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Asynchronous ventricular relaxation
LETTERS TO THE EDITOR
Therefore this apexcardiographic index is sensitive for ischemit heart disease but not specific for it. Jose M. Vklal, MD Carlos Saez de la Calzada, MD Cardiovascular Service Ciudad Sanitaria de la Seguridad Social “ 1 Ode Octubre” Madrid, Spain References A. slow filling parlod/rapld fflllnQ pwlod 1. S~~WWOA,~G,DW#UK,B.~~M~~ ratio In the apexcardkqam: relation to the dlagnosk of oororwy artery dleeaae. Am J CardkllQ78: 42~377-62.
REPLY
The preliminary data provided by Vidal and Saez de la Calzada indicate that the slow filling period/rapid filling period ratio does indeed increase in association with other disease states known to impair left ventricular compliance. This information is important and complements our investigation. However, the value of this ratio does provide clinically useful information in those subjects with chest pain syndromes who do not manifest acknowledged signs of valve or subvalve stenosis. In such patients a ratio greater than 2.8 suggests ischemit heart disease. We thank these investigators for their constructive comments. Kenneth B. Desser, MD, FACC Albert0 Benchimol, MD, FACC Good Samaritan Hospital Institute for Cardiovascular Diseases Phoenix, Arizona
ASYNCHRONOUS
VENTRICULAR
References 1. Alam SE, Tan8.y WA, Camwon A, Kunp KG. Asynchronous ventricular relaxation: an an~iographk temporal analysis of asynchrwous left ventricular relaxation In man. Am J Cwdlol 107% 43~41-8. 2. Attkrl Pl, Wltt SM, ‘&eon RF. Left ventrkular wall motion analysis during the Iso* lumk relaxation period. Clrculatlon 1973; 48:499-503.
REPLY
Our observations do not support Altieri’s assertion that asynchronous relaxation is normal, at least from a temporal standpoint. It is delayed, and particularly so in subjects with both asynchronous relaxation and coronary disease. Nor does the absence of asynchronous ventricular relaxation in abnormally contracting segments argue for normalcy. We suggest that delayed relaxation is an early and subtle abnormality that may not be present late in disease states, when contraction abnormalities appear. This hypothesis is supported by Altieri’s observation that asynchronous ventricular relaxation disappears as left ventricular function deteriorates. Asynchronous ventricular relaxation is still not well understood and its occasional appearance in a wide variety of disorders such as mitral valve prolapse and at the site of intracavitary pacemakers, as well as in occasional “normal” hearts should not overshadow the fact that it occurs in potentially ischemic hearts in the vast majority of instances. Even the “normal” patients are catheterized because of symptoms, usually suggestive of ischemic heart disease. Noninvasive studies such as systolic time intervals and echocardiography have documented the synchronous relaxation of the normal left ventricle and the duration of the active phase of relaxation. The time intervals for the normal isovolumic relaxation period obtained in our study by invasive techniques are well within these established norms.lp2 Asynchronous ventricular relaxation is an abnormal phenomenon, manifested by a prolongation of the isovolumic period as well as asynchrony of relaxation. Samir E. Alam, MD, FACC Harvey G. Kemp, Jr., MD, FACC Division of Cardiology Medical Service St. Luke’s Hospital Center New York, New York
RELAXATION
The article by Alam et al. presents a good analysis of left ventricular wall motion during the isovolumic relaxation period, but I disagree with their conclusions. In our article,2 we described the segmental early relaxation phenomenon as a normal motion during the isovolumic relaxation period. This was supported by its frequent presence in normally contracting left ventricles and by its infrequent occurrence in abnormally contracting areas. As we reported, the phenomenon disappeared as left ventricular function deteriorated. The segmental early relaxation phenomenon is seen in the left ventricle of patients with prolapse of the mitral valve, rheumatic heart disease, congenital heart disease and normal ventricles. The frequency and location is the same in all groups and, with deterioration of left ventricular function, the phenomenon disappears, as seen in patients with obstructive coronary disease. I believe that the segmental early relaxation phenomenon is a normal pattern of left ventricular wall motion during the isovolumic relaxation period. It is seen in all segments of the left ventricle, and the motion disappears during moderate to severe left ventricular dysfunction. Pablo I. Altieri, MD Cardiovascular Laboratory University of Puerto Rico Medical Sciences Campus Rio Piedras, Puerto Rico
1. Upton Ml, akon Do, Brown RI. Echocardkgaphk assessment of abnormal left ventricularrelaxation in man. Br Haart J 1978: 381001-9. 2. Bonchlmol A, EUb 0. A study of the period of kovolumlc relaxation In wmai subjects and In patients with heart disease. Am J Card101 1967; 19:196-206.
HEART SOUNDS INDUCED BY SWAN-GANZ CATHETER-I
Isner et al.’ described what they believed to be the first documentation of a nonejection click produced by a Swan-Ganz catheter and explained that the click arose from the slapping of the catheter against the right ventricular septum during systole. They failed to note the publication of our paper2 in which we documented phonocardiographically the production of mid systolic and early diastolic clicks due to a Swan-Ganz catheter inserted in a patient with cardiogenic shock. From fluoroscopic observation, we postulated that the clicks were produced by a snapping to-and-fro motion of the catheter
Augusl1990
The American Journal of CARDIOLOGY
Volume 46
349
Therefore this apexcardiographic index is sensitive for ischemit heart disease but not specific for it. Jose M. Vklal, MD Carlos Saez de la Calzada, MD Cardiovascular Service Ciudad Sanitaria de la Seguridad Social “ 1 Ode Octubre” Madrid, Spain References A. slow filling parlod/rapld fflllnQ pwlod 1. S~~WWOA,~G,DW#UK,B.~~M~~ ratio In the apexcardkqam: relation to the dlagnosk of oororwy artery dleeaae. Am J CardkllQ78: 42~377-62.
REPLY
The preliminary data provided by Vidal and Saez de la Calzada indicate that the slow filling period/rapid filling period ratio does indeed increase in association with other disease states known to impair left ventricular compliance. This information is important and complements our investigation. However, the value of this ratio does provide clinically useful information in those subjects with chest pain syndromes who do not manifest acknowledged signs of valve or subvalve stenosis. In such patients a ratio greater than 2.8 suggests ischemit heart disease. We thank these investigators for their constructive comments. Kenneth B. Desser, MD, FACC Albert0 Benchimol, MD, FACC Good Samaritan Hospital Institute for Cardiovascular Diseases Phoenix, Arizona
ASYNCHRONOUS
VENTRICULAR
References 1. Alam SE, Tan8.y WA, Camwon A, Kunp KG. Asynchronous ventricular relaxation: an an~iographk temporal analysis of asynchrwous left ventricular relaxation In man. Am J Cwdlol 107% 43~41-8. 2. Attkrl Pl, Wltt SM, ‘&eon RF. Left ventrkular wall motion analysis during the Iso* lumk relaxation period. Clrculatlon 1973; 48:499-503.
REPLY
Our observations do not support Altieri’s assertion that asynchronous relaxation is normal, at least from a temporal standpoint. It is delayed, and particularly so in subjects with both asynchronous relaxation and coronary disease. Nor does the absence of asynchronous ventricular relaxation in abnormally contracting segments argue for normalcy. We suggest that delayed relaxation is an early and subtle abnormality that may not be present late in disease states, when contraction abnormalities appear. This hypothesis is supported by Altieri’s observation that asynchronous ventricular relaxation disappears as left ventricular function deteriorates. Asynchronous ventricular relaxation is still not well understood and its occasional appearance in a wide variety of disorders such as mitral valve prolapse and at the site of intracavitary pacemakers, as well as in occasional “normal” hearts should not overshadow the fact that it occurs in potentially ischemic hearts in the vast majority of instances. Even the “normal” patients are catheterized because of symptoms, usually suggestive of ischemic heart disease. Noninvasive studies such as systolic time intervals and echocardiography have documented the synchronous relaxation of the normal left ventricle and the duration of the active phase of relaxation. The time intervals for the normal isovolumic relaxation period obtained in our study by invasive techniques are well within these established norms.lp2 Asynchronous ventricular relaxation is an abnormal phenomenon, manifested by a prolongation of the isovolumic period as well as asynchrony of relaxation. Samir E. Alam, MD, FACC Harvey G. Kemp, Jr., MD, FACC Division of Cardiology Medical Service St. Luke’s Hospital Center New York, New York
RELAXATION
The article by Alam et al. presents a good analysis of left ventricular wall motion during the isovolumic relaxation period, but I disagree with their conclusions. In our article,2 we described the segmental early relaxation phenomenon as a normal motion during the isovolumic relaxation period. This was supported by its frequent presence in normally contracting left ventricles and by its infrequent occurrence in abnormally contracting areas. As we reported, the phenomenon disappeared as left ventricular function deteriorated. The segmental early relaxation phenomenon is seen in the left ventricle of patients with prolapse of the mitral valve, rheumatic heart disease, congenital heart disease and normal ventricles. The frequency and location is the same in all groups and, with deterioration of left ventricular function, the phenomenon disappears, as seen in patients with obstructive coronary disease. I believe that the segmental early relaxation phenomenon is a normal pattern of left ventricular wall motion during the isovolumic relaxation period. It is seen in all segments of the left ventricle, and the motion disappears during moderate to severe left ventricular dysfunction. Pablo I. Altieri, MD Cardiovascular Laboratory University of Puerto Rico Medical Sciences Campus Rio Piedras, Puerto Rico
1. Upton Ml, akon Do, Brown RI. Echocardkgaphk assessment of abnormal left ventricularrelaxation in man. Br Haart J 1978: 381001-9. 2. Bonchlmol A, EUb 0. A study of the period of kovolumlc relaxation In wmai subjects and In patients with heart disease. Am J Card101 1967; 19:196-206.
HEART SOUNDS INDUCED BY SWAN-GANZ CATHETER-I
Isner et al.’ described what they believed to be the first documentation of a nonejection click produced by a Swan-Ganz catheter and explained that the click arose from the slapping of the catheter against the right ventricular septum during systole. They failed to note the publication of our paper2 in which we documented phonocardiographically the production of mid systolic and early diastolic clicks due to a Swan-Ganz catheter inserted in a patient with cardiogenic shock. From fluoroscopic observation, we postulated that the clicks were produced by a snapping to-and-fro motion of the catheter
Augusl1990
The American Journal of CARDIOLOGY
Volume 46
349