Louis E. Teichholz

Problems in Echocardiographic Volume Determinations: Echocardiographic-Angiographic Correlations in the Presence or Absence of Asynergy

The relation of minor and major axes of the left ventricle was determined in 100 left ventriculograms performed in the right anterior oblique projection. This relation taken over a wide range of volumes was used to derive a theoretically correct equation for determination of ventricular volume by echocardiography. The final equation was: V =[7.0/2.4 +d] (D3), where V = volume and D = the echocardiographically measured internal dimension. In 12 patients without asynergy, this equation accurately and directly calculated end-systolic and end-diastolic volumes whether the left ventricle was small or large. However, in 12 patients exhibiting left ventricular asynergy the correlation between angiographically and echocardiographically determined volumes was poor. Thus, caution is recommended in the use of time-motion echocardiography to calculate ventricular volumes in patients with coronary artery disease and possible left ventricular asynergy.

Angiographie morphology and the pathogenesis of unstable angina pectoris

In 110 patients with either stable or unstable angina, the morphology of coronary artery lesions was qualitatively assessed at angiography. Each obstruction reducing the luminal diameter of the vessel by 50% or greater was categorized into one of the following morphologic groups: concentric (symmetric narrowing); type I eccentric (asymmetric narrowing with smooth borders and a broad neck); type II eccentric (asymmetric with a narrow neck or irregular borders, or both); and multiple irregular coronary narrowings in series. For the entire group, type II eccentric lesions were significantly more frequent in the 63 patients with unstable angina (p Type II eccentric lesions were also present in 29 of 41 arteries in patients with unstable angina compared with 4 of 25 arteries in those with stable angina (p

Study of Left Ventricular Geometry and Function by B-Scan Ultrasonography in Patients with and without Asynergy

Abstract To assess the usefulness of B-scan ultrasonography in determining left ventricular geometry and function, 25 patients with various cardiac disorders were studied with B-scan imaging within 24 hours of performance of biplane cine angiography of the left ventricle. In 14 patients asynergy present on the left anterior oblique ventriculogram was also detected on the B-scan image. A good correlation was found between the area ejection fractions as determined from the B-scan and the ventriculographic silhouettes (r = 0.92). A good correlation was also found between the B-scan area ejection fraction and the biplane volume ejection fraction (r = 0.87), even in patients with left ventricular asynergy, in whom the quantification of left ventricular geometry and function by standard time-motion echocardiography may be inaccurate. Thus, B-scan ultrasonography appears to be a safe, noninvasive, easily repeated technic for the study of left ventricular geometry, ejection and segmental motion in patients with v...

Mitral valve prolapse: A review of associated arrhythmias

The syndrome of mitral valve prolapse with associated auscultatory-electrocardiographic findings is now well documented. Two representative cases of repetitive tachyarrhythmias in patients with mitral valve prolapse are discussed as well as an analysis of the 589 cases in the English literature of arrhythmias in patients with mitral valve prolapse. The average age of the patients was 38 years; 70 per cent of them were women. Symptoms were variable, but palpitations occurred in 44 per cent, lightheadedness in 12 per cent and syncope in 4 per cent. Premature atrial and/or ventricular contractions were found in 55 per cent, premature ventricular contractions in 45 per cent, supraventricular tachycardia in 6.1 per cent and ventricular tachycardia in 6.3 per cent. Sudden death was noted in 1.4 per cent. A discussion of the pathogenesis of arrhythmias and therapy concludes this review.

Septal perforator compression (Narrowing) in idiopathic hypertrophic subaortic stenosis

Thirteen patients with idiopathic hypertrophic subaortic stenosis were compared with two groups of subjects: 10 patients with chest pain, normal coronary arteries and a normal left ventricle, and 10 patients with left ventricular hypertrophy. Five of the latter had aortic stenosis and five had idiopathic left ventricular hypertrophy. Coronary arteriography revealed that the septal branches of the left anterior descending artery closed or narrowed during systole in patients with idiopathic hypertrophic subaortic stenosis and did not do so in the other patient groups. This narrowing is possibly related to an abnormal position of the septal arteries within the septum in idiopathic hypertrophic subaortic stenosis. Systolic compression of the septal perforator arteries is not a pathognomonic sign of idiopathic hypertrophic subaortic stenosis.

Spectrum of exercise thallium-201 myocardial perfusion imaging in patients with chest pain and normal coronary angiograms.

Abstract Twenty-seven consecutive patients with chest pain and no significant obstructive coronary lesions on arteriography were studied with thallium-201 myocardial imaging during exercise and at rest. Fifteen of the patients had typical and 12 atypical angina pectoris. All underwent treadmill exercise electrocardiographic testing; the results were abnormal in 10 patients (37 percent), normal in 14 (52 percent) and uninterpretable in 3 (11 percent). The exercise and resting thallium-201 myocardial images were normal in 23 patients (85 percent); the results of exercise testing were normal in 12 of these patients, abnormal in 8 and uninterpretable in 3. Four patients had a perfusion defect on exercise thallium-201 myocardial imaging; the defect filled in by 4 hours in two patients but persisted in the other two. In contrast, when thallium-201 myocardial imaging was performed in 28 consecutive patients with angiographic coronary artery disease, only 5 patients (16 percent) had normal exercise and resting thallium-201 myocardial images. Therefore, thallium-201 myocardial imaging offers a more effective means of identifying patients with chest pain and no obstructive coronary artery disease than the clinical history or the exercise electrocardiographic test, or both. However, 15 percent of these patients will have abnormal exercise thallium-201 myocardial images because of factors that have not yet been identified.

Acute coronary hemodynamic response to cigarette smoking in patients with coronary artery disease

The acute changes in coronary blood flow and coronary resistance that occur in response to cigarette smoking have not been accurately determined. To define the factors that affect this response, coronary sinus blood flow was measured in 16 patients (group I) with coronary artery disease and in 6 patients (group II) without angiographically detectable coronary disease. Seven patients (group IA) had severe (greater than or equal to 75%) proximal left coronary lesions and nine patients (group IB) had significant distal lesions with 50% or less proximal stenoses. Group I had a smaller overall increase (increases 1.6 +/- 5.3%) in coronary sinus blood flow than did group II (increases 7.7 +/- 6.1%) (p less than 0.05). Coronary resistance increased overall (increases 2.7 +/- 5.3%) in group I but decreased (decreases 2.4 +/- 3.4%) in group II (p less than 0.05). Patients in group IA had a highly significant increase in coronary resistance as compared with group IB (increases 7.0 +/- 4.2% versus decreases 0.9 +/- 2.6%) (p less than 0.001). Coronary sinus flow tended to decrease (decreases 1.2 +/- 4.6%) in group IA but to increase (increases 3.8 +/- 5.1%) in group IB (p = 0.06). It is concluded that smoking increases coronary resistance in patients with coronary artery disease. A greater impact is observed in patients with a severe proximal stenosis than in those with a distal stenosis. It is proposed that smoking increases coronary artery tone at the site of the stenosis, limiting the coronary flow response proportionally to the size of the affected vascular bed.

Left ventricular myxoma: Echocardiographic diagnosis and review of the literature

A 33 year old man with the findings of mild aortic stenosis had an echocardiographic diagnosis of left ventricular myxoma prolapsing through the aortic valve during each ventricular systole. The M-mode echocardiogram, B-scan ultrasonogram and angiograms of this patient are presented. The clinical characteristics in all the reported cases of left ventricular myxomas are reviewed.

Relation between exercise-induced changes in ejection fraction and systolic loading conditions at rest in aortic regurgitation

To examine the role of systolic wall stress at rest in determining left ventricular performance during exercise in aortic regurgitation (AR), systolic wall stress (measured by M-mode echocardiography) was related to changes in left ventricular function during maximal exercise (evaluated by radionuclide ventriculography) in 30 patients with chronic aortic regurgitation. Of these 30 patients, 7 had a normal exercise response, defined as an absolute increase in ejection fraction of 5% or greater (Group I) and 23 had abnormal exercise response, defined as no change (less than 5% change) or a decline (less than or equal to 5%) in ejection fraction (Group II). Patients in Group I had a significantly lower radius/wall thickness ratio (2.5 +/- 0.2 versus 3.1 +/- 0.1, p less than 0.01) and lower peak systolic wall stress (123 +/- 11 versus 211 +/- 12 X 10(3) dynes/cm2, p less than 0.01) than patients in Group II. An increase in ejection fraction during exercise was seen in 6 of the 9 patients with normal systolic wall stress at rest (less than 150 X 10(3) dynes/cm2), but in only 1 of 21 patients with elevated systolic wall stress (p less than 0.001). Peak systolic wall stress at rest varied linearly, and inversely with changes in left ventricular ejection fraction during exercise (r = 0.60, p less than 0.001). Groups I and II did not differ in ejection fraction at rest, clinical symptoms or maximal work load achieved.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative contrast echocardiography to evaluate mitral valve operations

Intraoperative two-dimensional contrast echocardiography was performed on 29 patients undergoing open heart surgery to determine the presence of mitral regurgitation before and immediately after the operative procedure: 14 patients had predominant mitral stenosis, 9 had severe mitral regurgitation and 6 had no mitral valve disease (control subjects). Two-dimensional echocardiography was performed by applying a 5 MHz transducer directly on the heart during injection of saline solution through an apical ventricular sump or transseptal needle, generating contrast microbubbles, with imaging in two planes. Baseline studies were performed after thoracotomy and pericardiotomy before cardiopulmonary bypass, and a second study was done after the operative procedure, with the patient off cardiopulmonary bypass with hemodynamic stabilization before chest closure. No control subject had contrast evidence of mitral regurgitation before or after cardiopulmonary bypass. Two of three patients with mitral valvuloplasty and two of five with commissurotomy required a second operative procedure before chest closure because of persistent mitral regurgitation detected by intraoperative two-dimensional contrast echocardiography. Thirteen of the 15 patients with valve replacement had no mitral regurgitation after cardiopulmonary bypass. Intraoperative two-dimensional echocardiographic findings correlated with data from postoperative clinical examinations and two-dimensional echocardiography-Doppler studies. It is concluded that two-dimensional echocardiography with contrast is an important intraoperative tool for assessing the presence and relative severity of mitral regurgitation after mitral commissurotomy, valvuloplasty or valve replacement. This technique may allow surgeons to be more aggressive in combining reparative operative procedures (that is, commissurotomy and valvuloplasty) in an attempt to retain native valves.