Left ventricular systolic and diastolic function after two-stage anatomic correction of transposition of the great arteries

Anatomic repair of transposition of the great arteries (TGA) has been developed because of concerns about right ventricular function after atrial repair by the Mustard or the Senning technique. This study assessed left ventricular systolic and diastolic function in three patients after two-stage anatomic repair. Two patients had a ventricular septal defect (one with coarctation), and the third patient had right ventricular dysfunction precluding atrial repair. All had pulmonary artery banding. The mean ages at the time of repair and catheterization were 2.75 and 4.9 years, respectively. The control group included 10 patients with insignificant or no cardiac disease. At cardiac catheterization the group with TGA had a higher mean end-diastolic volume index (110.9 +/- 4.74 ml/m2) compared to normal subjects (79.1 +/- 14.55; p less than 0.001), mean end-systolic volume index (37.3 +/- 3.69 vs 22.7 +/- 4.42; p less than 0.001), mass index (101.0 +/- 16.9 vs 68.2 +/- 12.34; p = 0.038), and stroke volume index (73.6 +/- 3.52 vs 56.5 +/- 12.1; p = 0.0027). The ejection fractions, end-diastolic and peak systolic pressures, and stresses were not different. There was no difference in the relationship between the mean rate-corrected velocity of circumferential fiber shortening and end-systolic stress for the group with TGA, but myocardial stiffness was markedly elevated (29.5 +/- 1.84 vs 10.8 +/- 2.20; p less than 0.001). Thus, this study found abnormalities of left ventricular size after two-stage anatomic repair of TGA in this group of patients with TGA.(ABSTRACT TRUNCATED AT 250 WORDS)     

Assessment of left ventricular function in secundum atrial septal defect by computer analysis of the M-mode echocardiogram.

Left ventricular function in 53 patients with secundum atrial septal defect was assessed by computer-assisted analysis of the left ventricular echocardiogram and by cardiac catheterization. The patients were divided into two groups, those younger and those older than 60 years, to investigate the effect of aging on left ventricular function. Cavity size was significantly smaller than normal (p less than 0.01) and septal motion was abnormal in 86%, but values for cardiac index, left ventricular end-diastolic pressure, velocity of circumferential fiber shortening, left ventricular filling rate, and duration of rapid filling were normal in both groups. Regional dynamics assessed in terms of peak rates of systolic thickening and diastolic thinning of the septum and posterior wall were also normal in both groups. We concluded that, although left ventricular minor dimensions are small, and septal motion is reversed in the majority of patients with atrial septal defect, left ventricular function is normal, and it does not appear to deteriorate with increased age, pulmonary hypertension, or the presence of right ventricular failure. The abnormal septal motion appears to be compensated for by enhanced septal and posterior wall percentage thickening.     

Left ventricular distensibility and passive elastic stiffness in atrial septal defect

Diminished left ventricular distensibility has been postulated as a cause of left ventricular failure in atrial septal defect. To evaluate this hypothesis the indexes of left ventricular compliance and stiffness were estimated in 15 patients with atrial septal defect and the results compared with those in 10 normal subjects. Age, peak left ventricular systolic pressure, end-diastolic pressure, ejection fraction and cardiac index did not differ significantly between groups. Left ventricular end-diastolic volume for the atrial septal defect group was significantly less than that for the control group (mean +/- SD, 61 +/- 9 ml/m2 versus 73 +/- 13, p less than 0.05) in keeping with previous studies. The slope of the log pressure-volume relation was significantly greater in the group with atrial septal defect than in the normal group (0.056 +/- 0.010 versus 0.044 +/- 0.008, p less than 0.01), consistent with increased chamber stiffness. For a group of six patients with atrial septal defect and elevated left ventricular end-diastolic pressure, normalized compliance was significantly less than that in the control group (0.017 +/- 0.001 versus 0.036 +/- 0.007, p less than 0.02). The slope k of the elastic stiffness-stress relation for the total group with atrial septal defect was significantly greater than that of the normal group (21.0 +/- 2.3 versus 18.1 +/- 2.3, p less than 0.01). An index of muscle fiber stretch (dV/VdP x end-diastolic stress x 100) was significantly less in the atrial septal defect group than in the control group (74 +/- 24 versus 106 +/- 22, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Normal left ventricular systolic function in adults with atrial septal defect and left heart failure

Systolic left ventricular contractile function has not been extensively evaluated in patients with atrial septal defect who have symptoms of left-sided congestive heart failure. This study examined left ventricular systolic function hemodynamically and angiographically in 6 such adult patients (Group A), 12 adult patients with atrial septal defect without heart failure (Group B) and 20 normal subjects. The mean (± standard error of the mean) left ventricular end-diastolic pressure was higher in patients in Group A (17 ± 0.8 mm Hg) than in patients in group B (6.9 ± 0.6 mm Hg) (p < 0.001). Both right atrial pressure (11 ± 1.3 versus 4.9 ± 0.5 mm Hg) (p < 0.001) and mean pulmonary arterial pressure (30 ± 1.8 versus 15 ± 1 mm Hg) were also higher in Group A than in Group B. Left ventricular cardiac index and stroke work index did not differ in the two groups.

Variables of left ventricular systolic function were similar in both groups of patients and in normal subjects: Ejection fraction was 0.71 ± 0.05 in Group A, 0.74 ± 0.02 in Group B and 0.74 ± 0.01 in normal subjects. Velocity of circumferential shortening was 1.38 ± 0.14 circumferences/s in Group A, 1.38 ± 0.07 circumferences/s in Group B and 1.27 ± 0.04 circumferences/s in normal subjects. There was no difference in left ventricular contractile function as indicated by the ratio of end-systolic wall stress to end-systolic volume index among the three groups: normal subjects, average 5.6 ± 0.19 versus 6.1 ± 0.5 in Group B and 6.0 ± 0.6 dynes × 10³/cm²/(ml/m²) in Group A.

This study of patients with atrial septal defect and left heart failure indicates that abnormal left ventricular systolic contractile function is probably not the cause of the symptoms and elevated left heart filling pressures observed in this group. An abnormality in left ventricular diastolic filling, perhaps related to the volume loaded right ventricle, may explain these changes.     

Assessment of left-to-right shunt and left ventricular function in isolated ventricular septal defect. Echocardiographic study.

This echocardiographic study was designed to assess left ventricular function and pulmonary blood flow in ventricular septal defect. Fifty-one patients aged 2 weeks to 21 years were investigated (group 2). Five of 10 operated patients were studied one week after surgical closure of the defect (group 3) and seven 3 to 6 weeks postoperatively (group 4). The control group consisted of 45 normal subjects aged 2 weeks to 21 (group 1). Left atrium/aortic root dimension ratio (LA/Ao) was used to express the pulmonary systemic flow ratio. Left ventricular chamber size was assessed by measurement of left ventricular end-diastolic dimension and volume. The left ventricular mass and the ratio of end-diastolic volume to left ventricular mass were determined to relate the degree of left ventricular hypertrophy to volume overload. Myocardial function was evaluated using ejection phase indices. Ventricular septal thickness, posterior wall thickness, and echocardiographic patterns of septal motion were also studied. The left atrium/aortic root dimension, end-diastolic volume, and left ventricular mass were significantly greater in group 2 patients (P less than 0.05) than in the normal controls. There was a very good correlation between LA/Ao and pulmonary/systemic flow ratio (r = 0.83). Eleven of the group 2 patients showed asymmetric septal hypertrophy (unrelated to shunt size) but left ventricular function as assessed by ejection phase indices appeared unimpaired. Immediately after operation (group 3) there was a deterioration in left ventricular function in 5 patients as shown by reduced ejection fraction, mean velocity of circumferential shortening, and relative changes in minor axis with systole. Septal motion was impaired but returned to normal in 3 to 6 weeks in 7 patients (group 4). Left atrial/aortic root dimension, end-diastolic volume, and left ventricular mass decreased significantly immediately after operation (group 3) but were still raised at 3 to 6 weeks (group 4).     

Assessment of left-to-right shunt and left ventricular function in isolated ventricular septal defect. Echocardiographic study.

This echocardiographic study was designed to assess left ventricular function and pulmonary blood flow in ventricular septal defect. Fifty-one patients aged 2 weeks to 21 years were investigated (group 2). Five of 10 operated patients were studied one week after surgical closure of the defect (group 3) and seven 3 to 6 weeks postoperatively (group 4). The control group consisted of 45 normal subjects aged 2 weeks to 21 (group 1). Left atrium/aortic root dimension ratio (LA/Ao) was used to express the pulmonary systemic flow ratio. Left ventricular chamber size was assessed by measurement of left ventricular end-diastolic dimension and volume. The left ventricular mass and the ratio of end-diastolic volume to left ventricular mass were determined to relate the degree of left ventricular hypertrophy to volume overload. Myocardial function was evaluated using ejection phase indices. Ventricular septal thickness, posterior wall thickness, and echocardiographic patterns of septal motion were also studied. The left atrium/aortic root dimension, end-diastolic volume, and left ventricular mass were significantly greater in group 2 patients (P less than 0.05) than in the normal controls. There was a very good correlation between LA/Ao and pulmonary/systemic flow ratio (r = 0.83). Eleven of the group 2 patients showed asymmetric septal hypertrophy (unrelated to shunt size) but left ventricular function as assessed by ejection phase indices appeared unimpaired. Immediately after operation (group 3) there was a deterioration in left ventricular function in 5 patients as shown by reduced ejection fraction, mean velocity of circumferential shortening, and relative changes in minor axis with systole. Septal motion was impaired but returned to normal in 3 to 6 weeks in 7 patients (group 4). Left atrial/aortic root dimension, end-diastolic volume, and left ventricular mass decreased significantly immediately after operation (group 3) but were still raised at 3 to 6 weeks (group 4).     

Comparative response of right and left ventricles to volume overload.

The cardiac volume data of 49 normal children were compared with those of 23 with secundum atrial septal defect and 24 with patent ductus arteriosus. Significantly smaller ventricular end-diastolic volumes were observed in the normal infants than in older children (right ventricle 53.9 versus 75.5 cm3/m2; left ventricle 46.7 versus 63.6 cm3/m2). "Distensibility" of the right ventricle (DRV), left ventricle (DLV) and left atrium increased normally with age. DRV and DLV were similar shortly after birth; thereafter, DRV increased more rapidly than DLV (mean DRV 12.7; mean DLV 7.8 cm3/m2 per mm Hg, P less than 0.001). In both atrial septal defect and patent ductus arteriosus, the ipsilateral (involved) ventricles had increased volume, increased output, normal ejection fraction and increased distensibility. The contralateral (left) ventricle in atrial septal defect was smaller than normal (39.6 versus 49.7 cm3, P less than 0.001), and had a smaller ejection fraction (0.63 versus 0.71, P less than 0.01) and output (3.70 versus 4.57 liters/min per m2, P less than 0.005). In contrast, the contralateral (right) ventricle in patent ductus arteriosus remained normal. Left atrial maximal volume was larger than normal in atrial septal defect (46.6 versus 35.9 cm3/m2, P less than 0.001). The left atrial and left ventricular volumes in patent ductus arteriosus were, respectively, 152 and 142 percent of normal, indicating comparable response to the volume load. The left head changes in atrial septal defect may be related both to a functionally restrictive defect and to the difference in distensibility of the ventricles.     

Apparent reduction of aortic and left heart chamber size in atrial septal defect

Although it is widely held that the size of the aorta and left atrium is diminished in patients with atrial septal defect, few data are available to support this contention. Therefore, aortic and left heart chamber dimensions in 24 patients with documentation of an atrial septal defect at cardiac catheterization were compared with those of 22 normal persons. The data were obtained using echocardiography, cineangiography and qualitative estimation of aortic size from chest X-ray films. Aortic size was similar in the patients with an atrial septal defect and normal subjects (1.7 cm/m² for both groups on angiography). Although the aortic diameter was estimated to be small in 12 of the 24 patients with an atrial defect on chest X-ray films, no difference existed in aortic measurements on echocardiography or angiography in patients judged to have normal as opposed to those judged to have reduced aortic size. Although the left atrial echographic dimension tended to be slightly greater in the patient group than in normal subjects (2.2 versus 1.9 cm/m²), this difference was not statistically significant. The echographic ratio of left atrial to aortic size was greater in the patient group (1.3 versus 1.1) (P < 0.02). Stroke index was similar in the two groups (37.5 versus 42.8 ml/m² with the dye-dilution technique and 35.1 versus 36.3 ml/m² on angiography). Although echocardiographic left ventricular diastolic dimension was slightly smaller in the patient group than in normal subjects (2.5 versus 3.0 cm/m²) (P < 0.02), diastolic volume index on angiography was similar in the two groups (50.1 versus 52.9 ml/m²). Thus, these data do not support the conventional belief that, because of a reduced stroke volume, the size of the aorta and left atrium is diminished in patients with an atrial septal defect.     

Radionuclide analysis of right and left ventricular response to exercise in patients with atrial and ventricular septal defects

In patients with ventricular or atrial septal defect, the ventricle which is chronically volume overloaded might not appropriately respond to increased demand for an augmentation in output and thereby might limit total cardiac function. In this study we simultaneously measured right and left ventricular response to exercise in 10 normal individuals, 10 patients with ventricular septal defect (VSD), and 10 patients with atrial septal defect (ASD). The normal subjects increased both right and left ventricular ejection fraction, end-diastolic volume, and stroke volume to achieve a higher cardiac output during exercise. Patients with VSD failed to increase right ventricular ejection fraction, but increased right ventricular end-diastolic volume and stroke volume. Left ventricular end-diastolic volume did not increase in these patients but ejection fraction, stroke volume, and forward left ventricular output achieved during exercise were comparable to the response observed in healthy subjects. In the patients with ASD, no rest-to-exercise change occurred in either right ventricular ejection fraction, end-diastolic volume, or stroke volume. In addition, left ventricular end-diastolic volume failed to increase, and despite an increase in ejection fraction, left ventricular stroke volume remained unchanged from rest to exercise. Therefore, cardiac output was augmented only by the heart rate increase in these patients. Right ventricular function appeared to be the major determinant of total cardiac output during exercise in patients with cardiac septal defects and left-to-right shunt.     

Effects of reduced left ventricular mass on chamber architecture, load, and function: a study of anorexia nervosa

We investigated the effects of reduction in left ventricular mass on cavity geometry, afterload, pump function, and exercise performance in 17 patients with anorexia nervosa and in 10 age-and sex-matched normal subjects. Left ventricular mass index determined by two-dimensional echo-cardiography was significantly lower than that in normal subjects (53 +/- 15 vs 79 +/- 18 g/m2; p less than .005). Left ventricular end-diastolic and end-systolic volume indexes were also reduced in patients with anorexia nervosa compared with normal subjects (49 +/- 11 vs 65 +/- 17 ml/m2, p less than .005; 14 +/- 5 vs 19 +/- 4 ml/m2, p less than .025). In spite of the reductions in left ventricular mass and volume indexes, left ventricular chamber architecture described as h/R ratio, mass to volume ratio, and short/long left ventricular axis ratio were normal. Left ventricular afterload assessed as end-systolic meridional and circumferential wall stress was normal (59 +/- 18 vs 79 +/- 19 dyne/cm2 X 10(3) and 170 +/- 26 vs 167 +/- 23 dyne/cm2 X 10(3)). Ejection fraction, percent fractional shortening, and the relationship between end-systolic wall stress and ejection fraction were all within normal limits. In seven patients restudied after a 15% to 20% weight gain, left ventricular mass and volume indexes increased significantly but end-systolic wall stress and ejection fraction did not change. Ten patients with anorexia nervosa and resting heart rates and systolic blood pressures significantly lower than control values underwent treadmill testing. Exercise duration, peak heart rate, peak systolic blood pressure, and peak oxygen consumption in these patients were all significantly lower than normal. The hypotensive effect of fasting resulted in an initial decrease in afterload, which was the stimulus for reduction in left ventricular mass. The left ventricular remodeling associated with the mass reduction occurred in such a way that (1) orthogonal, meridional, and circumferential wall stresses were normalized, (2) normal chamber shape and architecture were maintained, and (3) chamber function and stress-shortening relationships were preserved. Thus down-regulation of left ventricular mass per se, like up-regulation of left ventricular mass, is not associated with abnormal left ventricular function.     

Determinants of ventricular septal motion. Influence of relative right and left ventricular size.

To test the hypothesis that the ventricular septum moves during systole toward the center of the ventricular mass (so that the end-diastolic position of the septum within the heart should determine both the direction and the magnitude of septal motion during systole), echocardiograms from patients with several different hemodynamic burdens were analyzed. A linear relation was noted between the end-diastolic intracardiac position of the ventricular septum and the direction and magnitude of systolic septal motion in 1) forty three patients with an atrial septal defect )regression coefficient r = 0.80), 2) fourteen patients with other causes of right ventricular volume overload (r = 0.82), 3) nineteen patients with left ventricular volume overload (r = 0.74), 4) ten patients with right ventricular pressure overload (r = 0.93), 5) ten patients with left ventricular pressure overload (r = 0.80), 6) twenty-eight normal subjects (r = 0.82). We conclude that, in the presence of normal ventricular activation and contraction, the direction and magnitude of sepatal motion during systole is determined by the intracardiac position of the septum at enddiastole.     

Correlation between interventricular septal motion and left ventricular systolic-diastolic function in patients with left bundle branch block

The echocardiographic correlation between abnormal interventricular septal motion including systolic paradoxical, flat motion and early diastolic notch and ejection fraction, mean ventricular circumferential fiber shortening and early diastolic mitral filling velocity was studied in 46 patients with complete left bundle branch block. Systolic normal interventricular septal motion was used as the control. Ejection fraction was significantly smaller in the paradoxical(0.44 +/- 0.13, p < 0.02) and flat motion groups(0.38 +/- 0.09, p < 0.001) than in the normal group(0.54 +/- 0.1). Mean ventricular circumferential fiber shortening was significantly smaller in the flat motion group than in the normal group(0.72 +/- 0.19 vs 0.99 +/- 0.23 circ/sec, p < 0.002). The size of the notch was significantly smaller in the flat motion group than in the normal group (2.3 +/- 0.2 vs 4.8 +/- 0.8 mm, p < 0.0001). The deceleration rate of the notch was significantly slower in the paradoxical and flat motion groups than in the normal group(37.3 +/- 12.2, 31.3 +/- 8.1 vs 69.1 +/- 2.5 cm/sec, p < 0.0001). Early diastolic mitral filling velocity was slower in the flat motion group than in the other 2 groups. In conclusion, systolic flat interventricular septal motion showed more severe disturbances of left ventricular systolic and diastolic function than paradoxical interventricular septal motion in patients with complete left bundle branch block.     

Left ventricular performance in patients with coexistent mitral stenosis and aortic insufficiency

Isolated mitral stenosis and isolated aortic insufficiency impose unique and opposite loading conditions on the left ventricle. To assess these combined effects, hemodynamic and angiographic factors were compared among normal subjects and patients with isolated mitral stenosis, isolated aortic insufficiency or combined mitral stenosis and aortic insufficiency. Left ventricular end-diastolic volume index was lower in patients with combined lesions and severe or moderate aortic insufficiency than in patients with isolated severe or moderate aortic insufficiency (138 +/- 19 versus 206 +/- 20 cc/m2 and 87 +/- 5 versus 145 +/- 22 cc/m2, respectively) (p less than 0.05 for both). Left ventricular end-diastolic and end-systolic volume indexes were normal in two-thirds of patients with combined lesions and moderate or severe aortic insufficiency, whereas these indexes were high in all but one patient with isolated moderate or severe aortic insufficiency. Among patients with moderate or severe aortic insufficiency, 8 of 14 with isolated insufficiency had a reduced ejection fraction or circumferential fiber shortening rate compared with 5 of the 9 patients with combined lesions. Among patients with isolated aortic insufficiency, left ventricular end-systolic wall stress and end-diastolic and end-systolic volume indexes were higher (p less than 0.05) in those with reduced ejection performance than in those with normal ejection performance. These variables did not differ between patients with reduced or normal ejection performance in the group with combined lesions. The contractile index (ratio of end-systolic wall stress to end-systolic volume index) was significantly depressed in patients with severe aortic insufficiency in the groups with isolated aortic insufficiency or combined lesions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Relation of symptoms to contractility and defect size in infants with ventricular septal defect

Forty-two infants with a ventricular septal defect (VSD) (21 asymptomatic and 21 symptomatic) were compared with 17 control infants to determine if symptoms of congestive heart failure (i.e., tachypnea/poor growth) were due to depressed contractility or defect size, or both. Echocardiographic indexes of defect size, left ventricular performance (shortening fraction), preload (left ventricular end-diastolic dimension), afterload (left ventricular end-systolic wall stress) and contractility (the relation between velocity of circumferential fiber shortening and wall stress) were measured. Clinical assessment included measurement of weight and respiratory rate. Pulmonary and systemic blood flow were assessed in 17 symptomatic and 3 asymptomatic patients by cardiac catheterization. Although there was no significant difference in age, the symptomatic group had significantly lower weight (5.5 +/- 2.9 vs 7.3 +/- 2.3 kg, p less than 0.05) and a higher respiratory rate (53 +/- 14 vs 43 +/- 6 breaths/min, p less than 0.05), compared with control subjects. The mean pulmonary to systemic blood flow ratio in the symptomatic group was 2.9:1. Preload indexed for body surface area was significantly higher in the groups with a VSD compared with control subjects (asymptomatic, 8.5 +/- 1.7 cm/m2; symptomatic, 9.1 +/- 1.7 cm/m2; control subjects, 6.8 +/- 1.1 cm/m2; p less than 0.05). Shortening fraction, afterload and contractility were not significantly different among all groups. A defect size greater than 0.5 cm (or defect size indexed for body surface area greater than 1.8 cm/m2) was predictive of the presence of symptoms. It is concluded that contractility is normal in infants with a VSD. Symptoms may be related to pulmonary congestion.(ABSTRACT TRUNCATED AT 250 WORDS)     

Left atrial transport function in myocardial infarction. Importance of its booster pump function.

After myocardial infarction (MI), left ventricular (LV) end-diastolic pressure (EDP) is higher than mean pulmonary artery wedge pressure because of powerful atrial contraction. To evaluate the significane of atrial contraction to left ventricular function we studied 10 control (C) patients without cardiac disease and 17 patients from three to six weeks after acute myocardial infarction. Cardiac catheterization with simultaneous left ventricular diastolic pressure (DP) and left ventricular cineangiograms were obtained. Left ventricular volumes and pressure were (mean +/- SD): (SEE ARTICLE). Although left ventricular stroke volume was lower in the patients with myocardial infarction than in the control subjects (46 versus 56 ml/m2), atrial contraction contributed more to left ventricular filling during diastole (which is the same as left ventricular stroke volume) in the patients with myocardial infarction than in the controls (16 versus 10 ml/m2). The average atrial contribution to left ventricular end-diastolic volume was 11.9 per cent (C), 15.4 per cent (MI); to left ventricular end-diastolic pressure 20 per cent (C), 38.7 per cent (MI); and to left ventricular stroke volume 21.7 per cent (C), 35.1 per cent (MI). Atrial contribution to left ventricular stroke volume was 56 per cent in patients with a cardiac index less than or equal to 2.0 liters/min/m2 and 31 per cent in those with a cardiac index greater than 2 liters/min/m2 (p less than 0.01). Atrial contraction contributed 35 per cent to left ventricular stroke volume in patients with normal end-diastolic volume and in those with increased end-diastolic volume and 10 per cent to end-diastolic volume in patients with increased end-diastolic volume (p less than 0.001). In patients with myocardial infarction, atrial contraction made a large contribution to left ventricular filling and stroke volume irrespective of the type of left ventricular functional derangement that was present. The "booster pump" function of the atrium cannot be ignored in assessing left ventricular performance.     

"Ventricular function curve" from a single diagnostic left ventriculogram: technique, results and value

A programmable atrial pacemaker was used to vary sequential left ventricular end-dlastolic volumes. Left ventricular stroke volume and end-diastolic volume were used to construct a left ventricular “function curve”. Four successive beats from one diagnostic left ventricular angiogram were analyzed—a beat during atrial pacing at 5 to 10 beats faster than sinus rate, an atrial extrastimulus beat in the sinus nodal reset zone, a postextrastimulus beat and a sinus beat.Excluding measurements in postextrastimulus beats, left ventricular stroke volume decreased from 124 to 59 cc (P < 0.001) and ejection fraction from 0.67 to 0.52 (P < 0.001) as end-dlastolic volume decreased from 188 to 123 ce (P < 0.001). Mean rate of circumferential fiber shortening was independent of end-diastolic volume but was greater for postextrastimulus beats (1.54 circumferences/sec) than for sinus beats (1.28 circumferences/sec) (P < 0.001). Among six patients with increased left ventricular end-dlastolic volume (greater than 110 cc/m²), ejection fraction was abnormal (less than 0.54) in only one patient at increased end-diastolic volume but in three patients at reduced end-diastolic volume, despite a reduced afterload. However, in seven patients with a normal mean rate of circumferential fiber shortening, ejection fraction was normal at both increased and reduced end-diastolic volumes.This technique is safe and easy to use in man. This study demonstrates that ejection fraction is dependent on end-dlastolic volume with rapid changes of R-R interval. Therefore, both ejection fraction and end-diastolic volume should be measured when ejection fraction is used as an index of left ventricular performance, particularly if ejection fractions obtained from different angiograms are being compared.     

Left ventricule function and sickle-cell anemia. Echocardiographic study

The dimensions of the cardiac chambers and left ventricular function were studied by echocardiography in 40 patients with homozygous sickle cell disease (SS) and 25 patients with heterozygous sickle cell trait (12 AS, 10 SC, 3 BS) and compared with the same parameters in 30 normal subjects. Patients with homozygous SS disease had significantly larger left atrial (32.2 +/- 6.47 mm vs 26.62 +/- 5.64 mm; p less than 0.001), left ventricular (46.4 +/- 8.49 mm vs 39.97 +/- 5.29 mm; p less than 0.001) and right ventricular (17.95 +/- 5.08 mm vs 15.5 +/- 3.17 mm; p less than 0.02) dimensions: they also had higher indexed myocardial surfaces (11.48 +/- 2.36 cm2/m2 vs 8.21 +/- 1.97 cm2/m2; p less than 0.001) and indexed end diastolic left ventricular volumes (101.84 +/- 22.74 ml/m2 vs 65.05 +/- 10.81 ml/m2; p less than 0.001), a higher cardiac index (4.77 +/- 1.33 l/mn/m2 vs 3.58 +/- 1.08 l/mn/m2; p less than 0.001) and stroke volume (71.77 +/- 32.86 ml vs 49.56 +/- 13.39 ml; p less than 0.001). Peripheral resistances were significantly lower (1341 +/- 469 vs 1626 +/- 368 dynes/s/cm-5; p less than 0.01) as were the velocities of circumferential fibre shortening (VCF) (1.11 +/- 0.20 circ/s vs 1.28 +/- 0.24 circ/s; p less than 0.01). Two thirds of homozygous SS disease patients (27/40) had appearances of an anaemic heart with eccentric left ventricular hypertrophy, normal left ventricular systolic function, an increased cardiac index (5.01 +/- 1.19 l/mn/m2) and low peripheral arterial resistances.(ABSTRACT TRUNCATED AT 250 WORDS)     

Quantitative evaluation of left ventricular systolic function using bidimensional echocardiography: comparison with cineangiography

The aim of the study was to compare the evaluation of the left ventricular systolic function performed both by angiography and 2D-echocardiography on 80 subjects (31 with coronary artery disease, 18 with left ventricular volume overload, 10 with left ventricular pressure overload, 14 with mitral valve disease and 7 normal controls). The 2D-echocardiograms of the left ventricle with simultaneous measurement of the right arm systolic blood pressure was performed within 24 hours of the angiographic examination. The following parameters were obtained using the two methods: end-diastolic volume index, end-systolic volume index, ejection fraction, left ventricular mass index, mass/volume ratio, end-systolic circumferential stress, contractility expressed as end-systolic circumferential stress/end-systolic volume ratio; the end-systolic circumferential stress/ejection fraction ratio was calculated only by 2D-echocardiography. The afterload and contractility were not calculated in subjects with coronary artery disease and left ventricular outflow gradient. No statistically significant differences were shown between the two methods, except a slight under-estimation by echocardiography of the angiographic end-diastolic volume index (93.1 +/- 38.9 ml/m2 vs 115 +/- 39.9 ml/m2; p less than 0.01) and over-estimation of the mass/volume ratio (1.38 +/- 0.33 g/ml vs 1.2 +/- 0.44 g/ml; p less than 0.01) was shown between the two methods for all parameters. A depressed contractile state was also demonstrated by the end-systolic circumferential stress/ejection fraction ratio. The inter and intraobserver variability was 6.6 +/- 4.4% (range 0.16%) and 4.2 +/- 3% (range 1.11%) respectively.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evaluation of left ventricular function in patients with sickle cell anemia

The echocardiographic measurements of cardiac chamber dimension, ejection phase indices of left ventricular function and the systolic time intervals of 23 adult patients with sickle cell anemia were compared to those of normal control subjects. Patients with sickle cell anemia had a significantly greater mean left ventricular systolic dimension index, left ventricular diastolic dimension index, left ventricular mass, stroke volume index, interventricular septal width, aortic root index and left atrial index. No significant differences were noted between the mean velocity of circumferential fiber shortening, ejection fraction or systolic time intervals. The anemic population was divided into two groups; one consisting of patients less than 30 years old and the other of patients over 30 years old. There were no significant differences between the ventricular dimensions, velocity of circumferential fiber shortening, ejection fraction and systolic time intervals of the two groups. These data indicate that the chronic volume overload of sickle cell anemia is well tolerated without development of left ventricular dysfunction.     

Contraction of the interventricular septum in right ventricular overload studied by two-dimensional echocardiography

This study clarified the relationship between right ventricular (RV) overload and contraction of the interventricular septum using two-dimensional echocardiography. Seventeen patients with atrial septal defect (RV systolic pressure: 36 +/- 14 mmHg), 13 with mitral stenosis (49 +/- 19 mmHg), nine with primary pulmonary hypertension (87 +/- 21 mmHg) and 17 normal subjects (23 +/- 3 mmHg) were evaluated using two-dimensional echocardiography and cardiac catheterization. The circumferential lengths of the septum (Civs) and the left ventricular (LV) free wall (Cfw) were measured in the LV short-axis view at the level of the papillary muscles. In normal subjects, Civs was 3.4 +/- 0.5 cm and Civs/Cfw was 0.40 +/- 0.07. All patients with RV overload had longer Civs and greater Civs/Cfw as compared with the normal subjects. There was no significant difference in the Cfw among the cases with mitral stenosis and primary pulmonary hypertension and the normal subjects. Cfw in atrial septal defect was shorter than in the normal subjects. The percent contraction of Civs was decreased in mitral stenosis and primary pulmonary hypertension as compared with the normal subjects. No significant difference was found in the percent contraction of Civs between the normal subjects and the 11 patients with atrial septal defect with normal RV systolic pressure. However, in six patients with atrial septal defect with high RV systolic pressure, the percent contraction of Civs was decreased. There was an inverse correlation between RV systolic pressure and the percent contraction of Civs (r = -0.39, p less than 0.01), and RV ejection fraction (r = -0.52, p less than 0.01) defined by multiplegated equilibrium scintigraphy.(ABSTRACT TRUNCATED AT 250 WORDS)