permission from The Annals of Thoracic Surgery)}

\textbf{References}

1. Giannini F, Candilio L, Mitomo S, Ruparelia N, Chieffo A, Baldetti L,
et al. A practical approach to the management of complications during
percutaneous coronary intervention. JACC: Cardiovascular Interventions.
2018;11(18):1797-810.

2. Tavakol M, Ashraf S, Brener SJ. Risks and complications of coronary
angiography: a comprehensive review. Global journal of health science.
2012;4(1):65.

3. Hynes B. Enhancing Back-up Support During Difficult Coronary Stent
Delivery: Single Center Case Series of Experience with the Heartrail II
Catheter. Journal of Invasive Cardiology. 2011;23(3).

4. Dahm J, Wolpers H, Becker J, Hansen C, Felix S. Transradial access in
percutaneous coronary interventions. Herz. 2010;35(7):482.

5. Di Mario C, Sutaria N. Coronary angiography in the angioplasty era:
projections with a meaning. Heart. 2005;91(7):968-76.

6. Kern MJ. The Cardiac Catheterization Handbook.

7. Tan K, Sulke N, Taub N, Sowton E. Clinical and lesion morphologic
determinants of coronary angioplasty success and complications: current
experience. Journal of the American College of Cardiology.
1995;25(4):855-65.

8. Chawla R, Ahamad W, Sharma V. Techniques to overcome difficulty in
device deliverability to lesion in complex PCI. Current cardiology
reviews. 2020;16(2):117-24.

9. Peels HOJ, van Boven AJ, den Heijer P, Tio RA, Lie KI, Crijns HJ.
Deep seating of six French guiding catheters for delivery of new
Palmaz-Schatz stents. Catheterization and cardiovascular diagnosis.
1996;38(2):210-3.

10. Von Sohsten R, Oz R, Marone G, McCormick D. Deep Intubation of 6
French Guiding Catheters for Transradial Coronary Interventions. The
Journal of Invasive Cardiology. 1998;10(4):198-202.

11. Bartorelli AL, Lavarra F, Trabattoni D, Fabbiocchi F, Loaldi A,
Galli S, et al. Successful stent delivery with deep seating of 6 French
guiding catheters in difficult coronary anatomy. Catheterization and
Cardiovascular Interventions. 1999;48(3):279-84.

12. Attaran RR, Butman S, Movahed MR. Going around the bend: deep
inspiration facilitates difficult stent delivery in the native coronary
arteries. Texas Heart Institute Journal. 2011;38(3):270.

13. Shechter G, Resar JR, McVeigh ER. Displacement and velocity of the
coronary arteries: cardiac and respiratory motion. IEEE transactions on
medical imaging. 2006;25(3):369-75.

14. McLeish K, Hill DL, Atkinson D, Blackall JM, Razavi R. A study of
the motion and deformation of the heart due to respiration. IEEE
transactions on medical imaging. 2002;21(9):1142-50.

15. Movahed MR. Reverse Movahed Maneuver: Maximal Expiration Maneuver
during Saphenous Vein Graft Intervention for Facilitated Balloon and
Stent Delivery in Tortuous Vein Grafts--A Novel Technique. International
Journal of Angiology. 2016;25(05):e66-e9.

16. Movahed MR. Facilitating Stent Advancement by Using the Reverse
Movahed's Maneuver (Maximal Expiration) During Tortuous Vein Graft
Intervention. Cardiovascular Interventions. 2020;13(1):139-40.

17. Laramee LA, Hartzler GO. Effect of respiration on angiographic
assessment of saphenous vein graft stenoses. Catheterization and
cardiovascular diagnosis. 1989;17(4):243-5.

18. Wilhelm MJ, Igual M, Mury R, Tavakoli R, Pescia R, Vettiger B, et
al. Respiratory dependent compression of a venous bypass: therapy by
stenting. The Annals of thoracic surgery. 2005;80(5):1904-7.

19. Biel SI, Krone RJ. Left coronary artery dissection with an
amplatz-shaped catheter: the role of vigorous inspiration during
contrast injection. Chest. 1984;86(4):640-1.

\selectlanguage{english}
\FloatBarrier
\end{document}

