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PubMed1978

Origin of the basal systolic murmurs in mitral stenosis. A study with intracardiac phonocardiography.

In order to study the origin of the basal systolic murmurs in mitral stenosis, left and right heart catheterization was performed in 18 patients with mitral stenosis using intracardiac phonocardiography. Our data revealed that the basal systolic murmurs originated in the aorta, the pulmonary artery, and the outflow tract of the right ventricle. In 14 cases, we noted the maximal ejection systolic murmur in the aorta near the aortic valve. However, in two cases, there was a loud systolic murmur in the pulmonary artery. These murmurs occurred in early to mild-systole and were crescendo-decrescendo in configuration. The pitch of the murmur ranged from low to medium frequency in the majority of cases. They are produced by the turbulence of blood flow in the aorta and the pulmonary artery. A late systolic murmur was also recorded in the outflow tract of the right ventricle in two patients. This is thought to occur due to functional or relative infundibular stenosis of the right ventricle. It differs in location and timing from those in the aorta and the pulmonary artery. The outflow tract of the right ventricle is regarded as the third origin of the basal systolic murmur in mitral stenosis.

Adult↗

PubMed1988

Early partial systolic closure of the pulmonic valve relates to severity of pulmonary hypertension.

Ultrasound studies in pulmonary hypertension often show systolic partial closure of the pulmonic valve and early peaking of Doppler pulmonary flow velocity, but these findings are poorly understood. Our initial observations of earlier systolic partial closure with higher pulmonary pressures suggested that this phenomenon might relate to pressure. In 30 patients with documented pulmonary hypertension, the timing of systolic partial closure and the corresponding decrease in Doppler flow velocity related inversely to pulmonary artery pressure at catheterization. Peak flow preceded the systolic velocity decrease and also related inversely to pressure. Since changing flow velocity might reflect a changing driving force across the valve, we examined simultaneous high-fidelity catheter pressure tracings from the right ventricle and pulmonary artery from 24 patients with and without pulmonary hypertension. In 30 studies, a positive right ventricular to pulmonary artery pressure gradient was present early in systole, but the gradient decreased to a minimum value in mid-to-late systole. The timing of this minimum also related inversely to pressure. We conjectured that forces opposing ejection occur earlier in pulmonary hypertension, thereby decreasing the forward driving force and allowing earlier partial systolic closure.

Adult↗

PubMed1989

Noninvasive assessment of diastolic and systolic properties of ibopamine in patients with congestive heart failure.

The acute effect of a single oral 100 mg dose of ibopamine on systolic and diastolic left ventricular function in nine patients with congestive heart failure was assessed by quantitative M-mode and pulsed Doppler echocardiography. Echocardiography was performed at baseline and 30, 60, and 120 minutes after ingestion of drug. Indices of systolic and diastolic left ventricular function were derived from digitized tracings of the septal and posterior endocardial surfaces and transmitral and aortic valve velocity profiles. Ibopamine significantly improved systolic function as reflected by a decrease in the preejection period to left ventricular ejection time ratio from 0.57 +/- 0.16 at baseline to 0.47 +/- 0.15 (p less than 0.05) 30 minutes after ingestion of drug. The maximum improvements in stroke volume and cardiac output after ibopamine were from 63 +/- 35 to 72 +/- 40 ml (p less than 0.05) and 4.6 +/- 1.7 to 5.4 +/- 2.1 L/min (p = 0.05), respectively. The contribution of atrial systole to total diastolic filling increased from 32 +/- 10% at baseline to 37 +/- 12% (p less than 0.05) after 30 minutes and persisted for at least 120 minutes. The distribution of diastolic filling was significantly altered after ingestion of ibopamine as reflected by a decrease in the ratio of the time-velocity integrals of left ventricular filling during early diastole and atrial systole (Ei/Ai) from 2.44 +/- 1.08 at baseline to 1.98 +/- 0.97 (p less than 0.05) 30 minutes after drug. The decrease in the Ei/Ai persisted for at least 120 minutes. The duration of the effect of ibopamine on diastolic filling persisted longer than its effect on augmenting systolic function. The positive effect of ibopamine on systolic function makes it a promising drug in the treatment of congestive heart failure.

Adult↗

PubMed1992

Systolic anterior motion of the chordal apparatus after mitral ring insertion.

To describe the Doppler and two-dimensional echocardiographic characteristics of systolic anterior motion of the chordal apparatus after mitral annuloplasty, 24 consecutive patients (19 men and 5 women; mean age, 55 years) were studied with the use of serial Doppler and two-dimensional echocardiography, which included preoperative transthoracic, intraoperative epicardial, and postoperative transthoracic examinations at 1 week after annuloplasty and every 3 months thereafter for up to 12 months. Systolic anterior leaflet motion of the mitral valve was not seen in this series; however, chordal systolic anterior motion was seen in three patients during surgery and in one additional patient at the time of the 1-week transthoracic examination. During subsequent studies at 3-month intervals, chordal systolic anterior motion was not present. The left ventricular outflow tract velocities were normal in all patients with and without chordal systolic anterior motion. In conclusion, chordal systolic anterior motion should be differentiated from leaflet systolic anterior motion after mitral annuloplasty because the former is a transient, benign, and relatively common finding.

Adult↗

PubMed1993

Densitometric assessment of regional left ventricular systolic function during graded ischemia in the dog by use of dual-energy digital subtraction ventriculography.

Densitometric analysis of images obtained by digital subtraction angiography (DSA) allows for more reproducible and less operator-dependent quantitation of ventricular function. Conventional DSA uses temporal subtraction but is limited by misregistration artifacts. Dual-energy digital subtraction angiography (DE-DSA) is immune to such misregistration artifacts. The ability of DE-DSA to quantitate changes in regional ventricular volume resulting from ischemia was tested. Densitometric analysis of both phase-matched and ejection fraction DE-DSA images was used to quantitate regional left ventricular systolic function during four levels of ischemia ranging from mild to severe in open-chest dogs (n = 10). DE-DSA left ventriculograms were obtained by means of central venous injections of iodinated contrast medium. Ischemia was graded according to percentage of systolic wall thickening as measured by sonomicrometry. Phase-matched end-systolic images were obtained at each of four levels of ischemia by subtracting an end-systolic control image from each end-systolic ischemic image. Ejection fraction images were obtained at the control level and at each level of ischemia by subtracting an end-systolic image from an end-diastolic image of the same cardiac cycle. The resulting wall motion difference signals represent the changes in regional ventricular volumes and were quantitated by densitometry. Densitometry was able to detect the effect of all levels of ischemia on regional function, even the mildest. Densitometric analysis of both phase-matched and ejection fraction DE-DSA images provides a sensitive technique for detecting and quantitating the changes in regional left ventricular systolic volume that occur with ischemia.

Angiography, Digital Subtraction↗

PubMed1981

Abnormal mitral valve coaptation in hypertrophic obstructive cardiomyopathy: proposed role in systolic anterior motion of mitral valve.

Two dimensional echocardiographic evaluation utilizing the apical four chamber and apical long axis views was made in 10 normal subjects and 35 patients with hypertrophic cardiomyopathy, including 16 without and 19 with systolic anterior motion of the mitral valve. Mitral valve leaflets were imaged throughout the cardiac cycle. The normal subjects and the patients with hypertrophic cardiomyopathy without systolic anterior motion demonstrated mitral valve coaptation that seemed to involve the distal tip of the anterior leaflet. In contrast, patients with hypertrophic cardiomyopathy with systolic anterior motion demonstrated abnormal coaptation, so that the posterior leaflet coapted with a mid portion of the anterior leaflet, leaving a distal "residual" anterior leaflet in the left ventricle during systole. A sharp angulation of this distal leaflet in mid systole toward the interventricular septum is thought to represent systolic anterior motion. It is speculated that abnormal mitral leaflet coaptation in necessary for development of leaflet systolic anterior motion, which is correlated with dynamic left ventricular outflow gradients in hypertrophic obstructive cardiomyopathy.

Adult↗

PubMed1983

End-systolic dimension-wall thickness relations during myocardial ischemia in conscious dogs. A new approach for defining regional function.

Overall and regional left ventricular (LV) function was studied during progressive coronary stenosis in conscious dogs by determining the relations at end-systole between LV pressure, chamber dimensions, and regional LV wall thickness. An index of regional wall stress was also analyzed. Using ultrasonic dimension gauges, measurements were made of LV wall thickness in control and ischemic regions, and the external long- and short-axis LV diameters were determined; an implanted micromanometer measured LV pressure. Internal LV diameters were obtained from the external diameters by subtraction of wall thickness, and the index of regional wall stress employed a thick-walled ellipsoidal model. During regional ischemia, the LV long axis at end-systole did not change, whereas the short-axis diameter progressively increased (from 24 +/- 7 mm [standard deviation] to 30 +/- 9 mm, p less than 0.001, indicating a more spherical LV shape during ischemia). The end-systolic pressure did not change, and therefore the end-systolic pressure-diameter relation shifted progressively, suggesting a global decrease in LV contactility. The end-systolic points relating LV wall thickness in the ischemic region to the end-systolic LV pressure revealed the regional nature of the abnormality, showing a progressive displacement to the left, whereas there was no significant displacement of this relation in the control region. The application of this index over a range of loading conditions during partial vena caval occlusion was illustrated. Thus, the regional end-systolic wall thickness-pressure relation provides a new index for defining the regional contractile state of the LV myocardium which is potentially load-independent and offers the possibility for echocardiographic application.

Animals↗

PubMed1985

End-systolic left ventricular pressure-dimension shift during acute relief of volume overload in the conscious dog.

To test whether left ventricular (LV) end-systolic dimensions are determined only by end-systolic pressure for a given inotropic state, 7 conscious dogs were studied during abrupt closure of a fistula created between the left subclavian artery and the left atrial appendage. The dogs were instrumented with an LV pressure micromanometer and ultrasonic crystals measuring LV major- and minor-axis diameters and ventricular wall thickness. During beta-blockade treatment and for the same end-systolic pressure, closure of the fistula produced a 40% decrease in cardiac output; end-diastolic diameter decreased by 1.5 mm and end-systolic diameter decreased by 0.9 mm. Calculated end-systolic volume was similarly decreased by 1.3 ml for a decrease of 2.9 ml of end-diastolic volume. Thus, large end-diastolic dimensional variations associated with peripheral resistance decrease significantly modify the end-systolic pressure-diameter (and volume) relations in the conscious animal. It is suggested that indexes obtained from these relations should not be used in patients when systolic pressure variations are associated with large stroke volume variations.

Adrenergic beta-Antagonists↗

PubMed1986

Noninvasive evaluation of systolic and diastolic function in severe congestive heart failure secondary to coronary artery disease or idiopathic dilated cardiomyopathy.

The usefulness of systolic time intervals, diastolic time intervals and echocardiography in evaluating left ventricular (LV) function was determined in 69 patients with severe congestive heart failure. All systolic time intervals were markedly abnormal (preejection period/LV ejection time 0.59 +/- 0.18 vs 0.30 +/- 0.04, preejection period index 170 +/- 37 vs 117 +/- 11, LV ejection time index 372 +/- 26 vs 410 +/- 17; patients vs control subjects, p less than 0.05). Diastolic time intervals in patients were not different from those in control subjects. Echocardiographic measurements were all markedly abnormal (LV end-diastolic dimension 6.9 +/- 1.0 vs 4.8 +/- 0.4 cm, patients vs control subjects, p less than 0.05). No pattern of abnormalities distinguished ischemic cardiomyopathies from idiopathic dilated cardiomyopathies. The presence of LV conduction delay did not substantially alter results, except that exclusion of patients with LV conduction delay normalized the total time of systole (QA2) index (from 542 +/- 40 to 531 +/- 31 ms) and reduced but did not normalize prolongation in the preejection period index (from 170 +/- 37 to 162 +/- 29 ms). No systolic or diastolic interval strongly correlated with any hemodynamic or other independent measure of LV performance. Twenty-four patients were given inotropic or unloading agents, which significantly improved hemodynamic values. Systolic and diastolic intervals were measured at baseline and at maximal hemodynamic effect. The correlation of changes in hemodynamics with changes in systolic and diastolic intervals was only modest. Thus, although systolic time intervals and associated echocardiographic measurements can detect abnormal LV function, they cannot reliably detect a change in LV function or distinguish gradations of abnormality.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1986

Systolic functional response of normal older and younger adult left ventricles to dobutamine.

To determine the systolic functional response of the aged left ventricle to catecholamines, 16 healthy, physically active subjects aged 62 to 72 years (group A) and 19 healthy adults aged 18 to 28 years (group B) were evaluated before and during infusion of 8 micrograms/kg/min of dobutamine. Phonocardiograms, electrocardiograms and M-mode echocardiograms were recorded simultaneously with a carotid pulse tracing. End-diastolic dimension and end-systolic pressure remained unchanged in the 2 groups. End-systolic dimension decreased 0.3 cm (p less than 0.001) in group A and 0.5 cm (p less than 0.001) in group B. Fractional shortening increased (p less than 0.001) from 34 +/- 4% to 38 +/- 5% in group A and from 34 +/- 4% to 43 +/- 4% in group B. Mean velocity of circumferential fiber shortening (Vcf) increased 0.6 circ/s (p less than 0.001) in group A and 1 circ/s (p less than 0.001) in group B. End-systolic pressure/dimension ratio increased 3 mm Hg/cm (p less than 0.001) in group A and 8 mm Hg/cm (p less than 0.001) in group B. The changes in end-systolic dimension, fractional shortening, Vcf and end-systolic pressure/dimension ratio were more significant in group B (p less than 0.001). Thus, the left ventricular systolic functional response to dobutamine is diminished in healthy older persons.

Adolescent↗

PubMed1987

Antihypertensive effect of sustained-release isosorbide dinitrate for isolated systolic systemic hypertension in the elderly.

A double-blind, randomized trial was performed in 40 patients, mean age (+/- standard deviation) 80 +/- 4 years, with isolated systolic systemic hypertension to evaluate the antihypertensive effect of oral sustained-release isosorbide dinitrate (ISDN), 20 to 40 mg twice daily, vs placebo. After 12 weeks of treatment, supine systolic blood pressure (BP) decreased from 192 +/- 10 to 162 +/- 12 mm Hg with ISDN (p less than 0.001) and from 189 +/- 10 to 175 +/- 15 mm Hg with placebo (p less than 0.001). On the basis of variance analysis, the decrease in systolic BP was significantly lower with ISDN (27 mm Hg) than with placebo (13 mm Hg). Similar results were observed for supine and erect systolic BP measured at 8 AM and 4 PM, 8 and 12 hours after drug intake. No significant differences in diastolic BP, heart rate or side effects occurred. After the ISDN tapering off-period (2 weeks), systolic BP increased significantly but did not change with placebo. The study provided evidence that in elderly patients with systolic hypertension, sustained-release ISDN induced a selective and sustained decrease in systolic BP, antihypertensive effect was observed 8 and 12 hours after drug administration, and no tolerance phenomenon was noted.

Aged↗

PubMed1987

Enhanced left ventricular systolic performance at high altitude during Operation Everest II.

Serial rest and upright cycle exercise 2-dimensional echocardiographic studies were performed in 7 healthy young men during acclimatization to a simulated altitude of 29,000 feet (barometric pressure [PB] 240 torr) in a chamber for 40 days. In all subjects left ventricular (LV) end-diastolic, end-systolic and stroke volumes progressively decreased, with mean reductions of 21%, 40% and 14%, respectively, on ascent to 25,000 feet (PB 282 torr) at rest, and reductions of 23%, 43% and 14% during 60-W exercise. At PB 282 torr, mean arterial blood O2 partial pressures were 37 torr (rest) and 32 torr (exercise), with corresponding O2 saturations of 68% and 59%. All 3 indexes of LV systolic function examined--ejection fraction, ratio of peak systolic pressure to end-systolic volume and mean normalized systolic ejection rate at rest--were sustained in all subjects at high altitude despite reduced preload, pulmonary hypertension and severe hypoxemia. Increases in ejection fraction of 6% at rest and 10% during exercise developed at PB 282 torr and a higher mean normalized systolic ejection rate in association with elevated circulating catecholamines reflecting enhanced sympathetic activity. LV systolic function is not a limiting factor in compromising the exercise capacity of normal humans on ascent to high altitude, even to the peak of Mt. Everest.

Acclimatization↗

PubMed1993

Differentiating systolic from diastolic heart failure: pathophysiologic and therapeutic considerations.

PURPOSE: To compare and contrast the pathophysiology and therapy of heart failure with normal and abnormal systolic ventricular function. METHODS: Review of basic pathophysiologic mechanisms, clinical data, and therapeutic trials. CONCLUSIONS: The clinical features of heart failure may be similar regardless of whether ventricular function is normal or abnormal. However, the pathophysiologic mechanisms leading to heart failure with normal ventricular function differ considerably from those producing heart failure with abnormal systolic function. The key problems in heart failure with abnormal systolic function involve impaired contractility, neuroendocrine activation, increased intracardiac volume and pressure, and enhanced sensitivity to change in afterload. With normal systolic function, the key problem is an abnormal diastolic pressure/volume relationship, which may be due to a variety of active and passive processes affecting diastole. Assessing left ventricular systolic function is crucial before initiating therapy in a patient with heart failure, since treatment for systolic dysfunction may be ineffective or even counterproductive if symptoms are due to abnormal diastolic properties with preserved systolic function.

Clinical Trials as Topic↗

PubMed1984

Myocardial material mechanics: characteristic variation of the circumferential and longitudinal systolic moduli in left ventricular dysfunction.

Active systolic moduli for the circumferential (E theta) and longitudinal (E phi) axes of the left ventricle were determined along with circumferential and longitudinal contractile filament stress (sigma theta and sigma phi) and circumferential and longitudinal fiber strain (epsilon theta and epsilon phi). These material property parameters were determined at four points during cardiac systole. Thirty-nine patients comprising five clinical groups were evaluated using pressure and volume data acquired from single-plane cineangiography. The results indicate that the active moduli exponentially decrease during cardiac systole. Characteristic variations from normal differentiated the various pathological groups. With compensated volume overload, E theta was significantly reduced during the latter half of systole (p less than 0.25). With decompensated volume overload, both E theta and E phi were not significantly different from the normal group throughout cardiac systole. With compensated pressure overload, both E theta and E phi were significantly lower than the normal group at end-systole (p less than 0.005; p less than 0.005). With congestive cardiomyopathy, both E theta and E phi were significantly greater during the latter half of systole compared to the normal group (p less than 0.05 and p less than or equal to 0.025).

Adult↗

PubMed1994

Systolic blood pressure during submaximal exercise: an important correlate of cardiovascular disease risk factors in normotensive obese women.

Body fatness, plasma lipids, lipoproteins, indicators of glucose metabolism, and resting as well as submaximal treadmill exercise systolic blood pressures (BPs) were measured in a sample of 25 normotensive obese premenopausal women. No association was observed between body fatness, risk factors for cardiovascular disease, and resting BP. However, body fatness and plasma cholesterol, low-density lipoprotein cholesterol (LDL-CHOL), LDL apolipoprotein B (apo B), and apo B concentrations, as well as the high-density lipoprotein cholesterol to cholesterol (HDL-CHOL/CHOL) ratio, showed significant correlations with systolic BP measured during submaximal exercise. In addition, fasting plasma insulin concentrations and the glucose and insulin areas under the oral glucose tolerance test (OGTT) curve were both significantly associated with systolic BP during submaximal exercise. Partial correlation analyses revealed that the associations between submaximal exercise systolic BP and plasma apo B and LDL apo B levels were in part independent from the level of obesity. These results indicate that plasma concentrations of lipoproteins and insulin are important correlates of the systolic BP during submaximal exercise in obese premenopausal women. Further analyses performed on two subgroups indicated that women with high exercise systolic BP values exhibited significant differences in their metabolic profile in comparison to women with low BP during exercise. These results suggest that the absolute systolic BP recorded during submaximal exercise may be useful in the early detection of individuals at risk for the development of cardiovascular disease in resting normotensive obese women.

Adult↗

PubMed1992

Computer simulation of the effects of ventricular interdependence on indices of left ventricular systolic function.

The influence of ventricular interdependence on cardiovascular function has been convincingly demonstrated. In the intact cardiovascular system ventricular interdependence is always present, and thus measures of cardiac function include the contribution of ventricular interdependence (VI). A cardiovascular system model is presented and used to discuss how VI affects selected indices of left ventricular (LV) systolic function. Indices of LV function studied were the ejection fraction, stroke work, peak time derivative of ventricular pressure (dP/dT) and the LV end-systolic pressure-volume relationship. The effects of right ventricular (RV) volume through systolic VI on these indices are conveniently studied by comparing the model responses to pulmonary artery (PA) and vena caval (VC) occlusions; both PA and VC occlusion reduce LV volume, but the RV volume is increased by PA but reduced by VC occlusions. Through systolic VI the increase in RV volume with PA occlusion shifted the LV end-systolic pressure-volume relationship to the left and thus affected measures of LV maximum elastance. The LV ejection fraction, peak dP/dT and stroke work were all augmented by the increase in RV volume associated with the PA occlusion. Experimental studies comparing the responses to PA and VC occlusions are in broad agreement with the results described here. Systolic VI also shifted the cardiac function curve, a global measure of cardiac function, to the left. The results thus suggest that commonly used indices of LV systolic function are dependent on RV function and do not solely reflect LV function.

Cardiac Volume↗

PubMed1993

Abnormal renal function in isolated systolic hypertension correlation with ambulatory blood pressure.

Does ambulatory blood pressure correlate with the renal function damage better than clinic blood pressure in isolated systolic hypertension, as has been reported in other target organ involvement in combined systolic/diastolic hypertension? We investigated the correlation of serum beta-2 microglobulin concentration and both 24-h urine beta-2 microglobulin concentration and excretion as measures (suggestive) of glomerular filtration rate and tubular reabsorption, respectively with both ambulatory and clinic blood pressure in 19 health normotensive (68 +/- 4.9 years) and 50 isolated systolic hypertensive elderly individuals (69 +/- 5.4 years). Serum beta-2 microglobulin concentration and 24-h urine beta-2 microglobulin concentration and excretion were higher in the isolated systolic hypertension than in the normotensive group (P < 0.05). In isolated systolic hypertensive patients, 24-h urine beta-2 microglobulin concentration and excretion were related to ambulatory blood pressure (r = 0.32-0.40, P < 0.05), but not to clinic blood pressure; waking systolic blood pressure had the strongest correlation with both 24-h urine beta-2 microglobulin concentration and excretion among derivatives of ambulatory blood pressure (r = 0.35 and 0.40, P < 0.05). We conclude that ambulatory blood pressure, especially waking systolic blood pressure, is superior to clinical blood pressure in predicting renal function impairment, in isolated systolic hypertensive patients.

Aged↗

PubMed1996

'Abnormal' diastolic Doppler patterns in patients over age 65 with severe left ventricular systolic dysfunction.

OBJECTIVE: The purpose of this study was to determine whether Doppler diastolic filling patterns of the left ventricle are altered in patients over age 65 with poor left ventricular function, compared to patients with normal left ventricular systolic function. BACKGROUND: In elderly, healthy subjects, the mitral valve Doppler inflow pattern exhibits an increase in atrial contribution to left ventricular filling. Myocardial disease, which results in stiffness, may also cause an increase in A wave velocity. METHODS: Twenty-seven patients over age 65, with left ventricular systolic dysfunction, were age and sex-matched with 19 patients with normal left ventricular systolic function. Patients with significant mitral or aortic valvular disease were excluded. Maximal early inflow velocity, maximal atrial inflow velocity, heart rate, acceleration time and deceleration time were calculated. RESULTS: Comparing the group with normal left ventricular systolic function, the group with decreased left ventricular systolic function had pseudonormalization of the maximal early flow/atrial flow velocity ratio (1.7 +/- 1.3 vs. 0.9 +/- 0.3; P = 0.003), E wave velocity was similar (82 +/- 28 vs. 70 +/- 24 cm/s; P = n.s.), and A wave velocity was diminished (66 +/- 30 vs. 84 +/- 20 cm/s; P = 0.02). The acceleration time was similar for the groups (53 +/- 17 vs. 46 +/- 21 ms), but the deceleration time was shorter in patients with left ventricular systolic dysfunction (122 +/- 33 vs. 192 +/- 80 ms; P < 0.001). CONCLUSION: Such differences may relate to increased left atrial pressure, increased left ventricular diastolic pressure and/or decreased atrial systolic function. These findings are important when interpreting left ventricular filling indices by Doppler echocardiography in elderly patients.

Aged↗