Early diastolic clicks after the Fontan procedure for double inlet left ventricle: anatomical and physiological correlates

M mode echocardiograms and simultaneous phonocardiograms were recorded in four patients with early diastolic clicks on auscultation. All had double inlet left ventricle and had undergone the Fontan procedure with closure of the right atrioventricular valve orifice by an artificial patch. The phonocardiogram confirmed a high frequency sound occurring 60-90 ms after aortic valve closure and coinciding with the time of maximal excursion of the atrioventricular valve patch towards the ventricular mass. One patient had coexisting congenital complete heart block. The M mode echocardiogram showed "reversed" motion of the patch towards the right atrium during atrial contraction. Doppler flow studies showed that coincident with this motion there was forward flow in the pulmonary artery with augmentation when atrial contraction coincided with ventricular systole. The early diastolic click in these patients was explained by abrupt cessation of the motion of the atrioventricular valve patch towards the ventricular mass in early diastole. In one patient atrial contraction led to a reversal of this motion and was associated with forward flow in the pulmonary artery.     

Early diastolic clicks after the Fontan procedure for double inlet left ventricle: anatomical and physiological correlates.

M mode echocardiograms and simultaneous phonocardiograms were recorded in four patients with early diastolic clicks on auscultation. All had double inlet left ventricle and had undergone the Fontan procedure with closure of the right atrioventricular valve orifice by an artificial patch. The phonocardiogram confirmed a high frequency sound occurring 60-90 ms after aortic valve closure and coinciding with the time of maximal excursion of the atrioventricular valve patch towards the ventricular mass. One patient had coexisting congenital complete heart block. The M mode echocardiogram showed "reversed" motion of the patch towards the right atrium during atrial contraction. Doppler flow studies showed that coincident with this motion there was forward flow in the pulmonary artery with augmentation when atrial contraction coincided with ventricular systole. The early diastolic click in these patients was explained by abrupt cessation of the motion of the atrioventricular valve patch towards the ventricular mass in early diastole. In one patient atrial contraction led to a reversal of this motion and was associated with forward flow in the pulmonary artery.     

Effect of variation in PQ interval on patterns of atrioventricular valve motion and flow in patients with normal ventricular function

M-mode echocardiography and Doppler ultrasonography were used to study patterns of atrioventricular (AV) valve motion and flow in five patients with complete heart block, normal ventricular function and an implanted dual chamber pacemaker with programmable PQ intervals. Changes in AV valve motion and flow patterns resulting from steady state changes in PQ interval over the range studied (75 to 250 ms) were similar in all patients. Events reflecting AV valve opening and rapid ventricular filling bore a constant temporal relation to the Q wave and were unaffected by changes in PQ interval. Events reflecting atrial contraction occurred progressively earlier in diastole with lengthening of the PQ interval, until superimposition of atrial contraction on rapid ventricular filling at a PQ interval of 250 ms. The duration of mid-diastolic slow ventricular filling and overall diastole, defined with respect to an open valve, decreased with lengthening of the PQ interval. The onset of AV valve closure (A point) bore a constant temporal relation to the P wave, indicating that atrial systole initiated valve closure. However, completion of AV valve closure occurred progressively earlier with respect to the P wave as the PQ interval was decreased. This suggests an increasing contribution of ventricular systole to completion of AV valve closure with decreasing PQ interval. End-diastolic and end-systolic ventricular and atrial dimensions were independent of the PQ interval.     

Contrast echocardiographic features of pulmonary hypertension and regurgitation.

Linear contrast echo configuration on the pulmonary valve M-mode echogram was assessed in 28 patients with pulmonary hypertension, in 10 with pulmonary regurgitation, and in 10 normal subjects. Contrast echo parallel lines filling the total systolic phase of the pulmonary valve were recorded in normal subjects. Contrast echo lines stopping in early systole around the pulmonary valve mid-systolic notch were seen in all the patients with pulmonary hypertension in relation to changes with the pulmonary flow. Contrast echo lines reversing the early diastole and crossing the pulmonary valve echogram during diastole were detected in all the patients with pulmonary regurgitation, consistent with the reversed flow across the valve. The use of contrast echocardiography to diagnose both pulmonary hypertension and regurgitation may provide further useful information, particularly when the orientation and time of appearance of the contrast echo lines are related to the systolic and/or diastolic phases of the pulmonary valve M-mode echogram.     

Diastolic blood flow into the pulmonary artery in carcinoid heart disease

A patient with carcinoid heart disease manifested by mild pulmonary stenosis, severe tricuspid incompetence and mild tricuspid stenosis had unequivocal evidence of blood flow from the right ventricle into the pulmonary artery during ventricular diastole. Simultaneous right ventricular and pulmonary arterial pressure curves demonstrated that right ventricular diastolic pressure exceeded pulmonary arterial pressure during mid-diastole, indicating consistent mid-diastolic opening of the pulmonary valve. This was followed by a parallel increase in right ventricular and pulmonary arterial pressures throughout the rest of diastole. Right heart cineangiograms, obtained with right atrial dye injection, substantiated the pattern of flow from the right ventricle to the pulmonary artery during ventricular diastole. This previously unrecognized phenomenon is probably due to the combined effects of increased right atrial pressure, decreased right ventricular compliance and normal pulmonary arterial pressure.     

Pulmonary venous flow pattern--its relationship to cardiac dynamics. A pulsed Doppler echocardiographic study

We studied the physiology of pulmonary venous flow in 13 normal subjects and five patients with atrial rhythm disorders and atrioventricular conduction disturbances with pulsed Doppler and two-dimensional echocardiography. The left atrium, mitral valve, and pulmonary venous ostia were visualized through the apical four-chamber view. Mitral and pulmonary venous flows were obtained by placing the Doppler sample volume at the appropriate orifice. Pulmonary venous flow was biphasic: a rapid filling wave was observed during systole when the mitral valve was closed; a second wave was observed in diastole during the rapid ventricular filling phase of mitral flow, but was significantly delayed. In patients without atrial contraction (atrial fibrillation and sinoatrial standstill), the initial rapid filling was greatly diminished and only the second diastolic wave appeared to contribute to left atrial filling. In patients with high-grade atrioventricular block, each atrial contraction was followed by a surge in flow from the pulmonary veins. These results are consistent with data obtained from invasive measurements in both dogs and man, and confirm the validity of the use of pulsed Doppler echocardiography in the study of pulmonary venous flow. We suggest that pulmonary venous flow is influenced by dynamic changes in left atrial pressure created by contraction and relaxation of the atrium and ventricle. The initial peak in pulmonary venous flow occurs with atrial relaxation simultaneously with the reduction of left atrial pressure, and the second peak occurs with left ventricular relaxation and rapid transmitral filling of the ventricle.     

Supernormal left ventricular diastolic function in triathletes.

We studied the structural and functional heart adaptations of 52 male triathletes compared with those of 22 active, nonathletic men, by 2-dimensional Doppler echocardiography. Left ventricular diastolic function was evaluated by recording transmitral flow velocities. To exclude the influences of preload, left atrial pressure, and aortic pressure, left ventricular diastolic function was also evaluated by pulsed Doppler tissue imaging. Significant differences in cardiac structure and function were observed between the 2 groups. In the triathletes, the left ventricular diastolic function was completely normal, despite signs of mixed eccentric and concentric left ventricular hypertrophy, and this function was better than that in the control group. We measured 2 aspects of the late passive diastolic filling period in the triathletes: ASEAC value (the amplitude of excursion of the interventricular septal endocardium at the end of left ventricular diastole just after atrial contraction); and the time between onset of the P wave on the electrocardiographic tracing and onset of systolic septal movement on M-mode echocardiography. Pulsed Doppler tissue imaging confirmed these results. The E/A ratios (peak early left ventricular diastolic motion velocity divided by the peak atrial systolic motion velocity), measured by pulsed Doppler tissue imaging, yielded even more evidence for supernormal left ventricular diastolic function in the triathletes. Left ventricular relaxation and filling properties were measured along the longitudinal and transverse axes by pulsed Doppler tissue imaging, which was useful for evaluating left ventricular diastolic function. We determined that triathletes may develop supernormal left ventricular diastolic function with increased diastolic reserves.     

Diastolic opening of the pulmonary valve in a case of cardiomyopathy with restrictive dysfunction. Case report and review of the literature

In a case of cardiomyopathy with restrictive ventricular dysfunction a complete diastolic opening of the pulmonary valve immediately following the atrial contraction could be visualized by echocardiography and at the same time a forward blood flow into the pulmonary artery could be shown by conventional and color Doppler. The velocity of this flow (0.37 m/s) was as high as the maximal velocity of the systolic outflow. As an expression of the unpaired compliance of the right ventricle and a compensatory hyperkinetic right atrium the heart catheterization revealed a high a-wave of 18 mm Hg, which was transmitted into the right ventricle and the pulmonary artery. This produced a short diastolic pressure drop between the right ventricle and pulmonary artery causing an opening of the pulmonary valve which could be shown by echocardiography. In connection with similar cases in the literature the pathophysiology of this phenomenon is discussed.     

Effects of diltiazem on left ventricular diastolic behavior in patients with hypertrophic cardiomyopathy: evaluation with exercise pulsed Doppler echocardiography

To estimate the effects of diltiazem on the left ventricular diastolic abnormalities in patients with hypertrophic cardiomyopathy, transmitral flow velocity during diastole was studied before and immediately after dynamic leg exercise with the pulsed Doppler technique combined with two-dimensional echocardiography. Seventeen patients with hypertrophic cardiomyopathy and 24 apparently healthy men performed bicycle ergometer exercise in the supine position with the target heart rate set at 120 beats/min. The patients with cardiomyopathy were directed to perform the exercise at the same intensity after receiving 30 to 60 mg of diltiazem, three times daily, for 1 or 2 weeks. The pattern of transmitral flow velocity in diastole had two components, one corresponding to the rapid filling phase in early diastole and the other to the atrial contraction phase in late diastole. To assess left ventricular diastolic behavior, the following variables were analyzed: peak velocity in the rapid filling and atrial contraction phases, the ratio of peak velocity in the atrial contraction phase to that in the rapid filling phase, and pressure half-time. The changes in peak velocity in the atrial contraction phase, pressure half-time and the ratio of peak velocity in the atrial contraction phase to that in the rapid filling phase with exercise differed significantly between patients with hypertrophic cardiomyopathy with no medication and control subjects. After diltiazem, the response of these variables to exercise was almost identical in the two groups. These results suggest that diltiazem can lessen the left ventricular diastolic abnormality in patients with hypertrophic cardiomyopathy on dynamic exercise of mild intensity.     

A new use for M-mode echocardiography in detecting left ventricular diastolic dysfunction in coronary artery disease

Regional left ventricular (LV) diastolic function affects the global rate and pattern of LV filling. These changes may be detected by changes in the magnitude and timing of the increase in LV basal diameter during diastole. Because M-mode echocardiography possesses the high temporal and spatial resolution to detect such abnormalities, a group of 8 normal control subjects were compared with a group of 12 patients with coronary artery disease (CAD) to determine differences in the rate and timing of ventricular filling. The CAD patients had lower rates of fast filling expansion than the control subjects. The proportion of LV diastolic expansion during fast filling was lower. During atrial systole the increased rate of LV expansion was not significantly higher in the CAD patients, but the proportion of diastolic expansion occurring with atrial systole was increased. These changes may reflect a decrease in the rate and magnitude of early diastolic filling in the noncompliant ventricle and an increased reliance on active atrial transport. Thus, CAD alters the rate and pattern of LV filling. Changes in LV diameter as measured by M-mode echocardiography may be useful in detecting altered patterns of LV diastolic filling and identifying patients with CAD.     

Venous return and collapse of the right heart in cardiac tamponade

To elucidate the characteristics of venous inflow into the heart in cardiac tamponade, transmitral (TMF), transtricuspid (TTF) and superior vena cava (SVC) flows were examined using pulsed Doppler echocardiography in nine mongrel open-chest dogs. Cardiac tamponade was produced by the slow infusion of warmed normal saline into the pericardial sac. With increment of pericardial infusion, right atrial collapse (RAC) developed followed by right ventricular collapse (RVC). The systemic blood pressure became depressed and the left ventricular end-diastolic diameter decreased, even in the RAC state, indicating that RVC is not of the primary significance for cardiac tamponade. Characteristically, peak velocities of TMF and TTF in early diastole decreased concomitantly with RAC and RVC. Neither early diastolic filling time nor its acceleration time was altered during tamponade. These changes in blood flow were accompanied by decrements of transmural filling pressure and abnormal motion of the right ventricle. In SVC flow, the diastolic wave characteristically disappeared. This change seemed to be a reflection of the decrease in peak velocity of early diastolic filling flow into the right ventricle. That is, impairment of cardiac relaxation during cardiac tamponade is represented as decreased filling flow velocity in early diastole.     

Evaluation of pulmonary venous flow by transesophageal echocardiography in subjects with a normal heart: comparison with transthoracic echocardiography

Nineteen normal subjects and five patients with atrial fibrillation underwent transesophageal and transthoracic echocardiographic studies to evaluate the normal pulmonary venous flow pattern, compare right and left pulmonary venous flow and assess the effect of sample volume location on pulmonary venous flow velocities. Best quality tracings were obtained by transesophageal echocardiography. Anterograde flow during systole and diastole was observed in all patients by both techniques. Reversed flow during atrial contraction was observed with transesophageal echocardiography in 18 of the 19 subjects in normal sinus rhythm, but in only 7 subjects with transthoracic echocardiography. Two forward peaks during ventricular systole were clearly identified in 14 subjects (73%) with transesophageal echocardiography, but in none with the transthoracic technique. The early systolic wave immediately followed the reversed flow during atrial contraction and was strongly related to the timing of atrial contraction (r = 0.78; p less than 0.001), but not to the timing of ventricular contraction, and appeared to be secondary to atrial relaxation. Conversely, the late systolic wave was temporally related to ventricular ejection (r = 0.66; p less than 0.001), peaking 100 ms before the end of the aortic valve closure and was unrelated to atrial contraction time. Quantitatively, significantly higher peak systolic flow velocities were obtained in the left upper pulmonary vein compared with the right upper pulmonary vein (60 +/- 17 vs. 52 +/- 15 cm/s; p less than 0.05) and by transesophageal echocardiography compared with transthoracic studies (60 +/- 17 vs. 50 +/- 14 cm/s; p less than 0.05). Increasing depth of interrogation beyond 1 cm from the vein orifice resulted in a significant decrease in the number of interpretable tracings.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pseudoatrial gallop with atrioventricular block. Demonstration of a possible mechanism by echocardiography

A patient with marked first degree and intermittent second degree atrioventricular block was demonstrated to have an intermittent presystolic filling sound without the usual preceding atrial activity. Echocardiography disclosed late diastolic opening of the mitral valve coincident with the filling sound. When atrial contraction occurred at the onset of diastole, the mitral valve opened early and subsequently closed, thus delaying the normal rapid passive filling phase. On those cycles with presystolic filling sounds, the delayed passive filling phase terminated in presystole. We postulate that this delayed rapid filling phase of the cardiac cycle is the origin of the filling sound in presystole in the absence of the usual accompanying P wave.     

Mitral anulus motion. Relation to pulmonary venous and transmitral flows in normal subjects and in patients with dilated cardiomyopathy

The dynamics between mitral anulus motion, and, thus, motion of the base of the heart, and filling of the left atrium and ventricle were studied by Doppler echocardiography in 12 normal subjects and 28 patients with dilated cardiomyopathy. The normal motion of the mitral anulus is associated with two phases of inflow from the pulmonary veins. The first phase (J) of pulmonary venous inflow occurs during ventricular systole, concomitant with the descent of the mitral anulus toward the ventricular apex, the extent of which is 12.8 +/- 1.4 mm. The end of the descent of the anulus occurs at the cessation of aortic ejection. About 100 msec later, a rapid recoil of the mitral anulus toward the atrium coincides with the onset of transmitral filling. This rapid recoil contributes to the displacement of blood from the atria into the ventricles in early diastole. The second phase (K) of pulmonary venous flow begins in early diastole, with its peak occurring about 50 msec after the peak of transmitral flow. During atrial contraction, the mitral anulus moves slightly (2.4 +/- 0.7 mm) toward the atrium and then returns toward its initial position within 120 msec. This motion coincides with the A wave of transmitral flow. In patients with dilated cardiomyopathy, pulmonary venous flow and mitral anulus motion are markedly altered in comparison with normal subjects. In all patients, motion of the mitral anulus is either reduced or absent.(ABSTRACT TRUNCATED AT 250 WORDS)     

Pulmonary valve echo motion in clinical practice

Examination of the pattern of pulmonary valve echo motion provides useful diagnostic information in a variety of clinical situations. This report describes the normal patterns and variations in pulmonary valve echo motion. It further discusses the applications and limitations of M-mode and cross-sectional echocardiography in detecting obstruction to right ventricular outflow at both the valvular and infundibular level; the wide ranging effects of increases in pulmonary artery pressure on the pulmonary valve echogram; and alterations in right ventricular compliance and volume which may combine to produce diastolic opening of the pulmonary valve. It is emphasized that the thin pliable pulmonary leaflets move in response to local alterations in pressure and flow. The patterns of pulmonary valve echo motion, therefore, although not specific for any particular clinical disorder, may provide valuable, indirect information concerning local pressure and flow characteristics and, as such, may prove extremely helpful when applied to a specific clinical situation.     

超声心动图评价成人房间隔缺损封堵术后心脏结构和功能的变化

目的探讨超声心动图评价成人房间隔缺损(atrial septal defects,ASD)介入封堵术后心脏形态和功能变化。方法经超声心动图和心电图检查确诊为ASD并成功施行ASD封堵术的患者74例,年龄(35.63±12.74)岁,ASD直径为(16.29±5.11)mm。于封堵器堵闭术后24h、1个月、3个月、6个月和12个月进行经胸超声心动图追踪测量主动脉内径、左心室舒张末内径、左心室收缩末内径和右心室前后径,肺动脉内径和肺动脉瓣血流速度,右心房和右心室的上下径、主动脉瓣口血流速度、二尖瓣口血流速度、三尖瓣口血流速度和左心室射血分数,同时测量封堵器的直径和长度,并进行统计学分析。结果术后24h与术前相比,右心房内径、右心室内径、肺动脉内径、三尖瓣口血流速度和肺动脉瓣口血流速度均显著减少(P0.01);左心房内径、左心室内径、主动脉内径、二尖瓣口血流速度和主动脉瓣口血流速度均显著增加(P0.05);左心室射血分数无明显变化。房室大小和血流速度在术后24h内变化明显,在术后1个月后的随访中逐渐趋于稳定。结论封堵器介入封堵ASD,既纠正了解剖畸形,又改善了左心和右心系统的几何结构。     

Doppler echocardiographic demonstration of the differential effects of right ventricular pressure and volume overload on left ventricular geometry and filling.

To compare the effects of isolated right ventricular pressure and volume overload on left ventricular diastolic geometry and filling, 11 patients with primary pulmonary hypertension, 11 patients with severe tricuspid regurgitation due to tricuspid valve resection and 11 normal subjects were studied with use of Doppler echocardiographic techniques. Right ventricular systolic overload in primary pulmonary hypertension resulted in substantial leftward ventricular septal shift that was most marked at end-systole and early diastole and decreased substantially by end-diastole. Right ventricular diastolic overload after tricuspid valve resection resulted in maximal leftward ventricular septal shift at end-diastole sparing end-systole and early diastole. The early diastolic distortion of left ventricular geometry associated with right ventricular pressure overload resulted in prolongation of isovolumetric relaxation of the left ventricle (129 +/- 39 ms) and a reduction in early diastolic filling compared with values in normal subjects. Late diastolic distortion of left ventricular geometry associated with right ventricular volume overload had no influence on the duration of left ventricular isovolumetric relaxation (52 +/- 32 ms) but caused a reduction in the atrial systolic contribution to late diastolic filling of the left ventricle compared with values in normal subjects. In patients with right ventricular pressure overload, 52 +/- 16% of left ventricular filling occurred in early diastole compared with 78 +/- 11% in patients with right ventricular volume overload (p less than 0.001). The differential effects of systolic and diastolic right ventricular overload on the pattern of left ventricular filling appear to be related to the timing of leftward ventricular septal displacement.     

Diastolic ventricular septal motion in atrial septal defect: Analysis of M-mode echocardiograms in 31 patients

Previous echocardiographic studies suggest that diastolic motion of the ventricular septum reflects relative filling of the right and left ventricles. We studied 31 patients with atrial septal defect by M-mode echocardiography. Early diastolic posterior ventricular septal motion (DPSM) occurred in all patients. Measurement of DPSM correlated with pulmonary to systemic flow ratios (Qp:Qs) (r = 0.64, p < 0.001). All 15 patients with DPSM > 5 mm had a Qp:Qs > 2.5:1, whereas only 8 of 16 patients with DPSM < 5 mm had a shunt this large (p < 0.003). DPSM > 5 mm in patients with atrial septal defect is a specific but not sensitive echocardiographic sign of a large left-to-right shunt. Our findings substantiate the hypothesis that diastolic motion of the ventricular septum reflects relative filling of the ventricles.     

Echocardiographic patterns of pulmonary valve motion in valvular pulmonary stenosis

Echocardiographic tracings of the pulmonary valve were examined in 14 patients with isolated pulmonary stenosis, 20 normal subjects, 26 patients with pulmonary hypertension, 10 patients with a left to right shunt and 28 patients with various forms of heart disease other than pulmonary stenosis. Because of the plane of pulmonary valve motion and the angle of the ultrasonic beam, usually the echoes from only one posterior pulmonary leaflet were recorded. In normal patients atrial systole caused slight posterior motion of the pulmonary valve leaflet in late diastole (average 3, range 0 to 7 mm). The degree of valvular motion after atrial systole (the a wave) increased with inspiration. The position of the leaflet at the onset of ventricular systole varied with the depth of the a wave and the length of the P-R interval, but in the normal subjects the leaflet always returned to a base line or closed position at some time during the respiratory cycle. In 10 patients with moderate or severe pulmonary stenosis (gradient 50 to 142 mm Hg) the depth of the a wave increased markedly (average 10, range 8 to 13 mm). In patients with a gradient of more than 65 mm Hg (8 of 10) the leaflet never returned to a base line or closed position before ventricular systole. In three of four patients with mild pulmonary stenosis (gradient less than 50 mm Hg) and all patients with a left to right shunt or heart disease without pulmonary involvement the a wave was within the normal range. In 25 of 26 patients with pulmonary hypertension no a wave was present. In moderate to severe pulmonary stenosis, the exaggerated leaflet motion after atrial systole probably reflects increased right ventricular end-diastolic pressure and force of atrial contraction which, in the face of a normal or reduced pulmonary arterial pressure, produces a positive gradient across the valve in end-diastole.