External Carotid Pulse Research Articles

Reversible Subaortic Obstruction in Hypertensive Hypertrophic Cardiomyopathy

We identified 4 patients with pulmonary vascular congestion, a small left ventricular cavity seen echocardiographically, and normal indexes of systolic function. All patients had noninvasive evidence of subaortic obstruction and obliteration of the left ventricular cavity on apexcardiography and external carotid pulse tracings when treated with digitalis preparations, diuretics, and afterload-reducing medications. Considerable symptomatic improvement and resolution of pulmonary congestion were achieved with the use of either verapamil or β-receptor antagonists. Such therapy effectively abolished the noninvasive evidence of subaortic obstruction. We conclude that a certain subset of hypertensive patients are pharmacologically susceptible to obliteration of the left ventricular cavity and subaortic obstruction. Echocardiography is helpful in identifying these patients who represent a therapeutic challenge because their condition improves with administration of β-receptor antagonists and verapamil, but deteriorates appreciably with conventional therapy of vasodilators and inotropic agents.

Systolic Time Intervals in Isolated Septal Defects before and after Corrective Surgery

Systolic time intervals (STI) were analyzed in 34 patients with isolated ventricular septal defect (VSD) and undirectional left-to-right shunt. 14 of the patients who underwent corrective surgery were followed-up for at least 10 years. The measurements were obtained from simultaneous high speed photographic recordings of electrocardiogram, external carotid pulse and phonocardiogram. Before the operation the Q-I sound interval and, consequently, the pre-ejection period were significantly prolonged and the left ventricular ejection time significantly abbreviated, the degree of abbreviation relating with the magnitude of the shunt. The above deviations persisted after corrective surgery, and only several years after the operation the parameters studied became normal. It is concluded that the most likely explanation for these abnormalities is the depressed contractility of the left ventricle, secondary to the long-standing volume overload, which tends to persist after corrective surgery.

Systolic Time Intervals in Isolated Septal Defects before and after Corrective Surgery in Female Patients

Systolic time intervals (STI) were evaluated in 19 female patients with uncomplicated ostium secundum atrial septal defect (ASD), before, shortly after (within 2 months) and a long time after the corrective surgery (mean 13.2 years). The measurements were obtained from simultaneous high speed photographic recordings of electrocardiogram, external carotid pulse and phonocardiogram. Before the operation, a significant prolongation of Q-I heart sound interval was detected, together with a less prominent but statistically significant shortening of the left ventricular ejection time; the above alterations were not correlated with the magnitude of the shunt and disappeared shortly after corrective surgery. The STI were still normal a long time after surgical closure of ASD. In accordance with hemodynamic studies reported by other authors, our results confirm that the deviations of STI observed in ASD are due to a reduced diastolic filling of the left ventricle secondary to an apparent decreased distensibility.

Mechanocardiographic assessment of systolic time intervals in normal children.

Systolic time intervals (STI) were measured in 469 normal children, aged 5.0 to 16.9 years, using simultaneous recordings of the electrocardiogram, phonocardiogram and an external carotid pulse tracing. The data were analyzed to define the influence of sex, age, cardiac cycle length, body weight (BW), body length (BL), and body surface area (BSA) on the left ventricular STI. Regression, equations were evaluated for the calculation of normal standards for the following STI: electromechanical systole (QS2), left ventricular ejection time (LVET), pre-ejection period (PEP) systolic quotient (PEP/LVET), isovolumic contraction time (IVCT), electroacustical delay (QS1), and additionally for the so-called tension time (TT), upstroke time (UT), and the ascending index (UT/LVET) of the carotid pulse wave. Heart rate was found to influence all of the STI but the ratio UT/LVET, which revealed to be independent of any variable. Besides heart rate, BSA proved to be a second relevant independent variable for QS2 and LVET, respectively BL for PEP, PEP/LVET and QS1. These findings are in accordance to the results of comparable echocardiographic studies but disagree previous mechanocardiographic studies in smaller groups of children in whom age and not the above-mentioned parameters of the individual development seemed to influence the STI. A second set of equations was evaluated for the calculation of 95%-prediction intervals for the particular STI permitting to define abnormalities of the STI in individual children.

Phonocardiographic Characteristics of the St. Jude Prosthesis in the Aortic Position

immediately after it (Fig 2). It can be surmised that the early systolic sound observed in these patients may be related to max- imum excursion of the opening motion of the car- bon leaflets or turbulence created by transvalvular flow during left ventricular systole. The high fre- quency aortic closure sound is probably produced by coaptation of the leaflets and vibrations from the resonant prosthesis secondary to rapid decelera- tion of blood at end-systole. Other findings noted rji he St. Jude valvular prosthesis is a bileaflet pyro- lytic carbon device1 which is being implanted with increasing frequency. Knowledge of the aus- cultatory and phonocardiographic characteristics of artificial cardiac valves has proven to be useful in detecting their malfunction.� We describe here our observations on the phono- cardiographic features of the St. Jude prosthesis in the aortic position. Figure 1 shows the simultane- ously recorded carotid arterial pulse tracing, phono- cardiogram from the tricuspid area and lead 2 of the electrocardiogram from such a patient. The ma- jor component (M1) of the first heart sound com- plex is normal. An early systolic sound (ES) is present at the lower left sternal border. This sound is usually heard over the entire precordium, but is best recorded at the left parasternal location. The interval from the first heart sound to the opening or ejection sound ranges from 60 to 80 msec. Note that the ejection sound coincides in timing with the onset of the external carotid pulse upstroke. The aortic component (AC) of the second heart sound consists of a major high amplitude high frequency component followed by multiple lower amplitude medium to low frequency vibrations. This aortic closing sound is recorded in conjunction with the dicrotic notch of the external carotid pulse tracing. In all cases, the aortic closure sound was greater in amplitude than the opening ejection sound with an AC:ES amplitude ratio ranging from 5:1 to 8:1. Phonoechographic study indicates that the early systolic sound follows the opening point of the prosthetic leaflets by approximately 40 msec. The aortic component of the second heart sound is in- scribed at the time of ultrasonic valve closure or I 111111 I 11111111IIIIIIIIlII(IIIIl ltlJIjlIIIllII

Diagnosis of aortic stenosis in older age groups using external carotid pulse recording and phonocardiography.

Measurements made from carotid pulse tracings and phonocardiograms are helpful in the prediction of severe aortic stenosis in young patients. In the elderly, however, analysis of the carotid pulse tracing and, in particular, its maximum rate of rise has proved unreliable because the range of normal values for this age group has not been established. Consequently, we studied 44 young normal and 44 older normal subjects, 15 older patients with systolic hypertension, and 36 older patients with significant aortic stenosis. Measurements obtained from the carotid pulse included the left ventricular ejection time, upstroke time, half-rise time, and the maximum rate of rise. The peak of the systolic murmur in aortic stenosis was measured phonocardiographically from the Q wave of the simultaneously recorded electrocardiogram (QP interval). The results confirm that the maximum rate of rise of the carotid pulse of normal older subjects is much more rapid than that of young subjects. Among elderly patients with aortic stenosis, the maximum rate of rise falls within the range of the normal young. Measurement of the half-rise time is imprecise, and there is considerable overlap with the normal. This is also true of left ventricular ejection time. The upstroke time is unreliable because of wave distortion produced by the arteriosclerotic vascular bed. The two most valuable and easily recorded measurements are the maximum rate of rise and the QP interval. A maximum rate of rise of more than 1000 mmHg/s and a QP interval of less than 220 ms argue strongly against the diagnosis of severe aortic stenosis. These measurements provide a simple, non-invasive means of avoiding left heart catheterisation in older subjects suspected of having severe aortic stenosis.

Limitations of quantitative oculoplethysmography and of directional Doppler ultrasonography in cerebrovascular diagnosis: assessment of an air-filled OPG system.

500 consecutive patients were evaluated for extracranial disease of the internal carotid arteries by an automated, air-filled, digital oculoplethysmographic system (OPG) of the Kartchner type (Zira) and by supraorbital (SO) and supratrochlear (ST) directional Doppler ultrasonography. Cerebral arteriograms were performed in 58 patients (110 vessels), and OPG timing criteria for detecting hemodynamically significant carotid artery stenosis (60% or greater diameter reduction) were ascertained. Optimal criteria were a delay of one ocular pulse, relative to the other, of greater than 12 msec; and a delay of an ocular pulse, relative to the earlier ear (external carotid) pulse, of greater than 36 msec. These criteria correctly identified 73% of vessels with 0 to 59% stenosis and 76% of vessels with 60 to 100% stenosis. However, in 26% of the vessels, OPG was either inconclusive or inaccurate. Correct diagnosis of bilateral hemodynamically significant carotid artery stenoses was made by OPG in 6 of 9 affected patients. SO Doppler was normal in 70% of vessels with 0-59% stenosis, and abnormal in 75% of vessels with 60-100% stenosis. Corresponding percentages for ST Doppler were 95% and 44%. Abnormal Doppler responses to compression of contralateral facial branches were predictive of intracranial cross-collateralization in only 25% of patients. These results suggest that both quantitative OPG in its present form and directional Doppler studies have serious limitations as non-invasive diagnostic methods.

Systolic time intervals in isolated ventricular septal defect in the adult.

Little information is available on the length of the systolic time intervals in adult patients with isolated ventricular septal defects (VSD). In the present study the external carotid pulse and the phono- and electrocardiogram were recorded in 17 patients, mean age 29 years, with angiographically proved VSD. They had unidirectional left-to-right shunts with ratios of pulmonary-to-systemic blood flow (Qp/Qs) of 1-5.22. Their right ventricular pressures were normal or only moderately elevated. Left ventricular ejection time was consistently abbreviated, the degree of abbreviation relating significantly with Qp/Qs (r = -0.70, p less than 0.01). The preejection period was prolonged but the relationship between its degree of prolongation and Qp/Qs did not reach statistical significance (r = 0.4), p greater than 0.05). The relationship between the preejection period/left ventricular ejection time ratio (PEP/LVET) and Qp/Qs was statistically significant (r = 0.51, p less than 0.05). We conlcude that in adult VSD patients with normal right ventricular pressures, a hemodynamically important shunting, i.e., Qp/Qs above 1.4 or left-to-right shunt exceeding 30% of pulmonary blood flow, may be excluded in the presence of a normal left ventricular ejection time or a normal PEP/LVET ratio.

Assessment of the severity of aortic stenosis from the carotid pulse tracing.

The morphology of the externally recorded carotid pulse tracing was studied in 33 patients with valvular aortic stenosis for indices of severity. Comparisons were made with 10 normal controls. In aortic stenosis, initial upstroke time (IUT) of the carotid pulse, and left ventricular ejection time index were significantly higher and the rate of rise of the carotid pulse was slower than in the control group. Severity of stenosis (calculated valve area and mean pressure gradient) could not be predicted, however, from any of these indices. The IUT of the carotid pulse did correlate well with mean velocity of circumferential fiber shortening (mVcf) (r=-0.72). The rate of rise of the carotid pulse had also a correlation with mVcf(r=0.66). However, other commonly used hemodynamic indices (cardiac index, systemic vascular resistance, stroke volume, and ejection fraction) did not have a good correlation with IUT and rate of rise of the carotid pulse. These results suggest that we are able to separate by carotid pulse tracings aortic stenosis from normal subjects, but we cannot say what is the degree of severity of aortic stenosis from analysis of the external carotid pulse recording.

Noninvasive Estimation of Left Ventricular Function After Mitral and Aortic Valve Replacement With the Hancock Porcine Prosthesis

Left ventricular function was noninvasively assessed by echocardiography, and left ventricular ejection time index (LVETI) was derived from external carotid pulse tracings in 25 patients before (B) and an average of 17 days after (A) Hancock porcine valve implantation. Fifteen patients had aortic valve replacement and 10 had mitral valve replacement; 4 had a combined procedure. In the aortic and combined group, (n = 15) there were significant (P < 0.0025) changes of mean (± 1 SD) left ventricular end-systolic dimension (ESD), B = 5.1 ± 0.9, A = 4.3 ± 0.9 cm; end-diastolic dimension (EDD), B = 5.7 ± 1, A = 4.9 ± 0.9 cm; mean rate of circumferential fiber shortening (VCF), B = 0.37 ± 0.05, A = 0.75 ± 0.04 circumf/sec and LVETI, B = 0.45 ± 0.05, A = 0.39 ± 0.02 sec. In subgroups with preoperative aortic stenosis (n = 8), combined aortic stenosis and insufficiency (n = 3), and coexisting aortic and mitral disease (n = 4), there was a uniform reduction of ESD, EDD, and LVETI with an increase of VCF. In the isolated mitral valve replacement group (n = 10), the values were ESD (B = 4.6 ± 0.7, A = 4.4 ± 0.8 cm, P = not significant); EDD (B = 5.2 ± 0.6, A = 4.7 ± 0.8 cm, P < 0.0025); VCF (B = 0.36 ± 0.08, A = 0.7 ± 0.04 circumf/sec, P < 0.0025); and LVETI (B = 0.40 ± 0.03, A = 0.37 ± 0.03 sec P < 0.05). Patients with mitral stenosis (n = 2), mitral insufficiency (n = 3), and combined mitral stenosis and insufficiency (n = 5) all had a postoperative decrease in ESD, EDD, and LVETI with augmentation of VCF. We concluded that (1) early noninvasive assessment of left ventricular function after Hancock valve implantation indicates a significant hemody namic improvement, and (2) echocardiography combined with external ca rotid arterial pulse tracing analysis is useful for the follow-up of patients who receive Hancock valves.

Genesis of Heart Sounds

<h3>To the Editor.—</h3> I would like to make the following comments about the production of A2. Leatham¹recorded phonocardiograms and external carotid pulse tracings in ten healthy persons and concluded that the origin of the first component of S2 is associated with aortic valve closure by its relationship to the dicrotic notch. Although the foregoing hypothesis has been generally accepted, several investigators have reported that the first component of S2 precedes aortic valve closure by 5 to 30 ms.^2-4 To clarify this controversy regarding the relationship between the aortic valve closure and the first component of S2, we conducted a study on 20 subjects (<i>Geriatrics</i>26: 372-374, 1978). Simultaneous phono-cardiograms, ECGs, and echocardiograms were recorded on a strip-chart recorder. The points of separation and closure of the echoes of the two cusps of the aortic valve were considered to be the aortic opening and closing points, respectively. The

Influence of Muller's Maneuver on Mitral Valve Prolapse: Correlation with External Carotid Pulse Tracing and Echocardiogram

Influence of Muller's Maneuver on Mitral Valve Prolapse: Correlation with External Carotid Pulse Tracing and Echocardiogram

Normalization of the External Carotid Pulse Tracing of Hypertrophic Subaortic Stenosis during Muller's Maneuver

Distinct patterns in the tracing of the external carotid arterial pulse have been well documented in cases of idiopathic hypertrophic subaortic stenosis. 1 Benchimol A Legier JF Dimond EG The carotid tracing and apexcardiogram in subaortic stenosis and idiopathic myocardial hypertrophy. Am J Cardiol. 1963; 11: 427-435 Abstract Full Text PDF PubMed Scopus (15) Google Scholar The characteristic midsystolic retraction and late systolic wave associated with this disease have been noted to appear or become exaggerated during performance of Valsalva's maneuver. 2 Polis O Cleempoel H Hanson J et al. Value of Valsalva's maneuver in phonocardiography. Acta Cardiol. 1960; 15: 441-462 PubMed Google Scholar , 3 Rosenblum R Delman A Valsalva's maneuver and the systolic murmur of hypertrophic subaortic stenosis: A bedside diagnostic test. Am J Cardiol. 1965; 15: 868-870 Abstract Full Text PDF PubMed Scopus (4) Google Scholar We describe herein the “normalization” of a diagnostic carotid arterial pulse tracing during deep inspiration against a closed glottis (MÜller's maneuver) in a patient with subaortic stenosis. Distinct patterns in the tracing of the external carotid arterial pulse have been well documented in cases of idiopathic hypertrophic subaortic stenosis. 1 Benchimol A Legier JF Dimond EG The carotid tracing and apexcardiogram in subaortic stenosis and idiopathic myocardial hypertrophy. Am J Cardiol. 1963; 11: 427-435 Abstract Full Text PDF PubMed Scopus (15) Google Scholar The characteristic midsystolic retraction and late systolic wave associated with this disease have been noted to appear or become exaggerated during performance of Valsalva's maneuver. 2 Polis O Cleempoel H Hanson J et al. Value of Valsalva's maneuver in phonocardiography. Acta Cardiol. 1960; 15: 441-462 PubMed Google Scholar , 3 Rosenblum R Delman A Valsalva's maneuver and the systolic murmur of hypertrophic subaortic stenosis: A bedside diagnostic test. Am J Cardiol. 1965; 15: 868-870 Abstract Full Text PDF PubMed Scopus (4) Google Scholar We describe herein the “normalization” of a diagnostic carotid arterial pulse tracing during deep inspiration against a closed glottis (MÜller's maneuver) in a patient with subaortic stenosis.

Severity of aortic stenosis assessed by carotid pulse recordings and phonocardiography.

The external carotid pulse, the PCG, and the ECG were studied in 26 adult patients with valvular aortic stenosis whose systolic peak pressure gradients ranged from 18 to 165 mmHg. A significant correlation was found between the rapidity of the pulse upstroke, as measured by the T-time, and the location of the peak of the systolic murmur during ventricular ejection, on the one hand, and the gradient, on the other. The left ventricular ejection time (LVET) related directly and the pre-ejection period (PEP) indirectly with the gradient. There was a signficant inverse relationship between the PEP/LVET quotient and the pressure gradient but this quotient did not classify the patients according to the severity of the stenosis as well as the T-time and the location of the peak of murmur. When a combination of the T-time, the PEP/LVET, and the location of the peak of the murmur was used in each patient, a good discrimination between the patients was achieved. When the pressure gradient was above 50 mmHg, at lease one of the measurements was abnormal and when it exceeded 100 mmHg, at least two measurements were abnormal. The study further showed that it is possible to separate patients with valvular aortic stenosis from those with hypertrophic obstructive cardiomyopathy lidiopathic hypertrophic subaortic stenosis) or mitral insufficiency on the basis of carotid pulse tracings and PCGs.

Diastolic intervals in cardiomyopathy and abnormal thyroid states: alterations in isovolumic relaxation time and rapid filling time of depressed and enhanced myocardial contractility.

Diastolic and systolic time intervals were measured in 11 control subjects, 11 patients with cardiomyopathy, 7 hyperthyroid patients, and 5 hypothyroid patients. The isovolumic relaxation time (IVRT), rapid filling time (RFT), preejection period (PEP), left ventricular ejection time (LVET), and PEP/LVET ratio were found by simultaneously recording the ECG, phonocardiogram, external carotid pulse, and apexcardiogram. In cardiomyopathy the IVRT and RFT were prolonged (107.4 +/- 21.1 msec [P less than 0.01] and 111.0 +/- 10.0 [P less than 0.01] respectively) in comparison to the control subjects. (In the controls the IVRT was 85.7 +/- 18.4 msec and the RFT was 94.5 +/- 12.8 msec). In altered thyroid states the RFT was most affected; in hypothyroidism it increased to 123.9 +/- 25.2 (P less than 0.01) and in hyperthyroidism it decreased to 71.5 +/- 21.3 msec (P less than 0.01). In hyperthyroid patients the IVRT, although shorter than in control subjects, was not significantly altered, but it showed a significant increase after treatment. The RFT also returned toward normal after therapy in both groups (116.7 +/- 14.6 msec in hypothyroid patients and 89.0 +/- 23.1 msec in those with hyperthyroidism).

HEMODYNAMIC (HD) FEATURES OF HYPERTENSION AMONG HIGH SCHOOL STUDENTS

HD of 111 hypertensive (H) high school students and their response to exercise were determined by non-invasive techniques and compared with 67 normotensive (N). Left ventricular ejection time (LVET) and pre-ejection period (PEP) were determined from simultaneously recorded electrocardiogram (ECG), phonocardiogram and external carotid pulse tracings, cardiac index (CI), ejection fraction (EF), mean velocity of circumferential fiber shortening (Vcf) and percent shortening of internal diameter (SID) of the left ventricle were measured by echocardiography. Exercise was performed on a bicycle ergometer against 3 work loads ending with a 10 minute rest period. Heart rate (HR) and blood pressure (BP) were monitored during and after the exercise. ECG-VCG showed mild left ventricular hypertrophy in 40% of male H and 19% of female H. PEP was significantly shortened, PEP/LVET decreased in H when compared with N. CI was lower and EF, Vcf and SID higher in the H. The peak HR and BP during exercise in H were significantly higher and their return to baseline levels slower than N. The HD response to exercise was not significantly different between H and N. This study suggested that young H have an identifiable hemodynamic profile.

External carotid pulse recordings in hypertrophic obstructive cardiomyopathy.

External carotid pulse tracings were examined in 15 patients with hypertrophic obstructive cardiomyopathy (HOCM), the diagnosis being confirmed by catheterization of the left heart. Of 12 patients with intraventricular gradients at rest, 9 had a typical bifid pulse with midsystolic dipping. In one patient without a gradient at rest, midsystolic dipping occurred only in beats following extrasystoles (Brockenbrough phenomenon). The upstroke of the pulse wave was rapid in all the patients, a finding that distinguishes them from patients with valvular aortic stenosis. There was a correlation between the length of the left ventricular ejection time and the intraventricular gradient (r = 0.71) but as more than half the patients had normal or shortened ejection times, the diagnosis of HOCM cannot be based on measurements of this parameter. It is concluded that carotid pulse registrations are of considerable diagnostic value in patients suspected of having HOCM. As the pulse changes are correlated to the degree of left ventricular outflow obstruction, it is suggested that repeated pulse tracings may be used as a means for controlling the degree of obstruction once the diagnosis has been established in the individual patient.

163: Assessment of uraemic cardiomyopathy in childhood by systolic time intervals

Systolic time intervals (STI) are recorded in 48 children with chronic renal failure (CRF) for quantitative determination of impaired myocardial performance as a result of uraemic cardiomyopathy under conservative treatment or on haemodialysis (HD). Duration of total systole (DTS), pre-ejection-phase (PEP), ejection time (ET) and systolic quotient (SQ = ET/PEP) are estimated from simultaneous high speed tracings of the EKG, PKG and the external carotid pulse. The measured values are compared to the calculated values related to age and heart rate according to GOLDE. In non-dialysed children (mean SCR 9 mg%) there is a prolongation in PEP of 32% above normal (p < 0.05), indicating a reduced myocardial performance. The SQ is found shortened to 80% of normal (p < 0.05) corresponding to a diminished left ventricular ejection fraction. A correlation is also found between PEP, SQ and serum haemoglobin (r = 0.75/0.76). Following administration of digitalis PEP decreases (p < 0.05) and SQ increases (p < 0.05). On HD PEP and SQ improve significantly (p < 0.05) in the case that they have indicated a negative inotropic myocardial state before HD.

Left ventricular ejection and the Heather Index measured by non-invasive methods during postural changes in man.

Differences have been found, which are usually 1% or less, between the left ventricular ejection time measured from the external carotid pulse tracing, and from the rate of change of thoracic impedance (dZ/dt) waveform, using either the second heart sound or the X-point of the dZ/dt tracing as the end-point. The Heather Index obtained from the ECG and dZ/dt tracings has been correlated with other indices of cardiac performance. The changes observed in the physiological variables during head-up and head-down tilting were in the expected directions.

Influence of Prolapsed Mitral Leaflets on Aortic Blood Velocity

chocardiographicl and left ventriculographic2 data have clearly established that the auscultatory syndrome comprised of midsystolic click and late systolic murmur is based on mitral valve prolapse. During the past decade attention has been directed toward the influence of mitral valve prolapse on the external carotid pulse tracing and left ventricular apexcardi~gram.~-~ We report here aortic