Diagnostic Left Heart Catheterization Research Articles

Transseptal Left Heart Catheterization for a Patient With a Prosthetic Mitral Valve Using Live Three-Dimensional Transesophageal Echocardiography

The images and videos presented in this article illustrate a diagnostic transseptal left heart catheterization for a patient with a prosthetic mitral valve guided by live three-dimensional (3D) transesophageal echocardiography. This method provided high-quality 3D imaging that was useful in guiding transseptal puncture and demonstrating prosthetic valve function during this evaluation.

Iatrogenic Localized Ascending Aortic Intimal Hematoma During Left Coronary Artery Catheterization

A 79-year-old male underwent diagnostic left heart catheterization and coronary arteriography for symptoms of increasing angina pectoris. The patient’s cardiac history included that of coronary artery bypass surgery with three vein grafts (left anterior descending, circumflex, and right coronary arteries), and a coronary stent within the proximal portion of the left main coronary artery (so-called “protected left main”). He had a longstanding history of hypertension, hyperlipidemia, and Type II diabetes mellitus. Using 6 Fr catheters, an AL2 catheter was engaged within the left main coronary artery. After injection, “staining” of the ascending aorta and left sinus of Valsalva was noted (Fig. 1). The patient remained asymptomatic, but the procedure was then terminated. Computed tomography (CT) revealed a subintimal hematoma from the orifice of the left main coronary artery extending cranially to about 4 cm (Fig. 2), when visualized with sequential horizontal “cuts.” Transthoracic (TTE) and transesophageal echocardiography (TEE) were then performed to evaluate for a dissection flap. By TTE, there was no abnormality noted, but by TEE a subintimal hematoma was noted (Fig. 3).

18‐year experience with transseptal procedures through baffles, conduits, and other intra‐atrial patches

The presence of an intra-atrial patch (IAP) has been considered a relative contraindication to transseptal puncture (TSP). The purpose of this study is to determine the efficacy and safety of the TSP through baffles, conduits, pericardial patches and other prosthetic materials in the intra-atrial septum. We reviewed the records of all pediatric patients with IAP who underwent TSP at Texas Children's Hospital from November 1979 through February 1998. The review included the cardiac diagnoses, indications for TSP, technical difficulties and follow up echocardiograms specifically addressing residual atrial shunts A total of 1958 TSP were performed. Thirty-nine patients had IAP. Cardiac diagnoses in those 39 patients included D-transposition of the great arteries after Mustard (10) or Senning procedure (6), single ventricle variant post-Fontan operation (4), total anomalous venous return repair (4), atrioventricular canal repair (9) and atrial septal defect with patch repair (6). Patients' age ranged from 1–31 years (median 7 years). The duration from the time of surgical repair to TSP ranged from 0.1–21 years (median 5 years). Indications for TSP included diagnostic and therapeutic intervention for pulmonary venous obstruction (12), creation of a baffle fenestration (2), prosthetic mitral valve evaluation (1), left ventricular outflow tract evaluation (1), access the left heart for hemodynamic evaluation (23). The IAP was traversed in 38/39 patients (97.5%), followed by diagnostic or therapeutic prograde left-heart catheterization. No complications were encountered. Follow up echocardiography in 30/38 PTS demonstrated no residual shunting across the atrial septum except for two cases in which the atrial baffle had been intentionally fenestrated. Transseptal puncture through an intra-atrial patch is a safe procedure. This technique is effective in permitting diagnostic and therapeutic left heart catheterization and does not result in residual shunting through the patch. Cathet. Cardiovasc. Intervent. 50:434–439, 2000. © 2000 Wiley-Liss, Inc.

Cerebral microemboli during left heart catheterization

Background The aim of this study was to describe the rate of microemboli signals (MES) during left heart catheterization (LHC). Methods A monitoring of both middle cerebral arteries using transcranial Doppler ultrasonography was performed to investigate cerebral microemboli during LHC. Seventy-two patients undergoing LHC and 29 patients with LHC followed by coronary intervention were studied. Results During a standardized LHC (n = 52), 95 ± 45 MES were detected of which 67.5% occurred during injection of contrast media or saline solution, 30% during movements of wire and catheter, and 2% during catheter manipulation. During coronary interventions only, rotablation (n = 2) was followed by a massive increase in MES. The use of injection fluids prepared with minor gas content reduced the MES rate by 67% ( P < .05). All MES were clinically silent. Conclusions Cerebral microembolism is a current finding during LHC. The dependence of the MES rate during diagnostic LHC on the gas content of the injection fluids provides evidence that most of the MES are caused by microbubbles and not by solid emboli. The high rate of MES during coronary rotablation may be explained by the formation of cavitation bubbles. The clinical results of the MES during LHC appear to be benign. (Am Heart J 1999;137:162-8.)

Matching dicrotic notch and mean pulmonary artery pressures: implications for effective arterial elastance.

It has been suggested that pulmonary artery pressure at the end of ejection is close to mean pulmonary artery pressure, thus contributing to the optimization of external power from the right ventricle. We tested the hypothesis that dicrotic notch and mean pulmonary artery pressures could be of similar magnitude in 15 men (50 +/- 12 yr) referred to our laboratory for diagnostic right and left heart catheterization. Beat-to-beat relationships between dicrotic notch and mean pulmonary artery pressures were studied 1) at rest over 10 consecutive beats and 2) in 5 patients during the Valsalva maneuver (178 beats studied). At rest, there was no difference between dicrotic notch and mean pulmonary artery pressures (21.8 +/- 12.0 vs. 21.9 +/- 11.1 mmHg). There was a strong linear relationship between dicrotic notch and mean pressures 1) over the 10 consecutive beats studied in each patient (mean r = 0.93), 2) over the 150 resting beats (r = 0.99), and 3) during the Valsalva maneuver in each patient (r = 0.98-0.99) and in the overall beats (r = 0.99). The difference between dicrotic notch and mean pressures was -0.1 +/- 1.7 mmHg at rest and -1.5 +/- 2.3 mmHg during the Valsalva maneuver. Substitution of the mean pulmonary artery pressure by the dicrotic notch pressure in the standard formula of the pulmonary vascular resistance (PVR) resulted in an equation relating linearly end-systolic pressure and stroke volume. The slope of this relation had the dimension of a volume elastance (in mmHg/ml), a simple estimate of volume elastance being obtained as 1.06(PVR/T), where T is duration of the cardiac cycle. In conclusion, dicrotic notch pressure was of similar magnitude as mean pulmonary artery pressure. These results confirmed our primary hypothesis and indicated that human pulmonary artery can be treated as if it is an elastic chamber with a volume elastance of 1.06(PVR/T).

994-100 Acute Neurological Complications of Cardiac Catheterization: Natural History and Risk Factors

The development of an acute neurological deficit (ND) is a rare but dreaded complication of left heart catheterization. The natural history and predisposing risk factors for their development are not well known. We sought to determine the incidence, clinical outcome and variables associated with the development of ND from diagnostic left heart catheterization (LHC), angioplasty (PTCA) or valvuloplasty (V) in 6465 consecutive patients (pts) in the modern era. All cases of ND developing within 36 hours of LHC (n = 5245), PTCA (n = 1159) and V (n = 61) were collected prospectively. The clinical features and natural history of these events were studied and, using a case control method, each case was matched by month to 10, randomly chosen pts without ND, and the variables associated with developing ND were determined. Twenty-seven pts (0.4%) suffered a neurological deficit. The most common symptoms were: visual disturbances (n = 7; 26%). hemiparesis (n = 7; 26%), and facial droop (n = 7; 26%), Seizures occurred in 3 (11%), and one pt each developed dysequilibrium, transient global amnesia and transient unresponsiveness. Sixteen pts (59%) completely resolved at long-term follow-up with the majority (13/16) resolving within 24 hours. An additional 4 pts (15%) had minimal persistent deficits (diplopia, n = 2; homonymous hemianopsia, n = 2). Four pts (15%) had major deficits at follow-up (hemiparesis, n = 3; right upper extremity weakness, n = 1) and 3 pts (11%) died as a sequela. Clinical variables associated with ND and the odds ratio and confidence intervals: Female Sex 3.2; (1.4, 7.4) * Vascular Disease 3.1; (1.2, 8.0) ** ≥ 2 Coronaries Diseased 3.0; (1.2, 7.4) ** Ejection Fraction 0.4; (0.2, 1.0) ** Left Ventricular Hypertrophy (LVH) 2.9; 11.2, 7.3) ** * p &lt; 0.01 ** p &lt; 0.05 As a predictor of ND, female gender was independent of body surface area. Variables not associated with the development of ND included age, diabetes, hypertension, prior infarction or stroke, procedure performed, heparin dose and number of catheter exchanges. We conclude that ND occurred in 0.4% of left heart procedures and 59% resolved completely. Females have a threefold greater risk than males, and this risk is independent of body surface area. Pts with vascular disease, extensive coronary disease, LVH aand poor ventricular function are at increased risk for a neurological complication of catheterization.

Myocardial perforation in the cardiac catheterization laboratory: incidence, presentation, diagnosis, and management

The introduction of balloon valvuloplasty and new devices for coronary intervention has increased the incidence and changed the site and clinical presentation of cardiac perforation. We reviewed all cases of cardiac perforation that occurred during 11,845 consecutive catheterization procedures during a 6-yr period (1986-91). Fourteen cardiac perforations (overall incidence 0.12%) occurred as a result of the following procedures: mitral valvuloplasty 7 of 150 (4.7%), aortic valvuloplasty 4 of 260 (1.5%), pericardiocentesis 1 of 90 (1.1%), temporary pacer 1 of 1,660 (0.06%), and diagnostic left heart catheterization 1 of 6,965 (0.01%). Perforation was recognized in the catheterization laboratory in 11 patients, within 1 hr of leaving the laboratory in two patients, and 15 hr later in one patient. Hemodynamic evidence of tamponade developed in 13 patients and was confirmed by fluoroscopy (immobile heart borders) or echocardiography. Pericardiocentesis is definitive therapy in nearly half of the cases; the remaining patients require pericardiocentesis plus surgical repair of the perforation.

Improvement of endocardial border delineation in suboptimal stress-echocardiograms using the new left heart contrast agent SH U 508 A.

Recent studies have shown that the saccharide based echocardiographic contrast agent SH U 508 A opacifies the left ventricle after i.v. injection, thus possibly improving endocardial border definition. This study was performed to determine whether SH U 508 A can enhance the wall motion analysis in suboptimal echocardiographic images at rest and following pharmacological stress. Ten male patients (mean 58 years) exhibiting > or = 30% endocardial border dropout were examined prior to a diagnostic left heart catheterization. Five patients were stressed with Dobutamine, 5 with Dipyridamole. The wall motion was assessed visually (qualitatively) as well as computer-aided (quantitatively). The concordance between left ventricular angiography as 'gold standard' and resting echocardiography regarding the wall motion analysis was significantly improved from 64.5% to 90.3% following the injection of SH U 508 A (p < 0.05). A delineation score (0 = not delineated, 1 = delineated) of 12 individual wall segments was used. The mean delineation score at baseline was 6.1 +/- 1.4 at rest and 6.6 +/- 1.9 during stress. SH U 508 A significantly (p < 0.01) increased the score to 9.6 +/- 1.9 and 10.3 +/- 1.7, respectively. The intraobserver variability for assessing the delineation score was significantly (p < 0.04) improved by SH U 508 A. SH U 508 A, however, did not improve the quantitative assessment of the left ventricular function. Only 40% of the patients could be analyzed following SH U 508 A injection. No severe adverse reactions were seen. SH U 508 A led to a significant, clinically important, improvement in the interpretation of stress echocardiograms in patients with inconclusive routine echocardiograms.

Imaging of pulmonary vascular disease by intravascular ultrasound.

To assess the ability of intravascular ultrasound (IVUS) to image changes in the pulmonary arterial wall associated with pulmonary hypertension (PHT), 10 subjects requiring diagnostic right and left heart catheterization were studied. In addition to measurements of pulmonary artery pressure and pulmonary vascular resistance and pulmonary angiography, when indicated, all underwent simultaneous IVUS imaging in the pulmonary arterial system using a 20 MHz ultrasound transducer mounted on a 2 mm diameter catheter. Four patients had normal pulmonary artery pressures and 6 had varying degrees of PHT. Satisfactory ultrasound images were obtained in 9 out of the 10 patients. In those with normal pulmonary artery pressures ultrasound showed a thin vessel wall with no distinction between separate layers. In patients with systemic PHT, a three-layered vessel wall was apparent and areas compatible with intimal proliferation were seen. In a patient with pulmonary embolic disease areas consistent with mural thrombus were detected at sites of luminal narrowing on the pulmonary angiogram. IVUS is capable of imaging some of the morphological changes in the wall of the pulmonary artery known to occur in longstanding PHT and may therefore become a useful adjunct to haemodynamic measurements and pulmonary angiography for the in vivo assessment of pulmonary vascular disease.

Cardiac catheterization and coronary angiography using 5 french preformed (Judkins) catheters from the percutaneous right brachial approach: A comparative analysis with the femoral approach

This study describes a method for the performance of cardiac catheterization using 5 French preformed Judkins catheters from a percutaneous right brachial approach, and compares that technique to the more traditional percutaneous right femoral approach with 6 French catheters. One hundred consecutive patients requiring diagnostic left heart catheterization and selective coronary angiography were randomized according to femoral versus brachial arterial technique. Procedural efficiency, radiation exposure, and diagnostic film quality favored the femoral approach, while patient comfort, hemostasis time, time to ambulation, and decreased need for post-procedure nursing care favored the brachial approach. No differences were identified in complications. Cardiac catheterization from a right brachial artery percutaneous approach with 5 French preformed catheters has both advantages and disadvantages when compared with a more traditional femoral approach with 6 French catheters. Multiple factors should be considered before selecting an approach to diagnostic cardiac catheterization and each patient should be individually evaluated for determination of the optimal technique.

Long‐term clinical course of patients with angina and angiographically normal coronary arteries

In 88 of 103 consecutive patients with angina and normal coronary arteries, follow-up data could be achieved 6-11 years (9.2 +/- 1.2 years) after diagnostic left heart catheterization. Three of these patients died during follow-up (two noncardiac deaths and one death with no identifiable etiology). One patient suffered a documented myocardial infarction. In 40 patients (47%) chest pain diminished, while symptoms were unchanged in 20 (24%) or even worse in 25 (29%). Resolution or persistence of chest pain could not be predicted either by the character of pain (typical vs. atypical), the presence of hypertension, a left bundle-branch block, a positive exercise electrocardiogram or pathological pulmonary artery pressures during exercise, documentation of myocardial bridges, local wall motion abnormalities, or a left ventricular end-diastolic pressure greater than or equal to 13 mmHg. However, continuing chest pain was significantly more common in patients who revealed a 'slow-flow phenomenon' at initial coronary arteriogram. Thus, in patients with angina and normal coronary arteries the long-term course regarding frequency of morbid cardiac events is benign. However, more than half of the patients reported chest pain to be similar or even worse than at catheterization. Most clinical and invasive results at initial evaluation had no predictive value for the persistence of symptoms. The impact of 'slow-flow' in coronary arteriography, which was a phenomenon almost exclusive to patients with constant or even worse chest pain at follow-up, should be evaluated in larger patient populations.

Determinants of atrial natriuretic factor levels in coronary heart disease: significance of central pressures, heart chamber volumes and left ventricular mass

Atrial natriuretic factor (ANF) was determined in pulmonary and systemic arterial plasma during diagnostic left and right heart catheterization in twenty-three patients. In twenty of these patients ANF was subsequently measured in systemic arterial plasma during nuclear magnetic resonance (NMR) imaging of the heart with computation of left heart chamber volumes and left ventricular mass. Left ventricular end-diastolic pressure was the strongest independent predictor of pulmonary arterial plasma ANF, whereas cardiac index best predicted aortic plasma ANF. Both pulmonary and aortic plasma ANF correlated with systolic and diastolic pulmonary arterial pressure, left ventricular end-diastolic pressure and cardiac index. Left atrial volume index and left ventricular mass index did not correlate with systemic arterial plasma ANF whereas a positive linear correlation between left ventricular end-diastolic volume index and ANF could be demonstrated (r = 0.61, P less than 0.01). Left ventricular end-diastolic volume index was the most important independent predictor of systemic arterial plasma ANF. Systemic arterial plasma ANF might be a simple marker of left ventricular dilatation in patients with heart disease.

Correction for preload in assessment of myocardial contractility in aortic and mitral valve disease. Application of the concept of systolic myocardial stiffness.

With single-beat analysis, the new concept of systolic myocardial stiffness is applied to provide a new approach for the assessment of myocardial contractility in aortic and mitral valve disease. Seventy patients underwent diagnostic right and left heart catheterization. Twenty-six patients had aortic stenosis, 18 had aortic insufficiency, and 26 had mitral regurgitation. Patients with aortic stenosis were divided into two groups on the basis of left ventricular mass index less than 172 g/m2 (AS1) and mass index greater than or equal to 172 g/m2 (AS2). The mitral regurgitation patients were divided into those in normal sinus rhythm (MR1) and those in atrial fibrillation (MR2). Nine patients without significant coronary or cardiovascular disease served as controls. Thirteen patients with aortic stenosis and eight with aortic insufficiency were evaluated (average, approximately 18 months) after successful aortic valve replacement. With simultaneous left ventricular pressure and cineangiographic methods, myocardial contractility was assessed by the conventional ejection fraction-afterload relation (uncorrected for preload) and by two new methods that permit the correction of the ejection fraction for preload. Assessments of the contractile state by these two new methods differed from those by the conventional method in 20-40% of the cases studied. Contractile state improved postoperatively in aortic stenosis and aortic insufficiency even in patients with preoperative depressed contractile states. In patients with mitral regurgitation, there was considerable heterogeneity of contractile function preoperatively. Severe left ventricular hypertrophy in aortic stenosis was not a marker for postoperative outcome since contractility was normal postoperatively in AS1 and AS2 in equal numbers. This study demonstrates that preload correction is important in a preoperative assessment of contractility in aortic and mitral valve disease but that it is less important postoperatively, presumably because of reductions in the preload.

Ventricular function and coronary hemodynamics in hypertensive heart disease

Left ventricular function, wall geometry and coronary hemodynamics were analyzed in 114 patients with essential hypertension during diagnostic left heart catheterization, left ventriculography and coronary arteriography. Results of the study were as follows: 1. 1. Left ventricular function (as assessed from the cardiac index, stroke volume index, ejection fraction, mean velocity of circumferential fiber shortening, mean normalized systolic ejection rate, isovolumic indexes) was normal in patients with hypertensive hypertrophy, even with a large increase in muscle mass and even in the presence of concomitant coronary artery disease. Left ventricular function was impaired when regional contraction abnormalities or ventricular dilatation, or both, occurred and was inversely related to both cardiac size and systolic wall stress. 2. 2. Coronary blood flow (+18 percent), coronary resistance (+38 percent) and myocardial oxygen consumption (MVO 2) (+21 percent) were increased in essential hypertension. Coronary reserve was reduced even in hypertensive hypertrophy without evidence of coronary artery disease. MVO 2 per mass unit was directly correlated with systolic wall stress per cross-sectional area of the left ventricular wall. 3. 3. The appropriateness of left ventricular hypertrophy may be defined by the relation between pressure, mass to volume ratio and systolic wall stress. In hypertensive heart disease at least two types of inappropriate left ventricular hypertrophy occur: (a) low stress hypertrophy, with an increased mass to volume ratio, with normal left ventricular function and with normal or reduced MVO 2; and (b) high stress hypertrophy, with normal or low mass to volume ratio, impaired left ventricular function and increased MVO 2. It is concluded that the appropriateness of left ventricular hypertrophy, as a result of mass to volume ratio and stress, is a major determinant of left ventricular performance and of myocardial oxygen consumption, and that the individual history of left ventricular pressure load specifically may influence left ventricular function.

Transvascular endomyocardial biopsy in infants and small children: Description of a new technique

A miniaturized technique for transcatheter endomyocardial biopsy has been developed in the belief that myocardial biopsy performed in infancy, when the disease process in cardiomyopathy may be most active, should yield important etiologic and nosologic information. To obtain six biopsy specimens, three from each ventricle, adds about 1 hour to a diagnostic right and left heart catheterization. A no. 4 or 5 French forceps with a modified soft shaft is guided to the site in the apical septum of the right and left ventricles through a previously molded to measure guide tube of ultrathin radiopaque Teflon. With biplane fluoroscopy the guide tube is introduced as a sheath over a matching catheter and the catheter is removed. Contrast medium is injected to verify position, the forceps is introduced and the biopsy specimen is taken. If the forceps is sharp and pressure on the endocardium is light, evidence of biopsy is not discernible on examination of the heart 1 week later. The method was developed in small dogs and proved safe and effective in rabbits weighing 3 kg. Biopsy has been performed safely in children aged 4 1 2 months to 5 1 2 years and weighing 4.5 to 19.6 kg.

The surgical management of catheter injuries of the brachial artery

In 84 patients the wrist pulses were lost after diagnostic left heart catheterization via the brachial artery. Sixty-six of these patients underwent surgical exploration of the brachial artery for restoration of pulsatile arterial flow to the hand. This aim was achieved in 64 instances. In all cases, the artery was found to be occluded by fresh thrombus. In 36 patients, balloon thrombectomy and accurate arterial closure were successful. In the remainder, in addition to thrombectomy, indentification of an area of damage to the arterial wall required additional surgical measures, usually in the form of resection and anastomosis. The surgical approach to this problem and the importance of the recognition and treatment of arterial wall damage by the catheter are stressed in this paper.

Lupus cardiomyopathy: Cardiac mechanics, hemodynamics, and coronary blood flow in uncomplicated systemic lupus erythematosus

Right and left heart pressures, left ventricular volumes, indices of contractility, myocardial wall stiffness, and coronary blood flow were determined in five young women with systemic lupus erythematosus (SLE) during diagnostic right and left heart catheterization. Examinations revealed (1) increases of right and left ventricular enddiastolic pressures; (2) decreases of cardiac output, stroke volume, ejection fraction, contractility indices, diastolic left ventricular volume inflow; (3) decreases of pharmacologically induced coronary vasodilation in SLE. The results demonstrate impaired pump function, reduced contractility, increased myocardial wall stiffness, and decreased coronary vascular reserve in SLE. It is concluded that lupus cardiomyopathy associated with an impairment of left ventricular function may be apparent in young women with SLE who have no clinical signs of cardiac dysfunction.

Return of normal conduction after paroxysmal heart block. Report of a case with major discordance of electrophysiological and pathological findings.

This report describes a 52-year-old male with paroxysmal heart block as well as left and right bundle branch block, resulting in Stokes-Adams attacks. The patient experienced a return to 1:1 atrioventricular (A-V) conduction with narrow QRS within 48 hours of the attacks and heart block never recurred. Electrophysiological studies three weeks later revealed a narrow QRS, a normal H-V interval (36 msec), 1:1 A-V conduction up to an atrial paced rate of 210 beats/min, and normal refractory periods with atrial extrastimulus techniques (His-Purkinje system refractory periods less than 370 msec). The patient died from a cerebral embolus incurred during diagnostic left heart catheterization two days after electrophysiological studies. Postmortem examination revealed calcific aortic stenosis with calcific impingement upon the pars membranacea resulting in compression of the distal His bundle and marked disruption of the proximal portions of both bundle branches. This report documents a major limitation of electrophysiological studies, this limitation being that these studies may be totally normal on one occasion in a patient with pathologically significant chronic conduction disease, which may become clinically manifest on another occasion.

Free passage of lysine-vasopressin through the human pulmonary circulation.

The systemic pressure responses to lysine-vasopressin injected into the pulmonary artery were compared to those resulting from administration into the ascending aorta in six patients undergoing diagnostic right and left heart catheterization. Pulmonary injections exerted the same degree of pressor activity as aortic injections. It is concluded that vasopressin is not detectably inactivated during a single passage through the human pulmonary circulation, confirming a phenomenon already noted in animals.

Sound-pressure correlates of the aortic ejection sound. An intracardiac sound study.

The sound-pressure correlates of the aortic ejection sound (AES) were studied in six patients without aortic valve disease (group 1) and in nine patients with valvular aortic stenosis (group 2) during diagnostic left heart catheterization. Aortic root sound and pressure events were recorded by a catheter-tip micromanometer simultaneously with the external phonocardiogram, indirect carotid pulse, and electrocardiogram. The AES in group 1 patients was coincident with the onset of pressure rise in the aortic root. This relationship was not altered by drug administration, although variations in the amplitude of the AES occurred. It was concluded that the AES in patients without aortic valvular disease is an exaggerated ejection component of the normal first heart sound, and that it is a root phenomenon related to the forceful ejection of blood into the aorta. The AES in group 2 patients was delayed 24 to 40 msec after the onset of pressure rise in the aortic root, was coincident with the anacrotic notch, and introduced the aortic ejection murmur. Aortic root sound and pressure were recorded simultaneously with aortic valve motion during angiography in two patients utilizing a cine trace system. The AES occurred when the domed valve reached its maximal excursion, and the interval between the onset of aortic pressure rise and the AES was equal to the total time required for the piston-like ascent of the dome. It was concluded that the AES in valvular aortic stenosis is valvular in origin. The amplitude of the valvular AES correlated best with valve mobility on the angiogram, and no correlation existed between its presence and the severity of the valvular stenosis.