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Pressure pulse waves in the right ventricle: Alteration in patients with pulmonic stenosis and pulmonary hypertension
Pressure Pulmonic
Pulse Waves Stenosis
in the Right
and Pulmonary
TT7~illianz J. liashkind,
M.D.,
Ventricle:
Alteration
in Patients
With
Hypertension
Philadelphia,
Pa
‘The right ventricular pressure pulse reflects the volume of the right ventricular outflow, the resistance at the pulmonaq. valve, and the resistance oi the pulmonary arterial tree. It ma?- be distorted by various pathologic situations, the distortion reflecting the nature of the patholog-. Bouchard and (‘ornu’ reported the difference the>- noted between the contours of the right ventricular pressure tracings from patients with pulmonic stenosis ancl intact ventricular septum (hereafter called pulmonic stenosis) and those from patients with pulmonic stenosis and a ventricular septal defect (hereafter called tetralogy of Fallotj. It is the purpose of this paper to present a more detailed analysis of this difference, and to show the characteristic change in contour Ixoduced by pulmonary hypertension. In 33 patients with pnlmonic stenosis the diaglmsis ~a> considered to be suficientl~~ Nell established for inclusion of them in this report. To be included in this group each case had to fulfill at least one of the following criteria in addition to the clinical diagnosis: (1) neither left-toright nor right-to-left shunt, (2) anatomic confirmation at surgery* or autopsy, (3) definite &Gal improvement follolving pulmonnr)\-al\-atom)-. For iwlnsion in the group with tetralog)ofFallot each case had to fulfill at least one of the following criteria in addition to the clinical diagnosis: (1) cardiac catheter passed from the right ventricle directly into the aorta, (2) left-to-right shunt at the wntricular level, (3) definite clinical ilnpro\.ement following subclavian-puImonar)or aortic-oprllmonar~ anastomoses. By these standards there were 15 proved cases of tetralog). of Fallot and 18 proved cases of pulmonic stenosis. All tracings were recorded through a standard Conrnand-type cardiac catheter during routine right heart catheterization or via a small plastic. catheter inserted directly into the right ventricle at the time of surgery, using a Lilly capacitance type of electromanometer with a speed of response more than adequate for the analyses reported here.2 Twenty-three measurements on 21 patients with left-to-right intracardiac, shunts and pulmonary hypertension proved by direct measurement of the pulmonary arterial pressure are also reported. Fourteen of these patients had ventricular septal defects, 4 had the atrio\-entricul;lris communis s~ndromc, and 3 had patent dnctus arteriosus. This study u-as supported in part by grants from the Southeastern Pennsylvania Chapter of thr American Heart Association, and the Harrison Surgical Research Depart,ment of t,he lJniversit,y of Pennsylvania School of Medicine. Received for publication June 15, 19.59. *One patient with an infundibular stenosis revealed a small ventricular septal defect at t,he time of direct. exploration of the right ventricle, only after infundibular tissue had been resected. Since the right ventricular pressure at the time the tracing was made was 150/-10 as compared to 94/76 mm. Hg systemic pressure, and there was no evidence of increased oxygen content in the right ventricle. the case
is classified
functionally
with
t,he pulmonic
stenosis 36
group.
All patients classified as having tetralogy of Fallot had right ventricular pulse curves that were in all respects identical in contour to the normal right ventricular pulse curve except for elevated pressure. The shape can best be described as an inverted U (see Fig. 1). The right ventricular pressure tracings from the group having pulmonic stenosis show a detinite distortion of the curve (see Iyig. L), with a gradual upslope to a sharp peak, follo\ved by a slow descent to the diastolic level, i.e., an inverted \‘. Ln the tetralogy of Fallot group, the upslope duration averaged 21 per cent (expressed as per cent of the duration oi the s).stolic pulse wave), ranging from 13 to 29 per celit, whereas the clownsslope duration averaged 25 per cent, with a range of 9 to 37 per cent. The pulmonk stenosis group had an upslope of 54 per cent (range, 27 to 62 per cent), with a downslope ;Iveraging 53 per cent (range, 3X to 73 per cent). There is virtualI!no overlap between the two groups. ‘TweiltJ,-one of the 23 tracings from the right ventricle from 21 p;ltients \yith pulmonary hypertension show an initial rapid upslope, followed by ;I more gradual rise to a peak, then followed b>, a rapid descent to the diastolic level, giving the gabled contour seen in Fig. 4. The two exceptions were tracings recorded from two of the patients with patent ductus \vho were recatheterized approximately one year after ligation of the ductus. Pulmonary hypertensioil persisted in both, but the right ventricular pulse pressure curve sho\ved a distorted fat-topped contour.
;\ review of right ventricular pressure curves reproduced in various reports”-‘” may be summarized as follows: twent>.-four of twenty-five patients (authors’ diagnoses accepted as correct) with pulmonic stenosis showed the inverted V contour. Ten of twelve patients reported as having tetralogy of Fallot showed the inverted c’ type of curve. I+Yneberg and Wiggers13 progressively occluded the pulmonary artery in dogs and obtained right ventricular pressure tracings of the inverted V type. They ascribe the over-all changes as being due to right ventricular fatigue, but do not- discuss the specific changes in contour. \&Te have noted the same changes in contour in patients with intact ventricular septa who have small gradients across the pulmonaryvalve (see Fig. 3) and no signs of right ventricular fatigue. When there is an adequate pressure outlet from the right ventricle, whether this be through a normal valve or through a ventricular septal defect, the contour of the right ventricular pressure wave is normal, independent of the height of the pressure. When there is inadequate outlet from the right ventricle, even relative15 mild obstruction, the right ventricular pressure wave is distorted into the inverted \’ shape. The contour of the curves from the patients with pulmonnr> h>,pertension is a combination of both types of curves. The initial rapid upslope indicates that the outlet through the pulmonic valve and into the hilar vessels is adequate. The later slow upslope is indicative of the obstruction to flow offered by the narrowed pulmonary arterioles. Hypertrophy of the crista ventricularis may also be a factor in the contour distortion.
3s
K.\SHI(INI)
L.00
50
0
0 Fig.
l.-Tetralogy
of Ballot.
Fig.
4.--Pulmonary
hypertension
\Videspread use of open cartliotom). with extracorporeal circulation will allow more complete anatomic correction of these lesions, using essentially the same surgical approach. In man). instances, particularlyin the cyanotic infant, valvotom!, for pulmonic stenosis, some form of systemic-pulmonic anastomosis for tetralogy of Fallot, or some entirely different procedure for pulmonary hypertcxsiw, will be required. These varied surgical techniques necessitate accurate preoperative diagnosis. In this regard, the data obtained from analysis of the right ventricular pulse wave may be very valuable, particularly when the cardiac catheter cannot be advanced into the pulmonary artcrv.
Fifteen patients with proved pulmonic stenosis with ventricular septal defect (tetralogy of Fallot) demonstrated right ventricular pressure pulse contours of the normal inverted IT shape with elevated pressure (Fig. 1). Eighteen patients with proved pulmonic stenosis with intact ventricular septum (pulmonic stenosis) demonstrated right ventricular pressure pulse contours of an inverted V shape (Fig. 2). ‘T‘\ventJ.-one patients with proved pulmonaryhypertension showed a gablet\-pe contour of the right ventricular pressure pulse wave (Fig. 4). Two of these patients demonstrated this contour prior to ligation of a patent ductus arteriosus. Postoperatively, the contour WLS no longer typical. The use of this observation as an aid in diagnosis, and the mechanisms iirvolved in the production of these changes in contour is discussed. I xvish and aid.
1. 2. 3. 4. 2: 7. 8. 9. 10. 11.
l-7. 1 .i.
to thank
Dr.
Knchcl
-Ash, Dr.
Sidney
Friedman,
and
Dr.
Peter
Vanace
for
advice
Bouchard, F., and Curnil, C.: Etudes des courbes de pressions ventriculaire droite et artcrielle pulmonaire clans ies retrecissements pulmonaires. Arch. mat. coeur 47:417 1954. Lilly, J. C.: -A V’ariable Capacitor for Measurements of Pressure and nlechanical Displacements, J. Appl. Physics 18:613, 1947. Doxv, J. VV., Levine, H. D.. Elkin. XI., Haynes, F. 1X::., Hellems, H. K., Whittcnberger, J. A-., Ferris, B. G., Goodale, W. T., Harvey, W. P., Eppinger, E. C.! and Dexter, L.: Studies of Congenital Heart Disease. IV. I-ncomplicated Pulmonrc Stenosis, Circulation 1:267, 1950. Gnsul, B. M., Dillon, R. F., Vrla, V., and Hait, G.: Ventricular Septal Defects, J.A.hl.A. 161:847, 1957. JlcCord, RI., Van Elk, J., and Blount, S. G.: Tetralogy of Fallot, Circulation 16:736, 1957. Eldridge, F. L., and Hultgren, H. N.: Pulmonary Stenosis With Increased Pulmonary Blood Flow, AM. HEART J. 49:835, 1955. Horlick, L.. and Merriman, J. E.: Congenital V’alvular Stenosis of the Pulmonary and Aortic Valves M’ith Atria1 Septal Defect, ;\M. HEART J. 54:615, 1957. hIoflitt, G. I~., Zinsser, H. F., Kuo, I’. T., Johnson, J., and Schnabel, T. F., Jr.: Pulmonary Stenosis With Left-to-Right Intracardiac Shunts, Am. J. Med. 16:521, 1951. Brock. R. C.: Congenital Pulmonary Stenosis, Am. J. Med. 12:706, 1952. Blount. S. G., McCord! M. D., Mueller, H., and Swan, H.: Isolated Valvular I’uimonic Stenosis, Circulation 10:161, 1954. Connolly, D. C., Lev, R., Kirklin, J. W., and W’ood, E. II.: The Problem of Isolated Valvular vs. Infundrbular Pulmonic Stenosis, With Particular Reference to Cardiac Catheterization Data and Records Obtained at the Time of Operation, Proc. Staff Meet. Mayo Clin. 28:65, 1953. I’ollack, ;I. :I., Taylor, B. E., Odel, H. M., and Burchelf, H. B.: Pulmonary Stenosis Without Septal Defect, Proc. Staff Xleet. Mayo Clin. 28:65, 1953. Fineberg, M. H., and Wiggers, C. J.: Compensation and Failure of the Right Ventricle, AM. HEART J. 11:2X, 1936.
Pulse Waves Stenosis
in the Right
and Pulmonary
TT7~illianz J. liashkind,
M.D.,
Ventricle:
Alteration
in Patients
With
Hypertension
Philadelphia,
Pa
‘The right ventricular pressure pulse reflects the volume of the right ventricular outflow, the resistance at the pulmonaq. valve, and the resistance oi the pulmonary arterial tree. It ma?- be distorted by various pathologic situations, the distortion reflecting the nature of the patholog-. Bouchard and (‘ornu’ reported the difference the>- noted between the contours of the right ventricular pressure tracings from patients with pulmonic stenosis ancl intact ventricular septum (hereafter called pulmonic stenosis) and those from patients with pulmonic stenosis and a ventricular septal defect (hereafter called tetralogy of Fallotj. It is the purpose of this paper to present a more detailed analysis of this difference, and to show the characteristic change in contour Ixoduced by pulmonary hypertension. In 33 patients with pnlmonic stenosis the diaglmsis ~a> considered to be suficientl~~ Nell established for inclusion of them in this report. To be included in this group each case had to fulfill at least one of the following criteria in addition to the clinical diagnosis: (1) neither left-toright nor right-to-left shunt, (2) anatomic confirmation at surgery* or autopsy, (3) definite &Gal improvement follolving pulmonnr)\-al\-atom)-. For iwlnsion in the group with tetralog)ofFallot each case had to fulfill at least one of the following criteria in addition to the clinical diagnosis: (1) cardiac catheter passed from the right ventricle directly into the aorta, (2) left-to-right shunt at the wntricular level, (3) definite clinical ilnpro\.ement following subclavian-puImonar)or aortic-oprllmonar~ anastomoses. By these standards there were 15 proved cases of tetralog). of Fallot and 18 proved cases of pulmonic stenosis. All tracings were recorded through a standard Conrnand-type cardiac catheter during routine right heart catheterization or via a small plastic. catheter inserted directly into the right ventricle at the time of surgery, using a Lilly capacitance type of electromanometer with a speed of response more than adequate for the analyses reported here.2 Twenty-three measurements on 21 patients with left-to-right intracardiac, shunts and pulmonary hypertension proved by direct measurement of the pulmonary arterial pressure are also reported. Fourteen of these patients had ventricular septal defects, 4 had the atrio\-entricul;lris communis s~ndromc, and 3 had patent dnctus arteriosus. This study u-as supported in part by grants from the Southeastern Pennsylvania Chapter of thr American Heart Association, and the Harrison Surgical Research Depart,ment of t,he lJniversit,y of Pennsylvania School of Medicine. Received for publication June 15, 19.59. *One patient with an infundibular stenosis revealed a small ventricular septal defect at t,he time of direct. exploration of the right ventricle, only after infundibular tissue had been resected. Since the right ventricular pressure at the time the tracing was made was 150/-10 as compared to 94/76 mm. Hg systemic pressure, and there was no evidence of increased oxygen content in the right ventricle. the case
is classified
functionally
with
t,he pulmonic
stenosis 36
group.
All patients classified as having tetralogy of Fallot had right ventricular pulse curves that were in all respects identical in contour to the normal right ventricular pulse curve except for elevated pressure. The shape can best be described as an inverted U (see Fig. 1). The right ventricular pressure tracings from the group having pulmonic stenosis show a detinite distortion of the curve (see Iyig. L), with a gradual upslope to a sharp peak, follo\ved by a slow descent to the diastolic level, i.e., an inverted \‘. Ln the tetralogy of Fallot group, the upslope duration averaged 21 per cent (expressed as per cent of the duration oi the s).stolic pulse wave), ranging from 13 to 29 per celit, whereas the clownsslope duration averaged 25 per cent, with a range of 9 to 37 per cent. The pulmonk stenosis group had an upslope of 54 per cent (range, 27 to 62 per cent), with a downslope ;Iveraging 53 per cent (range, 3X to 73 per cent). There is virtualI!no overlap between the two groups. ‘TweiltJ,-one of the 23 tracings from the right ventricle from 21 p;ltients \yith pulmonary hypertension show an initial rapid upslope, followed by ;I more gradual rise to a peak, then followed b>, a rapid descent to the diastolic level, giving the gabled contour seen in Fig. 4. The two exceptions were tracings recorded from two of the patients with patent ductus \vho were recatheterized approximately one year after ligation of the ductus. Pulmonary hypertensioil persisted in both, but the right ventricular pulse pressure curve sho\ved a distorted fat-topped contour.
;\ review of right ventricular pressure curves reproduced in various reports”-‘” may be summarized as follows: twent>.-four of twenty-five patients (authors’ diagnoses accepted as correct) with pulmonic stenosis showed the inverted V contour. Ten of twelve patients reported as having tetralogy of Fallot showed the inverted c’ type of curve. I+Yneberg and Wiggers13 progressively occluded the pulmonary artery in dogs and obtained right ventricular pressure tracings of the inverted V type. They ascribe the over-all changes as being due to right ventricular fatigue, but do not- discuss the specific changes in contour. \&Te have noted the same changes in contour in patients with intact ventricular septa who have small gradients across the pulmonaryvalve (see Fig. 3) and no signs of right ventricular fatigue. When there is an adequate pressure outlet from the right ventricle, whether this be through a normal valve or through a ventricular septal defect, the contour of the right ventricular pressure wave is normal, independent of the height of the pressure. When there is inadequate outlet from the right ventricle, even relative15 mild obstruction, the right ventricular pressure wave is distorted into the inverted \’ shape. The contour of the curves from the patients with pulmonnr> h>,pertension is a combination of both types of curves. The initial rapid upslope indicates that the outlet through the pulmonic valve and into the hilar vessels is adequate. The later slow upslope is indicative of the obstruction to flow offered by the narrowed pulmonary arterioles. Hypertrophy of the crista ventricularis may also be a factor in the contour distortion.
3s
K.\SHI(INI)
L.00
50
0
0 Fig.
l.-Tetralogy
of Ballot.
Fig.
4.--Pulmonary
hypertension
\Videspread use of open cartliotom). with extracorporeal circulation will allow more complete anatomic correction of these lesions, using essentially the same surgical approach. In man). instances, particularlyin the cyanotic infant, valvotom!, for pulmonic stenosis, some form of systemic-pulmonic anastomosis for tetralogy of Fallot, or some entirely different procedure for pulmonary hypertcxsiw, will be required. These varied surgical techniques necessitate accurate preoperative diagnosis. In this regard, the data obtained from analysis of the right ventricular pulse wave may be very valuable, particularly when the cardiac catheter cannot be advanced into the pulmonary artcrv.
Fifteen patients with proved pulmonic stenosis with ventricular septal defect (tetralogy of Fallot) demonstrated right ventricular pressure pulse contours of the normal inverted IT shape with elevated pressure (Fig. 1). Eighteen patients with proved pulmonic stenosis with intact ventricular septum (pulmonic stenosis) demonstrated right ventricular pressure pulse contours of an inverted V shape (Fig. 2). ‘T‘\ventJ.-one patients with proved pulmonaryhypertension showed a gablet\-pe contour of the right ventricular pressure pulse wave (Fig. 4). Two of these patients demonstrated this contour prior to ligation of a patent ductus arteriosus. Postoperatively, the contour WLS no longer typical. The use of this observation as an aid in diagnosis, and the mechanisms iirvolved in the production of these changes in contour is discussed. I xvish and aid.
1. 2. 3. 4. 2: 7. 8. 9. 10. 11.
l-7. 1 .i.
to thank
Dr.
Knchcl
-Ash, Dr.
Sidney
Friedman,
and
Dr.
Peter
Vanace
for
advice
Bouchard, F., and Curnil, C.: Etudes des courbes de pressions ventriculaire droite et artcrielle pulmonaire clans ies retrecissements pulmonaires. Arch. mat. coeur 47:417 1954. Lilly, J. C.: -A V’ariable Capacitor for Measurements of Pressure and nlechanical Displacements, J. Appl. Physics 18:613, 1947. Doxv, J. VV., Levine, H. D.. Elkin. XI., Haynes, F. 1X::., Hellems, H. K., Whittcnberger, J. A-., Ferris, B. G., Goodale, W. T., Harvey, W. P., Eppinger, E. C.! and Dexter, L.: Studies of Congenital Heart Disease. IV. I-ncomplicated Pulmonrc Stenosis, Circulation 1:267, 1950. Gnsul, B. M., Dillon, R. F., Vrla, V., and Hait, G.: Ventricular Septal Defects, J.A.hl.A. 161:847, 1957. JlcCord, RI., Van Elk, J., and Blount, S. G.: Tetralogy of Fallot, Circulation 16:736, 1957. Eldridge, F. L., and Hultgren, H. N.: Pulmonary Stenosis With Increased Pulmonary Blood Flow, AM. HEART J. 49:835, 1955. Horlick, L.. and Merriman, J. E.: Congenital V’alvular Stenosis of the Pulmonary and Aortic Valves M’ith Atria1 Septal Defect, ;\M. HEART J. 54:615, 1957. hIoflitt, G. I~., Zinsser, H. F., Kuo, I’. T., Johnson, J., and Schnabel, T. F., Jr.: Pulmonary Stenosis With Left-to-Right Intracardiac Shunts, Am. J. Med. 16:521, 1951. Brock. R. C.: Congenital Pulmonary Stenosis, Am. J. Med. 12:706, 1952. Blount. S. G., McCord! M. D., Mueller, H., and Swan, H.: Isolated Valvular I’uimonic Stenosis, Circulation 10:161, 1954. Connolly, D. C., Lev, R., Kirklin, J. W., and W’ood, E. II.: The Problem of Isolated Valvular vs. Infundrbular Pulmonic Stenosis, With Particular Reference to Cardiac Catheterization Data and Records Obtained at the Time of Operation, Proc. Staff Meet. Mayo Clin. 28:65, 1953. I’ollack, ;I. :I., Taylor, B. E., Odel, H. M., and Burchelf, H. B.: Pulmonary Stenosis Without Septal Defect, Proc. Staff Xleet. Mayo Clin. 28:65, 1953. Fineberg, M. H., and Wiggers, C. J.: Compensation and Failure of the Right Ventricle, AM. HEART J. 11:2X, 1936.