- Email: [email protected]
Doppler-derived pulmonary arterial systolic pressure in patients with known systemic arterial pressures
with high blood flow (e.g., above the mitral valve) or during unstable catheter positions (e.g., right free wall). Even a 1” to 2°C increase in temperature may be critical to achieve permanent conduction block, and thus a successful ablation outcome.2*3The addition of a second dispersive electrode or even a single large surface-area dispersive electrode may result in greater current delivery and more optimal tissue heating, particularly if the baseline impedance is > 100 R. This
study demonstrated
that
m SlnQlO ~GURE 3. Graphs compari
cl Deublo
baseline impedance
(Z), root-mean-square
voltage
(If),
the location of the dispersive elec- deliveredcurrent(II,andcaxeter tip tempemture (Temp) for a single and double distrode has no significant effect on persive electrode configuration for patients with an impedance > 100 f2 (n = 9). Vertica/ bars represent + 1 SD. l p <0.05, for comparison of single versus double ele&ode con~gumtions . impedance, voltage, c-nt delivery, and tip temperature duriug radiofrequency catheter ablation. In addition, the study also showed that 1. Hindricks G, Haverkamp W. Determinants of radiofrequency-induced lesion size: what are the important parameters to monitor during energy doubling the surface area of the dispersive electrode application? In: Huang SK& ed. Radiofrequency Catheter Ablation of Carresulted in lower impedance, higher current delivery, disc Arrhythmias. Basic Concepts and Clinical Applications. Armonk, NY: ~~c~tiptemperatures,particularlywhen~e
Fumra,
baseline impedance was >lOO CLThese findings may have imp&ant implications for optimizing radiofrequency energy delivery using currently available radiofrequency generators.
2. Natb S, Lynch C IQ Whayne JG, Haines DE. Cellular electrophysiological effects of hyperthermia on isolated guinea pig papillary muscle. Implications for catheter ablation. Circuhtion 1993;88:1826-1831. 3. Simmers TA, De Bakker JMT, Wittkampf FHM, Hauer RNW. Effects of heating on impulse propagation in superfused canine myocardium. J Am Co11 Cardiol 1995;25:1457-1464.
199~7-121.
Doppler-Derived Pulmonary AHerBal Systolic Pressure in Patients With Known Systemic Arterial Pressures Eric Abergel,
MD, Gilles
Chatellier, MD, Pierre Toussaint, MD, Jean-Claude Jo&l Menard, MD, and Benoit Diebold, MD
Dib, MD,
hypertensive patients, echocardiography is Isurenwidely used to evaluate the impact of chronic presoverloading on left ventricular (LV) morphol-
was to investigate Doppler-derived pulmonary pressure determinants in hypertensive patients. ... ogy and function. Bight ventricular hemodynamics Among 1,9QO hypertensive patients consecuhave been less studied. Elevation of right-sided pres- tively referred to the Broussais hospital hypertension sures was observed in hypertensive patients during clinic day-care unit, and registered prospectively in right catheterization.‘-3 With use of noninvasive an echocardiographic database, 476 were selected on continuous-wave Doppler ultrasound, the pressure the basis of the following criteria: ( 1) absence of gradient between the right ventricle and right atrium history or signs referable to heart failure; (2) absence during systole can be estimated from the peak ve- of significant echographic valvular heart disease; and locities in the tricuspid regurgitant jet using the sim- (3) possibility of assessing the following variables: plified Bernoulli equation. In simultaneous Doppler usual M-mode and LV mass measurement, diastolic catheterization studies,4 estirhation of right atria1 function parameters (mitral E-and A-wave velocities pressure at 10 mm Hg allows calculation of right measured at the annulus, E-wave deceleration time), ventricular systolic pressure, equivalent to systolic tricuspid regurgitation spectrum measured by continpulmonary arterial pressure. The aim of the study uous-wave Doppler, systolic and diastolic blood pressures measured by a nurse at the end of echoFrom the Service de Cordiologie, Centre d’lnvestigations Cliniques, graphic examination, body mass index (weight [kg] / et Service d’lnformotique Medicate, Hopital Broussais, Paris, France. height [m’]). Obesity was defined as body mass inDr. Abergel’s address is: Depanement de Cardiologie, Hopitat Brousdex ~27.8 kg/m’ in men and ~27.3 kg/m* in sais, 96 rue Didot, 75674 Paris Cedex 14, France. Manuscript rewomen. LV mass was calculated using Devereuxceived September 9, 1995; revised manuscript received and acmodified American Society of Echocardiography cepted November 1 1, 1995. BRIEF REPORTS
767
regurgitation peak velocity and a constant value for right atria1 pressure.4The pulmonary pressure level is clinically important to appreciate severity and tolerance of any heart disease. Usually, in a healthy population, systolic pulmonary arterial pressure is considered normal when <30 mm Hg. In the present study, in a population of treated and untreated hypertensive patients of both sexes,41% had a systolic pulmonary arterial pressurevalue >30 mm Hg. The systolic pulmonary arterial pressure level was explained partially by age, body mass index, and systolic blood pressure, the strongest predictor being age. Pulmonary pressure increase with aging has been demonstratedin previous studies in normotensive patients free of coronary disease’ as well as in hypertensive patients.3 Intimal fibrosis of the pulmonary arteries occurs early in life (before age 40) in normal subjects. An increase in the incidence of intimal fibrosis with increasing age could therefore result in a decreasein pulmonary artery distensibility.5 Concurrently, with aging, systemic arterial alterations are known to reduce systemic arterial compliance. In middle-aged hypertensive patients, a positive correlation between pulmonary and systemic vascular resistancehas been shown,‘j suggesting a common pathologic process in both lesser and greater circulation. In the present study, the relation between both age and elevated systolic blood pressure could reflect a significant reduced arterial compliance. In contrast, diastolic blood pressure, which roughly reflects systemic arteriolar resistance, was not correlated with systolic pulmonary arterial pressure. These observations were made in a population in which the usual published values for correlation coefficients were observed between age, blood pressure, and LV mass (Table I). We also found that obesity, which leads to increasesin pulmonary blood volume and cardiac output,’ was related to systolic pulmonary arterial pressure. However, becausepulmonary circulation is a low-pressure system with high compliance, an increase in pulmonary blood volume should not lead to an increase in pressure. To explain the relation between systolic pulmonary arterial pressure and obesity, one can hypothesize that a decreasein pulmonary distensibility must be associatedwith an increasein blood volume. Elevated pulmonary presTABLE I Correlation Matrix for Systolic Pulmonary Arterial Pressure and Potential sures in hypertensive patients could Explanatory Variables also reflect a backward effect of LV LVMi FS Sex DT SBP BMI Variables SPAP E/A Age failure. Our patients were free of clinical signs of heart failure, but iz 0.17 0.28 0.08 systolic pulmonary arterial pressure E/A -0.16 -0.54 -0.1 level was significantly higher in the LVMi 0.14 0.07 0.23 -0.14 subgroup with a predominantly E FS 0.13 0.29 0.05 -0.22 -0.13 wave than in the subgroup with a Sex 0.01 0.02 -0.23 0.03 -0.33 0.12 DT 0.18 0.37 0.04 -0.46 0.15 0.16 -0.06 predominantly A wave. A predomSBP 0.19 0.21 0.09 -0.26 0.28 0.003 -0.07 0.15 inantly E-wave flow profile may DBP 0.007 0.04 0.04 -0.11 0.29 -0.04 -0.02 -0.01 0.57 reflect normal, but also high, LV Correlation coefficients > 0.10 differed significantly from 0 (p < 0.05). filling pressure. However, this facBMI = body mars index; DBP = diastolic blood pressure; DT = E-wave deceleration time; E/A = E- to tor was not an independent predicA-wave ratio; FS = left ventricule fractional shortening; LVMi = left ventricular mass indexed to body tor of systolic pulmonary arterial surface oreo; SBP = systolic blood pressure; SPAP = systolic pulmonary arterial pressure. pressure.
cube formula, and indexed to body surface area. LV hypertrophy was defined as > 125 g/m* in men and >llO g/m2 in women. Data are presented as mean ? 1 SD. Means were compared with the Student’s I test. Relations between continuous variables were assessedwith the Pearson’s correlation coefficient. Variables independently related to systolic pulmonary arterial pressure were identified using multiple linear regression analysis. The study group consisted of 237 men and 239 women, aged52 2 12years(range22to87),ofwhom 20% were obese.Most patientshad mild to moderate hypertension(blood pressure153 + 19/92 2 14 mm Hg). LV masswas 96 If: 22 g/m2 in men ( 11% had LV hypertrophy) and 83 ? 19 g/m* in women (6% had LV hypertrophy) . The E- to A-wave ratio was < 1 in 44% of patients,and the E-wave decelerationtime was 166 2 48 ms (range 80 to 400). Systolic pulmonary arterialpressurewas 29.9 ? 4.9 mm Hg (range 20 to 52). Systolic pulmonary arterial pressurewas higher in the group of 209 patientswith an E to A ratio > 1 than in the group of 261 patientswith E to A ratio 51 (30.5 t 5.2 vs 29.5 + 4.5 mm Hg, p ~0.02). Systolic pulmonary arterial pressurewas significantly correlated with age, body mass index, E- to A-wave ratio, E-wave deceleration time, indexed LV mass, fractional shortening,and systolic blood pressure,the most predictive single variablebeing age (Table I). In the multiple regressionequation,only 3 variableswere significantlyrelatedto systolicpuhnonary arterialpressure:age,body massindex, and systolicblood pressure (multiple r = 0.34). Consequently,when arbitrarily defining the “normal” by the mean 2 2 SDS,systolic pulmonary arterial pressure was normal when <38 mm Hg in nonobesepatients aged 560 years compared with 47 mm Hg in obese patients aged >60 years. ... In sustainedprimary hypertension, higher values of pulmonary pressureand resistancehave been previously reported mainly based on invasive investigations, whereas few data are available using noninvasive techniques. With use of continuous-wave Doppler, systolic pulmonary arterial pressure is easily and accurately calculated by adding the tricuspid
768
THE AMERICAN JOURNAL OF CARDIOLOGY@’
VOL. 77
APRIL 1, 1996
We cannot exclude the presence of confounding factors, such as tobacco consumption and antihypertensive treatments. Inaccurate blood pressure measurement could also lessen the value of some correlation coefficients. Our results should be confirmed by a prospective study using a more precise blood pressure measurement, such as ambulatory blood pressure in an untreated hypertensive population. clinical lutelpretation ofsystullc pulmonary arterial pressure in hypertensive patients should take into accountage,body&x,andsystokbloodpressurevalues. For example, in obesehypertensive patients aged >6Oyears,avalueofsystolicpulmonaryarterialpressureasbigbas47mmHgcouldbecomiderednomal.
1. Davidson WR, Fee EC. Influence of aging on pulmonary hemodynamics in a population free of coronary artery disease. Am J Cardiol 1990; 65:1454-1458. 2. Ferlinz I. Right ventricularperformance in essential hypertension. Circtdation 1980;61:156-162. 3. Ghali JK, Liao Y, Cooper RS. Cao G. Changesin pulmonary hemodynamics with aging in a predominantly hypertensive population. Am J Cardial 1992; 10:367-310. 4. Curtie PJ, Seward JB, Ghan KL, Fyfe DA, Hagler DJ, Mair DD, R&r
GS, Nishimura RA, Tajik AK. Continuous wave Doppler determination of right ventricular pressure: a simultaneous Doppler-catheteri&ion study in 127 patients. JAn Co11Cardiol1985;6:750-756. 5. Emirgil C, Sob01BJ, Campodonico S, Herbert WH, Mechkati R. Pulmonary circulation in the aged. J Appl Physial 1%7;23:631-640. 6. Fiorentini C, Barbier P, Gti C, Loaldi A, Tamborini G, Tosi E, Guazi MD. Pulmonary vascular overreactivity in systemic hypertension. A pathophysiological link between the greater and the lesser circulation. Hype&v&n 1985;7:995-1002. 7. Vaughan RW, Co&an TJ. Cardiopulmonary consequencesof morbid obesity. Li@ Sci 1980;26:2119-2127.
Effect of isolated Left Atrlal Enlargement on Mitral Annular Size and Valve Competence Masato
Tanimoto,
MD, and Ramdas
itral annulus is an integral part of the mitral apparatus and plays an important role in norAll mal mitral valve function. Normal mitral annular size and dynamics are important for mitral valve competence.l-5 The mitral annulus has been reported to be enlarged with left ventricular (LV) dilatation leading to mitral regurgitation, but the effect of isolated left atria1 enlargement on mitral annular size and valve function is not known. This clinical study investigates the effect of left atria1 enlargement on the size of the mitral annulus and mitral valve function. ... The echocardiographic databasewas searchedfor subjectswith normal LV systolic function and native mitral valve. Patients were included in the study if the following additional criteria were met: ( 1) technically adequatetransthoracic echocardiograms, (2) normal LV size and systolic function (both regional and global) to eliminate their confounding effects on mitral annular size and valve function, (3) absence of significant mitral annular calcification because it could affect the accuracy of measurementsand cause mitral regurgitation, (4) absenceof mitral valve prolapse becauseit could also affect the mitral annulus, and (5 ) absenceof rheumatic mitral valve diseaseor rupture of chordae tendineae. Of the 62 male patients who met thesecriteria, 25 were in atria1fibrillation and 37 were in normal sinus rhythm. The mean 2 SD age was 66 + 11 years (range 39 to 99). The principal clinical diagnosis From the Sections of Cardiology, Jerry 1. Pettis VA Hospital and Loma Linda University, toma Linda, California. This study was presented in part at the 67th scientific session of the American Heart Association at Dallas, Texas, November 1994. Dr. Pai’s address is: Cardiology (1 1 1 C), Jerry L Pettis VA Hospital, 1 120 1 Benton Street, loma Linda, California 92357. Manuscript received August 18, 1995; revised manuscript received November 6, 1995, and accepted November 7, 1995.
G. Pai, MD
included systemic hypertension (n = 14), coronary artery disease (n = lo), and restrictive cardiomyopathy (n = 9); among the rest, 5 were referred for evaluation of potential cardiac source of systemic embolism, 10 for evaluation of a systolic murmur, and 14 for evaluation of LV function. The patients were divided into 2 groups depending on arbitrarily chosen left atrial diameter cutoff: group I (n = 29) with a left atrial diameter of 545 mm, and group II (n = 33) with left atrial diameter of >45 mm. The echocardiograms were recorded with the patient lying in the left lateral decubitus position, and images were obtained in a routine fashion from the parastemal and apical windows. Various commercially available echocardiographic equipment with 2.5 MHz transducers was used; images were recorded on b-inch magnetic tape (super VHS tape) and the measurementswere made off-line using the commercially available measurement packages on this echocardiographic equipment. The cardiac chamber dimensions and LV wall thickness were recorded according to American Society of Echocardiography recommendations.6The mitral annular diameter was measured in apical 4and 2-chamber views between the hinge points of the anterior and posterior mitral leaflets in end-diastole, end-systole, and mid-diastole. End-diastole was defined as the frame preceding systolic mitral valve closure, end-systole as the frame preceding mitral valve opening in early diastole, and mid-diastole as the frame midway between end-systole and enddiastole. The mitral annular area was computed from these 2 diameters assumingelliptical geometry.7The left atria1area was planimetered in 4- and 2-chamber views in end-systole.The maximal mitral regurgitant jet area was determined by planimetry in apical 4and 2-chamber views, and the mean of these2 planes was used. Mitral regurgitation* was judged to be BRIEF REPORTS
769
study demonstrated
that
m SlnQlO ~GURE 3. Graphs compari
cl Deublo
baseline impedance
(Z), root-mean-square
voltage
(If),
the location of the dispersive elec- deliveredcurrent(II,andcaxeter tip tempemture (Temp) for a single and double distrode has no significant effect on persive electrode configuration for patients with an impedance > 100 f2 (n = 9). Vertica/ bars represent + 1 SD. l p <0.05, for comparison of single versus double ele&ode con~gumtions . impedance, voltage, c-nt delivery, and tip temperature duriug radiofrequency catheter ablation. In addition, the study also showed that 1. Hindricks G, Haverkamp W. Determinants of radiofrequency-induced lesion size: what are the important parameters to monitor during energy doubling the surface area of the dispersive electrode application? In: Huang SK& ed. Radiofrequency Catheter Ablation of Carresulted in lower impedance, higher current delivery, disc Arrhythmias. Basic Concepts and Clinical Applications. Armonk, NY: ~~c~tiptemperatures,particularlywhen~e
Fumra,
baseline impedance was >lOO CLThese findings may have imp&ant implications for optimizing radiofrequency energy delivery using currently available radiofrequency generators.
2. Natb S, Lynch C IQ Whayne JG, Haines DE. Cellular electrophysiological effects of hyperthermia on isolated guinea pig papillary muscle. Implications for catheter ablation. Circuhtion 1993;88:1826-1831. 3. Simmers TA, De Bakker JMT, Wittkampf FHM, Hauer RNW. Effects of heating on impulse propagation in superfused canine myocardium. J Am Co11 Cardiol 1995;25:1457-1464.
199~7-121.
Doppler-Derived Pulmonary AHerBal Systolic Pressure in Patients With Known Systemic Arterial Pressures Eric Abergel,
MD, Gilles
Chatellier, MD, Pierre Toussaint, MD, Jean-Claude Jo&l Menard, MD, and Benoit Diebold, MD
Dib, MD,
hypertensive patients, echocardiography is Isurenwidely used to evaluate the impact of chronic presoverloading on left ventricular (LV) morphol-
was to investigate Doppler-derived pulmonary pressure determinants in hypertensive patients. ... ogy and function. Bight ventricular hemodynamics Among 1,9QO hypertensive patients consecuhave been less studied. Elevation of right-sided pres- tively referred to the Broussais hospital hypertension sures was observed in hypertensive patients during clinic day-care unit, and registered prospectively in right catheterization.‘-3 With use of noninvasive an echocardiographic database, 476 were selected on continuous-wave Doppler ultrasound, the pressure the basis of the following criteria: ( 1) absence of gradient between the right ventricle and right atrium history or signs referable to heart failure; (2) absence during systole can be estimated from the peak ve- of significant echographic valvular heart disease; and locities in the tricuspid regurgitant jet using the sim- (3) possibility of assessing the following variables: plified Bernoulli equation. In simultaneous Doppler usual M-mode and LV mass measurement, diastolic catheterization studies,4 estirhation of right atria1 function parameters (mitral E-and A-wave velocities pressure at 10 mm Hg allows calculation of right measured at the annulus, E-wave deceleration time), ventricular systolic pressure, equivalent to systolic tricuspid regurgitation spectrum measured by continpulmonary arterial pressure. The aim of the study uous-wave Doppler, systolic and diastolic blood pressures measured by a nurse at the end of echoFrom the Service de Cordiologie, Centre d’lnvestigations Cliniques, graphic examination, body mass index (weight [kg] / et Service d’lnformotique Medicate, Hopital Broussais, Paris, France. height [m’]). Obesity was defined as body mass inDr. Abergel’s address is: Depanement de Cardiologie, Hopitat Brousdex ~27.8 kg/m’ in men and ~27.3 kg/m* in sais, 96 rue Didot, 75674 Paris Cedex 14, France. Manuscript rewomen. LV mass was calculated using Devereuxceived September 9, 1995; revised manuscript received and acmodified American Society of Echocardiography cepted November 1 1, 1995. BRIEF REPORTS
767
regurgitation peak velocity and a constant value for right atria1 pressure.4The pulmonary pressure level is clinically important to appreciate severity and tolerance of any heart disease. Usually, in a healthy population, systolic pulmonary arterial pressure is considered normal when <30 mm Hg. In the present study, in a population of treated and untreated hypertensive patients of both sexes,41% had a systolic pulmonary arterial pressurevalue >30 mm Hg. The systolic pulmonary arterial pressure level was explained partially by age, body mass index, and systolic blood pressure, the strongest predictor being age. Pulmonary pressure increase with aging has been demonstratedin previous studies in normotensive patients free of coronary disease’ as well as in hypertensive patients.3 Intimal fibrosis of the pulmonary arteries occurs early in life (before age 40) in normal subjects. An increase in the incidence of intimal fibrosis with increasing age could therefore result in a decreasein pulmonary artery distensibility.5 Concurrently, with aging, systemic arterial alterations are known to reduce systemic arterial compliance. In middle-aged hypertensive patients, a positive correlation between pulmonary and systemic vascular resistancehas been shown,‘j suggesting a common pathologic process in both lesser and greater circulation. In the present study, the relation between both age and elevated systolic blood pressure could reflect a significant reduced arterial compliance. In contrast, diastolic blood pressure, which roughly reflects systemic arteriolar resistance, was not correlated with systolic pulmonary arterial pressure. These observations were made in a population in which the usual published values for correlation coefficients were observed between age, blood pressure, and LV mass (Table I). We also found that obesity, which leads to increasesin pulmonary blood volume and cardiac output,’ was related to systolic pulmonary arterial pressure. However, becausepulmonary circulation is a low-pressure system with high compliance, an increase in pulmonary blood volume should not lead to an increase in pressure. To explain the relation between systolic pulmonary arterial pressure and obesity, one can hypothesize that a decreasein pulmonary distensibility must be associatedwith an increasein blood volume. Elevated pulmonary presTABLE I Correlation Matrix for Systolic Pulmonary Arterial Pressure and Potential sures in hypertensive patients could Explanatory Variables also reflect a backward effect of LV LVMi FS Sex DT SBP BMI Variables SPAP E/A Age failure. Our patients were free of clinical signs of heart failure, but iz 0.17 0.28 0.08 systolic pulmonary arterial pressure E/A -0.16 -0.54 -0.1 level was significantly higher in the LVMi 0.14 0.07 0.23 -0.14 subgroup with a predominantly E FS 0.13 0.29 0.05 -0.22 -0.13 wave than in the subgroup with a Sex 0.01 0.02 -0.23 0.03 -0.33 0.12 DT 0.18 0.37 0.04 -0.46 0.15 0.16 -0.06 predominantly A wave. A predomSBP 0.19 0.21 0.09 -0.26 0.28 0.003 -0.07 0.15 inantly E-wave flow profile may DBP 0.007 0.04 0.04 -0.11 0.29 -0.04 -0.02 -0.01 0.57 reflect normal, but also high, LV Correlation coefficients > 0.10 differed significantly from 0 (p < 0.05). filling pressure. However, this facBMI = body mars index; DBP = diastolic blood pressure; DT = E-wave deceleration time; E/A = E- to tor was not an independent predicA-wave ratio; FS = left ventricule fractional shortening; LVMi = left ventricular mass indexed to body tor of systolic pulmonary arterial surface oreo; SBP = systolic blood pressure; SPAP = systolic pulmonary arterial pressure. pressure.
cube formula, and indexed to body surface area. LV hypertrophy was defined as > 125 g/m* in men and >llO g/m2 in women. Data are presented as mean ? 1 SD. Means were compared with the Student’s I test. Relations between continuous variables were assessedwith the Pearson’s correlation coefficient. Variables independently related to systolic pulmonary arterial pressure were identified using multiple linear regression analysis. The study group consisted of 237 men and 239 women, aged52 2 12years(range22to87),ofwhom 20% were obese.Most patientshad mild to moderate hypertension(blood pressure153 + 19/92 2 14 mm Hg). LV masswas 96 If: 22 g/m2 in men ( 11% had LV hypertrophy) and 83 ? 19 g/m* in women (6% had LV hypertrophy) . The E- to A-wave ratio was < 1 in 44% of patients,and the E-wave decelerationtime was 166 2 48 ms (range 80 to 400). Systolic pulmonary arterialpressurewas 29.9 ? 4.9 mm Hg (range 20 to 52). Systolic pulmonary arterial pressurewas higher in the group of 209 patientswith an E to A ratio > 1 than in the group of 261 patientswith E to A ratio 51 (30.5 t 5.2 vs 29.5 + 4.5 mm Hg, p ~0.02). Systolic pulmonary arterial pressurewas significantly correlated with age, body mass index, E- to A-wave ratio, E-wave deceleration time, indexed LV mass, fractional shortening,and systolic blood pressure,the most predictive single variablebeing age (Table I). In the multiple regressionequation,only 3 variableswere significantlyrelatedto systolicpuhnonary arterialpressure:age,body massindex, and systolicblood pressure (multiple r = 0.34). Consequently,when arbitrarily defining the “normal” by the mean 2 2 SDS,systolic pulmonary arterial pressure was normal when <38 mm Hg in nonobesepatients aged 560 years compared with 47 mm Hg in obese patients aged >60 years. ... In sustainedprimary hypertension, higher values of pulmonary pressureand resistancehave been previously reported mainly based on invasive investigations, whereas few data are available using noninvasive techniques. With use of continuous-wave Doppler, systolic pulmonary arterial pressure is easily and accurately calculated by adding the tricuspid
768
THE AMERICAN JOURNAL OF CARDIOLOGY@’
VOL. 77
APRIL 1, 1996
We cannot exclude the presence of confounding factors, such as tobacco consumption and antihypertensive treatments. Inaccurate blood pressure measurement could also lessen the value of some correlation coefficients. Our results should be confirmed by a prospective study using a more precise blood pressure measurement, such as ambulatory blood pressure in an untreated hypertensive population. clinical lutelpretation ofsystullc pulmonary arterial pressure in hypertensive patients should take into accountage,body&x,andsystokbloodpressurevalues. For example, in obesehypertensive patients aged >6Oyears,avalueofsystolicpulmonaryarterialpressureasbigbas47mmHgcouldbecomiderednomal.
1. Davidson WR, Fee EC. Influence of aging on pulmonary hemodynamics in a population free of coronary artery disease. Am J Cardiol 1990; 65:1454-1458. 2. Ferlinz I. Right ventricularperformance in essential hypertension. Circtdation 1980;61:156-162. 3. Ghali JK, Liao Y, Cooper RS. Cao G. Changesin pulmonary hemodynamics with aging in a predominantly hypertensive population. Am J Cardial 1992; 10:367-310. 4. Curtie PJ, Seward JB, Ghan KL, Fyfe DA, Hagler DJ, Mair DD, R&r
GS, Nishimura RA, Tajik AK. Continuous wave Doppler determination of right ventricular pressure: a simultaneous Doppler-catheteri&ion study in 127 patients. JAn Co11Cardiol1985;6:750-756. 5. Emirgil C, Sob01BJ, Campodonico S, Herbert WH, Mechkati R. Pulmonary circulation in the aged. J Appl Physial 1%7;23:631-640. 6. Fiorentini C, Barbier P, Gti C, Loaldi A, Tamborini G, Tosi E, Guazi MD. Pulmonary vascular overreactivity in systemic hypertension. A pathophysiological link between the greater and the lesser circulation. Hype&v&n 1985;7:995-1002. 7. Vaughan RW, Co&an TJ. Cardiopulmonary consequencesof morbid obesity. Li@ Sci 1980;26:2119-2127.
Effect of isolated Left Atrlal Enlargement on Mitral Annular Size and Valve Competence Masato
Tanimoto,
MD, and Ramdas
itral annulus is an integral part of the mitral apparatus and plays an important role in norAll mal mitral valve function. Normal mitral annular size and dynamics are important for mitral valve competence.l-5 The mitral annulus has been reported to be enlarged with left ventricular (LV) dilatation leading to mitral regurgitation, but the effect of isolated left atria1 enlargement on mitral annular size and valve function is not known. This clinical study investigates the effect of left atria1 enlargement on the size of the mitral annulus and mitral valve function. ... The echocardiographic databasewas searchedfor subjectswith normal LV systolic function and native mitral valve. Patients were included in the study if the following additional criteria were met: ( 1) technically adequatetransthoracic echocardiograms, (2) normal LV size and systolic function (both regional and global) to eliminate their confounding effects on mitral annular size and valve function, (3) absence of significant mitral annular calcification because it could affect the accuracy of measurementsand cause mitral regurgitation, (4) absenceof mitral valve prolapse becauseit could also affect the mitral annulus, and (5 ) absenceof rheumatic mitral valve diseaseor rupture of chordae tendineae. Of the 62 male patients who met thesecriteria, 25 were in atria1fibrillation and 37 were in normal sinus rhythm. The mean 2 SD age was 66 + 11 years (range 39 to 99). The principal clinical diagnosis From the Sections of Cardiology, Jerry 1. Pettis VA Hospital and Loma Linda University, toma Linda, California. This study was presented in part at the 67th scientific session of the American Heart Association at Dallas, Texas, November 1994. Dr. Pai’s address is: Cardiology (1 1 1 C), Jerry L Pettis VA Hospital, 1 120 1 Benton Street, loma Linda, California 92357. Manuscript received August 18, 1995; revised manuscript received November 6, 1995, and accepted November 7, 1995.
G. Pai, MD
included systemic hypertension (n = 14), coronary artery disease (n = lo), and restrictive cardiomyopathy (n = 9); among the rest, 5 were referred for evaluation of potential cardiac source of systemic embolism, 10 for evaluation of a systolic murmur, and 14 for evaluation of LV function. The patients were divided into 2 groups depending on arbitrarily chosen left atrial diameter cutoff: group I (n = 29) with a left atrial diameter of 545 mm, and group II (n = 33) with left atrial diameter of >45 mm. The echocardiograms were recorded with the patient lying in the left lateral decubitus position, and images were obtained in a routine fashion from the parastemal and apical windows. Various commercially available echocardiographic equipment with 2.5 MHz transducers was used; images were recorded on b-inch magnetic tape (super VHS tape) and the measurementswere made off-line using the commercially available measurement packages on this echocardiographic equipment. The cardiac chamber dimensions and LV wall thickness were recorded according to American Society of Echocardiography recommendations.6The mitral annular diameter was measured in apical 4and 2-chamber views between the hinge points of the anterior and posterior mitral leaflets in end-diastole, end-systole, and mid-diastole. End-diastole was defined as the frame preceding systolic mitral valve closure, end-systole as the frame preceding mitral valve opening in early diastole, and mid-diastole as the frame midway between end-systole and enddiastole. The mitral annular area was computed from these 2 diameters assumingelliptical geometry.7The left atria1area was planimetered in 4- and 2-chamber views in end-systole.The maximal mitral regurgitant jet area was determined by planimetry in apical 4and 2-chamber views, and the mean of these2 planes was used. Mitral regurgitation* was judged to be BRIEF REPORTS
769