Assessment of Left Ventricular Function in Severe Aortic Regurgitation ALLEN D. JOHNSON, M.D., LCDR JOSEPH S. ALPERT, MC USNR, LCDR GARY S. FRANCIS, MC USNR, CDR W. VICTOR R. VIEWEG, MC USN, I. OCKENE, M.D., AND CAPT ARTHUR D. HAGAN, MC USN SUMMARY Echocardiographic (echo) measurements of left ventricular ejection phase indices - ejection fraction, percent shortening of the minor diameter (%AD), and velocity of circumferential fiber shortening (Vcf) - are said to be accurate reflections of their angiographic (angio) counterparts. Most studies correlating echo and angio left ventricular function parameters have induded relatively few patients with aortic regurgitation. Echo and angio measurements of left ventricular ejection phase indices thus might not correlate in these patients in whom left ventricular geometry may have been altered due to the volume overload.
To test this hypothesis, left ventricular ejection phase indices were determined by angiography and echocardiography and compared in 20 patients with isolated, symptomatic, severe aortic regurgitation. Ejection fraction, %AD, and Vcf by LAO cineangiograms and echo were uniformly higher than corresponding meaurements from RAO angio, and were often normal in the presence of other indicators of significant left ventricular dysfunction. We conclude that the usual, linear echocardiographic measurement of left ventricular wall motion may not reflect sigpificant myocardial dysfunction in patients with severe aortic regurgitation.
IN RECENT YEARS, many investigators have suggested that echocardiography may provide reproducible measurements of a number of different parameters of left ventricular function heretofore only available from analysis of cineangiograms. Echocardiographic ejection fraction and fiber shortening rates (Vcf) are said to reflect accurately their angiographic counterparts." Most of these studies, however, have not concerned patients with significant volume overload of the left ventricle. We recently noted discrepancies between echocardiographic and angiographic measurements of left ventricular ejection phase indices in patients with significant aortic regurgitation and the present study was designed to examine this observation in detail. In order to determine whether echocardiographic measurements of left ventricular function reflect their angiographic counterparts in patients with significant aortic regurgitation, we compared echocardiographic and angiographic measurements of left ventricular ejection phase indices in 20 patients with isolated severe aortic regurgitation who were being considered for aortic valve replacement.
arteriograms were normal. The remaining 11 patients were free of chest discomfort. Moreover, youth, female sex, and absence of risk factors made associated coronary artery disease highly unlikely. No patient had left bundle branch block by ECG. The patients (7 males, 13 females) ranged in age from 18 to 63 (mean 40) years. Sixteen patients had chronic and four patients acute aortic regurgitation (table 1). All patients manifested symptoms and signs of at least mild pulmonary congestion which prompted their admission to the hospital for catheterization. Four patients were in NYHA Class I, five, Class II, and eleven, Class III. Fifteen patients eventually underwent aortic valve replacement shortly after their catheterization. Aortic valve replacement was advised for those patients who had clearcut histories of symptomatic left ventricular failure supported by either hemodynamic and/or angiographic evidence of abnormal left ventricular pump or myocardial function.
Materials Twenty patients with isolated severe aortic regurgitation demonstrated by cardiac catheterization comprised the study population. Coronary arteriography was performed in nine patients who were either older than 40 years or had complained of chest pain. In each case, the coronary
Cardiac Catheterization
From the Department of Medicine, University of California, San Diego, and the San Diego Veterans Administration Hospital, the Cardiology Branch, Department of Internal Medicine, and the Clinical Investigation Center, Naval Regional Medical Center, San Diego, California; and Department of Medicine, Peter Bent Brigham Hospital, Boston, Massachusetts. Supported by Bureau of Medicine and Surgery Clinical Investigation Program Project 6-16-803. Presented in part at the 48th Annual Scientific Session of the American Heart Association in Anaheim, California, November, 1975. The opinions or assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the Navy Department or the naval service at large. Address for reprints: Allen D. Johnson, M.D., Cardiology Section, Department of Medicine, University of California at San Diego School of Medicine, La Jolla, California 92161. Received March 29, 1976; revision accepted June 25, 1976.
Methods
Routine hemodynamic measurements preceded left ventricular angiography in each case. Angiograms were performed in RAO and steep LAO projections injecting a total of 0.5 to 1.0 cc/kg of Renografin 76 through NIH or Cordis pigtail catheters during a 3 sec interval. The angiograms were exposed on 35 mm film using a Philips 6-inch or 9-inch image intensifier system. Single plane RAO left ventricular cineangiograms were obtained in 12 patients, and biplane studies were performed in eight patients. Ejection fraction was calculated using the method of Dodge,7 and the rate of circumferential fiber shortening (Vcf) was obtained using the method of Karliner et al.8 Care was taken to analyze only sinus beats, not following PVCs, early in the cineangiogram to avoid the depressant effects of radioopaque contrast material on left ventricular function. In the eight patients who had biplane cineangiograms, the longitudinal axes from the apex to the midpoint of the aortic valve plane in the RAO projection, and from apex to the midpoint of the mitral valve ring in the LAO projection,
Downloaded from http://circ.ahajournals.org/975 at CORNELL UNIVERSITY on April 26, 2015
976
CIRCULATION
VOL 54, No 6, DECEMBER 1976
TABLE 1. Hemodynamic, Angiographic, and Echocardiographic Data in 20 Patients with Significant Aortic
Regurgitation Patient
AOP
1 2 3 4 5 6
125/30 200/72 150/70 120/65 110/34 180/70 160/70 145/50 190/60 100/50 110/30 110/60 180/40 160/48 140/62 102/50 130/50 182/58 118/40 122/75 136/53
7 8 9 10 11 12 13 14 15 16 17 18 19 20
Mean
LVP
CI
125/12
2.1 2.8 3.4 2.5
200/22 170/12 120/60 142/14 180/14 170/30 150/24 200/8 100/25 110/22 110/60 180/14 180/18 140/8 132/13 130/13 182/10 118/28 122/4 142/21
2.8 2.2 2.5 2.6 1.8 3.0 2.1 1.2 2.8 2.7 3.6 2.4 3.4 2.8 2.5 1.9 2.6
Angi_ EDV
Comment
272 AVR 291 AVR 209 206 AVR, ABE 313 AVR 266 AVR 161 AVR 268 AVR -
313 -
-
188 233 233 177 186 312 238 225
AVR AVR, ABE AVR, ABE AVR, ABE AVR -
AVR *
AVR AVR AVR
SEM
p
%AD
Vcf
RAO Angio Echo
RAO Angio Echo
27.7 38.8 14.3 27.7 51.3 44.0 25.2 43.7 35.5 28.6 37.0 16.2 21.0 27.3 32.6 20.7 34.3 38.4 44.0 30.8 17.1 37.5 40.0 21.7 28.4 18.5 28.3 39.4 48.0 24.0 40.0 33.0 44.6 33.3 30.8 23.5 21.7 14.3 32.0 24.4 25.0 36.9 1.7 1.7
To test this hypothesis, left ventricular ejection phase indices were determined by angiography and echocardiography and compared in 20 patients with isolated, symptomatic, severe aortic regurgitation. Ejection fraction, %AD, and Vcf by LAO cineangiograms and echo were uniformly higher than corresponding meaurements from RAO angio, and were often normal in the presence of other indicators of significant left ventricular dysfunction. We conclude that the usual, linear echocardiographic measurement of left ventricular wall motion may not reflect sigpificant myocardial dysfunction in patients with severe aortic regurgitation.
IN RECENT YEARS, many investigators have suggested that echocardiography may provide reproducible measurements of a number of different parameters of left ventricular function heretofore only available from analysis of cineangiograms. Echocardiographic ejection fraction and fiber shortening rates (Vcf) are said to reflect accurately their angiographic counterparts." Most of these studies, however, have not concerned patients with significant volume overload of the left ventricle. We recently noted discrepancies between echocardiographic and angiographic measurements of left ventricular ejection phase indices in patients with significant aortic regurgitation and the present study was designed to examine this observation in detail. In order to determine whether echocardiographic measurements of left ventricular function reflect their angiographic counterparts in patients with significant aortic regurgitation, we compared echocardiographic and angiographic measurements of left ventricular ejection phase indices in 20 patients with isolated severe aortic regurgitation who were being considered for aortic valve replacement.
arteriograms were normal. The remaining 11 patients were free of chest discomfort. Moreover, youth, female sex, and absence of risk factors made associated coronary artery disease highly unlikely. No patient had left bundle branch block by ECG. The patients (7 males, 13 females) ranged in age from 18 to 63 (mean 40) years. Sixteen patients had chronic and four patients acute aortic regurgitation (table 1). All patients manifested symptoms and signs of at least mild pulmonary congestion which prompted their admission to the hospital for catheterization. Four patients were in NYHA Class I, five, Class II, and eleven, Class III. Fifteen patients eventually underwent aortic valve replacement shortly after their catheterization. Aortic valve replacement was advised for those patients who had clearcut histories of symptomatic left ventricular failure supported by either hemodynamic and/or angiographic evidence of abnormal left ventricular pump or myocardial function.
Materials Twenty patients with isolated severe aortic regurgitation demonstrated by cardiac catheterization comprised the study population. Coronary arteriography was performed in nine patients who were either older than 40 years or had complained of chest pain. In each case, the coronary
Cardiac Catheterization
From the Department of Medicine, University of California, San Diego, and the San Diego Veterans Administration Hospital, the Cardiology Branch, Department of Internal Medicine, and the Clinical Investigation Center, Naval Regional Medical Center, San Diego, California; and Department of Medicine, Peter Bent Brigham Hospital, Boston, Massachusetts. Supported by Bureau of Medicine and Surgery Clinical Investigation Program Project 6-16-803. Presented in part at the 48th Annual Scientific Session of the American Heart Association in Anaheim, California, November, 1975. The opinions or assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the Navy Department or the naval service at large. Address for reprints: Allen D. Johnson, M.D., Cardiology Section, Department of Medicine, University of California at San Diego School of Medicine, La Jolla, California 92161. Received March 29, 1976; revision accepted June 25, 1976.
Methods
Routine hemodynamic measurements preceded left ventricular angiography in each case. Angiograms were performed in RAO and steep LAO projections injecting a total of 0.5 to 1.0 cc/kg of Renografin 76 through NIH or Cordis pigtail catheters during a 3 sec interval. The angiograms were exposed on 35 mm film using a Philips 6-inch or 9-inch image intensifier system. Single plane RAO left ventricular cineangiograms were obtained in 12 patients, and biplane studies were performed in eight patients. Ejection fraction was calculated using the method of Dodge,7 and the rate of circumferential fiber shortening (Vcf) was obtained using the method of Karliner et al.8 Care was taken to analyze only sinus beats, not following PVCs, early in the cineangiogram to avoid the depressant effects of radioopaque contrast material on left ventricular function. In the eight patients who had biplane cineangiograms, the longitudinal axes from the apex to the midpoint of the aortic valve plane in the RAO projection, and from apex to the midpoint of the mitral valve ring in the LAO projection,
Downloaded from http://circ.ahajournals.org/975 at CORNELL UNIVERSITY on April 26, 2015
976
CIRCULATION
VOL 54, No 6, DECEMBER 1976
TABLE 1. Hemodynamic, Angiographic, and Echocardiographic Data in 20 Patients with Significant Aortic
Regurgitation Patient
AOP
1 2 3 4 5 6
125/30 200/72 150/70 120/65 110/34 180/70 160/70 145/50 190/60 100/50 110/30 110/60 180/40 160/48 140/62 102/50 130/50 182/58 118/40 122/75 136/53
7 8 9 10 11 12 13 14 15 16 17 18 19 20
Mean
LVP
CI
125/12
2.1 2.8 3.4 2.5
200/22 170/12 120/60 142/14 180/14 170/30 150/24 200/8 100/25 110/22 110/60 180/14 180/18 140/8 132/13 130/13 182/10 118/28 122/4 142/21
2.8 2.2 2.5 2.6 1.8 3.0 2.1 1.2 2.8 2.7 3.6 2.4 3.4 2.8 2.5 1.9 2.6
Angi_ EDV
Comment
272 AVR 291 AVR 209 206 AVR, ABE 313 AVR 266 AVR 161 AVR 268 AVR -
313 -
-
188 233 233 177 186 312 238 225
AVR AVR, ABE AVR, ABE AVR, ABE AVR -
AVR *
AVR AVR AVR
SEM
p
%AD
Vcf
RAO Angio Echo
RAO Angio Echo
27.7 38.8 14.3 27.7 51.3 44.0 25.2 43.7 35.5 28.6 37.0 16.2 21.0 27.3 32.6 20.7 34.3 38.4 44.0 30.8 17.1 37.5 40.0 21.7 28.4 18.5 28.3 39.4 48.0 24.0 40.0 33.0 44.6 33.3 30.8 23.5 21.7 14.3 32.0 24.4 25.0 36.9 1.7 1.7
