Diastolic closure rate of normal mitral valve

Comparative accuracy of two-dimensional echocardiography and Doppler pressure half-time methods in assessing severity of mitral stenosis in patients with and without prior commissurotomy

This study was undertaken to compare the accuracies of the two-dimensional echocardiographic (2DE) and Doppler pressure half-time methods for the noninvasive estimation of cardiac catheterization measurements of mitral valve area in patients with pure mitral stenosis both with and without a previous commissurotomy. Data were retrospectively obtained from 74 consecutive patients who underwent cardiac catheterization within a 30 month period for evaluation of mitral stenosis, and who had two-dimensional echocardiograms performed before catheterization. Six patients (8.1%) had technically inadequate 2DE images and their data were excluded from analysis. Two of these patients had undergone commissurotomy, while the remaining four had not. Continuous-wave Doppler echocardiographic examinations were attempted in 45 patients and adequate measurements of pressure half-times were obtained in all patients studied. Mitral valve area by two-dimensional echocardiography was measured as the planimetered area along the inner border of the smallest mitral orifice visualized during short-axis scanning, while pressure half-time was calculated as the interval between the peak transmitral velocity and velocity/square root 2 as measured from the envelope of the Doppler spectral signal. Calculations from catheterization represented the minimal valve area at rest as derived from the Gorlin formula with the use of pressure gradients and thermodilution measurements of cardiac output. Thirty-seven of the patients had had a previous mitral commissurotomy a mean of 11.2 +/- 5.4 years before, while the remaining 37 patients were previously unoperated. Mean valve area as determined at catheterization for the total group of patients ranged from 0.37 to 2.30 cm2 (mean = 1.08 +/- 0.42 cm2).(ABSTRACT TRUNCATED AT 250 WORDS)

The relationship of pulmonary artery wedge pressure to the posterior aortic wall echocardiogram in patients free of obstructive mitral valve disease

Aortic wall echocardiograms were obtained simultaneously with pulmonary artery wedge pressures (PAWP) in 21 patients free of obstructive mitral valve disease. There was a significant (p < 0.001) negative correlation between the fraction of passive posterior aortic wall motion occurring in the first third of diastole (the atrial emptying index--AEI) and the pulmonary artery wedge pressure (r = -0.91). The AEI for patients with normal PAWP (less than or equal to 12 mm. Hg) was 0.94 +/- 0.06 (mean +/- S.D.) compared with 0.61 +/- 0.20 for those with abnormal PAWP (> 12 mm. Hg). No patient with a normal PAWP had an AEI < 0.80, and no patient with a PAWP > 18 mm. Hg had an AEI > 0.66. These data suggest that analogous to the reported use of the AEI to estimate severity of mitral obstruction, the index provides a noninvasive measure of left ventricular filling pressure when the mitral valve is normal.

Changes of cardiac output caused by aging: an impedance cardiographic study

The various parameters of cardiac output were studied in 132 healthy subjects from 20 to 89 years of age by impedance cardiography. This noninvasive method supplied data that were similar to those found by others by dye dilution methods. All parameters of cardiac output decrease with age. However, we found a difference between the two sexes in the rate of decrease of the cardiac index: women had a more marked drop at an earlier age and then a steady course, while men had a progressive decrease from the youngest to the oldest group.

The influence of left ventricular late diastolic filling on the A wave of the left ventricular pressure trace

To study the influence of left ventricular (LV) late diastolic filling on the A wave of the LV pressure, simultaneously recorded echocardiographic LV dimensions and high-fidelity LV pressure measurements were taken in 24 patients. Group 1 comprised eight patients without LV hypertrophy (LVH) and LV end-diastolic pressure (LVEDP) less than or equal to 13 mm Hg. Group 2 comprised 16 patients with LVH secondary to aortic stenosis, idiopathic hypertrophic subaortic stenosis, or hypertension and increased LVEDP. Patients in group 2 had significantly thicker left ventricles, decreased mitral E-to-F slopes, and larger A waves in the LV pressure curve. On the basis of end-diastolic chamber stiffness, we divided group 2 into two populations: 12 patients (group 2A) with end-diastolic chamber stiffness similar to that in group 1, and four patients (group 2B) with markedly elevated end-diastolic chamber stiffness. Patients in group 2A had a larger atrial contribution to LV filling than those with markedly abnormal stiffness (group 2B). Therefore, in LVH an increased A wave in the LV pressure may be related to either elevated end-diastolic chamber stiffness or augmented left atrial volume transport.

Echocardiographic pattern of posterior mitral valve leaflet movement after mitral valve repair

The pattern of movement of the posterior leaflet at the time of opening of the stenosed mitral valve has been described as either anterior or posterior in direction. In 32 patients who underwent mitral annuloplasty, the anatomical features of the mitral apparatus were correlated with the postoperative echocardiographic pattern of movements of the posterior leaflet. Anterior movement of the posterior leaflet was associated with extensive disease of this leaflet, and posterior movement with minimal disease. No relation was found between valve orifice or anterior leaflet mobility and the pattern of movement of the posterior leaflet.

Changing diastolic closure rates (E to F slopes) in a patient with mitral stenosis: a case report

A patient with mitral stenosis and atrial flutter was found to have a normal diastolic closure rate (E to F slope). Following cardioversion, the typical echocardiographic features of mitral stenosis were found. After various interventions that increased heart rate, however, the diastolic closure rate increased. This report demonstrates, therefore, that the E to F slope is not always a fixed value in mitral stenosis and that under certain conditions it may even appear to be normal.

Echocardiographic findings in cardiogenic shock due to right ventricular myocardial infarction

The echocardiographic findings in a patient with cardiogenic shock secondary to acute right ventricular myocardial infarction based on typical clinical, electrocardiographic, and hemodynamic features are described. The echocardiogram demonstrated a large RV/LV minor axis ratio caused by a volume overload of the right ventricle and an underfilled left ventricle. The interventricular septum showed abnormal movement, presumably due to right ventricular overload or severe disease of the left anterior descending coronary artery. Diminished septal systolic thickening, as seen in our patient, may be explained by extension of the infarct from the right ventricle to the adjacent part of the septum. Predominant right ventricular involvement can be a cause for a correctable hypotension in patients with acute myocardial infarction and should therefore be recognized early. The echocardiographic picture demonstrated in our patient, when considered in conjunction with the clinical status, can be useful for early diagnosis.

The ventricular A wave: a new echocardiographic index of late diastolic filling of the left ventricle

Echocardiography was used to evaluate the late diastolic filling period of the left ventricle in 30 normal individuals, 25 patients with left ventricular hypertrophy, normal sinus rhythm, and either a normal or delayed mitral valve closure, and 15 patients with atrial fibrillation. The echocardiographic ventricular A wave (VAW) was defined as the difference between the end-diastolic and an earlier late-diastolic internal left ventricular dimension, and it was felt to primarily reflect the atrial contribution to late diastolic filling of the left ventricle. It disappeared during ventricular pacing and was significantly smaller than normal in patients with atrial fibrillation. The VAW was significantly larger in patients with left ventricular hypertrophy and normal mitral valve closure reflecting the greater contribution by atrial contraction to late diastolic filling in these patients. In patients with left ventricular hypertrophy and delayed mitral valve closure, the VAW was normal reflecting lesser ventricular enlargement with atrial contraction than in the other patients with left ventricular hypertrophy. This suggested a greater impairment to left ventricular filling in these patients. Therefore, the VAW appears to be an indicator of abnormalities of late diastolic filling caused by left ventricular hypertrophy.

Relation between phasic mitral flow and the echocardiogram of the mitral valve in man

Ten patients without valvular disease were studied by ventriculography, and the rate and pattern of phasic blood flow into the left ventricle were determined by ventricular volume determinations at intervals of 33 ms during a single diastolic filling period. The derived left ventricular inflow patterns were then compared with the echocardiographic mitral EF slope obtained no more than 25 minutes before left ventriculography. The steepness of the EF slope was found to be inversely correlated with the time required to reach peak inflow velocity (r = 0.80, P less than 0.01) and directly correlated with the peak left ventricular inflow velocity divided by the time required to reach peak velocity (r = 0.72, P less than 0.05). No correlation was found between mean flow velocity into the left ventricle and the EF slope (r = 0.40, P = NS). A significant inverse correlation was found between the EF slope and the fraction of the diastolic filling period elapsed when 50 per cent of the filling volume had entered the left ventricle (r = 0.85, P less than 0.01). These findings suggest that the time required to reach left ventricular peak inflow velocity is one of the determinants of the mitral EF slope.

Echocardiographic study of cardiac tamponade

We studied 14 patients with cardiac tamponade and pulsus paradoxus; 11 were studied after relief of tamponade by pericardiocentesis. Right ventricle diastolic diameter increased during inspiration in each of 12 patients; left ventricle diastolic diameter decreased during inspiration in each of 13. Mitral valve DE amplitude decreased with inspiration in 13 of 14 patients. Mitral valve E-F slope could be measured in eight patients, and was rounded and not measurable in six. Six of the eight showed inspiratory decrease in mitral E-F slope. Similar changes were observed in two other patients with pulsus paradoxus who had chronic obstructive airway disease. Twenty patients with large pericardial effusions and no tamponade did not show these changes. These results suggest inspiratory augmentation of right ventricular filling and inspiratory diminution of left ventricular filling, not only in cardiac tamponade, but in obstructive airway disease associated with pulsus paradoxus.

Echocardiography in ischemic heart disease

Echocardiographic findings in patients with ischemic heart disease are described; their correlations with clinical, hemodynamic and angiographic data are presented and discussed. Regional abnormalities of left ventricular wall motion and/or thickening during systole are detected in 84 per cent of patients with acute myocardial infarction and in a high percentage of patients with larger than or equal to 75 per cent narrowing of a major coronary artery. These abnormalities may occur with stress and may be reversible. Left ventricular wall thinning during systole indicates acute ischemia or infarction and thin, dense myocardial echoes indicate scar. Echocardiographic evidence of left ventricular dysfunction is useful in predicting heart failure and mortality in patients with acute myocardial infarction and in predicting surgical mortality for patients undergoing aneurysmectomy and/or coronary artery bypass surgery. Echocardiography has not proved useful in determining graft patency following coronary artery bypass surgery. Technical difficulties and limitations of echocardiography in patients with coronary artery disease are discussed.

Correlation of echocardiographic and clinical findings in patients with pericardial effusion

Clinical data and echocardiographic findings were correlated in 20 patients with pericardial effusion. Moderate to large effusions were associated with increased motion of the entire heart within the pericardial sac. A correlation was found between the estimated volume of fluid and the diastolic excursion and velocity of the right ventricular and left ventricular walls (P less than 0.01). For any given volume of fluid as estimated from the echocardiogram neoplastic effusions resulted in greater increments in wall motion (P less than 0.02). Patterns of "pseudo" mitral valve prolapse occurred and were correlated with the extent and timing of cardiac swinging and heart rate. A diminished E-F slope of the mitral valve echo and notch on the right ventricular epicardial echo during early systole were found in all four patients with pericardial tamponade. These preliminary observations suggest that echocardiographic examination of patients with pericardial effusion may provide clues to the presence or absence of tamponade in addition to providing an estimate of the quantity of fluid in the pericardial sac.

Correlates of the echocardiographic waves of the mitral valve in normal subjects of various ages

A cardiographic study was performed on 71 subjects including 14 children, 42 young and middle-aged adults, and 15 old persons without evidence of heart disease. The echocardiogram of the mitral valve was recorded in the A mode by an analog method and was compared with the electrocardiogram, phonocardiogram, apex cardiogram, and carotid and jugular tracings, simultaneously obtained. The intervals between the various waves recorded by these methods were measured and the results were compared with those reported in the literature. A comparison of the duration of the intervals in the various age groups showed statistically significant differences. In particular, the intervals between the second heart sound and the peak of the E-wave and the E-F intervals in the echogram were longer in adults than in children and also longer in old persons than in younger adults. This important age difference should always be taken into account before attributing any echocardiographic deviations to disease.

Measurement of diastolic closure rate of normal mitral valve

Published values for the diastolic closure rate of the normalmitral vary and reflect diffference in methods of recording and measurement. From strip chart records it was concluded that the form of the recorded mitral diastolic closure slope can vary, that reproducible measurements of the closure rate can be made from echograms in which diastolic closure approximates closely to a monophasic form, that the amplitude of these echograms is maximal, and that their closure movements remain essentially monophasic at chart speeds up to 100 mm/s. Measuring only complexes with essentially monophasic closure movements, the within and between-subjected variation of the normal mitral diastolic closure rate was investigated. The ranges obtained from multiple measurements in a single subject and from a group of 45 normal subjects were comparable but the distribution of the results differed. It was concluded that there was a real between-subject variation in the normal mitral diastolic closure rate and that the diastolic closure rate in a single subject should be determined by measurement of a series of complexes. The accuracy of measurement of the diastolic closure rate of the normal mitral valve has been improved by using strip chart records and by measuring only echograms in which diastolic closure approximates closely to a monophasic form.

Echocardiographic analysis of mitral valve motion after acute myocardial infarction

To examine the effects of acute myocardial infarction on mitral valve diastolic velocity, echocardiograms were performed in 18 patients on admission, daily in the Coronary Care Unit, and at 3-day intervals during the remainder of hospitalization. These patients were divided into three groups based on the time interval between onset of symptoms and initial echocardiogram. Five of six patients admitted within 5 hours of onset of myocardial infarction had a triphasic response of mitral valve diastolic velocity with a transient rise above initial values, followed by a fall to below initial values, and then a slow rise during recovery. Seven of eight patients admitted 1-2 days after onset of myocardial infarction had a biphasic response, i.e., a fall from initial values and then a slow rise. Four patients admitted later in the course of myocardial infarction had a monophasic response, i.e. low initial velocity followed by a slow recovery. We conclude that in patients with myocardial infarction the mitral valve diastolic velocity following myocardial infarction shows a triphasic response which may appear biphasic or monophasic depending on the interval between myocardial infarction and admission. The temporal pattern of mitral valve diastolic velocity changes may reflect the dynamic alterations of myocardial function and compliance that are occurring after acute myocardial infarction and during the recovery period.