Ivan A. D'Cruz

Submitral Calcification or Sclerosis in Elderly Patients: M Mode and Two Dimensional Echocardiography in ' 'Mitral Anulus Calcification' '

Submitral calcification or sclerosis was visualized with M mode echocardiography in 84 elderly patients, 35 of whom were also studied with two dimensional echocardiography. Posterior submitral calcification, commonly referred to as mitral anulus calcification, was present in 82 patients and was located in the angle between the posterior mitral leaflet and left ventricular posterior wall, rather than in the mitral anulus proper. M mode scans from the left ventricle to the left atrium showed that posterior submitral calcification ended abruptly in 66 cases, and in these it became contiguous with the posterior atrioventricular junction (true mitral anulus) in only 14 instances, in 16 patients the posterior submitral calcification sloped anteriorly to merge with the posterior aortic root. Anterior submitral calcification was visualized in 12 patients, 10 of whom also had posterior submitral calcification. Anterior submitral calcification was usually located immediately anterior to the base of the anterior mitral cusp. In two cases, if appeared to arise in the region between the aortic and mitral rings; in one instance, it was located in the mid left ventricle, in the mitral chordal region. We suggest that the terms anterior and posterior submitral calcification are more appropriate than mitral anulus calcification because in most cases such calcific deposits do not appear to be located in or to arise from the true mitral anulus.

Differences in the Shape of the Normal, Cardiomyopathic, and Volume Overloaded Human Left Ventricle

A transformation from the normal elliptical shape of the left ventricle that may accompany various disease states and that may be indicative of myocardial remodeling, has not been completely addressed in part because of the need for a descriptor of shape that is independent of chamber size. Accordingly, the goal of this study was twofold: to derive dimensionless echocardiographic descriptors of left ventricle chamber shape that are independent of chamber volume and to use these descriptors to quantitatively compare the shape of left ventricles that were either of normal size (81 +/- 17 ml, 19 patients) or were enlarged secondary to idiopathic cardiomyopathy (194 +/- 61 ml, 46 patients) or chronic aortic or mitral valve incompetence (196 +/- 67 ml, 14 patients). Two-dimensional and M-mode determined descriptors of left ventricle shape based on its width, length, and area were found to be independent of left ventricle volume. These descriptors were significantly greater in cardiomyopathy compared with the normal or dilated left ventricle secondary to valvular incompetence, indicating that the left ventricle had become nearly spherical. A spherical shape of the left ventricle was not observed with valvular incompetence. The ability to classify a patient as having either a normal or a cardiomyopathic left ventricle by discriminant function analysis was enhanced when both left ventricle size and shape were considered. In a prospective study using discriminant function and fractional shortening, we found that patients with valvular incompetence could be classified as having either a normal discriminant function and fractional shortening, an abnormal discriminant function and normal fractional shortening, or an abnormal discriminant function and fractional shortening.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic correlates of atrial contraction in normal and abnormal atrial rhythm

Abstract Echocardiographic manifestations of normal atrial contraction on the left ventricular posterior wall (LVPW), ventricular septum (VS), right ventricular anterior wall (RVAW), and the aortic root have not been described previously in detail. In 150 consecutive echocardiograms recorded from patients in normal sinus rhythm, we have been able to find correlates of normal atrial contraction (A waves) on the LVPW in 130, on the VS in 95, on the RVAW in 27, and on the aortic root in 107. These waves occurred on the aortic root 0.04 0.06 sec after the onset of the P wave, and they occurred on the other cardiac structures 0.06 0.10 sec after the onset of the P wave. That these waves were due to atrial contraction was established by their close temporal relationship to the P wave in normal and abnormal atrioventricular (AV) conduction and by their absence whenever the QRS complex was not preceded by a P wave. First-degree AV block was associated with “premature” mitral closure. Premature atrial contractions produced definite A waves on the aortic root, but less distinct waves on the other structures. These echocardiographic correlates of atrial contraction provide another noninvasive means of assessing the atrial contribution to ventricular filling. Echocardiographic study of ten patients in atrial flutter showed that atrial flutter contractions produced regular undulations on the mitral valve leaflets, tricuspid valve leaflets, left ventricular posterior wall, ventricular septum, aortic root and cusps, and the anterior and posterior left atrial wall. Echocardiographic observations made in 40 patients in atrial fibrillation frequently showed undulations on the mitral and tricuspid valves, aortic root, pulmonary valve cusp, and left atrial anterior wall. In some instances, the diastolic undulations on the mitral valve leaflets showed only minimal variations in amplitude and frequency even though the simultaneously recorded electrocardiogram showed marked irregularity of amplitude and frequency of atrial undulations.

Unusual echocardiographic appearances attributable to submitral calcification simulating left ventricular “masses”

Using M‐mode and cross‐sectional echocardiography, we visualized in five patients abnormal large echos attributable to anterior submitral calcification or sclerosis (on or near the ventricular aspect of the anterior mitral leaflet). Such abnormal echos on M‐mode echocardiography could have been mistaken for a mass in the left ventricular chamber. Autopsy in two cases confirmed the presence of nonrheumatic anterior submitral calcification. Echocardiographic features of anterior submitral calcification which are helpful in differentiating it from neoplastic or thrombotic ventricular masses include (1) less diastolic mobility and more echo density; (2) continuity with the base of the anterior mitral leaflet and/or the posterior aortic root region, whereas tumors or thrombi are attached to the left ventricular wall; and (3) calcification in the region of posterior “mitral annulus.” Cross‐sectional long‐axis views and M‐mode scanning from the left ventricle to the aortic root were particularly helpful in making the differentiation.