Left ventricular, central aortic, and peripheral pressure pulses in aortic stenosis∗

Left Ventricular, Central Aortic, and Peripheral Pressure Pulses in Aortic Stenosis* GEORGE RABER, B.S. nnd HARRY GOLDBERG, M.D. Philadelphia,

N

UMEROUSattempts mate the degree

spection

of the

pressure

pulses.1-3

shown

have heen made to esti-

in the prone position.

of aortic

done

peripheral

stenosis hl; in-

and

Katz

experimentally

Pennsylvania

and

that

central

aortic

associates’

needle

have

the position

as described

needle.

of the

With

anacrotic

notch was related to the degree of con-

pressure

of the

recording

in

animals.

Goldherg

and associates2 have shown that the position the anacrotic

notch

is a function

a 6”

of

by

continuous a

with recording

pressure or stroke volume as well as the degree

technic,t

the catheter

of aortic

tip lay in the left ventricle

associates3

have attempted

gree of obstruction

across

tained.

Simultaneous

mation

the de-

and left heart

could

has allowed

This

the amount

has provided

of

recording

the

and esti-

artery,

for

by the

this was accom-

with due allowance

time.

was measured

and the estimation Gorlin

pressure pulses in man.

employed,

for pulse

ent

at the

artery, aorta,

were not superimposed

method

transmission

culated

The systolic pressure gradiby planimetric

integration

of aortic valve area was cal-

by a modification

of the

formula

of

and Gorlin.9

For clinical

purposes

it has been found that

the brachial artery pressure pulse tracings may be substituted for those of the aorta in the

MATERIALS AND METHODS catheterization

brachial

recorded

for a more ac-

Simultaneous

Fick

simultaneously

electrocardiogram

and peripheral

arterial

by the direct then

the

The car-

plished by means of the simultaneously

curate

of the central

were

until

or aorta.

In those cases where the brachial

valve and has given opportunity evaluation

by photo-oscillographic

from the left ventricle,

and left ventricle

a method

manometer

polyoscillograph

was advanced

was obtained

Pressures

be oh-

with aortic

of obstruction

the

of the

and/or aorta.

for measure-

relationships

of the orifice size in patients

quantitating

output

method.

of the pressure

valve

catheterization

stenosis.6-8

diac

artery

recorded

a stenotic

ments of the pressure-flow

and

of left heart catheteri-

measurements

gradient right

to estimate

by the use of carotid

tracings. With the introduction zation4s5 accurate

Duchosal

through

or in some cases strain gauge man-

ometers

Recently,

A polyethyl-

type

writing

was

walled

monitoring

capacitance

of the pulse

obstruction.

thin

was inserted

on a direct

(Sanhorn),

#18G

previously.5

ene or nylon catheter

striction

aorta

Left atria1 puncture

by employing

of the right and

measurement

of the

aortic

systolic

pressure

left heart was performed in 19 patients, in whom the diagnosis of “pure” aortic stenosis was con-

gradient and valve area.8 In order to express the

firmed at surgery. Right heart catheterization was performed in the usual manner, except that the patient was

acrotic notch with respect to the peak of systolic

position

pressure, the distance in centimeters end-diastolic pressure to the anacrotic

of the anfrom the notch was

* From the Brith Sholom Cardiopulmonary Laboratory and the Departments of Medicine and Thoracic Surgery, Hahnemann Medical College and Hospital, and the Bailey Thoracic Clinic, Philadelphia, Pennsylvania. t Electronics for Medicine. White Plains, New York. 572

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Raber measured

and designated

as X.

The

and

distance

A distinct

Anacrotic Notch: slur was observed

pressure as Y.

The

percentage

tracing

from

the

expression:

whom there was no anacrotic

then

[X/Y

x

calculated

of 13 patients.

double

1001.

hump

The complete Brachial

data of these paThe

Artery and Aortic Pressures:

96 to 140 mm Hg. brachial

artery

The central

on

systolic

pressure

the brachial

aortic pressure

with that

thirteen

of the The

occasions.

of the aorta

78 and 136 mm Hg.

sys-

artery ranged from

simultaneously

The

ranged

between

The

diastolic

pressure

between

simultaneously the diastolic Hg.

The

60 and measured

two patients,

arterial

anacrotic aorta

aortic tracings,

were the same in

of the

aorta in five,

even

brachial

artery

artery

The pulse

exceeded

that of

terpreted

artery

pulse to the peak of systole varied and 0.26 sec.

It was greater

bethan

the upper limits of normal2 of 0.12 set in all but this value was 0.09

erotic

there was a double hump at

the second and slightly The

to

correspond

artery higher

to

time to this point

the

pressure

pulse;

aorta

in all

This was the

of the

double

anacrotic

there

in whom there was an ana-

on the

brachial

the three

was a double notch

of the pressure

in whom

there

aortic

peak,

[X/Y

In those

artery

[X/Y

In general, was

averaging

per

patients in the

notch

was

X 1001 being the contour

smoother

and

of

more

aorta.

Output and Pressures:

was reduced

of the

notch

the anacrotic

peaked than that of the central Ventricular

height

was an anacrotic

17 to 67 per cent.

tracing, in whom

1001 was 54-89

pulse.

tracing,

brachial

the

X

lower in all instances-the the

arterial patients

in the group

The

cardiac

as a whole,

3.7 and ranging from 2.6 to 5.6 l/min.

The stroke volume varied from 25 to 66 cc/beat.

of these two was

Although

valve flow, the latter was low for the group as a

of systole.

in these three tracing,

with

peak

patients

there was wide variation

whole, ranging tion seconds.

was 0.14, 0.18, and 0.16 sec. In the central

tracings

to be a reflection

notch

output

the crest of the brachial taken

and

respectively.

In three patients

in those

In those patients

central

in all cases but two.

The time from the onset of the brachial

0.10,

in the

artery

notch.

cent

in which

earlier

hump at the systolic crest if the first hump was in-

aorta from 12 to 56 mm Hg.

two patients

occurred

true

central

pressure

The

artery

anacrotic

tween 0.09

notch

than in the brachial

and not including

tracing

patients.

In the

pressures

of the brachial

all

cases but one where it was the same.

from 24 to 68 mm Hg and that of the

the more central

in

from the onset of the pres-

sure pulse ranged from 0.02 to 0.08 sec.

ranged pressure

notch was observed in the

tracing

100 mm Hg. central

pressure

notch

artery trac-

of the brachial

higher in the central

pulse

in the brachial

time of its occurrence The

and lower in six cases. The

in whom an anacrotic

A distinct anacrotic central

central

pressure ranged from 50 to 98 mm diastolic

two had

ing, its time from the onset of the pulse varied

that of the aorta in

pressure

all but one case, in which it was the same. ranged

of systole,

the peak on the dicrotic

from 0.06 to 0.16 sec.

of

systolic

artery exceeded

In those patients or slur was observed

elsewhere.‘O

tolic pressure of the brachial was measured

after

in

notch, three had a

side and one had a normal contour.

hemodynamic

tients will be presented

notch or

artery pressure

Of the six patients

at the peak

some flattening RESULTS

anacrotic

in the brachial

systole was

of

573

from the end-diastolic was designated

to the peak

Goldberg

the time from

aortic

in the aortic

from 100 to 232 cc/systolic The functional

valve was reduced,

ejec-

orifice size of the

ranging

from 0.3 to

the onset to the peak of systole ranged from 0.12

0.9 cm2.

to 0.28 sec. This time interval was more prolonged in the central aortic than in the brachial Of the artery tracing in all cases but four.

The systolic pressure of the left ventricle varied from 150 to 232 mm Hg and the diastolic from 7 to 26 mm Hg. The isometric contraction

latter,

period was prolonged in the majority rangins from 0.04 to 0.09 sec.

this time

and shorter cases. MAY, 1958

interval

in the aorta

was the same in two in the remaining

two

The contour

of cases,

of the curves of the left ventricle

Pressure

574

Pulses in Aortic Stenosis

2

10 Fig. 1. Simultaneously recorded bracbial artery (smooth curve) and aortic (multiple artifacts) pressure pulses in a patient with a normal aortic valve. Note earlier yet higher peak of bra&al artery pressure pulse. Time lines 0.1 sec. ECG above.

2. Simultaneously recorded brachial artery (smooth curve) and aortic (multiple artifacts) pressure pulses in a patient with aortic stenosis. Note the contours of the brachial artery and aortic curves more closely resemble one another than in the normal, although the aorta shows increase in the number of artifacts. Time lines 0.1 sec. ECG above.

and aorta did not resemble

one another

from

systole.

peak

curve

In

all cases,

appeared

the

slightly

later

of the

than

that

during

Fig.

the central

of the

central

pulse (Fig.

Normally

In all cases the pressure pulse of the left vcn-

on the anacrotus transmitted

peak and a slower decline

seen in human

There

after the dicrotic

The systolic ejection ranging

of the systolic ejection

Pulsus Alternans: was the frequent pulsus alternans brachial

between

to 0.34

period and the heart rate. observation

of a mechanical

in the left ventricle, by

sec.

the duration

An interesting occurrence

artery

characterized

period was gener-

from 0.23

was no correlation

in-

pressure

pulses.

regular

variations

aortic,

or

This

was

in

pulse

pressure without change in length of the cardiac cycle or electrocardiogram. occurred

This phenomenon

in 8 or 42 per cent of the patients

this series.

It was found to occur

systemic circulation

in

only in the

in all cases.

It has long been known

that as the arterial

to the periphery,

1).

to

However,

of the aortic pulse which is not the

periphery.”

subjects

This

is also

as demonstrated

by Fig.

in aortic stenosis, where there is a

decrease

in the violence

standing

waves are not set up.

ate and peripheral the central

peripheral

of systolic

discharge,

The intermedi-

pulses more closely resemble

pulsen (Fig. 2).

bulence

in aortic

stenosis

multiple

vibrations

The increased is expressed

seen on the aortic

tur-

by the pressure

pulse, and these are felt to be the anlage of the anacrotic

notch in the peripheral

In the experimental

animal

pulse13 (Fig. 2). during

constric-

tion of the aorta it has been shown that the contour of the aortic

and left ventricular

pulses do not resemble

one another

pressure during

the

time of systolic ejection and these changes are thought to be due to loss of energy across a stenotic valve and increased diastolic size.’

DISCUSSION pressure pulse proceeds

1.

the

over that of the more

in animals there is a small vibration

tricle showed a rapid rise to a smooth rounded

ally prolonged,

Thus

pulse pressure is increased

left ventricle.

cisura.

aorta.

aortic

there

The left ventricular the aorta,

pulse is higher than that of

rising to peaked

summit,

and with a

are changes in both magnitude and contour. The peripheral pulse exhibits a more rapid asThe diascent to an earlier, yet higher, peak.

steep descent. Thus in aortic stenosis the left ventricle contracts more “isometrically.” Also, in this condition the peak of the aortic pressure

tolic pressure

pulse is reached

falls slightly

as it is transmitted

THE

markedly AMERICAN

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than OF

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CARDIOLOGY

Raber and Goldberg

Fig. 3A. Left ventricular and aortic pressure pulses simultaneously recorded in a patient with a normal Time lines 0.1 sec. ECG above. aortic valve.

of the left ventricular

pressure

pulse

(Fig.

3,

Fig. 3B. Left ventricular and aortic pressure pulses simultaneously recorded in a patient with aortic stenosis. Note differences in height of two curves. Peak of aortic curves occurs later than that of the left ventricle. Left ventricular curve is more peaked and with steeper descent than in normal. Time lines 0.04 sec. ECG above.

A and B). The end-diastolic was elevated could

pressure in the left ventricle

in the

be explained

tricular

failure.

lation between and clinical

majority

was generally

failure

to failure,

in the pressure-volume

lationships

secondary

position of

Katz

shown experimentally striction reduced lower

made

elasticity

re-

and just

associates’

distal

to the

of the peripheral

on the

notch

ascending

the

little

aortic

pulse was

lar fibrillation.

associates2 of .the

Other

tracing

heart

of the myocardium

ance,i4 elasticity

with auricu-

factors to be considered

the contour

in the normal

who

brachial

period of the

and in patients

which may influence state

and

in contour

maneuver

Although vanced

of the arterial

are changes

in the

and peripheral

resist-

of the arterial

many

explanations

to explain

the position

it appears

tree15 and veloc-

as predominant.

to a

ship between

This

in either

raised

the di-

of the stroke volume

or pulse

pressure as well as the degree of obstruction

was

factors

Indeed

Figures

must be

4A,

and D show there is no demonstrable

limb.

resemblance

that multiple

have been adof the anacrotic

and no single event can be considered

moved

astolic pressure of the aorta near the origin of the coronary arteries, thus increasing flow to the

19%

Goldberg

tracing in the poststraining

Valsalva

notch,

however,

MAY,

arterial

considered

valvular aortic stenosis, as the posi-

myocardium. The influence

by

the changes

con-

to rheumatic

undoubtedly

noted

have

preparation,

tion of the ligature

bears

suggested

ity of ejection.ls

to correlate

notch with the degree

and the anacrotic position

is due to

that with increasing

of the aorta

valve, the amplitude

of the

to hypertrophy.

been

of the anacrotic

obstruction.

It is

elevation

in these individuals

have

pressure

of the left ventricle.

alteration Attempts

no corre-

the level of the diastolic

pressure

This

in some cases by left ven-

There

felt that in addition diastolic

of cases.

B,

the position of the anacrotic

the aortic

or brachial

pulse and the stroke volume,

artery

C,

relationnotch

pressure

pulse pressure, sys-

tolic pressure gradient and calculated aortic valve area. There was a similar lack of relationship between the time to the peak of systole and stroke volume, pulse pressure, systolic pressure gradient, and aortic valve area. Furthermore, Figure 5 shows the brachial artery tracings of four patients with various degrees of

Pressure

Pulses

in Aortic

Stenosis

b.

x

. .

L

=

*

.

x x

.

*

x x I

x

.

.

. .

* x

x

..

.

.

. . .

*

.

.

Fig. 4. Position of anacrotic notch [X/Y X 1001 in brachial artery and aorta plotted against: (a), stroke volume; (b), pulse pressure; (c), systolic pressure gradient; (d), aortic valve area. Note lack of correlation.

aortic

stenosis.

The

notch,

although

moving

the ascending

limb,

positions

in no way accurately

flect the degree of obstruction Although aortic

the anacrotic

stenosis,

of this disease.

of the anacrotic

to a lower position

patients

spite

notch the

in the brachial

with surgically

lack

of a systolic

artery

tracing,

pressure

erotic

notches

in their peripheral

anade-

gradient

arterial

trac-

ings with a delay to the peak of systole. versely,

one patient

of this group

stenosis had a normal

is not pathognomic

proved pure mitral stenosis have a distinct erotic

re-

at the valve.

notch usually is seen in

its presence Many

on

peripheral

with

Conaortic

pressure pulse

(Fig. 5, top). The

mechanical

pulsus altcrnans,

which was

found to occur only in the systemic in 48 per cent of our patients, unilateral Ferrer

pulsus alternans

and associatesI

recently

(Fig. 6).

the by

In their group

were shown to have this phenomenon in the systemic circulation only. Only one of these six,

needle, system.

however, had aortic stenosis. In their study, as in ours, there was no change in the end-diastolic

artery tracing may likewise be found in many other abnormal conditions, such as patent ductus arteriosus Two patients

and coarctation of the aorta. studied in this laboratory with

normal cardiovascular

systems have shown ana-

exhibiting

described

across the aortic valve during left heart catheterization. These were not felt to bc artifacts introduced by the position of the indwelling or to impedance in the manometric An anacrotic notch on the peripheral

of 21 patients

circulation

demonstrated

pulsus alternans,

pressure of the left ventricle,

aorta,

six

or brachial

artery, nor was it felt to be influenced by respiration. The explanation of this offered by Wiggers’* was that there were periodic changes in the state of the myocardium. However, Ferrer THE

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Fig. 5. Brachial artery pressure tracings in four patients with various degrees of aortic stenosis. Note position of notch does not reflect degree of ohstruction. B.A. pres. = brachial artery pressure; S.V. = stroke volume; S.P.G. = systolic pressure gradient; A.V.A. = aortic valve area.

Fig. 6. Left ventricular and brachial artery tracings superimposed showing mechanical pulsus alternans. ECG above.

MAY,1958

Pressure Pulses in Aortic Stenosis

578

and associates could offer no single explanation of its occurrence.r7 SUMMARY (1) Changes in the contour of the brachial artery, left ventricular, and aortic pressure pulses in aortic stenosis are discussed. (2) There is no demonstrable relationship between the position of the anacrotic notch or its time of occurrence and the stroke volume, pulse pressure, systolic pressure gradient, and aortic valve area. Thus the position of the anacrotic notch is no index of the degree of aortic stenosis. (3) Factors influencing contour of the arterial pressure pulse are discussed. (4) A high incidence of unilateral mechanical pulsus alternans is noted in the left ventricular and brachial artery pressure pulses.

REFERENCES 1. KATZ, L. N., RALLI, E. P.. and CHEER, S. N.: The cardiodynamic changes in the aorta and left ventricle due to stenosis of the aorta. J. Clin. Invest. 5: 205, 1927-28. 2. GOLDBERG,H., BAKST, A., and BAILEY, C. P.: The dynamics of aortic valvular disease. Am. Heart J. 47: 527, 1954. 3. DUCHOSAL,F. W., FERRERO, C., URDANETA,E., and LUPIN, A.: Advances in the clinical evaluation of aortic stenosis by arterial pulse recordings of the neck. Am. Heart J. 41: 861, 1956. 4. BOUGAS,J., MUSSER, B., and GOLDBERG,H.: Left heart catheterization. I. Clinical methods and applications. Am. Heart J. 52: 359, 1956. 5. MUSSER,B. G., BOUGAS,J., and GOLDBERG,H. : Left heart catheterization. II. With particular reference to mitral and aortic valve disease. Am. Heart J. 52: 567, 1956.

6. GOLDBERG, H., DICKENS, J., HAYES, E., JR., and RABER, G.: Simultaneous catheterization of the left and right heart. Ctrrlotion 12: 713, 1955. 7. WOOD, E. H., SUTTERER,W., SWAN, H. J. C., and HELMHOLZ,F. H., JR.: The technique and special instrumentation problems associated with catheterization of the left side of the heart. Proc. staff Meet. Mayo Clin. 31: 108, 1956. 8. GOLDBERG,H., DICKENS,J., RABER, G., and HAYES, E., JR.: Simultaneous (combined) catheterization of the left and right heart. Am. Heart J. 53: 579,1957. 3. GORLIN, R. and GORLIN, S. G.: Hydraulic formula for calculation of the stenotic mitral valve and other valves and central circulatory shunts. Am. Heart J. 41: 1, 1951. 10. GOLDBERG, H., SMITH, R. C., and RABER, G.: Estimation of the severity of aortic stenosis by combined heart catheterization. Am. J. Med. (In press). 11. WIGGERS, C. J.: Physiology in Health and Disease. Lea and Febiger, Philadelphia, 1949. 12. Dow, P.: The development of the anacrotic and tardus pulse of aortic stenosis. Am. J. Phynol. 131: 432, 1940. 13. FEIL, H. S. and KATZ, L. N.: The transformation of the central into the peripheral pulse in patients with aortic stenosis. Am. Heart J. 2: 12, 1956. 14. ALEXANDER, R. S.: Factors determining the contour of pressure pulses recorded from the aorta. Fed. Proc. 11: 738, 1952. 15. REMINGTON,J. W.: Volume quantitation of the aortic pressure pulse. Fed. Proc. 11: 750, 1952. 16. PETERSON,L. H. : Certain physical characteristics of the cardiovascular system and their significance in the problem of calculating stroke volume from the arterial pulse. Fed. Prx. 11: 762, 1952. 17. FERRER, M. I., HARVEY, R. M., COURNAND,A., and RICHARDS, D. W.: Cardiocirculatory studies in pulsus alternans of the systemic and pulmonary circulation. Circulation 14: 163, 1956. 18. WIGGERS, C. J.: Circulatory Dynamics. Modern Medical Monographs, Grune and Stratton, New York, 1952.

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