Atrial Pressure Curve Research Articles

The diagnosis of mitral incompetence from left atrial pressure curves.

The diagnosis of mitral incompetence from left atrial pressure curves.

The intracavitary electrocardiogram in the diagnosis of Ebstein's anomaly

The simultaneously recorded intracavitary electrocardiographic patterns and pressures in three cases of Ebstein's anomaly of the tricuspid valve have been described. The following findings are diagnostic of Ebstein's anomaly: 1. (1) Typical right ventricular intracavitary patterns with simultaneously obtained low atrial type pressure curves. 2. (2) Intracavitary right ventricular monophasic waves produced by pressure of the catheter tip against the wall of the distal portion of the low pressure chamber. The production of right ventricular extrasystoles by pressure of the catheter tip against the wall of the distal portion of the low pressure chamber is highly suggestive of this condition.

Difficulties in interpretation of right heart catheterization data

By means of illustrative case reports, the following difficulties in interpretation of data obtained by cardiac venous catheterization are described. 1. 1. The diastolic right atrial pressure was found to be several millimeters of mercury higher than diastolic right ventricular pressure in the absence of organic tricuspid stenosis. 2. 2. The diastolic right ventricular pressure was found to be one-third as high as the right ventricular systolic pressure in conditions other than constrictive pericarditis. 3. 3. Right ventricular systolic pressures may be somewhat higher than those in the pulmonary artery in the absence of pulmonary stenosis. Artefactually low pulmonary arterial pressure readings in the presence of pulmonary hypertension resulting from temporary obstruction of the catheter tip may cause an incorrect diagnosis of pulmonary stenosis to be made. 4. 4. Increase in oxygenation of right atrial blood may be produced by a septal defect between the left ventricle and right atrium. 5. 5. The observation of an increase in oxygen content of pulmonary arterial over right ventricular blood requires consideration of a number of possibilities. In addition to patency of the ductus arteriosus some of the other causes are variations in pulmonary flow; ventricular septal defect; anomalous pulmonary arteries; contamination of the sample by pulmonary venous blood, resulting from a peripheral location of the catheter tip. 6. 6. As the probable result of pulmonary valvular insufficiency, patent ductus arteriosus may be associated with an apparently greater increase in oxygenation of right ventricular than of pulmonary arterial blood. 7. 7. When the tip of a cardiac catheter enters a pulmonary vein after entering the cardiac shadow, caution is required to ascertain whether the pulmonary vein drains into the right or the left atrium. 8. 8. The pressure curve obtained by wedging the cardiac catheter tip into the coronary sinus or one of its tributaries may simulate a right ventricular pressure curve. 9. 9. Artefacts in the right atrial pressure curve resulting from motion of the catheter tip may cause a falsely high right atrial systolic pressure reading.

Left atrial pressure curve: significance of annular ascent wing.

Left atrial pressure curve: significance of annular ascent wing.

Left heart catheterization: II. With particular reference to mitral and aortic valvular disease

1. 1. Results of left heart catheterization in two normal individuals and 125 patients with rheumatic heart disease are presented. 2. 2. The normal pressure curves are described. No pressure gradients exist across a normal mitral or aortic valve. 3. 3. Characteristic findings of mitral stenosis are: (a) ventricular filling pressure gradient usually present throughout diastole, (b) giant “a” waves in the left atrial pressure tracing. 4. 4. Ventricularization of the left atrial pressure curve may occur in mitral regurgitation. A pressure gradient may be present, but unlike mitral stenosis, is found only early in diastole. A characteristic pressure tracing is obtained as the catheter is whipped back from ventricle to atrium within a single cardiac cycle. 5. 5. Aortic stenosis is characteristically accompanied by a systolic pressure gradient across the aortic valve. Giant “a” waves are observed in the left atrial pressure tracing. The end-diastolic pressure in the left ventricle is generally elevated. Possible causes for this are discussed.

Rheumatic tricuspid stenosis: A clinical and physiologic study with a suggested method of diagnosis

1. 1. Clinical and physiologic data are presented in thirteen cases of proved rheumatic tricuspid stenosis. 2. 2. The physiologic data of significance included (a) exaggerated “a” waves in the right atrial pressure curves in patients with a normal sinus rhythm and, more important from a diagnostic point of view, (b) significant atrioventricular pressure gradient during ventricular diastole. 3. 3. The significance of the clinical symptoms and signs is discussed. 4. 4. A method for determining the size of the tricuspid orifice during the course of cardiac catheterization is suggested.

Simultaneous left and right atrial pressure curves during Valsalva's experiment

When a Valsalva experiment is performed during simultaneous pressure measurements in the left and right atrium a typical difference in the two curves will be found. The left atrial pressure level will slowly decrease during a Valsalva experiment due to a damming up of blood in the venous system. The pressure in the right atrium on the other hand will not decrease as much during the Valsalva's experiment, or it may even increase. The pressure in a thick-walled left atrium due to mitral stenosis will not increase as much as the pressure in the right atrium during a Valsalva experiment. In the poststraining period there is a more pronounced pressure overshoot in the left atrium in front of mitral stenosis than in the right atrium or in a normal left atrium.

The diagnosis of tricuspid insufficiency; clinical features in 60 cases with associated mitral valve disease.

In a series of 146 patients with mitral stenosis studied by cardiac catheterization, 60 were found to have right atrial pressure curves diagnostic of tricuspid insufficiency. The clinical and hemodynamic features of these patients are reviewed. The oft-cited, classic manifestations of tricuspid insufficiency were found with relative infrequency and the diagnosis had been made clinically in less than one fourth of the cases. Modification of criteria for the diagnosis of tricuspid insufficiency is suggested.

Left atrial and pulmonary “capillary” pressure curves during Valsalva's experiment

Simultaneous measurements of the left atrial and pulmonary “capillary” pressures were made during the Valsalva maneuver in nine patients with mitral valve disease. 1. 1. The pulmonary “capillary” pressure curve paralleled the left atrial pressure curve both during and after the period of forced expiration. 2. 2. There was a decline in the pressure during the Valsalva maneuver. 3. 3. A pronounced decrease in the amplitude of peak 7 (representing opening of the mitral valve) during forced expiration was observed in all but one of the patients. In this patient mitral regurgitation was suspected and here the decrease in amplitude was less pronounced. 4. 4. After forced expiration was ended the pressures fell abruptly to below the resting values. This was followed by a rapid rise and overshoot above the normal levels. This overshoot phenomenon is attributed to the sudden increase in the pulmonary flow that follows release of the blood arrested in the venous system during the Valsalva maneuver.

Esophageal pressure pulse patterns (esophageal piezocardiogram): II. Observations in human beings with mitral valve disease

It would appear from this study that one can determine the contour of the left atrial pressure pulse curve by recording esophageal pulsations at the level of the left atrium with the technique which has been described. This relationship between the intra-atrial pressure pulse contour and the contour of the esophageal pressure pulse tracing (piezocardiogram) has been demonstrated by two kinds of evidence. The first evidence consisted of a study in animals wherein simultaneous recordings were made of left atrial pressure curves and curves of esophageal pressure pulsations. These studies showed that all phases of the atrial pressure curve were transmitted to the esophageal curve. The second type of evidence consisted in a comparison between direct intra-atrial pressure tracings which had been obtained by other investigators in human beings with mitral valve disease and the esophageal piezocardiograms which had been obtained by us in other human beings who also had mitral valve disease. This evidence, though circumstantial in a sense, appeared to us to be strongly convincing. Absolutely conclusive proof in human beings of the identity between the two sets of curves could be obtained only by simultaneous recording of the direct atrial and esophageal pressure curves in the same individual during mitral valve surgery. We have not yet been able to accomplish this. On the basis of the comparative evidence discussed above, it was possible to tentatively divide the piezocardiographic tracings into three categories, namely, predominant mitral insufficiency, mitral stenosis without insufficiency, and mitral stenosis with insufficiency. Tracings of patients with mitral insufficiency were characterized by a positive pressure wave which began its ascent in ventricular systole, rose progressively, and reached a peak in late systole just prior to the opening of the mitral valve. The pressure then declined precipitously. This wave contour corresponded very closely to the findings of Wiggers 4, 5 in animals with experimentally induced mitral insufficiency. He emphasized that the increase in atrial pressure and volume due to regurgitation did not reach substantial proportions in the early phases of ventricular systole. The greatest amount of regurgitation occurred during the latter phases of ventricular ejection, increasing even as ventricular pressure began to fall. The tracings of patients who had mitral stenosis with no insufficiency were characterized by a sharp, early systolic pressure peak and either a plateaulike sustained pressure elevation during the remainder of ventricular systole or a fall in pressure followed by a rounded wave of low amplitude. The tracings of patients with combined mitral stenosis and insufficiency were characterized by an early systolic pressure peak followed by a secondary rise in pressure beginning in mid-systole which then formed a secondary pressure peak in late systole. This secondary peak was often higher than the primary peak. Though we have shown that the contours of the esophageal and intra-atrial pressure curves are very similar, we do not wish to imply that one can determine the actual level of pressure within the atrium with this technique. Other techniques which have been applied to the study of mitral valve disease, such as cardiac catheterization, 6,7,8 particularly the recording of the pulmonary capillary pressure, 9,10 and electrokymography, 11 supply vital information about cardiopulmonary dynamics. However, none of these yields the type of information about the contour and range of variation of the left atrial pressure pulsation that this technique of esophageal recording does. We feel, therefore, that it offers useful, direct information about the nature of the impairment of the mitral valve.

The hemodynamic pattern in tricuspid valve disease

1. 1. The pressure curves from the right atrium in four patients with tricuspid regurgitation are presented. 2. 2. A pattern of severe organic tricuspid regurgitation is shown which is characterized by “ventricularization” of the right atrial pressure curve. 3. 3. The characteristics of the pressure curves aiding in differentiating organic from functional tricuspid regurgitation are discussed.