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