To clarify the phonocardiographic features of the murmur in cases of supracristal ventricular septal defect (VSD), we compared phonocardiograms with échocardiographie findings and data obtained by cardiac catheterization in 37 consecutive patients. The configurations of the systolic murmur were classified into three types: pansystolic murmur in 22 (59%), murmur with late systolic accentuation in 11 (30%) and early systolic murmur in 4 (11%). The shunt ratio from left to right in the group with pansystolic murmur was significantly larger than those in the other two groups (17 ± 10 vs. 9 ± 10 and 7 ± 8%, means ± SD, p < 0.05). Aortic valve prolapse was significantly less frequent in the group with early systolic murmur than in the other two groups (0 vs. 68 and 64%, p < 0.05). Large aortic valve prolapse, in which the valve lost its mobility because of complete herniation of the valve into the defect, was more frequent in the group with pansystolic murmur than in that with late systolic accentuation (45 vs. 9%, p < 0.05). In 3 of 4 patients with early systolic murmur, the flow across the defect, recorded by continuous-wave Doppler echocardiography, was interrupted in mid-systole and showed a similar pattern to that of the murmur recorded by phonocardiography. On the other hand, it continued until the second heart sound in the other two groups. We conclude that the shunt ratio and dynamic behavior of the aortic valve have important effects on the characteristics of the pattern of systolic murmur in cases of supracristal VSD.
The ability of electrocardiograms (ECG), vectorcardiograms (VCG) and body surface potential maps (BSPM) to predict left ventricular asynergy was evaluated in 100 consecutive patients with coronary artery disease, 51 patients (51%) of whom with and 49 (49%) without ventricular asynergy. With regard to the diagnosis of ventricular asynergy, the electrocardiographic sign of pathologic Q waves had a sensitivity of 58.8%, a specificity of 44.9%, a positive predictive value of 52.6%, and a negative predictive value of 51.2%. The vectorcardiographic pattern of myocardial infarction gave the corresponding predictive value of 66.7, 46.9, 56.7 and 57.5%, respectively. Finally, the so-called abnormal ‘early reversal’ BSPM - the abnormal BSPM pattern with absolute value of potential minimum over potential maximum in the early ventricular depolarization - achieved the corresponding predictive value of 84.3, 71.4, 75.4 and 81.4% respectively. Our data suggest that: (1) BSPM is useful in the detection of left ventricular asynergy, and (2) BSPM is superior to ECG and VCG in the diagnosis of left ventricular asynery.
The present study was performed in order to evaluate, by two-dimensional echocardiography, cardiac morphology in terms of chamber dimensions, as well as left ventricular (LV) volume and mass, in patients with systemic sclerosis (n = 30). Measurements were compared with those from age- and sex-matched controls (n = 48). The most prominent finding in patients was increased LV wall thickness. There was also a tendency in patients to have reduced LV cavity dimensions. Thus, interventricular septum (p < 0.0005), LV posterior wall (p < 0.05) and the wall thickness/cavity dimension ratio (p < 0.0005) were increased in patients compared to controls, as was LV mass index (p < 0.005). The stroke volume (p < 0.005), end-diastolic volume (p < 0.01) as well as end-diastolic volume index (p < 0.05) were decreased in the patient group, but not when body surface area was considered. Blood pressure, ejection fraction and end-systolic wall stress were similar in the two groups. We conclude that our patients with systemic sclerosis had a nondilated LV cavity, with an increased wall thickness and relative LV mass. LV hypertrophy was not explained by systemic hypertension and may therefore be secondary to myocardial fibrosis.
Two patients, with communicating and noncommunicating Stanford type A acute aortic dissection each, are reported with anatomic and hemodynamic features diagnosed by single-plane transesophageal echocardiography (TEE) with color flow imaging. TEE demonstrated a communicating dissection, more in detail than aortography and computed tomography, with an intimai flap, the extent of dissection, the dissecting intimai flap prolapse through the aortic valve during diastole, flow patterns in the true and false lumina, presence and absence of aortic valvular regurgitation, and absence of pericardial effusion. TEE showed the presence of a noncommunicating (variant) dissection, which was nondiagnostic by magnetic resonance imaging and aortography before surgery, with intramural thrombus (hematoma) formation and its extent and location, accurate measurement of aortic wall thickness, and the presence of an intimai flap or intramural blood flow. In addition, TEE also permitted evaluation of global and regional systolic performance. Therefore, TEE can be recommended as the first-line modality of choice for an early diagnosis of an acute thoracic aortic dissection.
To assess the safety of intravenous adenosine myocardial perfusion imaging in the elderly, we compared the outcome of younger and older patients from a cohort of 774 consecutive patients. Adenosine was administered as a 0.14mg/kg/min constant infusion for 6 min. There were 596 (77%) patients aged less than or equal to 70 years (group 1) and 178 (23%) patients aged >70 years (group 2). The incidence of noncardiac side effects (such as flushing, headache, etc.) and cardiac side effects (such as chest pain, ST segment depression, and hypotension) was not different between the two groups. There was a statistically nonsignificant increase in 2nd- and 3rd-degree atrioventricular block and in the discontinuation rate of adenosine in older patients. This was not associated with a clinically relevant adverse outcome. Other than age, there were no other variables predictive of differences in adverse outcome. The use of adenosine for myocardial perfusion imaging is as safe in younger patients as it is in older patients. There is a higher incidence of atrioventricular block and adenosine discontinuation in the elderly, but it is not associated with a clinically relevant adverse outcome.
Myocardial infarction results in wall motion abnormalities potentially associated with abnormal intracavitary blood flow patterns in the left ventricle. Magnetic resonance (MR) technique allows three-dimensional quantitative mapping of blood flow velocities. We performed three-dimensional MR velocity mapping in a modified left ventricular long axis plane in 10 patients with previous myocardial infarction and milder reduction of the left ventricular function. The early diastolic inflow pattern did not differ qualitatively from earlier published findings in normal subjects. At systole, a flow pattern similar to that found in normals was observed in 7 of our patients. In the remaining 3 patients two types of abnormal systolic flow patterns were observed resulting in a paradoxical flow directed towards the apex. The location and timing of the abnormal flow allowed a distinction between paradoxical flow into an aneurism and paradoxical flow towards an akinetic apex. Compared with other techniques currently available, three-dimensional MR velocity mapping permits a more detailed description and understanding of abnormal flow patterns caused by wall motion injury in patients with myocardial infarction. This potential of the method suggests that three-dimensional MR phase velocity mapping may become a useful tool in assessment of significance and treatment of regional left ventricular dysfunction.
The nuclear probe (NP) is a single-crystal nonimaging nuclear detector which provides accurate measurements of relative left ventricular volume and ejection fraction (EF). The purpose of this study was to assess the stability of end-diastolic volume (EDV), end-systolic volume (ESV), and the end-systolic pressure-volume relationship (ESPVR) during repeated pressure-volume loop measurements and after moving and repositioning the probe. Eleven patients had an equilibrium radionuclide angiogram performed followed by cardiac catheterization. EDV, ESV, and ESPVR were calculated from heart rate, cardiac output, and NP-derived EF. These measurements were repeated without moving the probe and after moving and repositioning it over the patients' chests. There was a good correlation between equilibrium radionuclide angiogram EF and probe EF (r = 0.86). There were no significant changes in EDV, ESV, or ESPVR during the repeated measurements or after repositioning the probe. It is concluded that the NP can provide accurate and reproducible measurements of EDV, ESV, and ESPVR for cardiac catheterization laboratory interventional studies.
The clinical value of exercise-induced ST segment depression (STx) and R wave amplitude (R(x)) in supraventricular extrasystoles, in the preceding sinus beat (STs and R(s) respectively), as well as the combination of the differences between the two of them (STx-s + R(x-s)) was studied in 96 patients with angiographically documented coronary artery disease (CAD) (group A) - 34 with myocardial infarction (group A(1)) and 62 without (group A(2)) - compared to 37 subjects with normal coronary arteries (group B). ST,, had greater values in group A than in group B (0.4 +/- 0.5 vs. -0.2 +/- 0.4 mm; p < 0.0001) as did R(x-s) (0.6 +/- 0.5 vs. -1.1 +/- 0.8 mm; p < 0.0001) and their combination (1.0 +/- 0.7 vs. -1.3 +/- 1.0 mm; p < 0.0001), while STx-s had similar values in groups A(1) and A(2) but R(x-s) values were higher in A(1) than in A(2) (P < 0.001). R(x-s), STx-s, and especially their sum (STx-s + R(x-s)) value was directly related to the number of vessel disease(0.7 +/- 0.5 mm for 1-, 1.1 +/- 0.7 mm for 2-, and 1.4 +/- 0.7 mm for 3-vessel disease; p < 0.0001), while it was significantly higher in patients with left ventricular dysfunction (-0.01 +/- 1.2 vs. 1.5 +/- 0.8 mm; p < 0.0001). The value of (STx-s + R(x-s)) improved sensitivity compared to the sinus signs (from 66 to 87%) as well as specificity (from 82 to 95%) for CAD detection, while for detection of left ventricular dysfunction it improved sensitivity (from 85 to 91%)with no gain in specificity. It is concluded that ST segment depression and R wave amplitude changes in exercise-induced supraventricular extrasystoles may be of greater diagnostic significance than in sinus beats, for the detection of CAD and left ventricular dysfunction.
To determine the prognostic value of left ventricular (LV) cavity dilatation in patients that exhibit an increased lung uptake of thallium during exercise thallium testing, we followed 167 patients who had either increased thallium lung uptake, LV cavity dilatation or both for a mean period of 2 years after testing. Of 157 patients with increased thallium lung uptake, 87 with a normal LV cavity size had 18 events (21%), while 70 with a dilated LV cavity had 31 events (44%) (p < 0.005). When only cardiac deaths and myocardial infarctions were considered as adverse events, 10 of 11 events (91 %) occurred in the patients with both increased thallium lung uptake and LV cavity dilatation (p < 0.001). Isolated LV cavity dilatation was uncommon in our study group. We conclude that the presence of LV cavity dilatation in patients presenting an abnormal lung uptake of thallium during exercise identifies a subgroup at higher risk for future cardiac events.
To determine the changes in left ventricular diastolic filling velocity profiles after aortic valve replacement and their relation to clinical functional status, 48 consecutive patients with severe aortic stenosis underwent preoperative cardiac catheterization and Doppler echocardiographic assessment before and 3 months after surgery. The patients were divided into two groups according to the functional class. Group I included 15 patients in New York Heart Association functional class I or II, and group II consisted of 33 patients in functional class III or IV, Before the operation, the left ventricular peak early filling velocity was higher, and the later atrial filling velocity was lower in group II than in group I, The ratio early/late filling velocities was higher and the deceleration time was shorter in group II patients. For overall 48 patients, the Doppler-derived left ventricular filling variables correlated significantly with functional class, pulmonary artery pressure, and left ventricular systolic function. After aortic valve replacement, early filling velocity (71 +/- 22 vs. 85 +/- 22 cm/s; p < 0.001) and early-to-late filling velocity ratio (0.70 +/- 0.14 vs. 0.88 +/- 0.23; p < 0.001) increased in group I, but decreased in group II (early filling velocity 92 +/- 26 vs. 80 +/- 25 cm/s; early-to-late filling velocity ratio 1.60 +/- 0.90 vs. 0.90 F 0.30; all p < 0.001). The improvement in functional class was closely related to changes in early-to-late filling velocity ratio (p < 0.02), but did not correlate with myocardial mass regression and changes in left ventricular systolic function. This prospective study indicates that left ventricular diastolic filling is often impaired in patients with aortic stenosis and contributes to the reduced functional capacity. Aortic valve replacement alters favorably the left ventricular diastolic function and, therefore, the patients' symptomatology.
Acute myocardial ischemia decreases conduction velocity through the ischemic myocardium and may produce QRS prolongation on the surface electrocardiogram. To investigate the effect of exercise-induced myocardial ischemia on the QRS duration, 124 patients who underwent diagnostic cardiac catheterization and exercise thallium-201 scintigraphy were studied. Seventeen patients had normal coronary arteries and 107 had coronary artery disease. QRS duration decreased with exercise in patients with normal coronary arteries (-3.7 ms, confidence interval -7.7 to 0.3) but increased in patients with coronary artery disease; exercise-induced QRS prolongation was directly related to the number of vessel disease (1.2 ms in patients with one-vessel disease; 8.7 ms in patients with two-vessel disease, and 10.5 ms in patients with three-vessel disease, p < 0.001). Likewise, exercise-induced QRS duration decreased in patients without exercise-induced reversible perfusion defects (-1.3 ms, confidence limits -2.8 to 0.2) but increased in patients with exercise-induced perfusion defects (9.7 ms in patients with one perfusion defect; 13.6 ms in patients with two perfusion defects, and 16.3 ms in patients with three perfusion defects, p < 0.001). Exercise-induced QRS prolongation was best related to the number of exercise-induced perfusion defects than to the number of vessel disease, p < 0.001. In conclusion, exercise-induced QRS prolongation in patients with coronary artery disease was directly related to the number of vessel disease and to exercise-induced perfusion defects. This QRS prolongation was better related to the number of reversible perfusion defects than to the number of vessel disease. Thus, exercise-induced QRS prolongation in patients with coronary artery disease may be a marker of exercise-induced myocardial ischemia.
Analysis of the transthoracic mitral flow velocity pattern is widely used for the noninvasive evaluation of the left ventricular diastolic function and left atrial pressure. On the other hand, transesophageal measurements of the pattern are useful for the intraoperative monitoring of cardiac performance. However, it is unclear whether transesophageal tracings of the mitral flow velocity pattern provide information comparable with transthoracic tracings in subjects with and without cardiac disorders. To clarify whether transthoracic and transesophageal measures of the mitral flow velocity pattern may be used to substitute each other, they were compared with each other in 14 normal volunteers and 19 patients with a variety of cardiac disorders. Results were as follows. (I)The transesophageal mitral peak early diastolic and late diastolic flow velocities (E and A velocities) were about 15% less than the transthoracic measurements. The ratio of the peak early to late diastolic flow velocities (E/A ratio) obtained by the transesophageal approach showed good correspondence to that obtained by the transthoracic approach. (2) Isovolumic relaxation time (IVRT) and deceleration time of early diastolic filling wave (DT), if corrected for heart rate, showed no significant difference between transesophageal and transthoracic measurements. We concluded that the transesophageal measurements off and A velocities are about 15% less than the transthoracic measurements, but that transesophageal measurements of E/A ratio, IVRT and DT may be used as substitutes of transthoracic measurements.
This study aimed at assessing the value of Tl-201 scans to detect restenosis following coronary stent implantation. Of 47 patients who had a coronary stent implantation, 38 with 44 stent implants underwent stress perfusion imaging and repeat coronary angiography 3 months after the procedure. The angiographic restenosis rate was 31.8%. A perfusion defect on stress image which showed redistribution at rest was considered a positive scan. Thallium scans were found to have a sensitivity of 71% and a specificity of 93.3%. A non-reperfusing defect was observed in all false-negative studies. Normal myocardial perfusion always co-existed with the patent stents, with no significant luminal compromise. An unimpaired perfusion on scan strongly suggested adequate patency of the stented arterial segment.
A consecutive series of 174 patients with acute myocardial infarction (MI) was prospectively monitored for pericardial friction rub to diagnose pericarditis (PER) and had three echocardiograms on days 1, 3 and 10 of hospitalization, to detect a pericardial effusion (PE). The relationship of heparin therapy to PER and PE was also studied. Patients with PER (n = 41, 23.6% of total) had a higher rate of anterior MI (65.9 vs. 36.8%, p < 0.001), heparin therapy (100 vs. 84.2%, p < 0.001) and PE (34.1 vs. 15.0%, p < 0.01) than those without PER; also the PE on day 1 was smaller in the patients with than without PER (0.5 +/- 1.2 vs. 2.3 +/- 2.7 mm, p < 0.005), but not different on days 3 and 10. Patients with PE (n = 34, 19.5% of total) differed from those without PE only in the incidence of PER (41 vs. 19%, p < 0.01). PE increased between days 1 and 3 (1.5 +/- 2.3 vs. 3.7 +/- 5.3 mm, p < 0.05), but was not different between days 3 and 10, during which it was 3.8 +/- 3.3 mm. No higher rate of complications was noted in connection with PER or PE, either in the hospital or for a mean of 20 months after discharge. Heparin therapy in patients with PER and PE did not have an untoward effect. Hence, PER and PE were frequent in patients with MI; their emergence even in patients receiving heparin did not alter the expected clinical outcome, both in the hospital and during a mean 20-month follow-up after discharge.
The effect of upright posture on hemodynamics of patients with dual chamber (DDD) pacemakers has been largely unexplored. The postural hemodynamic responses in 27 patients with DDD pacemakers were assessed by impedance cardiography calculations of stroke volume and sphygmomanometer measurements of blood pressure. Twenty patients with complete heart block (5 with heart failure) were studied in the VDD mode and 7 patients with sick sinus syndrome and severe chronotropic incompetence (fixed heart rate) were assessed in DVI (4) or VDD (3) modes. In contrast to the responses observed in normals, pacemaker patients' orthostatic responses included: (1) a reduction in systolic, diastolic and mean blood pressures; (2) fixed stroke volume in sick sinus syndrome or heart failure patients, and only modest stroke volume reductions in the remaining patients, and (3) a reduction in systemic vascular resistance. Thus, when assuming the upright position, DDD patients develop a hypotensive response with paradoxical maintenance of stroke volume. Even when AV synchrony is preserved, orthostatic hemodynamic abnormalities are detectable independently of the underlying heart disease. We assume that these abnormalities occur because of the altered autonomic state (autonomic dysfunction) induced by the abnormally depolarized ventricles.
In patients with systemic hypertension, the adaptation of left ventricle to pressure overload may manifest with four geometric patterns on the echocardiographic tracing, and each of them seems to reflect a different hemodynamic profile and to have a different prognostic value. The aim of this study was to analyze how the left ventricle adapts to pressure overload in a group of adult patients with valvular aortic stenosis, compared to a group of hypertensive subjects. Left ventricular (LV) mass indexed for body surface area and relative wall thickness (2 x posterior wall thickness/LV end-diastolic diameter) were measured on M-mode echo in 100 patients with essential hypertension of different severities and 80 patients with isolated valvular aortic stenosis (mean valve area by Doppler: 0.67 +/- 0.2 cm(2)). LV mass index was significantly higher in aortic stenosis compared to hypertensive patients (187 +/- 50 vs. 128 +/- 42 g/m(2); p < 0.001); mean wall thickness was also higher in the aortic stenosis group (13.6 +/- 2 vs. 11.3 +/- 2.2 mm; p < 0.01) while LV end-diastolic diameter and LV fractional shortening were similar in the two groups. Among hypertensive patients, LV mass and relative wall thickness were normal in 33%, whereas 22% had increased relative wall thickness with normal LV mass (concentric remodeling), 32% had increased mass and increased relative wall thickness ('typical' concentric hypertrophy) and 13% had increased LV mass with normal relative wall thickness (eccentric hypertrophy). Among aortic stenosis patients, none had a normal LV anatomy, 11% showed a concentric remodeling pattern, 69% a concentric hypertrophy and 20% an eccentric hypertrophy. It is of interest that most aortic patients with eccentric hypertrophy (14 out of 16) had a clinical picture of severe congestive heart failure associated with a significant LV dilation with a marked reduction of LV fractional shortening and more severe valve stenosis. In conclusion, compared to hypertensive patients, aortic stenosis patients show a larger LV hypertrophy probably indicating a higher hemodynamic overload. Furthermore, other than with hypertension, the presence of eccentric hypertrophy in patients with aortic stenosis usually indicates a more severe disease. The evaluation of the geometric pattern of the left ventricle may add useful information to the clinical evaluation of patients with chronic pressure overload.
Inspiratory diastolic forward flow in the pulmonary artery was monitored by pulsed Doppler echocardiography in a patient with severe tricuspid regurgitation following closure of a sedundum atrial septal defect. An inspiratory augmentation of the regurgitant murmur was not evident in this patient (absence of the Carvallo sign). Pulsed Doppler echocardiography and color flow mapping revealed a decrease in both the peak velocity and flow area of the tricuspid regurgitation in the right atrium during inspiration, associated with an increased mean right atrial pressure. It is possible that a transient inspiratory elevation of the right atrial pressure in excess of the pulmonary artery pressure may have resulted in diastolic forward flow in the pulmonary artery, thereby decreasing the regurgitant flow from the right ventricle to the right atrium, and eliminating the Carvallo sign.
Temporal variations of mitral regurgitant jet areas are never taken into account in the color Doppler grading of the regurgitation which relies on measurements of maximal areas alone, with variable success rate. The purpose was to study if the grading would be improved by averaging measurements of jet areas according to their temporal variations. Doppler grading relied on three-dimensional measurements of length and height of jet areas in the long axis and of their width in the short axis views, with calculation of the total regurgitant index. It was compared with angiographic grading in 40 patients with mitral regurgitation. Maximal areas were retained to calculate the maximal index when only less than 10% variation occurred throughout systole. In case of temporal variations, the index was weighted by averaging the measurements over early, mid and end systole. No temporal variation was noted in 26 patients (65%) who all but 3 were satisfactorily graded by the maximal index. In 14 patients (35%), temporal variations required calculation of the weighted index: it modified the grading for 11 patients (78.5%) all of mild and moderate grades overestimated by the maximal index, with success in 10 (90.9%), increasing the correlation coefficient between angiographic and Doppler grading from 0.79 (maximal) to 0.93 (weighted). Grading from maximal areas is convenient for severe and for most cases of regurgitation without temporal variations. Errors intervene for mild and moderate grades in case of temporal variations, and may be avoided by combining fourth temporal with spatial three-dimensional Doppler data.
This report describes the normal echocardiographic coronary wall features of the mid and apical segments of the left anterior coronary artery in 30 normal subjects as revealed by high-frequency transthoracic echocardiography. Both mid and apical segments were imaged in all subjects in short and long axis orientation. Their greatest length (as seen within the sector of a single frame) was respectively 21 +/- 6 and 17 +/- 5 mm, and the diameter and circumference were respectively 2.3 +/- 0.4 and 6.7 +/- 1 mm in the mid and 2.0 +/- 0.1 and 6.5 +/- 1 mm in the apical segment. In all subjects, the arterial wall was imaged as a smooth and regular echoreflective linear structure. In the mid segment of the 16 most echogenic subjects (53%), we distinguished a three-layered wall with a very thin and apparently noncontinuous line adjacent to the lumen, which was separated from the more echoreflective linear echo by a hypoechogenic space. A homogeneous red color-coded flow, filling the arterial lumen, was found in 14 of the 30 subjects (46%), in 8 of whom a spectral flow signal was also detected. These preliminary findings indicate that, in the near future, this method could become an effective part of the noninvasive armamentarium for the evaluation of coronary vessels and with further technological advances (e.g. an increase in carrier frequency) the quantitative noninvasive data concerning the thickness of the coronary wall may become a real possibility.
To clarify the characteristics of the jugular venous pulse and its genesis in Ebstein's anomaly, 7 patients with Ebstein's anomaly and 10 normal subjects were studied using phonomechanocardiography and M-mode, two-dimensional, and Doppler echocardiography. A right atrial pressure study was also performed in 4 of the 7 patients. There were 5 patients with predominant tricuspid regurgitation and 2 with a mild anomaly. A large 'c' wave was observed in the jugular venous pulse in 5 patients and in the right atrial pressure curve in 4. The upstroke of the jugular 'c' wave preceded that of the carotid arterial pulse by 35.0 ms. The interval from QRS complex onset to tricuspid valve closure was significantly longer and the dosing excursion of the anterior tricuspid leaflet significantly larger in the patients than in the normal subjects. There was a trend for a positive correlation between QRS onset to jugular 'c' wave peak interval and QRS onset to tricuspid valve closure interval. The jugular 'c' wave height exhibited significant positive correlations with the size of the atrialized right ventricle and the mitral to tricuspid anulus distance, but it showed no obvious correlation with the grade of tricuspid regurgitation. These results suggest that augmentation of the jugular 'c' wave is characteristic of Ebstein's anomaly and that it correlates closely with the severity of displacement of the tricuspid valve.
