Electrocardiographic changes and cardiac arrhythmias in patients receiving psychotropic drugs.

Eight patients had cardiac manifestations that were life-threatening in five while taking psychotropic drugs, either phenothiazines or tricyclic antidepressants. Although most patients were receiving several drugs, Mellaril (thioridazine) appeared to be responsible for five cases of ventricular tachycardia, one of which was fatal in a 35 year old woman. Supraventricular tachycardia developed in one patient receiving Thorazine (chlorpromazine). Aventyl (nortriptyline) and Elavil (amitriptyline) each produced left bundle branch block in a 73 year old woman. Electrocardiographic T and U wave abnormalities were present in most patients. The ventricular arrhythmias responded to intravenous administration of lidocaine and to direct current electric shock; ventricular pacing was required in some instances and intravenous administration of propranolol combined with ventricular pacing in one. The tachyarrhythmias generally subsided within 48 hours after administration of the drugs was stopped. Five of the eight patients were 50 years of age or younger; only one clearly had antecedent heart disease. Major cardiac arrhythmias are a potential hazard in patients without heart disease who are receiving customary therapeutic doses of psychotropic drugs. A prospective clinical trial is suggested to quantify the risk of cardiac complications to patients receiving phenothiazines or tricyclic antidepressant drugs.     

Angiographic diagnosis of posterior mitral valve leaflet prolapse

The left ventricular cineangiograms of 22 asymptomatic, apparently healthy male aviators without noninvasive (echocardiographic or auscultatory) evidence of mitral valve prolapse were reviewed and compared with those of 12 men with noninvasive evidence of mild mitral valve prolapse. The maximal protrusion of the posterior mitral valve leaflet superior and posterior to a line perpendicular to the long axis of the left ventricle at end-systole was measured from the right anterior oblique left ventricular cineangiogram by repeated observation of left ventricular inflow. The values were 7.5 +/- 1.6 mm in patients without mitral valve prolapse and 11.2 +/- 3.4 mm in patients with mitral valve prolapse (mean +/- 1 standard deviation). This measurement did not exceed 11 mm in any patient without prolapse. It is concluded that: 1) with meticulous attention to angiographic landmarks of the left ventricular inflow area, the limits of normal systolic posterior mitral leaflet motion can be defined; and 2) systolic motion outside these limits constitutes a quantitative criterion for the angiographic diagnosis of mitral valve prolapse.     

Constrictive pericarditis: New aspects

The current status of constrictive pericarditis is reviewed with regard to its etiology, physical signs, electrocardiographic findings and hemodynamic features. Angiographic aspects are also presented. The role and limitations of M-mode echocardiography in this disease are emphasized. The value of other noninvasive studies such as measurement of systolic time intervals, myocardial scanning and high-speed echocardiography is described. Emphasis is placed on the invasive and noninvasive methods that may be useful in separating restrictive cardiomyopathy from constrictive pericarditis. Methods of treatment, indications for pericardial resection and the current operative results are commented on briefly.     

Abbreviation of systolic time intervals in acute mitral regurgitation: effect of prosthetic mitral valve replacement.

Systolic time intervals were measured in 26 patients with mitral regurgitation (acute in 14 and chronic in 12). In 13 of these patients (7 with acute and 6 with chronic mitral regurgitation) systolic time intervals were also measured after mitral valve replacement. Total electromechanical systole corrected for heart rate (Q-S₂I) was of much shorter duration in the group with acute mitral regurgitation (472 ± 9 msec [mean ± standard error of the mean]) than in the group with chronic mitral regurgitation (516 ± 4.6 msec, P < 0.01). Before operation, the ratio of the preejection period (PEP) to left ventricular ejection time (LVET) and the angiographic ejection fraction did not differ in the groups with acute and chronic mitral regurgitation. The correlation between the $\text{PEP}\text{LVET}$ ratio and ejection fraction was r = ? 0.84, P < 0.01. Two weeks after operation, the $\text{PEP}\text{LVET}$ ratio increased in all patients, but the increase was greater in those with lower preoperative values for this ratio. The mechanism of the early postoperative increase in the $\text{PEP}\text{LVET}$ ratio is not clear, but serial studies performed over 6 months showed a return toward the preoperative value. It is concluded that preoperative systolic time intervals are useful for assessing left ventricular performance in all types of mitral regurgitation, but are especially useful for distinguishing between the acute and chronic varieties.     

Echocardiographic study of right ventricular wall motion in cardiac tamponade

Twenty-one patients had M-mode echocardiographic recordings during cardiac tamponade. Seventeen of 21 had posterior motion of right ventricular endocardium at 0.05 second or longer after opening of the mitral valve. Sixteen of 17 patients with a large pericardial effusion without cardiac tamponade had posterior right ventricular wall motion that ceased at 0.05 second or less after opening of the mitral valve. The finding of early diastolic posterior motion of the right ventricular wall may signify diastolic collapse of the right ventricle and aids the echocardiographic identification of cardiac tamponade.     

Left ventricular response to isometric exercise and its value in predicting the change in ventricular function after mitral valve replacement for mitral regurgitation

Reduced left ventricular (LV) afterload and its effect on the resting ejection fraction may lead to over-estimation of LV function in mitral regurgitation (MR). To evaluate LV function during increased afterload of the heart, an isometric handgrip test was performed during cardiac catheterization in 15 patients with mitral regurgitation (MR group) and in 9 normal subjects (normal group). Twelve months after successful mitral valve replacement (MVR) the patients were recatheterized, and the value of preoperative stress testing in predicting the change in resting ventricular function after surgery was estimated.Isometric exercise caused an increase in end-systolic wall stress, a measure of ventricular afterload, in both the MR group and the control group (p < 0.001). The ejection fraction remained unchanged in the control group, but decreased from 0.58 ± 0.08 to 0.53 ± 0.08 in the MR group (p < 0.001). After MVR, end-systolic wall stress increased significantly (p < 0.001) and the ejection fraction decreased from 0.58 ± 0.05 to 0.51 ± 0.1 (p < 0.05). A positive correlation existed between the change in the ejection fraction during preoperative stress testing and the change in the resting ejection fraction after MVR (r = 0.65, p < 0.01). In 8 patients whose resting ejection fraction was within normal limits (> 0.55) preoperatively, the ejection fraction was depressed (< 0.55) 1 year after surgery. In all but 1 of these patients the isometric exercise revealed the reduced ventricular response to afterload stress preoperatively (decrease of the ejection fraction > 0.03 during exercise). Therefore, the isometric exercise-induced change in LV function appears to predict the influence of MVR on LV function.     

Intermittent mitral regurgitation due to Beall valve dysfunction: analysis of 13 patients with atrial fibrillation

A unique hemodynamic event was noted in long-term survivors of mitral valve replacement with the Beall prosthesis. The event was a result of intermittent valve dysfunction and transvalvular mitral regurgitation (MR). At cycle lengths longer than 0.9 second that were preceded by shorter cycle lengths, 8 of 13 patients with Beall valve prostheses who had chronic atrial fibrillation (AF) intermittently had a marked unexpected decrease in peak left ventricular systolic pressure and a simultaneous increase in left atrial or pulmonary artery wedge "v" wave pressure. This event, which is a result of intermittent, severe MR, occurred more frequently at longer cycle lengths. In all 8 patients with the finding, severe valve disc wear was found at operation; however, 5 of these patients had only trace or 1+ MR on left ventricular angiography. In contrast, the event did not occur in 11 patients in chronic AF with organic MR or non-Beall valve MR, despite an appropriate number of sufficiently long cycles. The absence of the event in 5 Beall valve patients with significantly faster heart rates than in those with the event may in part be a result of its dependence on cycle length. This hemodynamic event, when present in a Beall valve recipient in AF, is an indication for valve replacement, even in the absence of angiographic evidence of severe MR.     

Ventriculographic and hemodynamic features of mitral regurgitation of cardiomyopathic, rheumatic and nonrheumatic etiology

Quantitative angiographic findings were reviewed in 40 patients with significant mitral regurgitation classified into three etiologic groups: group I, primary mitral regurgitation (prolapse, ruptured chordae); group II, mixed stenosis and regurgitation of rheumatic origin; and group III, cardiomyopathic mitral regurgitation. For patients in both groups I and II, left ventricular end-diastolic volume was directly related to regurgitant fraction, and ejection fraction was generally well maintained. In contrast, patients in group III had a depressed ejection fraction (less than 0.40) and end-diastolic volume that was disproportionately increased in relation to the degree of regurgitation. Left ventricular end-diastolic pressure was a poor indicator of severity of regurgitation in all patient groups. There was a significant negative correlation between forward cardiac index and regurgitant fraction. There was significant relation, although with considerable variation, between the normalized V wave and regurgitant fraction. The graphs of chamber size, ejection fraction and hemodynamic measures plotted against the severity of regurgitation in different patient groups provide a perspective for interpreting the findings in individual patients.     

Cardiac biopsy evidence for a cardiomyopathy associated with symptomatic mitral valve prolapse

Right ventricular endomyocardial biopsy was performed in 14 patients with mitral valve prolapse to determine the existence of an associated cardiomyopathic process. All 14 patients had echocardiographic, angiographic or auscultatory evidence of mitral valve prolapse, and all were symptomatic. The group had a high incidence rate of conduction system abnormalities (50 percent) and arrhythmias (64 percent), but only one patient had a significant hemodynamic abnormality. Light microscopy revealed an increase in endocardial and interstitial fibrosis in eight patients (57 percent). Electron microscopy, performed in 11 patients, showed mitochondrial degenerative changes in all 11. Nuclear chromatin clumping, intracell edema and myocyte degeneration were frequently present. It is concluded that endomyocardial and myocardial abnormalities exist in some symptomatic patients with idiopathic mitral valve prolapse.     

The nature and prevalence of the abnormal exercise electrocardiogram in mitral valve prolapse.

The maximal treadmill exercise tests in 43 subjects with mitral valve prolapse were retrospectively examined and compared to those of 24 consecutive patients with abnormal maximal treadmill tests and arteriographic evidence of obstructive coronary artery disease and 21 consecutive patients with abnormal treadmill tests with evidence of neither mitral valve prolapse nor coronary artery disease at catheterization. Twelve of 43 (28%) patients with mitral valve prolapse had greater than 0.1 mv. of flat or downsloping ST depression during or following treadmill exercise. Of these 12 patients, seven (58%) were found to have the pattern of abnormal treadmill test previously described as indicative of “vasoregulatory abnormalities”; four patients satisfied the diagnostic criteria for acoustically silent mitral valve prolapse, and only one had clinical or angiographic evidence of mitral regurgitation. The finding of the “vasoregulatory” pattern of abnormal ECG response was significantly less common in the groups with abnormal treadmill tests and coronary disease and with neither coronary disease nor mitral valve prolapse (p < .0025). We conclude that the finding of an abnormal treadmill test, particularly of the type associated with “vasoregulatory abnormalities,” should lead to the suspicion of mitral valve prolapse, even in the absence of symptoms and typical auscultatory abnormalities.     

Frequency and significance of M-mode echocardiographic evidence of mitral valve prolapse in clinically isolated pure mitral regurgitation: analysis of 65 patients having mitral valve replacement

To assess the reliability of M-mode echocardiographic patterns of mitral valve prolapse (MVP) (echo MVP) in detection of morphologic evidence of MVP (morphologic MVP), operatively excised mitral valves and corresponding M-mode echocardiograms from 65 patients with chronic, severe, isolated, pure mitral regurgitation (MR) were studied. Of the 65 patients, 45 (69%) had echo MVP (either holosystolic or mid-to-late systolic prolapse patterns on preoperative M-mode echograms) and 42 (93%) of them had morphologic MVP; of the 3 without morphologic MVP, 2 had ruptured chordae tendineae from infective endocarditis and 1 had papillary muscle dysfunction from atherosclerotic coronary heart disease. Of the 20 patients without echo MVP, 14 (70%) had no morphologic MVP (9 had papillary muscle dysfunction from coronary heart disease, 4 had infective endocarditis on previous normal valves and 1 had rheumatic heart disease). Of the 48 patients with morphologic MVP, 42 (88%) had echo MVP and most had considerably dilated mitral anulae; the other 6 had ruptured chordae tendineae with less degrees of anular dilatation. Of the 17 patients without morphologic MVP, 3 had echo MVP (coronary artery disease in 1 and infective endocarditis on a previous normal valve in 2); of the 14 with neither echo nor morphologic MVP, 9 had papillary muscle dysfunction from coronary artery disease, 4 had infective endocarditis on previously normal valves and 1 had rheumatic heart disease. The patients with very dilated mitral anuli and leaflet areas generally had holosystolic (hammocking) patterns on echo; the patients with small anuli and leaflet areas usually had mid-to-late systolic (buckling) prolapse patterns.     

Reliability and reproducibility of two dimensional echocardiograph measurement of the stenotic mitral valve orifice area.

A wide angle phased array sector scanner was used to find the optimal method, the reliability and the reproducibility of measuring the mitral valve area with two dimensional echocardiography in patients with rheumatic mitral stenosis. Initial experience with 18 patients revealed that tracing the early diastolic actual black-white interface of the perceived orifice was the most reliable method for drawing the mitral valve orifice area. Good interobserver correlation was obtained when two observers used either method to calculate the mitral valve area (r = 0.93). Similarly good intrastudy reliability was obtained when any one observer applied one measurement method to different diastolic cycles within the same study (r = 0.89). The phased array two dimensional echocardiogram properly differentiated patients with critical mitral stenosis from those with non-critical mitral stenosis, but the correlation between the echocardiographically and the hemodynamically derived mitral valve areas was less good than previously reported (r = 0.83). Imaging a test object with varied known orifice sizes and excised stenotic mitral valves of known orifice size with a phased array and mechanical sector scanner failed to reveal superiority of either instrument. Further testing with a phased array instrument revealed that the perceived orifice was critically dependent on receiver gains settings for any transmitted power level. Receiver gain settings too low led to image dropout, indicating a falsely large orifice. Receiver gain settings too high led to image saturation, indicating a falsely narrowed orifice. Six additional patients with predominant mitral stenosis later underwent imaging with strict attention paid to individual receiver gain settings. Combining the data from these 6 patients with those from the initial 18 patients gave a better correlation between the echocardiographic and hemodynamic calculated mitral valve areas (r = 0.92).Accurate noninvasive measurement of the mitral valve area with two dimensional echocardiography in patients with mitral stenosis appears to depend on use of the proper echocardiographic technique to localize the true commissural edge of the valve in early diastole, the correct instrument settings and the appropriate method for drawing the perceived orifice. The noninvasive measurement of the mitral valve orifice with two dimensional echocardiography in mitral stenosis provides clinically useful data that are reliable and reproducible if these factors are taken into account.     

Systolic and diastolic properties of the human left ventricle during valve replacement for chronic mitral regurgitation

M mode and two dimensional echocardiography were combined with pressure-flow data to analyze systolic mechanics and diastolic compliance in nine patients during valve replacement for chronic mitral regurgitation. Both M mode (six patients) and two dimensional (four patients) echographic analyses revealed large decreases in early postoperative shortening fraction (?24 ± 17 [standard deviation]percent M mode study, p < 0.01; ?30 ± 12 percent two dimensional study, p < 0.02), which were significantly different from small changes observed in control subjects (M mode study, + 7 ± 10 percent, 25 subjects and two dimensional study, ?7 ± 14 percent, 8 subjects). Additional data suggest that left ventricular compliance is increased in chronic mitral regurgitation and that elimination of the low impedance left atrial pathway by valve replacement is associated with a significant increase in wall stress (five patients, p < 0.02) that appears to be responsible for the decreased ejection fraction postoperatively. Analysis of hemodynamic variables other than ejection fraction and rate of circumferential shortening revealed no difference between five postoperative patients with chronic mitral regurgitation and five with coronary artery disease. These results in human subjects confirm predictions from studies in animal models and suggest that unique properties of chronic mitral regurgitation demand special attention when patients with this condition are being evaluated for surgery.     

M-mode echocardiography in constrictive pericarditis

M-mode echocardiograms from 40 patients with proven constrictive pericarditis and 40 subjects without evidence of cardiac disease were reviewed for features previously described in constrictive pericarditis. In this large series, no single feature of the M-mode echocardiogram could be considered diagnostic, although a pattern of normal left ventricular size and systolic function, mild left atrial dilation, flattened diastolic left ventricular posterior wall motion and abnormal septal motion was found in most patients. It is concluded that the M-mode echocardiogram can provide findings suggestive of constrictive pericarditis but must be used in conjunction with hemodynamic and other studies to establish the diagnosis.     

Hemodynamic changes after valve replacement with starr-edwards prostheses

A brief review of the pathophysiology of aortic and mitral valve disease and the hemodynamic results of valve replacement with caged ball prostheses are described. In most patients intracardiac pressures are restored to normal at rest, although there are small pressure gradients across mechanical valves. Severe pulmonary hypertension, if present, usually will regress. With exercise, abnormalities of left atrial pressure or left ventricular function may be found after valve replacement. The causes of failure to achieve hemodynamic improvement with surgery and the late return of congestive failure are discussed.