Reversal of left ventricular dilatation, hypertrophy, and dysfunction by valve replacement in aortic regurgitation

Although aortic valve replacement for aortic regurgitation relieves left ventricular volume overload, ventricular geometry does not consistently normalize. To assess the extent, determinants, and functional consequences of reversal of left ventricular dilatation and hypertrophy, 38 patients with severe aortic regurgitation were studied pre- and postoperatively by serial echocardiography and radionuclide cineangiography. Left ventricular end-diastolic dimension normalized in 58% of patients by 9 +/- 6 months postoperatively, at which time 50% of patients had normalized mass; cumulative normalization rose to 66% for end-diastolic dimension and 68% for left ventricular mass during further follow-up. All patients who had normalized end-diastolic dimension also had normal postoperative ejection fractions (mean 61 +/- 8%). In contrast, patients in whom the left ventricle remained dilated had a 42% prevalence of subnormal postoperative left ventricular ejection fraction. Preoperative left ventricular end-systolic dimension less than or equal to 55 mm identified 86% of patients in whom end-diastolic dimension normalized, whereas end-systolic dimension exceeded 55 mm in 81% of those with persistent dilatation; other proposed preoperative predictors of operative outcome correctly identified lower proportions (from 59% to 71%) of patients in whom left ventricular size did or did not normalize. In conclusion, aortic valve replacement resulted in normalized left ventricular chamber size and mass in two thirds of the patients selected for operation by current criteria; favorable geometric outcome is associated with persistence or recovery of normal left ventricular function.     

Changes in left ventricular size, wall thickness, and function in anemic patients treated with recombinant human erythropoietin.

Left ventricular size and function were evaluated in 15 anemic chronic hemodialysis patients before and after the administration of recombinant human erythropoietin (rHuEPO). All patients were studied with two-dimensional and M-mode echocardiographic examinations before the initiation of rHuEPO (T1) and at 28 +/- 7 weeks of rHuEPO therapy (T2). The two-dimensional targeted M-mode echocardiographic measurements obtained were: end-diastolic dimension (EDD); end-systolic dimension (ESD); stroke dimension (SD); dimensional shortening (SD/EDD); systolic posterior wall thickness (PWs); diastolic posterior and interventricular septal thickness; end-systolic wall stress (ESWS); and left ventricular mass. Mean hematocrit in these patients increased almost 50%. The EDD decreased from a mean value (+/- SEM) of 6.41 +/- 0.33 to 4.93 +/- 0.21 cm (p less than 0.05). ESD decreased from a mean value of 4.16 +/- 1.2 to 2.77 +/- 0.06 cm (p less than 0.05). The calculated mean SD decreased slightly but not significantly from 2.21 +/- 0.69 to 2.19 +/- 0.60 cm. The calculated SD/EDD increased from a mean 0.35 +/- 0.09 to 0.44 +/- 0.07 (p less than 0.05). ESWS fell from 59.2 +/- 12.2 to 37.6 +/- 9.3 gm/cm2 (p less than 0.01), and left ventricular mass fell (p less than 0.05) from 347 +/- 15.2 to 227 +/- 59 gm. There was no significant difference in resting heart rate or systolic blood pressure between T1 and T2. The increase in dimension shortening reflects afterload reduction, as indicated by the fall in end-systolic wall stress.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prognostic value of preoperatively determined end-systolic left ventricular diameter in patients with chronic aortic insufficiency--an echocardiographic study

Serial echocardiographic studies of Henry et al. (Circulation 61, 471 [1980]) in patients with chronic aortic regurgigation (AR) indicate that preoperative left ventricular end-systolic dimension (ESD) greater than 55 mm and fractional shortening (FS) less than 25% may identify patients with reduced postoperative survival. We retrospectively analyzed the onedimensional echocardiograms of 33 patients with AR without coronary artery disease who underwent operation from 1977 to 1981. Twenty-three patients with ESD less than or equal to 55 mm (group A, mean age 48 +/- 10 years) were followed 36 +/- 14 months postoperatively, ten patients with ESD greater than 55 mm (group B, eight patients with FS less than 25%; mean age 48 +/- 12 years) 40 +/- 10 months. In both groups there were no perioperative or late deaths. In group A the average preoperative NYHA functional class decreased from 2.6 to 1.4 postoperatively, in group B from 3.0 to 1.5 (A vs. B: NS). Preoperative FS was 35 +/- 8% in group A and 22 +/- 3% in group B, preoperative ESD 44 +/- 5 mm in group A and 62 +/- 7 in group B. Three years after operation, end-diastolic dimension was 54 +/- 8 mm compared with 68 +/- 5 mm preoperatively in group A (p less than 0.001) and 61 +/- 11 mm compared to 79 +/- 8 mm preoperatively in group B (p less than 0.001). According to these data, a significant postoperative decrease of end-diastolic dimension can be expected in most patients with AR and ESD greater than 55 mm. The long-term prognosis of this subgroup is not so impaired as to recommend aortic valve replacement to asymptomatic patients a priori.     

Effects of aerobic training on exercise tolerance and echocardiographic dimensions in untrained postmenopausal women

The cardiovascular effects of physical training were evaluated in a controlled trial involving 32 healthy, untrained, postmenopausal women. The subjects were randomly assigned to an aerobic exercise training program or a control group. The exercise group participated in at least three 40-minute supervised sessions per week for 8 months. Twenty-five subjects completed the study: eight in the control group and 17 in the training group. The training group had a significant increase over the training period in maximal oxygen consumption (27.3 +/- 4.6 ml/kg/min vs 30.8 +/- 5.4 ml/kg/min, p less than 0.05) and maximal treadmill exercise duration (9.8 +/- 2.6 minutes vs 11.3 +/- 2.2 minutes; p less than 0.05). The control group had no significant change in maximal treadmill exercise duration (9.0 +/- 1.2 minutes vs 9.2 +/- 1.4 minutes) but had a slight increase in maximal oxygen consumption (23.7 +/- 3.4 ml/kg/min vs 24.4 +/- 4.1 ml/kg/min, p less than 0.05). The training group had significant increases in M-mode echocardiographic left ventricular end-diastolic dimension (4.6 +/- 0.6 cm vs 4.8 +/- 0.4 cm, p less than 0.05) and calculated left ventricular ejection fraction (0.66 +/- 0.14 vs 0.74 +/- 0.12, p less than 0.05). M-mode echocardiograms demonstrated no significant change in left ventricular dimensions or wall thickness in the control group. In this group of untrained postmenopausal women, a training effect was associated with enhanced resting left ventricular ejection fraction and increased resting left ventricular end-diastolic dimension.     

Chronic aortic insufficiency: prediction of postoperative course based on preoperative relations of left ventricular end-diastolic volume to regurgitated blood volume

The range of appropriate left ventricular dilatation due to volume overload was defined in 21 patients with a stable course of chronic aortic regurgitation, by correlating the scintigraphically determined left ventricular end-diastolic volume with the regurgitated blood volume. 25 other patients with chronic aortic regurgitation, who were scheduled for valve replacement, were within this normal range (group 1); in nine patients, left ventricular end-diastolic volume exceeded the amount expected from the amount of regurgitation (group 2). Patients were followed up between 2 and 62 months postoperatively (average: 26 +/- 13 months). No patients from group 1, but four out of nine patients from group 2 (45%) died postoperatively from congestive heart failure. In 23 out of 24 patients from group 1, left ventricular ejection fraction was postoperatively within the normal range, although preoperative values had been severely depressed in three cases (lower than 40%). Ejection fraction remained depressed in one patient with persistent mitral regurgitation and in all patients from group 2. Global heart volume significantly decreased by 20% in group 1, whereas only minor changes (-15%) were observed in group 2 (group 1: from 1184 +/- 186 to 954 +/- 120 ml, 2p less than 0.001; group 2: from 1402 +/- 300 to 1185 +/- 294 ml). This was compared to the course of left ventricular end-diastolic diameter (group 1: from 7.1 +/- 0.9 to 5.5 +/- 0.7 cm (-23%), 2p less than 0.001; group 2: from 7.6 +/- 0.7 to 6.9 +/- 1.3 cm (-9%). In group 1, left ventricular ejection fraction significantly increased, whereas no significant changes were observed in group 2 (group 1: from 53 +/- 13 to 64 +/- 13% (+21%), 2p less than 0.001; group 2: from 29 +/- 7 to 32 +/- 14% (+10%]. It is concluded that the scintigraphically determined ratio of left ventricular end-diastolic volume to regurgitated blood volume provides important prognostic and functional information regarding the postoperative course of chronic aortic regurgitation. This ratio is more reliable than single radionuclide, electrocardiographic, roentgenographic or echocardiographic parameters.     

Relation of mitral valve prolapse to left ventricular size in Marfan's syndrome

Sporadic recent reports suggest that mitral valve prolapse (MVP) disappears with progressive left ventricular (LV) dilatation. To test this hypothesis, we sought to determine if an inverse relation exists between MVP and LV cavity size on M-mode echocardiograms in 83 patients with Marfan's syndrome. LV end-diastolic dimensions and presence or absence of MVP were determined. Forty-six patients had MVP. Of patients with an LV end-diastolic dimension less than or equal to 5 cm, 90% had MVP; only 19% of the 32 patients with abnormally large (greater than 5.8 cm) end-diastolic dimension had MVP. The prevalence of MVP in patients with an LV end-diastolic dimension of 5.1 to 5.8 cm was 69%. Thus, the prevalence of MVP was inversely related to LV cavity size. To determine whether appearance or disappearance of MVP was associated with decrease or increase in LV cavity size, serial echocardiograms from 67 patients (mean follow-up 42 months, range 3 to 99) were examined. These patients were separated into 3 groups based on changes in the LV end-diastolic dimension of greater than 1 cm over time. Group 1 consisted of 9 patients, all of whom had MVP and normal LV cavity size on their initial study. With subsequent increase in LV end-diastolic dimension (mean 1.42 +/- 0.3), MVP disappeared in 6 of the 9. Conversely, group 2 consisted of 4 patients, all of whom had dilated left ventricles on their initial echocardiogram and no evidence of MVP. After aortic valve replacement, the LV cavity size decreased (mean 2.3 +/- 0.7) and MVP appeared on follow-up studies.(ABSTRACT TRUNCATED AT 250 WORDS)     

Use of magnesium sulfate in hypertrophic cardiomyopathy with stenosis of the outflow route

10 patients with hypertrophic cardiomyopathy with left ventricular outflow obstruction were intravenously given 100 mg/kg b.w. of magnesium sulphate. Significant decrease of repolarization disorders was observed in ecg recordings. Polycardiographically estimated prolonged A2-O interval significantly shortened from 188 +/- 49 to 168 +/- 45 ms. Echocardiographic examinations revealed increase of the left ventricular end-diastolic dimension from 43 +/- 6 to 45 +/- 6 mm (p less than 0.05), acceleration of the diastolic, posterior wall motion from 5.7 +/- 3 cm/s to 7.2 +/- 2 cm/s (p less than 0.01) and shortening of prolonged left ventricular isovolumetric relaxation interval from 108 +/- 15 to 94 +/- 14 ms (p less than 0.05). Intrasystolic anterior, mitral leaflet motion towards the intraventricular septum also significantly decreased. There were no changes of heart rate, blood pressure and left ventricular systolic parameters after MgSO4 administration. Obtained data indicate the dynamic nature of left ventricular diastolic function impairment and its positive modification by magnesium sulphate administration.     

Is the clinical course of non-rheumatic aortic regurgitation the same as that of rheumatic aortic regurgitation?

To determine whether non-rheumatic (NR) aortic regurgitation (AR) has the same clinical and postoperative courses as rheumatic (R) AR, we performed a retrospective study using pre- and postoperative M-mode echocardiograms in 23 patients who underwent aortic valve replacement (AVR) under myocardial protection with hypothermic cardioplegia. The etiology of AR was diagnosed by two-dimensional echocardiography. The NR-AR group consisted of nine patients including four with aortic valve prolapse (AP) and five with bicuspid valve (BV), and the R-AR group included 14 patients. Patients with preoperative end-diastolic dimensions (EDD) of less than 6.0 cm were excluded from this study. The indication for AVR was NYHA functional class III or severer. The severity of preoperative NYHA functional class was similar among these three groups. During the 18-month follow-up period (range 2-32 months), there were no post-operative deaths nor congestive heart failure. Ages at surgery ranged from 17 to 54 years; 10 (71%) of 14 patients with R-AR were 40 years old or older, while seven (78%) of nine with NR-AR were under 39 years old (p less than 0.05). The pre-operative left ventricular end-diastolic pressure (LVEDP) in patients with BV-AR was highest among these three groups (R-AR: 14.5 +/- 3.9 mmHg, AP-AR: 9.5 +/- 4.1 mmHg, BV-AR: 22.0 +/- 2.7 mmHg, p less than 0.05). There was no significant difference in pre-operative M-mode echocardiographic results, except for the end-systolic dimension (ESD) between R-AR (5.20 +/- 0.55 cm) and BV-AR (4.78 +/- 0.18 cm) (p less than 0.05). The EDD one month after AVR was still abnormal (greater than or equal to 5.4 cm) in seven of the 14 patients with R-AR, and three of the four patients with AP-AR but none of the patients with BV-ARs (p less than 0.05 vs AP-AR). All patients with pre-operative ESD of less than 5.2 cm had normal EDD one month after AVR. In conclusion, the clinical course of NR-AR is different from that of R-AR. Furthermore, AP-AR regresses more differently after AVR than does BV-AR. Therefore, it is important to consider the etiology of chronic AR in determining the timing of surgery.     

Interventricular septal motion and left ventricular function after coronary bypass surgery: evaluation with echocardiography and radionuclide angiography.

To evaluate interventricular septal motion and left ventricular function after coronary bypass graft surgery, 40 patients were studied early postoperatively and serially for up to 16 months with echocardiography and radionuclide angiography. Early after operation mean left septal excursion decreased significantly from 4.6 +/- 0.4 (standard error) to 0.8 +/- 0.6 mm (P less than 0.001), and left septal motion was abnormal in 23 of the 40 patients. Mean right septal excursion reversed from 2.1 +/- 0.5 to -2.1 +/- 0.5 mm early after operation in the 22 patients in whom these measurements could be made, and 15 patients showed paradoxical right septal excursion. At a mean of 4 months after operation, only 7 of 35 patients followed up had abnormal left septal motion, and mean left septal excursion had returned toward normal (3.6 +/- 0.7 mm); mean right septal excursion remained reversed (--1.1 +/- 0.7 mm), and 6 of the 14 patients followed up had paradoxical motion. In the 22 patients whose wall thickness could be measured, mean septal thickening during systole decreased significantly from 35 +/- 4 to 21 +/- 3 percent early after operation (P less than 0.01). During late follow-up septal thickening returned toward normal (32 +/- 4 percent). Mean normalized posterior wall velocity increased significantly after operation from 0.76 +/- 0.03 to 1.01 +/- 0.05 sec-1 (P less than 0.001), but posterior wall thickening remained unchanged. Left ventricular end-diastolic dimension and the radionuclide-determined left ventricular ejection fraction were unchanged postoperatively. It is concluded that (1) echocardiographically detected abnormal septal movement is frequent early after coronary bypass graft operation; (2) both decreased myocardial contraction in the septum and increased anterior movement of the whole heart contribute to this abnormality; (3) the abnormalities in septal movement decrease during late follow-up in many patients but persist in some patients; and (4) posterior wall function tends to increase early after operation and therefore overall left ventricular function remains normal.     

Effects of labetalol on left ventricular mass and function in hypertension--an assessment by serial echocardiography

We determined echocardiographic (M-mode) indices of left ventricular mass and function serially at 1-month intervals in 10 patients with uncomplicated mild or moderate essential hypertension, before and after adequate control of blood pressure with labetalol, a combined alpha- and beta-receptor blocking agent. Seven patients had pretreatment echocardiographic evidence of left ventricular hypertrophy with disproportionate septal thickness in 4. Systolic blood pressure in the untreated state correlated well (r = 0.96) with left ventricular mass but poorly (r = 0.30) with diastolic pressure. Following a satisfactory blood pressure reduction, achieved in all patients, left ventricular mass decreased from 240.5 +/- 71.1 g to 159.5 +/- 40.7 g (P less than 0.01), interventricular septal thickness from 1.33 +/- 0.3 cm to 0.92 +/- 0.25 cm (P less than 0.01) and posterior wall thickness from 1.03 +/- 0.23 cm to 0.93 +/- 0.23 cm (P less than 0.05). While the maximum changes in left ventricular mass were noted by the end of first month (P less than 0.01) with insignificant changes thereafter, the correlation of fall in blood pressure with change in left ventricular mass was significant only after 2 months of treatment (P less than 0.05). Indices of left ventricular function (end-diastolic volume, ejection fraction, fractional diameter shortening, left atrial dimension and posterior aortic wall motion) were normal before treatment and remained unchanged during 3 months of treatment. In this short-term study, labetalol reduced left ventricular hypertrophy (expressed as left ventricular mass and wall thickness) without altering left ventricular function indices in patients with uncomplicated essential hypertension. This has important implications in the treatment of hypertensive patients.     

Relation between preoperative left ventricular muscle mass and outcome of the Fontan procedure in patients with tricuspid atresia

The relation between preoperative left ventricular muscle mass and clinical outcome of the Fontan procedure was evaluated retrospectively in 22 patients with tricuspid atresia who were selected for this physiologic surgical correction by conventional hemodynamic criteria. Patients were divided into two groups: group A (excellent or good outcome) and group B (poor outcome or death) based on the clinical course assessed up to 9.5 years postoperatively. Thirteen of 22 group A patients did not have prolonged, clinically significant, systemic venous hypertension and were not on long-term diuretic drug therapy. Nine of 22 group B patients either had clinically significant systemic venous hypertension, required long-term diuretic drug therapy or died (3 patients). Age at surgery, pulmonary arteriolar resistance, left ventricular ejection fraction, end-diastolic volume, end-diastolic pressure, systemic oxygen saturation and pulmonary to systemic blood flow ratio (Qp/Qs) were not statistically different between the two groups. Left ventricular muscle mass, both in group A patients (92 +/- 31 g/m2) and in group B patients (146 +/- 61 g/m2), was greater than the normal mean value (p less than 0.01 and p less than 0.001, respectively). Left ventricular muscle mass in group B was significantly greater than in group A (p less than 0.01). Furthermore, left ventricular muscle mass/end-diastolic volume (mass/volume) ratio, reflecting the extent of left ventricular hypertrophy relative to volume overload, was significantly greater in group B (1.1 +/- 0.28) than in group A (0.84 +/- 0.21) (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison of the effects of nitroprusside and nifedipine on diastolic properties in patients with hypertrophic cardiomyopathy: Altered left ventricular loading or improved muscle inactivation?

The calcium channel blocking agent, nifedipine, has been shown to improve indexes of left ventricular relaxation, diastolic filling and compliance in patients with hypertrophic cardiomyopathy. The mechanism of action of nifedipine on diastolic properties in patients with hypertrophic cardiomyopathy is unclear and could result from an improvement in myocardial inactivation or from systemic vasodilation and left ventricular unloading. To distinguish between these mechanisms, the effects of nifedipine and the vasodilator nitroprusside on left ventricular diastolic properties were compared in 10 patients with nonobstructive hypertrophic cardiomyopathy using simultaneous micromanometer left ventricular pressure and echocardiographic measurements. Left ventricular peak systolic pressure was comparable during nitroprusside infusion (132 +/- 38 mm Hg) and after nifedipine (132 +/- 32 mm Hg). During nitroprusside infusion, the decrease in left ventricular end-diastolic pressure (22 +/- 11 to 17 +/- 11 mm Hg, p less than 0.05) was associated with a decrease in left ventricular end-diastolic dimension. In contrast, the decrease in left ventricular end-diastolic pressure after nifedipine (22 +/- 11 to 18 +/- 10 mm Hg, p less than 0.05) was associated with no reduction of left ventricular end-diastolic dimensions, suggesting an increase in left ventricular distensibility. Compared with nitroprusside, nifedipine was associated with less prolongation of the left ventricular isovolumic relaxation time and less depression of the peak left ventricular posterior wall thinning rate and peak left ventricular internal dimension filling rate. These data suggest that the effects of the calcium channel blocker, nifedipine, on diastolic mechanics in hypertrophic cardiomyopathy result not only from systemic vasodilation but also from improved cardiac muscle inactivation.     

Echocardiographic estimation of critical left ventricular size in infants with isolated aortic valve stenosis

With the current trend to performing surgical valvotomy for infantile aortic stenosis without cardiac catheterization, there is a need to develop echocardiographic criteria for adequacy of left ventricular size. The echocardiograms and catheterization data of all 25 infants less than 3 months of age undergoing aortic valvotomy for isolated aortic valve stenosis from September 1980 through July 1990 were reviewed. Significant differences (p less than 0.05) between the survivors and nonsurvivors were noted for age at operation (30 +/- 28 vs. 3 +/- 1.5 days), mitral valve diameter (10.1 +/- 1.7 vs. 7.7 +/- 1.5 mm), left ventricular end-diastolic dimension (18.4 +/- 6.4 vs. 11.4 +/- 3 mm), left atrial dimensions (15.3 +/- 3.8 vs. 10 +/- 2.4 mm), left ventricular cross-sectional area on the parasternal long-axis echocardiogram (4 +/- 1.9 vs. 2 +/- 1.9 cm2) and angiographically determined left ventricular end-diastolic volume (43 +/- 23 vs. 11 +/- 5 ml/m2). There was no difference with respect to patient weight, body surface area, aortic root dimension or left ventricular ejection fraction. Left ventricular cross-sectional area less than 2 cm2 as measured on the parasternal long-axis echocardiogram was found in 5 of 7 nonsurvivors and 0 of 12 survivors, making this a risk factor for perioperative death (p less than 0.05). Left ventricular end-diastolic dimension less than 13 mm was found in 5 of 6 nonsurvivors and 2 of 17 survivors, making this another risk factor for early mortality (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Left ventricular filling in dilated cardiomyopathy: relation to functional class and hemodynamics

Left ventricular systolic function does not correlate well with functional class in patients with dilated cardiomyopathy. To determine whether the correlation is better with Doppler indexes of left ventricular diastolic function, 34 patients with dilated cardiomyopathy (M-mode echocardiographic end-diastolic dimension greater than 60 mm, fractional shortening less than 25%, increased E point-septal separation) were studied. Patients were classified into two groups according to functional class. Group 1 consisted of 16 patients in New York Heart Association functional class I or II; group 2 included 18 patients in functional class III or IV. Left ventricular dimensions, fractional shortening, left ventricular mass, meridional end-systolic wall stress, peak early and late transmitral filling velocities and their ratio, isovolumetric relaxation period and time to peak filling rate were computed from pulsed wave Doppler and M-mode echocardiograms and calibrated carotid pulse tracings. Right heart catheterization was performed in 20 of 34 patients. No differences were observed between groups with regard to age, gender distribution, heart rate, blood pressure and M-mode echocardiographic-derived indexes of systolic function. Peak early filling velocity (72 +/- 13 versus 40 +/- 10 cm/s, p less than 0.001) was higher and atrial filling fraction (27 +/- 4% versus 46 +/- 8%, p less than 0.001) was lower in group 2 than in group 1. The ratio of early to late transmitral filling velocities was higher in group 2 patients (2.3 +/- 0.5 versus 0.7 +/- 0.2, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Changes of the degree of hypertrophy in hypertrophic obstructive cardiomyopathy under medical and surgical treatment

The aim of our study was to establish the extent to which therapy of hypertrophic obstructive cardiomyopathy (HOCM) can influence the degree of hypertrophy. By means of two-dimensionally guided M-mode echocardiography, 120 patients with HOCM (age range 4-72 years, mean age 41 years) were observed over an average period of 49 +/- 41 months. Depending on the respective therapy, we formed four patient groups: group 1: 13 patients without any therapy (follow-up period 31 +/- 30 months); group 2: 27 patients receiving propranolol (follow-up period 47 +/- 34 months); group 3: 50 patients receiving verapamil (follow-up period 39 +/- 27 months), and group 4: 30 patients with myectomy (follow-up period 34 +/- 32 months). In group 4, as expected, the thickness of the interventricular septum (IVS) decreased postoperatively (from 24.2 +/- 4.5 to 19.8 +/- 6.7 mm, p less than 0.05), and the left ventricular posterior wall (LVPW) thickness also decreased later postoperatively (from 13.0 +/- 2.6 to 11.9 +/- 2.3 mm, p less than 0.05). The left ventricular diameters increased. In groups 2 and 3 treated with pharmacotherapy as in the untreated patients of group 1, on average there was no change in IVS and LVPW thickness nor in the left ventricular diameters (with the exception of increasing left ventricular end-diastolic diameter in the propranolol-treated group). In contrast to group 1, in occasional cases there were substantial decreases of IVS thickness (11% of the patients in group 2, 13% in group 3) or LVPW thickness (13% of the patients in group 2, 12% in group 3).(ABSTRACT TRUNCATED AT 250 WORDS)     

Long-term prognosis of patients with mildly dilated cardiomyopathy.

The long-term prognosis of patients with mildly dilated cardiomyopathy (MDCM) was investigated in 21 patients. MDCM was defined as left ventricular ejection fraction < or = 40% and left ventricular end-diastolic volume < or = 120 ml/m2 by left ventriculography. During a follow-up period of 6.8+/-3.7 years, there were 9 cardiac events (5 heart failure deaths, 2 sudden deaths, and 2 re-hospitalizations for heart failure). Only in the patients without cardiac events was there a significant decrease in left ventricular size (end-diastolic dimension decreased from 58+/-6 mm to 50+/-8 mm, p<0.001) and an improvement in systolic function (fractional shortening increased from 17+/-5% to 26+/-11%, p=0.007). However, left atrial dilation was observed in the patients with an event (from 39+/-5 mm to 43+/-5 mm, p=0.02). Based on proportional hazard analysis, left ventricular end-diastolic pressure and mean pulmonary artery pressure at diagnosis and left atrial dimension at the time of follow-up were significant predictors of poor outcome. A subset of patients with MDCM has impaired hemodynamics at diagnosis, left atrial dilation at follow-up and a poor prognosis, and must be followed carefully even if the left ventricular dilatation is mild.     

Change of left atrial systolic pressure waveform in relation to left ventricular end-diastolic pressure

The relation between the left atrial systolic pressure waveform and left ventricular end-diastolic pressure was observed in 17 patients who underwent diagnostic cardiac catheterization. Left atrial pressure and left ventricular pressure were simultaneously recorded from a multisensor catheter before and during angiotensin infusion. Left ventricular systolic pressure and left ventricular end-diastolic pressure were 133 +/- 17 and 12.3 +/- 3.2 mm Hg, respectively, before angiotensin infusion and increased to 168 +/- 18 (p less than 0.01) and 19.4 +/- 4.5 mm Hg (p less than 0.01), respectively, during infusion. The left atrial systolic pressure curve consisted of two positive waves--a first wave (A) and a second wave (A'). The A and A' wave pressures were 11.6 +/- 2.3 and 10.2 +/- 3.9 mm Hg, respectively, before angiotensin infusion and 16.5 +/- 2.9 (p less than 0.01) and 18.1 +/- 4.7 mm Hg (p less than 0.01), respectively, during infusion. The ratio of A'/A of left atrial systolic pressure was 0.81 +/- 0.27 before angiotensin infusion and 1.08 +/- 0.14 (p less than 0.01) during infusion. The ratio of A' to A of left atrial systolic pressure was linearly related to left ventricular end-diastolic pressure before and during (p less than 0.01) angiotensin infusion. The amplitude of the A wave exceeded that of the A' wave at normal left ventricular end-diastolic pressures. However, as the left ventricular end-diastolic pressure increased either at rest or during angiotensin infusion, the amplitude of the A' wave increased and often exceeded that of the A wave. These results suggest that the second (A') wave might be attributed to the increased reflection associated with increased left ventricular end-diastolic pressure.     

Effects of physical deconditioning after intense endurance training on left ventricular dimensions and stroke volume

To determine the role of preload in maintaining the enhanced stroke volume of upright exercise-trained endurance athletes after deconditioning, six highly trained subjects undergoing upright and supine bicycle ergometry were characterized before and after 3, 8 and 12 weeks of inactivity that reduced oxygen uptake by 20%. During exercise, oxygen uptake, cardiac output by carbon dioxide rebreathing, cardiac dimensions by M-mode echocardiography, indirect arterial blood pressure and heart rate were studied simultaneously. Two months of inactivity resulted in a reduction in stroke volume, calculated as cardiac output/heart rate, during upright exercise (p less than 0.005) without a significant change during supine exercise. A concomitant decrease in the left ventricular end-diastolic dimension from the trained to the deconditioned state was observed in the upright posture (5.1 +/- 0.3 versus 4.6 +/- 0.3 cm; p = 0.02) but not with recumbency (5.4 +/- 0.2 versus 5.1 +/- 0.3 cm; p = NS). There was a strong correlation between left ventricular end-diastolic dimension and stroke volume (r greater than 0.80) in all subjects. No significant changes in percent fractional shortening or left ventricular end-systolic dimension occurred in either position after cessation of training. Estimated left ventricular mass was 20% lower after 3 and 8 weeks of inactivity than when the subjects were conditioned (p less than 0.05 for both). Thus, the endurance-trained state for upright exercise is associated with a greater stroke volume during upright exercise because of augmented preload. Despite many years of intense training, inactivity for only a few weeks results in loss of this adaptation in conjunction with regression of left ventricular hypertrophy.     

Evaluation of left ventricular posterior wall movement after open mitral commissurotomy by echocardiogram: with reference to the effect of papilloplasty

Left ventricular posterior wall movement in 20 patients with mitral stenosis (MS) was measured using M-mode echocardiogram in order to evaluate the improvement of myocardial function after open mitral commissurotomy (OMC) and compared between the cases with (10 patients) and without (10 patients) papilloplasty. The maximum left ventricular end-diastolic posterior wall velocity (LVPEVdmax) was increased from 71 +/- 12 to 90 +/- 16 mm/s in OMC patients (p less than 0.01) and from 59 +/- 19 to 101 +/- 28 mm/s in OMC + P patients (p less than 0.001). The maximum left ventricular systolic posterior wall velocity (LVPWVsmax) showed an increase from 51 +/- 9 to 62 +/- 10 mm/s in OMC patients (p less than 0.02) and from 48 +/- 10 to 69 +/- 8 mm/s in the OMC + P group (p less than 0.001). The mean LVPWVs increased from 35 +/- 8 to 48 +/- 8 mm/s in the OMC + P group (p less than 0.01). These parameters correlate fairly well with stroke volume index (SVI), ejection fraction (EF), and fractional shortening (FS) derived from internal LV dimensions. Thus, the posterior wall movement may prove to be useful as an index for evaluating the improvement of LV function after OMC.     

Serial left ventricular performance evaluated by cardiac catheterization before, immediately after and at 6 months after balloon aortic valvuloplasty

Although impaired ventricular function has been shown to improve after aortic valve replacement, there are few data on hemodynamic changes after balloon aortic valvuloplasty based on follow-up catheterization. Of 71 patients surviving 6 months after balloon aortic valvuloplasty, 41 agreed to late recatheterization. All patients had pre- and postvalvuloplasty and 6 month catheterization data measured with high fidelity micromanometer pressure recordings and simultaneous digital subtraction left ventriculography. The hemodynamic result immediately after valvuloplasty included a reduction in the aortic valve gradient and a moderate increase in aortic valve area (0.51 +/- 0.14 to 0.81 +/- 0.19 cm2, p less than 0.0001). Ejection fraction increased slightly (52 +/- 18 to 55 +/- 17%, p less than 0.0001) despite a decrease in peak positive rate of rise of left ventricular pressure (dP/dt 1,650 +/- 460 to 1,500 +/- 490 mm Hg/s, p less than 0.05). There was also a decrease in left ventricular afterload and a small decrease in preload. At 6 month recatheterization, the mean aortic valve gradient and area were similar to baseline values, with 31 (76%) of 41 patients demonstrating valvular restenosis. At 6 months many left ventricular hemodynamic variables, including peak positive dP/dt and stroke work, also resembled prevalvuloplasty values. However, left ventricular end-diastolic volume was reduced (111 +/- 40 ml at 6 months versus 136 +/- 52 ml before valvuloplasty, p less than 0.01). The mean left ventricular ejection fraction was unchanged from prevalvuloplasty values in the study group of 41 patients, but was significantly improved in 9 of 15 patients with a baseline ejection fraction less than 50%.(ABSTRACT TRUNCATED AT 250 WORDS)