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Right parasternal lift in atrial septal defect
Right parasternal lift in atrial septal defect Teruo Fukumoto, M.D. Morio Ito, M.D. Makoto Arita, M,D.* Motoharu Tetsuo, M.D. Takehiko Fujino, M.D. Hiroto Mashiba, M.D., F.A.C.C.** Fukuoka, Japan
It has been generally accepted that right ventricular overloads produce a palpable impulse in the left parasternal region, 1 and that the recording of this amplitude indicates these overloads. ~-:' Previous investigations were concerned only with the left parasternal movement. We have recently noticed a characteristic movement in the right parasternal region in patients with atrial septal defect of the secundum type (ASD). In this paper we describe the right parasternal as well as the left parasternal movement patterns by means of kinetocardiographic methods in patients with secundum ASD. We hope to show that the left parasternal lift is, as others have conjectured, of high amplitude in early systole, and th e right parasternal lift is of high amplitude in midsystole. We also hope to draw attention to the clinical importance of bedside ohservation of the right and left parasternal lifts in ASD. Material and methods
Fifty-two patients with ASD aged 14 to 46 years (18 males and 34 females) were studied (Table I). In all cases, the diagnosis of ASD was established by clinical examination, chest x-ray, right cardiac catheterization, and selective pulmonary arteriography. Pulmonary-to-sysFrom the First Department of Medicine, Faculty of Medicine, Kyushu University, Fukuoka, Japan. Received for Publication July 19, 1976. Accepted for publication Aug. 4, 1976. Reprint request: Teruo Fukumoto, M.D., First Department of Medicine, Faculty of Medicine, Kyushu University, Maidashi 3-1-1, Fukuoka 812, Japan. *Presently, Department of Physiology, Kyushu University. **Presently, Professor, First Department of Medicine, Tottori University, Tottori, Japan.
December, 1977, Vol. 94, No. 6, pp. 699-704
temic flow ratios were measured by the Fick principle. One day prior to cardiac catheterization, the impulses at the left and right parasternal regions were examined by kinetocardiography. Recordings were obtained in the supine position during expiration using a strain gauge transducer (SBIT, Nihon Koden), and a direct writing fourchannel polygraph (WI-180, Nihon Koden)? ~ This recording system has an infinite time constant with a linear response for frequencies of zero to 15 Hz. The left and right parasternal impulses were recorded either in the fourth or fifth intercostal space. As a control, 30 healthy adults aged 18 to 26 years (12 males and 18 females) were examined by the same procedures, In addition, six patients with ventricular septal defect (VSD) aged 14 to 24 years, five cases with patent ductus arteriosus (PDA) aged 18 to 36 years, a n d eight cases with tricuspid insufficiency combined with mitral stenosis and mitral insufficiency aged 26 to 46 years, were examined. Results
Kinetocardiographic tracings obtained from the ASD group and control groups could be divided into four patterns of systolic precordial movement: normal, hyperkinetic, bifid, and sustained. The normal and hyperkinetic patterns were characterized by an early systolic outward movement followed by a systolic retraction. In the normal pattern, the amplitude of the systolic outward movement measured with reference to the presystolic line was smaller than half of the
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699
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Fig. 1. Three basic patterns of the kinetocardiographic tracings classifed according to the movement during systole. Normal (A), Bifid (B), and sustained patterns (C) are demonstrated in electrocardiogram (top tracing) and phonocardiogram (bottom tracing). T a b l e I. Incidences of various p a t t e r n s of k i n e t o c a r d i o g r a p h i c t r a c i n g observed in the h e a l t h y a n d in atrial s e p t a l defect ( A S D ) p a t i e n t s (see t e x t for e x p l a n a t i o n ) Healthy subjects Location examined
ASD subjects
Pattern
No. of cases(%)
No of cases (%)
R VP (ram. Hg)
Qp/Qs
Normal Hyperkinetic Bifid Sustained
30 (100.0) Q ( 0.0) 0 ( 0.0) 0 ( 0.0)
5 ( 9.6) 0 ( 0.0) 37 (71.2) 10 (19.2)
30.6 _+ 5:8 -39.8 ___13.5 55.9 _ 31.5
1.24 _+ 0.30*
Right parasternal region
2.98 _+ 0.98* 2.85 _ 1.26
Left parasternal region
Normal Hyperkinetic Bifid Sustained
25 ! 83.3) 5 (16.7) 0 ( 0.0) 0 ( 0.0)
12 (23.1) 23 (44.2) 0 ( 0.0) 17 (32.7)
33.0 _ 10.2 41.2 _+ 13.0 -43.7 _+ 25.9
1.90 _+ 0.73 3.02 _ 1.09 3.14 ___1.15
Total
30 (100.0)
52 (100.0)
*Significant at the 0.01 level. t o t a l a m p l i t u d e (Fig. 1A), while in t h e h y p e r k i , netic p a t t e r n i t was larger t h a n h a l f the t o t a l a m p l i t u d e of t h e recordings (Fig. 2B). I n t h e bifid p a t t e r n , t h e r e was a n e a r l y systolic o u t w a r d m o v e m e n t followed b y r e t r a c t i o n below the base line, a n d t h e r e a f t e r a d o m i n a n t midsystolic o u t w a r d m o v e m e n t w i t h its p e a k in l a t e systole (Fig. 1B, a n d 2A): I n t h e s u s t a i n e d p a t t e r n , an o u t w a r d m o v e m e n t c o n t i n u e d f r o m early to late Systole {Fig. 1C).
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T a b l e I shows the incidence of e a c h of t h e four p a t t e r n s in the control a n d A S D subjects. All h e a l t h y subjects showed t h e n o r m a l p a t t e r n in the right p a r a s t e r n a l region, whereas 83.3 per cent showed the n o r m a l , a n d 16.7 per cent showed the h y p e r k i n e t i c p a t t e r n s in the left p a r a s t e r n a t region, B y c o n t r a s t , 9.6 pe r cent, 71,2 pe r cent, a n d 19.2 per cent of A S D p a t i e n t s showed n o r m a l , bifid, an d s u s t a i n e d p a t t e r n s , respectively, in the right p a r a s t e r n a l region, a n d 23.1 per cent, 44.2
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Right parasternal lift in ASD per cent, and 32.7 per cent showed normal, hyperkinetic, and sustained patterns, respectively, in the left parasternal region. No case of ASD showed a hyperkinetic pattern in the right parasternal region nor a bifid pattern in the left parasternal region. On the other hand, all cases with VSD and 75 per cent of PDA showed the normal pattern in the left and right parasternal regions (these are not listed in the TableL Almost all of them showed the normal value of right ventricular systolic pressure i mean value -- standard deviation: 24.2 __ 4.2 ram. Hg in VSD, 26.3 -=_ 5.3 ram. Hg in PDA) and a relatively low pulm0nary-to-systemic flow ratio (1.3 -- 0.6, 1.7 _-- 0.3, respectively). A patient suffering from PDA, who has high pulmonary to systemic flow ratio (Qp/Qs:3.0) and normal pulmonary artery pressure (26 mm. Hg), ShoWed the bifid pattern in the right and the hyperkinetic pattern in the left parasternal region. All cases with tricuspid insufficiency showed the sustained pattern in the right and left parasternal regions. The last two columns of Table I give the mean right ventricular systolic pressure (RVP) and pulmonary-to-systemic flow ratio (Qp/Qs) with their standard deviations for each type of kinetocardiographic patterns observed at the right and left parasternal regions in ASD cases. In the right parasternal region, right ventricular systolic pressure was noted to be highest in the sustained pattern, somewhat lower in the bifid, and lowest in the normal pattern. Qp/Qs was noted to be lower with the normal pattern than with bifid or sustained patterns, showing a significant difference (P < 0.01) between normal and bifid patterns. With left parasternal region recordings, both R v P and Qp/Qs were lowest with the normal pattern. No significant difference was noticed in RVP and Qp/Qs in normal, hyperkinetic, and sustained patterns. Table II gives the incidence of each of the kinetocardiographic patterns among the four groups of ASD. They are subdivided according to values of right ventricular systoliC pressure (RVP) and pulmonary-to-systemic blood flow ratio (Qp/Qs). In the group of low ventricular systolic pressure and low pulmonary flow (RVP < 50 mm. Hg, Qp/Qs < 2.0), the pattern in the right parasternal region was normal in 55.6 per cent and bifid in 44.4 per cent. In two groups
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A
B
-
0.5
sec
Fig. 2. Tracings from a 26-year-oldfemale patient with ASD (right ventricular systolicpressure: 30 ram. Hg, pulmonic-tosys[emicflowratio: 2.8). Kinetocardiographictracingsshow a bifid pattern at the right parasternal region (.4) and a hyperkinetic pattern movementat the left parasternal region (B) in the level at the fifth intercostal space. with increased pulmonary flow (group of RVP < 50 mm. Hg, Qp/Qs->_ 2,0 arid t h a t of RVP -->_50 ram. Hg, Qp/Qs > 2,0), the pattern in the right parasternal region was bifid in more than 80 per cent, while none Of patierits showed a normal pattern. In the group of high right ventricular systolic pressure and low pulmonary flow (RVP > 50 mm. Hg, Qp/Qs < 2.0), the right parasternal pattern was sustained in 80 per cen.t. By contrast, the Patterns in the left parasternal region were normal in about 78 per cent of ASD patients with relatively low right ventricular systolic pressure a n d a low pulmonary fl0w (RVP < 50 mm. Hg, Qp/Qs < 2.0). Of 38 cases with increased pulmonary flow (Qp/Qs ~ 2.0), normal, hyperkinetic and sustained patterns were observed in 10.5 per cent, 55.3 per cent, and 34.2 per cent, reSpectively. These patterns were also Observed in 20 per cent, 40 per cent, and 40 per cent of cases with high right ventricular systolic
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Table II. P a t t e r n s of kinetocardiographic tracings and h e m o d y n a m i c d a t a of ASD
(see t e x t for explanation)
Hemodynamicgroup I
RVP (mm.Hg) I Qp/Qs < 50 < 50 50 -_ 50
< ~ = <
2.0 2.0 2.0 2.0
Right parasternal impulse No. of cases INormal Bifid 9 (100) 32 (100) 6 (100) 5 (100)
5 (55.6) 0 (0.0) 0 (0.0) 0 (0.0)
pressure and low p u l m o n a r y flow ( R V P _> 50 mm. Hg, Q p / Q s < 2.0). Discussion
It has been r e p o r t e d t h a t ASD t e n d s to show an impulse of a hyperkinetic or a sustained p a t t e r n in the left p a r a s t e r n a l region. T h e s e p a t t e r n s correspond to the increased p u l m o n a r y blood flow ASD and to the high p u l m o n a r y resistance ASD, ~-8 respectively. In addition, we noted in p a t i e n t s with A S D a right p a r a s t e r n a l lift too high in a m p l i t u d e to be ignored. B y kinetocardiographic recording of this lift in the right p a r a s t e r n a l f o u r t h intercostal space, the impulse had an early systolic retraction and midsystolic o u t w a r d m o v e m e n t with its peak at late systole (Figs. 1B, and 2A ). This was named a "bifid p a t t e r n precordial m o v e m e n t . " T h e bifid p a t t e r n m o v e m e n t in the right parasternal region was observed in 84 per cent of the cases with a high p u l m o n a r y flow ASD and 45 per cent of low flow ASD. All n o r m a l subjects, 55 per cent of the cases of low flow and low right ventricular systolic pressure ASD, but none with high flow ASD showed the n o r m a l pattern. Cases with the bifid p a t t e r n m o v e m e n t at the right parasternal region showed a significantly (P < 0.01) higher p u l m o n a r y flow t h a n those cases with the n o r m a l p a t t e r n . T h e left parasternal m o v e m e n t , however, did not show such a good 9 correlation with h e m o d y n a m i c s as the right parasternal m o v e m e n t . F r o m these findings, it m a y be concluded t h a t the bifid p a t t e r n in the kinetocardiographic tracings in the right parasternal region is more useful for characterizing high p u l m o n a r y flow A S D t h a n tracings from the left p a r a s t e r n a l region. On the o t h e r hand, the sustained p a t t e r n in the right p a r a s t e r n a l region was observed in 80 per
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4 (44.4) 27 {84.4) 5 (83.3) 1 {20.0)
Left parasternal impulse Sustained I NormallHyperkineticlSustained 0 (0.0) 5 (15.6) 1 (16.7) 4 (80.0)
7 (77.8) 4 (12.5) 0 (0.0) 1 (20.0)
2 {22.2) 17 (53.1) 4 (66.7) 2 (40.0)
0 (0.0) 11 (34.4) 2 (33.3) 2 (20.0)
cent of the cases of high right v e n t r i c u l a r systolic pressure and low p u l m o n a r y flow ASD {high resistance ASD) and in 16 per cent of high p u l m o n a r y flow ASD groups. This would seem to reflect pressure overload r a t h e r t h a n v o l u m e overload in the right ventricle. A similar p a t t e r n was observed in cases with m i t r a l valve stenosis associated with p u l m o n a r y hypertension. 8 With regard to other left-to-right s h u n t diseases such as ventricular septal defect and p a t e n t d u c t u s arteriosus, no definite conclusion can be drawn from this investigation. T h e only patient with a high p u l m o n a r y flow, showed the bifid p a t t e r n in the right p a r a s t e r n a l kinetocaro diogram. Almost all other cases with ventricular septal defect and p a t e n t d u c t u s arteriosus had small left-to-right s h u n t and showed a n o r m a l pattern. In ASD, the volume and speed o f the right ventricular filling are increased by the s h u n t fl0w. T h e volume ejected in systole is m u c h greater t h a n n o r m a l as it includes the s h u n t flow fraction. T h e increased volume is expected to increase the speed and amplitude of the right ventricular and p u l m o n a r y a r t e r y m o v e m e n t , " which leads to a high a m p l i t u d e precordial lift, a bifid p a t t e r n m o v e m e n t in the right p a r a s t e r n a l region, and a hyperkinetic p a t t e r n m o v e m e n t in the left parasternal region. In a relatively low p u l m o n a r y flow ASD, the right Ventricular or p u l m o n a r y a r t e r y m o v e m e n t s are not so increased as to show the bifid pattern. Tricuspid insufficiency causes rapid and increased right ventricular fillings. It has been reported to produce a systolic r e t r a c t i o n in the left a n d diastolic lift in the right p a r a s t e r n a l regions.12 13 N o n e of the cases of ASD examined in this s t u d y had tricuspid insufficiency and only a few cases of tricuspid insufficiency combined
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Right parasternal lift in A S D
with m i t r a l valve diseases were e x a m i n e d by this method. E v e n t h o u g h t h e y were n o t so t y p i c a l and severe, their right precordial m o v e m e n t p a t t e r n s were different f r o m t h e bifid p a t t e r n in configuration a n d in phase. T h e r e are only a few reports with respect to the right p a r a s t e r n a l i m p u l s e of ASD. 2' 3 . 8 - 1 o Eddiem a n and associates'-" 3 only referred to an early systolic o u t w a r d m o v e m e n t a n d described the different k i n e t o c a r d i o g r a p h i c p a t t e r n s in pressure and v o l u m e overloaded right ventricles with specific reference to ASD. A l t h o u g h these a u t h o r s emphasized t h e systolic r e t r a c t i o n in t h e left p a r a s t e r n a l region, a midsystolic o u t w a r d movem e n t was also d e m o n s t r a t e d in their right p a r a sternal impulse tracings, :~ which c o r r e s p o n d s to the bifid wave m o v e m e n t described in this paper. A l t h o u g h k i n e t o c a r d i o g r a p h i c t r a c i n g is very useful in detecting the bifid p a t t e r n in the right p a r a s t e r n a l region, TM such findings can be detected also b y palpation. T h i s is a c c o m p l i s h e d by p u t ting the fingers on the right a n d left p a r a s t e r n a l regions s i m u l t a n e o u s l y . T h e difference in t h e a m p l i t u d e a n d p h a s e of t h e precordial o u t w a r d m o v e m e n t in each region can easily be perceived as a reciprocal m o v e m e n t : a large o u t w a r d movem e n t of the early s y s t o l e in the left p a r a s t e r n a l region {impulse of h y p e r k i n e t i c p a t t e r n ) followed by an o u t w a r d m o v e m e n t during m i d s y s t o l e on the right side (impulse of the bifid p a t t e r n ) (Fig.
2). Summary and conclusion In 52 cases with atrial septal defect of the ostium s e c u n d u m t y p e (ASD) a n d 49 control subjects, right a n d left p a r a s t e r n a l i m p u l s e s were recorded b y the k i n e t o c a r d i o g r a p h i c m e t h o d . T h e s e tracings were divided into four p a t t e r n s according to t h e systolic m o v e m e n t : n o r m a l , hyperkinetic, bifid, a n d sustained. In 30 h e a l t h y subjects, a n o r m a l p a t t e r n movem e n t was observed in all cases in t h e right p a r a s t e r n a l region, a n d a n o r m a l (83.3 per cent) or a h y p e r k i n e t i c p a t t e r n {16.7 per cent) was seen in the left p a r a s t e r n a l region. I n cases with A S D , n o r m a l , bifid a n d sustained p a t t e r n s were observed in 9.6 per cent, 71.2 per cent, a n d 19.2 per c e n t in t h e right p a r a s t e r n a l region. Of 38 A S D cases with increased p u l m o n a r y b l o o d flow, n o r m a l , bifid, a n d sustained
American Heart Journal
p a t t e r n s were observed in 0 per cent, 84.2 per cent, and 15.8 per cent, respectively. Of the cases with high right v e n t r i c u l a r systolic pressure a n d low p u l m o n a r y flow A S D , these p a t t e r n s were seen in 0 per cent, 20 per cent, a n d 80 per cent, respectively. In t h e left p a r a s t e r n a l region, n o r m a l , hyperkinetic, a n d s u s t a i n e d p a t t e r n s were observed in 23.1 per cent, 45.2 per cent, a n d 32.7 per cent of all A S D cases. T h e y were observed in 10.5 per cent, 55.3 per cent, a n d 34.2 per cent, respectively, of the cases with increased p u l m o n a r y flow and in 20 per cent, 40 per cent, a n d 40 per cent of the cases w i t h high right v e n t r i c u l a r systolic pressure a n d low p u l m o n a r y flow. Thus, the k i n e t o c a r d i o g r a p h i c p a t t e r n in t h e right p a r a s t e r n a l region showed m o r e i n t i m a t e correlation w i t h h e m o d y n a m i c d a t a t h a n t h a t in the left p a r a s t e r n a l region. T h e bifid p a t t e r n m o v e m e n t in t h e right p a r a sternal region was f o u n d to be a reliable sign of A S D a n d was f r e q u e n t l y a c c o m p a n i e d b y t h e h y p e r k i n e t i c p a t t e r n m o v e m e n t in t h e left p a r a sternal region. T h e s e c h a r a c t e r i s t i c m o v e m e n t s were easily perceived b y s i m u l t a n e o u s l y p u t t i n g two fingers on the right a n d left p a r a s t e r n a l regions. The authors are grateful to Professor Toshiyuki Yanase of our department for his guidance and to Professor David H. Spodick of the Cardiology Division, St. Vincent Hospital, Worcester, Mass., for his thoughtful review of this manuscript. REFERENCES 1. Wood, P.: Congenital heart disease. A review of its clinical aspects in the light of experience gained by means of modern techniques, Br. Heart J. 2:639, 1950. 2. Eddleman, E. E., Jr., Hughes, M, L., and Thomas, H. D.: Estimation of pulmonary artery pressure and pulmonary vascular resistance from ultra low frequency precordial movement (Kinetocardiograms), Am. J. Cardiol. 4:662, 1959. 3. Eddleman, E. E., Jr., Holt, J. H., and Bancroft, W. H.: Computer analysis of the kinetocardiogram from patients with atrial septal defect, AM. HEARTJ. 71:435, 1966. 4. Nagle, R. E., and Tamara, F. A.: Left parasternal impulse in pulmonary stenosis and atrial septal defect, Br. Heart J. 29:735, 1967. 5. Gillam, P. M. S., Deliyannis, A. A., and Mounsey, J. P. D.: The left parasternal impulse, Br. Heart J. 26:726, 1966. 6. Kesteloot, H., and Willems, J.: Relationship between the right apex cardiogram and the right ventricular dynamics, Acta Cardiol. 22:64, 1967. 7. Tanabe, Y., Sakamoto, M., Kobayashi, T., Fujino, K., and Mashimo, K.: The relation of left parasternal impulse and right ventricular systolic pressure. A kineto-
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cardiographic and apexcardiographic study, Jap. Heart J: 1 ! :213, 1970. 8. Fukumoto, T., Ito, M., Tets 0, M., Fukushima, I., Fujino, T., Imanishi, S., Ito, S., and Mashiba, H.: Precordial movements in adults with mitral stenosis and atrial septal defect (Abstr.), Jpn. Circ. J. 37:606, 1973. 9. Fukumoto, T., Ito, M., Fukushima; I., Fujino, T., Yasuda, H., Ito, S., Kanaya, S. and Mashiba, H.: Studies of kinetocardiogram. Left and right parasternal impulse in atrial septal defect, Cardiovasc. Sound Bull. 4:373, 1974. 10. Fukumoto, T.: Studies of straingauge kinetocardiogram.
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Recording methods and its clinical implication, Jpn. Circ. J. 36:13131 1972. 11. Mtiller, 0., and Shillingford, J.: The blood flow in the right atrium and superior vena cava in tricuspid incompetence, Br. Heart J. 17:163, 1955. 12. Boicourt, 0. W., Nagle, R. E., and Mounsey, J. P. D.: The clinical significance of systolic retraction of the apical impulse, Br. Heart J. 27:379, 1965. 13. Armstrong, T. G., and Gotsman, M. S.: The left parasternal lift in tricuspid incompetence, AM. HEART J. 88:183, 1974.
December, 1977, Vol. 94, No. 6
It has been generally accepted that right ventricular overloads produce a palpable impulse in the left parasternal region, 1 and that the recording of this amplitude indicates these overloads. ~-:' Previous investigations were concerned only with the left parasternal movement. We have recently noticed a characteristic movement in the right parasternal region in patients with atrial septal defect of the secundum type (ASD). In this paper we describe the right parasternal as well as the left parasternal movement patterns by means of kinetocardiographic methods in patients with secundum ASD. We hope to show that the left parasternal lift is, as others have conjectured, of high amplitude in early systole, and th e right parasternal lift is of high amplitude in midsystole. We also hope to draw attention to the clinical importance of bedside ohservation of the right and left parasternal lifts in ASD. Material and methods
Fifty-two patients with ASD aged 14 to 46 years (18 males and 34 females) were studied (Table I). In all cases, the diagnosis of ASD was established by clinical examination, chest x-ray, right cardiac catheterization, and selective pulmonary arteriography. Pulmonary-to-sysFrom the First Department of Medicine, Faculty of Medicine, Kyushu University, Fukuoka, Japan. Received for Publication July 19, 1976. Accepted for publication Aug. 4, 1976. Reprint request: Teruo Fukumoto, M.D., First Department of Medicine, Faculty of Medicine, Kyushu University, Maidashi 3-1-1, Fukuoka 812, Japan. *Presently, Department of Physiology, Kyushu University. **Presently, Professor, First Department of Medicine, Tottori University, Tottori, Japan.
December, 1977, Vol. 94, No. 6, pp. 699-704
temic flow ratios were measured by the Fick principle. One day prior to cardiac catheterization, the impulses at the left and right parasternal regions were examined by kinetocardiography. Recordings were obtained in the supine position during expiration using a strain gauge transducer (SBIT, Nihon Koden), and a direct writing fourchannel polygraph (WI-180, Nihon Koden)? ~ This recording system has an infinite time constant with a linear response for frequencies of zero to 15 Hz. The left and right parasternal impulses were recorded either in the fourth or fifth intercostal space. As a control, 30 healthy adults aged 18 to 26 years (12 males and 18 females) were examined by the same procedures, In addition, six patients with ventricular septal defect (VSD) aged 14 to 24 years, five cases with patent ductus arteriosus (PDA) aged 18 to 36 years, a n d eight cases with tricuspid insufficiency combined with mitral stenosis and mitral insufficiency aged 26 to 46 years, were examined. Results
Kinetocardiographic tracings obtained from the ASD group and control groups could be divided into four patterns of systolic precordial movement: normal, hyperkinetic, bifid, and sustained. The normal and hyperkinetic patterns were characterized by an early systolic outward movement followed by a systolic retraction. In the normal pattern, the amplitude of the systolic outward movement measured with reference to the presystolic line was smaller than half of the
American Heart Journal
699
Fukumoto
et al.
Fig. 1. Three basic patterns of the kinetocardiographic tracings classifed according to the movement during systole. Normal (A), Bifid (B), and sustained patterns (C) are demonstrated in electrocardiogram (top tracing) and phonocardiogram (bottom tracing). T a b l e I. Incidences of various p a t t e r n s of k i n e t o c a r d i o g r a p h i c t r a c i n g observed in the h e a l t h y a n d in atrial s e p t a l defect ( A S D ) p a t i e n t s (see t e x t for e x p l a n a t i o n ) Healthy subjects Location examined
ASD subjects
Pattern
No. of cases(%)
No of cases (%)
R VP (ram. Hg)
Qp/Qs
Normal Hyperkinetic Bifid Sustained
30 (100.0) Q ( 0.0) 0 ( 0.0) 0 ( 0.0)
5 ( 9.6) 0 ( 0.0) 37 (71.2) 10 (19.2)
30.6 _+ 5:8 -39.8 ___13.5 55.9 _ 31.5
1.24 _+ 0.30*
Right parasternal region
2.98 _+ 0.98* 2.85 _ 1.26
Left parasternal region
Normal Hyperkinetic Bifid Sustained
25 ! 83.3) 5 (16.7) 0 ( 0.0) 0 ( 0.0)
12 (23.1) 23 (44.2) 0 ( 0.0) 17 (32.7)
33.0 _ 10.2 41.2 _+ 13.0 -43.7 _+ 25.9
1.90 _+ 0.73 3.02 _ 1.09 3.14 ___1.15
Total
30 (100.0)
52 (100.0)
*Significant at the 0.01 level. t o t a l a m p l i t u d e (Fig. 1A), while in t h e h y p e r k i , netic p a t t e r n i t was larger t h a n h a l f the t o t a l a m p l i t u d e of t h e recordings (Fig. 2B). I n t h e bifid p a t t e r n , t h e r e was a n e a r l y systolic o u t w a r d m o v e m e n t followed b y r e t r a c t i o n below the base line, a n d t h e r e a f t e r a d o m i n a n t midsystolic o u t w a r d m o v e m e n t w i t h its p e a k in l a t e systole (Fig. 1B, a n d 2A): I n t h e s u s t a i n e d p a t t e r n , an o u t w a r d m o v e m e n t c o n t i n u e d f r o m early to late Systole {Fig. 1C).
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T a b l e I shows the incidence of e a c h of t h e four p a t t e r n s in the control a n d A S D subjects. All h e a l t h y subjects showed t h e n o r m a l p a t t e r n in the right p a r a s t e r n a l region, whereas 83.3 per cent showed the n o r m a l , a n d 16.7 per cent showed the h y p e r k i n e t i c p a t t e r n s in the left p a r a s t e r n a t region, B y c o n t r a s t , 9.6 pe r cent, 71,2 pe r cent, a n d 19.2 per cent of A S D p a t i e n t s showed n o r m a l , bifid, an d s u s t a i n e d p a t t e r n s , respectively, in the right p a r a s t e r n a l region, a n d 23.1 per cent, 44.2
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Right parasternal lift in ASD per cent, and 32.7 per cent showed normal, hyperkinetic, and sustained patterns, respectively, in the left parasternal region. No case of ASD showed a hyperkinetic pattern in the right parasternal region nor a bifid pattern in the left parasternal region. On the other hand, all cases with VSD and 75 per cent of PDA showed the normal pattern in the left and right parasternal regions (these are not listed in the TableL Almost all of them showed the normal value of right ventricular systolic pressure i mean value -- standard deviation: 24.2 __ 4.2 ram. Hg in VSD, 26.3 -=_ 5.3 ram. Hg in PDA) and a relatively low pulm0nary-to-systemic flow ratio (1.3 -- 0.6, 1.7 _-- 0.3, respectively). A patient suffering from PDA, who has high pulmonary to systemic flow ratio (Qp/Qs:3.0) and normal pulmonary artery pressure (26 mm. Hg), ShoWed the bifid pattern in the right and the hyperkinetic pattern in the left parasternal region. All cases with tricuspid insufficiency showed the sustained pattern in the right and left parasternal regions. The last two columns of Table I give the mean right ventricular systolic pressure (RVP) and pulmonary-to-systemic flow ratio (Qp/Qs) with their standard deviations for each type of kinetocardiographic patterns observed at the right and left parasternal regions in ASD cases. In the right parasternal region, right ventricular systolic pressure was noted to be highest in the sustained pattern, somewhat lower in the bifid, and lowest in the normal pattern. Qp/Qs was noted to be lower with the normal pattern than with bifid or sustained patterns, showing a significant difference (P < 0.01) between normal and bifid patterns. With left parasternal region recordings, both R v P and Qp/Qs were lowest with the normal pattern. No significant difference was noticed in RVP and Qp/Qs in normal, hyperkinetic, and sustained patterns. Table II gives the incidence of each of the kinetocardiographic patterns among the four groups of ASD. They are subdivided according to values of right ventricular systoliC pressure (RVP) and pulmonary-to-systemic blood flow ratio (Qp/Qs). In the group of low ventricular systolic pressure and low pulmonary flow (RVP < 50 mm. Hg, Qp/Qs < 2.0), the pattern in the right parasternal region was normal in 55.6 per cent and bifid in 44.4 per cent. In two groups
American Heart Journal
A
B
-
0.5
sec
Fig. 2. Tracings from a 26-year-oldfemale patient with ASD (right ventricular systolicpressure: 30 ram. Hg, pulmonic-tosys[emicflowratio: 2.8). Kinetocardiographictracingsshow a bifid pattern at the right parasternal region (.4) and a hyperkinetic pattern movementat the left parasternal region (B) in the level at the fifth intercostal space. with increased pulmonary flow (group of RVP < 50 mm. Hg, Qp/Qs->_ 2,0 arid t h a t of RVP -->_50 ram. Hg, Qp/Qs > 2,0), the pattern in the right parasternal region was bifid in more than 80 per cent, while none Of patierits showed a normal pattern. In the group of high right ventricular systolic pressure and low pulmonary flow (RVP > 50 mm. Hg, Qp/Qs < 2.0), the right parasternal pattern was sustained in 80 per cen.t. By contrast, the Patterns in the left parasternal region were normal in about 78 per cent of ASD patients with relatively low right ventricular systolic pressure a n d a low pulmonary fl0w (RVP < 50 mm. Hg, Qp/Qs < 2.0). Of 38 cases with increased pulmonary flow (Qp/Qs ~ 2.0), normal, hyperkinetic and sustained patterns were observed in 10.5 per cent, 55.3 per cent, and 34.2 per cent, reSpectively. These patterns were also Observed in 20 per cent, 40 per cent, and 40 per cent of cases with high right ventricular systolic
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Table II. P a t t e r n s of kinetocardiographic tracings and h e m o d y n a m i c d a t a of ASD
(see t e x t for explanation)
Hemodynamicgroup I
RVP (mm.Hg) I Qp/Qs < 50 < 50 50 -_ 50
< ~ = <
2.0 2.0 2.0 2.0
Right parasternal impulse No. of cases INormal Bifid 9 (100) 32 (100) 6 (100) 5 (100)
5 (55.6) 0 (0.0) 0 (0.0) 0 (0.0)
pressure and low p u l m o n a r y flow ( R V P _> 50 mm. Hg, Q p / Q s < 2.0). Discussion
It has been r e p o r t e d t h a t ASD t e n d s to show an impulse of a hyperkinetic or a sustained p a t t e r n in the left p a r a s t e r n a l region. T h e s e p a t t e r n s correspond to the increased p u l m o n a r y blood flow ASD and to the high p u l m o n a r y resistance ASD, ~-8 respectively. In addition, we noted in p a t i e n t s with A S D a right p a r a s t e r n a l lift too high in a m p l i t u d e to be ignored. B y kinetocardiographic recording of this lift in the right p a r a s t e r n a l f o u r t h intercostal space, the impulse had an early systolic retraction and midsystolic o u t w a r d m o v e m e n t with its peak at late systole (Figs. 1B, and 2A ). This was named a "bifid p a t t e r n precordial m o v e m e n t . " T h e bifid p a t t e r n m o v e m e n t in the right parasternal region was observed in 84 per cent of the cases with a high p u l m o n a r y flow ASD and 45 per cent of low flow ASD. All n o r m a l subjects, 55 per cent of the cases of low flow and low right ventricular systolic pressure ASD, but none with high flow ASD showed the n o r m a l pattern. Cases with the bifid p a t t e r n m o v e m e n t at the right parasternal region showed a significantly (P < 0.01) higher p u l m o n a r y flow t h a n those cases with the n o r m a l p a t t e r n . T h e left parasternal m o v e m e n t , however, did not show such a good 9 correlation with h e m o d y n a m i c s as the right parasternal m o v e m e n t . F r o m these findings, it m a y be concluded t h a t the bifid p a t t e r n in the kinetocardiographic tracings in the right parasternal region is more useful for characterizing high p u l m o n a r y flow A S D t h a n tracings from the left p a r a s t e r n a l region. On the o t h e r hand, the sustained p a t t e r n in the right p a r a s t e r n a l region was observed in 80 per
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4 (44.4) 27 {84.4) 5 (83.3) 1 {20.0)
Left parasternal impulse Sustained I NormallHyperkineticlSustained 0 (0.0) 5 (15.6) 1 (16.7) 4 (80.0)
7 (77.8) 4 (12.5) 0 (0.0) 1 (20.0)
2 {22.2) 17 (53.1) 4 (66.7) 2 (40.0)
0 (0.0) 11 (34.4) 2 (33.3) 2 (20.0)
cent of the cases of high right v e n t r i c u l a r systolic pressure and low p u l m o n a r y flow ASD {high resistance ASD) and in 16 per cent of high p u l m o n a r y flow ASD groups. This would seem to reflect pressure overload r a t h e r t h a n v o l u m e overload in the right ventricle. A similar p a t t e r n was observed in cases with m i t r a l valve stenosis associated with p u l m o n a r y hypertension. 8 With regard to other left-to-right s h u n t diseases such as ventricular septal defect and p a t e n t d u c t u s arteriosus, no definite conclusion can be drawn from this investigation. T h e only patient with a high p u l m o n a r y flow, showed the bifid p a t t e r n in the right p a r a s t e r n a l kinetocaro diogram. Almost all other cases with ventricular septal defect and p a t e n t d u c t u s arteriosus had small left-to-right s h u n t and showed a n o r m a l pattern. In ASD, the volume and speed o f the right ventricular filling are increased by the s h u n t fl0w. T h e volume ejected in systole is m u c h greater t h a n n o r m a l as it includes the s h u n t flow fraction. T h e increased volume is expected to increase the speed and amplitude of the right ventricular and p u l m o n a r y a r t e r y m o v e m e n t , " which leads to a high a m p l i t u d e precordial lift, a bifid p a t t e r n m o v e m e n t in the right p a r a s t e r n a l region, and a hyperkinetic p a t t e r n m o v e m e n t in the left parasternal region. In a relatively low p u l m o n a r y flow ASD, the right Ventricular or p u l m o n a r y a r t e r y m o v e m e n t s are not so increased as to show the bifid pattern. Tricuspid insufficiency causes rapid and increased right ventricular fillings. It has been reported to produce a systolic r e t r a c t i o n in the left a n d diastolic lift in the right p a r a s t e r n a l regions.12 13 N o n e of the cases of ASD examined in this s t u d y had tricuspid insufficiency and only a few cases of tricuspid insufficiency combined
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Right parasternal lift in A S D
with m i t r a l valve diseases were e x a m i n e d by this method. E v e n t h o u g h t h e y were n o t so t y p i c a l and severe, their right precordial m o v e m e n t p a t t e r n s were different f r o m t h e bifid p a t t e r n in configuration a n d in phase. T h e r e are only a few reports with respect to the right p a r a s t e r n a l i m p u l s e of ASD. 2' 3 . 8 - 1 o Eddiem a n and associates'-" 3 only referred to an early systolic o u t w a r d m o v e m e n t a n d described the different k i n e t o c a r d i o g r a p h i c p a t t e r n s in pressure and v o l u m e overloaded right ventricles with specific reference to ASD. A l t h o u g h these a u t h o r s emphasized t h e systolic r e t r a c t i o n in t h e left p a r a s t e r n a l region, a midsystolic o u t w a r d movem e n t was also d e m o n s t r a t e d in their right p a r a sternal impulse tracings, :~ which c o r r e s p o n d s to the bifid wave m o v e m e n t described in this paper. A l t h o u g h k i n e t o c a r d i o g r a p h i c t r a c i n g is very useful in detecting the bifid p a t t e r n in the right p a r a s t e r n a l region, TM such findings can be detected also b y palpation. T h i s is a c c o m p l i s h e d by p u t ting the fingers on the right a n d left p a r a s t e r n a l regions s i m u l t a n e o u s l y . T h e difference in t h e a m p l i t u d e a n d p h a s e of t h e precordial o u t w a r d m o v e m e n t in each region can easily be perceived as a reciprocal m o v e m e n t : a large o u t w a r d movem e n t of the early s y s t o l e in the left p a r a s t e r n a l region {impulse of h y p e r k i n e t i c p a t t e r n ) followed by an o u t w a r d m o v e m e n t during m i d s y s t o l e on the right side (impulse of the bifid p a t t e r n ) (Fig.
2). Summary and conclusion In 52 cases with atrial septal defect of the ostium s e c u n d u m t y p e (ASD) a n d 49 control subjects, right a n d left p a r a s t e r n a l i m p u l s e s were recorded b y the k i n e t o c a r d i o g r a p h i c m e t h o d . T h e s e tracings were divided into four p a t t e r n s according to t h e systolic m o v e m e n t : n o r m a l , hyperkinetic, bifid, a n d sustained. In 30 h e a l t h y subjects, a n o r m a l p a t t e r n movem e n t was observed in all cases in t h e right p a r a s t e r n a l region, a n d a n o r m a l (83.3 per cent) or a h y p e r k i n e t i c p a t t e r n {16.7 per cent) was seen in the left p a r a s t e r n a l region. I n cases with A S D , n o r m a l , bifid a n d sustained p a t t e r n s were observed in 9.6 per cent, 71.2 per cent, a n d 19.2 per c e n t in t h e right p a r a s t e r n a l region. Of 38 A S D cases with increased p u l m o n a r y b l o o d flow, n o r m a l , bifid, a n d sustained
American Heart Journal
p a t t e r n s were observed in 0 per cent, 84.2 per cent, and 15.8 per cent, respectively. Of the cases with high right v e n t r i c u l a r systolic pressure a n d low p u l m o n a r y flow A S D , these p a t t e r n s were seen in 0 per cent, 20 per cent, a n d 80 per cent, respectively. In t h e left p a r a s t e r n a l region, n o r m a l , hyperkinetic, a n d s u s t a i n e d p a t t e r n s were observed in 23.1 per cent, 45.2 per cent, a n d 32.7 per cent of all A S D cases. T h e y were observed in 10.5 per cent, 55.3 per cent, a n d 34.2 per cent, respectively, of the cases with increased p u l m o n a r y flow and in 20 per cent, 40 per cent, a n d 40 per cent of the cases w i t h high right v e n t r i c u l a r systolic pressure a n d low p u l m o n a r y flow. Thus, the k i n e t o c a r d i o g r a p h i c p a t t e r n in t h e right p a r a s t e r n a l region showed m o r e i n t i m a t e correlation w i t h h e m o d y n a m i c d a t a t h a n t h a t in the left p a r a s t e r n a l region. T h e bifid p a t t e r n m o v e m e n t in t h e right p a r a sternal region was f o u n d to be a reliable sign of A S D a n d was f r e q u e n t l y a c c o m p a n i e d b y t h e h y p e r k i n e t i c p a t t e r n m o v e m e n t in t h e left p a r a sternal region. T h e s e c h a r a c t e r i s t i c m o v e m e n t s were easily perceived b y s i m u l t a n e o u s l y p u t t i n g two fingers on the right a n d left p a r a s t e r n a l regions. The authors are grateful to Professor Toshiyuki Yanase of our department for his guidance and to Professor David H. Spodick of the Cardiology Division, St. Vincent Hospital, Worcester, Mass., for his thoughtful review of this manuscript. REFERENCES 1. Wood, P.: Congenital heart disease. A review of its clinical aspects in the light of experience gained by means of modern techniques, Br. Heart J. 2:639, 1950. 2. Eddleman, E. E., Jr., Hughes, M, L., and Thomas, H. D.: Estimation of pulmonary artery pressure and pulmonary vascular resistance from ultra low frequency precordial movement (Kinetocardiograms), Am. J. Cardiol. 4:662, 1959. 3. Eddleman, E. E., Jr., Holt, J. H., and Bancroft, W. H.: Computer analysis of the kinetocardiogram from patients with atrial septal defect, AM. HEARTJ. 71:435, 1966. 4. Nagle, R. E., and Tamara, F. A.: Left parasternal impulse in pulmonary stenosis and atrial septal defect, Br. Heart J. 29:735, 1967. 5. Gillam, P. M. S., Deliyannis, A. A., and Mounsey, J. P. D.: The left parasternal impulse, Br. Heart J. 26:726, 1966. 6. Kesteloot, H., and Willems, J.: Relationship between the right apex cardiogram and the right ventricular dynamics, Acta Cardiol. 22:64, 1967. 7. Tanabe, Y., Sakamoto, M., Kobayashi, T., Fujino, K., and Mashimo, K.: The relation of left parasternal impulse and right ventricular systolic pressure. A kineto-
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cardiographic and apexcardiographic study, Jap. Heart J: 1 ! :213, 1970. 8. Fukumoto, T., Ito, M., Tets 0, M., Fukushima, I., Fujino, T., Imanishi, S., Ito, S., and Mashiba, H.: Precordial movements in adults with mitral stenosis and atrial septal defect (Abstr.), Jpn. Circ. J. 37:606, 1973. 9. Fukumoto, T., Ito, M., Fukushima; I., Fujino, T., Yasuda, H., Ito, S., Kanaya, S. and Mashiba, H.: Studies of kinetocardiogram. Left and right parasternal impulse in atrial septal defect, Cardiovasc. Sound Bull. 4:373, 1974. 10. Fukumoto, T.: Studies of straingauge kinetocardiogram.
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Recording methods and its clinical implication, Jpn. Circ. J. 36:13131 1972. 11. Mtiller, 0., and Shillingford, J.: The blood flow in the right atrium and superior vena cava in tricuspid incompetence, Br. Heart J. 17:163, 1955. 12. Boicourt, 0. W., Nagle, R. E., and Mounsey, J. P. D.: The clinical significance of systolic retraction of the apical impulse, Br. Heart J. 27:379, 1965. 13. Armstrong, T. G., and Gotsman, M. S.: The left parasternal lift in tricuspid incompetence, AM. HEART J. 88:183, 1974.
December, 1977, Vol. 94, No. 6