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Diagnostic Postextrasystolic Carotid Pulse Wave Change in Idiopathic Hypertrophic Subaortic Stenosis: Echocardiographic Correlation
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I
GRAPHIC TECHNIQUES IN CARDIOLOGY
Diagnostic Postextrasystolic Carotid Pulse Wave Change in Idiopathic Hypertrophic Subaortic Stenosis: Echocardiographic Correlation * Flavia Reich, M.D.; Sergio V. Cabizuca, M.D.; Alberto Benchimol, M.D., F.C.C.P.; Kenneth B. Dresser, M.D., F.C.C.P.; and Connie Sheasby
systolic anterior motion (SAM) of A characteristic the anterior mitral valve leaflet has been dem-
onstrated by echocardiography in patients with idiopathic hypertrophic subaortic stenosis (IHSS) .1-3 Beat-to-beat alterations of left ventricular geometry, afterload and contractility may alter the degree of outflow tract obstruction4 in association with this disease. Diagnostic postextrasystolic changes of the external carotid pulse tracingS and echocardiogram t .2 have been noted in such subjects. We describe here the postextrasystolic carotid pulse tracing and echocardiogram from a patient with dynamic left ventricular outflow tract obstruction. Figure 1 shows the simultaneously recorded mitral area phonocardiogram, external carotid arterial pulse tracing, lead 3 of the electrocardiogram, left ventricular pressure and echocardiogram in a 41year-old man who presented with chest pain, presyncope an~ a systolic murmur at the tricuspid area. At cardiac catheterization, there was no resting gradient within the left ventricle or across the aortic valve. The septal-to-posterior left ventricular wall ratio was 2.2, diagnostic of asymmetrical septal hypertrophy (ASH). During sinus rhythm, the external carotid arterial pulse tracing showed a small nondiagnostic midsystolic dip and the echocardiogram demonstrated mild SAM of the anterior mitral valve. Catheter evoked premature ventricular beats (beats 2, 3, 5) which were succeeded by larger postextrasystolic left ventricular pressures and diagnostic "spike and dome" configurations of the carotid • From the Institute for Cardiovascular Diseases, Good Samaritan Hospital, Phoenix. SUPPQrted in part by the E. Nichols & Kim Sigsworth Memorial Funds. Reprint requests: Dr. Benchimol, 1033 East McDowell Road, Phoenix 85006
CHEST, 69: 6, JUNE, 1976
arterial pulse (beats 4 and 6). The major midsystolic carotid pulse retractions correlated well with enhanced SAM of the anterior mitral valve. After inhalation of amyl nitrite, a left venbicular intracavity pressure gradient of 35 mm Hg was recorded. To our knowledge, the simultaneously recorded phenomena described here have not been previously reported in a patient with ASH and postextrasystolic evoked IHSS. Abnormally positioned papillary muscles,6-8 distortion of the left ventricular cavity by hypertrophy of the septum and hydrodynamic forces generated by left ventricular contraction have all been considered possible causes of SAM in patients with IHSS.9 Potentiation of myocardial contraction following a premature stimulus lO and enhanced left ventricular preload ll are accepted mechanisms which account for postextrasystolic dynamic obstruction to left ventricular emptying and characteristic intra-arterial pulse contour changes l2 in patients with IHSS. It can be sunnised that augmented left ventricular contractility following the premature depolarizations resulted in increased SAM and revealed the diagnostic carotid arterial pulse tracing described here. In conclusion, multiple graphic representations of intracardiac events and simultaneous external pulse recording aid in elucidating the dynamic nature of IHSS.
REFERENCES 1 Shah PM, Gramiak R, Kramer DH: Ultrasound localization of left ventricular outflow obstruction in hypertrophic obstructive cardiomyopathy. Circulation 40:3-11, 1969 2 Popp RL, Harrison DC: Ultrasound in the diagnosis and evaluation of therapy of idiopathic hypertrophic subaortic stenosis. Circulation 40:905-914, 1969 3 Pridie RB, Oakley eM: Mechanism of mitral regurgita-
DIAGNOSTIC POSTEXTRASYSTOUC CAROTID PULSE WAVE CHANGE IN IHSS 115
..._-----.!
400·2,OOOHz. -~.,.
VPC
,..".'
LV PW
PMV
~lsec~ FIGURE 1. Simultaneously recorded mitral area (MA) phonocardiogram, external carotid pulse tracing (cr), lead 3 (L III) of the electrocardiogram, left ventricular (LV) pressure and echocardiogram in a 41 year old man with IHSS. (SR systolic retraction, SAM systolic anterior motion, IVS = interventricular septum, RV = right ventricle, AMV = anterior mitral valve, PMV = posterior mitral valve, LVPW = left ventricular posterior wall, LV = left ventricle and VPC ventricular premature contraction). See discussion.
=
=
=
4
5 6 7 8
tion in hypertrophic obstructive cardiomyopathy. Br Heart J 32:203-208, 1970 Braunwald E, Lambrew cr, Rockoff SD, et al: Idiopathic hypertrophic subaortic stenosis. I. A description of the disease based upon an analysis of 64 patients. Circulation 30:Suppl IV:3-119, 1964 Benchimol A, Roper PA, Desser KB: Postextrasystolio changes in the carotid pulse tracing of mild hypertrophic subaortic stenosis. Chest 67:344-345,1975 Simon AL, Ross J Jr, Gault JH: Angiographic anatomy of the left ventricle and mitral valve in idiopathic hypertrophic subaortic stenosis. Circulation 36:852-867, 1967 Roberts WC: Valvular, subvalvular, and supravalvular aortic stenosis: morphologic features. Cardiovasc Clin 5:98-126, 1973 King JF, Reis RL, Bolton MR, et al: Superior-to-inferior septal hypertrophy in IHSS: the fundamental determinant
776 REICH. ET AL
9
10 11
12
of obstruction. (Abstract) Circulation 48:Suppl IV:6, 1973 Henry WL, Clark CE, Griffith JM, et al: Mechanism of left ventricular outflow obstruction in patients with obstructive asymmetrical septal hypertrophy. ( Idiopathic hypertrophic subaortic stenosis). Am J Cardiol 35:337345,1975 Hoffman BF, Bindler E, Suckling ED: Post-extrasystolic potentiation of contraction in cardiac muscle. Am J Physioll85:95-102, 1956 Sonnenblick EH, Spiro D, Spotnitz HM: The ultrastructural basis of Starling's law of the heart. The role of the sarcomere in determining ventricular size and stroke volume. Am Heart J 68:336-346, 1964 Brockenbrough E, Braunwald E, Morrow AG: A hemOdynamic technic for the detection of hypertrophic subaortic stenosis. Circulation 23:189-194,1961
~HEST,
69: 6, JUNE, 1976
I
GRAPHIC TECHNIQUES IN CARDIOLOGY
Diagnostic Postextrasystolic Carotid Pulse Wave Change in Idiopathic Hypertrophic Subaortic Stenosis: Echocardiographic Correlation * Flavia Reich, M.D.; Sergio V. Cabizuca, M.D.; Alberto Benchimol, M.D., F.C.C.P.; Kenneth B. Dresser, M.D., F.C.C.P.; and Connie Sheasby
systolic anterior motion (SAM) of A characteristic the anterior mitral valve leaflet has been dem-
onstrated by echocardiography in patients with idiopathic hypertrophic subaortic stenosis (IHSS) .1-3 Beat-to-beat alterations of left ventricular geometry, afterload and contractility may alter the degree of outflow tract obstruction4 in association with this disease. Diagnostic postextrasystolic changes of the external carotid pulse tracingS and echocardiogram t .2 have been noted in such subjects. We describe here the postextrasystolic carotid pulse tracing and echocardiogram from a patient with dynamic left ventricular outflow tract obstruction. Figure 1 shows the simultaneously recorded mitral area phonocardiogram, external carotid arterial pulse tracing, lead 3 of the electrocardiogram, left ventricular pressure and echocardiogram in a 41year-old man who presented with chest pain, presyncope an~ a systolic murmur at the tricuspid area. At cardiac catheterization, there was no resting gradient within the left ventricle or across the aortic valve. The septal-to-posterior left ventricular wall ratio was 2.2, diagnostic of asymmetrical septal hypertrophy (ASH). During sinus rhythm, the external carotid arterial pulse tracing showed a small nondiagnostic midsystolic dip and the echocardiogram demonstrated mild SAM of the anterior mitral valve. Catheter evoked premature ventricular beats (beats 2, 3, 5) which were succeeded by larger postextrasystolic left ventricular pressures and diagnostic "spike and dome" configurations of the carotid • From the Institute for Cardiovascular Diseases, Good Samaritan Hospital, Phoenix. SUPPQrted in part by the E. Nichols & Kim Sigsworth Memorial Funds. Reprint requests: Dr. Benchimol, 1033 East McDowell Road, Phoenix 85006
CHEST, 69: 6, JUNE, 1976
arterial pulse (beats 4 and 6). The major midsystolic carotid pulse retractions correlated well with enhanced SAM of the anterior mitral valve. After inhalation of amyl nitrite, a left venbicular intracavity pressure gradient of 35 mm Hg was recorded. To our knowledge, the simultaneously recorded phenomena described here have not been previously reported in a patient with ASH and postextrasystolic evoked IHSS. Abnormally positioned papillary muscles,6-8 distortion of the left ventricular cavity by hypertrophy of the septum and hydrodynamic forces generated by left ventricular contraction have all been considered possible causes of SAM in patients with IHSS.9 Potentiation of myocardial contraction following a premature stimulus lO and enhanced left ventricular preload ll are accepted mechanisms which account for postextrasystolic dynamic obstruction to left ventricular emptying and characteristic intra-arterial pulse contour changes l2 in patients with IHSS. It can be sunnised that augmented left ventricular contractility following the premature depolarizations resulted in increased SAM and revealed the diagnostic carotid arterial pulse tracing described here. In conclusion, multiple graphic representations of intracardiac events and simultaneous external pulse recording aid in elucidating the dynamic nature of IHSS.
REFERENCES 1 Shah PM, Gramiak R, Kramer DH: Ultrasound localization of left ventricular outflow obstruction in hypertrophic obstructive cardiomyopathy. Circulation 40:3-11, 1969 2 Popp RL, Harrison DC: Ultrasound in the diagnosis and evaluation of therapy of idiopathic hypertrophic subaortic stenosis. Circulation 40:905-914, 1969 3 Pridie RB, Oakley eM: Mechanism of mitral regurgita-
DIAGNOSTIC POSTEXTRASYSTOUC CAROTID PULSE WAVE CHANGE IN IHSS 115
..._-----.!
400·2,OOOHz. -~.,.
VPC
,..".'
LV PW
PMV
~lsec~ FIGURE 1. Simultaneously recorded mitral area (MA) phonocardiogram, external carotid pulse tracing (cr), lead 3 (L III) of the electrocardiogram, left ventricular (LV) pressure and echocardiogram in a 41 year old man with IHSS. (SR systolic retraction, SAM systolic anterior motion, IVS = interventricular septum, RV = right ventricle, AMV = anterior mitral valve, PMV = posterior mitral valve, LVPW = left ventricular posterior wall, LV = left ventricle and VPC ventricular premature contraction). See discussion.
=
=
=
4
5 6 7 8
tion in hypertrophic obstructive cardiomyopathy. Br Heart J 32:203-208, 1970 Braunwald E, Lambrew cr, Rockoff SD, et al: Idiopathic hypertrophic subaortic stenosis. I. A description of the disease based upon an analysis of 64 patients. Circulation 30:Suppl IV:3-119, 1964 Benchimol A, Roper PA, Desser KB: Postextrasystolio changes in the carotid pulse tracing of mild hypertrophic subaortic stenosis. Chest 67:344-345,1975 Simon AL, Ross J Jr, Gault JH: Angiographic anatomy of the left ventricle and mitral valve in idiopathic hypertrophic subaortic stenosis. Circulation 36:852-867, 1967 Roberts WC: Valvular, subvalvular, and supravalvular aortic stenosis: morphologic features. Cardiovasc Clin 5:98-126, 1973 King JF, Reis RL, Bolton MR, et al: Superior-to-inferior septal hypertrophy in IHSS: the fundamental determinant
776 REICH. ET AL
9
10 11
12
of obstruction. (Abstract) Circulation 48:Suppl IV:6, 1973 Henry WL, Clark CE, Griffith JM, et al: Mechanism of left ventricular outflow obstruction in patients with obstructive asymmetrical septal hypertrophy. ( Idiopathic hypertrophic subaortic stenosis). Am J Cardiol 35:337345,1975 Hoffman BF, Bindler E, Suckling ED: Post-extrasystolic potentiation of contraction in cardiac muscle. Am J Physioll85:95-102, 1956 Sonnenblick EH, Spiro D, Spotnitz HM: The ultrastructural basis of Starling's law of the heart. The role of the sarcomere in determining ventricular size and stroke volume. Am Heart J 68:336-346, 1964 Brockenbrough E, Braunwald E, Morrow AG: A hemOdynamic technic for the detection of hypertrophic subaortic stenosis. Circulation 23:189-194,1961
~HEST,
69: 6, JUNE, 1976