trauma nor prolonged postischemic ventricular dysfunction (stunned myocardium) is relevant for the occurrence of ST-segment depression after transplantation. Thus, this event appears to be affected by myocardial disorders associated with rejection. This hypothesis is sustained by the fact that we could not find an increase in heart rate preceding ST-segment depressions or a correlation with reduced left ventricular function unless there was clear evidence for coronary vessel disease or unspecific myocardial graft failure. 1. Kemnitz J, Cohnert T, Sch%fers HJ, Helmke M, Wahlers T, Herrmann G, Schmidt RM, Haverich A. A classification of cardiac allograft rejection. A
modification of the classification by Billingham. Am JSurg Pathol 1987;11:50351.5. 2. Kemnitz J, Choritz H, Cohnert TR, Haverich A, Borst HG, Georgii 1. Predictive implications of bioptic diagnosis in cardiac allografts. J Hearc Tramplant 1989:8:315-329. 3. F&gh MC, Alihani MR, Helfrich GB, Khirabadi BS, Lim K, Ramwell PW. Lipid mediators in organ transplantation. Trmsplant Proc 1986(suppl 14);18:2024. 4. Gage JE, Hess OM, Murakami T, Ritter M, Grimm J, Krayenbuehl HP. Vasoconstriction of stenotic coronary arteries during dynamic exercise in patients with classic angina pcctoris: reversibility by nitroglycerin. Circulation 1986; 73~865%816. 5. Berman DS, Rozanski A, Knoebel SB. The detection of silent ischemia: cautions and precautions. Circulation 1987;75:101-105. 6. Crawford MH, Mendoza CA, O’Rourke RA, White DH, Boucher CA, Gorwit J. Limitations of continuous ambulatory electrocardiogram monitoring for detecting coronary artery disease. Ann Intern Med 1978;89:1-5.
Usefulnessof Systolic Excursion of the Mitral Anulus as an Index of Left Ventricular Systolic Function Ramdas G. Pai, MD, Monty M. Bodenheimer, Richard D. Adamick, MD -
MD,
tudies in both humans and nonhuman animals show that the mitral anulus changes its size, shape and S position during the cardiac cycle.1-3 Left ventricular (LV) contraction results in shortening along both the short and long axis of the left ventricle. With each systole, the mitral anulus moves toward the apex in a cephalocauda1 direction.1-3 It has also been observed that the displacement of the mitral anulus during the systole is reduced with dilated cardiomyopathy.4 We examined the relation between the amount of systolic excursion of the mitral anulus and LV systolic function as measured by radionuclide ventriculography and a variety of echocardiographic techniques. Fiftv-seven consecutive patients (35 men, 22 women, mean age 65.6 years [range 31 to 84) with a wide range of LV ejection fraction (23 to 84%), who had both an echocardiogram and radionuclide ventriculography within 2 days of each other, comprised the study group. Those who had a change in treatment or the clinical state in between these 2 studies were excluded (n = 3). Two-dimensional and Doppler echocardiograms were obtained with a Hewlett-Packard 77020ACsystem, with the patients in the left lateral position whenever possible. Left parasternal long-axis, short-axis and apical views were obtained in a conventional way and recordings were videotaped. M-mode recordings were obtained on paper and measurements made according to the recommendations of the American Society of Echocardiography.5 LV volumes were calculated using the method of Teicholz et a1.6 LVfractional shortening and ejection fraction were calculated in a standard manner.6,7 LV mass was calculated using the method described by Troy et aL8
From the Harris Chasanoff Heart Institute, Long Island Jewish Hospital, New Hyde Park, New York. Manuscript received June 21, 1990; revised manuscript received and accepted August 17, 1990.
222
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME 67
Sudha M. Pai,
MD,
Jerome
H. Koss,
MD,
and
Mitral anular excursion was measuredfrom the apical If-chamber view, where the movement of the mitral anulus is parallel to the ultrasound beam. Measurements were obtainedfrom frame-by-frame replay of the videotape, as shown in Figure 1. The total systolic excursion of the lateral margin of the mitral anulus was measured from the videoscreen as the distance between its highest position in diastole (point D) and its lowest position in systole (point s>. The systolic excursion of the medial margin of the mitral anulus was also measured in a similar manner. The mean of these measurements was taken as the average systolic excursion of the mitral anulus. We preferred to use the 2-dimensional method in preference to the M-mode method, as described previously, because lateral motion of the heart may introduce errors in the latter.2p4 Radionuclide ejection fractions (EF-MUGA) were obtained by LVbloodpool imaging using technetium 99m labeled red blood cells in a conventional manner: EFMUGA = 100 X (LVEDC - LVESC)/LVEDC, where LVEDC is the LVend-diastolic count and LVESC is the LV end-systolic count. LVradionuclide ejection fraction was correlated with the systolic excursion of the mitral anulus, ejection fraction by different echocardiographic methods and various LV measurements using linear regression by the leastsquares method. In a similar way, the systolic excursion of the mitral anulus was also correlated with various continuous variables. Means were compared using Student’s unpaired t test. There was a good agreement between the measurement of the systolic excursion of the mitral anulus obtained by the same observer on 2 different occasions (r = 0.97, standard error of the estimate = 0.7 mm) and that obtained by 2 different observers (r = 0.91, standard error of the estimate = I .3 mm). LVejection fraction by the radionuclide method correlated with all methods of estimating LVfunction (Ta-
FIGURE 1. Method of measwtng the systolic excursion of the mitral amdus: From the apical 4-chamber view, the systolic excursion of the medial and the lateral parts ol the mitral anulus are measured from the highest point in diastole (point D) to the lowest point in systole (point S) by frame-by-frame playback of the videotape. LA = left atrium; LV = left ventride, MV = mitral valve; RA = right atrium; RV = right venbicle.
TABLE I Correlates of Left Ventricular Radionuclide Ventriculography
ble I), but the best correlation was with the systolic excursion of the mitral anulus (r = 0.95), as shown in
Ejection Fraction by
Variable
r
SEE (% EF)
pValue
SEMA-M (mm) SEMA-L (mm) SEMA (mm) EF-EST (%) EF-TEI (%) FS (%)
0.93 0.94 0.95 0.89 0.84 0.82
6.8 6.1 5.9 8.3 10.1 10.6
modification of the classification by Billingham. Am JSurg Pathol 1987;11:50351.5. 2. Kemnitz J, Choritz H, Cohnert TR, Haverich A, Borst HG, Georgii 1. Predictive implications of bioptic diagnosis in cardiac allografts. J Hearc Tramplant 1989:8:315-329. 3. F&gh MC, Alihani MR, Helfrich GB, Khirabadi BS, Lim K, Ramwell PW. Lipid mediators in organ transplantation. Trmsplant Proc 1986(suppl 14);18:2024. 4. Gage JE, Hess OM, Murakami T, Ritter M, Grimm J, Krayenbuehl HP. Vasoconstriction of stenotic coronary arteries during dynamic exercise in patients with classic angina pcctoris: reversibility by nitroglycerin. Circulation 1986; 73~865%816. 5. Berman DS, Rozanski A, Knoebel SB. The detection of silent ischemia: cautions and precautions. Circulation 1987;75:101-105. 6. Crawford MH, Mendoza CA, O’Rourke RA, White DH, Boucher CA, Gorwit J. Limitations of continuous ambulatory electrocardiogram monitoring for detecting coronary artery disease. Ann Intern Med 1978;89:1-5.
Usefulnessof Systolic Excursion of the Mitral Anulus as an Index of Left Ventricular Systolic Function Ramdas G. Pai, MD, Monty M. Bodenheimer, Richard D. Adamick, MD -
MD,
tudies in both humans and nonhuman animals show that the mitral anulus changes its size, shape and S position during the cardiac cycle.1-3 Left ventricular (LV) contraction results in shortening along both the short and long axis of the left ventricle. With each systole, the mitral anulus moves toward the apex in a cephalocauda1 direction.1-3 It has also been observed that the displacement of the mitral anulus during the systole is reduced with dilated cardiomyopathy.4 We examined the relation between the amount of systolic excursion of the mitral anulus and LV systolic function as measured by radionuclide ventriculography and a variety of echocardiographic techniques. Fiftv-seven consecutive patients (35 men, 22 women, mean age 65.6 years [range 31 to 84) with a wide range of LV ejection fraction (23 to 84%), who had both an echocardiogram and radionuclide ventriculography within 2 days of each other, comprised the study group. Those who had a change in treatment or the clinical state in between these 2 studies were excluded (n = 3). Two-dimensional and Doppler echocardiograms were obtained with a Hewlett-Packard 77020ACsystem, with the patients in the left lateral position whenever possible. Left parasternal long-axis, short-axis and apical views were obtained in a conventional way and recordings were videotaped. M-mode recordings were obtained on paper and measurements made according to the recommendations of the American Society of Echocardiography.5 LV volumes were calculated using the method of Teicholz et a1.6 LVfractional shortening and ejection fraction were calculated in a standard manner.6,7 LV mass was calculated using the method described by Troy et aL8
From the Harris Chasanoff Heart Institute, Long Island Jewish Hospital, New Hyde Park, New York. Manuscript received June 21, 1990; revised manuscript received and accepted August 17, 1990.
222
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME 67
Sudha M. Pai,
MD,
Jerome
H. Koss,
MD,
and
Mitral anular excursion was measuredfrom the apical If-chamber view, where the movement of the mitral anulus is parallel to the ultrasound beam. Measurements were obtainedfrom frame-by-frame replay of the videotape, as shown in Figure 1. The total systolic excursion of the lateral margin of the mitral anulus was measured from the videoscreen as the distance between its highest position in diastole (point D) and its lowest position in systole (point s>. The systolic excursion of the medial margin of the mitral anulus was also measured in a similar manner. The mean of these measurements was taken as the average systolic excursion of the mitral anulus. We preferred to use the 2-dimensional method in preference to the M-mode method, as described previously, because lateral motion of the heart may introduce errors in the latter.2p4 Radionuclide ejection fractions (EF-MUGA) were obtained by LVbloodpool imaging using technetium 99m labeled red blood cells in a conventional manner: EFMUGA = 100 X (LVEDC - LVESC)/LVEDC, where LVEDC is the LVend-diastolic count and LVESC is the LV end-systolic count. LVradionuclide ejection fraction was correlated with the systolic excursion of the mitral anulus, ejection fraction by different echocardiographic methods and various LV measurements using linear regression by the leastsquares method. In a similar way, the systolic excursion of the mitral anulus was also correlated with various continuous variables. Means were compared using Student’s unpaired t test. There was a good agreement between the measurement of the systolic excursion of the mitral anulus obtained by the same observer on 2 different occasions (r = 0.97, standard error of the estimate = 0.7 mm) and that obtained by 2 different observers (r = 0.91, standard error of the estimate = I .3 mm). LVejection fraction by the radionuclide method correlated with all methods of estimating LVfunction (Ta-
FIGURE 1. Method of measwtng the systolic excursion of the mitral amdus: From the apical 4-chamber view, the systolic excursion of the medial and the lateral parts ol the mitral anulus are measured from the highest point in diastole (point D) to the lowest point in systole (point S) by frame-by-frame playback of the videotape. LA = left atrium; LV = left ventride, MV = mitral valve; RA = right atrium; RV = right venbicle.
TABLE I Correlates of Left Ventricular Radionuclide Ventriculography
ble I), but the best correlation was with the systolic excursion of the mitral anulus (r = 0.95), as shown in
Ejection Fraction by
Variable
r
SEE (% EF)
pValue
SEMA-M (mm) SEMA-L (mm) SEMA (mm) EF-EST (%) EF-TEI (%) FS (%)
0.93 0.94 0.95 0.89 0.84 0.82
6.8 6.1 5.9 8.3 10.1 10.6
