David H. Kramer

Ultrasound Cardiography: Contrast Studies in Anatomy and Function

Ultrasound cardiography has become established as a valuable clinical tool in the detection of pericardial effusion (1) and the study of mitral valve disease (2, 3). The tricuspid valve can also be detected (4), and studies have been made of left ventricular stroke volume (5) and wall thickness (6). On the other hand, the extension of the ultrasonic method to the study of other cardiac structures has been slow because of the difficulty in recognizing the source of the echoes. Even here, however, Edler (7) has gained useful knowledge in the recognition of the origin of these echoes by the passing of needles into cadavers in duplication of the path of the ultrasonic beam and by the study of excised hearts. The purpose of this presentation is to describe a method for the ultrasonic identification of the cardiac chambers in the living subject. It is based on the intracardiac injection of substances that produce echoes at the site of injection as well as downstream in the flow pattern and permit identification...

Ultrasound localization of left ventricular outflow obstruction in hypertrophic obstructive cardiomyopathy.

Simultaneous recordings of reflected ultrasound from the anterior mitral leaflet and left ventricular outflow, the ECG, the phonocardiogram, and a recording of the carotid artery pulse were obtained in six patients with hypertrophic obstructive cardiomyopathy. Abnormal sharp systolic anterior movement (SAM) of the mitral leaflet was observed. This movement began with the onset of ventricular ejection and reached a peak with the initial peak in the arterial pulse. The leaflet was apposed to the interventricular septum up to 60% of the ejection period. In the latter part of systole as the mitral leaflet moved away from the interventricular septum, the arterial pulse showed a second systolic wave. Onset of SAM coincided with onset of the systolic murmur. Spontaneous variations in amplitude of SAM coincided with alterations in contour of the arterial pulse and in the intensity of the murmur. Administration of methoxamine to four patients resulted in disappearance of SAM. In one patient following surgery, the SAM of the mitral leaflet was noted only in the post-ectopic beats. This specific abnormality of mitral leaflet movement represents the localization of dynamic outflow obstruction in hypertrophic obstructive cardiomyopathy.

Permanent pervenous atrial pacing from the coronary vein.

Permanent pervenous atrial pacing from the coronary vein has been attempted in 14 patients. Several types of arrhythmias including symptomatic bradycardia, “bradytachy” syndrome, and refractory ventricular tachyarrhythmia-fibrillation have been successfully treated with pervenous atrial pacing in 10 patients for 1 to 30 mo. Longterm atrial pacing was unsuccessful in four patients; in two of these four this was due to high atrial pacing thresholds. To date there has been no evidence of pacemaker perforation or pacemaker-induced coronary vein thrombosis. It is concluded that permanent pervenous atrial pacing from the coronary vein is a reliable method of atrial pacing without resorting to thoracotomy.

Determinants of Atrial (S4) and Ventricular (S3) Gallop Sounds in Primary Myocardial Disease

Abstract Clinical, hemodynamic and angiographic correlates in 23 patients with primary myocardial disease and either atrial (S4) or ventricular (S3) gallop sounds differentiated the two groups. Tho...

Influence of the timing of atrial systole on mitral valve closure and on the first heart sound in man

Abstract Simultaneous recordings of electrocardiogram, phonocardiogram, indirect carotid pulse and pulsed ultrasound cardiogram of the anterior mitral leaflet were obtained in patients with heart block. In patients with compensated heart failure and heart block, the timing of mitral valve closure was a function of the timing of atrial systole for all beats with an effective diastolic P wave and a P-R interval greater than 0.2 second. Once closed, the mitral valve stayed closed through the remainder of diastole. In 1 patient with acute left heart failure, diastolic P waves did not result in mitral valve closure. The amplitude of the first heart sound was closely related to the timing of mitral valve closure. The mitral valve closure in diastole was silent, and the subsequent first sound was small. When the valve closed in early systole, the amplitude of the first sound was related to the rate and amplitude of the valve closure movement. The timing of mitral valve closure in relation to the left ventricular pressure pulse may be the important determinant of production of the first sound.

Permanent Pervenous Atrial Pacing From the Coronary Vein Long-Term Follow-Up

This report details our clinical experience during a 12 to 63 month follow-up period in 30 patients with permanent pervenous atrial pacemakers implanted in the coronary vein prior to May 1972. Indications for permanent atrial pacing included 20 patients with symptomatic sinus bradycardia, seven with atrial brady-tachy syndrome refractory to pharmacologic therapy, and three patients with atrial overdrive suppression for intractible ventricular arrhythmias. The average duration of atrial pacing was 29.2 + 2.4 (SEM) months, median 24 months. A bipolar electrode

The acute hemodynamic effects of ethacrynic acid and furosemide in patients with chronic postcapillary pulmonary hypertension.

The acute hemodynamic effects of either ethacrynic acid or furosemide were studied in 27 patients who underwent diagnostic right and transseptal left heart catheterization. Twentythree patients had postcapillary pulmonary hypertension secondary to isolated or predominant mitral stenosis. Of these, 21 patients were in New York Heart Association functional class 111, and one each in class II and IV. In the remaining four patients pulmonary artery pressures were normal. Two patients had aortic stenosis and one each coronary artery disease and nonobstructive cardiomyopathy. All four patients were in class H. Cardiac index, pressures, and pulmonary blood volume (PBV) were measured in the control state and 20, 40, and 60 min after diuretic administration. Pulmonary extravascular fluid volume (PEV) was measured in the control state and at 60 min post drug infusion. A similar hemodynamic response was observed for each drug. Significant reductions in pulmonary artery and left atrial mean pressures, cardiac index, and plasma volume occurred over the one hour observation period and were accompanied by a significant diuresis. However, despite reductions in central pressures and blood flow, PBV, PEV, and PEV/PBV remained unchanged, as did systemic arterial pressure. Since 23 of the subjects had postcapillary pulmonary hypertension it is postulated that the failure of PBV to decrease significantly despite significant decreases in pulmonary artery mean pressure is related to altered pressure volume characteristics in the pulmonary vascular bed in which the lung is operating on a steep portion of its pressure volume curve. The failure of the PEV to decrease supports the concept that the pulmonary extravascular space is relatively resistant to early decreases in pulmonary capillary pressure induced acutely. The failure of the pulmonary extravascular fluid volume to decrease despite a fall in plasma volume and pressures corresponds to the well recognized delay in resolution of radiologic evidence of pulmonary congestion.

Permanent Pervenous Atrial Synchronized Ventricular Pacing

Permanent pervenous atrial synchronized ventricular pacing was successfully accomplished in three patients. Atrial sensing was obtained from an electrode positioned in the coronary vein. Atrial electrograms with P waves greater than 1.5 mv were present in all three cases. Ventricular stimulation was accomplished through a separate electrode placed in the right ventricular apex. The left cephalic vein admitted both catheters, and the two electrodes were connected to an implantable P wave synchronized unit. The beneficial hemodynamic effects of atrial synchronized ventricular pacing were clinically evident. This new pervenous technique provides an optimal method of synchronized pacing in patients with heart block, intact sinoatrial activity and significantly compromised cardiac function.

Mechanisms and significance of pacemaker-induced extracardiac sound

The frequency of pacemaker-induced extracardiac sound was studied in 26 patients with transvenous pacemakers and 2 with transthoracic units; mechanisms of this sound are described in 3 patients. In each case the extracardiac sound was associated with skeletal muscle contraction. In Case 1 intercostal muscle contraction was located at the site of a previously spliced transthoracic electrode wire, thereby suggesting stimulus leak. In Case 2 pacemaker-induced extracardiac sound developed at the site of an indifferent unipolar electrode, and the intensity of the sound was related to the output of the pacemaker generator. Pacemaker-induced extracardiac sound was detected in a third patient in whom a bipolar transvenous electrode was in apparent good position on routine chest roentgenogram. Right heart angiograms demonstrated that the catheter tip had perforated the right ventricular apex. The intensity of the sound appeared to be determined by the proximity of the electrode tip to the skeletal muscle as well as by the strength of the electrical stimulus.