Left Ventricular Posterior Wall Motion Research Articles

Postoperative Normalization of Left Ventricular Noncompaction and New Echocardiographic Signs in Aorta to Left Ventricular Tunnel

We report postoperative normalization of left ventricular noncompaction in a neonate undergoing successful neonatal surgery for type II aorta to left ventricular tunnel (ALVT) associated with a large patent ductus arteriosus, floppy and extremely redundant anterior mitral leaflet, right coronary artery arising directly from the tunnel, and severe left ventricular noncompaction. We also described 2 novel echocardiographic findings in ALVT including "triple wavy line sign" on M-mode echocardiography which disappeared 1 month after operation and "abnormally increased left ventricular posterior wall motion" on M-mode of standard parasternal long-axis view on color tissue Doppler imaging (TDI) that also normalized postoperatively. We showed that proper definition of endocardial border is extremely important in strain and strain rate imaging in the context of left ventricular noncompaction. Preoperative longitudinal strain and strain rate were significantly decreased in comparison to radial strain and strain rate. Circumferential strain and strain rate were normal.

Utility of Transmural Myocardial Strain Profile for Prediction of Early Left Ventricular Dysfunction in Patients With Duchenne Muscular Dystrophy

Myocardial damage in Duchenne muscular dystrophy (DMD) has lethal outcomes, making early detection of myocardial changes in patients with DMD vital, because early treatment can help prevent the development of myocardial fibrosis. The aim of the present study was, therefore, to test the hypothesis that transmural strain profile (TMSP) analysis can predict future left ventricular (LV) dysfunction in patients with DMD with preserved ejection fraction. We studied 82 consecutive patients with DMD without LV wall motion abnormality, with an ejection fraction of 60 ± 5% (all ≥55%) and age 11 ± 3 years. Echocardiography was performed at baseline and 1 year of follow-up. TMSP in the posterior wall was evaluated from the mid-LV short-axis view. A normal TMSP pattern (1 peak in the endocardium, group 1) was seen in 44 patients, and TMSP with a notch (2 peaks in the endocardium, group 2) in the remaining 38 (46%). Wall motion abnormality in the posterior wall was observed in 16 patients (42%) in group 2 at 1 year of follow-up but in none of the patients in group 1 (42% vs 0%; p <0.001). Importantly, multivariate analysis showed that only TMSP with a notch (odds ratios 1.524, p <0.001) was an independent determinant of the presence of LV posterior wall motion abnormality at 1 year of follow-up. In conclusion, subclinical LV dysfunction can be detected by evaluation of TMSP in patients with DMD who do not have wall motion abnormalities by conventional echocardiography. TMSP with a notch proved effective for evaluating subtle early changes in patients with DMD and might be useful for predicting LV dysfunction.

SPY Imaging Assessment Correlates with Transesophageal Echocardiogram Assessment of Ventricular Function during Off-Pump Coronary Artery Bypass Grafting

Intraoperative assessment of graft anastomoses is commonly performed after off-pump coronary artery bypass grafting (OPCAB). The SPY imaging system allows intraoperative graft assessment. We document correlation between intraoperative SPY images and wall motion abnormality by transesophageal echocardiogram (TEE) during OPCAB. A 79-year-old female underwent OPCAB. Intraoperative graft patency assessment was performed with the SPY and left ventricular wall motion was assessed by TEE. SPY imaging demonstrated poor flow trough the distal vein graft anastomosis to the posterior descending artery, which correlated with a new posterior wall motion hypokinesis. After graft revision, SPY imaging demonstrated good distal flow and the TEE demonstrated normalization of the left ventricular posterior wall motion. SPY technology allows the surgeon to accurately assess graft patency intraoperatively and allows immediate correction of a technical problem.

Decreased amplitude of left ventricular posterior wall motion with notch movement to determine the left posterior septal accessory pathway in Wolff-Parkinson-White syndrome

OBJECTIVETo determine preoperatively, by analysing asynchronous left ventricular wall motion, whether to approach through the right ventricle or the left ventricle when carrying out catheter ablation of the accessory pathway...

Influence of Aging on Systolic Left Ventricular Wall Motion Velocities Along the Long and Short Axes in Clinically Normal Patients Determined by Pulsed Tissue Doppler Imaging

Our objective was to evaluate the influence of aging on left ventricular (LV) regional systolic function along the long and short axes in clinically normal patients. We recorded LV wall motion velocity patterns at the mid-wall portion of the middle of the LV posterior wall in the parasternal long-axis view (short-axis direction) and at the endocardial portion of the middle of the LV posterior wall in the apical long-axis view (long-axis direction) with pulsed tissue Doppler imaging in 80 normal patients (age range 15 to 78 years). In all patients the LV pressure curve and its first derivative (dP/dt) were recorded. The systolic wave of the LV posterior wall motion velocity pattern exhibited 2 peaks, the first (Sw 1) and second (Sw 2) systolic waves. No significant changes were seen with aging in the percent LV fractional shortening determined by M-mode echocardiography, LV ejection fraction determined by left ventriculography, the peak Sw 1 and Sw 2 along the short axis, the peak Sw 2 along the long axis, and the peak dP/dt. The peak Sw 1 along the long axis correlated inversely with age ( P < .0001) but did not correlate significantly with the peak dP/dt. These results suggest that shortening of the longitudinal fibers in early systole is impaired with increased age in healthy individuals. This impairment results in insufficient spherical change in the LV cavity, although global LV pump function and myocardial contractility are maintained. (J Am Soc Echocardiogr 1999;12:921-6.)

Evaluation of Left Ventricular Contraction Abnormalities in Patients with Dilated Cardiomyopathy with the Use of Pulsed Tissue Doppler Imaging

The left ventricular (LV) systolic wave, as recorded by pulsed tissue Doppler imaging, usually consists of 2 components (Sw 1 and Sw 2). However, the clinical significance of these waves has not been studied in patients with dilated cardiomyopathy (DCM) and sinus rhythm. We studied 25 patients with DCM (DCM group) and 22 age-matched normal subjects (control group). The LV posterior wall motion velocities along the short and long axes were recorded by pulsed tissue Doppler imaging, and the peak velocities of the Sw 1 and Sw 2 and the times from the electrocardiographic Q wave to the peak Sw 1 and Sw 2 (Q-Sw 1 and Q-Sw 2, respectively) were determined. In all patients cardiac catheterization was performed immediately after the noninvasive examination, and the LV end-diastolic pressure and peak dP/dt were determined. The LV end-diastolic pressure and peak dP/dt were significantly greater and lower, respectively, in the DCM group. The peak Sw 1 along the long axis was significantly greater than Sw 1 and Sw 2 along the short axis and Sw 2 along the long axis in the control group. The peak Sw 1 and Sw 2 along the long and short axes were all significantly lower in the DCM group than in the control group. The Q-Sw 1 along the long axis was significantly shorter than that along the short axis, whereas no significant difference was seen in the Q-Sw 2 in either axis in any patient. The Q-Sw 1 and Q-Sw 2 along both axes were significantly longer in the DCM group than in the control group. All systolic pulsed tissue Doppler imaging variables, particularly the peak Sw 1 along the long axis, correlated well with the peak dP/dt in all patients. LV contractility along both the short and long axes is commonly impaired in patients with DCM. In particular, peak Sw 1 along the long axis is a useful parameter for evaluating LV myocardial contractility during isovolumic contraction. (J Am Soc Echocardiogr 1999;13:913-20.)

Pulsed Tissue Doppler Imaging of Left Ventricular Systolic and Diastolic Wall Motion Velocities to Evaluate Differences Between Long and Short Axes in Healthy Subjects

Our objective was to evaluate in healthy subjects the left ventricular (LV) wall motion velocities along the long and short axes by means of pulsed tissue Doppler imaging (TDI) to clarify the differences in the LV systolic and diastolic function between both axes. Wall motion velocities were recorded at the mid-wall portion of the middle site of the LV posterior wall in the parasternal long-axis view, and at the subendocardial portion of the middle site of the LV posterior wall in the apical long-axis view by pulsed TDI in 35 healthy subjects (mean age 26 ± 10 years, mean heart rate 72 ± 7 bpm). In all subjects, the LV pressure curve, its first derivative (dP/dt), the LV wall motion velocity, the phonocardiogram, and the electrocardiogram were simultaneously recorded. The systolic wave of the LV posterior wall motion velocity exhibited 2 peaks: the first and second systolic waves (Sw l and Sw 2 , respectively). The diastolic wave also exhibited 2 peaks, the early diastolic and atrial systolic waves. The Sw l along the long axis was greater than either the Sw 1 and Sw 2 along the short axis or the Sw 2 along the long axis. The peak Sw 1 along the long axis coincided with the peak dP/dt and was slightly earlier than the peak Sw l along the short axis. The onset of Sw 1 along the long axis coincided with the onset of the first heart sound. The Sw 2 along the short axis was greater than that along the long axis. The early diastolic wave along the short axis was greater than that along the long axis, whereas the atrial systolic wave along the long axis was greater than that along the short axis. Thus, in healthy subjects, shortening of the longitudinal fibers predominated over that of the circumferential fibers during early systole, whereas shortening of the circumferential fibers predominated over the longitudinal fibers during the ejection phase. During diastole, the circumferential fibers predominated in the LV wall expansion at early diastole, whereas the longitudinal fibers predominated at atrial systole. In conclusion, pulsed TDI provided information that is useful in understanding the characteristics of LV wall motion along the long and short axes. (J Am Soc Echocardiogr 1999;12:308-13.)

Left Ventricular Systolic Wall Motion Velocities Along the Long and Short Axes Measured by Pulsed Tissue Doppler Imaging in Patients with Atrial Fibrillation

Pulsed tissue Doppler imaging was performed to measure systolic left ventricular (LV) posterior wall motion velocity along the long and short axes and to evaluate the relationships between the systolic variables and the maximum first derivative (peak dP/dt) of the LV pressure curve and the 2 preceding R-R intervals in 39 patients with atrial fibrillation (AF). The study group consisted of 22 patients with AF only, 17 patients with dilated or ischemic cardiomyopathy and AF, and 25 healthy control subjects in sinus rhythm. The systolic component of the LV posterior wall motion velocity was divided into the first (Sw 1 ) and second (Sw 2 ) systolic waves. The peak Sw 1 along the long axis was greater than either that along the short axis or the peak Sw 2 s along the long and short axes in the control and AF-only groups. The peak Sw 1 along the long axis was lower in the AF-only group than in the control group, and those along the short and long axes were lower in the dilated AF group than in the other groups. The peak Sw 1 almost coincided with the peak dP/dt. The peak Sw 1 along the long axis correlated closely with the peak dP/dt, and the ratio of the preceding R-R interval to the interval before the preceding (“prepreceding”) R-R interval in both AF groups, particularly in the dilated AF group, and the slopes of their relationships were steeper in the dilated AF group than in the AF-only group. The peak Sw 2 along the short axis was greater than that along the long axis in the control and AF-only groups. The peak Sw 2 along the long axis was lower in the AF-only group than in the control group, and those along the short and long axes were lower in the dilated AF group than in the other groups. The peak dP/dt was lower and the LV end-diastolic pressure was higher in the dilated AF group than in the other groups. In conclusion, peak Sw 1 along the long axis is useful for the evaluation of isovolumic myocardial LV contractility, and the interval-force relation and the Frank-Starling mechanism are important factors of beat-to-beat variability in systolic LV function in patients with AF. (J Am Soc Echocardiogr 1999;12:121-8.)

Left ventricular diastolic properties of hypertensive patients measured by pulsed tissue doppler imaging

Examination of left ventricular (LV) diastolic dysfunction in hypertensive patients has been based on parameters obtained from the transmitral flow velocity during pulsed Doppler echocardiography. However, these parameters are affected by loading conditions. We evaluated LV diastolic function along the longitudinal and transverse axes by pulsed tissue Doppler imaging (TDI) in 50 hypertensive (HT) patients and 36 age-matched healthy volunteers (N). Transmitral flow velocity was recorded by pulsed Doppler echocardiography. LV posterior wall motion velocity along the longitudinal and transverse axes also was recorded by pulsed TDI. In both groups, peak early diastolic velocity of the LV posterior wall (Ew) along the transverse axis (N: 15.8+/-5.2 cm/s, HT: 12.2+/-4.4 cm/s) was higher than that along the longitudinal axis (N: 12.7+/-3.1 cm/s, HT: 9.5+/-3.3 cm/s). Peak atrial systolic velocity of the LV posterior wall (Aw) along the longitudinal axis (N: 9.1+/-1.8 cm/s, HT: 9.7 +/-2.6 cm/s) significantly exceeded that along the transverse axis (N: 8.0+/-2.2 cm/s, HT: 8.4+/-2.4 cm/s) in both groups. The Ews were lower and the Aws were higher along both axes in the patient group than in the control group. The time intervals from the aortic component of the second heart sound to the peak of the early diastolic wave (IIA-Ews) along both the transverse (N: 142+/-18 ms, HT: 154+/-19 ms) and longitudinal (N: 151 16 ms, HT: 162+/-20 ms) axes were longer in the patient group. In 29 patients, Ews along both axes correlated negatively (transverse: r = -0.80, P < .0001; longitudinal: r = -0.71, P < .0001) and IIA-Ews correlated positively (transverse: r = 0.81, P < .0001; longitudinal: r = 0.74, P < .001) with the time constant of the LV pressure decay during isovolumic diastole. The Aws along both axes in the 24 patients without pseudonormalization in transmitral flow velocity correlated positively (transverse: r = 0.60, P < .001; longitudinal: r = 0.74, P < .0001) with the LV end-diastolic pressure. In conclusion, LV relaxation and filling along the longitudinal and transverse axes were impaired in many patients with hypertension. Pulsed TDI was useful for evaluating LV diastolic dynamics in this disease.

Noninvasive detection of left ventricular diastolic dysfunction using M-mode echocardiography to assess left ventricular posterior wall kinetics in hypertrophic cardiomyopathy

In patients with hypertrophic cardiomyopathy (HC), it is difficult to determine the severity of left ventricular (LV) diastolic dysfunction. Three different patterns of LV posterior wall motion were found by M-mode echocardiography in patients with HC, and the use of these patterns is proposed as a new noninvasive index of the severity of LV diastolic dysfunction. M-mode echocardiograms were recorded prospectively from 35 patients with HC, and the posterior wall motion pattern in late systole and early diastole was classified into the following 3 types: (1) normal motion (n = 9); (2) flat motion — flat motion from late systole to early diastole, followed by rapid backward movement (n = 13); and (3) downward motion — slow backward movement from late systole (n = 13). There were no differences in the severity or type of hypertrophy, LV systolic function and pulsed Doppler indexes of LV filling among these 3 groups. However, LV end-diastolic pressure was increased in the groups with flat (15 ± 6 mm Hg) and downward (16 ± 9 mm Hg) motion. Furthermore, the maximal rate of decrease in LV pressure (normal 1,450 ± 300, flat 1,250 ± 300 and downward 860 ± 80 mm Hg/s) and the time constant of LV pressure reduction (normal 60 ± 15, flat 70 ± 25 and downward 101 ± 34 ms) showed a stepwise deterioration from the normal to the flat and then to the downward motion groups. Determination of the pattern of LV posterior wall motion appears to be useful for semiquantitatively assessing the presence and severity of LV diastolic dysfunction in HC, especially during relaxation and early diastolic filling.

Doppler echocardiographic measurement of low velocity motion of the left ventricular posterior wall

A new noninvasive method using pulsed Doppler echocardiography was developed to assess left ventricular (LV) posterior wall motion dynamics. Seventeen normal subjects and 23 patients undergoing cardiac catheterization were prospectively studied. The sample volume was placed within the LV posterior wall endocardium just apical to the mitral valve sulcus using a posteriorly angulated low parasternal view. The wall filter was set at 100 Hz to record the low velocities of the LV posterior wall motion. The Doppler signal was morphologically similar to the rate of change of the LV posterior wall endocardium excursion obtained by a digitized M-mode echocardlogram, and showed 3 major waves: a systolic wave (S), an early dlastolic wave (E) and a late diastolic wave (A). The peak velocities of LV posterior wall endocardium excursion were also determined by M-mode echocardlographic technique. We found a significant linear correlation between peak E-wave velocity and M-mode peak diastolic endocardial velocity (r = 0.90, p < 0.001) and between peak S-wave velocity and M-mode peak systolic endocardial velocity (r = 0.81, p < 0.001). M-mode peak systolic endocardial velocity showed an Important overlap between control subjects and patients with normal and patients with abnormal LV posterior wall motion on the angiogram. In contrast, peak S-wave velocity was a better discriminator, and a peak S-wave velocity <7.5 cm/s was associated with abnormal LV posterior wall motion with an 83% sensitivity, 100% specificity and 95% accuracy. In patients with coronary artery disease but normal systolic LV posterior wall motion and normal global systolic LV function, peak S-wave velocity was not different when compared to control subjects. Peak E-wave velocity and E A were significantly lower than in control subjects (p < 0.01) and peak A-wave velocity was greater (p < 0.01). In conclusion, these data suggest that pulsed Doppler echocardiography can be used for the direct analysis of LV posterior wall instantaneous low velocities and appears to be more informative than M-mode technique for systolic measurements. Thus, detection of abnormal LV posterior wall diastolic motion by pulsed Doppler echocardiography may, upon additional confirmation, be used as a new noninvasive method to gain insight into global LV diastolic performance.

Reduced diastolic left ventricular posterior wall motion in patients with constrictive pericarditis — incidence, hemodynamic and clinical correlations

In 24 patients with constrictive pericarditis proven by cardiac catheterization, the amplitude of diastolic left ventricular posterior wall motion was evaluated by M-mode echocardiography and compared to the results of 24 healthy volunteers. The amplitude was significantly less in constrictive pericarditis patients than in normal controls (0.3 ± 0.2 mm versus 3.9 ± 0.4 mm) ( P < 0.001). No constrictive pericarditis patient demonstrated a higher value than 2 mm whereas none of the healthy volunteers had an amplitude less than 3 mm. In 11 of 13 constrictive pericarditis patients who underwent pericardiectomy, an increase in amplitude was observed. In 6 patients the amplitude returned to normal limits after surgery. No significant correlation between the degree of heart failure or the level of left ventricular end-diastolic pressure and the reduction of the amplitude was found. In addition, the amplitude of left ventricular diastolic posterior wall motion did not allow a clear separation between patients who could be treated medically and those requiring pericardiectomy.

Mechanisms of the development and resolution of paradoxical interventricular septal motion after uncomplicated cardiac surgery

Of 16 patients with normal preoperative left ventricular (LV) function studied by simultaneous two-dimensional and M-mode echocardiography before and after uncomplicated cardiac surgery, M-mode interventricular septal motion remained normal in seven (group I) and was paradoxical in nine (group II) 7 to 13 days postoperatively, but was normal in all 12 patients (7 group II) studied 3 to 18 months later. An abnormal systolic increase in normalized septal curvature, the essential feature of truly paradoxical septal motion, was not observed in either group during any study period (mean = 0.92 ± 0.08), nor were significant differences found in septal thickening, LV fractional shortening, or fractional area change. In contrast, systolic anterior motion of the LV center increased from −0.1 ± 1.6 mm preoperatively to 4.8 ± 2.5 mm postoperatively in group II ( p < 0.001), and the LV posterior wall motion: thickening ratio increased from 1.10 ± 0.33 to 2.16 ± 0.45 ( p < 0.01), but both parameters had returned to preoperative levels at the follow-up study. Both parameters remained stable in group I during all study periods. In addition, direct intraoperative M-mode recordings (n = 14) demonstrated normal septal motion in both groups before chest closure, but esophageal echocardiograms (n = 10) demonstrated exaggerated anterior systolic LV motion within 2 hours of surgery in those from group II. Thus, early after uncomplicated cardiac surgery, apparently paradoxical septal motion relative to a fixed reference point is an artifact due to exaggerated cardiac mobility that resolves with the progressive restraining effect of postoperative adhesions.

Deferoxamine Improves Left Ventricular Function in ß-Thalassemia

Serial echocardiographic examinations were made to study the changes in left ventricular (LV) function and wall mass in 35 patients with thalassemia followed up for 5.5 +/- 2 years (mean +/- SD). Twenty patients received deferoxamine sulfate for 2.0 +/- 0.6 years (drug group) and 15 patients did not (nondrug group). Repeated blood transfusions were used to maintain the pretransfusion hemoglobin levels at 9 g/dL (90 g/L). Deferoxamine therapy improved LV function and decreased LV wall mass. Percentage shortening of LV diameter improved in the drug group (5.0% +/- 3.9%) and deteriorated in the nondrug group (-6.8% +/- 5.6%). Similarly, the maximum velocity of LV posterior wall motion improved in the drug group (16.1 +/- 20.1 mm/s) and deteriorated in the nondrug group (-18.3 +/- 19.0 mm/s). Left ventricular wall mass decreased in the drug group when compared with the nondrug group. In a subset of the drug group, pathologic natural deterioration in LV systolic function was reversed by treatment. Correlation studies indicated that frequent blood transfusions together with chelation therapy reduced LV dilatation and wall thickness, but blood transfusions alone did not have the same effect. Thus, treatment of patients with thalassemia with modest blood transfusions and deferoxamine can prevent deterioration and may even improve their LV systolic function, associated probably with arrest and reversal of the pathologic process that increases LV wall mass.

Two-dimensional echocardiographic detection of left ventricular posterior wall motion abnormalities using an inferior angulation view

Two-dimensional echocardiography is frequently used to detect left ventricular (LV) wall motion abnormalities. Modification of the apical 4-chamber view by inferior angulation of the transducer provides a superior image for detection of regional wall motion abnormalities of the LV posterior wall. The inferior angulation image was prospectively compared with the standard parasternal short-axis image for detection of posterior LV wall motion abnormalities as defined by contrast left ventriculography in 63 consecutive patients. Posterior wall akinesia was present on the contrast left ventriculogram in 22 of the 63 patients. The parasternal short-axis image was judged technically inadequate for interpretation in 7 patients (11%). The inferior angulation image was technically adequate for interpretation in all patients. The sensitivity, specificity and accuracy of the inferior angulation image for detection of LV posterior wall motion abnormality was 91%, 80% and 84%, respectively, vs 67%, 71% and 70% for the parasternal short-axis image. The differences between the sensitivity, specificity and accuracy for the 2 views were not statistically significant. These observations indicate that the inferior angulation image provides a useful plane for routine echocardiographic analysis of regional LV wall motion either as a primary method to detect posterior wall motion abnormality or as a confirmatory view to document posterior wall motion abnormality.

Echo-phonocardiographic evaluation of the Björk-Shiley mitral prosthesis

Ninety patients were studied with combined echophonocardiography after Björk-Shiley disc prosthetic mitral valve replacement. They were evaluated every 6 months (mean follow-up 6 years). Nine cases of left ventricular (LV) failure and 6 cases of prosthetic malfunction (5 paravalvular leaks and 1 thrombosis) were detected; 1 case was confirmed at necropsy and the other 5 cases were surgically verified and repaired. The following measures of prosthetic malfunction were evaluated: opening and closing velocity, maximal amplitude of the prosthesis, septal motion 6 months after operation, LV diastolic diameter, protodiastolic hump, variations during same record of the interval between aortic valve closure sound to the phono and mitral valve opening to the echo, and interval between aortic valve closure sound and maximal excursion of the LV posterior wall. All measures studied were useful for detecting prosthetic malfunction, but 2 are more useful in individual cases: variations of the Interval between second heart sound and mitral valve opening and the interval between the aortic valve closure sound and LV posterior wall motion. These 2 intervals also allow discrimination between normal function, prosthetic malfunction and LV failure.

M-mode echocardiography in constrictive pericarditis

M-mode echocardiograms from 40 patients with proven constrictive pericarditis and 40 subjects without evidence of cardiac disease were reviewed for features previously described in constrictive pericarditis. In this large series, no single feature of the M-mode echocardiogram could be considered diagnostic, although a pattern of normal left ventricular size and systolic function, mild left atrial dilation, flattened diastolic left ventricular posterior wall motion and abnormal septal motion was found in most patients. It is concluded that the M-mode echocardiogram can provide findings suggestive of constrictive pericarditis but must be used in conjunction with hemodynamic and other studies to establish the diagnosis.

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Our objective was to evaluate in healthy subjects the left ventricular (LV) wall motion velocities along the long and short axes by means of pulsed tissue Doppler imaging (TDI) to clarify the differences in the LV systolic and diastolic function between both axes. Wall motion velocities were recorded at the mid-wall portion of the middle site of the LV posterior wall in the parasternal long-axis view, and at the subendocardial portion of the middle site of the LV posterior wall in the apical long-axis view by pulsed TDI in 35 healthy subjects (mean age 26 ± 10 years, mean heart rate 72 ± 7 bpm). In all subjects, the LV pressure curve, its first derivative (dP/dt), the LV wall motion velocity, the phonocardiogram, and the electrocardiogram were simultaneously recorded. The systolic wave of the LV posterior wall motion velocity exhibited 2 peaks: the first and second systolic waves (Swl and Sw2 , respectively). The diastolic wave also exhibited 2 peaks, the early diastolic and atrial systolic waves. The Swl along the long axis was greater than either the Sw1 and Sw2 along the short axis or the Sw2 along the long axis. The peak Sw1 along the long axis coincided with the peak dP/dt and was slightly earlier than the peak Swl along the short axis. The onset of Sw1 along the long axis coincided with the onset of the first heart sound. The Sw2 along the short axis was greater than that along the long axis. The early diastolic wave along the short axis was greater than that along the long axis, whereas the atrial systolic wave along the long axis was greater than that along the short axis. Thus, in healthy subjects, shortening of the longitudinal fibers predominated over that of the circumferential fibers during early systole, whereas shortening of the circumferential fibers predominated over the longitudinal fibers during the ejection phase. During diastole, the circumferential fibers predominated in the LV wall expansion at early diastole, whereas the longitudinal fibers predominated at atrial systole. In conclusion, pulsed TDI provided information that is useful in understanding the characteristics of LV wall motion along the long and short axes. (J Am Soc Echocardiogr 1999;12:308-13.)

M-mode echocardiographic features of severe aortic valve endocarditis.

We describe and discuss the M-mode echocardiographic features in 10 patients with infective endocarditis of the aortic valve requiring surgery. Operative findings and aortic valve histology were obtained in each case. Vegetations were visualized in six out of seven patients (86%) with proven vegetations while pre-existing aortic valve disease masked their echocardiographic recognition in one patient. Diastolic echoes indistinguishable from vegetations were recorded from the ragged edge of a perforated aortic cusp in one patient who at operation had no demonstrable vegetations. Left ventricular outflow tract (LVOT) echoes were seen in five patients. Non-vibrating LVOT echoes were identified as vegetations while rapidly vibrating LVOT echoes were recorded from a flail aortic cusp. Premature mitral valve closure (PMVC) was seen in five out of seven patients (70%) with a short (less than or equal to four month) history of severe aortic regurgitation. Subannular aneurysms were detected in three out of five patients (60%) with this complication. Increased septal and left ventricular posterior wall motion suggestive of severe aortic regurgitation was seen in each case. The detection of a flail aortic valve leaflet, PMVC and subannular aneurysms indicates the need for surgery. The demonstration of vegetations defines a further subgroup of patients who should be managed in a centre with facilities for cardiac surgery. Echocardiography obviated the need for pre-operative cardiac catheterization in nine out of 10 patients (90%).

Systolic anterior motion of the mitral valve with and without asymmetric septal hypertrophy. Role of left ventricular posterior wall motion.

Abnormal systolic anterior (SAM) motion of the mitral valve without asymmetric hypertrophy of the interventricular septum was observed in 16 patients (group 1). 5 of the 16 patients had no other evidence of heart disease and the remaining 11 had a variety of cardiac disorders. Left ventricular dimensions, septal and posterior wall thickness, left ventricular ejection fraction, the mean velocity of circumferential fiber shortening, and the mean velocity of the posterior wall and septal contraction was measured by echocardiography in all patients in group 1. These measurements were compared with similar measurements in 14 patients with idiopathic hypertrophic subaortic stenosis (group 2) and in 11 normal subjects (group 3) to evaluate the role of the left ventricular contractility with particular reference to the left ventricular posterior wall motion in production of SAM. All patients with SAM (groups 1 and 2) showed significantly higher indexes of left ventricular contractility, particularly posterior wall velocity, and normalized mean posterior wall velocity, when compared to the normal subjects. The significantly higher posterior wall and the normalized mean posterior wall velocities in all patients with SAM suggest that the exaggerated systolic anterior motion of the left ventricular posterior wall plays an important role in production of SAM in the presence or absence of asymmetric septal hypertrophy.