Mario R. Testelli

Electrocardiographic diagnosis of myocardial infarction in the presence of bundle branch block (right and left), ventricular premature beats and wolff-parkinson-white syndrome

Summary The diagnostic difficulties in the recognition of myocardial infarction in the presence of bundle branch block and the Wolff-Parkinson-White syndrome are discussed. However, through a “deductive” approach in the analysis of the electrocardiogram, such difficulties may be eliminated to a great extent. The knowledge of the sequence of cardiac activation in normal and abnormal circumstances as in bundle branch block, “pre-excitation syndrome”, and extrasystolia, is fundamental. To sum up, the “deductive” approach to clinical electrocardiography not only facilitates the general diagnosis but also indicates the limitations in arriving at a precise diagnosis of infarction.

On the mechanism of production of the heart sounds

Abstract The mechanisms of the heart sounds have been investigated by means of animal experiments and the recording of tracings in normal human subjects. Simultaneous tracings of pressure have been recorded in dogs from the two ventricles, from one ventricle and its respective atrium, and from the aorta and pulmonary artery. The time relationship of the motion of the various valves was revealed by these tracings plus simultaneous external phonocardiograms. Simultaneous intracardiac phonocardiograms confirmed these data. Selective phonocardiograms have been recorded through various filters in man, together with low-frequency tracings of the precordium, carotid and aortic tracings, and jugular tracings. The following conclusions have been reached (Fig. 11): 1. 1. The first sound is made of 3 phases: low-pitched beginning, due to 2. myocardial tension; higher-pitched central phase, due to valvular events; lowpitched final phase, due to vascular phenomena. The central phase contains at least 4 vibrations which correspond to the motion of the 4 valves in the following order: mitral closure, tricuspid closure, pulmonic opening, aortic opening. Whenever one or more large vibrations correspond to the phase of ejection, they are likely to be of a vascular nature. 3. 2. The second sound is made of 3 phases: low-pitched beginning, due to eddies preceding the valvular closure; higher-pitched central phase, due to closure of the semilunar valves; and low-pitched final phase, due to final vibrations plus opening of the A-V valves. The central and final phases correspond, firt, to the closure of the semilunar valves and, then, to the opening of the A-V valves, in this order: aortic closure, pulmonic closure, tricuspid opening, mitral opening. 4. 3. Rapid filling of the ventricles is usually nonsimultaneous, in this order: rapid filling of right ventricle, rapid filling of left ventricle. These data confirm some interpretations of previous workers but exclude others. Time intervals for the various phases are given for large dogs. Measurements taken in phonocardiograms of normal persons, recorded with a technique which is identical to that used in dogs, indicate that similar figures can be used in man.

Intracardiac Phonocardiography in Mitral and Aortic Valve Lesions

Abstract Intracardiac phonocardiograms were studied during left heart catheterization in two normal subjects and 15 patients with mitral or aortic valve lesions. Data pertaining to normal intracardiac, left atrial and left ventricular sounds are discussed. Data obtained in mitral stenosis, mitral insufficiency, aortic stenosis and aortic insufficiency are reported. The murmurs were best recorded in those chambers which received the blood flow (normal or pathologic) during the production of each murmur. Observations dealing with the third or fourth heart sound and with the mitral opening snap are reported.

Apical diastolic and presystolic murmurs of proved functional nature

Abstract We have collected a series of thirty-two clinical cases in which a diastolic or presystolic murmur simulating that of mitral stenosis was recorded in the phonocardiogram. The functional nature of the murmur was proved in nine by autopsy, in ten by right heart catheterization (pulmonic stenosis or septal defect), and in thirteen by left heart catheterization, which revealed the absence of a mitral gradient. A clinical error was made in most cases, except those in which an entirely different clinical picture was present (congenital heart disease, recent myocardial infarct). The phonocardiogram was correctly interpreted in most cases. However, in five cases the tracing was interpreted as being consistent with mitral stenosis. In two of them a “dynamically insignificant” mitral stenosis was suspected, although not proved . In the other three, no stenosis whatsoever was finally admitted. A case in which the murmur was probably due to acute rheumatic carditis is discussed in detail and repeated tracings are presented. The various causes which can lead to a clinical error are listed and it is shown that, in many of these cases, a phonocardiogram helps to rule out mitral stenosis. It is further shown that in a few exceptions even the phonocardiogram can be misinterpreted. Left heart catheterization often reveals the absence of a mitral block thus reducing the doubtful cases (dynamically insignificant lesion) to a minority.

Intracardiac electrocardiography; observations during left heart catheterization in man.

Abstract Observations are reported of intracardiac electrocardiography recorded during left heart catheterization, performed by the direct transthoracic puncture of the left atrium. The report deals with 14 cases of rheumatic mitral or aortic valvular lesions, and 1 case of syphilitic aortic insufficiency. Three other cases were discarded because of failure of the catheter to pass through the mitral valve. In eight cases catheterization of the right chambers was also performed with recording of intracardiac potentials. Right and left heart catheterizations and i.e. ECGs obtained in a case of atrial septal defect and one case of primary pulmonary hypertension are also presented. The maneuver of multiple pullbacks was used. Attention is called to the proper technique so as to prevent artefacts. When normal sinus rhythm is present, the intracardiac P wave in the left atrium falls in the second part of a simultaneously recorded standard lead P. The asynchronism between the intracardiac and peripheral P waves was found to vary between 0.05 and 0.09 sec in cases with predominant mitral stenosis, with variations of less than 0.02 sec in a single case. This increased asynchronism is due to the late inscription of the intrinsicoid deflection of the P wave in the left atrium, as shown by the findings in three cases in which right and left heart catheterizations were performed. The degree of asynchronism was found to be inversely proportional to the voltage of the intracardiac P wave. No correlation was seen between the voltage of the P wave recorded in either atrium and the P in a standard lead. No relationship was found between the P wave inside of the left atrium and the values of atrial pressure, or calculated mitral valve area or resistance. In cases of atrial fibrillation, polymorph and irregular waves were recorded in both atria. In atrial flutter, “f” waves were recorded. The ventricular complex within the left atrium was strictly related to the QRS as recorded within the left ventricle. The P waves inside the ventricle were normally flat; only one exception was encountered. In atrial fibrillation or flutter, no atrial activity was recorded in either ventricle. The patterns of premature ventricular beats and of subendocardial injury are presented. Normal left ventricular complexes were recorded in cases of isolated right ventricular hypertrophy. In cases of left ventricular hypertrophy, on the contrary, increased voltage of the intraventricular QRS was recorded. ST and T wave changes were found in the presence of left ventricular hypertrophy or “strain.” Comparison between intracardiac unipolar leads and left precordial leads was made; discordant points were presented and an explanation was attempted. Occasional rS patterns within the left ventricle were observed and are discussed.

Duration of right ventricular pressure curve in transient right bundle branch block: Observations during catheterization in man

Abstract The duration of the right ventricular pressure curve in transient right bundle branch block has not previously been studied. During approximately 2,000 consecutive heart catheterizations, right bundle branch block was produced in 37 patients. In 4 of the 37, transient right bundle branch block was recorded. These 4 patients had different hemodynamic conditions. Photographic superimposition and amplification of the tracings shows that after right bundle branch block (1) the duration of the S-T interval is shortened because the end of S is inscribed much later than the end of T, and (2) the duration of the right ventricular pressure curve is shortened because the upstroke is delayed while the downstroke is not. In the presence of an obvious delay in the onset, no obvious change is seen in the velocity of inscription of the systolic rising phase of the ventricular pressure pulse after right bundle branch block. These observations indicate that only the presystolic slope pressure (the foot before the onset of ventricular contraction) shows the effects of the altered right ventricular activation when right bundle branch block is produced during catheterization in man.