Yasuharu Nimura

Semiquantitative grading of severity of mitral regurgitation by real-time two-dimensional Doppler flow imaging technique

An attempt was made to determine whether mitral regurgitation could be detected and its severity evaluated semiquantitatively by newly developed real-time two-dimensional Doppler flow imaging in 109 patients who underwent left ventriculography. In the Doppler flow imaging technique, Doppler signals due to blood flow in the cardiac chambers are processed using a high speed autocorrelation technique, so that the direction, velocity and turbulence of the intracardiac blood flow are displayed in the color-coded mode on the monochrome B-mode echocardiogram in real time. Mitral regurgitant flow was imaged as a jet spurting out from the mitral valve orifice into the left atrial cavity. It was noted that the regurgitant jet in the left atrial cavity had a variety of orientations and dynamic features when studied by the present technique. The sensitivity of the technique in the detection of mitral regurgitation was 86% as compared with that of left ventriculography. Mitral regurgitation in the false negative cases was mostly mild. On the basis of the farthest distance reached by the regurgitant flow signal from the mitral valve orifice, the severity of regurgitation was graded on a four point scale and these results were compared with those of angiography. A significant correlation (r = 0.87) was found between Doppler imaging and angiography in the evaluation of the severity of mitral regurgitation. A similar result was obtained for the evaluation based on the area covered by the regurgitant signals in the left atrial cavity. Thus, noninvasive semiquantitative evaluation by real-time two-dimensional Doppler flow imaging appears to be a promising clinical technique.

Augmentation of atrial contribution to left ventricular inflow with aging as assessed by intracardiac Doppler flowmetry.

The influence of aging on the left ventricular (LV) function in diastole was investigated from the aspect of the mitral inflow pattern using 2-dimensional Doppler echocardiography. The subjects for the investigation were 69 persons who were diagnosed as healthy by a checkup examination. The peak velocity in the rapid filling phase and that in the atrial contraction phase tended to decrease and to increase with aging, respectively. However, these tendencies were not statistically significant. However, the ratio of the atrial contraction phase to the rapid filling phase showed a significant increase with aging (r = 0.82, p less than 0.001). Therefore, it is considered that the mitral flow conditions are influenced by aging. The result obtained is also interpreted to mean that the LV distensibility in early diastole is impaired with aging and that the contribution of the atrial contraction to LV filling is compensatorily augmented.

Smoke-like echo in the left atrial cavity in mitral valve disease : its features and significance

In some patients with mitral stenosis, a smoke-like echo is observed in the left atrial cavity. The present study in 116 consecutive patients with rheumatic mitral valve disease investigated the echocardiographic features and clinical significance of this echo. The smoke-like echo is characterized by the following echocardiographic features: 1) it is composed of numerous microechoes; 2) it curls up slowly in the enlarged left atrial cavity; and 3) it vanishes as soon as it pours into the ventricular cavity. Hemostasis in the left atrial cavity was considered to be an important underlying condition for development of the echo. Hemorheologic conditions indicated that the shear rate of blood flow in the left atrial cavity was calculated to be low enough for the development of red blood cell aggregation. These conditions suggest that the source of the smoke-like echo might be aggregated cells due to hemostasis in the left atrial cavity. Left atrial thrombi were detected in many patients who had this echo in the left atrial cavity. Although it has not been conclusively determined that the presence of the smoke-like echo is a necessary condition for thrombus formation, this echo appears to be closely related to thrombus formation in the left atrial cavity. It is concluded that the presence of this echo indicates severe left atrial hemostasis and is a warning for thrombus formation.

Evaluation of tricuspid regurgitation by pulsed Doppler and two-dimensional echocardiography.

We analyzed tricuspid regurgitation noninvasively using ultrasonic pulsed Doppler and twodimensional echocardiography in 66 patients in whom tricuspid regurgitation was suspected from routine clinical evaluation. All of the patients also underwent right ventriculography. Ten healthy subjects served as controls. In 62 of 66 patients, the study was adequately performed. In 58 of 62 patients, pansystolic abnormal Doppler signals were detected in the right atrial cavity, and were interpreted to indicate tricuspid regurgitant flow. Two-dimensional echocardiograms in the parasternal four-chamber view demonstrated that the region in which the abnormal Doppler signals were detected was spindle-shaped and extended from the tricuspid orifice toward the right atrial posterior wall parallel to the interatrial septum. The severity of regurgitation was graded on a four-point scale, based on the distance reached by the abnormal signals from the tricuspid orifice toward the posterior wall. For comparison, the right ventriculograms were evaluated on a four-point scale similar to the Sellers classification of mitral regurgitation. The grades by the two methods matched exactly in 36 cases, differed by one level in 23 and by two levels in three. Thus, the two methods showed a good correspondence. Similar results were obtained for the grading based on the area covered by the abnormal signals. We conclude that noninvasive grading of tricuspid regurgitation by ultrasonic pulsed Doppler and two-dimensional echocardiography is practicable.

Clinical applications of a new type of real-time two-dimensional Doppler flow imaging system

The clinical significance of a newly developed real-time 2-dimensional (2-D) Doppler flow imaging technique was assessed. In the instrumentation of the echocardiograph, the pulsed Doppler mechanism was incorporated in a wide-angle, phased-array system. The Doppler flow signals obtained from the cardiac chamber were processed on the basis of the autocorrelation principle. The direction, velocity and variance of the intracardiac blood flow were calculated in real time and displayed in the color-coded mode on the television screen, and were superimposed on the 2-D echocardiographic image of the heart. The technique was used in 20 healthy subjects and 100 cardiac patients. The new technique clearly visualized the whole aspect of intracardiac blood flow by the cine mode in real time; thus, the technique may be called Doppler cineangiocardiography. The mitral inflow and the aortic ejection flow were clearly demonstrated. A regurgitant jet from the valve orifices was dynamically visualized as seen in the cineangiogram. The spatial orientation and extent of the regurgitant jet were easily assessed. The jet stream through the stenotic mitral orifice was well imaged in the left ventricular cavity, showing a variety of stream directions. Intracardiac shunts in ventricular septal defect and atrial septal defect were clearly visualized. The defect could be localized on the interventricular septum on the basis of the site where the shunt flow spurted, although the echocardiographic interruption was not demonstrated in the 2-D echocardiographic image of the cardiac structure. Although some technical problems remain, our new technique greatly improves the diagnostic efficacy of ultrasound.

Analysis of heart motion with ultrasonic Doppler method and its clinical application

Abstract 1. 1. The ultrasonic Doppler method has been used to obtain information on the movements of the heart. 2. 2. The time of development of valvular movements is determined; a wide range of variation under various conditions is shown. 3. 3. In cases of coronary sclerosis, hypertension, etc., the opening of the mitral valve is delayed, revealing a prolonged duration of isometric relaxation. The abnormalities develop prior to myocardial change in the ECG. 4. 4. In cases of mitral stenosis the closing of the mitral valve is delayed and the opening is quickened, showing the shortening of isometric relaxation. 5. 5. In cases of mitral valvular disease with auricular fibrillation the shorter the preceding R-R, the more delayed is the closing of the mitral valve. 6. 6. Prolonged isometric relaxation develops even in cases of nephritis, hypothyroidism, liver disease, etc. 7. 7. The time relationship between the opening of the mitral valve, the closing of the semilunar valves, and the end of the T wave is referable to the following modes: (a) a delayed opening of the mitral valve; (b) early development of the opening of the mitral valve; (c) early development of the closing of the semilunar valves (Hegglin syndrome); (d) coexistence of (a) and (c); (e) early development of the opening of the mitral valve subsequent to early development of the closing of the semilunar valves in cases of marked Hegglin syndrome.

Assessment of coronary blood flow by transesophageal two-dimensional pulsed Doppler echocardiography

Abstract Recent advances in Doppler echocardiographic techniques enable us to estimate coronary flow dynamics in patients. 1–5 These methods, however, require invasive procedures, and repeated examinations in the same patient are undesirable. Although noninvasive detection of coronary flow with conventional Doppler technique from a transthoracic approach has been performed, 6,7 technical problems—effects of cardiac motion and difficulty in differentiating coronary blood flow from other intracardiac flow—remain. Transesophageal pulsed Doppler echocardiography, 8 originally reported to estimate mitral regurgitation, 9 may also be available in detecting coronary flow when combined with 2-dimensional echocardiography. In the present study, we attempted to detect coronary flow by the transesophageal Doppler technique.

Thallium perfusion and cardiac enzyme abnormalities in patients with familial hypertrophic cardiomyopathy.

Twelve patients of five families with familial hypertrophic cardiomyopathy were examined. Within each family, the older patients showed dilation or diminished contraction of the left ventricle by echocardiography or angiocardiography more frequently than did younger patients. LDH1 fraction (lactic dehydrogenase isoenzyme) and MB-CPK (creatinine phosphokinase isoenzyme) were increased in 7 of 10 patients. Thallium-201 myocardial scintigraphy showed perfusion defect or hypoperfusion in 9 of 10 patient. Eleven cases demonstrated remarkable hypertrophy at the macroscopic level. Marked fibrosis was observed in all 5 of the 11 patients whose histologic findings were obtained. In two necropsy cases, disarray was found throughout the right and left ventricles and the pattern of fibrosis was massive. These findings were different from those of ordinary hypertrophic cardiomyopathy. It is possible that each patient with familial hypertrophic cardiomyopathy may develop more prominent thallium and enzyme abnormalities as he becomes older, regardless of whether he develops a dilated cardiomyopathy picture.

Intracardiac flow pattern in mitral regurgitation studied with combined use of the ultrasonic pulsed doppler technique and cross-sectional echocardiography

Abstract Thirty patients with mitral regurgitation confirmed by left ventriculography were studied from a transcutaneous approach with combined use of the ultrasonic pulsed Doppler technique and cross-sectional echocardiography. The location of the abnormal Doppler signals was revealed with cross-sectional echocardiography, displayed in two dimensional images. Abnormal Doppler signals, never detected in healthy subjects, were recorded during systole at the mitral area and in the left atrial cavity in patients with mitral regurgitation. In the left atrial cavity, these signals were detected in 11 patients. They were either bidirectional or unidirectional and of a wide velocity range. The area in which these signals were detected was mapped on the cross-sectional echocardiogram, and the map was considered to show the main direction and distribution of regurgitant flow from the mitral ostium into the left atrial cavity. The main direction of the regurgitant flow determined with this method closely coincided with that revealed by angiocardiography. At the mitral area, abnormal Doppler signals were detected in 28 patients. These signals were powerful, bidirectional and of a wide range of velocity. It is believed that these signals indicate not only the mitral regurgitant flow, but also the vibration of the mitral valve. Thus, the combined use of the ultrasonic pulsed Doppler technique and cross-sectional echocardiography is advantageous for the transcutaneous detection and analysis of regurgitant flow in mitral regurgitation.

Improvement in mitral flow dynamics during exercise after percutaneous transvenous mitral commissurotomy. Noninvasive evaluation using continuous wave Doppler technique.

Evaluation of mitral flow dynamics during exercise is critically important in patients who receive percutaneous transvenous mitral commissurotomy (PTMC) because limited mitral flow during exercise provokes hemodynamic deterioration and involves cardiogenic symptoms in patients with mitral stenosis. To examine mitral flow dynamics during exercise, we applied continuous wave Doppler technique in 20 patients with mitral stenosis. Exercise Doppler study was performed 2 days before and 5 days after PTMC. PTMC increased mitral valve area from 1.0 +/- 0.3 (mean +/- SD) to 1.9 +/- 0.5 cm2 and decreased mean transmitral pressure gradient from 8 +/- 2 to 4 +/- 1 mm Hg at rest. Moreover, PTMC decreased mean transmitral pressure gradient from 21 +/- 6 to 11 +/- 4 mm Hg at submaximal exercise. The extent of an increase in mitral valve area by PTMC correlated with a decrease in the mean transmitral pressure gradient at the submaximal exercise (r = -0.76, p less than 0.01) and that at rest (r = -0.52, p less than 0.05). Heart rate after PTMC during exercise was significantly lower than that before PTMC, indicating that the compensatory mechanism (tachycardia) to increase cardiac output during exercise is less necessary after PTMC. Thus, we conclude that the mitral flow dynamics during exercise is improved, as well as the resting mitral flow dynamics 5 days after PTMC, and that exercise Doppler study enabled us to make a noninvasive evaluation of the mitral flow dynamics in patients who receive PTMC.