Mitral Stenosis Group Research Articles

Percutaneous double-valve balloon valvotomy for multivalve stenosis: Immediate results and intermediate-term follow-up

Ten patients each with combined mitral and tricuspid stenosis (group 1) and with combined mitral and aortic stenosis (group 2) underwent double-valve balloon valvotomy as a single staged procedure. The aortic valve was dilated by the Mansfield balloon technique, whereas the mitral and tricuspid valves were dilated with either the Mansfield or Inoue balloon. The mitral valve area increased from 0.78 ± 0.21 cm 2 to 2.05 ± 0.56 cm 2 ( p < 0.0005) in group 1 and from 0.75 ± 0.20 cm 2 to 2.1 ± 0.59 cm 2 ( p < 0.05) in group 2. The tricuspid valve area increased from 1.11 ± 0.41 cm 2 to 2.52 ± 0.69 cm 2 ( p < 0.0005). In group 2, the transaortic gradient decreased from 93.56 ± 17.7 mm Hg to 28.56 ± 7.8 mm Hg ( p < 0.0005) and the valve area increased from 0.37 ± 0.05 cm 2 to 1.03 ± 0.25 cm 2 ( p < 0.005). The excellent symptomatic and hemodynamic results were sustained at 30.3 ± 9.8 months of follow-up in group 1 and at 23.5 ± 9.1 months in group 2. Double-valve balloon valvotomy is feasible and safe and provides excellent immediate and intermediate-term follow-up results in selected patients with multivalve disease. A longer follow-up in a larger number of cases is needed to define further the role of this therapy. (Am Heart J 1997;133:64-70.)

Transesophageal pulsed Doppler echocardiographic study of pulmonary venous flow in mitral stenosis.

For evaluation of pulmonary venous flow (PVF) in mitral stenosis, transthoracic and transesophageal echocardiography were performed in 33 patients with mitral stenosis and 20 normal controls. The peak systolic flow velocity of the PVF was significantly lower in patients with mitral stenosis and atrial fibrillation. The peak diastolic flow velocity of the PVF was significantly lower in the patients with mitral stenosis than in normal controls. The diastolic wave recorded as laminar flow in the mitral stenosis group showed a peak in the rapid filling phase with a gradually descending slope of velocity during mid to late diastole. There was a significant negative correlation between the peak diastolic flow velocity of the PVF and the pressure half time from transmitral flow obtained by continuous wave Doppler in the mitral stenosis group. These results demonstrate that evaluation of the PVF is helpful in understanding hemodynamic events between the left atrium and left ventricle in patients with mitral stenosis.

978-120 Exercise Performance in Moderate Mitral Stenosis is Limited by Cardiac Output Reserve Rather than Maximal Pulmonary Capillary Wedge Pressure

To assess the hemodynamic limitations of exercise in patients with mitral stenosis (MS), 29 patients with MS (mean age 49, mean valve area 1.4 cm 2 ) and 29 age matched controls underwent symptom limited upright bicycle exercise with simultaneous expired gas analysis, right heart catheterization and radionuclide angiography. Supine rest hemodynamics and left ventricular volumes were abnormal in MS patients compared to control. Despite maximal (MAX) exercise effort, MS patients achieved a lower MAX heart rate (HR) and oxygen consumption (VO 2 /kg) compared to control. With exercise. other intergroup differences were accentuated, especially for MAX cardiac index (CI), pulmonary capillary wedge pressure (PCWP), and end-diastolic volume index (EDVI) Rest and Exercise Hemodynamics VO 2 kg HR PCWP CI EDVI REST MS 2.6 75.8 19.1 2.4 51.5 Control 3.4 68.4 8.2 3.4 76.6 MAX MS 10.4 131.0 29.1 4.0 43.1 Control 23.5 162.3 8.4 7.8 65.2 Mean values shown (p ≤ 0.05 MS vs Control for all values) For the MS group, MAX VO 2 /kg was predicted by MAX CI (r = 0.6) but not by MAX PCWP. Exercise was limited by fatigue rather than shortness of breath in 18/29 patients in the MS group, suggesting a low output state as a reason for exercise termination. No difference was seen in MAX PCWP between patients stopping due to fatigue and those stopping due to shortness of breath (27.3 vs 32.0 mmHg, p = 0.4). Exercise tolerance in patients with moderate mitral stenosis is not limited by MAX PCWP but by failure to augment cardiac output due to abnormal left ventricular diastolic filling and to chronotropic incompetence.

Effects of exercise on plasma level of brain natriuretic peptide in congestive heart failure with and without left ventricular dysfunction

This study was designed to determine whether plasma brain natriuretic peptide (BNP) increases in response to exercise in patients with congestive heart failure and to show what kind of hemodynamic abnormalities induce increased secretion of BNP during exercise. Plasma levels of atrial natriuretic peptide (ANP) and BNP and hemodynamic parameters were measured during upright bicycle exercise tests in seven patients with dilated cardiomyopathy and nine with mitral stenosis. At rest, there were no intergroup differences in cardiac output or pulmonary capillary wedge pressure; however, the group with dilated cardiomyopathy had higher left ventricular end-diastolic pressures and lower left ventricular ejection fractions than did the group with mitral stenosis. Plasma ANP levels were comparable between the dilated cardiomyopathy group (170 ± 77 [SE] pg/ml) and the mitral stenosis group (106 ± 33 pg/ml) ( p, not significant), whereas BNP was significantly higher in the dilated cardiomyopathy group (221 ± 80 pg/ml) than in the other group (37 ± 10 pg/ml) ( p < 0.05). The plasma concentration of BNP but not of ANP significantly correlated with left ventricular end-diastolic pressure and volume. Exercise increased plasma ANP and BNP in the two groups. The dilated cardiomyopathy group had a larger increment in BNP (+157 ± 79 pg/ml) than did the mitral stenosis group (+17 ± 5 pg/ml) ( p < 0.05), although the increase in pulmonary capillary wedge pressure was greater in the mitral stenosis group. Thus exercise increases plasma levels of BNP, and impaired left ventricular function may be a main factor in the greater increment in BNP during exercise in patients with congestive heart failure.

Different secretion patterns of atrial natriuretic peptide and brain natriuretic peptide in patients with congestive heart failure.

The plasma levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) are increased in relation to the severity of congestive heart failure (CHF). This study was designed to examine whether the secretion patterns of ANP and BNP vary with underlying cardiac disorders of CHF with different degrees of overload in atria and ventricles. We measured plasma levels of ANP and BNP in the aorta in 20 patients with mitral stenosis (MS) in whom atria are mainly overloaded, 30 patients with dilated cardiomyopathy (DCM) in whom both atria and ventricles are overloaded, and 20 control subjects during cardiac catheterization. Pulmonary capillary wedge pressure (PCWP) was significantly higher in the MS and DCM groups (16.7 +/- 4.7 mm Hg and 15.1 +/- 7.7 mm Hg, respectively) than in the control group (7.2 +/- 1.1 mm Hg, p < 0.01), whereas there was no significant difference between the MS and DCM groups. Left ventricular end-diastolic pressure (LVEDP) was significantly higher in the DCM group than in the MS group (16.4 +/- 7.8 mm Hg versus 7.6 +/- 2.0 mm Hg, p < 0.01), and the level was comparable between the MS and control groups (7.6 +/- 2.0 mm Hg versus 6.8 +/- 1.2 mm Hg, p = NS). The plasma ANP level was significantly higher in the MS and DCM groups (356 +/- 169 pg/ml and 331 +/- 323 pg/ml, respectively) than in the control group (98 +/- 41 pg/ml, p < 0.01), whereas there was no significant difference between the MS and DCM groups. The plasma BNP level was significantly higher in the DCM group than in the MS group (333 +/- 405 pg/ml versus 147 +/- 54 pg/ml, p < 0.01), and the level was significantly higher in the MS group than in the control group (147 +/- 54 pg/ml versus < 10 pg/ml, p < 0.01). The plasma levels of ANP and BNP had a highly positive correlation with PCWP in the DCM group (p < 0.01). On the other hand, in the MS group, the plasma ANP level had a highly significant correlation with PCWP (p < 0.01) but the plasma BNP level did not. We conclude that plasma levels of BNP mainly reflect the degree of ventricular overload and that the secretion patterns of ANP and BNP vary with underlying cardiac disorders of CHF with different degrees of overload in atria and ventricles.

Mechanical restitution of isolated human ventricular myocardium subjected to in vivo pressure and volume overload

The aim was to make a comparison of the mechanical and electrical refractory properties of isolated strips of human ventricular myocardium obtained from patients with either left ventricular pressure overload, volume overload, or normal left ventricular function. Strips of ventricular myocardium were obtained at the time of cardiac surgery from 17 patients with aortic stenosis, representing pressure overload, 14 patients with aortic regurgitation, representing volume overload, and nine patients with mitral stenosis, representing normal left ventricular function. Muscle strips were mounted isometrically in a tissue bath, superfused with physiological saline at 37 degrees C, and stimulated at 1 Hz. Mechanical restitution curves were constructed from the isometric twitch tension obtained from extrastimuli during a special stimulus protocol. Transmembrane action potentials were recorded using glass microelectrodes and restitution of the upstroke velocity of action potentials studied in the presence of high external potassium concentration. The aortic stenosis group was older and had higher left ventricular systolic pressures and thicker left ventricular walls than the other groups. Electrocardiographic evidence of left ventricular hypertrophy was present in both the aortic stenosis and aortic regurgitation groups. Peak tension, time to peak tension, and the maximum rates of rise and fall of tension were not significantly different between groups. The time constant of the initial rapid recovery phase of mechanical restitution (tau 1) was prolonged in the aortic stenosis group, at 603(SEM 80) ms v 367(53) ms in the aortic regurgitation group (p < 0.005), and 259(70) ms in the mitral stenosis group (p < 0.005). There was a positive correlation between tau 1 and left ventricular wall thickness (p < 0.05). Neither "normal" nor "slow" (in the presence of raised external potassium) transmembrane action potentials differed in the groups studied. The mean time constant of recovery of "slow" action potential dV/dtmax was slower in the aortic stenosis group, but this difference was not significant. These data are consistent with the hypothesis that the rate of recovery of calcium release from the sarcoplasmic reticulum is slowed in myocardial hypertrophy due to pressure overload in man and provides a possible explanation of the occurrence of mechanical alternans in such patients.

Balloon valvuloplasty for mild mitral stenosis

Of a total number of 288 patients with mitral stenosis treated by percutaneous balloon valvuloplasty, 21 patients had a basal mitral area equal to or greater than 1.5 cm2, as measured hemodynamically. The immediate hemodynamic results of this particular group of patients with mild mitral stenosis are described, as well as the clinical and echo doppler findings at follow-up (22 +/- 12 mo). Patients with mild mitral stenosis (group I) had more pliable valves (p less than 0.01), as assessed by echo, and higher incidence of sinus rhythm (p less than 0.02) than that observed in the remaining 267 patients (group II). After valvuloplasty the valve area increased in group I from 1.7 +/- 0.2 to 3.1 +/- 0.7 cm2 (p less than 0.0001). This mean final area was significantly different (p less than 0.0001) than that observed in group II (1.98 +/- 0.6 cm2). No patients with mild mitral stenosis developed progression of mitral regurgitation, and none had any other major complications. Most of them reached a grade I final functional status. At echo doppler follow-up studies we did not observe significant changes in the mean mitral gradient as compared with the immediate hemodynamic results. These findings suggest that early mitral balloon valvuloplasty could be an alternative in trying to favorably influence the natural course of the rheumatic mitral disease in selected patients.

Effects of exercise on transmitral gradient and pulmonary artery pressure in patients with mitral stenosis or a prosthetic mitral valve: A doppler echocardiographic study

Doppler echocardiography was used to determine changes in transmitral gradient and pulmonary artery pressure after exercise in 12 patients with mitral stenosis and 11 patients with a prosthetic mitral valve. The mean transmitral gradient in the mitral stenosis group was 9 ± 7 mm Hg at rest and increased to 17 ± 8 mm Hg after exercise. In patients with a prosthetic mitral valve, exercise resulted in an increase in mean transmitral gradient from 5 ± 2 to 8 ± 3 mm Hp. Calculated pulmonary artery systolic pressure increased with exercise from 41 ± 19 to 70 ± 32 mm Hg in the mitral stenosis group and from 28 ± 8 to 39 ± 15 mm Hg in patients with a prosthetic valve.Exercise Doppler echocardiographic evaluation of changes in transmitral gradient and pulmonary artery systolic pressure was found to be technically simple and an important addition to the noninvasive evaluation of patients with mitral valve disease.

Left atrial spontaneous echo contrast in mitral valve disease: An indicator for an increased thromboembolic risk

The incidence of left atrial spontaneous echo contrast was evaluated in 52 patients with isolated or predominant mitral valve stenosis (Group 1) and 70 other patients who had undergone mitral valve replacement (Group 2). All patients were studied by conventional transthoracic and transesophageal two-dimensional echocardiography. Spontaneous echo contrast could be visualized within the left atrium in 35 Group 1 patients (67.3%) (including 7 patients with sinus rhythm) and 26 Group 2 patients (37.1%) (all with atrial fibrillation).Patients with spontaneous echo contrast had a significantly larger left atrial diameter and a greater incidence of both left atrial thrombi and a history of arterial embolic episodes than did patients without spontaneous echo contrast. Association between spontaneous echo contrast and left atrial thrombi and a history of arterial embolization (considered individually or in combination) showed a high sensitivity and negative predictive value. It is concluded that spontaneous echo contrast is a helpful finding for identification of an increased thromboembolic risk in patients with mitral stenosis and after mitral valve replacement.

Left predominant coronary circulation in patients with valvular aortic stenoses.

This study was conducted to examine whether a correlation exists between the incidence of aortic stenosis and predominant left coronary perfusion. Therefore, coronary angiograms of 77 patients with mitral stenosis (Group 1), 50 patients with combined mitral valve disease and pure mitral insufficiency (Group 2), 61 patients with aortic insufficiency with or without mitral valve disease (Group 3), 49 patients with pure aortic stenosis (Group 4), and 69 patients with combined aortic valve disease and aortic stenosis with concomitant mitral valve disease (Group 5) were reviewed. Group 6 consisted of 20 patients with coronary heart disease. A statistically significant accumulation of left coronary circulation was found in patients with pure aortic stenosis (Group 4) (33%) as well as in patients with combined aortic valve disease (19%). The frequency of predominant left coronary circulation was comparable in all other patients (Group 1: 8%; Group 2: 10%; Group 3: 8%; Group 6: 7.5%). Thus, the presence of left predominance in a diagnostic coronary arteriogram performed in a patient with aortic stenosis could be a clue that the aortic stenosis is congenital.

The incidence of thromboembolism and the hemocoagulative background in patients with rheumatic heart disease.

We discussed the existence of a thrombotic tendency and the relationship between the high incidence of thromboembolism and the thrombotic tendency in patients with rheumatic heart disease (RHD). The augmentation of platelet function was detected in all kinds of rheumatic valvular disease from the finding of high values of plasma beta-thromboglobulin (72 ng/ml, normal 29 ng/ml). The existence of hypercoagulation was also detected in patients with mitral stenosis by showing low levels of plasma antithrombin III (AT III), while fibrinolytic reaction remained normal. The degree of hypercoagulation became augmented in the order of cases of mitral stenosis (MS) complicated by both atrial fibrillation and chronic congestive heart failure, MS complicated only atrial fibrillation and MS with normal sinus rhythm (AT III: 19.6, 25.0, 26.7 mg/dl, respectively). On the contrary, hypercoagulation, the degree of which was almost the same as that in the respective MS groups, also existed in comparable controls of non-RHD, accompanied by the acceleration of fibrinolytic reaction as shown by the decrease in activity of plasma alpha 2-plasmin inhibitor. Therefore, it was concluded that thrombotic tendency certainly existed in patients with MS compared to those with non RHD and that it was one of the causes of the significantly high incidence of thromboembolism in comparison with non RHD.

僧帽弁狭窄症の手術前後における左室機能評価

1. For the purpose of evaluation of the left ventricu lar function of mitral stenosis in early postoperative period, the left ventricular function of 29 patients (18 cases of pure mitral stenosis (MS),3 cases of MS+ aortic regurgitation (AR), and 8 cases of atrial septal defect (A SD))were evaluated in early postoperative period (6-35 hours after operation) comparing with those of preoperative and late postoperative period (3-8 weeks after operation)2. In control group (ASD), cardiac index (CI), stroke inde x (SI) and stroke work index (SWI) did not remarkably change, although pulmonary arterial pressure (PAP) and pulm onary arterial resistance (PAR) were decreased in early postoperative period. The arterial pressure (AP) and heart rate (HR) did not show signifcant change.3. The patients of pure MS were divided in 4 grou ps accordingt o PAP and cardiac rhythmus. In group I, PAP was bellow 25 mmHg with sinus rhythmus, in group II, PAP was bellow 25 mmHg with atrial fibrillation, in group III, PAP was higher than 25 mmHg with sinus rhythmus, in group IV, PAP was higher than 25mmHg with atrial fibrillation. In group I and II, CI, SI, and SWI were remarkably decresed during early postoperative period, but in group III and IV, they were unchangable or little improved in this period. However, in late postoperative period, CI, SI and SWI were improved significantly as compared with those of preoperative period in all four groups.4. PAP of group III and IV with pulmonary hypertension, fell in early postoperative period. However, in group III, PAP increased again after the short duration of decreased pressure. The decrease of PAP in group I and II was little demonstrated. PAR was tended to increase in early postoperative period in all groups. Particularly, in group III, PAR rose remarkablly, however, in all groups, PAR lowered bellow preoperative value in late postoperative period5. The right atrial pressure (RAP) was tended to increase in early postoperative period, but the left atrial pressure (LAP) fell in all groups, especially in group III and group IV. The LAP and RAP in MS group were higher than those of ASD group in early postoperative period and the correlation of LAP and RAP in MS group was poor. The estimation of LAP from RAP in early postoperative period of MS group was difficult.6. The left ventricular function curves with volu me overloading in control group (ASD)located in left upper quadrant but those in MS group located in right lower quadrant in early postoperative period. Particularly the left ventricular function curves of group I located more left upper portion than other groups, and that of group IV located rather right lower portion than other groups. The slopes of left ventricular function curves were gentle except that of group I, which revealed the depletion of left ventricular performance.7. The value of CI obtained by means of volume load, in early postoperative period (6 hrs after operation) had good correration to the value of CI at rest in late postoperative period.8. The evaluation of left ventricular function curves obtained in early postoperati ve period was usefull for the postoperative patient management.

Long-term follow-up of patients who have undergone valve replacements for acquired valvular disease: a clinical and hemodynamic study.

Thirty-three cases, comprizing 5 of mitral regurgitation (MR), 11 of mitral stenosis (MS), 11 of aortic regurgitation (AR) and 6 of AR and mitral steno-regurgitation (MSR), underwent both preoperative and postoperative heart catheterization in association with a muscle exercise test. Comparisons were made between preoperative and postoperative clinical symptoms, hemodynamics and cardiac functions. The following results were obtained: 1) Improvements in clinical symptoms and hemodynamics at rest were observed in all but two patients. 2) Abnormalities in hemodynamics were obtained after the muscle exercise test, even in cases exhibiting normal hemodynamics at rest. 3) An increase in pulmonary artery mean pressure was noted in MR and MS groups after the muscle exercise test. 4) The cardiac function index values in both the MR and MS groups showed lower levels than those in both the AR and AR + MSR groups. 5) The presence of atrial fibrillation and extent of myocardial fibrosis were related to improvements in postoperative cardiac functions.

Factors influencing long-term survival after mitral valve replacement.

Thirty-seven consecutive cases of mitral valve replacement have been retrospectively reviewed. The prognostic significance of preoperative clinical, hemodynamic and quantitative angiographic factors for survival has been evaluated. In the Mitral stenosis (MS) group, all of the patients who showed small Stroke volume index (SVI) (less than 45 ml/m2) with pulmonary hypertension died from the low output syndrome. The prognosis was poor in patients who had large cardiothoracic ratio (CTR) in the MS group. Aortic valve replacement must be considered when moderate aortic regurgitation is associated with mitral valve disease. In the MR factors for predicting the survival. The eccentricity ratio is also a sensitive parameter for recognizing a patient who will have a poor prognosis after mitral valve replacement. The main mode of death was found to be heart failure due to myocardial impairment.

Echocardiographic Assessment of Mitral Stenosis by the Left Atrial Emptying Index

Echocardiograms were performed in 35 patients prospectively with mitral stenosis to determine the usefulness of the left atrial emptying index (AEI) in estimating mitral valve orifice area (MVOA). Twnety-five control patients without evidence of cardiac disease had an AEI of 0.91 +/- 0.01. In the mitral stenosis group, the mean AEI was 0.47 +/- 0.09, with Gorlin and Gorlin calculated MVOAs of 1.44 +/- 0.56. There was close correlation between the AEI and MVOA (r = 0.93). The AEI did not correlate well with the left atrial size (r = 0.10), or the EF slope of the mitral valve (r = 0.20). The AEI was useful in separating patients with mitral stenosis into mild, moderate, and severe groups. Twelve out of 12 patients with severe mitral stenosis (MVOA less than or equal to 1.0 sq cm) had an AEI of less than or equal to 0.42. Ten out of 13 patients with moderate mitral stenosis (MVOA of 1.1--1.5 sq cm) had an AEI of 0.43 to 0.51. Eight out of ten patients with mild mitral stenosis (MVOA greater than or equal to 1.6 sq cm) had an AEI of greater than or equal to 0.52. The overall predictive value of the AEI in subclassifying the severity of mitral stenosis was 86 percent. In conclusion, the AEI appears to be a sensitive index in estimating MVOA in mitral stenosis.

REDUCTION OF PULMONARY HYPERTENSION BY NITROPRUSSIDE

The action of nitroprusside on pulmonary circulation was studied in patients with pulmonary hypertension due to mitral stenosis (group I) or to primary lung disease (group II) and in patients with normal pulmonary artery pressure (group III). Nitroprusside 20 microgram/min decreased systolic and mean pulmonary artery pressure in groups I and II while higher doses were necessary to produce a similar pressure reduction in group III. Diastolic pulmonary artery pressure was reduced by 40 microgram/min nitroprusside in all groups. Systemic arterial pressure declined during nitroprusside infusion similary in all groups in a dose-related manner; cardiac index remained unaltered. Pulmonary vascular resistance was reduced by 20 microgram/min nitroprusside in group I, not below 200 microgram/min nitroprusside in group II and remained unchanged in group III. Peripheral vascular resistance declined in all groups with nitroprusside infusion. The study suggests direct relaxation of the pulmonary vasculature by nitroprusside.

Hemodynamic changes associated with injection of angiocardiographic contrast medium in assessment of valvular lesions.

Measurements of flow and pressures related to the left heart were made on 21 patients immediately prior to and at intervals of 2 and 4 minutes after angiocardiography. These patients had normal mitral valves (group 1), mitral incompetence (group 2), or mitral stenosis (group 3). There was an increase in left ventricular end-diastolic pressure accompanied by an increase in "pulmonary artery wedge" (PA wedge) pressure in all patients. Patients with mitral valve disease generally develop higher PA wedge pressures; those with mitral stenosis develop, in addition, significantly increased mean diastolic and end-diastolic gradients across the mitral valve. These increased gradients in mitral stenosis are due to increased flow across the mitral valve, which results from a combination of increased cardiac output and decreased diastolic filling time. Diagnostic angiocardiography affords an opportunity of observing the effects of valve lesions at a higher flow rate and is particularly useful in those patients with normal PA wedge pressure and small gradients initially.

Studies of Heart Sounds by Frequency Band Recoridings of Mingograph.

By recording heart sounds and murmurs of 102 cases from mitral valve disease and functional murmur groups in frequency bands of 12.5, 25, 50,100,200, and, 400c/sec. by mingograph, phonocardiographic studies were carried out. The results are as follows : 1) In the mitral stenosis group, loud and high frequency components in the first heart sound were evident when compared to the second sound. The ratio of thd greatest amplitude of the first and second sounds was significant for a differentiation from steno-insufficieny group. The systolic murmurs in mitral steno-insuffiency cases were not recorded satisfactory from channel 4 (100c/sec) and over. Good recordings of diastolic murmurs were obtained in the low frequency bands in both groups, but above channel 4 poor recordings were also seen. The channels 2 and 3, i.e. 25 to 50c/sec showed a most clear characteristic picture of both groups, but the presystolic murmurs showed a tendency to appear in a some what higher freqnency bands. 2) The diastolic murmurs of aortic insufficiency were recorded satisfactory up to the high frequency bands and its characteristic forms were most clearly seen in channels 3 and 4 (50 to 100 c/sec). 3) The second sounds of the congenital heart disease group all showed loud and high frequency components, but this was most evidedt in A.S.D. All types of congenital cases showed a similar tendency of possesing compoents of relattively high frequency in systolic murmurs when compared to the first sound. The durations of murmurs were long in V.S.D. and Eisenmeger type and short in A.S.D. and pulmonary stenosis. 4) Functional systolic murmurs were soft and short and their frequency were low. A rapid reduction of satisfactory recording were seen over channel 4 (100c/sec).

The effects of the Valsalva-like maneuver upon the circulation in normal individuals and patients with mitral stenosis.

A Valsalva-like maneuver was performed during cardiac catheterization by a normal group of individuals and a group of patients with acoustic evidence of mitral stenosis. The latter group was subdivided according to its response to the maneuver. The mild group, like the normal group, showed an overshoot of blood pressure and a bradycardia in the post-straining period, whereas the severe mitral stenosis group did not. The relatively undisturbed dynamics of the mild mitral stenosis group, in contrast to the marked disturbance in the severe group, was felt to be due to the amount of obstruction at the mitral valve. Additional data from the cardiac catheterizations of these patients is presented to substantiate this concept. This simple maneuver may prove to be a bedside method for the evaluation of the dynamic significance of mitral stenosis.