Mitral valve early diastolic closing velocity in the echocardiogram: Relation to sequential diastolic flow and ventricular compliance

APRIL

The American

Journal

1976

of CARIXOLOGY VOLUME NUMBER

@ 37 5

CLINICAL STUDIES

Mitral Valve Early Diastolic In the Echocardiogram: Diastolic

ANTHONY RICHARD

N. DeMARIA, R. MILLER,

T. MASON,

Relation to Sequential

Flow and Ventricular

MD, MD,

MD,

FACC

FACC

EZRA A. AMSTERDAM, MD, WILLIAM MARKSON, BS DEAN

Closing Velocity

FACC

FACC

From the Section of Cardiovascular Medicine, Departments of Medicine and Physiology, University of California, School of Medicine, Davis, Calif. This study was supported in part by a research grant from the Golden Empire Heart Association, Sacramento, Calif. and Research Program Project Grant HL 14780 from the National Heart and Lung Institute. National Institutes of Health, Bethesda, Md. Manuscript accepted October 8, 1975. Address for reprints: Anthony N. DeMaria, MD, Sacramento Medical Center, 2315 Stockton Blvd., Sacramento, Calif. 95817.

Compliance

Uncertainty exists regarding the determinants of mitral valve early diastolic closing velocity (E-F slope) in the echocardiogram. Accordingly, the mitral E-F slope, sequential atrioventricular flow in each third of diastole in the cineangiogram and an index of ventricular compliance (A volume/A pressure normalized by end-diastolic volume) were obtained in 10 normal subjects, 10 patients with coronary artery disease and marked dyssynergy and 9 patients with hypertrophic cardiomyopathy. The E-F slope of 103 f 20 mm/set (mean f standard deviation) in normal subjects was greatly reduced In patients with coronary artery disease and hypertrophic cardiomyopathy (54 f 22 and 27 f 16 mm/set, respectively, P
April 1976

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DETERMINANTS

OF MITRAL E-F SLOPE-DeMARIA

ET AL.

___

-_

-_

ES

DI

VOL

73

138

D2 150

_ D3 185

%

0

58

II

31

Detection of cardiovascular disease by recognition of abnormalities of mitral valve motion is the cornerstone of the clinical application of echocardiography. Thus ultrasound has proved to be both a sensitive and a specific noninvasive technique for the evaluation of mitral stenosis,1*2 mitral valve prolapse,3-7 idiopathic hypertrophic subaortic stenosiss-13 and left atria1 myxoma14 as well as bacterial endocarditis involving the mitral valveI and aortic regurgitation.16 Moreover, several studies have suggested a role for the mitral valve echogram in the evaluation of cardiac performance by virtue of its ability to mirror alterations in left ventricular inflowI and diastolic pressure.18 Although a large reduction in early diastolic closing velocity of the mitral valve, or decreased E-F slope, has long been recognized as a classic echocardiographic manifestation of mitral stenosis, it is a common echocardiographic finding in other conditions. Re‘cently it has been suggested that the mitral E-F slope may be a function of left ventricular total diastolic fillingsJ7Jg or diastolic compliance,20,21 but the precise determinants of this movement remain uncertain. In this study we evaluated the relation of mitral early diastolic closing velocity in the echogram to sequential diastolic flow and total diastolic compliance of the left ventricle as determined by cardiac catheterization and cineangiography. Materials

and Methods

Case material: Twenty-nine patients without mitral or aortic valve disease who underwent cardiac catheterization and coronary arteriography constituted the study population. There were 14 men and 15 women aged 39 to 63 years (mean 52). The group was composed of 10 normal subjects referred for cardiac evaluation because of atypical chest pain without other clinical evidence of organic heart disease, 9 patients with idiopathic hypertrophic cardiomyopathy and 10 patients with coronary artery disease. Mitral regurgitation was absent in all patients with coronary disease

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April 1976

The American Journal of CARDIOLOGY

Volume 37

FIGURE 1. Case 10 (representative normal subject). Mitral valve echogram (lefl), sequential left ventricular diastolic flow from cineangiogram (center) and mean total diastolic compliance index (C~ov) (right). Ventricular volumes were obtained angiographically in the right anterior oblique view. The left ventricular volume at the end of the first third of diastole (Dl) is depicted by the silhouette of alternating dots and dashes, the middle third (D2) by the dashed line, the final third (D3) by the solid line; end-systole (ES) is indicated by the dotted line. The absolute sequential volumes (VOL) and the percent (‘XI) of sequential diastolic inflow ire given. AM = anterior mitral leaflet; ECG = electrocardiogram; IS = interventricular septum. The solid line in the echogram shows the E-F slope.

and was only minimal in two patients with hypertrophic cardiomyopathy. Since previous studies in our laboratoryz2 have shown that alterations in ventricular compliance are related to the presence and extent of ventricular dyssynergy, the patients with coronary artery disease selected for this study manifested extensive left ventricular dyskinesia in the cineangiogram.

Echocardiography: Echocardiograms were performed in a standard fashion during held mid-expiration within 24 hours of catheterization in all patients. Although ultrasonic tracings could not routinely be recorded during cardiac catheterization, such simultaneous examinations were accomplished in a subset of five patients and were compared with the results of the echocardiographic study performed during the previous 24 hour period. Echocardiograms were obtained with patients in the supine or 30’ left lateral decubitus position using an Ekoline 20A (Smith-Kline Instruments) ultrasonoscope interfaced to either an Electronics for Medicine Model DR8 photographic or Honeywell Model 1856 fiberoptic recorder. Mitral E-F slope was measured as the descent of the anterior leaflet from maximal opening at the E point to its position at the end of the first third of diastole. To ensure uniformity of measurement among patients, early diastolic closure was evaluated in an echographic sector that included both mitral leaflets, and an average was taken of three beats that manifested maximal velocity. In six persons whose mitral echogram demonstrated an abrupt change in velocity during the first third of diastole (Fo),~~ the total duration of diastole was obtained by measuring the time between separation and coaptation of the mitral leaflets, and the E-F slope was determined from the E point to the position of the mitral leaflets at the termination of one third of this interval.

Left ventricular angiography: Sequential left ventricular diastolic flow was determined by analysis of the temporal pattern of filling of this chamber as recorded by cine-

angiography.24 Left ventricular cineangiography was performed in the 30’ right anterior oblique projection on 35 mm film taken at 64 frames/set using a Philips image intensifier system with 9 inch magnification. The ventricle was opacified with 0.75 to 1 cc/kg body weight of Hypaque

DETERMINANTS OF MITRAL E-F SLOPE-DeMARIA

ET AL.

,020

FIGURE 2. Case 17 (representative

patient with idiopathic hypertrophic cardiomyopathy). Mitral valve echogram (lefl), sequential left ventricular diastolic flow from cineangiogram (center) and mean total diastolic compliance index (right). Abbreviations as in Figure 1.

___ ES

Mm, 15 percent (Winthrop) containing 25 percent sodium diatrizoate and 50 percent meglumine diatrizoate injected at 300 Ib/ir?. This method of calculating sequential diastolic flow has been applied previously in comparison of patients with mitral insufficiency, aortic stenosis and coronary artery diseasez5 as well as those with various degrees of severity of ischemic heart disease.22 With use of the right anterior oblique single plane technique,26s27 fractional increments of left ventricular volume were measured at the end of early, middle and late diastole and the percent of diastolic filling was determined for each of these three equal time periods. Values for end-diastolic and end-systolic left ventricular volume, stroke volume and left ventricular ejection fraction were also obtained from cineangiograms. Although some workers 28*2ghave pointed out the difficulties in assessing left ventricular volume by single plane angiography in patients with coronary artery disease who have wall motion abnormalities, most investigators22~25-27 have found that left ventricular cineangiography in the right anterior oblique projection provides a reliable estimation of left ventricular volume. However, the possibility that minor discrepancies in the determination of left ventricular volume by single plane angiography may have occurred and thereby might account for small differences in the groups with coronary artery disease and hypertrophic cardiomyopathy cannot be completely excluded. An index of mean left ventricular diastolic compliance was obtained as A volume/A pressure,30r31 where A volume equals diastolic volume change measured as stroke index, determined from cardiac output measured by dye-dilution technique using left ventricular injection and correcting for body surface area; and A pressure equals change in left ventricular diastolic pressure, measured from the lowest level of early diastolic pressure to end-diastole 0.04 second after onset of the QRS complex. Left ventricular pressure was obtained by use of a high fidelity micromanometer catheter (Statham SFlz4). Three consecutive left ventricular beats immediately before and after the cardiac output determinations were averaged for A volume/A pressure for each patient. Since ventricular volume influences the functional passive pressure-volume curve, the value for observed compliance was normalized by end-diastolic volumes.30,31

z-

;I-

VOL

24

27

65

G 96

%

0

4

51

45

Results Technically satisfactory echocardiograms and left ventricular cineangiograms were available in all patients; representative examples are shown in Figures 1 to 3. Since no significant difference could be demonstrated between values for heart rate or echocar-

diograms obtained during cardiac catheterization and thos? recorded during the preceding 24 hours in patients with such studies, the echocardiographic data obtained during routine precatheterization examinations were analyzed. Individual data for each variable analyzed are shown in Table I.

Left ventricular performance: Cardiac index and stroke volume of 2.96 f 0.45 liters/min per m2 body surface area and 103 f 30 cc, respectively (group mean f standard deviation) in normal subjects were not significantly different from values in the patients with hypertrophic cardiomyopathy (2.98 f 0.46 liters/min per m2 and 110 f 38 cc) or those with coronary artery disease (2.72 f 0.53 liters/ min per m2 and 87 f 0.20 cc). Left ventricular enddiastolic pressure, similar in normal subjects and patients with coronary disease (9 f 3 versus 10 f 5 mm Hg, was significantly greater in the group with hypertrophic cardiomyopathy (15 f 5 mm Hg) (P <0.05). Left ventricular end-diastolic volume was greater (225 f 72 cc) in patients with coronary disease than in normal subjects or patients with hypertrophic cardiomyopathy (155 f 41 and 168 f 77 cc, respectively), but this difference was statistically significant only for normal subjects (P <0.02). Left ventricular ejection fraction was also similar in normal subjects and patients with cardiac hypertrophy (67 f 5 percent and 68 f 11 percent, respectively) but was significantly reduced in the patients with coronary artery disease (39 f 10 percent) (P
April 1976

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Volume 37

695

DETERMINANTS OF MITRAL E-F SLOPE-DeMARIA

ET At

FIGURE 3. Case 28 (representative patient with coronary artery disease). Mitral echogram (left), sequential left ventricular diastolic flow (center) and mean total diastolic compliance index (right). Abbreviations as in Figure 1.

___ ES

TABLE

VOL

123

%

0

16

48

36

I

Summary

of Data % Flow

Vol Flow

CZW? “0.

1 2 3 4 : 7 8 9 10 Mean SD

1 I3

213

313

45 54 38

25 46 16 45 23 18

32 21 17 10 39 28

58 45 43 58 48.4 *IO.4

16 39 27 11 26.2 t12.6

26

43 2;

:z Z.0 t8.8

MEF

Comp

213

313

A. Normal

Subjects

l/3

115 :z

0.090 0.070 0.060 0.050 0.045 0.060

33 35 110 49 20 67

20 58 26 49 22 24

110 98 75 128 103.4 i-20.6

0.080 0.040 0.070 0.075 0.064 +0.02

54 45 39 65 51.7 t25.1

16

104 79 140

:: 16 4 32 22 4 23 16 20.2 ill.5

22 36 47 40 39 32 51 40 39 38.0 kg.8

50 27 37 56 29 46 45 37 45 41 .o t12.1

31 57 15 10 35 20 12 39 22 26.8 t15.2

0.020 0.030 0.030 0.040 0.038 0.040 0.020 0.040 0.010 0.029 +0.01

:: 15 5 38 14 3 17 19 24.2 t20.8

3.10 2.60 3.90 2.77 3.00 2.81

I; :

24 15

2.60 3.44

12 9

33 39

24 21

43 29

23 22 24 25 26 27 28 29 Mean SD

44 13 24 12 6 18 16

30 45

26 42 54 54 65 34 36 46 43.4 ~14.2

z.9 k14.1

32: 29 48 48 10 30.7 1-11.8

53 50

0.025 0.027

36 34

82 70 50 38 12 60 38 83 53.6 ~21.8

0.053 0.018 0.040 0.030 0.020 0.018 0.038 0.016 0.029 *0.012

48 11 22 7 7 11 10 42 22.8 *I 5.8

1:

;z z 24.5 k7.6

ii.8 514.6

69 49 34 79

30 64 44 56 42 21 38 31 45 43.2 +13.1

2:&i 2.96 50.45

90.3 +2.5

EDV

110 169 224 174 191 93 125 141 135 185 154.7 t40.7

ESV

32 52 z: 39 65 31 36 53 73 50.4 +15.1

SV

78 117 165 109 126

HR

EF

80

:: 112 103.2 k30.4

0.71 0.69 0.73 0.63 0.66 0.58 0.75 0.67 0.68 0.60 0.67 kO.05

137 182 93 140 107 65 74 78 115 110.1 +37.9

0.63 0.66 0.57 0.46 0.74 0.84 0.75 0.80 0.73 0.68 +0.11

76 70 70 80 94 80 90

g”t

:: 56 60 78 :: :: 66.8 kg.8

Cardiomvopathv

;A 33 29 51 42.7 120.7

C. Patients With Coronary 20 21

LVED

;: 28 11 35 21

9. Patients With Hvpertrophic 11 12 13 14 15 16 17 18 19 Mean SD

Cl

Artery

2.95 3.32 2.76 3.80 3.08 3.40 2.10 2.53 3.08 2.98 i-O.46

9 17 20 18 11 16 11 8 23 14.8 k5.2

216 275 163 289 143

69 93

z 97 158 168.4 +76.9

1:: 36 12 24 19 43 57.2 k43.7

:: 78.4 t9.3

Disease

26

45 26

2.30 2.47

12

225 158

117 71

108

0.47 0.55

77 96

44 :: 20 20 30 30 28 10 27.4 +9.7

18 36 50 32 68 21 22 44 36.2 t15.7

2.62 2.85 3.20 3.60 3.24 2.64 2.60 1.72 2.72 kO.53

17 I: 11 4 4

197 255 186 163 318 183 183 379 224.7 k72.6

87 168 94 104 213 122 123 283 138.2 t65.5

110 z:: 92 59 105 61 9”:

0.55 0.34 0.49 0.36 0.33 0.33 0.32 0.25 0.39 +0.10

rz;

8 10 9.6 +4.7

86.5 +_20.0

:: 71 :: z.5 ?I 6.3

Cl = cardiac index (liters/min per to’); Comp = angiographic index of left ventricular compliance; EDV = left ventricular end-diastolic volume by cineangiogram (cc); EF = ejection fraction; ESV = end-systolic volume by cineangiogram (cc); % Flow = the percentage of total diastolic flow occurring in the first (l/3), second (2/3) and final (3/3) third of diastole; HR = heart rate (beats/minj; LVED = left ventricular enddiastolic pressure (mm Hg); MEF = echocardiographic mitral early diastolic closing velocity (mm/set); SV = stroke volume (cc); Vol flow = absolute volume of flow in each third of diastole (cc).

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DETERMINANTS

diastolic flow: Sequential diastolic was measured both as the percent and absolute volume of left ventricular filling during each third of diastole (Table I, Fig. 4A). The group mean and standard deviation for percent of left ventricular inflow in the initial third of diastole in the normal subjects was 48 f 10 percent, which was significantly reduced to 20 f 11 percent in patients with hypertrophic disease (P
% FLOW-k3

0~ MITRAL

E-F

SLOPE-DEMARIA

ET

AL.

DIASTOLE

flow

N

C

H

MITRAL

120

E-F

N

CAD

D

SLOPE

H

COMPLIANCE

CAD

N

INDEX

H

CAD

*p<.oo1 FIGURE 4. Mean values and 1 standard deviation for the percent of left ventricular flow (A) and the absolute volume of flow in the initial third of diastole (B), the mitral echographic E-F slope (C) and the total left ventricular diastolic compliance index (D) for normal subjects (N), patients with idiopathic hypertrophic cardiomyopathy (H) and patients with coronary artery disease (CAD).

70 1

.

I

I

60 w

.

.

/

/

/

.

N H . CAD r = 0.87

a

I 50

25

100

75

125

150

175

MITRAL E-F SLOPE (mm/set) FIGURE tial third subjects coronary

5. Relation of the percent of left ventricular filling in the iniof diastole to the echographic mitral E-F slope in normal (N) and patients with hypertrophic cardiomyopathy (H) and artery disease (CAD).

.I0 t

. B

y

. .075-

iz sY

.

. .50

8

I

3 .

AA

5

i 2

.

..

.025

-

8

. .

..

. .

.

.

l -N A-H

. %

=-CAD n

.

r = .67

.

. I 25

50

75

100

125

150

175

MITRAL E-F SLOPE (mm/set) FIGURE 6. Relation between total left ventricular diastolic compliance index normalized for end-diastolic volume (EDV) and the echographic mitral E-F slope in normal subjects (N) and patients with hypertrophic cardiomyopathy (H) and coronary artery disease (CAD).

April 1976

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of CARDIOLOGY

Volume

37

697

DETERMINANTS

w

..d?

OF MITRAL E-F SLOPE-DeMARIA

ET AL.

HYPERTROPHICY =.66X + 2.5

IOO-

60-

Transmitral

I

20

40

60

80

100

120

140

MITRAL E-F SLOPE (mm/set) FIGURE 7. Relation of the percent of the initial third of left ventricular diastolic filling to the echographic mitral E-F slope in normal subjects (N) and patients with hypertrophic cardiomyopathy and coronary artery disease (CAD). The linear regression equations are given for each group.

tained for percent flow in the first third of diastole), ventricular compliance was generally reduced in patients with a mitral early diastolic closing velocity of less than 75 mm/set (Fig. 6). Relation of mitral slope to diastolic flow in hypertrophic cardiomyopathy and coronary disease: The disparity between the comparable reduc-

tion in diastolic flow and the greater reduction in mitral early diastolic closing velocity prompted further investigation (Fig. 4C). Therefore the relation -of the percent of ventricular inflow in the first third of diastole to the mitral E-F slope was determined separately for the group of normal subjects and the patients with hypertrophic cardiomyopathy and coronary artery disease (Fig. 7). The slope of this relation was greater in the patients with hypertrophic cardiomyopathy (Y = 0.66X + 2.5) than in either the group with coronary artery disease (Y = 0.46X) or the normal subjects (Y = 0.35X + 12), with correlation coefficients of 0.88, 0.70 and 0.70, respectively. Thus, for any value of ventricular inflow in the initial third of diastole, the E-F slope was reduced to a greater extent in the patients with hypertrophic cardiomyopathy than in those with coronary artery disease or in normal subjects. Discussion Although echocardiography has become an important diagnostic tool for the clinical cardiologist and has been demonstrated to reflect accurately the movement of both norma1”2-34 and abnormal mitral valves,23 the precise determinants of mitral leaflet motion in the echocardiogram remain uncertain. Thus, previous studies have suggested a relation between mitral early diastolic closing velocity in the echocardiogram and transmitral valve flo~,*J~J~,~~ interaction of left atria1 and left ventricular pressure,23 and left ventricular diastolic compliance.8J0,21 In addition, mitral early diastolic reclosure has been attributed to a ring-vortex system formed within the left ventricle as a result of lack of lateral dispersion of

696

transmitral blood flow during diastolic filling that may be susceptible to influence by alterations of left ventricular geometry. 36,37Our findings indicate that transmitral diastolic flow is a principal determinant of the mitral E-F slope in the echogram.

April 1976

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Volume 37

diastolic

inflow

and the E-F slope:

The motion of the mitral valve echogram during early diastole is a composite of the movements of the mitral valve anulus and the anterior leaflet.23 Thus the initial portion of the mitral E-F slope represents movement of the anulus posteriorly or away from the echo transducer that is followed by excursion of the anterior leaflet in a similar direction. On occasion, the early posterior motion of the mitral ring may produce an abrupt change in velocity of the mitral valve echogram at a point between the E and F points designated Fo. 23 An Fo point was present in six persons in our study, and in these cases the mitral E-F slope was determined from the E point to the position of the mitral leaflets at the end of the initial third of diastole. We thereby related the effects of mitral valve diastolic inflow during the initial third of diastole to the excursion of the anterior mitral leaflet at the termination of the first third of diastole in all 29 patients. In addition, uniformity of measurement of the mitral E-F slope was assured by selecting only the echographic complexes containing both anterior and posterior leaflets that manifested the maximal velocity of excursion. Previous studies38r3g have demonstrated that the mitral E-F slope is subject to alteration in the presence of rapid heart rates. Thus, superimposition of atria1 contraction upon the period of rapid ventricular filling during early diastole may occur at accelerated heart rates, resulting in an obliteration of the mitral early diastolic closing velocity. Therefore all echograms included in our study were obtained at a heart rate of less than lOO/min, and in no case was the echographic deflection produced by atria1 contraction found to encroach upon the mitral E-F slope. The diastolic compliance of the left ventricle represents the dynamic relation of the responses of ventricular volume to changes in ventricular pressure throughout relaxation. In this study, we used an index of compliance that related the change in left ventricular volume to simultaneous change in chamber pressure. The measure of mean diastolic distensibility thus obtained was corrected for end-diastolic volume to normalize the influence of chamber size upon this property. 24 Although it is likely that alterations of ventricular compliance during any portion of diastole will be reflected in mean diastolic compliance, the comparison of mitral closing velocity in early diastole to an average estimate of compliance for the entire period of diastole may account for some of the discrepancy observed between these two derived variables. Hemodynamic correlations with mitral early diastolic closing velocity: Several differences in hemodynamic variables were noted among the three groups of subjects evaluated. Thus, although cardiac

DETERMINANTS OF MITRAL E-F SLOPE-DeMARIA

index and stroke volume were similar in all groups, the end-diastolic pressure was greater in the patients with hypertrophic cardiomyopathy than in either the normal subjects or those with coronary artery disease, whereas the ejection fraction was lower and end-systolic volume greater in the patients with coronary disease than in either of the other two groups. In addition, end-diastolic volume was greater in the patients with coronary disease than in the normal subjects. These differences were related in part to the selection of patients with coronary disease on the basis of the presence of left ventricular dyskinesia since previous studies in our laboratories have shown that abnormalities in ventricular compliance are related to the presence and extent of ventricular dyssynergy.22 In this study, we found no correlations between any of these hemodynamic variables and mitral early diastolic closing velocity. Thus, these variables do not appear to affect mitral E-F slope significantly. Moreover, the expression of diastolic filling in terms of percent of stroke volume served to negate the influence of differences of absolute ventricular individual and cardiac index among volume subjects.24 Early left ventricular inflow and E-F slope: A good correlation was observed between the percent of ventricular inflow during the first third of diastole and the mitral early diastolic closing velocity in the echocardiogram (Fig. 5). This finding is consonant with the data of McLaurin et a1.,40 who noted a decrease in early left ventricular diastolic filling in patients with right ventricular pressure overload who manifested a reduced mitral E-F slope, and the data of Laniado et al.,lg who were able to relate the mitral E-F slope to the amount of transmitral flow in dogs. Thus, left ventricular filling occurred primarily in the initial third of diastole in normal subjects (Fig. l), and these subjects manifested the most rapid E-F slope (Fig. 4, A and B). By contrast, the greatest proportion of ventricular filling in the groups with hypertrophic cardiomyopathy and coronary disease took place during the final third of diastole (Fig. 2 and 3), thereby occurring during the period of the A wave of the mitral echogram and resulting in reduced mitral reclosure velocity (Table I). Although diastolic flow during the middle third of diastole was slightly greater than that during the initial period, a major increase in closing velocity was usually not recorded during this interval. The absence of an increased E-F slope during the middle third of diastole was most probably related to the small increment in flow during this period, imposition of the atria1 contraction wave, and the effects of the ventricular filling that occurred during the first third of diastole upon the

ET AL.

position of the mitral leaflets. Our finding that in the patients with hypertrophic cardiomyopathy and coronary disease with reduced compliance ventricular filling occurred in the final third of diastole is consistent with additional data obtained in our laboratories indicating the major importance of atria1 contraction to ventricular filling in patients with a noncompliant ventricle.41 It therefore appears that the magnitude of left ventricular filling during the initial third of diastole is the major determinant of the mitral E-F slope. Left ventricular compliance and E-F slope: An attempt was made in this study to establish a relation between the mitral E-F slope and total left ventricular compliance. Although a general relation between these variables was observed, in that nearly all patients with a mitral E-F slope of less than 75 mm/set had a reduced compliance index, a close correlation could not be demonstrated between the E-F slope and ventricular compliance for individual patients (Fig. 6). Thus, although decreases in left ventricular diastolic compliance usually result in reductions of transmitral flow in the first third of diastole and thereby diminish mitral valve early diastolic closing velocity, it would appear that the mitral E-F slope does not provide accurate assessment of total left ventricular compliance in individual patients. E-F slope in hypertrophic cardiomyopathy versus coronary artery disease: Whereas left ventricular filling during the initial third of diastole was comparably reduced in patients with hypertrophic cardiomyopathy and coronary artery disease, the mitral E-F slope was decreased to a greater extent in the group with cardiac hypertrophy (Fig. 4C). One possible mechanism for this phenomenon is that cardiac hypertrophy results in anatomic alterations in the relation of the papillary muscles to the mitral valve, so that the mitral leaflets are impeded in their normal closing motion in response to left ventricular filling. Alternatively, the alteration of ventricular geometry induced by cardiac hypertrophy may produce different effects upon the postulated left ventricular vortex of inflow pathways than the alteration produced by coronary disease, and thus create more profound changes of mitral valve motion for any reduction in transmitral flow. In any event, it is clear that left ventricular inflow during the initial third of diastole is not the only factor influencing the mitral E-F slope. Acknowledgment We gratefully acknowledge the technical assistance of Alexander Neumann and Robert Kleckner and the secretarial assistance of Leslie Silvernail, Alicia Glynn, Gail Garnas and Marilyn McChesney.

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1963 3. Segal BL, Likoff W, Kingsley B: Echocardiography: clinical applications in mitral stenosis. JAMA 193:161-167, 1966 4. Dillon JC, Haine CL, Chang S, et al: Use of echocardiography

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DETERMINANTS OF MITRAL E-F SLOPE-DeMARIA

in patients 1971

with prolapsed

ET AL

mitral valve. Circulation

43:503-507, 24.

5. Kerber RE, lsaeff DM, Hancock EW: Echocardiographic patterns in patients with the syndrome of systolic click and late systolic murmur. N Engl J Med 284:691-693, 1971 6. Popp RL, Brown OR, Silverman JF, et al: Echocardiographic abnormalities in the mitral valve prolapse syndrome. Circulation 49:428-433, 1974 7. DeYaria AN, King JF, Bogren H, et al: The variable spectrum of echographic manifestations of the mitral valve prolapse syndrome. Circulation 50:33-40, 1974 8. Shah PM, Gramiak R, Kramer DH: Ultrasound localization of left ventricular outflow obstruction in hypertrophic obstructive cardiomyopathy. Circulation 40:3-l 1, 1969 9. Popp RL, Harrison DC: Ultrasound in the diagnosis and evaluation of therapy of idiopathic hypertrophic subaortic stenosis. Circulation 40:905-914, 1969 IO. Abbasi AS, MacAlpin RN, Eber LM, et al: Echocardiographic diagnosis of idiopathic hypertrophic cardiomyopathy without outflow obstruction. Circulation 46:897-904, 1972 11. Henry WI, Clark CE, Glancy DL, et al: Echocardiographic measurement of the left ventricular outflow gradient in idiopathic hypertrophic subaortic stenosis. N Engl J Med 288:989-993, 1973 12. Henry WL, Clark CE, Epstein SE: Asymmetric septal hypertrophy: the unifying link in the IHSS disease spectrum. Circulation 471827-832, 1973 13 King JF, DeMaria AN, Reis RL, et al: Echocardiographic assessment of idiopathic hypertrophic subaortic stenosis. Chest 641723-731, 1973 14. Wolfe SB, Popp RL, Feigenbaum H: Diagnosis of atrial tumors by ultrasound. Circulation 39:615-622, 1969 15. Dillon JC, Feigenbaum H, Konecke LL, et al: Echocardiographic manifestations of valvular vegetations. Am Heart J 86:898704, 1973 16. Winsberg F, Gabor GE, Hernberg JG, et al: Fluttering of mitral valve in aortic insufficiency. Circulation 41:225-229, 1970 17. Fischer JC, Chang S. Konecke LL, et al: Echocardiographic determinations of mitral valve flow (abstr). Am J Cardiol 29: 262, 1972 18. Konecke LL, Feigenbaum H, Chang S, et al: Abnormal mitral valve motion in patients with elevated left ventricular diastolic pressures. Circulation 47:989-996, 1973 19. Laniado S, Yellin E, Kotler M, et al: A study of the dynamic relations between the mitral valve echogram and phasic mitral flow. Circulation 51:104-113, 1975 20. Gulnones MA, Gaasch WH, Waisser E, et al: Reduction in the rate of diastolic descent of the mitral valve echogram in patients with altered left ventricular diastolic pressure-volume relations. Circulation 49:246-254, 1974 21. Bergeron GA, Cohen MV, Teichholz LE, et al: Echocardiographic analysis of mitral valve motion after acute myocardial infarction. Circulation 51:82-87, 1975 22. Miller RR, Zelis R, Massumi RA, et al: Left ventricular compliance: relation to different patterns of left ventricular dyssynergy (abstr). Am J Cardiol 31:147, 1973 23. Zaky A, Nasser WK, Feigenbaum H: A study of mitral valve ac-

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25. 26.

27. 28.

29.

30.

31.

32.

33.

34.

35.

36. 37. 38. 39.

40.

41.

37

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