(1) Death or the serious nonfatal complications of myocardial infarction and/or cerebral embolus occur in an unacceptable 1.5% of all patients examined; the occurrence is ten times higher in institutions performing fewer than 100 examinations/year than in those doing more than 400/year. Reported death rates vary more than one hundred fold, from 0.05% to 8%.1, 2 (2) The serious complications, primarily thrombotic, occur eight times more frequently when the percutaneous transfemoral approach is used. (3) Fifty-five percent of laboratories using a femoral method do fewer than 50 cases/year. As volume increases, the complication disparity between the brachial and the femoral approach dramatically narrows to near equality.The reported complication rates are unacceptably high. Two clearly evident factors emerge: (1) the competence of the operator (training and main-

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In five patients with total A-V block studied by thermodilution, infusion of 10 to 25 ml of cold saline into the right ventricle over a period of several seconds resulted in lowering right atrial temperature usually 0.25 to 0.7 second after P waves not followed in normal temporal sequence by QRS complexes. In three of these patients, in whom left heart catheterization was performed, the same phenomenon could be detected during and after infusion of cold saline into the left ventricle while temperature was measured by a thermistor introduced by transseptal route into the left atrium. Isolated atrial contractions, although capable of partially closing the A-V valves as indicated by the higher ventricular than atrial pressure, lead to atriogenic reflux from the ventricle. Ventricular contraction, however, whether normal or extrasystolic, produced efficient closure of the A-V valves.

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