The three-plane ballistocardiogram in heart failure†

The three-plane ballistocardiogram in heart failure†

Seminar on Ballistocardiography:‘ The Three-Plane Ballistocardiogram in Heart Failure+ 1~~1~~1.4~ T ballistocardiographs HE SIMPLE pioneer er...

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Seminar

on Ballistocardiography:‘

The Three-Plane

Ballistocardiogram

in Heart Failure+ 1~~1~~1.4~

T

ballistocardiographs

HE SIMPLE

pioneer

era,

1937-50,

foot movement.

Because

was the point

generated often

at the end

of systole

variations

in

IJ,

With

associated onary

the

with

disease,

ative height between nea,

gallop

and

edema

coronary

deep

respiratoryheadward

valvular,

changes rhythm,

or pulmonary

was

clear-cut.

disease

abnormal

ballistocardiograms.

head-foot

patients

failure,

barely

records

to be inscribed,

tolic

patterns,

able

mia,

beriberi,

with

or

* This issue contains schedule January: t From

of the articles

with

severe

to be flat long might

waves

In general, patients due to aortic reflux,

disease

head-foot waves

is never

with .4-V

show

clisease

have

is about gram

of large

enough

for sys-

would

firmly

the Department

III,

recording

there

Starr

held

shallow,

respirator)between those

has

table

\I-here

I, \vaucs and

in

there

and

disease,

pulse

curves.

motion

a device

for K

variation

Lvith a

the shoulders

the

old and with

a

In the in IJ

in the l)allistocardio-

head-foot

against

in

been

variation H and

be in the brachial

displacement,

and

of a subject

a,gc, or health

deep

sensing becomes

in 1.J is small, young,

healed

betwrcn

infarction,

and noris not

.A patient whose 1.1 \ca\cs during espiration almost disappeared if he smoked on a Starr table usually shows very- little change if hc

smokes

while

hc is on one of the aperiodic

suspen-

sions.

large

Part VI of the Seminar on Ballistocardiography icditrd by Sidney already published. and of future articles in this seminar. may be found

1359, issue (Vol.

naive

disappeared,

difference and

variation mals

amplitude.

had

amplitude

striking.

high pulse pressures shunts, uremia, ane-

hyperthyroidisrn

low

situation.

large

practically

as little

head-foot

On

failure, and small

the sophisticated

respiratory

Even Iv-hen one records

congcstivc

heart

acceleration

marked,

in youth

as there

showed

normal

the

toward

this early

plane,

arc

sometimes

from

suspension,

from

free of symp-

failure,

hand,

aperiodic change

sort of reversed

or hypertension,

had

records

h).peremia Patients with

toms or signs of heart the other

which

great

as dk-sp-

in

pressures

v-essels

development

almost

in rel-

pulse

of the pioneers

device

IW’ pattern,

and such indices

not

\Vith

The correlation

R4” pattern.

of hilar

or cor-

was an increase

even

small

patterns.

s!-stems

K waves

large

the “early

“M”

waves

with

pulsations to

systolic

systolic

Lvhile those

beyond

of myocardial

often

of H, giving

these

very

main

onset

or of L, the “late

normal

head-

\vere sen-

In subjects

hypertension, there

in the

only

devices

showed

and

the

N. Y.

in or transmitted

part of the body.

the age of 50, they

wave.

these

M.D.

Brooklyn,

the shin or a footboard

of impact,

sitive to the forces the caudal

used

recorded

Dock,

R. Xrhcit. u.D.). .A on pp. 101-102 of the

NO. 1).

of Medicine,

State

University

of Krw

York

Downstatr

Medical

Center.

Brooklyn,

New

York.

384

TIIE AMERICAN

IOURNAL

OF

CARDIOLOGY

385

I jock EFFECT OF AGING ON FORCE AT SHOULDER .4ND

If one tween

saddlr

pendently of the

from

only

there

deeper

variation than

the

shoulder

comparable pick-up shoulder,

the

pattern,

shoulder.

from,

The

body

acceleration

‘l‘he

seems

to

right

some

force

chiefly

stroke

volume

shoulder

incwases

or apcrioclic

ver)- littl(b increase the fact that at a time decreases forces

table

shows

that

of

subjcctsl evoked

tq

is a large pulmonic

Starr

pattern

recorded

side supports

sultjccts.

pulmonic

is held

by stiff spriqs,

coils in magnetic are all integrated MARCII. 1959

fields.’

produce

striking:

changes

than

half those

of more

findings,

including

t)loocl

make coronary

arterial

strony

Such changes in shoulder or aperiodic

only

disease

older

with

tions

in systolic

b)

thosr

in the hwd-foot

the out-

otic

and

subjects

may show

force

respirator!

Lvhich arc p1anc.l.”

emph!sematous

men,

the

or

are lnuch accclcrom-

etcr cur\.es. or in curves of lateral and ventral motion of the thorax. I,ateral from

choles-

a certnint)

prot)at)ilit!-.3

less e\-idcnt

as obtained

across

Ciyarctte smoking, pattern in normal

terol levels,

motion is sensed 1,) These \-elocity- curves

t)y condensers

\vhosc* other

infor-

or aperi-

It shou-s lar~r maria-

\-olume

the thorax with The platform axilla.

and

does

01’ such

shoulder

on the

pattern

t)ec,n con-

yi\-es more

than

curves.

no effect

in tht head-foot

is sc’cn as

nai\.et&

trace

age and disease.

! oung

under

snug in rach

tions \cith

but

decrease,

of the

value

odic accelerometer

shoM

field at the level of the and dorsoventral force

from a platform

of clinical

curves

stroke

force,

mation

the

c;f the Head-

force

six )‘ears> Ice hale

the head-foot

inspiration,

we w?ll deal

of head-foot

apparatus,

rightward

regardless

has

BALLISTC~CARDIOGRAhl

light coils in a magnetic shins, and M.ith lateral

that,

from

cur\-es

of the traces.

past

which

to these curves.

presentation,

the

in the head-foot

M.ith those

photoelectricall>-.’ and

deflection

Over

troughs

in displacement

recorded

The

METI~ODS 01; RECORDIYXGTHREE-PLANE

In this

as

back\varcl,

vinced

pulnronar)

or

shins

in

and

correspond

\zard, up\vard

arising

no inspiratory

left ventricular

1.

suspension

\vhen

accelerometer

also contribute

the shoul-

Starr

and

there

in IJ during

slightly,

curves

up to 50 per cent.

they show

w-hen

for

the peaks

closel>-

in older

inspiration,

and

put,

plane

to forces thr

ITis. I Simultaneous brad-foot ballistora~dioqrarr,s from a 5%yrar-old man. wcdgcd brnvren a yokv on thr shorllders and a seat plate on the ischial tubcmsitirs. Thr upper curve is from the spring platform of the shollldcr yoke, the lower cnrve from the ischial platform. Sensitivity of latter is twice that of shoulder. Taken in held expiration: during inspiration ~trouldrr IJ incrrascd 30 prr cmt. ischi;.l IJ OVCI‘30 prr cwt.

as the

of Figure

to forces

ejection,

of 1.J during

than, from

resemble

pattern,

t)e due

ventricular

increase

weaker

from

part

the familiar

in aperiodic

mainl?.

Starr

at the

displacement

due

of

ischial

the lo\vcr

inscribed

closely

from

that

accelerometer

of the body \vith

artery.

from much

of shoulder

apparentI!-

the aorta,

of the

seen in the curves

curves

larger

Tet waves

times

those

SO,

inscribed

inscribed

aperiodic

der displacement The

curves

the forces

are actually

from the \vhole

much

to four

at

o\w

in the To

40

than

K, and

1).

or legs, which

well as different

under

men

sensitivity-

be two

t)ecause

of the trunk

men

simultaneously

(Fig.

size, must

inde-

of compression

man)-

in IJ

in those

tuberos-

is recorded

from

is a strikingly

bc-

like a

K at shoulder

\vith

ischium

are

curves loI\-er

Ho\~r\w,

respirator)from

the

firmI!shaped

the ischial

motion

th(sse t\vo points

slightly

ischium.

against

head-foot

trunk,

show

subject

)-okr and a plate

pressed

so that

Starr

a normal

a shoulder

hicvcle ities,

bvedgcs

AT ISCHIUM

clorsocuwes \-aria-

rcwrsr

of

In a frw kyphthe clorso\-c.ntral

cur\es resemble the usual head-foot pattern of HIJ lvaves, and show similar changes \vith respiration curvt’s

or are

smoking. \-er!-

Lvith accelPromcters the

latcxral

cur\‘es

Lb’hile

different

from

these those

on the aperiodic are

not

verl

he;lcl-foot wcorded pl;ttform.

differwt

fro111

The those of lateral

force obtained

eters at the shoulder

level,

Three-Plane

\vith

when

Ballistocardiograrn

accelerom-

lateral

motion

at the feet is restrained.

In

this

IalA

presentation

and will indicate ography,

case

lower

In the latter

peaks

replaces

peaks

and

usually. foot

the

coincide

in the lateral, the

broader

summit I

hc

scrii,cd. ferent raph!.,

are

synchronous in the other

at its lowest when

asynchronism some Our

there

is no reason

to expect

force

to coincide

\VC \\ould

expect

cause

in

following

gram, arc head\vard,

at

the

planes,

fined

any more forces

In

tolic pressure

dips

ventricular

duccd,

than which

ma)- differ

in

high

by venous

or back-

called

H in all planes;

rightward

or backward

Q are called

\vhich

FAILURE

at

0.16

volume

and conventions Kings

County

purposes,

existing

L.

in use Hospital

Clinic, from which have heen derived.

.-\ND MYOCARDIAL

failure, for our

as the situation

peaks

.J; and the head-

when

be

length,

is high,

the

formerly

situations, and artAa1

tnyocardial to total

de-

one or both

the reI\-ith

the

imposed

failing

ventricle

or a strep

handled and

normal.

is like a man

ljurdcn even

pressure

1))

volume

per beat than

ventricle

\vith

supplied

without more

who climb,

distress.

byhen stroke

are normal

or low,

has suffered a loss of efficiency in its contractile function. In

failure cycle

my-ocardial

cal turn-over

stroke

more work

a heal,)

the m!.ocardium or cotnpetcncc tion

and

is nornlal,

is associated

rates

systole

is prolonged

length, heat are

and

high

in relafiber

and chemi-

in relation

be impaired by the salt-retaining oids or even by high-salt diets, ‘I’HEAMERICAN

diastolic

production,

mechanical \\ork performed. ence has shown that ventricular

FAILURE may

cases he

In these

of

dias-

diastole

in the artery

or when

return

under

with

end

in cases coml)incd

failure

pressure

be doing

those

after the end of T is called

for the technics

tires

as well as

at the

volume

in

in early

fil,rosis.

ventricle,

must

volume, normal

low in early

myocardial

diastolic

tither

t‘\‘cn

eml)arrassment,

or even increased

m).ncardial

&fusion. instance

is high

pericardial

diastolic

Heart failure, pericarditis and

special

is above

end

\Vhen

to be syn-

forces

rightward

and at the Palo Alto Medical our fig-ures and information

Heart

that

of mechanical

The

headward,

laboratories

HEART

indicates

peaks

to the waves

force starting

SO much

diastole.

the Q wave of the electrocardio-

to 0.28 set after ward

K is in-

\ ulume

a sustained

prricardial

is the

the ventricular

pressure,

ballisto-

from pressure

and

in dif-

pressure.

diastolic

diastolic

stroke

without

constrictive

failure

diastolc

waves to

diastolic includes

J

head-

the

return

tamponade

In such

different planes. The first waves ward,

in

planes.

or contribute

\vhich

in clcctrocardioy-

the electric

three

Thus,

when

experience

in three

Myocardial

and the lateral

difficulty

cardiograptiers.

heart

has a

footward

a commonplace

in end

so defined,

headward

planes.

point

its peak,

rise

maintain

I))- vc‘nous

and

with later

cannot

imposed

to ,T

has caused

chronous

\,cntricles

of the headequal

than

‘This planes,

those

pattern waves

its plateau

at

with

frontward

\zarcl J is approaching ma\

three

l‘ig. 2. Herr ;~ntlin strtjsrqurnt tt‘aws, the ballistocardiograms arc taken wit11 head-foot at top. Iatrral in middle, dorsovrntral at bottom. From a 40-yrar-old woman with atria1 fibrillation and mitral insufficiency. ‘Thr protodiastolic MN dominate. but lmlikr most casts is smallrst in the Iatrral planc-.

The

dorsoventral

.J is usually

lx

with

K

lateral

ma)-

ripple

(I;ig.

discasr

H peak is normally

and

H. but lateral

deep

The

or M;\:

in

hiJ complex.

of the

in time

hut

seen.

a small

M”

pattern

in coronary

normal

troughs

trace

rarel)

pattern

Thus,

“early

The

is hjklhfn

insufficiency

as

for small,

waves.

is .JkL.

M”

31, M-hile the classical is h!jj’R.

letters

large,

is hi.Jklmn, the

“late

mitral

use “M”

H or L waves,

as in clectrocardi-

case

relatively

pattern

is HLJ, the

large

wake forms,

for

normal

free

with

1)~ using

upper the

we do not

for the pattern

to the

Clinical experiefficiency can adrenal sterand it can I)e

JO'JRN"L OF CARDIOLOGY

improved

I))- sodium

depletion

squill,

or strophanthus.

of digitalis,

Ballistocardiography in

the

kinetic

failure

can only

hydraulic

I)ut does ele\-ate it nrust

suw, force

and

rapidly

inflow

of presystolic

thing

through

when valve

or M-hen the ventricle dial

tarnponade

return,

arc exaggerations form,

failure--the

is systolic

is embarrassed

under

by pericarwhen

of those

venous

of heart

seen,

rapid

exercise?

increases

phenomena

heavy

reflux valves,

Indeed,

subjects or fever

the

the

Rapid

or the semilunar

nicotine,

so that

of atria1 hence

ma)- rise.

there

in normal

excitement,

and more

force

or constriction.

occurs

are USUfill

and

to myocardial

occurs

an ‘4-l’

inflow

The

from

failure,

which

inflow

in

flow phases

bc increased,

pres-

increase

in heart

empty.

may

is not peculiar

same

an

lcntricles

they

also

\-cIocity

nornlal

show

than

systole

cause

‘These inflow

than

kymograms

of sytolic

of protodiastolic

to ventricles.

ally shorter

velocil)

atria1 and venous

inevitably

\-elocity

re\cal changes Since heart

forces.

ma\- or may not impair

ejection

atria

or by glucosides

failure

in less marked

physiologic

loads

in normal

hearts. AND HE-\RT FAILURE

IN.TERREL.\TICIKS 01: ANGINA

(Xinicians

have

long

usually

decreased

or

failure

set in, and

that

during

angina1

cardial monary or

seizures, the

with

of the most of the

is that

almost

curring

during

recording

Starr’s

method,

changes

in

this

onl>. the IJK

preted

as e\idencc

nearly

all srvcre

the

entire

large waves.

These

can

c1c11ce for myocardial MARCH,

t 9.i’)

gallop frotn

nitro-

evidences

bout

of angina,

of head-foot

traces

the change inand can be interejection. bouts

Rut

and

presystolic

or large

be interpretrd with

in

of angina,

is disturl>ed,

failure,

by

cases, as discussed

complex

there early

\.enous

are H

as evi-

a rise in pul-

\vith

attack

phenomena

from

I)ricf inflow

in size of the pro-

ballistic

wa\cs

during

seen in chronic

heart

failure

(Fig. 3).

also appear as transient smoking in some patients co\*ered

rapid,

increase

and presystolic

the angina1 The

pressure,

the transient

todiastolic oc-

by very striking

In many Seminar,

manic causing

ballistocardiographic

e\:ery

onl!-

rhythm

Fi#. 3. .Inyina p
angina1

important

of altered

pattern

of

in the pul-

relief

or prolonged

protodiastolic,

of m)-o-

during

is accompanied

in pattern.”

elsewhere volves

of moisture

disappearing

heart

examined no fading

Yet occasionally

sensitivity

method

sounds,

is noted

angina

when

had no evidence

no evidence

One

that

patients

aftcrnans

glycerin. of

most

gallop

al\-coli.

pulsus

aware

disappeared

seizures

failure----no

first sounds,

been

clinical

effects known

episodes

of cigarette to ha\-c reof coronar). clis-

case, and in young people lvho sho\v \.ery fast rates and large systolic forces on smoking-. The former usually show striking changes in systolic waves

during

the expiratorv

phase

after smoking

(Fig. 4), while the young normals, sensitive tobacco, do not. The large diastolic \I-arcs the latter

group

probably

to in

are due to high rates of

388

The

Three-Plane

l>lood flo~v, not to myocardial

damaTe

coronar!.

5 1.

\.asoconstriction

In this report,

(Fig.

vcaled

that

much

due to

we shall deal I\-ith prolonged

and painless heart failure, emphasize

Rallistocardio~ram

but it is necessary

ballistocardiography

greater

has

myocardial

to re-

impairment

during angina1 seizures than had Ixen suspected from clinical forgotten

observation.

.41so, it must not be

that a few puffs on a cigarette

patient bvith coronary

in the ballistocardiogram

e\‘en I\-hen no pain or

electrocardiographic

changes

fects of the cigarette

may include

\va\‘cs similar

I))- a

disease ma)- cause changes These

occur.

cf-

protodiastolic

to those occurring

in m)-ocardial

failure. THE CHANGES IN PATTERN SEE\ IN HE.ART F.AIIXRE C;icmgrs in I./ systolic

onl>, change

in the

I,1 \va\-e bvhich can with confidence

ascribed to myocardial recorded This

The

Il,hce:

by Starr”

failure is alternation,

in his Figure

1, second role.

has the same significance

as pulsus alter-

nans, and like it may lx especially first few cycles after an rctopic patient.

FVhen no alternation

strated in carotid right \.rntricular

ma&cd

in the

Ixat, as in Starr’s can l)c demon-

pulse curves, the altcrnaticn

I)allistocardiographic

1.J must

lx first

hc ascriljcd

in to

failure with alternation

monar)

in pularterial flow and pulse pressure-s. Othel

changes

in IJ,

notching

tude, Ina). occur \vith many Ixanch enccs

other

in ejection

conditions velocity,

such

and also as

bundle

causing

difl’cr-

or shunts causing dif-

in \,olume flow of the t\vo ventricles.

However,

notching

hvhich is corrected depletion

of J or low amplitude with digitalization

can he ascribed

evaluation

tracts

in ampli-

heart failure

L)lock and hypertension

fercnccs

This

of ,J, drcreasc

during

IJ

or sodium

to myocardial

failure.

can only he made from serial

by one familiar

with the clinical

features

in Atria1

(Presystolic)

Il’aws:

In sinus

waves,

small

large in the lateral gallop, causing produces large ward.

and treatment. Cllan,ces

atria1

Thus

two

planes,

arc

relatively- small lateral waves headward and

rapid

ing and filling

in

vcr)

trace, while a protodiastolic

passive early

diastolic

due to atria1 systole

may

force, backfillhave

rhythm, the cffcct of atria1 forces can be estatllished only in cases of complete heart block.

quite different vectors of force. Atria1 systolc is followed 1)~ two headward, rightward, and

AS reported by us previously’ (Figs. 10 and 13 in that publication), the head-foot waves due to

backward

atriaI systole may be lar,qe, but in most cases the lateral waves are the largest. The situation shown

in Figure

6 is noteworthy

because

the

peaks,

about

0.1

and 0.25

set after

P, and the second wave is usually much larger. When P-R intervals are less than 0.18 second in sinus rhythm, such waves may coincide with the H wave of ventricular systole. These I-HE

AMERICAN

JOURNAL

OF

C.\RDIOI,OGY

forces

are increased

and

prohahly

waves which

the

Howe\,er,

large

fibrillation,

Therefore,

tion,

purely

a large

fwcc’s,

rassmcnt

cl-idcncc

and tricuspid lailurc,

tolic n \va\-cs when at normal

hwd\vard through

or long

forws

P-R

start

larxc

is prolonycd. specific This ma) orifice,

prcsys-

or large

H

Th(. large carl)

the A-\-

orifice.

(~111jar-

\vith no c\-idcnce

cause

high

normal

H J is

discasc.

Ijut only. of very flo\v and

Q

1x1~ an).

hcad\vard

val\-ular

not

CM)

Ixforc

of m!.ocarclial

may

Q,

and rcyarcled

gallop,

P-R intcr\zls. are

before

1)~ large.

than

stenosis.

P-R

atria1 \vave

to atria1 activity

in casc*s \vithout

Mitral

failuw,

also

to or larycr

and

I I ~vavcs

base-line

to prcsystolic

of mycardial uxws

the

Q may

is equal

abnormal

failure

large

contrac-

large

H has its upstroke

as equk-alent

prot)aM>-

in isometric

severe

coward

can it t)e ascriljcd

during therapy.

of an al)normall~-

volume

1I following

which

H

in some cases laryer

ma)- he a prcsytolic

returns

lvhcn

large

effective

ventricular

cases with there

lvhich

rapid

after

motion

blood

In some

and

also occur

also pla)- a part in causing tllr “early M” pattern.

intervals,

and angina,

of most

hcconiing

smaller

lvith

\.entricular and

H waves

and

associated

failure

cause

arc so often seen in these conditions.

of atria1 cscrcise

I.iTcct of smoking on an obvsc lvornan, 26 Fig. i. Thr control head-foot years trld : no cardiac disordrr. B?lo\V. thr effrct of live tracts ‘31lCl Il,acl II abow~. puffs on d ciqawttr: first live cycles in qcntle expiration. last two c!clvs in inspiration. Marked acceleration of rate and inrrrasc-d systolic forcr during inspiration, as \scll as a laruf YIN wa‘, c and shortened K. arr producrd ‘I-hew t+J-ects may all be dur to prrssor. Ix smoking. accvl~rator. .~ntl vcnoprcssor actions of nicotine.

in heart

are

cavidcnce

\-clocit). \vith

of

of flop

Ix dur

to a

a I,ric%f but

Only in the last beat can the ventricular h1.J pattern be scan frer of atria1 wavcs~ Fig. 6. C:omplete heart block. and only the preceding atria1 beat shows thr purr atria1 forces, with no interference from ventricular systolic or protoAtria1 forces are small rxcept in thr lateral plan?, where the huge CIwaves reach a peak mow than diastolic waves. ‘Therr beats the lateral h or J is almost lost in the atria1 wave. 0.2; xx after onset of I’. In the first threr ventricular 1s a gallop wax c‘. NO, which is small in the lateral plane and most striking in the dorsoventral tracr. MARCH,

1959

3%)

The ‘l’hree-Plane

rapid

jet when

row

orifice

The

force

with

the mass

pressure

with varies

here, when

stenosis

has

excluded

cepted

as signs

number

can of

tall

I;

L

Figure

cxpiratory GonaIl?,,

velopcd L, or .A-\’

with

which

a

that

This

situation

~nuscles

This seen

tjreathing.

in

Occa-

If they

as in Figure

late in s).stole

orifiw. large

and

tic clue

the

dies out.

and

systolic

rapid

This

SCCI~S

of the X-1’ septum

LM

only really

rise

or AM.\.(Prototliastolic~) cvidencc

to rc-

is augmented the

waws

arc (qua1

1atc.r

thcsc

protodiastolic

than

the

is cxactl) gallop

late

is hwrd

or apes

sis, or marked

of

atria1

of

nomena

cannot

\vcll-compcnsatcd chccrfbl

prognostic

plants.

than

6, is it as

sut~cndocardial rcflux,

t)c’ prcscnt.

f2)rillation

finding;

swn

film)OCCIIIX

gallop

Its

it

usuall)

rcgularl~

M-hen prcsystolic atria1

or \vhrn

WI\Y

as in Figuw

ytolic

th(l proto-

the \-cntriclc

diastolc

phcnomcnon,

mitral

fitjrillation,

show

largest

pericarditis.

\\‘Thcn

to or 1arqr1

as when

in early Thr

rarcl)-.

.l‘his

protodi-

or rccorclrd,

tracings

rapidly

or MN:

as 0.

the same

failuw

\va\.c.

I.1 NXV~X in unc or more

significance diastolic

L

The

Tl;lr’~.):

than

force

The

of hrart

astolic

in constrictive.

is not

\\a\ t‘s

ot)scurr.

in the ballistocardiogram

is LM

unlikcl!

remains

d(>pcndat)lc

mow

contraction

K tend

trcatmcnr.

in systolc.

end

footward

cffectivc

changes

arc

(and in A-1. \~al\~~lar

short

with

onl)~

wa\w

vcrt

wfilling

to high

L

Both

to normal

arose

can

discasc.

rmpries

K or augment

headward

that

ap-

dr-

hcatl\varcl

if the force therefore

failure

1;1wral

Largct

arc also seen in heart

7, it

arc

One

in heart

kymography

or during

forws

the normal volume

sincta the 11sua1 plant

is

and 1, tall during

discasc.

could

when

latter

of the L ma)

wsonancc.

of protodiastolc oppose

the

is a

vertical.

t)c expcctcd

that

stenosis),

Large

commvn

are the only atmormalit?

heart

ventricular

septum,

papillary

In

stenosis

When

on rcco\.rr)-,

phasr tjoth.

systolic

be ac-

prognoses,

fairly

K, some

of normal

t)c conccdcd

isometric

noted

A

fit the

K waves

normal

must

not

phase

in a patient proach

often

t)ad

K is very short

short

A-V

H wa\w failure.

or Ijudy

does

4, whcrc

the

out

in the ballistocardio-

wave.

to “l)ounce”

explanation

at

as would

point

and in mitral

I)y a very deep

IX dw

of

almost

usuall>- are not seen bvith large

of an A-L7 valve

with

Waoes:

failure

hcadward

preccdcd

waves

but

cause for thcw

and L

in heart

horizontal 1, waves

directly

at rest.

A4bnormal

finding

jet.

the square

myocardial

of cases of angina taken

with

large

this was the chief anomaly gram

velocity

as elsewhcrr, hut

Only

or to a nar-

high

of blood

velocity. tIeen

is clew-ated,

sustained

Ballistocardio#ram

in

phc-

at)s(‘nc(*

in

is aI\va).s

a

its atwncc

in a

five years after three severe bouts of anqinal Fig, 7. Effect of improved clinical state, from a man with indigestion, pain. The first set of tracings taken when rate was 96. blood pressure 150/100: the second seven months later. ratr 70. Headward H begins before Q, lateral H is reduplicated. blood pressure 120/80; weight down from 195 to 165 pounds. I and K footward are much deeper as circulatory state improves; headward and backward IJ are larger and occm Change in IJ vector may be Notch in lateral K corresponds with headward L wave. later, but lateral IJ is smaller. due to lower diaphragm

after weight

loss. I‘HE AMERICAN

JOCJRNA’.

OF CARDIOLOGY

fibrillator

haling

signs or symptoms

nary cnorgemvnt purr mitral

raises a strong suspicion thar

stenosis is present,

incompatil)lr

of pulmo-

Fiy. 9. \\Zvocardial infarction anti bundles branch block. from a i%ycar-old man. with mininml heart failure- in thr pr-csrncr of postinfarction bllndlr branch block ;md ancxrysm of left lateral w,rll. ‘I% hwd-foot trxc is normal. tht kitrral shovs nutc.l~vti .I. tall H and a layc protodiastolic xcavc.

with rapid

for this lesion is

protodiastolic

inflo\%

and dcrp ?LI or tall N wa\‘cs. In the presence cicnc!..

of marked

protodiastolic

\LYI\YY~na!- I)c found lnitral

stc,nosis.

tricuspid

gallop

or large

even

with

a very

tight

It is only when these \-al~&~r

or pc~ric;~rdial causrs

are vxcludrcl

cl~asrolic gallop or large M to 0 taken as cL\icicncc of In)-ocardial

that

proto-

\va\.es can 1)~ failure, overt OI

Phis is sec’n in aortic valve disease and

Iatcnt.

in

insufli-

M and N

h)pvrtcnsion

with

m).ocardial

\vrll as in myocarditis,

beriberi

and othc,r causes ol‘ myocardial failure.

The most frequent

infarction,

especially

tit>- hospital KlSC.

uremia

overloading

frequent,

and

cause is myocardial

nutritional

anemia

and

In the heart dis-

hypertension,

and h~-pt,rt~l~-roidislil with atria1 fibrillation relativcl!

as

disease,

in private patients.

population with

failure, heart

but hypertension

are

and coro-

nar) disease, often with no history of chest pain, remain

the most common

causes of protodias-

tolic gallop phenomena. As \cas noted by the Hopkins groups,B in pericarditis with constriction the protodiastolic waves of large amplitude in the lateral

trace.

are usually

The head-foot

best seen trace often

is normal in cases of heart failure, mitral insufficienc)-. ventricular aneurysm, and constricMARCH.

l’l!ic)

Fip. IO. hlitral insuflicimcy. from a mmllan. 27 yrars old, with well-comprnsatcd mitral insufticirnc)-. ‘The hvad-foot trace is normal as recorded from the shins, brat thr insert in thr electrocardiographic strip sho\vs two cycles from the head-foot curve lecordcd from thr shouldrr. Hrrc the protodiastolic hcadward tlnxst is talk than .I and coincides with thv I&ward and Gontward hZ in thr other planes. Thr “mitral“ notch on HI shows hrrc, hllt not at shins.

ti1.e

pcricarditis

when

hug?

waves are present in other plants

protodiastolic (Figs. 8,9, and

10). Only occasionally is a protodiastolic recorded in the shoulder head-foot trace, that from the aperiodic accelerometer, shin or Starr table trace is normal

wave or in

when the (Fiy. 10).

392

.l’he Three-Plane

Ballistocardiogram

Fig. 11. Gallop with increased MN wave, from a woman, aged 43, with mitral insufficiency and atria1 fibrillation treated with IIS’. J is small and bizarrr. Large protodiastolir forcr in all planes. This forcr acts ventrally, while acting hcadward and rightward. in this patient with a giant left atrium. Thy apical heart sounds, from a record taken the same day. and with R waves of thr electrocardiogram marked with black dots. is insertrd above to show thr loud gallop sound, G. The first sound is followed by a murmur‘; thr second sound is not rrrorded at thr apex.

E\,en more

unusual

is a normal

\vhcn large protodiastolic anothclr

plant.

does occur the force

However,

(Figs.

lateral

trace

waves arc present the

fact

that

in this

2 and 6) is further proof that

axes of the heart,

like the electrical

axes, ma)- shift over such a \vidc angle that rccords of either electrical plane

or kinetic force in a single Significant

arc inadequate.

forces

1~ present in one plane in one sul,jcct,

may

in another

:

1~2

Fig. 12. Summation wallop with larqc IIN \vavcs, from a woman lvith hypertension and constrirtivv pcrirarditis. ‘l’hr aprx heat and heart sounds (lrft t1ppcr.j and jugular pulw (riglit upper) wcrc rccortird with electrocardiogram and position of P wavrs rnarhrd by black triangles hrforc inserting abovc clectloca~tlioqrarn H~lqr hfi% rrcordrd with thr: ballistocardiogram. waves begin 0.1 6 SK aftrr second sound : the. gallop round begins at 0.12 src and is maximal ,lt 0.16 WC. whrn the apical thrust in diastolr is rrflcctcd and protodiastolic dip in .jugular p&r is sharply rcvcrs~ti. Ttw H and .J waws arr fusrd. wcept in front-back plnnc.

plane in others, and in all three in a fe(‘~.(Figs. 11,

\vard L could pass for a large prcsystolic

12, and 13).

This is the record of a vigorous man of 67, \vho

Szr,/xGn/)osed

and Protodinstolic

.hiul

J1hws.

had

had

asthma,

rwotional

\va\‘c‘.

tachycardia

and

h>-pcrtcnsion

since his late twenties.

lorcc, when diastolc is brief, ma)- not hc maximal

ord indicates

a lar,Tc systolic force at a pulse rate

until after atria1 systole has begun,

of 11 H,‘min, certainly

As is apparent

the

in Figure

ballistocardiographic

“summation In Figure

gallop”

thus causing

equivalent

of

the

of the phonocardiogram.

13, although

WC, the presystolic

12, the protodiastolic

P-K is prolonged

wave is distinct

to 0.20

and prcsys-

large

dorsovcntral

a high minute and

lateral

The

rcc-

Ilo\v. The

1.J \t‘a\‘c’s arc

characterisric

of wlphysematous mm with torThe peak of .T is 0.08 WC wrlicr tuous aortas. t)ack\vard than headward, 0.06 rar1ic.r than

curs after Q, while in the frontal plane, a large footlvard force, certainly of atria1 origin, I)egins

Death from cerct)ral arterial thromrightward. Ilosis, five months later, made it possible 10 confirm the absence of coronary disease or an! car-

at 0 and H is maximal

diac

tolic only in one plane;

Identification It70ws

of

in Taclyardia:

Late

in another

its peak

OC-

0.13 second later. Systolic

and

Protodiastolic

At rates over 120,,‘min it

t,ecomcs difficult to identify late s).stolic from protodiastolic wa~res, especially in the head-l&t plane. Thus, in Figure 14, the K wave is maximal after onset of atria1 systolc, and head-

abnormality

of t)oth ventricles. this h>-pertcnsive

except

moderate

thickenins

The late .J and K peaks, in man

with tachycardia

[Q-K

= 0.43 SK), contrast strikingly with the early .I Ind K in t)racl\-cardia with low diastolic prcssurcs, in Figure 6 ((2-K = 0.30 SCC), although the Q-H inter\-al is the same, 0.15 WC: in Iwth. TIII:

ALIERIC-IN

JC’L’RNAL

OF

CRDIOI.O(:Y

\\‘ithout

ficult

14

rhr

did

tolic 1I.I.

dorsowntral

rwt

mnsist

of a deep

\\;I\ c‘. and

a jrnall

‘Thus 21 normal

txh nlisdi;tynuscd all error

TIlis

I~outs swim

it \\,ould

in

64-)w~r-old

.T

in

be dif-

in Figure

a Iarqe

prcsys-

or small

I)allistocardiogram this

oi pal-ox)-srnal Tllilt

LM,

.l \\‘a\-e,

patirnt

pattern. 1.7, a similar

of twad\vard

c~\;cc.pt

trace

as an estrcmel)

;I\~oid
rlorso\-c~nll2l In Fi:llr,r wlf.

tract

to prove’ that the head-foot

al,normal I)>

difficulty

hyperth!mid fibrillation,

UYIVCSlike those Fiqurc

fusrd \vould oncJ

stud!

of the

prcsvnts man, has

a huqc

in Figure

14 is r-awlv

it\vith 14>

equaled

Idrntilication of ballistic waves in tachyFir. 14. cardia. From <1 67-year-old man with emotional Tkcusrion in text. t,lc-hywrdia and t-mphysrma.

Supcrimpoxd large atria1 and early systolic F1g. li. waves. from a man with healed infarction, who succcssThe upper fully undwwrnt abdominal aortic grafting. apex cur~v is litted to electrocardiogram taken with I)allistocardiogram; It shows the sustained apical thrust A GH complex dominates of a wntt-iculdr aneurysm. Iwad-foot tract: a huge HI, brginning before (2, is thr main I’GL~ICWin lateral. while front-back shows distinct :itrial tz in prt-systolr, small H after (2. normal .1. Tht L o1’IC \vavc is e\,idenr. halt asvnchronous. l.MS prcltodi j37 ill all pl.Irll~~.

Identification Ii. From a male*. :qad cussiun in tcyt. Fiq

of ballistic waves in tarhycardia. 64, with hypcrthyroidism. Dis-

304

‘IX

l)V L, never never Hwc

thcrr

\.rntral in spite failure

equaled

approaches plant

by H.

is a large

atria1

and it seems

of rhc large is prcsc‘nt

In

L, is often

Figure

15, J

t>xcceded

wave

by H.

in the dorso-

safe to conclude

stroke

as thcx

‘Three-Plane

volume,

GIUSC

that,

mbwzardial

of incwased

One

Lva)‘s to clarif!picious wrvc

the significance

l)ut not diagnostic the effwt

thr upper thrrc

forces

rarl>- and late in diastole. ~Yffw/ o/ Errl-~~.~:

Hallistocardiograrn of cur\.cs

most

helpful

‘l‘hlls, in 16, it is ot)\,ious that

in Figure

is alternation

in hradward

second and km-th clc

(0.89

.I waves

SK).

However,

after moderate

wcrcise,

.J: t)ut ttw small

cycles

(0.86, and

bcforc,

h(w

is not a consequence

in rhc

10.77,0.82

smaller

H.

of the tall waves

represent

I jut scums

.J: since

to

I)y vxc,rcisr.

is 0.10 SN aftct

bvavc marked

at the same

.U’tc.r the

AAlt?rliation cylc lrngth

cardiac,

that it is H rather

tually

H.J ILLI\TS

aggravated

the peak

(2, occurs

cy-

tract,

.J is C’\WI shorter

Q, it is obvious

Thr

cy-

XC).

than

digitalizcd

alternating.

short

a lougcr lower

of varying

t)c a true pulsus altcrnans, Since

.J aftrr

0.00 XC),

than

in a fibrillating:

after

occw

the tall fused

occur after short c~zlrs longer

is to ()I)-

of stress or of rhcrat-,).

tracts

cles (0.85, 0.80 KC), the large of thr

of sus-

al)normality

than

,J \vhich

with

? ~na)- ac-

is

its pcaak, 0.25 SW after

time as the .J peaks

\wforr

In an)- t’vcnt, the change after wwexertion. cisc in this paticnL, with littlr rise in pulse rate, leaves

little

prrscnt. Efect

dout)t

that

111)ocardial

of Digitalization:

The

tolic force in cases of heart travenous

Pulsus alternans (upper) acccnruatrd Fig. 16. rsrrcise (lower trnciq). Discussion in trxt.

Fig. 17. Effect of digitalis. Postmyocardial Discussion in text. after diqitalization.

by

infarction;

injection

after

some

Fig.

119Y),

1)). mouth Fig.

conxcstivc

3.)‘0

(our

and

marked

havp

been

In

failure.

incrcasc

failure

of digitalis

minutes

reported

three-plane

(A,

82;:

changes

Hrforr

11~ in-

t)c striking dr Soldati’s

after

rli+taIis

tJ,!- Starr

tracings

digitalis.

is

in S>X-

trcatcd

may

Fig.

failure

(R)

(his

from

out

‘l‘rn

days

I hck

patients

Fivcn digitalis

lication”). dccrcasc

it was in thr

striking

in Figs.

sur\i\wl

This

two bouts dc.1 eloped

days

on

17.11

\va~es

17B, from

of myocardial

conrcstiw

digitalis

the

to 70

rate

(Fiy.

front-back

plant

s!-stolic

digitalis

in this aml)ulator)-

oral

was also a

with

disorders

which

is clearl>-

fatal,

wa\es

a man

and

have

markedly

there

\vas

il grcnt

dral.

I)igitalis:

hwrr.

l‘hcre

diseaw

I.J. qc‘ciall>‘I%~ arw.

foot

AINOP.

c.q~tional the

or prognoses

I);tsed on a single

after

the> clcctrical

or kinetic

elderly

hvoman

led to increase

in

stud)

patients

with

failure

gallop

sounds

I)ut not thr

amplitude

of head-

the onl>- c\+dcncc

rcducrd,

rcduccd

))ut I)ackward

This

protodiastolic plane,

force

1 .J prol)abl~Ilcre

MIV

was one of the cxthough

force

\vas

it was equal

hradward.

Thr

was related

to k>.phosiJ

again

the \raluc

of digi-

established the prescncc which \vas not indicated

any other ol)jccti\,c finding. .\s in ~lcctrocardiograph~,

trivial

on

value

if hc

in the

three-plane

digitalis

thrrap)

which

in

ma)- lcatl

to conBeof \,aluc-.

has pro\~l

protodiastolic of latent

the

tract

digitalis

or

of proph\-lactic

soundly

man.

men, clwibrws

failure

111,1\-I)c

in clcl~~l~ pa-

IXUXI~CX muc-h on

salt

lnorc

clcpletioll.

manaacnlc’nt

seems

the to 1~

cstal)lishcd.

large

clear I,)- the ballistocardiograml, was no change in the relatively

This failure

\Vhcn

ol

(hen

the patient.

or cmph>-wnatous

of large

ticnts.

his-

diagnoses

often arc clilticul t to hc*ar or

in kyphotic

normal

of all

of thr> heart.

following

disorders

be oh-

wt of tracings

force

01‘ the chanycs

gcsti\ c heart cause

for anatomic

concerning

1,nllistocardiogram

onI\.

dcpcndal)lc

I))- an t~xpcricnccd

data

wcord

and c~nph! sema.

slo\\- pulw. myocardial

of

of thr

The

and

is no cxcux

onstration

systolic

talis \vas made althoy~h thwc

she

a detailed

drscril)ctl

be

in serial

comparison

disap-

\vhw

can

of change

1)~ meticulous

notching

c*\idcnt.

findings

rate

almost

\\-as no c\idcncc

plane,

C~SCS whew

front\\w(l

and

footward

not s~(‘n in the lateral to

sc‘r\2iions,

increased

\vas

I~catnc~ Itlow

I)!- their

grcatl!-

in lateral

of hcsatlt\ ;~rti .I and Ii.

c\-aluattcl

Thrrc

and little cnl&cment in two wwks,

latwrator\-

has no other

may

for )-cars in patients The free of all synptoms.

tory.

to

patients

abnormalities

includiry

rcsponsc

in

to Iw rapidi!

findings

and

and

prove

data,

incrcasrd

This

ph+cai

may

marked

as constant

nz~! I)(’ the

of discasc

and decrease \va\‘es in the

patient.

is apparent.

old coronar)~

I\-ho arc acti\.e

100 min

had cdc111;1 of legs u hwz, as was her custom, \\ allictl

and 10

l)allistocardiogral1I

vcr\’

pa cscnt

fell

from

and

who

After

18‘4 .rnd 18B anothw

diyii;tlis

widencc

infarction

17B),

pwr~l.

In Fiyurcs

of)jcctivc

failure.

strikiq ilnprovemcnt in breathing Huge diastolic in fatiy_;ll)ilit\.. lat~~~tl and

the nornlal

only

pul)-

disappearance

phenomenon

17‘4 and

later (Fiq.

that

protodiastolic

f’baturc.

sho\vn

from

or

(Fig. 9 in a previous

found

deviations

of 1,)

A

three-plant

small

platform

thorax

to record

l,allistocarcliograph, on

lateral

and the shin pick-up maximal of valvular, tion.

amount

springs and

under

front-back

for head-foot

of clinical

pcricardial,

using

placed

force,

a the

furcc gi\.cs a

information

in casts

or myocarclial

clysfunc-

The Three-Plane Thr force

most

changes

associated

and

rapid

with

as

as increased not

in height

\vavc can be ascribed thr

is sern

talis or sodium

dvplction.

Sincca mitral pcricarditis

early

diastolic

cxcludin,g medical is the

valve

sytolic

I.1

fillirlg

these

failure

insufFiciency the

pro\res

or that

of such

the

in 1,

4.

onI)- lvhen with

digi-

5.

or cunstric-

same

as myocardial

discascs

cause

of

to disappear

produce

therapy main

of

of K or incrcasr

to heart

abnormality

tive

the fit)rillation.

less dcpcndal)lv Shortrning

3.

systole,

atria1

form

Ijut

heart

in

in prcystolc

Ijut occur,

arc

protodiastolic

contraction

atria

Ballistocardiogram

changes failure,

in

correction

myocardial

al)normalitics

6.

onl>1)) 7.

failure in the

8.

ballistocardiogram.

REFERENCES

9.

1. I~OCK, W. : The value of lateral ballistocardiograms in differentiating aortic tortuosity from myocardial dysftinction. .4m. J. M. SC. 228: 325, 1954.

10.

2. RIX~Y, E. W. and

HENLIERSON, C. B.:

1Iethod

11. of