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Electrical and mechanical asynchronism in the cardiac cycle
Electrical
and Mechanical
Asynchronism
in the Cardiac
Cycle
of 100 Ventricular
Premature
A Study
by Simultaneous
Right
Beats
and Left Ventricular
Catheterization* PHILIP
SAMET, hi.~., F.A.c.c.,
LEONARD
SILVERMAN,
and ROBERT Miami
E
LECTRICPIL ventricular in
block
bundle with
block,
idioventricular
Parkinson-White premature
beats
or
be
stances-asynchronism ventricular
contraction
systole
the onset of ventricular semilunar Earlier
the presence
ventricular
Department
Florida, and
man
Howard
United
States
Institute,
of
or
the
in the basal percutaneous
of Fisher.2’ into
Two
the
left
of
middle
during
Sinai
ventricular
Hospital,
of Medicine,
Memorial
Hospital,
Medical in part
Health
and
by
a grant
or 0.01 exact
De-
National
Public
Heart
Health
corrections
Miami,
system
National from
Gables,
t Employing el a1.40 the delay composed
the
from the Heart
Service
Statham
P23.4.4
delay
P23D
Institute. 482
atrium were
gauges.
on the proximal or on the catheter,
on
in pulse wave trans-
ventricuiar
strain
for a system (passing gauge
nylon
gauge
0.006
to the
30
Braunwald for a system
catheter, cm
(125 long,
cm
in
and
to be 0.012
a
sec.
of 22 in. of polyethyl-
a 17T needle
polyvinyl
measured
and
was noted
composed
through
according
transmission
tubing
set,
and 0.00
All pressure curves _~. ___~
of Gordon
heart
polyvinyl
0.01
curves,
curves,
method
as described
to the nearest
employed.?
48 in. of black strain
strain
were made
delay,
in pulse wave
of a right black
needle),
Research
the
length), The
Florida
left
catheter,
for delay
for left ventricular
Florida, Institute,
by a grant
were
catheter curves
triple-lumen
systems
see for right
recording
ene tubing
States
P23G
of Surgery, Coral
puncture
strain gauges.
0.01 set
or
of a Cournand
Left
needles the
were recorded
et irl. ‘Q This
measured
the
into
double-lumen
in these catheter
by Gordon
Miami
of the
Research
Service,
mission
needle
P23D
curves
P23AA
#17T
Left ventricular
Statham
Appropriate
and left
and
lumen
long
A polyethylene
one
of a Cournand
Statham
has per-
of right
with
state.
by a modificatiot?’
transthoracic
7-in.
atrium.
through
ventricular
development
and the Department
Public
Right lumen
of Cardiology
Supported
H-2735,
of mechaniof
School
Hughes
recorded
postabsorptive
was performed
posterior
inserted
Association.
t United
supine
catheterization
technic
of the
Laboratory
Mt.
Section
of Miami
Florida.
Fellow,
the
of Medicine,
Miami,
Heart
in
of Medicine,
and Jackson
the
heart
in the presence
Cardio-Pulmonary
Florida,
University
of
to demonstrate
or absence
recording
curves the
partment
onset
catheterization24-31
simultaneous
Beach,
the
(opening
The
electrical
Right heart catheterization was performed in the usual manner,
of the isometric
failed
asynchronism
asynchroof
AND METHODS
studiesl-23
asynchronism.
*From
MATERIAL
and into the left ventricle.
and left heart
mitted
consequence
was advanced
conclusively
right
is a necessary
an opportu-
mechanical
asynchronism.
circum-
in the normal)
ejection
have
affording
whether
valve).
cal ventricular electrical
nism
asynchro-
such
either
(onset
of ventricular
beats, thereby
tachycardia.
under in
Florida
nity to determine
Wolff-
H. BERNSTEIN, M.D.,
M.D
premature
heart
the
ventricular
expected
Beach,
in ventricular
ventricular
mechanical
would
period
and
S. LITWAK,
occurs
complete
rhythm,
syndrome,
Theoretically, nism
asynchronism
branc’h
M.D.,~ WILLIAM
tubing sec.
but not an 18T and a Statham The
delay for a
THE AMERICAN JOURNAL OF CARDIOLOGY
Samet,
Silverman,
Bernstein, TABLE
Physical
Case
No.
Cathet.
!
+
Age
2
75
3
119
4
81
i
Rh.
I M
Comments ._~~_
HD
EH
murmur,
MS
mild
XF
Graham
CHF
III
49
F
Rh.
HD
EH
MS
36
M
Rh.
HD
EH
AI AS NSR
58
M
Rh.
HD
EH AS minimal
Rh.
F
33
in 18 Patients
Diagnosis
pectoris 5
I
and Diagnoses
1 Sex
214
1
Characteristics
183
and Litwak
HD
III
MI
Steellr
Recurrent
C
L.V.H.
II
Mild
AI AF angina
and
non-obstructive
Previous
AF II C
~.
ECG
AI
emphysema
MS
~_
mitral
in 1950
on Auoroscopy
Predominant
C:
~~
stenosis:
commissurotomy
D
AI AF III
C
EH
mitral
studied
pulmonary
also present
arterial
emboli;
9 weeks
after
also commis-
surotomy 6
85
Rh.
HD
EH
MI
MS
AI AF III
7
44
Rh.
HD
EH
MS
SB II C
Giant
D
left atrium
L.A.-L.V.
mean
dient Rh.
8
HD
EH
MS
NSR
1
I B
month III
Rh.
3
HD
EH
AI NSR
gra-
5 mm Hg at rest
post-commissurotomy:
C pre-op
Palpitations
I B
diastolic
less than
represent
only
symp-
post-commissurotomy-;
II
tom 10
66
Rh.
HD EH AS AI MS NSR
11
86
Rh.
HD
EH
MS
NSR
.4symptomatic
I B
1 year
I B
C pre-op Rh.
12
HD
EH
murmur Rh.
13
HD
MS
III EH
NSR
Graham
Diastolic
Steelle
MS
NSR
10 months
I B
III Cong.
14
HD
angina Rh.
15
EH
AS
minimal
AI
rumble
not heard
EH
post-commissurotomy;
C pre-op
Large
NSR
mean
systolic
LV-B.A
gra-
block
pres-
dient
pectoris
HD
apical
D
AS
AI
MS
NSR
III
Right
C
bundle
branch
after
mitral
ent Rh.
98
16
HD
EH
MS
MI
NSR
1
II C
year
commissu-
rotomy 17
Rh.
95
HD
EH
MS
minimal
AS AF
II
Arterial
C
emboli;
BA systolic 115
18
.48
~
F
Rh.
HD
EH
MS
AF
mild
CHF
III
Graham
D
Steelle
mal
aortic
ventricle Rh.HD
=
Rheumatrc
CHF
=
Congestive
NSR
=
Normal
were recorded recorder,
heart
heart
sinus
disease;
failure;
rhythm;
on a 6 channel
EH
MI SB
=
=
cathode
=
Enlarged
Mitral
Sinus
bradycardia;
MS
=
AI
Cong.
=
time lines were
Mitral Aortic
HD
at 0.10,
ray photographic
$ at a paper speed of 75 mm/set;
heart;
insufficiency;
=
0.04
or 0.02
made
Statham the
P23D
delay
Statham
for P23G
first system sures.
strain
gauge
36-48
in.
strain
second
was employed strain
tions
starting
gauge with
tems were employed $ Electronics 1959
equaled
system through #112
sec.
0.002
all right
described
above I).
(Table
I).
for left heart
Finally, and
erally a
pres-
When
used
premature
sysThe
three
Plains.
N. Y.
sys-
or miniLeft
Atria1 =
fibrillation;
4ortic
stenosis;
disease.
intervals.
Errors
electrocardiographic
of parallax
Nineteen
rheumatic V,
QRS
or Va was recorded, c.omplex
premature complex beat.
upright
premature
ventricular
When
complex premature
pressure lead
were heart
made
as a left
complex
in lead
beat;
(Table
I).
upright
as a right
a predominantly 1 or lead
gcn3 (see
in 18 patients
disease
a predominantly
lead in lead
curves.
1 or lead
was interpreted
beat;
was interpreted
mature premature
studies
or congenital
QRS
tricular
leads were recorded
1 and Vbr occasionally
II).
heart
#l 11. last
Table with
third
= AS
with the ventricular
leads
The
for all catheterizaThe
simultaneously
sec.
catheterization.
White
and a
was
The
catheterization
was utilized
for Medicine,
tubing tubing
measured
#69 (Table
system
0.004
of polyethylene
gauge
catheterization
P23G
APRIL.
in. of polyethylene
was used for recording
The
through tem
up of 36-48
AF
heart
set
murmur insufficiency.
were thus eliminated. One or more
system
stenosis;
LV-
not enlarged.
insufficiency;
Congenital
minimal
gradient
ven-
downward
ventricular
3 was recorded,
prean
1 or a downward
3 was interpreted a downward
QRS
as a right complex
484
Electrical
and
Mechanical
in lead 1 or a” upright complex in lead 3 was interpretcd as a left ventricular premature beat. Justification for this interpretation of the site of origin of ventricular premature beats from the prccordial or limb leads may bc found in the publications of Sodi-Pallareqx2 Barker,“” and Holzmann.~~ Barker33 states: “Left ventricular cxtrasystoles have the general appearance of right bundle branch block. Right ventricular cxtrasystolcs bear a close resemblance to left bundle branch block.” Barker PI n1.35 produced ventricular extrasystoles in the exposed human heart in the course of pericardiostomy and noted that right ventricular beats produced upright dellections in lead 1 : downward deflections were produced in extrasystolrs from the left ventricle. These findings were confirmed by other invcstigatotxg6~“’ \;l’ilson cf al.aY state: “There can be no reasonable doubt that, in ma” as in the dog, the potcn
Of these 100 were selected for study. The remainder were discarded because either the left or the right ventricular curve was considered technically inadcquatc for detailed time rneasurcments, gcner-aliy because of the dcgrcc of prentwtrrrity of the ventricular be,tt. The accurate measurc’nwnt of the onset of the right or left vcntricular pressure curve was dillicult or impossible when the extrasystole occurred early in the cardiac cycle.
KESULTS The
ing the predominant atria1 fibrillation These
time
relationships
rhythrnm-sinus are
right and left ventricular
pressure
01
QRS
relationships
premature
for
ljcats are
III and I\‘, respecti\cl>
The range for QRS ular
rhythm
in Ta l)lc II.
for conducted
the corresponding
listed in TatAs
for
pressure curves dur-
-are illustrated
intervals
complexes;
cur\c
to upstroke of left ventricinterval
is shown
in the
fourth column,
from 0.02 to 0.09 sec., corrected
for mechanical
delay in transmission
sure wave. vals ranging QRS
of the pres-
‘The mode electrical-mechanical
tervals arc also listed,
TABLE Time
electrical-mechanical
the right and left ventricular
tial variations of the right side of the precordium (leads V, and Vl) ordinarily resemble the potential variations of the anterior surface of the right vrntriclc. while the potential variations of the left side of the precordiurn (leads V:> and Vti) ordinarily resemble the potential variations of the antcrolateral surfacc of the lrft ventricle.” Over 400 ventricular prctnature beats wcrc produced in the exposed dog heart by Samet, Bernstein and Litwak.3” Right ventricular stinmlation resulted in a” upright deflection in Vi; left ventricular stimulation resulted in a downward deflection in Vi. Several hundred ventricular premature beats were recorded in ma” during- right and left heart catheterization.
Electrical-Mechanical
Asynchronism
from 0.04-0.06
to upstroke
in-
the most common sec.
of right
inter-
The range for
ventricular
pressure
II
Relationships
During
the Predominant
Rhythm
QRS-LV Case “umber
1 7
6 7 8 3 10 11 32 13 14 15 16 17 18
interval
QRS-RV
ECG lead
Basic rhythm
NSR .4trial Atria1 Atria1 ntrial NSR NSR NSR NSR NSK NSR NSR NSR NSR, NSR Atria1 Atria1
fibrillation fibrillation tihrillation fibrillation fibrillation fibrillation
RBBB fibrillation fibrillation
Lead Leads Leads Leads Leads Leads Leads I,ead Leads Lead Leads Lead Leads Leads Leads Leads Leads Leads Leads
-I
3 1 and 1 and 1 and 1 and 1 and 1 and 3 1 and 1 1 and V, 1 and 1 and 1 and 1 and 1 and 1 and 1 and
~
LV-RV
relationship (xc,
.I Range
.4trial Atria1
interval
(SK)
(XC)
0.03-O VS Va V’s Vti Vs Vc Ve Vg Vg Vg VFi Vg Ve V, Vti
Range
Mode
~ 06
1 0.03~0.05 0 0660 07 0.04~0.07 0.04~0 07 0.05~0.07 0.03-O 04 0 0550 07 0 0330.04 0 02-0.05 0.04~0.07 0 0550.07 0 0330 05 0.06-0.08 0 0660.07 0.04~0.07 0 08-0.09 0 06-0.08 0 0660 08
Range
Mode
Mode
_
’ 0.05 0.04 0.06 0.04 0.05 0 06 0.04 0.06 0.03 0.05 0.06 0.06 0.04 0.06 0.07 0.05 0.08 0.06 0.06
0 .04--O. (16 0.04-O 05 0.04-O 06 0.03-0.06 0.06~~0.08 0.04~0 07
0.05 -0 07 0.0330 07 0.06 0.07 0.09~0 11 0.07-0.10 0.07-O 09 0.05-O 06 0.05 0 07
TITI:
0 05 0 05 0.05 0.04 0.07 0.04 0 08 0 09 0.04 0.07 0.06 0 06 0 05 0 08 0 10 0 08 0 08 0 05 0 05
AMP:RICAN
to +0.01 0.00 to +0.01 -0.02 to 0.00 -0.03 to +o 01 +0.01 to $0 02 -0.03 to +0.01 +o.oi to +o 05 +o 02 to +o 03 0.01 to +0.02 +0.02 to +0.03 0 00 to +0.01 -0.01 0 00 to -0 01 to +o 03 0.00 to +o 02 +0.02 to +0.04 +o 03 to +o, 04 -0.01 to +o 01 --0.03 to -0 01 -0 01 to +o 01 0.00
JO”RN.41.
OF
0 00 +0.01 -0.01 0 00 +0.02 -0 01 +0.04 +0.03 +0.01 +o 03 0 00 0.00 +0.02 +0.02 +0.03 +0.03 0.00 -0.01 -0.01
C:ARDIOLOGY
Samet,
Silverman,
Bernstein,
TABLE Electrical-Mechanical
Time
III During
Right
Ventricular
LV-RV relationship
QRS-RV interval
QRS-LV interval
Case number
Relationships
485
and Litwak
Premature
Electricalmechanical correlation
1
Beats
Electrical-mechanical delay
(set)
(see
0.06 0.07 0 05
-0 03
NO
0.09 0 07
-0.02 -0.02
No No
None None NOM
3
0.12
0.13
+0.01
NO
Both ventricles
7
0.15
0 07
-0.08
Yes
Left ventricle
8
0.12 0.07
0.07 0.03
-0.05 -0.04
Yes
Left ventricle
Yes
None
0.12
0.15
0.03
NO
Both ventricles
0.07 0.07 0.08 0.08 0 .08 0.11 0.10 0 08 0.07 0.08 0.08 0.08 0.08
0.06 0.07 0.08 0 08 0.07 0.10 0.07 0.07 0.07 0.08 0.08 0.08 0.08
-0.01 0.00 0.00 0.00 -0.01 -0.01 -0.03 -0.01 0.00 0.00 0.00 0.00 0.00
No No No NO
Non? None None
0.10 0.12
0.09 0.11
-0.01
NO N0
None
-0.01
0.06
-0.06
Yes
Left ventricle
‘SK)
1
0
9 11
14
15
09
0.12
None None None None
NO NO
NO No No No No NO
NOlIe
None
None None None None
NO
Left ventricle
curve interval
is given in the fifth column,
0.03 to 0.11 sec.
The most common
tervals are 0.05-0.08 The
right Thr
to +O.Oj
ventricular-left
stroke treme:
ranyc
WC.
prcccdrd
ventricular
up-
are shown in the sixth colof these values is -0.03
That
than 0.11 set has been defined as showing electrical-tnechanical isometric
sec.
stroke relationships umn.
from
mode in-
is. the right ventricular
the left by 0.03
the left ventricular
upstroke
Right Ventricular Premature Beats: right ventricular
set
in Table
up-
electrical
set at one expreceded
delal- in onset of ventricular
contraction.
III.
premature
In 20 of the 24 premature
asynchronism
mechanical
asynchronism
contraction.
Twent)--foul
beats are analyzed beats,
is not accompanied
b)
in onset of \-entricular
In 20 of the 24 beats. the time re-
that of the right b)- 0.05 set at the other extreme.
lationships
The
tricular contraction falls between - 0.03 SPC and fO.03 sec. In 18 of the 24 complexes, the QKS
nontlal
range.
therefore,
somewhat
arbi-
traril!. has Iwen defined as -0.03 to +0.03 see. An)- lrft-right \.entricular upstroke relationship \vithin thi< intcr\,al is defined the normal QKS
range.
to \ entricular
In
as falling
a similar
upstroke
within
fashion
interval
any
greater
to onset
between
onset of right and left \-en-
of ventricular
contraction
interval
is
normal, that is, less than 0.12 sec. In 4 beats the left ventricle alone is delayed ; in 2 beats twth ventricles
are delayed.
486
Electrical
and
Mechanical TABLE
Electrical-Mechanical
Time
QRS-LV interval (WI.)
0 0 0 0 0
QRS-R\ i,terv:rl (SK)
+o -0 -0 -0
03 01 02 03
1)OR
0 13
+o
05
0 08
0 00 14 0 11
+n 01
n 12
n 15
+o
03
0 12 0 II
0 16 15 14
n
G +o
:: 03
12 0 13 0 13
0 n 15 17 0 16
G +o
:: 03
0 0 n 0
0 0 0 0
+o +n -0 -0
04 04 03 03 02
n IO
09
+o
18 I4 05 OS
II 14
0 16
+o
12 I? 13 14 12 10 14 13 16 16 0 13
0 0 0 0 n 0 0 0 0 0
$:: +o +o
n 13 13 1) n pi 0 I5
0 I6 iI17
0.04 n 05
n
16 16 1s 1s 12 15 17 17 12 16 16
vmlri(
Both Both Borh Right Both Rorh Both
ventrrcles ventrirlrs ventricles ventricle ventricles wntricles ventricks
;:
+o
02
0 OR 0
-co
04
0 WI 0 00 0 12
+o
0 0’9 0 10 0 13 0 10 11 07
0 13 0 13 0 09
$0 01
10 0 11
+o 05 - 0 (IL n3 n on +O 02
+o +tr
0 no 03 01
0 12 10 0
::r S’i
II nh 0 Oh 0 OH
0 n 0 0
+o +o -0 +o
: :: 0 Oh n 09
0 11 13 0 IO 0 14
to + 0 08 05 +(I 04 +o 05
I6 II OS I6
O’J 05 01 OR
n OH 10 0
0 18 13
::
z
13
0 no
0 IO
+o
01
15
0 11
0 08
-0
03
11 0 OR
”0 13 10
$::
::
n 10 0 13
0 12 14
$ir
::
0 1.3 0 13 0.11 0 07 0 10 n 14
II 0 0 0 0 (I
0 01) I) 00 +n 01 +0 06 +o 03 -0 01
Borh vrntriclrs Both venlrirles Right ventricle Right ventricle Riqht ventricle Both ventricles
0 14 0 15
0 15 0 16
+r, +o
01 01
0 12 I3 0 10 0 14
13 0 14 0 13 15
::
8:
Both Both Horh Both Right Both
I6
17
18
I
~
0
lc
04 0 00 03
$j
II 0’1 00 II 0 07
Right
:: 0: 01 0 00 +o OS +o 03 +o 04 -0 04 0 00 +n 03
16 0(I 17
n 13 0 06
Beats
-0
0 0 0 0 0 0 0 0
n
Premature
+n 01
0 n 09
14 10 OX 08
Left Ventricular
L\‘-RV rrlarionship (WC)
0 IO 0 11 0 05 0 05
0 II 0 12
IL
IV During
07 12 07 OH
0 II
1 II
Relationships
Asynchronism
13 13 12 13 13 13
ventricks ventricles ventricles ventricles ventricle ventricles
I THE AMERICAN
JOURNAL
OF
CARDIOLOGY
Samet, Left
Silverman,
I’entricular Premature Beats:
Scventb--six
ventricular
premature
Table
In 52 heats mechanical
IX’.
beats
are
analyzed
set of right and left ventricular -0.03
between
complexes
lnechanical
In 1 beat,
the right
pressure
spite origin of the premature In 22 complexes,
contraction
was within
ventricular
onset
cles. ular
In
32
complexes
contraction
despite
origin
three
beats,
complex
?f
set)
for both
the
onset
origin
(QRS
but
ventri-
both brat
sides in the
only right venHowever,
of the
the
to
of ventric-
on
premature
Findiq r:
cal asynchronism QRS
limits
right
in
premature com-
ventricular
was not so dela\-ed.
Swnmary tricular
the onset of ventricular normal
on the left side, the left ventricular
\\-as delayed
pre-
1,~ 0.04 sec. de-
was delayed.
despite
is present.
beat in the left ven-
delayed
of the
contraction
complex plex
was
In 23
upstroke
In 19 complexes
left ventricle. tricular
<0.12
curves
SK.
as)-nchronism
cedes that of the left ventricle tricle.
bet\veen on-
and +0.03 ventricular
in
asynchro-
nism is not present, the relationship falling
Bernstein,
premature
co~nplrxes.
asynchronism \-entricular
the opposite
in 72 of 100 ven-
beat
considerable
(with
the
as)nchronism upstroke
in the left ventricle.
interest
was
preceding
stances? despite premature silateral
the univentricular
beat.
in-
in 34 in-
onset of the
In three instances only the ip-
ventricle
traction,
It is of
that the QRS-ejection
ter\-al was dela)-ed for both ventricles
was delayed
a finding- opposite
in onwt of conto that
to he ex-
pectcd. Examples
of these relationships
in Figures I to 4.
are illustrated
In Figure 1, the left ventricu-
lar upstroke precedes the right t>)-0.03 set in the first and sinus
third
beats.
corrected
beats, The
lar upstrokes
ventricular
for pulse wave precedes
conducted beats
are
In the middle complex,
premature
are identical
right ventricle Figure
the normally
right
by 0.01 sec.
a right ventricular
beat, the ventricuin time;
transmission
when cordelay,
the
the left b)- 0.01 sec.
In
2, the right \.entricular upstroke precedes
and last beats.
type
that of
In one in-
that of the left 11~ 0.04 set, despite origin of the premature
the left by 0.01
curve on the side of origin
was noted.
stance, reverse mechanical found, the right \ entricular
lwats with widened aherrant mechanical
QRS complex preceding
ventricle)
In 27 complexes of the expected
pressure
mechani-
487
Litwak
of the premature
rectcd
In summar!,
was absent
and
corrected
set
in the normall>- conducted The
b)- 0.01 sec.
a left ventricular
right l-cntricular
first
curve is
In the second complex,
premature
beat, the left ventric-
Fig. 1. In the normall!, conductrd first and third beats, the onsrt of lrft ventricular contraction precedes that of the right ventrick by 0.03 WC. In the right ventricular premature beat (second bvat), the right ventricular onset precedes that of the left by 0.01 set when the former is corrected for pulsr wave transmission dclav. Note however that whereas the left vrntricular upstroke prt-CP~PS that of th? right in the first and last beats, in thr Aiddlr brat the rtverse is true. APRIL,
1959
Electrical
and JZlechanical
Asynchranisrn
Fig. 2. Mechanical asynchronism is absent in the first ventricular premature beat (second complex) but is present in the second (third complex). Srr text.
Fig. 3. Mechanical asynchronism is absent following the left ventricular premature brat (first complex). See text.
ular upstroke is 0.01 set ahead of the right, when
corrected
a suitable
left ventricular
QRS-right third
correction
(0.01 set) is applied to the However, the ventricular interval.
complex
chronism,
demonstrates
mechanical
asy-n-
the left ventricular upstroke preccdIn Figure 3 the left
ing the right by 0.06 sec. and right ventricular
upstrokes
arc identical
in
I)\ 0.01
set).
cal as)-nchronisrn
is present
lar curve side.
is slightly
stroke is ~vcll ahead
In the first complex
mature
beat,
a left ventricular
the left ventricular
upstroke
prcis at
portion
same phenomenon dle beat of Figure
the same time as that of the right, if 0.01 set is subtracted from the QRS-right lcntricular
left ventricular
upstroke
stroke precedes
to correct
for
mechanical
pulse wa\se transmission. Figure 4 illustrates one further normal precedes tracings,
delay
in
+
first tIeat, the left ventricular
How-
is that in the
of that on the right premature
beats,
of the left ventricular
up-
of that on the ri,ght.
The
is demonstrated 1 where the mrrt
contraction
in the midof right and
is identical
in time,
the major portion of the right ventricular
relationship point.
ahsad
In the left lcntricular
The right ventricular sec.
in all three
first beat, ti:c entire upstroke of the left Ientricu-
the largest
1,~ 0.01
next 3 heats are
beats, and mechani-
U-W, the point to IX emphasized
the normal beat, the second and third complexes. curve is corrected
The
premature
up-
that of the left, a reversal of the
notrd in the two normal
I~ats.
In the upstroke
the right 1)~ 0.02 set (0.03 set on the before the right ventricular curve is
Many studies have been reported the problem of whether mechanical 7X1: AMERICAN
~OURXI\L.
relative to asynchro-
OF CARDIOLOGY
&met, nism
in onwt
essary
of ventricular
consequence
drpolarization ture
beats
rcct
evidence
produced and
then
noted
a del.ry
\Volferth from
tion
in
front
In the
sul+cts
itlock,
of the QRS carotid
Iwndle
t)ranch
also employed
Ijinations
01’ the electrocardiogram. apes
these
and
studicx
asynchronism
the
conclusion
had
was
calectrical txen
complex
to
and
of aor-
as a result
of a
simi-
ranged
0.32 see.
data
Nichol”
of the carotid
al.’
la)~d
heat),
from
the from
0.16 and
and
to 0.28
On the other \\-a\ c \vas must
branch onset
curves
and
I~lock. comparison
Kich-
Eppingcr
of
right that
in the carotid
\vith bundle
and Sch\vedel”-?”
side
In none of the and
left
possible.
ICatz’” noted
not delayed
patients
Metlnick
hand,
see. avcsraqc
on the ipsilatcral
It-as a direct
pressure
upstrolx
have ;~lso pul)lishcd as demonstrating dc-
of thcsc ventricular
ix as
wntricular
et al. lo
activity
Ixtwccn
QKS
Ixat
co-\~~orkers.“~‘”
Ixrndle
studies
the
Goldberg”
intwpreted
mechanical
\vhen
to carotid
in sul>,jerts with relationship
0.11 to 0.22 WC,
a right
QRS
‘1 Irft
to carotid
prctnature
1 (therefore
,lnd Fllin(rer J_
in man
1 (thcwforc, the QKS
In 13 casts,
Liosslnan
Cournand z
in lead
Jxat),
inter\xl
com-
Incchanical
from the onset
ranyed
in lead
prcnlaturc
ards,
From that
the)
the inter\xl
of a \.entricular
upright
the
trac-
reached
demonstrated.
to thv same conclusion
lar stud!-.
the
sound
pulsations.
that
of vcntriculai
to the onset
premature inter\.al
et
pulse
tracings
artcry
I)ctween
heart
\\-a~ do\yn\\xrd
0.17 see.
pulsa-
various
wnous
roc~ntyenkvlnographic pulmonary
correlation came
cartliofirams,
beat
a\-er:lyc
intn.\.al t)luck,
co~nplex
upstroke
sec,a~‘crageO.l7scc.\l’ol-
and Margolies
and
this
found
Ihc site of ori$n
11
frown
a\-cray::i~ 0.1 1 see.
tr-acin,Ts, tic
artery
his associates9
i)cats \\ith
of chv QRS
ventricular
complcs
normals
0.09 to 0.15 set, with
z
studied
me-surin,q
and
corrclatc
artcxr\. pulse Ii-it h fair SUCCCSS. In 10 casts. \VllM the QKS co1np1c.s of a ventricular prcmaturr
prol)lems
Rothlwrgcr’
in the p~~lsc \sa\~
In
lan~e\~as0,16toO.?l
ings,
only indi-
Ixlsic
could
189
I,itbali
premature
IAock.
IAock esp
tmnch
nclck.
rangrd
forth
the
of the right
the,
reports
and
C&e:<
in
prcma-
and Margolies”~’
the onset
the hqinniny
is a ncc-
t)ranch
and
Iwanch
C;ISCSof left Imndle intcwal
with
Eppingrr
I)rmdle
that side.
Ijundle
of these
dealing
ol,tainc*d.
Bernstein.
asynchronism
in ventricular
complete:
In the o,real majorit!was
contraction
of clcctrical
as occurs and
Silverman,
branch wrrr
IJock.
the pulse arter\
in
Sanwt, 21I)lc to dcmon-
490 strate
Electrical ventricular
only one-third
mechanical
and Mechanical
asynchronism
dle branch block studied b). simultaneous kymography monaq
of the ascending
artey.
confirmed
in
of 61 patients Lvith complete
Rraunwald
aorta
in 15 patients
electropul-
NORMAL
LNSR
d
NORMAL
(NSR
OR
with complctc fortunately.,
I))- simultane-
1
of the right and left ventricles with
bundle
txanch
in the
subjects
AFIIRANGE)
.
LVPC
AF)(MODEI
0
RVPC
f
’
i
i
!
txanch
Mock and In
right bundle Ixanch
vrctorcardiographic
available
OR
complete
Mock, 5 \vith left Ijundlc
and Morrow4’ have
these findings recentl!
ous catheterization
hun-
and
Asynchronism
Mock.
Un-
data \vere not
with
right
bundle
. :
’
l
d
I
-.08
!
I
I
- .04
_.06
I
-.02
.oo
I
+.02
I
I
+ .04
I
I
I
+.06
+.oe
The normal range has been taken as Fig. 5. Time relation between onset of right and left ventricular contraction. -0.03 to +0.03 sec. That is, at one extreme the right ventricular upstroke precedes the left by 0.03 see (-0.03); at the other extreme the left upstroke precedes the right by 0.03 xc (+0.03). The lowermost row is the mode figure for The upper row is the range data for conducted beats-hence there are conducted beats in 19 studies in 18 patients. The two intermediate rows arc for the prematur? ventricular beats. twice as many points as in the lowermost row.
a
8
f r---1
00
02
04
06
I
I
‘3
‘5
I 1 11I
I
T
08
Fig. 6. Time relation between onset of the QRS complex conducted QRS complexes, either during atria1 fibrillation
and right ventricular contraction. or normal sinus rhythm. THF;
AMERICAX
JOURNL
“Normal”
OF
refers
CARDIOLOGY
to
Samet, Ijranch
block,
so that
trophy
ma); have
branch
block.
h!.pertrophy
right
mereI\-
Ijundle
branches
are
with
and left heart
these
Wipers”’
employing
defect
branch
this older
of
be tlcmonstrarrd
results ure the
from
the
the reactions
to
J the
mode
lowermost
figures
uppermost
row
range,
between
yen-
time
relation
These results could not Ix confirmed tricle.” 1,~ &met, Bernstein and Litwak.‘“’ The data
plex
and
in this present
normalI\-
and left \,entricular
the corresponding
pressure
ing simultalleous tion.
In
rig-ht and asynchronism conducted
Fig. 7. meaning APRIL,
deal with comparison
right
most left
dur-
catheteriza-
the limits
Iwats was not noted.
premature observed These
the onset
i.c..
onset
in the
during findings
complex
[Ieats:
inter\,al
-0.03
the
row
and left ventricular
sec.
of the
QRS
6.
is normal
data
complexes
(mode)
and
circles The
‘I‘he com-
for
the
are gi\,tn uppermost
are for the right circles
are for the
QRS-right
\rentric-
or minimall!-
dela!,ed
premature ventricular
contraction.
left
contraction
The
the closed
lxats.
QRS-right
to $0.03
ventricular
QRS
and
on
fall in the normal
onset
for the right \,enrricular ever.
of the right
systoles
The open
left \.cntricular ular
It is readil!.
Figure
lou-c.rmost
row (ranqc).
on the
are shown
II).
of most
conducted
;
of points
for the range
of right in
row
onwf of
is gi\.en
(Table
ljctween
is illustratrd
ventricular of
beats,
Tirnc relation br*tween onset of the QRS as in Figure 6. 1953
on
olxaincd
(72 of 100 lxats)
ventricular
be!-ond
contraction
curves
and left heart
instances
of the
of the In Fig-
between
contraction
horizontal
to 0.08 of a second
study
one-
analysis
relation
ricular
premature
in the other
could
approximarcl>-
Graphic
time
and lc.ft xnt
ventricular
than
asynchronism
in only
seen that
earlier
on the
of In
artery.
of the prcsc’nt study is of intcrcst.
corresponding the
studies”-‘”
pulmonar)-
mechanical
two
of right
appreciably
stud!.
and
earlier
electrok~t~lograph)-
of the sul),jccts.
right
the intraventricular
during
.~~M~J.c~s(!f l/w ihtn;
Mock
combined
recorded
aorta
or
block:
noted
simultaneous
In the first place, the pressure within sides. the ventriclr. stimulated lxgins to rise from 0.03
onset
differ
with those
third
491
Litivak
the ascending
in the
txanch
from
sides of the heart,
stimuli
agree
lesions
data
are simultaneously
left and right
hyper-
studies
bundle
and
bundle
catheterization.
notes : “\Vhen
pressures artificial
septal
bilateral
in human
Bernstein,
ventricular
postmortem
of the side of the I)undle
consistc’nt
right
right
in right
to intcaratrial
nlitral stenosis. The Yatcr.,$; which re\.ealcd regardless
ventricular
simulated
as may occur due
Silverman,
lwats. intcr\.al
“h-ormal”
Howis (~I)-
has the fame
492
Electrical
viously delayed
in most left \-entricular
ture systoles. to the
This latter
conclusion
asynchronism right
the
the
right
tion
of Figure
premature
tricular
heats.
beats,
In short,
dela!-cd
for both ventricles Ijcats.
,for
C0usP.r
Lack
question
chronism
discussed
scrvations
muscle
ventricles deep
t)oth similar
trical
ventricular
ficult
to conceive
showed
the
abolition
electrical
of a frog’s resulted
recorded
Findings
in patients
right with
patients
and left heart
bundle to date.
was
almost
ahscncc
tu sup-
\.entricular of
he related of the
branch
in both
Electrical cur
Ijundlc
\rcntricular
to the
fact
that
conduction
s\steln
IAock have
frcqumtl)
bundle
ventricular
in man
in
tx-anchcs.
heart
block
with
wcrc tion.
branch
an
heats
problem
ventricular
is a necessary
in intact
indicate
as) nchronism
that
in ventricular
prcmsturc
of simultaneous
unset at)sent
I)cats
QKS
produced
contraction
in 72 of 100 Iventricular
heart
mechanical seen durheart
asynchronism
isometric
aljerrant
catheteriza-
coml)ined
Mechanical
of ventricular
the course
is infrequently
ing the course catheterization.
cons?The data
during
ri,yht and left heart results
is a
as)-nchronism
situations.
man
M:olff-
mechanical
ventricular
in the alxn,c
obtained
rhythm, paper
of whether
oc-
complete the
This
as),nchronism
The
and
syndrome.
of electrical
may
block,
idio\,cntricular
premature
of the
quence
asynchronism
in bundle
\:cntricular
with widcncd
pretnaturr
in was Ijeats
co~nplcxes.
REFERENCES
tIeat while
branch
Our
and
data
on
catheterization block are limited
In one
patient
\vith
complete left bundle branch block (with vectorcardiographic as well as electrocardiographic the onset of ventricular data verification), contraction
lesions
in cardiol-
continue
electrocardiogram
in Bundle Branch Block:
simultaneous
shown
tcxt))ooks
it is ol
in almost
Berthad and Bertha unchanged. have come to similar conclusions.
remained Schutzag
to two
there which
t)e separated.
of the mechanical
simultaneously
of elec-
Secondly,
perfusion solution
is
it is dif-
and
txmdle
of simultaneous
contracting
can
complete
such as occurs
has
in the literature cycle
that
a calcium-free
complete
in the prcscnce
so.
may
previ-
data:
\Yith complete
The
studies?”
as 1~11
and
mechanical
in patients
block.
ventricular
condi-
asynchronism since
of
histologic
study
both
these
ventricle
branch
recent
papers,‘“.“”
concept
Parkinson-White
function
Kushm&”
Under
mechanical
cardiac
that
a dominant
also doing
that
in the
MinesJ7 with
is prohal)le
of one
two
muscles)
ventricles.”
observations
demonstrate
the
ventricle.“”
asynchronism,
tf,e other
of the foul
of each
have
cvcn
oh-
and t)ull)ospiral,
mechanical
nc)t to Ix cspcctcd
several
each
two
bulhospiral
\,iewx
\.entricular
events
: “It
bundles
in emptbinq
heats,
comprisinp;
and
has stated
cspressed
without
L\Yth rc-
sinospiral
sinospiral
muscle
tions
has been
detai1.43
First,
bundles
the
Morro\\,
electrokymo,yraphic recent
that of the
asyn-
frequently
to the formation
Gregga”
.1 synchronism:
mechanical
premature
(superficial
contributes
are
more
are pertinent.
discrete
deep
such
in some
to ventricular
and
M~chaniral
is not found
pre\iously spect
of
port
and
preccdcd
and
to note that
ogy,‘“,”
asynchronism
ventricular
is minimal.
as to why
of Braunwald
right
confirmation)
In view of thcsc data
asynchronism is
complete
vector
upstroke
I+ 0.03 sec.
interest
onset
with
(with
the left \,entricular
ously puhlishcd
\ren-
block
right
with
durin,y left ventricular
delay
in another
branch
as those
\:entricular
right
l)undle
on11
left ven-
QRS-ventricular During
the bilateral
The
right
of
inspec-
during
but not during the
not
the QRS-left
is also delayed
Ixats.
Ixats,
but
However,
that
tricular
premature
is tlelal-ed
systoles,
7 reveals
interval
the onset
Asynchronism
t\Vo ventricles:
lead
mechanical
since
contraction
premature
might
ventricular
is to he noted,
left
prema-
ohscrvation
that
\rentricular
with
and Mechanical
simultaneous
in
the
2. EPPINGER, H. and KO.I.HHERGI~, W.: Urber dit. Suksrssion dcr Kontraktion dcr beidrm Herzkammern. %mlr,ilh/. f. Pllysiol. 24: 1053. 1910. 3. KATZ, L. N.: ‘I’hr asynchronism of right and Irft ventricular contractions and the independent variations in their duration. .lvi. J. Phyriol. 72: 655,
1925. 4. KATZ, 1.. N. : ‘I‘hr asynchronism
of thv contraction procrss in the right and left ventriclrs. Am. .f. Phqriol. 72: 218. 1925. 5. WIGGERS. C. .I. and BANVS, hi. G.: On the indrTHE
AMERICAN
JOIJRNAL
OF CARDIOI.O(:Y
Samct, prnderlw
of clcctrical
thr malnmalian
Silverman,
and mechanical
activity
501
‘l’hc
side, of the significant
type
01 bundle
branch
lesion
in thr
7-r. :l.
block.
22.
.Im.
nism in contraction type
%fARGOLIES.
town
I’hvu-
ofthc of
E&17i ./. 10: 425. NICFIOI., .\. D.:
in the so-called
branch
block.
23.
branch
of lead
: 72,
Am. Heart J. 9
block.
24.
9. CASXS,
hf.
K..
B.AT.TRO. A..
dlaqnosis
of the
extras)-stoles
and
Goh.z.4~~~.
site of origin
in human
brings.
of
anomalous
Hmt .J. 11.
stimulation
33
RI~ARUS.
atrioventricular
: 308,
25.
electrical
the cardiac
cycle
ical states. &URN
in normal
and
HARVEI.. R.
M.,
brtwwn
26.
I.:
rvclr
Rela-
events
and
.JR.:
28.
of qjection
hit. Hart .J.
of thr left ventricle
Asincrrmismo de
in bun-
rama.
Rw.
ventricular
arpnt.
30.
in bundle
17fl. .21(//.63:
1930.
830.
C.
.J.:
mxnmalian
The
GRoEUkL.
F.
asynchronism brw. 18.
surface
Transient
E.:
.lrch.
31.
studirs.
of
the
stimuli.
pathological
of the
heart
z&h.
hrart
32.
cham-
block:
33.
19: 750.
G. F.. GII.I.I(:K. W.
bi.:
ies of awnchronism ROSENMAY. K. H.. trawntricnlar
F. G., BOONE. B. R.. and Electrokymo~raphic
of ejection
ScHwEDer. .I.
B..
Elrctrokymoqraphic 1959
P:cK.
34.
stud-
from thy vrntriclcs.
Thormc
ALH~MME,
.I.:
left
:
JR.
and
P..
anricu.-lrch.
The
broncho-
awicular
presswc.
1953. G.. and
~~ALMSTROM,
pressure 718.
Uccr.~.
measuwments
I,. G.: in
man.
1953.
GOLUBERG. H.. DICKENS, 6., KABER,
!VOOD,
E:.
Simultaneous
G., and HA\-es,
(combined)
cathctrriza-
heart.
I$p~~rr.J. 53:
.&.
H..
W..
SUTTERER,
F.:
The
SWAIV, H. J. C.,
trchnic
and
strnmentation
problems
associated
zation
left
of the
of the
side
and
special
in-
with cathrtrri-
htart.
Pror.
sst/g
Mayo C1zu. 31 : 108, 1956.
R~ORROW.
G..
A.
BRAUNWALD.
E. H.:
transbronchial
Left
in physiologic
L. hl., effect
MALLER.
.1. A.,
cathctcrization
Technique
and diagnostic
by
and
appli-
inlwtiqations.
1957. P., BERNSTEIN. W. H., SII.VKR-
TURKEWITZ.
H.. and
of exercise
upon
ventricular
gradient
SODI-PALLARES,
E.,
heart
route:
Circdation16: 1035. I.IT\VUL R. S.. S,*nre-r.
B.\RKER.
J.
LESSER.
the mean
11. C.:
diastolic
in mitral
lrft
stc‘nosis.
195:.
D. and CALDER.
AVu~r’ Hnrc~
K. M.:
Mosby.
St.
I,onis.
1956.
p.
The l?nifmlnr Electrucnrlfi~l~~nl,r. .I
M.:
Review
KAIZ. of
thr
I,. N.:
Press, 35.
In-
literature.
196. 1950. S~MET,
HOL~\IANN. M.
.4pplrton.
New
York,
P..
studies
hfARVIN,
S., ~~ACLEOD, heart.
1052.
of
MED~CK. the
H.:
rrlationship
process
tion of the human 1932.
A. G.,and
ALESANU&.R..~.:
observed
Am. Heart J. 5 beats
Staples
p. 458.
H. M. and OUGHTERSON,
of premature and
1952,
excitatory
human 36.
: Clinical Elrctrocurnio,ortlphv.
New York,
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block:
‘4rch. I?,/. .2lcd. 86:
APRIL.
in
.J.
transbronchiqur.
of
Clinicnf Interpri~lntmn.
Am. Hm,t J. 35: 971. 1948.
21.
ob-
p. 478.
~:IIAMRC RLAIN.
20.
recordings
cathrtrrization
42’). Electro-
Med.
in
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de la pression
LINDEN, K.
II/ Electrocnrdio~m,hhy,
1944.
Int.
M.,
voie
./. Thoruric Sur,~. 34: 449, and
br-
1952.
and
auricnlar
atrial-left
101-_ ELLIN(:ER.
V. 0..
Thr
1925.
Physiological
E\,brr. ,Zled. @ Surq. 2: 352.
KR1m4RIl.44~.
Ventricu-
reactions
to artificial
of the function
cardiocraphir 1’).
B@RK,
thr
3: 325,
block.
J.
mcasnrement
M~V,
346.
11.:
branch
muscular
ventric-les
4m. .I. I’hrs~of. ‘3: 1’.
:
.I. B.:
asynchronism
disease.
La measure
par
ALLISON. P. R.
cation
lar asynchronism W~cce~s.
:
: 741.
and SIIARP,
1936. BRAWE-X~ENENDEZ. 11. and SOLARI. I,. h.
valvular
I,EMOI&E,
gauchr
.Ifet.
cn cl
carded.
SCII\~EI>EL.
570. 1957. 29.
de-
E., and ORTAS. 0.:
dr I.1 contraction
syndromr.
of the relationship
left heart
tion of thr left and right
The
.+n. Heart J. 10: 681, 1935.
block.
14. BATTRO. .I.. BRA~N-~~EYENDEZ.
16.
J..
H~I.MI~OLZ. H.
lay in onset dlr branch
1i.
Fxc~rwr.
E..
I..
Thr
bc--
c-vents of the
use of pressurr
of
:inn. Sur,~. 138:
mechanical
of man.
KATZ, 1~. N.. 1~Arw.r. H.. and BOHNINC,. A.:
bloqnto
diaqnosis
Left
clin-
60: 65, 1947.
D. W..
27.
of
M.
.1. B.:
relation
.4m. Heor/ .I. 39: 841,
C~rrulntion 7: 669.
11 : 1, 1049. 13.
cycle.
III/.‘!.CI,PZII45
H.
abnormal
electrical
m thr cardinc
M.
FERRER,
INI). A.. and RICIIARDS.
rrlationship wrnts
FERRER.
and mechanical
Tr. .4. Am. Phyricians B..
COBLENT/.
Am.
.JR.. COURNAND, A., MOTLEY.
and
and mechanical
at transthoracic
laire
of
in a case
excitation.
H..
studies
1). I . . : The
scopic
D. ‘l‘., and
brtbzrrn
Sequence
1’147.
I). W..
I.. DRI.SI)AI.E. tion
12.
:
and contraction
and mechanical
MEDNICK.
Lx FF.RVRE. .I.
ventricular
the
in Wolff-Parkinson-White
calcctricnl
F~sal:~.
Scwven~~, of
SW<. 30: 379, 1955.
of ventricular
Arch. Int. .Vrd. 67:
KOSSMAN. (1. I;. and GOLDBERG, H. H.
of the
.wt,n. -3 :
./. 40: 430, 1950.
P..
the
K.:
76,194l. 10.
S.\MII..
tained
1933.
Thr
cyclr
the cardiac
inver-
events
Hl0l. 3
and
studies
the rlcctrical
twwn
interpretation
mechanical
H..
Electrokymographic
rim.
1935.
Thr
sion in bundle
ventricles
bundle
MEDNICK.
.lnl. Hmt
Asynchro-
-4. :
and
Proc. s0c. Ex@r.
lOSO.
SZMT,~:. P..
cxdiac
Mio~.w%? 1’1%.(1. C:. and common
clcctrical cycle.
I:ll.ctrokvlllog-raphic
common
: 187.1733.
CZNI1,48
8.
A.. and BEI.LE.~. S.:
403
Litwak
cxdiac
1926. 6. \VOI.FEK I ~1. C:. C.. ~IARG~I.IES,
’
and brtwwm
in
215
.Im. J. Phvriol. 76:
wntricle.
Bernstein,
resulting ventricles.
in the
: 720,
.A. W.: from
cxpowd
1930. diwct
Thr
form
stimrtla-
‘4N1. &Yzr/ .I. 7
: 471)
494 37.
Electrical VANDER VEER, heart.
38.
:
.I. B.
the mechanical
Prcmaturc
stimulation
heats 1933.
H..
&TRIM,
MENEZES DE OIJVEIRA, R.,
N.,
gram.
KOSSMAN. C.
:
P. S.
The
by
17.. HECHT,
precordial
F. F., H. H.,
SCARSI,
K.,
40.
GORDON, A. J., BRAUNWALI), E., MOS~OVITZ, H. L.,
Cnpuhlishcd
snre impulse
ventricular YATER,
\V.
block: teen
S.:
:
Delay
in transmission
a cardiac
cathrter
contraction
A. G.:
in human
bundle
M.:
Rrview casts
tailed
with
histologic
Pathogen&s of the
literature:
necropsy study
of
bundle Report
conduction
SAMET,
P.,
MEDNICK,
Electrokymographic chanical
H.,
studies
asynchronism
F’roccpdin~s of the First r@hy. National Htxrt p. 83.
J.
B.:
and
me-
cycle:
in
SCIIWXDEL.
of rlvztrical
in the
cardiac
analysis
VorKang
H. and SCIIU~,
5 I. WOOD, P.
nnrl
of vcn1956.
of thv action van
Aktions-
in Hcrzrn
bri
%t.xhr. f. Biol. 88
: 369,
dcs
das Vrrhalten
Hrrzens.
Ztschr.
f.
bri
drr
Bird.
89:
1030. 1956.
qf
thr He~enrt. Saunders,
p. 396.
Philadelphia,
Sounds: 53.
: Ubcr
Mechanogramm
C. I(. : I1ismv.r
LEAT~~AM, .I.: 414.
1;.
lmd
: D~.w~T of the Heart md Circulotmn.
pincott.
1956,
in Symposium
II.
(Xnical
Lip-
p. 230. on Cardiovascular
asprcts.
&c&&n
16:
1957.
BRAUN\%.ALU. I-., FISHMAN, X. P.. and COURNAND,
Cmjwuncr
mz Electrokymog-
Time
Institutr.
Brthrsda,
chambrrs,
1950,
IIrnlth
physiology
die Brrziehungen
:Iktiunsstrom
Philadelphia,
52.
and
in
p. 21.
.J. J’hyrinl. 46: 188, 1913.
~luskarin~crqiftung.
555,1929 50. FRIEDRERG.
system.
.4x/z. Znt. .Med. 62: 1, 1938.
43.
and
and
.Irrr. lLIC/zrt.J.
Z’/z~sio/‘. KPII. 36: 400.
Kontraktions
Warnelshung
of sixde-
+_natomy
Ubcr
H.: und
Anatomy
units.
On functional
R. G.:
hRT~1.4.
van
branch
and of six cases with of thr
heart.
structural
1928~1929.
of
branch
normal
function.
BERTHA, dcr
49.
Sequence
MINES.
Strom
and vinyl
J. iippl. I’hy.tiol. 8 : 573, 1956.
E. and MORROW,
RUSHMER, K. F.:
of elyctrolytcs.
of a pres-
.4nz. .J. .I/led. 23 : 205, 1957.
block.
42.
R.
LITWAK.
48.
through
tubing.
41. BRAUN~ALII,
and
data.
and AMRAM, S. S. plastic
H.,
W.
46. 47.
SAMET,
of the
23: 455, 1042. 45. GREGG, II. C.: Cordm~ry Circulation D&a (P. Ixa. Philadelphia. 1950, triculal-
39.
‘I’hc
.I. S.:
physiology
rlectrocardio-
.4Ni. Hf%Yl J. 27 : 19. 1944. P., BERNSTEIIV,
ilsynchronism
44. ROBB,
human
F. D., ROSENBAU~,
EKLANGER, and BARKER,
Mechanical
pl-oducrd
of thy cxpoard
:Im. Z&III J. 8: 807,
WILSON, F. N., .TOHNSTON.
and
relationship
of dynamic
pulmonary
artery
events and
A.:
in the cardiac aorta
in man.
Circzrlntmn Rpr. 4: 100, 1956.
THE AMERICAN JOURNAL OF CARDIOLOGY
and Mechanical
Asynchronism
in the Cardiac
Cycle
of 100 Ventricular
Premature
A Study
by Simultaneous
Right
Beats
and Left Ventricular
Catheterization* PHILIP
SAMET, hi.~., F.A.c.c.,
LEONARD
SILVERMAN,
and ROBERT Miami
E
LECTRICPIL ventricular in
block
bundle with
block,
idioventricular
Parkinson-White premature
beats
or
be
stances-asynchronism ventricular
contraction
systole
the onset of ventricular semilunar Earlier
the presence
ventricular
Department
Florida, and
man
Howard
United
States
Institute,
of
or
the
in the basal percutaneous
of Fisher.2’ into
Two
the
left
of
middle
during
Sinai
ventricular
Hospital,
of Medicine,
Memorial
Hospital,
Medical in part
Health
and
by
a grant
or 0.01 exact
De-
National
Public
Heart
Health
corrections
Miami,
system
National from
Gables,
t Employing el a1.40 the delay composed
the
from the Heart
Service
Statham
P23.4.4
delay
P23D
Institute. 482
atrium were
gauges.
on the proximal or on the catheter,
on
in pulse wave trans-
ventricuiar
strain
for a system (passing gauge
nylon
gauge
0.006
to the
30
Braunwald for a system
catheter, cm
(125 long,
cm
in
and
to be 0.012
a
sec.
of 22 in. of polyethyl-
a 17T needle
polyvinyl
measured
and
was noted
composed
through
according
transmission
tubing
set,
and 0.00
All pressure curves _~. ___~
of Gordon
heart
polyvinyl
0.01
curves,
curves,
method
as described
to the nearest
employed.?
48 in. of black strain
strain
were made
delay,
in pulse wave
of a right black
needle),
Research
the
length), The
Florida
left
catheter,
for delay
for left ventricular
Florida, Institute,
by a grant
were
catheter curves
triple-lumen
systems
see for right
recording
ene tubing
States
P23G
of Surgery, Coral
puncture
strain gauges.
0.01 set
or
of a Cournand
Left
needles the
were recorded
et irl. ‘Q This
measured
the
into
double-lumen
in these catheter
by Gordon
Miami
of the
Research
Service,
mission
needle
P23D
curves
P23AA
#17T
Left ventricular
Statham
Appropriate
and left
and
lumen
long
A polyethylene
one
of a Cournand
Statham
has per-
of right
with
state.
by a modificatiot?’
transthoracic
7-in.
atrium.
through
ventricular
development
and the Department
Public
Right lumen
of Cardiology
Supported
H-2735,
of mechaniof
School
Hughes
recorded
postabsorptive
was performed
posterior
inserted
Association.
t United
supine
catheterization
technic
of the
Laboratory
Mt.
Section
of Miami
Florida.
Fellow,
the
of Medicine,
Miami,
Heart
in
of Medicine,
and Jackson
the
heart
in the presence
Cardio-Pulmonary
Florida,
University
of
to demonstrate
or absence
recording
curves the
partment
onset
catheterization24-31
simultaneous
Beach,
the
(opening
The
electrical
Right heart catheterization was performed in the usual manner,
of the isometric
failed
asynchronism
asynchroof
AND METHODS
studiesl-23
asynchronism.
*From
MATERIAL
and into the left ventricle.
and left heart
mitted
consequence
was advanced
conclusively
right
is a necessary
an opportu-
mechanical
asynchronism.
circum-
in the normal)
ejection
have
affording
whether
valve).
cal ventricular electrical
nism
asynchro-
such
either
(onset
of ventricular
beats, thereby
tachycardia.
under in
Florida
nity to determine
Wolff-
H. BERNSTEIN, M.D.,
M.D
premature
heart
the
ventricular
expected
Beach,
in ventricular
ventricular
mechanical
would
period
and
S. LITWAK,
occurs
complete
rhythm,
syndrome,
Theoretically, nism
asynchronism
branc’h
M.D.,~ WILLIAM
tubing sec.
but not an 18T and a Statham The
delay for a
THE AMERICAN JOURNAL OF CARDIOLOGY
Samet,
Silverman,
Bernstein, TABLE
Physical
Case
No.
Cathet.
!
+
Age
2
75
3
119
4
81
i
Rh.
I M
Comments ._~~_
HD
EH
murmur,
MS
mild
XF
Graham
CHF
III
49
F
Rh.
HD
EH
MS
36
M
Rh.
HD
EH
AI AS NSR
58
M
Rh.
HD
EH AS minimal
Rh.
F
33
in 18 Patients
Diagnosis
pectoris 5
I
and Diagnoses
1 Sex
214
1
Characteristics
183
and Litwak
HD
III
MI
Steellr
Recurrent
C
L.V.H.
II
Mild
AI AF angina
and
non-obstructive
Previous
AF II C
~.
ECG
AI
emphysema
MS
~_
mitral
in 1950
on Auoroscopy
Predominant
C:
~~
stenosis:
commissurotomy
D
AI AF III
C
EH
mitral
studied
pulmonary
also present
arterial
emboli;
9 weeks
after
also commis-
surotomy 6
85
Rh.
HD
EH
MI
MS
AI AF III
7
44
Rh.
HD
EH
MS
SB II C
Giant
D
left atrium
L.A.-L.V.
mean
dient Rh.
8
HD
EH
MS
NSR
1
I B
month III
Rh.
3
HD
EH
AI NSR
gra-
5 mm Hg at rest
post-commissurotomy:
C pre-op
Palpitations
I B
diastolic
less than
represent
only
symp-
post-commissurotomy-;
II
tom 10
66
Rh.
HD EH AS AI MS NSR
11
86
Rh.
HD
EH
MS
NSR
.4symptomatic
I B
1 year
I B
C pre-op Rh.
12
HD
EH
murmur Rh.
13
HD
MS
III EH
NSR
Graham
Diastolic
Steelle
MS
NSR
10 months
I B
III Cong.
14
HD
angina Rh.
15
EH
AS
minimal
AI
rumble
not heard
EH
post-commissurotomy;
C pre-op
Large
NSR
mean
systolic
LV-B.A
gra-
block
pres-
dient
pectoris
HD
apical
D
AS
AI
MS
NSR
III
Right
C
bundle
branch
after
mitral
ent Rh.
98
16
HD
EH
MS
MI
NSR
1
II C
year
commissu-
rotomy 17
Rh.
95
HD
EH
MS
minimal
AS AF
II
Arterial
C
emboli;
BA systolic 115
18
.48
~
F
Rh.
HD
EH
MS
AF
mild
CHF
III
Graham
D
Steelle
mal
aortic
ventricle Rh.HD
=
Rheumatrc
CHF
=
Congestive
NSR
=
Normal
were recorded recorder,
heart
heart
sinus
disease;
failure;
rhythm;
on a 6 channel
EH
MI SB
=
=
cathode
=
Enlarged
Mitral
Sinus
bradycardia;
MS
=
AI
Cong.
=
time lines were
Mitral Aortic
HD
at 0.10,
ray photographic
$ at a paper speed of 75 mm/set;
heart;
insufficiency;
=
0.04
or 0.02
made
Statham the
P23D
delay
Statham
for P23G
first system sures.
strain
gauge
36-48
in.
strain
second
was employed strain
tions
starting
gauge with
tems were employed $ Electronics 1959
equaled
system through #112
sec.
0.002
all right
described
above I).
(Table
I).
for left heart
Finally, and
erally a
pres-
When
used
premature
sysThe
three
Plains.
N. Y.
sys-
or miniLeft
Atria1 =
fibrillation;
4ortic
stenosis;
disease.
intervals.
Errors
electrocardiographic
of parallax
Nineteen
rheumatic V,
QRS
or Va was recorded, c.omplex
premature complex beat.
upright
premature
ventricular
When
complex premature
pressure lead
were heart
made
as a left
complex
in lead
beat;
(Table
I).
upright
as a right
a predominantly 1 or lead
gcn3 (see
in 18 patients
disease
a predominantly
lead in lead
curves.
1 or lead
was interpreted
beat;
was interpreted
mature premature
studies
or congenital
QRS
tricular
leads were recorded
1 and Vbr occasionally
II).
heart
#l 11. last
Table with
third
= AS
with the ventricular
leads
The
for all catheterizaThe
simultaneously
sec.
catheterization.
White
and a
was
The
catheterization
was utilized
for Medicine,
tubing tubing
measured
#69 (Table
system
0.004
of polyethylene
gauge
catheterization
P23G
APRIL.
in. of polyethylene
was used for recording
The
through tem
up of 36-48
AF
heart
set
murmur insufficiency.
were thus eliminated. One or more
system
stenosis;
LV-
not enlarged.
insufficiency;
Congenital
minimal
gradient
ven-
downward
ventricular
3 was recorded,
prean
1 or a downward
3 was interpreted a downward
QRS
as a right complex
484
Electrical
and
Mechanical
in lead 1 or a” upright complex in lead 3 was interpretcd as a left ventricular premature beat. Justification for this interpretation of the site of origin of ventricular premature beats from the prccordial or limb leads may bc found in the publications of Sodi-Pallareqx2 Barker,“” and Holzmann.~~ Barker33 states: “Left ventricular cxtrasystoles have the general appearance of right bundle branch block. Right ventricular cxtrasystolcs bear a close resemblance to left bundle branch block.” Barker PI n1.35 produced ventricular extrasystoles in the exposed human heart in the course of pericardiostomy and noted that right ventricular beats produced upright dellections in lead 1 : downward deflections were produced in extrasystolrs from the left ventricle. These findings were confirmed by other invcstigatotxg6~“’ \;l’ilson cf al.aY state: “There can be no reasonable doubt that, in ma” as in the dog, the potcn
Of these 100 were selected for study. The remainder were discarded because either the left or the right ventricular curve was considered technically inadcquatc for detailed time rneasurcments, gcner-aliy because of the dcgrcc of prentwtrrrity of the ventricular be,tt. The accurate measurc’nwnt of the onset of the right or left vcntricular pressure curve was dillicult or impossible when the extrasystole occurred early in the cardiac cycle.
KESULTS The
ing the predominant atria1 fibrillation These
time
relationships
rhythrnm-sinus are
right and left ventricular
pressure
01
QRS
relationships
premature
for
ljcats are
III and I\‘, respecti\cl>
The range for QRS ular
rhythm
in Ta l)lc II.
for conducted
the corresponding
listed in TatAs
for
pressure curves dur-
-are illustrated
intervals
complexes;
cur\c
to upstroke of left ventricinterval
is shown
in the
fourth column,
from 0.02 to 0.09 sec., corrected
for mechanical
delay in transmission
sure wave. vals ranging QRS
of the pres-
‘The mode electrical-mechanical
tervals arc also listed,
TABLE Time
electrical-mechanical
the right and left ventricular
tial variations of the right side of the precordium (leads V, and Vl) ordinarily resemble the potential variations of the anterior surface of the right vrntriclc. while the potential variations of the left side of the precordiurn (leads V:> and Vti) ordinarily resemble the potential variations of the antcrolateral surfacc of the lrft ventricle.” Over 400 ventricular prctnature beats wcrc produced in the exposed dog heart by Samet, Bernstein and Litwak.3” Right ventricular stinmlation resulted in a” upright deflection in Vi; left ventricular stimulation resulted in a downward deflection in Vi. Several hundred ventricular premature beats were recorded in ma” during- right and left heart catheterization.
Electrical-Mechanical
Asynchronism
from 0.04-0.06
to upstroke
in-
the most common sec.
of right
inter-
The range for
ventricular
pressure
II
Relationships
During
the Predominant
Rhythm
QRS-LV Case “umber
1 7
6 7 8 3 10 11 32 13 14 15 16 17 18
interval
QRS-RV
ECG lead
Basic rhythm
NSR .4trial Atria1 Atria1 ntrial NSR NSR NSR NSR NSK NSR NSR NSR NSR, NSR Atria1 Atria1
fibrillation fibrillation tihrillation fibrillation fibrillation fibrillation
RBBB fibrillation fibrillation
Lead Leads Leads Leads Leads Leads Leads I,ead Leads Lead Leads Lead Leads Leads Leads Leads Leads Leads Leads
-I
3 1 and 1 and 1 and 1 and 1 and 1 and 3 1 and 1 1 and V, 1 and 1 and 1 and 1 and 1 and 1 and 1 and
~
LV-RV
relationship (xc,
.I Range
.4trial Atria1
interval
(SK)
(XC)
0.03-O VS Va V’s Vti Vs Vc Ve Vg Vg Vg VFi Vg Ve V, Vti
Range
Mode
~ 06
1 0.03~0.05 0 0660 07 0.04~0.07 0.04~0 07 0.05~0.07 0.03-O 04 0 0550 07 0 0330.04 0 02-0.05 0.04~0.07 0 0550.07 0 0330 05 0.06-0.08 0 0660.07 0.04~0.07 0 08-0.09 0 06-0.08 0 0660 08
Range
Mode
Mode
_
’ 0.05 0.04 0.06 0.04 0.05 0 06 0.04 0.06 0.03 0.05 0.06 0.06 0.04 0.06 0.07 0.05 0.08 0.06 0.06
0 .04--O. (16 0.04-O 05 0.04-O 06 0.03-0.06 0.06~~0.08 0.04~0 07
0.05 -0 07 0.0330 07 0.06 0.07 0.09~0 11 0.07-0.10 0.07-O 09 0.05-O 06 0.05 0 07
TITI:
0 05 0 05 0.05 0.04 0.07 0.04 0 08 0 09 0.04 0.07 0.06 0 06 0 05 0 08 0 10 0 08 0 08 0 05 0 05
AMP:RICAN
to +0.01 0.00 to +0.01 -0.02 to 0.00 -0.03 to +o 01 +0.01 to $0 02 -0.03 to +0.01 +o.oi to +o 05 +o 02 to +o 03 0.01 to +0.02 +0.02 to +0.03 0 00 to +0.01 -0.01 0 00 to -0 01 to +o 03 0.00 to +o 02 +0.02 to +0.04 +o 03 to +o, 04 -0.01 to +o 01 --0.03 to -0 01 -0 01 to +o 01 0.00
JO”RN.41.
OF
0 00 +0.01 -0.01 0 00 +0.02 -0 01 +0.04 +0.03 +0.01 +o 03 0 00 0.00 +0.02 +0.02 +0.03 +0.03 0.00 -0.01 -0.01
C:ARDIOLOGY
Samet,
Silverman,
Bernstein,
TABLE Electrical-Mechanical
Time
III During
Right
Ventricular
LV-RV relationship
QRS-RV interval
QRS-LV interval
Case number
Relationships
485
and Litwak
Premature
Electricalmechanical correlation
1
Beats
Electrical-mechanical delay
(set)
(see
0.06 0.07 0 05
-0 03
NO
0.09 0 07
-0.02 -0.02
No No
None None NOM
3
0.12
0.13
+0.01
NO
Both ventricles
7
0.15
0 07
-0.08
Yes
Left ventricle
8
0.12 0.07
0.07 0.03
-0.05 -0.04
Yes
Left ventricle
Yes
None
0.12
0.15
0.03
NO
Both ventricles
0.07 0.07 0.08 0.08 0 .08 0.11 0.10 0 08 0.07 0.08 0.08 0.08 0.08
0.06 0.07 0.08 0 08 0.07 0.10 0.07 0.07 0.07 0.08 0.08 0.08 0.08
-0.01 0.00 0.00 0.00 -0.01 -0.01 -0.03 -0.01 0.00 0.00 0.00 0.00 0.00
No No No NO
Non? None None
0.10 0.12
0.09 0.11
-0.01
NO N0
None
-0.01
0.06
-0.06
Yes
Left ventricle
‘SK)
1
0
9 11
14
15
09
0.12
None None None None
NO NO
NO No No No No NO
NOlIe
None
None None None None
NO
Left ventricle
curve interval
is given in the fifth column,
0.03 to 0.11 sec.
The most common
tervals are 0.05-0.08 The
right Thr
to +O.Oj
ventricular-left
stroke treme:
ranyc
WC.
prcccdrd
ventricular
up-
are shown in the sixth colof these values is -0.03
That
than 0.11 set has been defined as showing electrical-tnechanical isometric
sec.
stroke relationships umn.
from
mode in-
is. the right ventricular
the left by 0.03
the left ventricular
upstroke
Right Ventricular Premature Beats: right ventricular
set
in Table
up-
electrical
set at one expreceded
delal- in onset of ventricular
contraction.
III.
premature
In 20 of the 24 premature
asynchronism
mechanical
asynchronism
contraction.
Twent)--foul
beats are analyzed beats,
is not accompanied
b)
in onset of \-entricular
In 20 of the 24 beats. the time re-
that of the right b)- 0.05 set at the other extreme.
lationships
The
tricular contraction falls between - 0.03 SPC and fO.03 sec. In 18 of the 24 complexes, the QKS
nontlal
range.
therefore,
somewhat
arbi-
traril!. has Iwen defined as -0.03 to +0.03 see. An)- lrft-right \.entricular upstroke relationship \vithin thi< intcr\,al is defined the normal QKS
range.
to \ entricular
In
as falling
a similar
upstroke
within
fashion
interval
any
greater
to onset
between
onset of right and left \-en-
of ventricular
contraction
interval
is
normal, that is, less than 0.12 sec. In 4 beats the left ventricle alone is delayed ; in 2 beats twth ventricles
are delayed.
486
Electrical
and
Mechanical TABLE
Electrical-Mechanical
Time
QRS-LV interval (WI.)
0 0 0 0 0
QRS-R\ i,terv:rl (SK)
+o -0 -0 -0
03 01 02 03
1)OR
0 13
+o
05
0 08
0 00 14 0 11
+n 01
n 12
n 15
+o
03
0 12 0 II
0 16 15 14
n
G +o
:: 03
12 0 13 0 13
0 n 15 17 0 16
G +o
:: 03
0 0 n 0
0 0 0 0
+o +n -0 -0
04 04 03 03 02
n IO
09
+o
18 I4 05 OS
II 14
0 16
+o
12 I? 13 14 12 10 14 13 16 16 0 13
0 0 0 0 n 0 0 0 0 0
$:: +o +o
n 13 13 1) n pi 0 I5
0 I6 iI17
0.04 n 05
n
16 16 1s 1s 12 15 17 17 12 16 16
vmlri(
Both Both Borh Right Both Rorh Both
ventrrcles ventrirlrs ventricles ventricle ventricles wntricles ventricks
;:
+o
02
0 OR 0
-co
04
0 WI 0 00 0 12
+o
0 0’9 0 10 0 13 0 10 11 07
0 13 0 13 0 09
$0 01
10 0 11
+o 05 - 0 (IL n3 n on +O 02
+o +tr
0 no 03 01
0 12 10 0
::r S’i
II nh 0 Oh 0 OH
0 n 0 0
+o +o -0 +o
: :: 0 Oh n 09
0 11 13 0 IO 0 14
to + 0 08 05 +(I 04 +o 05
I6 II OS I6
O’J 05 01 OR
n OH 10 0
0 18 13
::
z
13
0 no
0 IO
+o
01
15
0 11
0 08
-0
03
11 0 OR
”0 13 10
$::
::
n 10 0 13
0 12 14
$ir
::
0 1.3 0 13 0.11 0 07 0 10 n 14
II 0 0 0 0 (I
0 01) I) 00 +n 01 +0 06 +o 03 -0 01
Borh vrntriclrs Both venlrirles Right ventricle Right ventricle Riqht ventricle Both ventricles
0 14 0 15
0 15 0 16
+r, +o
01 01
0 12 I3 0 10 0 14
13 0 14 0 13 15
::
8:
Both Both Horh Both Right Both
I6
17
18
I
~
0
lc
04 0 00 03
$j
II 0’1 00 II 0 07
Right
:: 0: 01 0 00 +o OS +o 03 +o 04 -0 04 0 00 +n 03
16 0(I 17
n 13 0 06
Beats
-0
0 0 0 0 0 0 0 0
n
Premature
+n 01
0 n 09
14 10 OX 08
Left Ventricular
L\‘-RV rrlarionship (WC)
0 IO 0 11 0 05 0 05
0 II 0 12
IL
IV During
07 12 07 OH
0 II
1 II
Relationships
Asynchronism
13 13 12 13 13 13
ventricks ventricles ventricles ventricles ventricle ventricles
I THE AMERICAN
JOURNAL
OF
CARDIOLOGY
Samet, Left
Silverman,
I’entricular Premature Beats:
Scventb--six
ventricular
premature
Table
In 52 heats mechanical
IX’.
beats
are
analyzed
set of right and left ventricular -0.03
between
complexes
lnechanical
In 1 beat,
the right
pressure
spite origin of the premature In 22 complexes,
contraction
was within
ventricular
onset
cles. ular
In
32
complexes
contraction
despite
origin
three
beats,
complex
?f
set)
for both
the
onset
origin
(QRS
but
ventri-
both brat
sides in the
only right venHowever,
of the
the
to
of ventric-
on
premature
Findiq r:
cal asynchronism QRS
limits
right
in
premature com-
ventricular
was not so dela\-ed.
Swnmary tricular
the onset of ventricular normal
on the left side, the left ventricular
\\-as delayed
pre-
1,~ 0.04 sec. de-
was delayed.
despite
is present.
beat in the left ven-
delayed
of the
contraction
complex plex
was
In 23
upstroke
In 19 complexes
left ventricle. tricular
<0.12
curves
SK.
as)-nchronism
cedes that of the left ventricle tricle.
bet\veen on-
and +0.03 ventricular
in
asynchro-
nism is not present, the relationship falling
Bernstein,
premature
co~nplrxes.
asynchronism \-entricular
the opposite
in 72 of 100 ven-
beat
considerable
(with
the
as)nchronism upstroke
in the left ventricle.
interest
was
preceding
stances? despite premature silateral
the univentricular
beat.
in-
in 34 in-
onset of the
In three instances only the ip-
ventricle
traction,
It is of
that the QRS-ejection
ter\-al was dela)-ed for both ventricles
was delayed
a finding- opposite
in onwt of conto that
to he ex-
pectcd. Examples
of these relationships
in Figures I to 4.
are illustrated
In Figure 1, the left ventricu-
lar upstroke precedes the right t>)-0.03 set in the first and sinus
third
beats.
corrected
beats, The
lar upstrokes
ventricular
for pulse wave precedes
conducted beats
are
In the middle complex,
premature
are identical
right ventricle Figure
the normally
right
by 0.01 sec.
a right ventricular
beat, the ventricuin time;
transmission
when cordelay,
the
the left b)- 0.01 sec.
In
2, the right \.entricular upstroke precedes
and last beats.
type
that of
In one in-
that of the left 11~ 0.04 set, despite origin of the premature
the left by 0.01
curve on the side of origin
was noted.
stance, reverse mechanical found, the right \ entricular
lwats with widened aherrant mechanical
QRS complex preceding
ventricle)
In 27 complexes of the expected
pressure
mechani-
487
Litwak
of the premature
rectcd
In summar!,
was absent
and
corrected
set
in the normall>- conducted The
b)- 0.01 sec.
a left ventricular
right l-cntricular
first
curve is
In the second complex,
premature
beat, the left ventric-
Fig. 1. In the normall!, conductrd first and third beats, the onsrt of lrft ventricular contraction precedes that of the right ventrick by 0.03 WC. In the right ventricular premature beat (second bvat), the right ventricular onset precedes that of the left by 0.01 set when the former is corrected for pulsr wave transmission dclav. Note however that whereas the left vrntricular upstroke prt-CP~PS that of th? right in the first and last beats, in thr Aiddlr brat the rtverse is true. APRIL,
1959
Electrical
and JZlechanical
Asynchranisrn
Fig. 2. Mechanical asynchronism is absent in the first ventricular premature beat (second complex) but is present in the second (third complex). Srr text.
Fig. 3. Mechanical asynchronism is absent following the left ventricular premature brat (first complex). See text.
ular upstroke is 0.01 set ahead of the right, when
corrected
a suitable
left ventricular
QRS-right third
correction
(0.01 set) is applied to the However, the ventricular interval.
complex
chronism,
demonstrates
mechanical
asy-n-
the left ventricular upstroke preccdIn Figure 3 the left
ing the right by 0.06 sec. and right ventricular
upstrokes
arc identical
in
I)\ 0.01
set).
cal as)-nchronisrn
is present
lar curve side.
is slightly
stroke is ~vcll ahead
In the first complex
mature
beat,
a left ventricular
the left ventricular
upstroke
prcis at
portion
same phenomenon dle beat of Figure
the same time as that of the right, if 0.01 set is subtracted from the QRS-right lcntricular
left ventricular
upstroke
stroke precedes
to correct
for
mechanical
pulse wa\se transmission. Figure 4 illustrates one further normal precedes tracings,
delay
in
+
first tIeat, the left ventricular
How-
is that in the
of that on the right premature
beats,
of the left ventricular
up-
of that on the ri,ght.
The
is demonstrated 1 where the mrrt
contraction
in the midof right and
is identical
in time,
the major portion of the right ventricular
relationship point.
ahsad
In the left lcntricular
The right ventricular sec.
in all three
first beat, ti:c entire upstroke of the left Ientricu-
the largest
1,~ 0.01
next 3 heats are
beats, and mechani-
U-W, the point to IX emphasized
the normal beat, the second and third complexes. curve is corrected
The
premature
up-
that of the left, a reversal of the
notrd in the two normal
I~ats.
In the upstroke
the right 1)~ 0.02 set (0.03 set on the before the right ventricular curve is
Many studies have been reported the problem of whether mechanical 7X1: AMERICAN
~OURXI\L.
relative to asynchro-
OF CARDIOLOGY
&met, nism
in onwt
essary
of ventricular
consequence
drpolarization ture
beats
rcct
evidence
produced and
then
noted
a del.ry
\Volferth from
tion
in
front
In the
sul+cts
itlock,
of the QRS carotid
Iwndle
t)ranch
also employed
Ijinations
01’ the electrocardiogram. apes
these
and
studicx
asynchronism
the
conclusion
had
was
calectrical txen
complex
to
and
of aor-
as a result
of a
simi-
ranged
0.32 see.
data
Nichol”
of the carotid
al.’
la)~d
heat),
from
the from
0.16 and
and
to 0.28
On the other \\-a\ c \vas must
branch onset
curves
and
I~lock. comparison
Kich-
Eppingcr
of
right that
in the carotid
\vith bundle
and Sch\vedel”-?”
side
In none of the and
left
possible.
ICatz’” noted
not delayed
patients
Metlnick
hand,
see. avcsraqc
on the ipsilatcral
It-as a direct
pressure
upstrolx
have ;~lso pul)lishcd as demonstrating dc-
of thcsc ventricular
ix as
wntricular
et al. lo
activity
Ixtwccn
QKS
Ixat
co-\~~orkers.“~‘”
Ixrndle
studies
the
Goldberg”
intwpreted
mechanical
\vhen
to carotid
in sul>,jerts with relationship
0.11 to 0.22 WC,
a right
QRS
‘1 Irft
to carotid
prctnature
1 (therefore
,lnd Fllin(rer J_
in man
1 (thcwforc, the QKS
In 13 casts,
Liosslnan
Cournand z
in lead
Jxat),
inter\xl
com-
Incchanical
from the onset
ranyed
in lead
prcnlaturc
ards,
From that
the)
the inter\xl
of a \.entricular
upright
the
trac-
reached
demonstrated.
to thv same conclusion
lar stud!-.
the
sound
pulsations.
that
of vcntriculai
to the onset
premature inter\.al
et
pulse
tracings
artcry
I)ctween
heart
\\-a~ do\yn\\xrd
0.17 see.
pulsa-
various
wnous
roc~ntyenkvlnographic pulmonary
correlation came
cartliofirams,
beat
a\-er:lyc
intn.\.al t)luck,
co~nplex
upstroke
sec,a~‘crageO.l7scc.\l’ol-
and Margolies
and
this
found
Ihc site of ori$n
11
frown
a\-cray::i~ 0.1 1 see.
tr-acin,Ts, tic
artery
his associates9
i)cats \\ith
of chv QRS
ventricular
complcs
normals
0.09 to 0.15 set, with
z
studied
me-surin,q
and
corrclatc
artcxr\. pulse Ii-it h fair SUCCCSS. In 10 casts. \VllM the QKS co1np1c.s of a ventricular prcmaturr
prol)lems
Rothlwrgcr’
in the p~~lsc \sa\~
In
lan~e\~as0,16toO.?l
ings,
only indi-
Ixlsic
could
189
I,itbali
premature
IAock.
IAock esp
tmnch
nclck.
rangrd
forth
the
of the right
the,
reports
and
C&e:<
in
prcma-
and Margolies”~’
the onset
the hqinniny
is a ncc-
t)ranch
and
Iwanch
C;ISCSof left Imndle intcwal
with
Eppingrr
I)rmdle
that side.
Ijundle
of these
dealing
ol,tainc*d.
Bernstein.
asynchronism
in ventricular
complete:
In the o,real majorit!was
contraction
of clcctrical
as occurs and
Silverman,
branch wrrr
IJock.
the pulse arter\
in
Sanwt, 21I)lc to dcmon-
490 strate
Electrical ventricular
only one-third
mechanical
and Mechanical
asynchronism
dle branch block studied b). simultaneous kymography monaq
of the ascending
artey.
confirmed
in
of 61 patients Lvith complete
Rraunwald
aorta
in 15 patients
electropul-
NORMAL
LNSR
d
NORMAL
(NSR
OR
with complctc fortunately.,
I))- simultane-
1
of the right and left ventricles with
bundle
txanch
in the
subjects
AFIIRANGE)
.
LVPC
AF)(MODEI
0
RVPC
f
’
i
i
!
txanch
Mock and In
right bundle Ixanch
vrctorcardiographic
available
OR
complete
Mock, 5 \vith left Ijundlc
and Morrow4’ have
these findings recentl!
ous catheterization
hun-
and
Asynchronism
Mock.
Un-
data \vere not
with
right
bundle
. :
’
l
d
I
-.08
!
I
I
- .04
_.06
I
-.02
.oo
I
+.02
I
I
+ .04
I
I
I
+.06
+.oe
The normal range has been taken as Fig. 5. Time relation between onset of right and left ventricular contraction. -0.03 to +0.03 sec. That is, at one extreme the right ventricular upstroke precedes the left by 0.03 see (-0.03); at the other extreme the left upstroke precedes the right by 0.03 xc (+0.03). The lowermost row is the mode figure for The upper row is the range data for conducted beats-hence there are conducted beats in 19 studies in 18 patients. The two intermediate rows arc for the prematur? ventricular beats. twice as many points as in the lowermost row.
a
8
f r---1
00
02
04
06
I
I
‘3
‘5
I 1 11I
I
T
08
Fig. 6. Time relation between onset of the QRS complex conducted QRS complexes, either during atria1 fibrillation
and right ventricular contraction. or normal sinus rhythm. THF;
AMERICAX
JOURNL
“Normal”
OF
refers
CARDIOLOGY
to
Samet, Ijranch
block,
so that
trophy
ma); have
branch
block.
h!.pertrophy
right
mereI\-
Ijundle
branches
are
with
and left heart
these
Wipers”’
employing
defect
branch
this older
of
be tlcmonstrarrd
results ure the
from
the
the reactions
to
J the
mode
lowermost
figures
uppermost
row
range,
between
yen-
time
relation
These results could not Ix confirmed tricle.” 1,~ &met, Bernstein and Litwak.‘“’ The data
plex
and
in this present
normalI\-
and left \,entricular
the corresponding
pressure
ing simultalleous tion.
In
rig-ht and asynchronism conducted
Fig. 7. meaning APRIL,
deal with comparison
right
most left
dur-
catheteriza-
the limits
Iwats was not noted.
premature observed These
the onset
i.c..
onset
in the
during findings
complex
[Ieats:
inter\,al
-0.03
the
row
and left ventricular
sec.
of the
QRS
6.
is normal
data
complexes
(mode)
and
circles The
‘I‘he com-
for
the
are gi\,tn uppermost
are for the right circles
are for the
QRS-right
\rentric-
or minimall!-
dela!,ed
premature ventricular
contraction.
left
contraction
The
the closed
lxats.
QRS-right
to $0.03
ventricular
QRS
and
on
fall in the normal
onset
for the right \,enrricular ever.
of the right
systoles
The open
left \.cntricular ular
It is readil!.
Figure
lou-c.rmost
row (ranqc).
on the
are shown
II).
of most
conducted
;
of points
for the range
of right in
row
onwf of
is gi\.en
(Table
ljctween
is illustratrd
ventricular of
beats,
Tirnc relation br*tween onset of the QRS as in Figure 6. 1953
on
olxaincd
(72 of 100 lxats)
ventricular
be!-ond
contraction
curves
and left heart
instances
of the
of the In Fig-
between
contraction
horizontal
to 0.08 of a second
study
one-
analysis
relation
ricular
premature
in the other
could
approximarcl>-
Graphic
time
and lc.ft xnt
ventricular
than
asynchronism
in only
seen that
earlier
on the
of In
artery.
of the prcsc’nt study is of intcrcst.
corresponding the
studies”-‘”
pulmonar)-
mechanical
two
of right
appreciably
stud!.
and
earlier
electrok~t~lograph)-
of the sul),jccts.
right
the intraventricular
during
.~~M~J.c~s(!f l/w ihtn;
Mock
combined
recorded
aorta
or
block:
noted
simultaneous
In the first place, the pressure within sides. the ventriclr. stimulated lxgins to rise from 0.03
onset
differ
with those
third
491
Litivak
the ascending
in the
txanch
from
sides of the heart,
stimuli
agree
lesions
data
are simultaneously
left and right
hyper-
studies
bundle
and
bundle
catheterization.
notes : “\Vhen
pressures artificial
septal
bilateral
in human
Bernstein,
ventricular
postmortem
of the side of the I)undle
consistc’nt
right
right
in right
to intcaratrial
nlitral stenosis. The Yatcr.,$; which re\.ealcd regardless
ventricular
simulated
as may occur due
Silverman,
lwats. intcr\.al
“h-ormal”
Howis (~I)-
has the fame
492
Electrical
viously delayed
in most left \-entricular
ture systoles. to the
This latter
conclusion
asynchronism right
the
the
right
tion
of Figure
premature
tricular
heats.
beats,
In short,
dela!-cd
for both ventricles Ijcats.
,for
C0usP.r
Lack
question
chronism
discussed
scrvations
muscle
ventricles deep
t)oth similar
trical
ventricular
ficult
to conceive
showed
the
abolition
electrical
of a frog’s resulted
recorded
Findings
in patients
right with
patients
and left heart
bundle to date.
was
almost
ahscncc
tu sup-
\.entricular of
he related of the
branch
in both
Electrical cur
Ijundlc
\rcntricular
to the
fact
that
conduction
s\steln
IAock have
frcqumtl)
bundle
ventricular
in man
in
tx-anchcs.
heart
block
with
wcrc tion.
branch
an
heats
problem
ventricular
is a necessary
in intact
indicate
as) nchronism
that
in ventricular
prcmsturc
of simultaneous
unset at)sent
I)cats
QKS
produced
contraction
in 72 of 100 Iventricular
heart
mechanical seen durheart
asynchronism
isometric
aljerrant
catheteriza-
coml)ined
Mechanical
of ventricular
the course
is infrequently
ing the course catheterization.
cons?The data
during
ri,yht and left heart results
is a
as)-nchronism
situations.
man
M:olff-
mechanical
ventricular
in the alxn,c
obtained
rhythm, paper
of whether
oc-
complete the
This
as),nchronism
The
and
syndrome.
of electrical
may
block,
idio\,cntricular
premature
of the
quence
asynchronism
in bundle
\:cntricular
with widcncd
pretnaturr
in was Ijeats
co~nplcxes.
REFERENCES
tIeat while
branch
Our
and
data
on
catheterization block are limited
In one
patient
\vith
complete left bundle branch block (with vectorcardiographic as well as electrocardiographic the onset of ventricular data verification), contraction
lesions
in cardiol-
continue
electrocardiogram
in Bundle Branch Block:
simultaneous
shown
tcxt))ooks
it is ol
in almost
Berthad and Bertha unchanged. have come to similar conclusions.
remained Schutzag
to two
there which
t)e separated.
of the mechanical
simultaneously
of elec-
Secondly,
perfusion solution
is
it is dif-
and
txmdle
of simultaneous
contracting
can
complete
such as occurs
has
in the literature cycle
that
a calcium-free
complete
in the prcscnce
so.
may
previ-
data:
\Yith complete
The
studies?”
as 1~11
and
mechanical
in patients
block.
ventricular
condi-
asynchronism since
of
histologic
study
both
these
ventricle
branch
recent
papers,‘“.“”
concept
Parkinson-White
function
Kushm&”
Under
mechanical
cardiac
that
a dominant
also doing
that
in the
MinesJ7 with
is prohal)le
of one
two
muscles)
ventricles.”
observations
demonstrate
the
ventricle.“”
asynchronism,
tf,e other
of the foul
of each
have
cvcn
oh-
and t)ull)ospiral,
mechanical
nc)t to Ix cspcctcd
several
each
two
bulhospiral
\,iewx
\.entricular
events
: “It
bundles
in emptbinq
heats,
comprisinp;
and
has stated
cspressed
without
L\Yth rc-
sinospiral
sinospiral
muscle
tions
has been
detai1.43
First,
bundles
the
Morro\\,
electrokymo,yraphic recent
that of the
asyn-
frequently
to the formation
Gregga”
.1 synchronism:
mechanical
premature
(superficial
contributes
are
more
are pertinent.
discrete
deep
such
in some
to ventricular
and
M~chaniral
is not found
pre\iously spect
of
port
and
preccdcd
and
to note that
ogy,‘“,”
asynchronism
ventricular
is minimal.
as to why
of Braunwald
right
confirmation)
In view of thcsc data
asynchronism is
complete
vector
upstroke
I+ 0.03 sec.
interest
onset
with
(with
the left \,entricular
ously puhlishcd
\ren-
block
right
with
durin,y left ventricular
delay
in another
branch
as those
\:entricular
right
l)undle
on11
left ven-
QRS-ventricular During
the bilateral
The
right
of
inspec-
during
but not during the
not
the QRS-left
is also delayed
Ixats.
Ixats,
but
However,
that
tricular
premature
is tlelal-ed
systoles,
7 reveals
interval
the onset
Asynchronism
t\Vo ventricles:
lead
mechanical
since
contraction
premature
might
ventricular
is to he noted,
left
prema-
ohscrvation
that
\rentricular
with
and Mechanical
simultaneous
in
the
2. EPPINGER, H. and KO.I.HHERGI~, W.: Urber dit. Suksrssion dcr Kontraktion dcr beidrm Herzkammern. %mlr,ilh/. f. Pllysiol. 24: 1053. 1910. 3. KATZ, L. N.: ‘I’hr asynchronism of right and Irft ventricular contractions and the independent variations in their duration. .lvi. J. Phyriol. 72: 655,
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AMERICAN
JOIJRNAL
OF CARDIOI.O(:Y
Samct, prnderlw
of clcctrical
thr malnmalian
Silverman,
and mechanical
activity
501
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01 bundle
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22.
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I’hvu-
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The
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.4m. Heor/ .I. 39: 841,
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MEDNICK.
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MEDNICK.
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I:ll.ctrokvlllog-raphic
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CZNI1,48
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403
Litwak
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’
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215
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.A. W.: from
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1930. diwct
Thr
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‘4N1. &Yzr/ .I. 7
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38.
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.I. B.
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P. S.
The
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\V.
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S.:
:
Delay
in transmission
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A. G.:
in human
bundle
M.:
Rrview casts
tailed
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histologic
Pathogen&s of the
literature:
necropsy study
of
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conduction
SAMET,
P.,
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H.,
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F’roccpdin~s of the First r@hy. National Htxrt p. 83.
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R. G.:
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