Harvey J. Berger

Intact systolic left ventricular function in clinical congestive heart failure.

Clinical congestive heart failure (CHF) is traditionally associated wtih significant left ventricular (LV) systolic dysfunction. Over a 1-year period, 58 patients with CHF and intact systolic function (LV ejection fraction [EF] 62 +/- 11%) were identified. An objective clinical-radiographic CHF score was used to document the clinical impression. Based on radionuclide evaluation of peak filling rate, 38% of these patients were found to have a significant abnormality in diastolic function as measured by peak filling rate (less than 2.50 end-diastolic volume/s). An additional 24% of the patients had probable diastolic dysfunction with borderline abnormal peak filling rate measurements (2.5 to 3.0 end-diastolic volume/s). The disease states most frequently associated with CHF and intact systolic function were coronary artery disease and systemic hypertension. During a 3-month sampling period 42% of patients with clinical diagnosis of CHF referred to the nuclear cardiology laboratory were found to have intact systolic function; thus, intact systolic function is not uncommon in patients with clinical CHF. Abnormal diastolic function is the most frequently encountered mechanism for the occurrence of CHF. Definition of systolic and diastolic function appears relevant for development of optimal therapeutic strategies for the treatment of patients with CHF.

Multiple gated cardiac blood pool imaging for left ventricular ejection fraction: Validation of the technique and assessment of variability

The intrinsic variability and accuracy of left ventricular ejection fraction determined by multiple gated cardiac blood pool imaging was evaluated in 83 patients. Ejection fraction by gated studies correlated well with data from first pass radionuclide angiocardiography (r = 0.94) and from contrast angiography (r = 0.84). Intra- and interobserver variabilities of absolute ejection fraction were minimal (mean +/- standard deviation 1.4 +/- 1.2 and 1.6 +/- 1.5 percent, respectively) and were not different for normal (ejection fraction 55 percent or greater) and abnormal patients. Ejection fraction was determined twice in 70 patients: on the same day at intervals separated by 1 to 2 hours (41 patients) and on 2 different days (29 patients). Ejection fraction ranged from 18 to 91 percent and was normal in 37 patients. There was no difference in mean serial variabilities of absolute ejection fraction for all repeat studies performed on the same and separate days (3.3 +/- 3.1 versus 4.3 +/- 3.1 percent (not significantly different). The mean variability of absolute ejection fraction for repeat studies in normal patients was significantly greater than in abnormal patients (5.4 +/- 4.4 versus 2.1 +/- 2.0 percent, P less than 0.01). The incidence rate of absolute interstudy changes of 5 percent or more was significantly higher in normal than in abnormal patients (P less than 0.01). This differential variability should be considered in interpreting sequential changes in left ventricular ejection fraction. To be attributed to nonrandom physiologic alterations, the absolute change in ejection fraction should be 10 percent or more in normal patients and 5 percent or more in abnormal patients.

Assessment of cardiac performance with quantitative radionuclide angiocardiography: Right ventricular ejection fraction with reference to findings in chronic obstructive pulmonary disease

A reproducible noninvasive technique for measuring righ ventricular ejection fraction was developed using first pass quantitative radionuclide angiocardiography. Studies were obtained in the anterior position with a computerized multicrystal scintillation camera with high count rate capabilities. Right ventricular ejection fraction was calculated on a beat to beat basis from the high frequency components of the background-corrected right ventricular time-activity curve. In 50 normal adults, right ventricular ejection fraction averaged 55 percent (range of 45 to 65 percent). This radionuclide measure of right ventricular function was reproducible, with minimal inter- and intraobserver variability, and was sensitive to changes in inotropic state induced with isoproterenol. In 36 patients with chronic obstructive pulmonary disease, right ventricular ejection fraction ranged from 19 to 71 percent. All 10 patients with corpulmonale, as well as 9 additional patients, had an abnormal right ventricular ejection fraction. Arterial oxygen tension and forced expiratory volume were depressed significantly more in patients with abnormal right ventricular ejection fraction than in subjects with normal right ventricular function. There was no relation between abnormalities in right and left ventricular ejection fraction.

Physiologic correlates of right ventricular ejection fraction in chronic obstructive pulmonary disease: A combined radionuclide and hemodynamic study☆

Abstract The pathophysiologic correlates of right ventricular ejection fraction, as well as its relation to contractile function as assessed by systolic pressure-volume data, were evaluated in 20 patients with chronic obstructive pulmonary disease. Radionuclide and hemodynamic measurements were obtained simultaneously. Baseline determinations were obtained in all patients. In seven patients, studies were repeated after intravenous administration of sodium nitroprusside. This procedure allowed characterization of right ventricular performance at decreased afterload and provided two points necessary for definition of the right ventricular systolic pressure-volume relation. Seventeen of the 20 patients had a depressed right ventricular ejection fraction (less than 45 percent). There was a strong inverse linear correlation between right ventricular ejection fraction and afterload as assessed by peak or mean pulmonary arterial pressure (r = −0.81) and pulmonary vascular resistance index (r = −0.73). Right ventricular ejection fraction also correlated, although less strongly, with preload as assessed by right ventricular end-diastolic volume index (r = −0.56) and mean right atrial pressure (r = −0.51). It did not correlate with cardiac index, the ratio of peak pulmonary arterial pressure to right ventricular end-systolic volume index, arterial oxygen tension or left ventricular ejection fraction. After nitroprusside administration, mean arterial pressure, peak pulmonary arterial systolic pressure and pulmonary vascular resistance index decreased significantly. The slope (E) and the volume intercept (V 0 ) of each pressure-volume line were determined. Administration of dobutamine resulted in a leftward shift from the endsystolic pressure-volume line. There were poor correlations between E and right ventricular ejection fraction, as well as between E and the control ratio between pulmonary arterial systolic pressure and end-systolic volume index. These data demonstrate that, in addition to intrinsic contractile influences, right ventricular ejection fraction is highly dependent on afterload, but less dependent on preload. Right ventricular ejection fraction is a poor indicator of the slope of the systolic pressure-volume relation, raising questions concerning its use as an independent index of chamber contractility.

Variability in sequential measures of left ventricular performance assessed with radionuclide angiocardiography

The variability of left ventricular ejection fraction, normalized mean ejection rate and regional wall motion was evaluated from first pass quantitative radionuclide angiocardiograms obtained with a computerized multicrystal scintillation camera. Three radionuclide studies separated by an average of 4.3 days were obtained in each of 20 patients. Ejection fraction and ejection rate obtained on the first, second and third studies did not differ significantly. The mean (+/- standard deviation) variability of sequential ejection fraction measurement was 4.4 +/- 3.6 percent, and of sequential ejection rate was 0.56 +/- 0.47 sec(-1). Variations in measurements were not related to fluctuations in heart rate or blood pressure. Variability in ejection rate was significantly greater in patients with normal function than in those with abnormal function. Regional wall motion analysis was constant in 19 of 20 patients. Thus, sequential quantitative radionuclide angiocardiography allows reproducible serial assessment of left ventricular performance that can be performed with a low level of intrinsic variability.

Cardiac prostaglandin release during myocardial ischemia induced by atrial pacing in patients with coronary artery disease

The relation between myocardial release of prostaglandin and myocardial ischemia was studied in 12 selected patients with multivessel coronary artery disease. These 12 were chosen for analysis because they experienced angina pectoris, ischemic electrocardiographic changes and decreased myocardial lactate uptake during atrial pacing. Simultaneous aortic and coronary sinus blood samples were obtained at rest, during angina and after recovery and were assayed for prostaglandins F, E and A with radioimmunoassay. Cardiac release of prostaglandin F was observed during angina in 11 of 12 patients. Aortic prostaglandin levels remained constant throught each study. During angina, the mean aortovenous difference (+/- standard error) was -0.30 +/- 0.04 ng/ml (P less than 0.001) for prostaglandin F and -0.10 +/- 0.03 ng/ml (Pless than 0.001) for prostaglandin E. There was no significant release of prostaglandin A. Blood samples were also drawn at subanginal heart rates in two patients. Prostaglandin F was released only during angina. In three control patients with a chest pain syndrome and normal coronary arteries, comparable atrial pacing produced no release of prostaglandin F, E or A. These results, together with the known vascular and metabolic actions of prostaglandins, suggest that these pharmacologically active compounds may also play a physiologic role in the cardiac response to ischemia in man.

Radionuclide assessment of right and left ventricular exercise reserve after total correction of tetralogy of Fallot

First pass radionuclide angiocardiography under conditions of rest and exercise was utilized to evaluate a group of 16 postoperative patients who had undergone total surgical correction of tetralogy of Fallot. Functional data were related to thallium-201 myocardial imaging at rest, a noninvasive means of detecting right ventricular hypertrophy. All 16 patients were asymptomatic and 15 demonstrated normal right ventricular ejection fraction (equal to or greater than 45 percent) at rest. However, 13 patients manifested abnormal right ventricular ejection fraction responses to exercise (normal response is an absolute increment in an ejection fraction of 5 or greater percent). For the entire group, right ventricular ejection fraction at rest was 55 +/- 2 percent, whereas at exercise it was 52 +/- 2 percent (p = not significant). In contrast, left ventricular ejection fraction responses were normal in all patients. Thallium-201 imaging revealed substantial right ventricular uptake consistent with residual right ventricular hypertrophy, which was quantifiable in all patients. Thus, abnormalities in right ventricular performance during exercise may be detected readily by this radionuclide approach in these postoperative patients despite their asymptomatic clinical status and generally normal right ventricular performance at rest.

Contrasting acute effects of vasodilators (nitroglycerin, nitroprusside, and hydralazine) on right ventricular performance in patients with chronic obstructive pulmonary disease and pulmonary hypertension: A combined radionuclide-hemodynamic study

Fourteen patients with chronic obstructive pulmonary disease, mild to moderate pulmonary hypertension, and diminished right ventricular (RV) ejection fraction were studied acutely with use of a combined radionuclide-hemodynamic approach to assess and contrast the effects of 3 vasodilators on RV performance and central hemodynamic function. Nitroglycerin significantly decreased mean right atrial pressure, RV end-diastolic volume index, mean pulmonary artery pressure, cardiac index, and arterial oxygen tension, but did not affect pulmonary vascular resistance index and increased RV ejection fraction. Nitroprusside had similar effects on mean right atrial pressure, RV end-diastolic volume index, mean pulmonary artery pressure, cardiac index, and arterial oxygen tension, but also mildly decreased pulmonary vascular resistance index and did not alter RV ejection fraction. In contrast, hydralazine decreased pulmonary vascular resistance index and increased cardiac index and RV ejection fraction. The increase in ejection fraction correlated well with the decrease in pulmonary vascular resistance. These data suggest that in patients with mild to moderate secondary pulmonary hypertension, acute administration of hydralazine results in a substantial improvement in RV performance by virtue of decreasing pulmonary vascular resistance. In contrast, nitroglycerin and nitroprusside demonstrate predominant effects that reduce preload, cardiac index, and arterial oxygen tension. Based on these data, afterload reduction with vasodilators such as hydralazine may be potentially useful in selected patients with pulmonary disease and secondary pulmonary hypertension and appear preferable to agents that primarily reduce preload. Further long-term studies are necessary to establish therapeutic efficacy.

Noninvasive diagnosis of pulmonary arterial hypertension in chronic obstructive pulmonary disease: Right ventricular ejection fraction at rest

Because right ventricular ejection fraction (RVEF) depends on impedance to RV ejection, the hypothesis was tested that an abnormality in radionuclide-determined RVEF would be a useful noninvasive predictor of pulmonary artery (PA) hypertension in patients with chronic obstructive pulmonary disease (COPD). Simultaneous measurements of resting RVEF and PA pressure were made in 30 patients with COPD. All were stable and without clinical evidence of respiratory decompensation or congestive heart failure. Eleven patients had normal (less than 20 mm Hg) mean PA pressure and 19 patients had PA hypertension. The average RVEF was 41 +/- 7% (range 29 to 60%). Five patients had normal (greater than 45%) and 25 patients depressed RVEF. An inverse linear relation between mean PA pressure and RVEF was present (r = -0.74). In the group with normal PA pressure, RVEF averaged 48% (range 42 to 60%). In the group with PA hypertension, RVEF averaged 36% (range 29 to 44%). RVEF was significantly higher in the group with PA hypertension. Using RVEF less than 45% as an indicator of PA hypertension, the sensitivity was 100%, the specificity 55%, and the predictive accuracy of a positive result 79%. Using RVEF less than or equal to 40% as an indicator of PA hypertension, the sensitivity was 75%, the specificity 100%, and the predictive accuracy of a positive study 100%. Thus, radionuclide-determined RVEF using the first-pass technique and a multicrystal camera is a useful noninvasive test for diagnosing PA hypertension in patients with advanced COPD.

Comparison of exercise radionuclide angiocardiography and thallium-201 myocardial perfusion imaging in coronary artery disease

Abstract First pass radionuclide angiocardiography and thallium-201 myocardial perfusion imaging were performed at rest and during exercise in 48 patients with chest pain: 39 with angiographically documented coronary artery disease and 9 with normal coronary arteries. Maximal graded upright bicycle exercise was used for both studies to assure identical exercise conditions. All nine patients without coronary artery disease had normal exercise thallium images, normal exercise regional wall motion and at least a 5 percent absolute increase in left ventricular ejection fraction during exercise (normal exercise left ventricular reserve). Ischemic S-T segment depression was demonstrated in 17 (44 percent) of the 39 patients with coronary artery disease. Findings on the two exercise tests were concordant in all cases. New or augmented thallium perfusion defects were detected in 24 (62 percent) of the 39 patients, whereas abnormal exercise left ventricular reserve was present in 33 (85 percent) (p