DECEMBER1976
The American
Journal
of CARDIOLOGY@ VOLUME 36 NUMBER7
CLINICAL STUDIES
Left Ventricular Performance in Mitral Regurgitation Assessed With Systolic Time Intervals and Echocardiography
KENNETH
L. WANDERMAN,
MARK J. GOLDBERG, MD RICHARD S. STACK, MD ARNOLD M. WEISSLER, MD,
MD*
FACC
Detroit, Michigan
From the Department of Medicine, Wayne State University and Harper Hospital, Detroit, Mich. Manuscript received April 7, 1976; revised manuscript received June 25, 1976, accepted June 30, 1976. *Present address: Cardiology Service, Soroka Medical Center and Ben Gurion University of the Negev, Beer Sheva, Israel. Address for reprints: Arnold M. Weissler, MD, Department of Medicine, Wayne State University, 540 E. Canfield Ave., Detroit, Mich. 48201.
Among 22 patients with isolated mitral regurgitation of various origins, systolic time intervals (preejection period [PEP] index, left ventricular ejection time [LVET] index and PEPILVET) and echocardiographic measures of left ventricular performance (end-diastolic diameter [Dd], end-systolic diameter [Ds], and the percent change In minor axis diameter [ % AD]) were calculated. The patients were classified into two groups, those with a normal or supernormal %AD (group I, 15 patients) and those with a decreased % AD (group II, 7 patients). On group analysis, prolongation of the preejection period, shortening of the left ventricular ejection time and an increase in PEP/LVET was generally characteristic of patients with mitral regurgitation. These changes were accentuated when mitral regurgitation was complicated by echocardiographic evidence Of diminished left ventricular contractile performance ( % AD less than 30 percent). An increase in PEPILVET to greater than 0.50 was consistently associated with abnormal left ventricular performance, whereas a normal PEP&VET ratio reflected normal or supernormal left ventricular performance. An inverse linear relation was found between PEP/LVET and %AD. When compared with previous data on the relation of these variables among patients without valve insufficiency, PEP&VET proved to be increased for any level of % AD in mitral regurgitation. The state of digitalization did not appear to influence the relation between PEP/LVET and % AD.The use of echocardiographic measurements augments the determination of systolic time Intervals in the analysis of left ventricular performance in patients with mitral regurgitation. Noninvasive methods for assessing left ventricular performance are well established in conditions involving the myocardium, such as coronary artery, hypertensive and primary myocardial disease. In particular, systolic time interval determinations have been found an effective means of quantitating left ventricular performance in these conditions.1-3 In cardiac valve disease, however, the reliability of these measurements is less clear since both the valve defect and altered left ventricular function
December 1976
The American Journal of CARDIOLOGY
Volume 38
831
VENTRICULAR PERFORMANCE IN MITRAL REGURGITATION-WANDERMAN
can alter the systolic time intervals. In mitral regurgitation the interplay of these factors is difficult to delineate. Recent studies have documented the accuracy of echocardiographic methods in assessing left ventricular chamber performance in both valve and nonvalve disease.4-s In view of this newer application of the echocardiographic approach, this investigation on the combined use of systolic time intervals and echocardiographic measures in evaluating left ventricular performance in mitral regurgitation was initiated. Methods Twenty-two patients with mitral regurgitation without other hemodynamically significant valve disease were studied (Table I). Fourteen were male and eight female; their ages ranged from 16 to 69 years. The condition was of rheumatic origin in five patients (including three with ruptured chordae tendineae found at open heart surgery). It was caused by papillary muscle dysfunction due to coronary artery disease in three, healed infective endocarditis in three and prolapse of one or more mitral valve leaflets in nine. In two patients the cause could not be established. Among the nine patients with mitral valve prolapse, the condition was confirmed with echocardiography and contrast ventriculography in seven patients and with echocardiography alone in two (abrupt mid-systolic displacement or distinct U-shaped pansystolic posterior displacement of the leafletsg,lO).
Summary
no.
Systolic time intervals: All patients had simultaneous electrocardiographic, phonocardiographic and carotid arterial pulse tracings recorded photographically at paper speed of 100 mm/set using an Electronics for Medicine VR-6 system. Systolic time intervals were measured as described previously.1v2 The left ventricular ejection time (LVET) and preejection period (PEP) were corrected for heart rate with use of linear regression equations, and were expressed as their respective indexes (LVETI and PEPI).ls2 The ratio of PEP/ LVET was calculated using the uncorrected values for preejection period and left ventricular ejection time. Echocardiography: An echocardiogram was recorded in all patients, with a Unirad series 100 echograph utilizing a 2.25 megahertz 0.5 inch (1.27 cm) transducer focused at either 5 or 7.5 cm, with a repetition rate of l,000/hertz. The recordings were made on a Tektronix recorder. The transducer was usually held in the fourth intercostal space just to the left of the&ernum, although occasionally it had to be placed in the third or fifth intercostal space to obtain resolution of the interventricular septum and left ventricular posterior wall endocardial echoes. Left ventricular minor axis dimensions were measured from recordings made with the ultrasonic beam so directed that the interventricular septum and the left ventricular posterior wall endocardium were clearly delineated in a position where the inferior mitral valve apparatus echoes (inferior edges of the leaflets or chordae tendineae) were evident. The left ventricular end-diastolic diameter (Dd) was measured from the endocardium of the interventricular septum to the endocardium of the posterior wall at the time of the
I
TABLE
Case
ET At
of Clinical, Age (yr) & Sex
Noninvasive
Grade (MR)
NYHA Class
and Hemodynatiic
Dig.
Data %AD
Etiology Group
I
Dd (mm)
PEPI (msec)
LVETI (msec)
PEP/ LVET
LVEDP (mm Hg)
PCW, (mm Hg)
PA,,, (mm Hg)
(%AD 30 percent or more)
1
6JM
III
III
Yes
PMV
42
63
131
381
0.39
11
12
22
3’ 4 5 6 :
40M 26M 22M 54M 16F 46F 18F
III IV III IV III II
I II II IV III II
NO No No Yes Yes No
PMV Post IE RHDtRC RHD+RC PMV
:; 35 40 61 ::
57 50 57 75 57 47
124 130 164 145 117 114 134
420 379 410 380 343 395 367
0.40 0.32 0.48 0.44 0.40 0.38 0.46
13 : 14 8 125
8 5 1: 16 4
149 13 24 37 24 13
51M 61M 63F 48F 40M 60F 52M
III III IV III IV III II
III II Ill II Ill III III
Yes Yes Yes Yes Yes Yes Yes
PMV Post IE PMD Unknown Post I E PMV PMD
49 34
6”: 47 58 ::
137 140 150 174 133 163 142 140 +4.4
391 391 407 380 406 395 371 388 i-5.0
0.41 0.40 0.43 0.48 0.40 0.46 0.45 0.42 to.01
18 18 0 14 18 11 17 11.3 ?I.4
25 23 5 15 26 8 17 13 +3.4
36 33 20 19 40 12 22 22.5 +2.6
359 369 370 358 369 374 374 368 k2.5
0.72 0.53 0.68 0.53 0.67 0.64 0.67 0.63 kO.03
10 15 :“4
::
7 11 7 14.3 k3.5
15 13 10 17.1 k3.1
23 63 32 38 16 23 16 30.1 r6.2
9 10 11 12 13 14 15 Mean f SEM
Group 16 17 18 19 20 21 22 Mean
64M 51M 45F 49M 25F 63M 69M
III Ill III III III III III
? SEM
III IV 1’1’1 III IV ItI
Yes Yes Yes Yes Yes Yes Yes
PMV Unknown RHD+RC PMD RHD PMV RHD
:: 38 46 31 40 52.0 II (%AD 23 27 26 26 29 19 22 25 -t 1.3
52 55 57 i2.0
less than 30 percent) 71 51 :z 58 :“o 63 t2.J
183 145 186 146 163 191 182 171 rJ.4
:tt
Dd = left ventricular end-diastolic diameter; Dig. = maintenance digitalis therapy; LVEDP = left ventricular end-diastolic pressure; LVETl = left ventricular ejection time index; MR = mitral regurgitation; NYHA class = New York Heart Association functional class; PA, = mean Pul= ratio of preejection period monary arterial pressure; PCW, = mean pulmonary wedge pressure; PEPI = preejection period index; PEP/LVET to left ventricular ejection time; %AD = percent change in minor axis diameter; PMD = papillary muscle dysfunction due to coronarv artery disease; PMV = prolapsed mitral valve; Post lE = postinfective endocarditis; RC = ruptured chordae tendineae; RHD = rheumatic heart disease; SEM = standard error of the mean.
832
December
1978
The American Journal of CARDIOLOGY
Volume 38
VENTRICULAR PERFORMANCE IN MITRAL REGURGITATION-WANDERMAN
TABLE
ET AL.
II
Data in 25 Normal
Subjects
A. Normal B. Mitral regurgitation 1. Group I (%AD>30) P Value 2. Group II (%AD
The American
Journal
of CARDIOLOGY@ VOLUME 36 NUMBER7
CLINICAL STUDIES
Left Ventricular Performance in Mitral Regurgitation Assessed With Systolic Time Intervals and Echocardiography
KENNETH
L. WANDERMAN,
MARK J. GOLDBERG, MD RICHARD S. STACK, MD ARNOLD M. WEISSLER, MD,
MD*
FACC
Detroit, Michigan
From the Department of Medicine, Wayne State University and Harper Hospital, Detroit, Mich. Manuscript received April 7, 1976; revised manuscript received June 25, 1976, accepted June 30, 1976. *Present address: Cardiology Service, Soroka Medical Center and Ben Gurion University of the Negev, Beer Sheva, Israel. Address for reprints: Arnold M. Weissler, MD, Department of Medicine, Wayne State University, 540 E. Canfield Ave., Detroit, Mich. 48201.
Among 22 patients with isolated mitral regurgitation of various origins, systolic time intervals (preejection period [PEP] index, left ventricular ejection time [LVET] index and PEPILVET) and echocardiographic measures of left ventricular performance (end-diastolic diameter [Dd], end-systolic diameter [Ds], and the percent change In minor axis diameter [ % AD]) were calculated. The patients were classified into two groups, those with a normal or supernormal %AD (group I, 15 patients) and those with a decreased % AD (group II, 7 patients). On group analysis, prolongation of the preejection period, shortening of the left ventricular ejection time and an increase in PEP/LVET was generally characteristic of patients with mitral regurgitation. These changes were accentuated when mitral regurgitation was complicated by echocardiographic evidence Of diminished left ventricular contractile performance ( % AD less than 30 percent). An increase in PEPILVET to greater than 0.50 was consistently associated with abnormal left ventricular performance, whereas a normal PEP&VET ratio reflected normal or supernormal left ventricular performance. An inverse linear relation was found between PEP/LVET and %AD. When compared with previous data on the relation of these variables among patients without valve insufficiency, PEP&VET proved to be increased for any level of % AD in mitral regurgitation. The state of digitalization did not appear to influence the relation between PEP/LVET and % AD.The use of echocardiographic measurements augments the determination of systolic time Intervals in the analysis of left ventricular performance in patients with mitral regurgitation. Noninvasive methods for assessing left ventricular performance are well established in conditions involving the myocardium, such as coronary artery, hypertensive and primary myocardial disease. In particular, systolic time interval determinations have been found an effective means of quantitating left ventricular performance in these conditions.1-3 In cardiac valve disease, however, the reliability of these measurements is less clear since both the valve defect and altered left ventricular function
December 1976
The American Journal of CARDIOLOGY
Volume 38
831
VENTRICULAR PERFORMANCE IN MITRAL REGURGITATION-WANDERMAN
can alter the systolic time intervals. In mitral regurgitation the interplay of these factors is difficult to delineate. Recent studies have documented the accuracy of echocardiographic methods in assessing left ventricular chamber performance in both valve and nonvalve disease.4-s In view of this newer application of the echocardiographic approach, this investigation on the combined use of systolic time intervals and echocardiographic measures in evaluating left ventricular performance in mitral regurgitation was initiated. Methods Twenty-two patients with mitral regurgitation without other hemodynamically significant valve disease were studied (Table I). Fourteen were male and eight female; their ages ranged from 16 to 69 years. The condition was of rheumatic origin in five patients (including three with ruptured chordae tendineae found at open heart surgery). It was caused by papillary muscle dysfunction due to coronary artery disease in three, healed infective endocarditis in three and prolapse of one or more mitral valve leaflets in nine. In two patients the cause could not be established. Among the nine patients with mitral valve prolapse, the condition was confirmed with echocardiography and contrast ventriculography in seven patients and with echocardiography alone in two (abrupt mid-systolic displacement or distinct U-shaped pansystolic posterior displacement of the leafletsg,lO).
Summary
no.
Systolic time intervals: All patients had simultaneous electrocardiographic, phonocardiographic and carotid arterial pulse tracings recorded photographically at paper speed of 100 mm/set using an Electronics for Medicine VR-6 system. Systolic time intervals were measured as described previously.1v2 The left ventricular ejection time (LVET) and preejection period (PEP) were corrected for heart rate with use of linear regression equations, and were expressed as their respective indexes (LVETI and PEPI).ls2 The ratio of PEP/ LVET was calculated using the uncorrected values for preejection period and left ventricular ejection time. Echocardiography: An echocardiogram was recorded in all patients, with a Unirad series 100 echograph utilizing a 2.25 megahertz 0.5 inch (1.27 cm) transducer focused at either 5 or 7.5 cm, with a repetition rate of l,000/hertz. The recordings were made on a Tektronix recorder. The transducer was usually held in the fourth intercostal space just to the left of the&ernum, although occasionally it had to be placed in the third or fifth intercostal space to obtain resolution of the interventricular septum and left ventricular posterior wall endocardial echoes. Left ventricular minor axis dimensions were measured from recordings made with the ultrasonic beam so directed that the interventricular septum and the left ventricular posterior wall endocardium were clearly delineated in a position where the inferior mitral valve apparatus echoes (inferior edges of the leaflets or chordae tendineae) were evident. The left ventricular end-diastolic diameter (Dd) was measured from the endocardium of the interventricular septum to the endocardium of the posterior wall at the time of the
I
TABLE
Case
ET At
of Clinical, Age (yr) & Sex
Noninvasive
Grade (MR)
NYHA Class
and Hemodynatiic
Dig.
Data %AD
Etiology Group
I
Dd (mm)
PEPI (msec)
LVETI (msec)
PEP/ LVET
LVEDP (mm Hg)
PCW, (mm Hg)
PA,,, (mm Hg)
(%AD 30 percent or more)
1
6JM
III
III
Yes
PMV
42
63
131
381
0.39
11
12
22
3’ 4 5 6 :
40M 26M 22M 54M 16F 46F 18F
III IV III IV III II
I II II IV III II
NO No No Yes Yes No
PMV Post IE RHDtRC RHD+RC PMV
:; 35 40 61 ::
57 50 57 75 57 47
124 130 164 145 117 114 134
420 379 410 380 343 395 367
0.40 0.32 0.48 0.44 0.40 0.38 0.46
13 : 14 8 125
8 5 1: 16 4
149 13 24 37 24 13
51M 61M 63F 48F 40M 60F 52M
III III IV III IV III II
III II Ill II Ill III III
Yes Yes Yes Yes Yes Yes Yes
PMV Post IE PMD Unknown Post I E PMV PMD
49 34
6”: 47 58 ::
137 140 150 174 133 163 142 140 +4.4
391 391 407 380 406 395 371 388 i-5.0
0.41 0.40 0.43 0.48 0.40 0.46 0.45 0.42 to.01
18 18 0 14 18 11 17 11.3 ?I.4
25 23 5 15 26 8 17 13 +3.4
36 33 20 19 40 12 22 22.5 +2.6
359 369 370 358 369 374 374 368 k2.5
0.72 0.53 0.68 0.53 0.67 0.64 0.67 0.63 kO.03
10 15 :“4
::
7 11 7 14.3 k3.5
15 13 10 17.1 k3.1
23 63 32 38 16 23 16 30.1 r6.2
9 10 11 12 13 14 15 Mean f SEM
Group 16 17 18 19 20 21 22 Mean
64M 51M 45F 49M 25F 63M 69M
III Ill III III III III III
? SEM
III IV 1’1’1 III IV ItI
Yes Yes Yes Yes Yes Yes Yes
PMV Unknown RHD+RC PMD RHD PMV RHD
:: 38 46 31 40 52.0 II (%AD 23 27 26 26 29 19 22 25 -t 1.3
52 55 57 i2.0
less than 30 percent) 71 51 :z 58 :“o 63 t2.J
183 145 186 146 163 191 182 171 rJ.4
:tt
Dd = left ventricular end-diastolic diameter; Dig. = maintenance digitalis therapy; LVEDP = left ventricular end-diastolic pressure; LVETl = left ventricular ejection time index; MR = mitral regurgitation; NYHA class = New York Heart Association functional class; PA, = mean Pul= ratio of preejection period monary arterial pressure; PCW, = mean pulmonary wedge pressure; PEPI = preejection period index; PEP/LVET to left ventricular ejection time; %AD = percent change in minor axis diameter; PMD = papillary muscle dysfunction due to coronarv artery disease; PMV = prolapsed mitral valve; Post lE = postinfective endocarditis; RC = ruptured chordae tendineae; RHD = rheumatic heart disease; SEM = standard error of the mean.
832
December
1978
The American Journal of CARDIOLOGY
Volume 38
VENTRICULAR PERFORMANCE IN MITRAL REGURGITATION-WANDERMAN
TABLE
ET AL.
II
Data in 25 Normal
Subjects
A. Normal B. Mitral regurgitation 1. Group I (%AD>30) P Value 2. Group II (%AD
