Left Ventricular Cineangiography Research Articles

Extravasation of contrast into the myocardium and coronary vein during left ventricular cineangiography

Extravasation of contrast into the myocardium and coronary vein during left ventricular cineangiography

Acute myocardial infarction in patients with angiographically normal coronary arteries: clinical features and medium term follow-up

Acute myocardial infarction (MI) in patients with normal coronary arteries has been recognized for several years. In most cases its etiology is unknown. The objective of the present study was to describe clinical features and medium term follow-up of those patients. Between April 1991 and December 1996, 9860 coronary angiographies were performed in our hospital. During this period 17 patients with documented myocardial infarction and completely normal coronary arteries were identified. Acute myocardial infarction was defined as the clinical event with acute angina pectoris, ST-elevation typical for myocardial infarction, and an increase in serum creatinine phosphokinase (CPK) above 125 U/l. The mean peak CPK was 675 U/l (range: 129-1760 U/l). All 17 patients revealed significant ST-segment elevation. According to the ECG criteria there was no predilection for a specific location of MI (9 anterior MIs and 8 inferior MIs). Thrombolytic therapy was performed in 9 patients. In 12 patients areas of localized hypo- or akinesia were shown on left ventricular cineangiography. The mean ejection fraction was 61.5+/-10.3%. The age and sex distribution revealed a bimodel character: there was a younger age group of 9 patients, all men with a mean age of 35.9 years (31-43) and all strong cigarette smokers (mean 28 cigarettes/day) and there was an older group of 7 patients (1 man, 6 women) with a mean age of 56,4 years (47-68) and no significant association with cigarette smoking. During a mean follow-up period of 48.6 months (31-85 months) no patient died and no patient suffered from recurrent chest pain and used nitroglycerin occasionally. Patients with acute MI and angiographically normal coronary arteries show a bimodal sex and age distribution: a younger age group, all men and uniformly strong cigarette smokers and an older group predominantly women with no significant association with cigarette smoking. Both groups seem to have a favorable prognosis.

Prediction of functional recovery of viable myocardium after delayed revascularization in postinfarction patients: Accuracy of dobutamine stress echocardiography and influence of long-term vessel patency

OBJECTIVESWe sought to evaluate Dobutamine stress echocardiography (DSE) for predicting recovery of viable myocardium after revascularization with cineangiography as a gold standard for left ventricular (LV) function. We studied the influence of late vessel reocclusion on regional LV function.BACKGROUNDDobutamine stress echocardiography is a well established evaluation method for myocardial viability assessment. In previous studies the reference method for assessing LV recovery was echocardiography; long-term vessel patency has not been systematically addressed.METHODSSixty-eight patients with a first acute myocardial infarction (AMI) and residual stenosis of the infarct related artery (IRA) underwent DSE (mean ± standard deviation) 21 ± 12 days after AMI to evaluate myocardial viability. Revascularization of the IRA was performed in 54 patients by angioplasty (n = 43) or bypass grafting (n = 11). Coronary angiography and LV cineangiography were repeated at four months to assess LV function and IRA patency.RESULTSSensitivity and specificity of DSE for predicting myocardial recovery after revascularization were 83% and 82%. In the case of late IRA patency, specificity increased to 95%, whereas sensitivity remained unchanged. In the 16 patients with myocardial viability and late IRA patency, echocardiographic wall motion score index decreased after revascularization from 1.83 ± 0.15 to 1.36 ± 0.17 (p = 0.0001), and left ventricular ejection fraction (LVEF) increased from 0.52 ± 0.06 to 0.57 ± 0.06 (p = 0.0004), whereas in five patients, reocclusion of the IRA prevented improvement of segmental or global LV function despite initially viable myocardium.CONCLUSIONSDobutamine stress echocardiography is reliable to predict recovery of viable myocardium after revascularization in postinfarction patients. Late reocclusion of the IRA may prevent LV recovery and influence the accuracy of DSE.

Analytical expression of effective afterload in aortic and mitral regurgitation.

Effective arterial elastance (Ea) is the coupling parameter between the left ventricle and peripheral circulation in normal subjects. If left ventricular end systolic pressure (Pes), contractility (Es) and Ea are known, left ventricular end diastolic volume (LVEDV) and ejection fraction of the ventricle are completely determined. The aim of this study was to give an analytical expression for Ea in patients with mitral and aortic regurgitation, and predict both LVEDV and the effect of vasodilator therapy on LVEDV. Twenty-three subjects with atypical chest pain, 15 patients with mitral insufficiency and 11 with aortic insufficiency underwent diagnostic cardiac catheterization, coronary angiography, and left ventricular cineangiography, which was analyzed quantitatively. Ea was 2.05 +/- 0.63 in normal subjects, while it was 1.28 +/- 0.71 and 1.57 +/- 0.87 in patients with mitral and aortic insufficiency, respectively. All these groups differed with ANOVA test (p = 0.0031). We tested the ability of the analytical expressions for Ea in normal subjects, and patients with mitral insufficiency or aortic insufficiency to predict measured Ea and LVEDV. Ea and LVEDV were predicted rather accurately in every case (p < 0.0001). We used published data to test the effect of resistance modulation on LVEDV. Predicted and measured LVEDV were linearly correlated both in aortic (p < 0.0001) and mitral insufficiency (p = 0.027). Moreover, in some cases a left ventricular enlargement after vasodilator therapy could be anticipated because of an unbalanced decrease in resistance and heart rate. Ea seems to be the coupling parameter between the left ventricle and the peripheral circulation not only in normal subjects, but also in patients with mitral or aortic regurgitation; its measurement before administering vasodilating drugs may be useful in order to predict the effects on LVEDV, and achieve an optimal ventriculoarterial coupling.

A Comparison Between Systolic Aortic Root Pressure and Finger Blood Pressure

Digital photoplethysmography is used to assess hemodynamic variability and baroreflex sensitivity. Numerous studies have critically evaluated the accuracy of the photoplethysmographic device against peripheral pressure. The aim of our study was to compare finger blood and aortic root pressure. We prospectively compared simultaneous recordings of systolic pressure at the aortic root and finger level over three consecutive respiratory cycles in 15 patients (56+/-11 years) undergoing routine cardiac catheterization. Data were obtained at baseline, during deep breathing maneuver (0.1 Hz), and after left ventricular cineangiography. At baseline, systolic finger pressure overestimated systolic aortic pressure (145.2+/-22.5 vs 115.0+/-20.1 mm Hg; p<0.001). The pressure difference (30.2+/-17.0 mm Hg) was not influenced by systolic aortic pressure. There was no relationship between pressure difference and the main determinants of the pulse wave amplification phenomenon. There was a beat-to-beat relationship between finger and aortic pressure in 14 of 15 subjects (slope ranging from 0.37 to 1.70; ordinate: from -56 to +98 mm Hg). During the deep breathing maneuver and after left ventricular cineangiography, finger pressure still overestimated aortic pressure by 32.3+/-15.0 mm Hg and 38.3 13.9 mm Hg, respectively (each p<0.001). There was a beat-to-beat relationship between systolic aortic root pressure (IAoBP) and systolic finger (FBP) in 13 of 15 patients, with major scattering of both slopes and ordinates. Throughout the study, there was no predictable relationship between the level of IAoBP and pressure bias. As expected, FBP was almost always higher than IAoBP. Importantly, the differences in systolic pressure did not correlate with known determinants of the pulse wave amplification phenomenon. The device must be used cautiously if one wants to noninvasively track spontaneous or induced changes in IAoBP.

Effects of Stenting of Recent or Chronic Coronary Occlusions on Late Vessel Patency and Left Ventricular Function

Due to high rates of late vessel reocclusion, balloon angioplasty of recent or chronic coronary occlusions is not associated with a sustained improvement in left ventricular function. Recent studies have suggested that stent implantation at coronary occlusions significantly reduces late vessel occlusion. We thus designed a study to analyze the effect of stent implantation at coronary occlusions on late vessel patency and left ventricular function. Twenty-four consecutive patients with recent or chronic coronary occlusions had successful stent implantation and were enrolled in a 6-month angiographic follow-up program. Contrast left ventricular cineangiography, at baseline and 6-month follow-up, as well as preprocedural, postprocedural, and follow-up angiograms analyzed with quantitative angiography were available in 22 of the patients (92%). At follow-up, no vessel reocclusion was observed and 32% of the patients, as analyzed by the >50% diameter stenosis criterion, had restenosis. There was a significant improvement in global left ventricular function with a decrease in both left ventricular end-diastolic volume index (LVEDVI, p <0.01) and left ventricular end-systolic volume index (LVESVI, p <0.0001) and an increase in left ventricular ejection fraction (LVEF, p <0.0001). Similarly, regional wall motion in the territory of the recanalized artery was also significantly improved (p <0.05). These effects were associated with a reduction in left ventricular filling pressure (p <0.0001). Stent implantation following balloon angioplasty of recent or chronic coronary occlusion is associated with a low rate of late vessel reocclusion, a reduction in cardiac volume, and an increase in ejection fraction. Such effects on left ventricular volumes could have a significant impact on patient survival.

Collagen scar formation after acute myocardial infarction: relationships to infarct size, left ventricular function, and coronary artery patency.

Left ventricular function after acute myocardial infarction (AMI) is determined by the expansion of the infarct zone and remodeling of the noninfarcted myocardium. An occluded infarct-related artery (IRA) is an independent risk factor for remodeling. Changes in myocardial collagen metabolism were evaluated in 36 patients with suspected AMI. The plasma creatine kinase MB fraction and myoglobin release curves were analyzed for assessment of early reperfusion and infarct size. Collagen scar formation was evaluated by measurement of serum concentrations of the aminoterminal propeptide of type III procollagen (PIIINP), the aminoterminal propeptide of type I procollagen (intact PINP), and the carboxyterminal propeptide of type I procollagen (PICP). Plasma renin activity and urine excretion of cortisol and aldosterone were also measured. Coronary angiography and left ventricular cineangiography were performed during early hospitalization. The serum concentration of PIIINP increased from 3.50+/-0.20 to a maximum of 5.08+/-0.36 microg/L (n=32) in the patients with AMI, whereas the concentrations of intact PINP and PICP tended to decrease. The area under the curve (AUC) of PIIINP during the first 10 postinfarction days was larger in patients with severe heart failure or ejection fractions < or = 40% than in those with no heart failure or with an ejection fraction > 40% (P<.05 and P<.01, respectively), and it was also larger in the patients with TIMI grade 0 to 2 flows than in those with TIMI 3 flows (P<.05), despite similar enzymatically determined infarct sizes. No significant correlations between PIIINP and neurohumoral parameters were observed. The AUC of PIIINP and the change in PIIINP during the first 4 days were significantly correlated with indices of cardiac function. Collagen scar formation after AMI can be quantified by measurement of serum PIIINP concentrations. Scar formation is more prominent in large infarctions causing left ventricular dysfunction and in patients with occluded IRAs.

1014-100 MCI-154, a Novel Calcium Sensitizer, Has Beneficial Hemodynamic Effects in Pacing-Induced Heart Failure

To assess the efficacy of MCI-154 (MCI), a new cardiotonic agent with calcium (Ca2+) sensitizing action, on left ventricular (LV) function in heart failure (HF), we studied nine anesthetized dogs before (C) and after pacinginduced HF (245 bpm for 2–4 weeks). LV cineangiography and pressure (P) (tip-manometer) were obtained before and during infusion of MCI (1.0 μg/kg/min for 15 min) in C and HF. Heart rate (HR) and LV systolic pressure were unchanged with MCI. MCI augmented LV systolic function assessed by ejection fraction (EF) and end-systolic P-volume ratio (Ees) evaluated by IVC occlusion. MCI also augmented LV relaxation assessed by the time constant (Tau) of LVP decay in both C and HF. However, inotropic and lusitropic effects of MCI were more striking in HF than in C as follows:Empty CellLVEDP (mmHg)LVEDV (ml)EFEes (mmHg/ml)Tau (msec)C-1*-7+0.12*+ 1.37*-3*HF-7**-7+0.16**+1.87*-15***p &lt; 0.05**p &lt; 0.01 p &lt; 0.05 p &lt; 0.01 MCI exerts its potent inotropic activity in HF. In addition, despite the effect of myofilament sensitization to Ca2+. MCI improves LV relaxation in HF more than in C without HF. MCI may be a useful agent in the treatment of HF.

Myocardial Infarction With Angiographically Normal Coronary Arteries

To determine the prevalence rate and clinical and hemodynamic profile of patients with myocardial infarction (MI) with angiographically normal coronary arteries, we analyzed 3,403 consecutive angiograms performed within a 4.5-year period. Of these studies, 1,124 were performed following an acute MI. Through a computerized search, 12 patients were identified who had documented MI with normal or insignificant (< 30% stenosis in one epicardial vessel only) coronary disease. Q-wave MI developed in five patients (group A) and non-Q-wave MI developed in seven patients (group B). Group A patients were all men whereas group B patients were all women. Overall, group A patients were younger (p = 0.003), had a longer smoking history (p = 0.008), and a higher cardiac index (p = 0.005). In ten patients, areas of localized dyskinesia or hypokinesia were shown on left ventricular cineangiography. Mitral valve prolapse was present in four of the patients and varying degrees of mitral regurgitation were identified in another six. The prevalence rate of MI with angiographically normal coronary arteries was 1% in this study. This entity had a bimodal age and sex distribution: a younger age group, all men, with a stronger cigarette smoking history who had Q-wave MI vs an older age group, all women, and no significant association with cigarette smoking who developed non-Q-wave MI. A mean follow-up of 4 years demonstrated a favorable prognosis in both groups.

Is angiographic ventriculography necessary for the assessment of ischemic patients?

A total of 53 patients with a provisional diagnosis of ischemic heart disease and without any clinical evidence of valvular, congenital, or primary muscle heart disease were studied by echocardiography and biplane left ventricular cineangiography. For angiographic ejection fraction analysis, a program developed in our department for use on an Apple Macintosh computer interfaced to a digitizing tablet was employed. Echocardiographic outlines of systolic and diastolic images were traced with a digitizing system on the screen and ejection fractions were calculated by a program incorporated in the echo machine. Good echo windows allowing ejection fraction calculations were present in 35 patients. There was a good correlation between angiographic and echocardiographic ejection fraction (r = 0.7, SEE = 0.09), and wall motion assessment revealed no significant discrepancies between the two image modalities. The remaining 18 patients had poor echo windows, preventing accurate echocardiographic determination of the ejection fraction. However, limited assessment of left ventricular size and wall motion was possible in all patients and allowed the identification of those who had impaired left ventricular function as judged by angiography (angiographic ejection fraction < 35%). We conclude that even in patients with poor echo windows echocardiographic assessment of left ventricular function provides clinical information similar to angiography which should not be considered mandatory for the investigation of ordinary ischemic patients.

Interstudy reproducibility of biplane cine nuclear magnetic resonance measurements of left ventricular function

Cine nuclear magnetic resonance (NMR) imaging, as a noninvasive and high-resolution imaging modality, has been shown to be reliable for determining absolute left ventricular (LV) volumes and ejection fraction. A relatively new gradient echo cine NMR approach using 2 orthogonal long-axis planes (2- and 4-chamber) aligned with the true axes of the left ventricle has been previously developed and validated against radiographic biplane LV cineangiography. The aim of the present investigation was to determine the reproducibility of this more rapid cine NMR approach for the measurement of LV volumes and ejection fraction. Eighteen normal subjects underwent 2 cine NMR studies, on different days, using a 1.5-tesla clinical imaging system. Studies were analyzed on-line and blindly by 2 independent observers. Intraobserver error was also determined in a blinded manner. Mean values of measurements determined by this method in this group of normal subjects were end-diastolic volume (120 ± 20 ml), end-systolic volume (39 ± 9 ml) and ejection fraction (67 ± 4%). Paired analysis of data revealed no significant bias between interstudy, interobserver or intraobserver measurements, except for interobserver end-diastolic volume, where the first observer measurements were slightly elevated (5.6 ± 7.8 ml) compared with the second. This resulted in a small difference in ejection fraction (1.7 ± 2.3%) between observers. The absolute variation between measurements (square root of variance components) was low for all interstudy, interobserver and intraobserver comparisons: end-diastolic volume was <±6.7 ml, end-systolic volume <±3.5 ml and ejection fraction <±2.4%. These results demonstrate the potential of the biplane cine NMR intrinsic long-axis approach to obtain reliable and sequential measurements of LV volumes and function in subjects without segmental wall motion abnormalities, using practical acquisition and analysis times.

Intraoperative transesophageal color-coded Doppler echocardiography for evaluation of residual regurgitation after mitral valve repair

Because mitral valve competence after mitral valve reconstruction is awkward to assess during this procedure, we evaluated in this respect transesophageal color-coded Doppler echocardiography in 23 patients undergoing mitral valve reconstruction for severe mitral regurgitation. Transesophageal echocardiographic examinations were performed after induction of anesthesia but before sternotomy (baseline), after mitral valve repair before decannulation, and at sternal closure, all at similar mean aortic pressure and echocardiographic instrument settings. The degree of mitral regurgitation by transesophageal color Doppler flow mapping was visually quantified on a 5-point scale (0 to 4), pending the left atrial extent of the regurgitant jet. This was compared with the degree of mitral regurgitation by left ventricular cineangiography performed within several weeks after operation and also visually quantified on a 5-point scale (0 to 4), with use of the right anterior oblique projection. There was good correlation between the two methods (r = 0.83; p less than 0.001). We conclude that residual mitral regurgitation, as assessed by transesophageal color flow mapping in the operating room, highly correlates with the ultimate mitral regurgitation by cineangiography. Therefore transesophageal echocardiography can be helpful for evaluation of mitral valve competence during mitral valve reconstruction, and hence, in case of repair failure, allow valve replacement in the same surgical session, thus avoiding reoperation.

Ventricular arrhythmias and left ventricular myocardial function in chronic chagasic patients

To study the relationship of complex ventricular arrhythmias to the presence and extent of myocardial damage, 556 chronic chagasic patients were submitted to an extensive protocol, including left ventricular cineangiography and Holter monitoring, and properly classified according to clinical, electrocardiographic and hemodynamic findings. Stages of the clinical-hemodynamic classification corresponded to increasing degrees of myocardial damage, age, prevalence and complexity of ventricular arrhythmias. Myocardial damage (particularly left ventricular dilatation) was the most important clinical factor linked to the presence of complex ventricular arrhythmias. A clear difference in terms of ventricular function was found only when arrhythmias were grouped into simple (Lown grades I and II) and complex (grades III and IV) forms. It is recommended that any classification for chagasic patients must be based on signs of myocardial involvement, instead of clinical or electrocardiographic findings alone. Evaluation should include accurate determination of left ventricular myocardial function, along with the search for the presence of complex ventricular arrhythmias and abnormalities of conduction.

Left ventricular volume measurement using cardiac axis nuclear magnetic resonance imaging. Validation by calibrated ventricular angiography.

Proton nuclear magnetic resonance (NMR) imaging has the potential to serially assess left ventricular (LV) volumes with optimal accuracy because it is a high-resolution, three-dimensional, noninvasive modality. Previous NMR studies to assess LV volumes have been suboptimal, as they have used either planes aligned with the axes of the body, which are compromised by partial volume effects, or spin-echo techniques that have been time-consuming to acquire and analyze. Accordingly, for LV volume measurement, we developed a gradient-echo (cine) NMR strategy that uses two orthogonal planes intersecting along the intrinsic long axis of the heart (two-chamber and four-chamber). This approach was validated against calibrated contrast biplane LV cineangiography (CATH) and also compared with a previously reported short-axis spin-echo NMR method. Twenty-one patients underwent CATH and NMR (long-axis, n = 21; short-axis, n = 14) within a 3-day interval. Although both long- and short-axis NMR LV volumes and ejection fractions correlated well with CATH (r greater than 0.90, p less than 0.001 in all), end-diastolic volumes by both long-axis (161 +/- 85 ml) and short-axis (151 +/- 81 ml) NMR were systematically less than those by CATH (182 +/- 85 ml) (p less than 0.05). Consequently, ejection fractions by long-axis (48 +/- 17%) and short-axis (49 +/- 17%) NMR consistently underestimated those by CATH (54 +/- 16%, p less than 0.05). End-systolic volumes by long-axis (94 +/- 71 ml) and short-axis (87 +/- 72 ml) NMR were not significantly different from those by CATH (92 +/- 69 ml). Both NMR techniques had low intraobserver and interobserver variation (less than 11%); however, short-axis spin-echo NMR involved longer acquisition/reconstruction (35 versus 18 minutes) and analysis (25 versus 10 minutes) times. We conclude that both short-axis spin-echo and long-axis gradient-echo NMR approaches reliably estimate LV volumes. Currently, the long-axis strategy appears more practical for clinical use because the scan and analysis times are relatively short.

Role of two-dimensional echocardiography, pulsed, continuous wave and color flow Doppler techniques in the assessment of ventricular septal rupture after myocardial infarction

Two-dimensional echocardiography, pulsed and continuous wave Doppler techniques were used for the evaluation of 15 consecutive patients (9 men, 6 women; mean age 71 years, range 61 to 79) with ventricular septal rupture due to acute myocardial infarction (7 anterior, 8 posterior). Standard and modified off-axis 2-dimensional echocardiographic views from parasternal, apical and subcostal windows correctly identified this defect in 14 of the 15 patients. Pulsed Doppler echocardiography confirmed the presence of left-to-right-sided shunt by showing a high-velocity, aliased, systolic flow and a low-velocity diastolic flow in the right ventricle in 14 patients. Continuous wave Doppler echocardiography showed a high-velocity systolic and lowvelocity diastolic flow signal of left-to-right shunt in 14 patients. Color flow Doppler imaging identified a left-to-right shunt in all 6 patients in whom it was performed. Doppler and 2-dimensional echocardiographic studies missed a small apical septal defect in 1 patient with anteroseptal myocardial infarction. Two-dimensional echocardiography correctly diagnosed right ventricular infarction in all 5 patients with posteroinferior infarction. Ventricular septal rupture and/or left-to-right-sided shunt was confirmed in all 15 patients by the following: surgical inspection in 11, necropsy in 3, left ventricular cineangiography in 5 and right-sided heart catheterization and oximetry data in 13 patients. Data indicate that 2-dimensional echocardiography correctly shows the precise location of septal rupture in most patients after acute myocardial infarction and allows assessment of left and right ventricular infarction and function. Pulsed, continuous wave and color flow Doppler imaging shows the presence and location of left-to-right-sided shunt and differentiates this lesion from acute mitral regurgitation. Complete Doppler and 2-dimensional echocardiographic studies make invasive and potentially hazardous left ventricular cineangiography unnecessary for the majority of patients with ventricular septal rupture.

Left atrial function in acute transient left ventricular ischemia produced during percutaneous transluminal coronary angioplasty of the left anterior descending coronary artery

Left atrial (LA) function was studied in 32 patients during percutaneous transluminal coronary angioplasty of the proximal left anterior descending artery with a dual micromanometer positioned transseptally in the left atrium and in the left ventricle. In 10 patients LA and left ventricular (LV) cineangiography was performed 30 minutes before percutaneous transluminal coronary angioplasty and 30 seconds after the occlusion of the left anterior descending coronary artery. Thirty seconds after left anterior descending occlusion, LV peak systolic pressure decreased from 135 ± 12 to 106 ± 9 mm Hg (p < 0.05) and LV maximum dP dt decreased from 1,634 ± 136 to 1,137 ± 127 mm Hg/s (p < 0.01). Simultaneously, LA mean pressure increased from 11 ± 2 to 29 ± 1 mm Hg (p < 0.001) and LA maximum dP dt increased from 177 ± 13 to 381 ± 21 mm Hg (p < 0.001). There was a difference between LV end-diastolic pressure and LA mean pressure of 1.5 mm Hg at rest and 7.8 mm Hg during ischemia and LA pulse pressure increased from 16 ± 3 to 26 ± 3 mm Hg (p < 0.05) together with increase of LA A and V waves peak pressure. LV stroke volume index decreased from 46 ± 5 to 43 ± 3 ml/m 2 (difference not significant). The LA maximal volume increased from 18 ± 2 to 29 ± 3 ml/m 2 (p < 0.001). LA volume before LA contraction increased from 29 ± 2 to 54 ± 3 ml/m 2 (p < 0.001). The LA stroke volume increased from 23 ± 2 to 35 ± 4 ml/m 2 (p < 0.001) and the ratio of contribution of LA contraction to LV stroke volume index increased from 26 ± 5 to 57 ± 9% (p < 0.001). LV isovolumic relaxation time shortened from 82 ± 7 to 57 ± 5 ms (p < 0.001). Thus, left atrial function plays an important role in maintaining overall cardiac function during LV ischemia by reactive hyperactivity.

The value of cine nuclear magnetic resonance imaging for assessing regional ventricular function

Previous nuclear magnetic resonance (NMR) imaging studies to assess left ventricular function have used multiple axial planes, which are compromised by partial volume effects and are time consuming to acquire and analyze. Accordingly, an imaging approach using cine NMR and planes aligned with the true cardiac axes of the left ventricle was developed in views comparable with left ventricular cineangiography. Cine NMR imaging was used to assess regional wall motion and was validated by comparison with biplane left ventricular cineangiography. Fifty-nine patients underwent cineangiographic and NMR studies within 72 h. A poor quality NMR study precluded analysis in 4, leaving a study group of 55 patients (mean age 58 ± 12; 17 women).Cine NMR movie loops were acquired in two long-axis planes: 1) right anterior oblique plane, parallel to the septum, and 2) four chamber orthogonal plane, perpendicular to the septum (this view is comparable to the angio-graphic left anterior oblique view). To assess regional wall motion, the left ventricle in both clue NMR and cineangio-graphic images was divided into five segments and graded on a five point grading scale from 3 for normal through 0 for akinesia and −1 for dyskinesia. Regional wall thickening was used qualitatively to aid in the analysis of wall motion. For the 275 segments compared in the right anterior oblique view, agreement was within one grade in 263 (95.6%) of 275 segments, whereas absolute agreement was observed in 171 (62%) of 275 segments. In the left anterior oblique view, of 200 segments evaluated, agreement within one grade was achieved in 184 segments (92%) and agreement was complete in 132 (66%).It is concluded that biplane cine NMR imaging, using two intrinsic left ventricular long-axis planes, permits noninvasive assessment of regional left ventricular function in views comparable to standard angiographic projections.

Left Atrial Systolic Antegrade Flow in Patients With Mitral Regurgitation: A Pulsed Doppler Sign Displayed by Color Flow Imaging

Twenty-two patients with severe mitral regurgitation were observed to have turbulent systolic antegrade flow on pulsed Doppler mapping of the left atrium. All were studied by color flow imaging to delineate the mechanism of this peculiar flow. Pulsed Doppler findings of an eccentric regurgitant flow in one side, an antegrade systolic flow with slightly delayed onset in the other side, and a low velocity flow near the posterior wall, were consistant with the theory of a large eccentric regurgitant jet swirling in the left atrium. Color flow imaging confirmed this mechanism in all patients. Nineteen patients had flail mitral valve with a positive predictive value of 86%. The other three patients had deformed rheumatic mitral valve. The severity of mitral regurgitation was confirmed in all 16 patients studied by left ventricular cineangiography. We have shown that the antegrade systolic left atrial flow is the result of the swirling of a large regurgitant eccentric jet, is commonly observed with flail mitral valve, can occur in patients with deformed rheumatic mitral valve without flail leaflet, and most significantly indicates the presence of severe mitral regurgitation.

Depressed myocardial contractility and normal ejection performance after aortic valve replacement in patients with aortic regurgitation

Left ventricular cineangiography and pressure measurement were performed in 33 patients with chronic aortic regurgitation before and after aortic valve replacement and in 25 normal control subjects. Stress and volume were analyzed. The 33 patients were divided into three groups based on preoperative end-systolic volume index: 15 with an index of less than 100 ml/m2 (group I), 12 with an index of 100 to 200 ml/m2 (group II), and six with an index of more than 200 ml/m2 (group III). Afterload estimated as end-systolic stress, which was significantly elevated in all groups before operation, returned to normal postoperatively. Systolic pump function improved postoperatively in all groups; group I and group II showing the most improvement with group III still having an abnormal ejection fraction. The ratio of end-systolic stress to end-systolic volume index, which is an index of contractile state that is relatively independent of preload and afterload, was abnormal in each group preoperatively. Postoperatively, the ratio improved in each group (from 2.8 +/- 0.5 to 4.8 +/- 0.9 for group I, from 1.4 +/- 0.3 to 3.2 +/- 0.6 for group II, and from 0.8 +/- 0.2 to 2.6 +/- 0.8 for group III, compared with 5.9 +/- 1.0 for control subjects). Group I had normal values whereas group II and group III had subnormal ratios, suggesting a depressed contractility. All 15 patients in group I had values that fell within the 95% confidence limits of the linear inverse relationship between ejection fraction and end-systolic stress for control subjects. Nine of the 12 patients in group II and all six in group III had values that fell below the 95% confidence limits of the normal ejection fraction-end-systolic stress relationship. Aortic valve replacement may reduce afterload and improve systolic pump function in many patients with aortic regurgitation. However, there is a subgroup of patients who, despite normal or near-normal pump performance as assessed by ejection fraction, have depressed myocardial contractility characterized by an abnormal relationship between end-systolic stress and either ejection fraction or end-systolic volume.

Valsalva maneuver: a test of the functional state of cardiac innervation in Chagasic myocarditis

The ratio between maximal and minimal R-R intervals measured during the Valsalva maneuver is an adequate means of studying the functional state of the cardiac parasympathetic nervous system. We studied the changes in heart rate evoked during the Valsalva maneuver in 49 asymptomatic Chagasic patients with different degrees of myocardial involvement. The Chagasic patients were divided in three groups. Twelve patients had no evidence of heart disease except for an abnormal myocardial biopsy. Sixteen patients had a normal electrocardiogram but revealed evidence of localized myocardial damage as shown by left ventricular cineangiography. Twenty-one patients had abnormal electrocardiograms and revealed multiple areas of abnormal left ventricular wall motion. The Valsalva ratio (mean ± standard error) was 1.62 ± 0.12 for controls, 1.52 ± 0.10 for those with an abnormal biopsy, 1.48 ± 0.06 for those with localized myocardial damage, and 1.31 ± 0.04 for those with an abnormal electrocardiogram. There were no statistically significant differences between the control group (normal sero-negative subjects) and those patients with normal electrocardiograms. Results in those with an abnormal electrocardiogram, however, were statistically different ( P < 0.05) from the other groups. These results are in discordance with the commonly accepted hypothesis that cardiac parasympathetic denervation causes a dilated myocardiopathy in patients with chronic Chagasic myocarditis.