Prediction of right ventricular systolic pressure in pulmonary stenosis from combined vectorcardiographic data

In 38 patients with isolated unoperated pulmonary stenosis a systematic search was made for optimal VCG criteria for the prediction of peak systolic right ventricular pressure. Fifty VCG measurements, seven ECG measurements, and age of each patient were entered into a stepwise multiple regression computer program.The best individual predictors were found to be the QRS loop rotation in the horizontal plane and the closely related QRS dislocation along the 135 to 315 degree horizontal plane axis (r = 0.78). Five VCG criteria were better than the best ECG criterion (R V₁, r = 0.72). Thirty-three of the 58 variables showed significant correlations with the pressure (p < 0.01). Since the confidence intervals are large with this sample size and degree of correlation, conclusions regarding the superiority of one predictor vs. another should be drawn with great care.The multivariate equation selected by the computer involved four VCG variables and age; this improved the correlation coefficient to 0.93. This improvement from data combination is larger than in previous studies, probably because all variables were given equal opportunity to enter the equation.The results were tested on a secondary sample of 19 patients with pulmonary stenosis as their main cardiac lesion. Although this sample was less homogeneous, the formula-derived pressure estimates remained reasonably good (r = 0.88). The study suggests that the diagnostic power of ECG and VCG could be increased through the proper combination of easily obtainable measurements.     

NT-proBNP correlates with right heart haemodynamic parameters and volumes in patients with atrial septal defects

BACKGROUND: To investigate the role of N-terminal pro-BNP (NT-proBNP) for the estimation of right heart failure and pulmonary pressure in patients with atrial septal defects (ASD) before and after percutaneous defect closure. METHODS: We performed correlation analysis for NT-proBNP and right ventricular systolic pressure (RVSP) as well as right ventricular enddiastolic and endsystolic volume (RVEDV, RVESV) determined by cardiac magnetic resonance imaging (MRI) before and up to one year following ASD closure. Additionally NT-proBNP concentrations were correlated with right atrial (RA) and RV enddiastolic pressure (RVEDP), ASD size and interatrial left-to-right shunt. RESULTS: Baseline RVSP was 33+/-8 mmHg, which decreased significantly during follow-up. Initially, NT-proBNP levels were 240+/-93 pg/ml. After closure, a reduction to 116+/-62 pg/ml was obvious (p<0.01). Baseline MRI showed enlarged RV volumes in all individuals. At six and twelve months follow-up a significant reduction of RVEDV and RVESV was apparent. A positive correlation was noted between RV volumes and NT-proBNP (r=0.65, p<0.05). Furthermore RA pressure, RVEDP, RVSP and left-to-right shunt significantly correlated to peptide levels. No correlation was seen between ASD size and NT-proBNP. CONCLUSION: NT-proBNP correlates to right ventricular dilatation, pulmonary pressure and left-to-right shunt in volume load of the right heart caused by an underlying ASD.     

Echocardiographic ventricular shape analysis in congenital heart disease with right ventricular volume or pressure overload

In this 2-dimensional (2-D) echocardiographic study, a computerized Fourier analysis technique refined from one that allows quantification of changes in septal shapes in normal fetuses, newborns and infants allowed analysis of left ventricular (LV) shapes in 14 patients with right ventricular (RV) volume overload (atrial septal defects), 5 with volume and pressure overload (total anomalous pulmonary venous connection), and 10 with pressure overload (complete transposition of the great arteries [TGA] with intact ventricular septum). Diastolic shape factors in the 3 groups were significantly different from those of normal subjects (p less than 0.01). Highest diastolic values were found in patients with TGA (mean 4.59 +/- 1.28). Systolic shape factors were similar in patients with atrial septal defect and normal subjects. Significant differences existed between normal subjects and patients with total anomalous pulmonary venous connection, with the greatest differences in systolic shape factor being 5.61 for TGA vs 1.87 (p less than 0.005) for normal subjects. Shape factor correlated well with hemodynamic data for RV/LV systolic pressure ratios (r = 0.93, p less than 0.001) for normalized interventricular pressure differences (r = -0.95, p less than 0.001). The lower the normalized systolic pressure difference or the higher the RV/LV ratio, the more the septum encroached into the LV cavity. Significant but weaker correlations were noted for values during diastole. Quantitative application of Fourier shape factor analysis to LV shapes allows numerical expression of visually interpreted distortions over a wide range of geometric alterations.     

Measurement of the right ventricular systolic pressure in ventricular septal defect--a simultaneous correlative study with Doppler echocardiography and dual cardiac catheterization]

To assess the reliability of Doppler echocardiography (DE) in measuring the right ventricular systolic pressure (RVSP) in ventricular septal defect (VSD), both left and right heart catheterization (Cath) and DE were performed simultaneously in 59 cases with VSD. Systolic shunt velocities through VSD were recorded by DE and converted into the peak instantaneous (delta P-PD) and mid-systolic (delta P-MD) pressure gradients using the simplified Bernoulli equation RVSP was estimated by subtracting delta P-PD from the brachial artery systolic pressure (BASP) measured by a cuff sphygmomanometer (method A) and by subtracting delta P-MD from BASP (method B). The left ventricular systolic pressure (LVSP), RVSP, and the peak instantaneous (delta P-PC) and the peak-to-peak (delta P-PP) pressure gradients were measured from pressure c rves. The comparison between BASP and LVSP yielded a good correlation (r = 0.90, SEE = 0.76 kPa). There were also good correlation of interventricular pressure gradients measured by two techniques (r = 0.98, SEE = 0.83-0.93 kPa). Although RVSP estimated by method A correlated well with that measured by Cath, there was a significant underestimation (P < 0.05). On the other hand, RVSP estimated by method B agreed highly with that measured by Cath and there was no significant difference between the two means. We conclude that DE offers a reliable technique for estimating RVSP in VSD noninvasively.     

Atrial septal defect in adults: the influence of age and haemodynamic parameters on the results of surgical repair

INTRODUCTION: Indications for closure of atrial septal defect (ASD) are well established in children but still unclear in adult patients. There is also a discrepancy regarding the natural history of the defect and benefits of ASD closure and long-term prognosis. AIM: The aim of the study was to evaluate the outcome of surgical closure of atrial septal defect (ASD) with respect to age and selected haemodynamic parameters. METHODS: The study involved 52 patients with ASD, aged 38.6+/-15 years. All patients had a clinical examination, echocardiography, Holter ECG monitoring and cardiopulmonary exercise test (CPX) prior to and at least one year after the surgery. The results were analysed for the entire group of patients and then for the following subgroups of pts.: aged <40 and ?40 years; with right ventricular systolic blood pressure (RVSP) < or =30 and >30 mmHg; and with shunt volume ratio (Qp/Qs) <2.5 and > or =2.5. RESULTS: After repair of ASD, a significant improvement of the clinical status, as defined by NYHA class, was observed. At the same time, a constant or even increased incidence of arrhythmias was found. Repair of the defect resulted in a significant reduction of the right ventricular diameters in all studied subgroups. Among all evaluated parameters, only age at time of the operation was significantly associated with right ventricular diameter after surgery (b=0.598; p <0.001). Exercise capacity was found to have significantly increased after surgery, regardless of age, RVSP and Qp/Qs, but it remained significantly reduced in patients with pulmonary arterial hypertension compared to subjects with normal RVSP before ASD repair. A significant correlation was shown between peak oxygen consumption and RVSP both before (r=-0.68; p <0.001) and after (r=-0.38; p=0.01) surgery. CONCLUSIONS: Patients benefit from surgical closure of ASD regardless of age and previous RVSP and Qp/Qs. Age at the time of surgery and pulmonary arterial pressure determine long-term results and improvement of echocardiographic and ETT parameters.     

The determinants of right ventricular function in patients with atrial septal defect

OBJECTIVE: The purpose of this study was to ascertain the determinants of right ventricular (RV) systolic and diastolic functions in patients with atrial septal defect. METHODS: Thirty-three patients with atrial septal defect having left to right shunt were enrolled in this study. RV function parameters were assessed echocardiographically. RV systolic function was assessed using tricuspid tissue Doppler S velocity (St). With regard to RV diastolic function parameters, E/A ratio, deceleration time (DT), E/Et ratio (Et = tissue Doppler E velocity), RV isovolumetric relaxation time (RVIVRT) were assessed. RV myocardial performance index (MPI) was calculated as an index of both systolic and diastolic function. Pulmonary artery stiffness (PAS) was also calculated. After echocardiography, right and left heart catheterization was performed. Mean pulmonary artery pressure (MPAP), mean right atrial pressure (MRAP), systemic flow (Qs), pulmonary flow (Qp), systemic vascular resistance (SVR), and pulmonary vascular resistance (PVR) were obtained using the data of invasive measurements. RESULTS: In multivariate analysis, MPAP was found to be the parameter closest related to RVIVRT (r = 0.73, p < 0.001) and E/Et (r = 0.66, p < 0.001), while PAS was found to be the parameter closest related to MPI (r = 0.53, p = 0.002). In addition, St velocity was found the only parameter related to PVR (r = -0.39) in univariate analysis. There was no relationship between QP/QS and any of the RV function parameters. CONCLUSION: The pulmonary vascular bed appears to be the predictor of the RV functions in patients with atrial left to right shunts, and the amount of the shunt seems to have no direct adverse influence on the RV functions.     

Left ventricular function in right ventricular overload: asymmetry of the left ventricular ejection

This study clarified regional and global functions of the distorted left ventricle due to right ventricular overload by means of gated radionuclide ventriculography (RNV). Cardiac catheterization and RNV were performed in 13 cases of atrial septal defect (ASD), 13 of pure mitral stenosis (MS), 10 of primary pulmonary hypertension (PPH), and 10 of normal subjects (NL). Right ventricular systolic pressure (RVSP) was 32.9 +/- 13.9, 45.0 +/- 12.2, 88.3 +/- 17.1, and 21.2 +/- 4.5 mmHg, respectively. RNV was performed with a 99mTc-red blood cell in a vivo labeling technique. The end-systolic LAO view of the left ventricle was halved into septal and free-wall sides. The end-diastolic halves were determined in the same plane. Ejection fractions of the global left ventricle (LVEF), global right ventricle (RVEF), the septal half of the left ventricle (SEPEF), and the free-wall half of the left ventricle (FWEF) were obtained. LVEF was 56.8 +/- 9.8% in NL, 52.8 +/- 10.5% in ASD, and 49.5 +/- 12.9% in PPH. In MS, LVEF (47.0 +/- 13.0%) was smaller than those in the other groups. RVEF was 37.0 +/- 5.2% in NL, 43.7 +/- 15.5% in ASD, and 32.8 +/- 11.5% in MS. In PPH, RVEF (25.0 +/- 10.6%) was smaller than those in the other groups. SEPEF was smaller in AS D (42.5 +/- 13.2%), MS (40.4 +/- 13.1%), PPH (40.5 +/- 12.5%) than in NL (53.5 +/- 8.5%). Systolic function of the septal half of the left ventricle was disturbed by right ventricular overload. RVEF (r = -0.35, p less than 0.05) and SEPEF (r = -0.51, p less than 0.01) had negative correlations with RVSP. As RVSP rose, systolic function of the septal half of the left ventricle was more severely disturbed. FWEF was the same among the four groups; NL (57.0 +/- 12.6%), ASD (48.6 +/- 15.2%), MS (50.5 +/- 12.0%), and PPH (51.1 +/- 12.3%). Right ventricular overload does not affect systolic function of FWLV. There was a good correlation between SEPEF and LVEF in NL (r = 0.81), though in PPH this correlation was poor (r = 0.64). In patients with PPH the septal side of the left ventricle does not act as a part of the global left ventricle. Systolic function of the septal side of the left ventricle is disturbed due to the distortion of the ventricular septum, but systolic function of the free-wall side is maintained within a normal range, when the left ventricular myocardium is kept normal.(ABSTRACT TRUNCATED AT 400 WORDS)     

Noninvasive estimation of right ventricular systolic pressure in ventricular septal defect by a continuous wave Doppler technique

Noninvasive determination of right ventricular systolic pressure was attempted in 27 patients with ventricular septal defect based on the peak velocity of left-to-right shunt flow as measured in the right ventricle by a continuous wave Doppler technique. The systolic pressure gradient between the ventricles (delta p: mmHg) was calculated according to the simplified Bernoulli's formula, delta p = 4 V2, where V (m/sec) is the peak velocity of the left-to-right shunt flow. Right ventricular systolic pressure was determined by subtracting delta p from the systolic blood pressure measured in the upper arm, which was regarded as the left ventricular systolic pressure. The peak velocity of left-to-right shunt flow could be measured in all patients except one with muscular ventricular septal defect, and values ranged from 0.6 to 4.8 m/sec. The peak velocity of left-to-right shunt flow decreased inversely with the increase in right ventricular systolic pressure. The values of right ventricular systolic pressure determined by the continuous wave Doppler technique correlated highly (r = 0.820) with those determined by cardiac catheterization. The peak velocity of left-to-right shunt flow also showed high negative correlations with the pulmonary to systemic pressure ratio (r = -0.876) and pulmonary to systemic resistance ratio (r = -0.855). These results indicate that the continuous wave Doppler technique is clinically useful for determination of right ventricular systolic pressure as well as the pulmonary to systemic pressure ratio and pulmonary to systemic resistance ratio.     

Moderate Altitude Increases Right Ventricular Pressure and Oxygen Desaturation in Adolescents with Surgically Closed Septal Defect

Objectives. Abnormal right ventricular systolic pressure response (RVPR) during exercise has previously been demonstrated in patients with septal defects of the heart. Our study investigated whether moderate altitude affects RVPR and oxygen saturation during rest and exercise in patients with surgically closed septal defects. Design. Ten patients with surgically closed heart septal defects (six secundum atrial septal defects, four ventricular septal defects) were examined by cardiopulmonary exercise testing and by echocardiography at rest and during supine cycling at sea level. After 2 hours in a hypobaric chamber at 2500 m/8200 ft altitude, exercise echocardiography was repeated. Results. During sea level exercise four patients showed abnormal RVPR (>50 mm Hg). Acute hypoxic exposure led to right ventricular systolic pressure increase above 40 mm Hg in two patients. During altitude exercise seven patients showed abnormal RVPR. Average maximal right ventricular systolic pressure was 56.5 ± 12.7 mm Hg and average for the lowest oxygen saturation was 80.0 ± 5.7%. Two patients had simultaneous oxygen desaturation below 80% and right ventricular systolic pressure above 50 mm Hg. Conclusions. Moderate altitude affects right ventricular systolic pressure and oxygen saturation in adolescents with surgically closed ventricular or atrial septal defects. Moderate altitude may induce or aggravate abnormal RVPR and oxygen desaturation during exercise in these patients.     

Right ventricular dilatation and intraventricular septal motion after surgical closure of atrial septal defect

The persistence of right ventricular dilatation and paradoxical interventricular septal motion are two echocardiographic abnormalities rarely reported after surgical closure of atrial septal defects. The aim of this study was to identify the predictive factors of these abnormalities in the long-term and to study their functional consequences. One hundred and two patients aged 18 +/- 14 years (range 1-62 years) underwent closure of atrial septal defects. Thirty-five patients were under 10 years of age, 33 were 10 to 20 years of age and 34 were over 20. Fifty-six patients were female. The rhythm was sinus in the great majority of cases (97%). Three patients, all over 40 years of age, were in atrial fibrillation. Before surgery, right ventricular dilatation was observed in 95 patients (91.2%), paradoxical septal wall motion in 93 patients (91.2%), the ratio of pulmonary/systemic output was 2.7 +/- 0.6 (range 1.7 to 7.4) and over 2 in 90% of patients: pulmonary systolic pressure was 32.3 +/- 12 mmHg and over 40 mmHg in 18 patients (17.6%). Ninety-four patients were followed up regularly with a mean follow-up time of 5.5 +/- 3.6 years (1-14 years). The right ventricle remained dilated in 37 patients (39.4%) after surgery: the right ventricular dimension decreased from 36 +/- 1 to 27.8 +/- 6.2 mm (p = 0.001). The ratio of end diastolic right ventricular/left ventricular dimension also decreased from 1.07 +/- 0.31 to 0.56 +/- 0.12 (p = 0.0001). Multivariate analysis identified two predictive factors of persistent right ventricular dilatation: age > 40 years (p = 0.009) and a pulmonary/systemic flow ratio > 3 (p = 0.03). Interventricular septal wall motion remained paradoxical in 21 patients (22%). Multivariate analysis identified two predictive factors of persistent paradoxical septal motion: age > 40 years (p = 0.02) and systolic pulmonary pressures > 40 mmHg (p = 0.03). These abnormalities remained asymptomatic in all but two patients with persistent long-term hypertension and a residual atrial septal defect. The persistence of right ventricular dilatation and paradoxical septal motion was quite common, with older age at surgery, systolic pulmonary artery pressure > 40 mmHg and a ratio of pulmonary/systemic blood flow > 3, being predisposing factors. These abnormalities were clinically asymptomatic when isolated.     

Noninvasive assessment of left atrial maximum dP/dt by a combination of transmitral and pulmonary venous flow.

OBJECTIVES: The study assessed whether hemodynamic parameters of left atrial (LA) systolic function could be estimated noninvasively using Doppler echocardiography. BACKGROUND: Left atrial systolic function is an important aspect of cardiac function. Doppler echocardiography can measure changes in LA volume, but has not been shown to relate to hemodynamic parameters such as the maximal value of the first derivative of the pressure (LA dP/dt(max)). METHODS: Eighteen patients in sinus rhythm were studied immediately before and after open heart surgery using simultaneous LA pressure measurements and intraoperative transesophageal echocardiography. Left atrial pressure was measured with a micromanometer catheter, and LA dP/dt(max) during atrial contraction was obtained. Transmitral and pulmonary venous flow were recorded by pulsed Doppler echocardiography. Peak velocity, and mean acceleration and deceleration, and the time-velocity integral of each flow during atrial contraction was measured. The initial eight patients served as the study group to derive a multilinear regression equation to estimate LA dP/dt(max) from Doppler parameters, and the latter 10 patients served as the test group to validate the equation. A previously validated numeric model was used to confirm these results. RESULTS: In the study group, LA dP/dt(max) showed a linear relation with LA pressure before atrial contraction (r = 0.80, p < 0.005), confirming the presence of the Frank-Starling mechanism in the LA. Among transmitral flow parameters, mean acceleration showed the strongest correlation with LA dP/dt(max) (r = 0.78, p < 0.001). Among pulmonary venous flow parameters, no single parameter was sufficient to estimate LA dP/dt(max) with an r2 > 0.30. By stepwise and multiple linear regression analysis, LA dP/dt(max) was best described as follows: LA dP/dt(max) = 0.1 M-AC +/- 1.8 P-V - 4.1; r = 0.88, p < 0.0001, where M-AC is the mean acceleration of transmitral flow and P-V is the peak velocity of pulmonary venous flow during atrial contraction. This equation was tested in the latter 10 patients of the test group. Predicted and measured LA dP/dt(max) correlated well (r = 0.90, p < 0.0001). Numerical simulation verified that this relationship held across a wide range of atrial elastance, ventricular relaxation and systolic function, with LA dP/dt(max) predicted by the above equation with r = 0.94. CONCLUSIONS: A combination of transmitral and pulmonary venous flow parameters can provide a hemodynamic assessment of LA systolic function.     

Value of ventricular geometry in the evaluation of direct ventricular pressure

OBJECTIVE: To determine the echocardiographic end-systolic ventricular geometry value in evaluating right ventricular systolic pressure (RVSP). MATERIAL AND METHODS: We studied prospectively 68 patients (mean age = 6.0 +/- 5.0 years), submitted to cardiac catheterization for cardiac disorders not involving left ventricular (LV) outflow tract obstruction, within 24 hours after two-dimensional echocardiographic (2D echo) examination. 2D echo evaluation of RVSP was performed using end-systolic LV transverse orthogonal diameters (TDR). The LV transverse orthogonal diameters (antero-posterior and supero-inferior) were measured on a parasternal short-axis image, at the tips of papillary muscles. 2D echo semi-quantitative evaluation of RVSP was tested correlating TDR with hemodynamic RVSP/LV systolic pressure (LVSP) ratio--group 1. We also used regression equation derived from the first 35 patients to quantify RVSP in the last 33 patients--group 2. In these cases, systolic systemic arterial pressure measured by sphygmomanometry was taken as LVSP. RESULTS: The TDR ranged from 1.0 to 2.1 (mean = 1.5 +/- 0.3) and the RVSP/LVSP ratio from 0.3 to 1.7 (mean = 0.7 +/- 0.4). All patients with RVSP/LVSP greater than or equal to 65% have TDR greater than or equal to 1.3 and when RVSP less than or equal to 35 mmHg we always obtained TDR less than or equal to 1.2. The correlation between 2D echo estimated and catheter measured RVSP shows, for group 1, r = 0.88 and y = 1.1X-0.88 and, for group 2'. r = 0.88. CONCLUSION: In the absence of LV systolic obstruction, TDR is a reliable non invasive method in evaluating the RVSP.     

Pulmonary arterial pressure and plasma concentration of atrial natriuretic factor (ANF) in patients with heart disease

To study the factors controlling the release of atrial natriuretic factor (ANF), we analyzed the peripheral plasma ANF concentration in 34 patients with heart disease who underwent cardiac catheterization. A significant positive correlation between plasma ANF concentration and pulmonary arterial pressure (systolic, r = 0.87; diastolic, r = 0.75; mean, r = 0.85; each p less than 0.001) was found in all the patients examined. There were significant positive correlations between plasma ANF concentration and systolic right ventricular pressure (r = 0.86, p less than 0.001), pulmonary capillary wedge pressure (r = 0.50, p less than 0.01) and mean right atrial pressure (r = 0.39, p less than 0.05). A weak but significant negative correlation was found between plasma ANF concentration and stroke volume index (r = -0.43, p less than 0.05). The correlation coefficient between plasma ANF concentration and mean pulmonary arterial pressure was significantly stronger than those between plasma ANF concentration and pulmonary capillary wedge pressure, and between plasma ANF concentration and mean right atrial pressure (p less than 0.05 and p less than 0.01, respectively). In 10 patients with mitral valvular disease, significant correlations with plasma ANF concentration were also found for pulmonary arterial pressure (systolic, r = 0.80; diastolic, r = 0.82; mean, r = 0.82; each p less than 0.01). These findings suggest that pulmonary arterial pressure may play an important role in the mechanism of release of ANF from atrial cardiocytes.     

Validation of Doppler-derived interventricular pressure gradients in patients with ventricular septal defect comparing with catheterization study]

To evaluate the accuracy of Doppler echocardiography for measuring the interventricular pressure gradient in patients with ventricular septal defect (VSD), Doppler echocardiography and dual catheters were performed simultaneously in 31 cases with VSD ranging from 9 to 40 years old. The systolic jet velocities through VSD were recorded by the continuous-wave Doppler technique and converted to the peak instantaneous pressure gradient (delta Pp) and the mean pressure gradient (delta Pm) using a modified Bernoulli's equation with the aid of computer system. Both left and right heart catheters were performed to record the left (LVSP) and the right (RVSP) ventricular systolic pressure simultaneously. Guided by the color flow image Doppler technique, the tip of the right heart catheter was carefully placed within the jet area of the right ventricle. The following parameters were measured from the ventricular pressure curves, the peak instantaneous pressure gradient (IPG), the peak to peak pressure gradient (PPG) and the mean pressure gradient (MPG). The comparison between delta Pp and PPG yielded an excellent correlation (r = 0.99, SEE = 0.69 kPa). There was a close agreement between delta Pp and IPG (r = 0.99, SEE = 0.64 kPa). However, the correlation between delta Pm and MPG was also high (r = 0.98, SEE = 0.67 kPa). We conclude that Doppler echocardiography offers a reliable technique for measuring the interventricular pressure gradient in patients with VSD.     

Prediction of pulmonary arterial pressures from electrovectorcardiographic data in pediatric patients with rheumatic mitral valve disease.

The Frank vectorcardiogram (VCG) and the electrocardiogram (ECG) were used to predict pulmonary arterial pressures in 30 pediatric patients with rheumatic mitral valve disease. The patients' ages ranged from eight to 14 1/2 years. Eleven were male and 19 were female. Sixteen had mitral stenosis, eight had mitral regurgitation and six had mitral stenosis and regurgitation. Mean pulmonary arterial wedge pressure ranged from 5-32 mmHg. All patients underwent complete catheterization and angiocardiographic study. None had significant gradient across the right ventricular outflow tract. Right maximum spatial vector (Rmsv) was calculated using Frank VCG.R in V1 and S in V5 of ECG were also measured. Rmsv, RV1, and SV5 were correlated with pulmonary arterial pressures (systolic, diastolic and mean). Pulmonary artery systolic pressure and Rmsv bear the best correlation (r=0.773). The correlation coefficient for pulmonary artery diastolic pressure and Rmsv was 0.698. Rmsv as calculated from Frank VCG is useful in prediction of pulmonary arterial pressures (systolic and diastolic) in pediatric patients with rheumatic mitral valve disease.     

Balloon catheter dilation of severe pulmonary restenosis 11 years after surgical valvulotomy

A young girl who underwent repair of an atrial septal defect and pulmonary valvulotomy when 6 years of age, presented with clinical and haemodynamic signs of pulmonary restenosis 11 years later: right ventricular systolic pressure (RVSP) of 130 mmHg with a systolic RV/PA pressure gradient of 105 mmHg. Pulmonary valvuloplasty was performed using a balloon catheter (20 mm X 40 mm). Two inflations were necessary to correct the hour glass deformity of the balloon caused by the stenosis. After valvuloplasty the RVSP was 75 mmHg and the RV/PA gradient 55 mmHg. The calculated pulmonary valve surface area increased from 0.36 cm2 to 0.72 cm2. Angiography performed immediately after dilatation showed improved valvular mobility but here was persistant severe infundibular hypertrophy. The intensity of the pulmonary systolic murmur decreased. The good result obtained in this case shows that percutaneous valvuloplasty may be considered when restenosis occurs several years after surgical valvulotomy. Control catheterisation performed two months after dilatation confirmed the good initial haemodynamic result.     

The VCG in ventricular septal defect in the first two years of life. Qualitative and quantitative analyses (author's transl)].

A group of 37 patients, less than 2 years old, with a ventricular septal defect of variable degree, and a left to right shunt, were studied by vectorcardiography. The duration, the direction and the aspect of the QRS loop on the three orthogonal planes, the voltage of the 0.01; 0.02; 0.04 vectors, the right and the left maximum spatial vectors and their projection on the H and F planes were analyzed and correlated to the right ventricular systolic pressure and Qp/Qs. A clockwise or an eight-type loop on the frontal plane, regardless of RVSP, was observed; on the H plane the loop is, usually, counterclockwise when the pressure is low or medium, and can be of the eight-type but never clockwise when the pressure is systemic. Very interestingly, the quantitative analysis showed a consistent increase of the LMSV. A progressive relationship between the spatial vectors and the right ventricular pressure was noted. The diagnosis of combined ventricular hypertrophy depend upon the following findings: the majority of cases showed a large, counterclockwise and anterior QRS loop on the H with the maximum vector to the left and anteriorly; in all cases the 0.01; 0.02; 0.04 vectors were enlarged, thus warranting the diagnosis of combined ventricular hypertrophy in the first few months of life. 4 cases with low RVSP presented increased initial forces to the right and anteriorly directed, while the major portion of the loop was in the left posterior quadrant on the H plane, with a counterclockwise direction. In our view, the differential diagnosis between this type of aspect and that of diastolic overload of the left ventricle can rest only on the increased voltage of the 0,02 vector which means both systolic and diastolic overload of the right ventricle when accompanied by an increased 0.01 vector which indicates volume overload of left ventricle. Likewise only a quantitative analysis can help in differentiating a combined ventricular hypertrophy from a normal tracing in children under 6 months who show an eight-type loop on the H plane with initial and medium vectors directed anteriorly to the left and counterclockwise, and terminal vectors to the right, posteriorly and clockwise, or in those cases with an anterior clockwise loop on the H plane. Moreover, in the first month of life, the VCG of large VSD with increased pulmonary flux and pressure, can be differentiated from the normal by the QRS loop on the H plane which is clockwise, with initial vectors directed to the left and anteriorly with increased LMSV.     

左束支区域起搏与右室间隔部起搏对房室传导阻滞患者新发房颤及心功能影响的对比

目的 探讨左束支区域起搏（LBBAP）对高心室起搏比例患者中远期新发房颤及心功能影响。方法 以因II度以上房室传导阻滞行DDD起搏器植入患者为研究对象,患者随机入组LBBAP高心室起搏比例组（LBBAPhigh组）、右室间隔部起搏（RVSP）高心室起搏比例组（RVSP-high组）、RVSP低心室起搏比例组（RVSP-low组）。随访内容包括：各随访节点心房频率大于180次/min、持续时间大于1 min且发生自动模式转换（AMS）事件、动态心电图、超声心动图参数、NT-proBNP水平。分析三组患者的临床基本特征,使用Kaplan-meier法绘制患者新发房颤的时间曲线,并采用COX比例风险模型进行多因素相关性分析。对比三组患者半年期心超参数与NTproBNP水平。结果 与LBBAP-high组比较,起搏QRS宽度RVSP-low组升高（P <0.01）,RVSP-high组升高（P<0.01）。随时间延长,患者术后新发房颤发生率逐渐增高。三组患者记录到房颤事件共有59例（57%）,其中,LBBAP-high组15例（44%）、RVSP-low组11例（38%）、RVSP...     

Frequency and direction of interatrial shunting in valvular pulmonic stenosis with intact ventricular septum and without left ventricular inflow or outflow obstruction: An analysis of 127 patients treated by valvulotomy

This report summarizes observations in 127 patients who underwent pulmonic valvulotomy for valvular pulmonic stenosis with intact ventricular septum and without obstruction to left ventricular inflow or outflow. Of the 127 patients, 30 (24%) preoperatively by dye dilution curves had shunting at the atrial level: in 19 (63%), the shunt was right-to-left, and in the other 11 (27%), entirely left-to-right. The patients with right-to-left interatrial shunts had severe pulmonic valve stenosis (average peak systolic pressure gradient = 120 ± 11 mm. Hg) and small (average diameter 1.1 ± 0.1 cm.) sized defects in the atrial septum (patent foramen ovale). In contrast, the patients with left-to-right shunts had mild to moderate pulmonic valve stenosis (average peak systolic pressure gradient = 60 ± 5 mm. Hg) and relatively large (average diameter = 2.8 ± 0.1 cm.) defects in the atrial septum (true atrial septal defect). The patients with right-to-left interatrial shunts had no significant differences in right versus left atrial pressures. The patients with left-to-right interatrial shunts, however, had left atrial pressures significantly greater than right atrial pressures (7 ± 0.5 vs 5 ± 0.5, p < 0.05). No significant differences were found in ventricular end-diastolic pressures.     

Continuous wave Doppler determination of right ventricular pressure: a simultaneous Doppler-catheterization study in 127 patients

Simultaneous continuous wave Doppler echocardiography and right-sided cardiac pressure measurements were performed during cardiac catheterization in 127 patients. Tricuspid regurgitation was detected by the Doppler method in 117 patients and was of adequate quality to analyze in 111 patients. Maximal systolic pressure gradient between the right ventricle and right atrium was 11 to 136 mm Hg (mean 53 +/- 29) and simultaneously measured Doppler gradient was 9 to 127 mm Hg (mean 49 +/- 26); for these two measurements, r = 0.96 and SEE = 7 mm Hg. Right ventricular systolic pressure was estimated by three methods from the Doppler gradient. These were 1) Doppler gradient + mean jugular venous pressure; 2) using a regression equation derived from the first 63 patients (Group 1); and 3) Doppler gradient + 10. These methods were tested on the remaining 48 patients with Doppler-analyzable tricuspid regurgitation (Group 2). The correlation between Doppler-estimated and catheter-measured right ventricular systolic pressure was similar using all three methods; however, the regression equation produced a significantly better estimate (p less than 0.05). Use of continuous wave Doppler blood flow velocity of tricuspid regurgitation permitted determination of the systolic pressure gradient across the tricuspid valve and the right ventricular systolic pressure. This noninvasive technique yielded information comparable with that obtained at catheterization. Approximately 80% of patients with increased and 57% with normal right ventricular pressure had analyzable Doppler tricuspid regurgitant velocities that could be used to accurately predict right ventricular systolic pressure.