On the potential for iatrogenic effects of psychiatric crisis services: The example of dialectical behavior therapy for adult women with borderline personality disorder

OBJECTIVE

Although previous research has suggested that people with a history of using psychiatric crisis services are at higher risk for suicide, it is unclear whether this link is attributable to individual risk factors or iatrogenic effects of service utilization. We examined this question by analyzing data from a randomized controlled trial of dialectical behavior therapy (DBT), a treatment for highly suicidal individuals in which patients took advantage of crisis services less than those in the comparison condition. We hypothesized that crisis-service utilization during a treatment year, rather than pretreatment indicators of suicide risk, would be associated with higher suicide risk after treatment, and that DBT's treatment effects would be partially attributable to this association.

METHOD

Participants were 101 women (Mage = 29.3, 87% Caucasian) with recent suicidal and self-injurious behaviors meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association [APA], 1994) criteria for borderline personality disorder. We examined relationships between suicidal ideation (using the Suicide Behaviors Questionnaire; Linehan, 1981), number of suicide attempts (using the Suicide Attempt Self-Injury Interview; Linehan, Comtois, Brown, Heard, & Wagner, 2006), and number of psychiatric inpatient admissions and psychiatric emergency-room (ER) visits (using the Treatment History Interview; Linehan & Heard, 1987) from the years prior to, during, and following treatment.

RESULTS

Treatment-year psychiatric ER visits were the sole predictor of the number of follow-up year suicide attempts. Treatment condition and pretreatment inpatient admissions predicted treatment-year psychiatric ER visits. Finally, there was evidence that DBT resulted in fewer suicide attempts at follow-up, in part because getting DBT led to fewer psychiatric ER visits.

CONCLUSION

In this population and context, data suggest that crisis-service utilization conveys risk for suicide. DBT may reduce suicide risk in part by reducing use of these services. (PsycINFO Database Record

Behavioral Assessment of the Negative Emotion Aspect of Distress Tolerance: Tolerance to Emotional Images

The current behavioral tasks assessing distress tolerance measure tolerance to frustration and tolerance to physical discomfort, but do not explicitly assess tolerance to negative emotion. We closely evaluated the conceptual distinctions between current behavioral tasks and self-report tasks assessing distress tolerance, and then developed a new behavioral distress tolerance task called the Emotional Image Tolerance (EIT) task. The EIT task retains elements of existing behavioral tasks (e.g., indices of persistence) while augmenting the reliability and content sufficiency of existing measures by including multiple trials, including a variety of negative affect stimuli, and separating overall task persistence from task persistence after onset of distress. In a series of three studies, we found that the EIT correlated with extant behavioral measures of distress tolerance, the computerized mirror-tracing task and a physical cold pressor task. Across all of the studies, we also evaluated whether the EIT correlated with self-report measures of distress tolerance and measures of psychopathology (e.g., depression, anxiety, and binge eating). Implications for the refinement of the distress tolerance construct are discussed.

Meta-emotions as predictors of drinking to cope: a comparison of competing models

To further elucidate how individual differences in the frequency with which people get upset about having negative emotions (i.e., meta-emotions) and how often they experience negative emotions (i.e., trait emotions) are related to drinking to cope, we tested direct and mediated path models predicting drinking to cope in a sample of emerging adult drinkers. We hypothesized that the mediated model would find more support, such that anxiety sensitivity and non-acceptance (meta-emotions) would be indirectly related to drinking to cope via associations with trait anxiety and trait nonanxious negative affect (trait emotions), respectively. Both models were tested with bootstrapping using concurrently measured self-report data from 544 college-enrolled emerging adults. Although both the mediated and direct models yielded acceptable fit indices, only the predictions of the mediated model were supported and findings suggest that non-acceptance might be more strongly related than anxiety sensitivity to drinking to cope. If replicated using better controlled idiographic paradigms, the present results would support a novel model of the relation between secondary negative emotions and emotion-focused coping and might suggest that interventions that target meta-emotion could be effective among emerging adult alcohol misusers.

Multidimensional assessment of beliefs about emotion: development and validation of the emotion and regulation beliefs scale

Recent work has extended the idea of implicit self-theories to the realm of emotion to assess beliefs in the malleability of emotions. The current article expanded on prior measurement of emotion beliefs in a scale development project. Items were tested and revised over rounds of data collection with both students and nonstudent adult online participants. Exploratory and confirmatory factor analyses revealed a three-factor structure. The resulting scale, the Emotion and Regulation Beliefs Scale, assesses beliefs that emotions can hijack self-control, beliefs that emotion regulation is a worthwhile pursuit, and beliefs that emotions can constrain behavior. Preliminary findings suggest that the Emotion and Regulation Beliefs Scale has good internal consistency, is conceptually distinct from measures assessing individuals' beliefs in their management of emotions and facets of emotional intelligence, and predicts clinically relevant outcomes even after controlling for an existing short measure of beliefs in emotion controllability.

Speeches, strangers, and alcohol use: the role of context in social stress response dampening

According to the Stress Response Dampening model, problem drinking develops after learning that alcohol limits the stress response in anxiety-provoking situations. However, laboratory-based studies testing alcohol's effects on social anxiety have yielded mixed results. The current study was the first to examine stress response dampening across two contexts: a performance-based (a speech) and an interaction-based (a conversation) social situation. Undergraduates (N = 62; M(age) = 22.85; 31% women; 81% Caucasian) were randomly assigned to consume an alcoholic (target BAC = .08%; n = 22), placebo (n = 20), or nonalcoholic control (n = 20) beverage followed by the anxiety-inducing social tasks. Results revealed a 3 (alcohol condition) × 2 (social task condition) × 4 (measurement point) interaction, controlling for baseline subjective state anxiety and trait social anxiety. The pattern of scores over the course of the task varied across alcohol conditions for the speech, but not the conversation. Specifically, participants in the alcohol and placebo conditions evidenced increased subjective anxiety following the first measurement point prior to the speech and their anxiety remained elevated at all subsequent measurements. Participants in the nonalcoholic control condition evidenced stable subjective anxiety ratings for all speech measurement points. Results did not support stress response dampening for either type of social situation. Instead, the only between-group difference found was that the placebo group reported greater subjective anxiety than the nonalcoholic control group after the speech. Concerns about alcohol's negative effects on one's performance might have led to increased anxiety. Findings shed light on previous inconsistent findings and highlight the need to consider context and timing in understanding drinking to cope with social anxiety.

The effect of steady-state increases in systemic arterial pressure on the duration of left ventricular ejection time

The effect of steady-state increases in systemic arterial pressure on the duration of left ventricular ejection time was studied in 11 normal male subjects. Methoxamine, a pressor amine of predominantly vasoconstrictor activity but lacking significant inotropic effect, was administered intravenously resulting in an average increase in mean arterial pressure of 27 mm Hg. Heart rate was held constant by high right atrial pacing, and there was no significant change in cardiac output. During methoxamine infusion, when stroke volume, heart rate, and inotropic state were held constant, left ventricular ejection time increased as mean arterial pressure increased. There was a highly significant correlation between the increase in mean systolic blood pressure and the prolongation of left ventricular ejection time (r = 0.870). In one subject, an increase in mean systolic pressure of 75 mm Hg prolonged left ventricular ejection time 55 msec, producing paradoxical splitting of the second heart sound. The prolongation of left ventricular ejection time during infusion was not blocked by the prior intravenous administration of atropine sulfate or propranolol hydrochloride, thus ruling out both vagal inhibition of the left ventricle and reflex withdrawal of sympathetic tone as its cause. In three subjects, left ventricular end diastolic pressure was measured and found to be significantly increased. This finding suggests that the normal left ventricle maintains a constant stroke volume in the presence of an increased pressure load by the Frank Starling mechanism. This study concludes that arterial pressure must be included as a prime determinant of left ventricular ejection time along with stroke volume, heart rate, and inotropic state in intact man.

Noninvasive/invasive correlates of exaggerated ventricular interdependence in cardiac tamponade

Ventricular interdependence is that property of the normal heart such that distension of one ventricle alters the distensibility and filling pressure of the other. This phenomenon coupled with reciprocal changes in right and left heart venous return during normal quiet respiration results in minor decreases in left ventricular stroke volume, systolic blood pressure, pulse pressure, total electromechanical systole (Q-A2), left ventricular ejection time and mitral e-wave velocity during inspiration and minor increases in these parameters during expiration. Opposite changes in these parameters occur in the right heart with increases occurring during inspiration and decreases during expiration. Exaggerated ventricular interdependence occurs in cardiac tamponade when the pericardial constraint limits the total contents in the pericardial sac. This, together with the decreased effective left ventricular filling pressure which occurs during inspiration, is responsible for the exaggerated decrease in stroke volume, blood pressure, pulse pressure, left ventricular ejection time and mitral e-wave velocity in this condition. These observations, together with the echocardiographic findings of right atrial collapse, right ventricular collapse, and inferior vena cava plethora constitute the noninvasive diagnosis of pericardial tamponade. The utility of these noninvasive tests in detecting both the presence and degree of increased pericardial pressure was evaluated in 33 invasively studied patients with pericardial effusion. In Group 1 (n = 13) intrapericardial pressure was elevated but less than both right atrial pressure and pulmonary wedge pressure, in Group 2 (n = 10) intrapericardial pressure equaled right atrial pressure but was less than pulmonary wedge pressure, and in Group 3 (n = 10) intrapericardial pressure equaled right atrial pressure and pulmonary wedge pressure. From these data it is concluded that right atrial and right ventricular collapse are highly sensitive techniques for predicting increased intrapericardial pressure in all three groups, but fail to predict the level of intrapericardial pressure and the severity of hemodynamic compromise. However, the absence of inferior vena cava plethora helped separate Group 1 patients from Groups 2 and 3 patients, thereby aiding in distinguishing a group of patients with severe hemodynamic derangement requiring urgent intervention. Exaggerated reciprocal changes in mitral and tricuspid e-wave velocity is a very sensitive finding for increased intrapericardial pressure. However, its presence correlates poorly with the severity of tamponade. Acute pericardial tamponade is a clinical diagnosis determined by the integration of the history, physical exam and appropriate noninvasive physiologic and imaging techniques.

Reversed closure sequence of the mitral and tricuspid valves in congestive heart failure

OBJECTIVES

The purpose of this study was to evaluate functional and hemodynamic factors that determine the mitral-tricuspid and aortic-pulmonary valve closure sequence in patients with dilated cardiomyopathy.

BACKGROUND

The physiologic factors determining closure sequence of cardiac valves in various forms of heart disease have been found to be complex. Few data exist for dilated cardiomyopathy, particularly for differentiating the effects of a conduction delay versus changes in ventricular performance.

METHODS

A group of 64 patients were compared with 36 control subjects. Timing of valve closure and electromechanical intervals were determined by combined M-mode echocardiography, phonocardiography and apexcardiography. Hemodynamic data from right heart catheterization were available in 46 patients.

RESULTS

In all control subjects, the aortic valve closed before the pulmonary valve and the mitral valve closed before the tricuspid valve. In the study group, 30 patients (49%) had reversed aortic-pulmonary valve closure and 27 (90%) of these had a left-sided conduction delay. There were 38 patients (60%) who had reversed mitral-tricuspid valve closure, but this was unrelated to the presence of a left-sided conduction delay. The presence of high ventricular filling pressures and poor systolic function was associated with delayed closure of both the mitral and the tricuspid valve. This caused the closure sequence to be related to the size of the difference between mean pulmonary artery wedge pressure and mean central venous pressure and also the magnitude of right ventricular dysfunction. Patients with a low wedge pressure (< 16 mm Hg) and a low central venous pressure (< 10 mm Hg) had a low prevalence of mitral-tricuspid valve closure reversal (30%). Those with a high wedge pressure (> 16 mm Hg) but a low central venous pressure had a high prevalence (86%) of reversal of mitral-tricuspid valve closure. Patients with high wedge and central venous pressures had a moderate prevalence (47%) of mitral-tricuspid valve closure reversal. Similar findings were observed for right ventricular dysfunction. If the right ventricle was normal or severely dysfunctional, a reversed closure sequence was less common (52% and 41%, respectively) than if moderate dysfunction was present (78%).

CONCLUSIONS

Aortic-pulmonary valve closure sequence is strongly related to the presence of a left-sided conduction delay. The mitral-tricuspid valve closure sequence is unrelated to a conduction delay but can be reversed by relative differences in the severity of systolic dysfunction and filling pressures between the two ventricles.

Lisinopril for severe congestive heart failure

Lisinopril, a new converting enzyme inhibitor, was studied hemodynamically in 55 patients. The response to 2.5-, 5- and 10-mg doses showed significant increases in cardiac index and significant reductions in pulmonary artery wedge, right atrial, pulmonary arterial and systemic arterial pressures, as well as in systemic vascular resistance. Significant changes in most parameters were present at 24 hours. A dose-response relation for most parameters was noted. Over a 3-month period, 47 patients were followed up, with improvement in functional capacity and symptomatic status. Metabolic parameters did not change over time, although 26% showed evidence of reversible renal dysfunction. Only 3 patients (6.4%) required discontinuation because of adverse effects. A subgroup of patients reassessed at 3 months demonstrated maintenance of hemodynamic effects. The present study demonstrates that (1) the hemodynamic effects of lisinopril are of relatively long duration; (2) within certain limits, a dose-response relation can be defined; and (3) the drug has an acceptable long-term tolerability profile.

Effect of heart rate alterations produced by atrial pacing on the pattern of diastolic filling in normal subjects

To determine the effect of heart rate alterations on diastolic timing intervals and filling parameters, 10 normal patients were paced from the right atrium at 30 and 50 beats/min above their baseline rates. M-mode echocardiograms of the aortic valve, mitral valve and left ventricle were obtained and digitized at baseline and with each pacing rate. With increased atrial pacing, left ventricular systolic time became an increasingly greater proportion of cycle length while the diastolic filling period occupied a lesser proportion of the cycle length. The time to peak filling rate and the rapid filling period occupied a greater proportion of the diastolic filling period. The peak filling rate increased progressively with increased atrial pacing (baseline 128 +/- 19 mm/s, first paced rate 146 +/- 27 mm/s, p less than 0.05 vs baseline; second paced rate 167 +/- 23 mm/s, p less than 0.01 vs baseline and first paced rate). The early diastolic filling fraction and rapid filling fraction also increased with pacing. Increasing the heart rate resulted in an alteration of the time course of diastolic filling and extent of diastolic filling during the rapid filling period. Interventions that improve diastolic filling and increase heart rate may in part be due to heart rate changes.

Modulation of hemodynamic effects with a converting enzyme inhibitor: acute hemodynamic dose-response relationship of a new angiotensin converting enzyme inhibitor, lisinopril, with observations on long-term clinical, functional, and biochemical responses

The hemodynamic effects of varying oral doses of the long-acting converting enzyme inhibitor lisinopril were studied in an acute, single-blind, parallel fashion in 55 patients with moderate to severe congestive heart failure. Doses of 2.5, 5.0, and 10 mg produced a significant increase in cardiac index and significant reductions in pulmonary capillary wedge, right atrial, pulmonary arterial, and systemic arterial pressures and systemic vascular resistance. The changes were present up to 24 hours after dosing for most parameters. There was a clear-cut dose-response relationship observed. Forty-seven patients were followed over a 3-month period, during which functional status and exercise tolerance improved. Although 26% showed some evidence of renal dysfunction with lisinopril, these changes could be normalized by decreasing either the lisinopril or the diuretic dose. These data demonstrate that the hemodynamic changes with the long-acting converting enzyme inhibitor lisinopril can be modulated with dose adjustment in patients with congestive heart failure. They also suggest that renal function changes may be normalized by adjustment of either the dose of lisinopril or the diuretic dose.

Atrial septal defect: attenuation of respiratory variation in systolic and diastolic time intervals

The effects of pathologic states on right and left ventricular function have been studied extensively. However, there have been few studies on the interrelations between right and left ventricular function in normal human subjects and in patients with disease. Respiratory effects on ventricular interrelations reflected by diastolic time, right or left ventricular systolic time and ventricular performance (pre-ejection period/ejection time ratio) were studied in 12 normal subjects and 15 patients with a normal pressure-large shunt atrial septal defect. Simultaneous pulmonary artery (intracardiac manometer recordings) and left ventricular external recordings were performed in both groups. Left ventricular diastolic time increased with inspiration in the normal subjects and decreased in the patients with atrial septal defect (12.6 +/- 2.39 [1 SE] versus -13.4 +/- 3.48 ms, p less than 0.001). Left ventricular systolic time and ejection time decreased with inspiration in the normal group and remained unchanged in the patient group (-7.6 +/- 0.95 versus -0.9 +/- 0.77 ms, p less than 0.001 and -10.4 +/- 1.09 versus -1.7 +/- 0.80 ms, p less than 0.001, respectively). Left ventricular pre-ejection period/ejection time ratio increased with inspiration in the normal subjects and remained unchanged in the patients with atrial septal defect (0.03 +/- 0.008 versus 0 +/- 0.01, p less than 0.01). Right ventricular diastolic time decreased with inspiration in normal and patient groups (-8.8 +/- 1.6 versus -17 +/- 3.87 ms).(ABSTRACT TRUNCATED AT 250 WORDS)

Noninvasive evaluation of systolic and diastolic function in severe congestive heart failure secondary to coronary artery disease or idiopathic dilated cardiomyopathy

The usefulness of systolic time intervals, diastolic time intervals and echocardiography in evaluating left ventricular (LV) function was determined in 69 patients with severe congestive heart failure. All systolic time intervals were markedly abnormal (preejection period/LV ejection time 0.59 +/- 0.18 vs 0.30 +/- 0.04, preejection period index 170 +/- 37 vs 117 +/- 11, LV ejection time index 372 +/- 26 vs 410 +/- 17; patients vs control subjects, p less than 0.05). Diastolic time intervals in patients were not different from those in control subjects. Echocardiographic measurements were all markedly abnormal (LV end-diastolic dimension 6.9 +/- 1.0 vs 4.8 +/- 0.4 cm, patients vs control subjects, p less than 0.05). No pattern of abnormalities distinguished ischemic cardiomyopathies from idiopathic dilated cardiomyopathies. The presence of LV conduction delay did not substantially alter results, except that exclusion of patients with LV conduction delay normalized the total time of systole (QA2) index (from 542 +/- 40 to 531 +/- 31 ms) and reduced but did not normalize prolongation in the preejection period index (from 170 +/- 37 to 162 +/- 29 ms). No systolic or diastolic interval strongly correlated with any hemodynamic or other independent measure of LV performance. Twenty-four patients were given inotropic or unloading agents, which significantly improved hemodynamic values. Systolic and diastolic intervals were measured at baseline and at maximal hemodynamic effect. The correlation of changes in hemodynamics with changes in systolic and diastolic intervals was only modest. Thus, although systolic time intervals and associated echocardiographic measurements can detect abnormal LV function, they cannot reliably detect a change in LV function or distinguish gradations of abnormality.(ABSTRACT TRUNCATED AT 250 WORDS)

Phonoechocardiography and intracardiac phonocardiography in hypertrophic cardiomyopathy

The salient phonoechocardiographic features of patients having hypertrophic cardiomyopathy (HCM) with or without left ventricular outflow tract (LVOT) gradients are reviewed. Intracardiac sound and pressure recordings from high fidelity catheter-tipped micromanometers have documented that the precordial murmur is the summation of both the systolic ejection murmur (SEM) arising from the LVOT, as well as the mitral regurgitant murmur recorded from the left atrium. The intensity of the precordial murmur varies directly with the LVOT gradient, which in turn is determined primarily by the contractility and loading conditions of the left ventricle. Reversed splitting of the second heart sound (S2) with paradoxical respiratory movement is a common finding in HCM, and when present, almost always denotes a significant LVOT gradient. It is due to marked lengthening of the left ventricular ejection time secondary to prolongation of the contraction and relaxation phases of left ventricular systole. The presence of a fourth heart sound (S4) is the rule in HCM when normal sinus rhythm is present, and is a reflection of a forceful left atrial contraction into a hypertrophied noncompliant left ventricle. A third heart sound (S3) is also common in HCM, and often the initial vibrations occur before the 0 point of the apexcardiogram (ACG) and continue giving the auscultatory impression of a diastolic rumble. When associated with a loud S1, which is frequently present, the clinical presentation may mimic mitral stenosis. This is particularly true when the patient has chronic atrial fibrillation. Careful attention to evidence of marked left ventricular hypertrophy as well as the typical echocardiographic findings of HCM preclude this diagnosis. In conclusion, phonoechocardiography is a simple non-invasive technique which almost always makes the definitive diagnosis of HCM.

Venous systolic thrill and murmur in the neck: a consequence of severe tricuspid insufficiency

A palpable venous systolic thrill and murmur at the base of the neck are described as new physical findings in five patients with severe tricuspid regurgitation. In two of these patients, the tricuspid valve had been resected as treatment for infective endocarditis related to intravenous drug abuse. The third patient had severe chronic pulmonary disease with right heart failure. The fourth patient had a complex congenital defect in which the mitral valve served as the venous atrioventricular valve and was severely incompetent. The fifth patient suffered from long-standing rheumatic mitral and tricuspid disease with pulmonary hypertension 10 years after placement of a mitral prosthesis. From these observations, it is apparent that pulsatile retrograde flow in the cervical veins resulting from severe right-sided atrioventricular valve incompetence can produce a palpable systolic thrill and murmur at the base of the neck.

Left ventricular diastolic filling in patients with coronary artery disease and normal left ventricular function

Abnormal left ventricular diastolic filling (DF) has been noted in coronary disease (CD) patients with normal left ventricular function (NLVF). Inclusion of patients with regional wall disease, hypertension, and left ventricular hypertrophy may be responsible for abnormal DF. We evaluated left ventricular DF curves derived from gated blood pool scans in 21 normals (group 1), in 38 CD patients with NLVF specifically defined (group 2), and in 28 CD patients with ejection fractions greater than 50% and regional disease (group 3). The peak filling rate (PFR), mean filling rate (MFR), the percentage of stroke volume filled at one third of diastole (%SV-1/3 DT) and at the end of the rapid filling period (%SV-RFP) were determined. Groups 1 and 2 had similar DF parameters. Group 2 patients with 75% obstructive left anterior descending disease (LAD) had a reduced %SV-RFP and PFR (2.56 +/- 0.56 end-diastolic volumes/sec [EDV/S]) as compared to normals (3.11 +/- 0.65 EDV/S, p less than 0.01). Group 3 patients had a reduced PFR (2.14 +/- 0.53 EDV/S, p less than 0.001), MFR, %SV-1/3 DT, and %SV-RFP. DF in CD patients with NLVF was similar to normals in a select group of patients but was abnormal in patients with regional disease and greater than 75% LAD disease with NLVF.

Echophonocardiographic estimates of pulmonary artery wedge pressure in mitral stenosis

The efficacy of noninvasive indexes for predicting pulmonary artery wedge (PAW) pressure was reviewed in 77 patients with mitral stenosis. M-mode echocardiography and phonocardiography were used to measure the aortic valve closure-mitral valve E-point interval (A2-E) and the electrocardiographic Q wave-mitral valve closure interval (Q-C) close to the time of diagnostic cardiac catheterization. During catheterization, in 65 patients PAW pressure was measured and in 12 left atrial (LA) pressure was measured. The A2-E and Q-C intervals taken alone had only modest correlation with PAW pressure (r = -0.54 and r = 0.46, respectively). The correlation was weakest in patients with atrial fibrillation and best in sinus rhythm when heart rate variation between invasive and noninvasive studies was within +/- 5 beats. Substitution of V-wave pressure for mean PAW pressure and correction for variation in blood pressure improved the A2-E correlation (r = -0.64), as did combining the A2-E and Q-C intervals into a ratio [(Q-C)/(A2-E)] (r = 0.62). However, the best results were obtained in patients where LA pressure was measured directly (r = -0.91 for A2-E), suggesting the PAW pressure is not always an accurate reflection of LA pressure. In conclusion, many factors in addition to LA pressure affect the Q-C and A2-E intervals which, in many situations, decrease their predictive value. However, if used appropriately, these intervals may allow an estimation of PAW pressure.

The noninvasive assessment of pulmonary capillary wedge pressure in mitral regurgitation

The interval between the aortic closure sound and the mitral opening snap (A2-OS) has been shown to have a significant inverse correlation with pulmonary capillary wedge pressure (PCW) in mitral stenosis. The present study critically examines the relationship of several noninvasively determined diastolic intervals to PCW in patients with relatively pure mitral regurgitation (MR). Fifty-seven patients with MR of diverse etiologies were studied with echocardiograms and phonocardiograms in addition to right and left heart catheterization. Noninvasive determination of the time intervals of aortic closure sound to mitral valve opening (A2-MO), mitral D point to E point (D-E), aortic closure sound to mitral E point (A2-E), the interval from the onset of the QRS to mitral closure (Q-C), and the ratio Q-C/A2-E were compared to invasive measurements of mean PCW, the height of the V wave of PCW (PCW-V), and the ratio of PCW-V to left ventricular (LV) peak systolic pressure (PCW-V/LV). Correlation between each of the five noninvasive intervals and each of the three invasive pressure measurements was then determined. Of the noninvasive intervals studied, A2-MO had the best inverse correlation with all measures of PCW. All 18 patients having a short A2-MO (less than 40 msec) had a PCW-V of greater than or equal to 40 mm Hg and all seven patients having a long A2-MO (greater than 85 msec) had a PCW-V of less than 22 mm Hg. A2-E also had a strong inverse correlation with PCW.(ABSTRACT TRUNCATED AT 250 WORDS)

Intermittent mitral regurgitation due to Beall valve dysfunction: analysis of 13 patients with atrial fibrillation

A unique hemodynamic event was noted in long-term survivors of mitral valve replacement with the Beall prosthesis. The event was a result of intermittent valve dysfunction and transvalvular mitral regurgitation (MR). At cycle lengths longer than 0.9 second that were preceded by shorter cycle lengths, 8 of 13 patients with Beall valve prostheses who had chronic atrial fibrillation (AF) intermittently had a marked unexpected decrease in peak left ventricular systolic pressure and a simultaneous increase in left atrial or pulmonary artery wedge "v" wave pressure. This event, which is a result of intermittent, severe MR, occurred more frequently at longer cycle lengths. In all 8 patients with the finding, severe valve disc wear was found at operation; however, 5 of these patients had only trace or 1+ MR on left ventricular angiography. In contrast, the event did not occur in 11 patients in chronic AF with organic MR or non-Beall valve MR, despite an appropriate number of sufficiently long cycles. The absence of the event in 5 Beall valve patients with significantly faster heart rates than in those with the event may in part be a result of its dependence on cycle length. This hemodynamic event, when present in a Beall valve recipient in AF, is an indication for valve replacement, even in the absence of angiographic evidence of severe MR.

Isovolumic relaxation period in hypertrophic cardiomyopathy

Previous reports have demonstrated that patients with hypertrophic cardiomyopathy have a prolonged isovolumic relaxation period as a result of a delay in mitral valve opening, reflecting a reduced rate of fall of left ventricular pressure. This period as measured from the aortic closure sound (A2 on phonocardiogram) to the opening of the mitral valve (on echocardiogram) was determined in 84 patients with hypertrophic cardiomyopathy and compared with findings in 31 normal volunteers. The duration of the isovolumic relaxation period in the 84 patients had a wide range from 0 to 160 ms (mean 71 +/- 32) that was not significantly different from that in normal subjects (63 +/- 11 ms). However, it was possible to identify a group of 15 patients with an extremely short isovolumic relaxation period, 2 standard deviations below the normal range. This shortening was due to a marked delay in aortic closure sound (A2) due to late left ventricular-aortic pressure crossover, as well as early opening of the mitral valve secondary to elevated left atrial pressure, which was confirmed by hemodynamic correlations and digitized echocardiographic data. In this subset of patients, A2 is a poor marker of the onset of rapid left ventricular pressure decline and, thus, the interval from A2 to mitral valve opening is not a valid reflection of left ventricular relaxation. It is concluded that in hypertrophic cardiomyopathy, both the timing and sequence of relaxation are abnormal, as is the rate of relaxation. Furthermore, the isovolumic relaxation period is multifactorially determined and depends not only on the rate of left ventricular pressure decline, but also on the magnitude of the pressure drop from A2 to mitral valve opening. All of these determinants must be kept in mind when the isovolumic relaxation period is used as a measure of left ventricular relaxation.

Cardiac tamponade: hemodynamic observations in man

Hemodynamic studies were performed before and after pericardiocentesis in 19 patients with pericardial effusion. Right atrial pressure decreases significantly, from 16 +/- 4 mm Hg (mean +/- SD) to 7 +/- 5 mm Hg in 14 patients with cardiac tamponade. This change was accompanied by significant increases in cardiac output (3.87 +/- 1.77 to 7 +/- 2.2 l/min) and inspiratory systemic arterial pulse pressure (45 +/- 29 to 81 +/- 23 mm Hg). The remaining five patients did not demonstrate cardiac tamponade, as evidenced by lack of significant change in these hemodynamic parameters. In all patients with tamponade, right ventricular end-diastolic pressure (RVEDP) was elevated and equal to pericardial pressure; equilibration was uniformly absent in patients without tamponade. During gradual fluid withdrawal in the tamponade group, significant hemodynamic improvement was largely confined to the period when right ventricular filling pressure remained equilibrated with pericardial pressure. In 10 patients with tamponade and pulsus paradoxus, pulmonary arterial wedge pressure (PAW) was equal to pericardial pressure except during early inspiration and expiration when it was transiently less and greater, respectively; however, inspiratory right atrial pressure never fell below pericardial pressure. In these 10 patients, PAW decreased significantly following pericardiocentesis (P less than 0.001). In the remaining four patients with tamponade but without pulsus paradoxus, all of whom had chronic renal failure, PAW was consistently higher than pericardial pressure or RVEDP and did not decrease after pericardiocentesis. These data tend to confirm the hypothesis that in patients with tamponade, the venous pressure required to maintain any given cardiac volume is determined by pericardial rather than ventricular compliance. When pericardial compliance determines diastolic pressure in both ventricles, relative filling of the ventricles will be competitive and determined by their respective venous pressures (pulmonary vs systemic), which vary with respiration and alternately favor right and left ventricular filling. This results in pulsus paradoxus. However, if pulmonary arterial wedge pressure is markedly elevated before the onset of tamponade, as in patients with chronic renal failure, then pericardial compliance may only determine right ventricular filling pressure. In such cases, pulsus paradoxus may be absent.

Pulmonary hypertension in the CREST syndrome variant of progressive systemic sclerosis (scleroderma)

Severe pulmonary hypertension without pulmonary fibrosis occurred in 10 patients with the CREST syndrome (calcinosis, Raynaud's phenomenon, esophageal dysfunction, sclerodactyly, telangiectasia), reputedly a benign variant of progressive systemic sclerosis. Time from the initial symptom, Raynaud's phenomenon, to the recognition of pulmonary hypertension was as long as 40 years. Pulmonary hypertension and increased pulmonary vascular resistance was shown in all patients. Autopsy examination in three of six deaths attributable to pulmonary hypertension showed intimal proliferation with myxomatous change in the small- and medium-sized pulmonary arteries similar to changes in the digital arteries of patients with scleroderma and Raynaud's phenomenon, and interlobular renal arteries of those with "scleroderma kidney." It is concluded that the CREST syndrome is not entirely benign but may be complicated, after a long clinical course, by progressive pulmonary vascular obliteration, pulmonary hypertension, and death in the absence of significant pulmonary fibrosis.

Undesirable cardiac arrhythmias associated with rate hysteresis pacemakers

The introduction of the ventricular inhibited pulse generator with the feature of rate hysteresis has been associated with a variety of rhythm disturbances, some causing serious concern. This pulse generator has two different pacing rates: (1) the automatic rate, which is the interval between two successive paced beats (usually 860 msec or 70/min), and (2) the hysteresis interval, which results in a 1,000 msec delay between a sensed cardiac contraction and the next pacemaker discharge. The hysteresis interval after a sensed signal may result in long pauses that may predispose to the development of serious cardiac arrhythmias. Two examples of this type of complication were recently observed. One patient had bigeminal rhythm with mechanically ineffective cardiac contractions and an effective cardiac rate of 35/min; he experienced dyspnea and weakness during these prolonged episodes. Another patient had repeated episodes of ventricular fibrillation. The cardiac arrhythmias were not controlled by antiarrhythmic agents, and both patients required replacement of the pulse generator. The proposed advantages of pulse generator hysteresis are (1) prolongation of battery life, and (2) maintenance of effective atrial transport; these advantages may be outweighed by undesirable cardiac arrhythmias that may be associated with this mode of pacemaker function. Rate hysteresis cardiac pacemakers should be reserved for patients having predominantly sinus rhythm without ventricular irritability. In patients with frequent ectopic ventricular activity, atrial fibrillation or high degree atrioventricular block, the rate hysteresis pacemaker offers no advantage over the conventional demand pacemaker. For patients with frequent ectopic ventricular activity not easily controlled by antiarrhythmic agents, consideration should be given to the use of a permanent demand pacemaker with external rate control, which may provide greater flexibility in arrhythmia management.

Surgical treatment of acute aortic regurgitation in infective endocarditis

During a six-year period 15 consecutive patients with isolated aortic regurgitation due to infective endocarditis were encountered. None had prior significant aortic valve disease. Elective valve replacement was performed in 13 patients; emergency operation was needed in only 1 patient because of intractable pulmonary edema. One patient died suddenly from acute heart block while undergoing medical treatment. Preoperative cardiac catheterization studies in 10 of the 14 patients revealed gross elevations of left ventricular end-diastolic pressure, pulmonary hypertension, depressed cardiac output, and 3 to 4+ aortic regurgitation. There was 1 early and 1 late postoperative death, both due to systemic embolism, yielding an overall surgical mortality of 14%. After a mean follow-up of 18 months, 10 of the 11 patients are in New York Heart Association Functional Class I. Most patients with acute aortic regurgitation secondary to infective endocarditis have clinically observable congestive heart failure and will eventually require valve replacement. If congestive heart failure can be stabilized by a medical regimen, a course of antibiotic therapy can be administered and elective valve replacement can be performed. The time taken for preoperative antibiotic treatment is not associated with irreversible myocardial damage sufficient to influence the results of operation.

Alterations of right ventricular systolic time intervals by chronic pressure and volume overloading

Right ventricular (RV) systolic time intervals and hemodynamic parameters were determined by micromanometric techniques in 13 subjects with normal right ventricles (NRV). These data were compared to those of 16 patients with pulmonary hypertension (PH) or predominant pressure overloading and 13 individuals with uncomplicated secundum atrial septal defects (ASD) or predominant volume overloading. In PH, the QP2 interval tends to remain within the normal range due to reciprocal changes in isovolumic contraction (ICT) and ejection (RVET) times. Elevations of pulmonary artery diastolic pressure are associated with increases in the mean rate of isovolumic pressure rise (MRIPR) (r = 0.84), but the latter change does not fully compensate for the widened ventriculoarterial diastolic pressure difference and ICT becomes prolonged (P less than 0.001). Factors other than stroke index depression which may contribute to the decreased duration of RVET (P less than 0.001) include tricuspid regurgitation and elevation of pulmonary vascular impedance. In ASD, QP2 is significantly prolonged (P less than 0.025) due to a significant increase in RVET (P less than 0.005). In contrast to NRV, a linear correlation of RVET and stroke index was not present, which suggested an alteration of ejection dynamics in this group. Despite a high incidence of complete or incomplete right bundle branch block the interval from QRS onset to rapid RV pressure upstroke was not prolonged. This is most probably the result of peripheral bundle branch block of genesis of the QRS pattern by right ventricular hypertrophy.

Coronary arteritis in systemic lupus erythematosus

Acute myocardial infarction in systemic lupus erythematosus may be due to an atheromatous or arteritic process. Confirmation of the latter etiology has previously been made only at postmortem examination. A 45-year-old white woman with known systemic lupus erythematosus developed anginal pain and multiple episodes of acute myocardial infarction. During this period, there was serologic but no other clinical evidence of active systemic lupus erythematosus. Serial coronary angiographic studies were strongly suggestive of an arteritic process based upon (1) a saccular aneurysm with no obstructive lesions in a coronary artery supplying an area of recent transmural myocardial infarction and (2) the development of significant obstructive lesions in a previously normal coronary artery over a period of 18 days. This case illustrates the difficulties in distinguishing between atherosclerosis and arteritis using a single coronary angiographic study. The distinction is significant because of the different therapeutic interventions required.

The contribution of tricuspid valve closure to the first heart sound. An intracardiac micromanometer study

The sound-pressure correlates of the second high frequency component of a split first heart sound (S1) were investigated in 27 patients. An external phonocardiogram was recorded with high fidelity sound and pressure from the left and right atria in 21 patients, from the pulmonary artery in 14 of these, and from the central aorta in 11. In the remaining six patients, high fidelity recordings from the central aorta and right-sided chambers were obtained with an external phonocardiogram. The external component of S1 that coincided with a left atrial C wave and "internal sound" was defined as M1. In those cases where the left atrial pressure was not recorded, this component could be identified by a low frequency transient in the central aortic pressure trace. The other external high frequency component of S1 that was synchronous with a separate right atrial C wave and "internal sound" was defined as T1; with two exceptions, M1 preceded T1. The two exceptions which caused reversal of this order, so that T1 preceded M1, were due to chronic left bundle branch block and mitral stenosis. In both cases, T1 was shown to be distinctly separated from the upstroke of pressure rise in the central aorta. This finding was also demonstrated in three cases of right bundle branch block and one case with aortic valvular disease. The usual asynchrony of ventricular contraction was altered by induction of ventricular premature systoles; the separation of externally identifiable M1 and T1 components and their internal markers was predictably altered by this maneuver. The occurrence of T1 was variable in relation to the upstroke of the pulmonary artery pressure, which suggests that it is not related to pulmonic ejection. It is concluded that micromanometrically recorded right and left atrial C waves can serve as markers for externally recordable M1 and T1 components of the first heart sound. In addition, T1 is frequently an externally recordable and audible event.

Determinants of variation between Fick and indicator dilution estimates of cardiac output during diagnostic catheterization. Fick vs. dye cardiac outputs

Simultaneous Fick and duplicate dye cardiac outputs were done in 105 patients with various cardiovascular diseases during routine cardiac catheterization. Dye was injected into the pulmonary artery and sampled from the brachial artery. Nineteen patients had mitral and/or aortic valvular regurgitation. Eighty-four per cent of the duplicate dye cardiac outputs agreed within 10 per cent variation from the line of identity, and 98 per cent were within 25 per cent. There was no systematic difference between the Fick and dye methods. Seventy-five per cent agree within 20 per cent variation from the line of identity. However, individual variation ranged from -27 to +58 per cent. There was, also, no systematic difference between Fick and dye methods either with low cardiac index or valvular regurgitation. Variation between the two methods was less with low cardiac index and greater with higher cardiac index. The variation was not increased in the presence of valvular regurgitation. The variation in the two methods could partly be explained by errors in the measurement of arteriovenous oxygen difference and oxygen consumption. When the injection is made into the pulmonary artery and sampled from the brachial artery, dye outputs are valid irrespective of the level of resting cardiac index and valvular regurgitation as long as there are enough points to draw a straight line from semilogarithmic trace of the descending limb.

Mobitz II atrioventricular block due to infra-Hisian block and bundle branch extrasystoles

An asymptomatic elderly male presented with complete right bundle branch block, left anterior fascicular block and Mobitz Type II second degree atrioventricular block. In addition, he was noted to have ventricular premature systoles. Electrophysiologic studies demonstrated two apparently different mechanisms for the second degree A-V block--infra-Hisian block and A-V block due to bundle branch extrasystoles arising in the affected right bundle branch. Concealed conduction of the bundle branch extrasystoles as the proximate cause of infra-Hisian block could not be excluded. However, both forms of A-V block were evidently dependent upon significant distal conduction system disease; this consideration was felt to warrant permanent pacemaker implantation.

Sound pressure correlates of the Austin Flint murmur. An intracardiac sound study

Mitral valve motion and pressure correlates of the Austin Flint murmur (AFM) were investigated in nine patients with aortic regurgitation using high fidelity catheter tip micromanometers and the mitral valve echocardiogram (MVE). External phonocardiography demonstrated a mid-diastolic murmur (MDM) in eight subjects and a presystolic murmur (PSM) in five. Maximum intensity of both AFM components was found in the left ventricular (LV) inflow tract; the murmur was not recordable in the left atrium (LA). In two patients, an apparent AFM was recorded in the intracardiac phonocardiogram when absent externally. Only one subject had a significant late diastolic "reversed" or LV to LA gradient; in this patient, presystolic mitral regurgitation was shown angiographically but no PSM was present and MVE revealed absence of atriogenic mitral valve re-opening. In two subjects, a PSM disappeared from the external phono when a "reversed" gradient occurred during the diastolic pause following a ventricular premature systole; this LV to LA gradient was associated with diastolic mitral regurgitation recordable in the left atrial phono. In two patients, LV inflow phono showed the MDM to begin 80-120 msec after the aortic second sound and during the D to E phase of the MVE. The rate of early diastolic mitral valve closure in patients (152 +/- 24 mm/sec) was not significantly different from 13 normals (232 +/- 10 mm/sec). With regard to the genesis of the AFM, the present study concludes: 1) diastolic mitral regurgitation plays no role, and 2) antegrade mitral valve flow is required but simultaneous retrograde aortic flow may also be necessary.

Reversibility of left ventricular asynergy by nitroglycerin in coronary artery disease

To evaluate the potential reversibility of left ventricular asynergy in patients with coronary artery disease, pre- and postnitroglycerin left ventriculography was performed in 32 subjects. In four other subjects left ventriculography was repeated without intervention of nitroglycerin. Changes in ejection fraction and percentage of systolic shortening of three minor axes from the first to the second angiogram were then calculated. Changes were not significant for the myocardial infarction group or for the control group without the intervention of nitroglycerin. Normal left ventricles showed small but significant changes (p less than 0.05). Patients with coronary artery disease but without previous myocardial infarction who demonstrated asynergy in their first angiogram showed three types of response: (1) no significant change (p less than 0.05)-irreversible asynergy; (2) significant change (p less than 0.025) with residual dysfunction-partially reversible asynergy; (3) significant change (p less than 0.001) without residual dysfunction-completely reversible asynergy. It is concluded that postnitroglycerin ventriculography is useful in assessing the reversibility of left ventricular asynergy in patients with coronary artery disease.

Determination of site of infection in endocarditis

Medical-surgical treatment of antibiotic refractory endocarditis requires determination of the site of infection, which is not always possible with conventional cardiac catheterization. The cases of two patients with right-sided endocarditis who survived after combined medical-surgical therapy are presented. One had persistent Pseudomonas aeruginosa bacteremia and three possible sites of infection. Multiple quantitative blood cultures proximal and distal to each suspected site indicated the pulmonary valve alone was infected. The second had sustained bacteremia with three enteric organisms and no apparent valvular abnormality. Quantitative cultures excluded the abdomen as the continuing source of bacteremia and suggested the tricuspid valve was infected. This was confirmed by a second catheterization using multiple cultures in conjuction with dye dilution studies, intracardiac phonocardiography, and angiography. These bacteriologic and cardiologic techniques may be especially useful in detecting right-sided endocarditis and may also be helpful in detecting concomitant infection of both sides of the heart.