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Transesophageal color flow Doppler and echocardiographic features of normal and regurgitant St. Jude Medical prostheses in the mitral valve position
FlGURE 2. The sensitivity and soecificity of different electrocardiographic (ECG) criteria of lsft ventricular hypertrophy are compared. Because the sensitivity and the accuracy of the RVs:RVs ratio >0.6!5 are much higher, this index is the best for screening of left ventricular hypertrophy in the hypertensive patient. LR + LS = largest R wave plus largest S wave (amplitude) in precordial leads; R-E score = Romhilt-Estes point score system; RaVL = R-wave ampliide in aVL; RV5 + SVl = R-wave amplitude in lead Rs or Rs (the largest) plus S-wave amplitude in lead VI; RVs:R& >0.65 = RVs:RVs voltage ratio >0.65
Raw
LR+LS
Rw4wt
m SPEClFlClTY
El SENSKIVKY ity, specificity and accuracy of each cutoff point studied in the RV&RVs voltage ratio, and other measurements, are listed in Table I and shown in Figure 1. A comparisonamongR&RVs >0.65 and other criteria is shown in Figure 2. As the ratio RV6:RVs increases,the specificity increasesat the expenseof sensitivity. A ratio RV6:RVs >0.65 yields the best accuracy for thesepatients, for whom a techniquewith high sensitivity is needed.A ratio RV6:RVs >0.60 has the bestsensitivity but poorer specificity and a lesseraccuracy. The other criteria have a very high specificity but a sensitivity far less than the RVk:RVj voltage ratio.
According to our data, a ratio between the R-wave voltage of leads V6 and Vs X.65 is a simple and useful index of LV hypertrophy in the hypertensive patient, with a sensitivity of 8970, a specificity of 21% and an accuracy of 64%. This index is much better than most frequently
I ACCURACY
EC0
CRITERIA
used ones for the study of cardiac hypertrophy in systemic hypertension, given that a highly sensitive technique is needed for screening. This is more important if we realize that electrocardiographic LV hypertrophy has independent prognostic significance in hypertension5
1. Koito H, Spodick DH. Accuracy of the RV6:RV5 voltage ratio for increased left ventricular mass. Am J Cardioi 1988;62:986-987. 2. Spodick DH, Koito H. Differential sensitivity of the RV6:RV5 voltage ratio by pathogenesis of left ventricular hypertrophy and diagnostic cutpoint. Am J Cardial
1989;64:817-819.
3. Chou T-Ch. Left ventricular hypertrophy. In: Electrocardiography in Clinical Practice. 0rhtdo:Grune & Stratton, 1986;46-65. 4. Devereux RB, Philips MC, Casale PB, Eisenberg RR, Kligfield P. Geometric determination of electrocardiographic left ventricular hypertrophy. Circulation 1983;67:907-911.
5. Kannel WB, Dannenberg AL. Prevalence and natural history of electrocardiographic left ventricular hypertrophy. In: Messerli FH, ed. The Heart and Hypertension. New York:Yorke Medical Books, 1987;53-61.
ransesophageal Color Flow Doppler and Echocardiographic Features Of Normal and Regurgitant St. Jude Medical Prostheses in the Mitral Valve Position Mohsin Alam, MD, Jeffrey B. Serwin, MD, Howard S. Rosman, MD, Mita Sheth, MD, Irene Sun, RN, RDMS, Norman A. Silverman, MD, and Sidney Goldstein, MD ransthoracic echocardiography and color flow Doppler have been shown to be of value in evaluating regurgitant St. Jude Medical (SJM) prostheses in the From the Henry Ford Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Anesthesia, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, Michigan 48202. Manuscript received April 16,199O; revised manuscript received and accepted May 21, 1990.
aortic valve position.” These studies have emphasized the limitations of this technique in diagnosing SJM mitral regurgitation because of flow masking and signal attenuation produced by the echo-reflective metallic valves2 Transesophageal echocardiography and color flow Doppler overcome these problems and show promise in evaluating normal functioning and regurgitant SJM mitral valves.3,4This report describes our transesophageal ultra-
THE AMERICAN
JOIJRNAL
OF CARDIOLOGY
OCTOBER
1, 1990
sound experience with 28 normal functioning and 8 regurgitant SJM prostheses in the mitral valve position. Transthoracic and transesophageal echocardiography and colorpow Doppler studies were performed in 36 patients with SJMprostheses in the mitral position by previously reported techniques.’ At transesophageal study, the valves had been in place from I day to 42 months (mean 12 months). Of the 36 transesophageal valve studies, 28 appeared normal and 8 had features of valve regurgitation. In the 8 patients, regurgitation was substantiated by cardiac catheterization and angiography in 4, and valve replacement surgery in 5. The prosthetic valve replacement surgery was performed within 8
days of transesophagealstudy. In IZpatients the transesophageal study was performed in the operating room, whereasin 24 others the tests wereperformed on awake patients. All valves were evaluated by color flow Doppler for the presenceor absenceof valve regurgitation. The color flow gain and reject settings were adjusted to just below the level at which background noisewasseen.The color flow Doppler regurgitant jet length, width, duration, location, shapeand color characteristicswere evaluated by playing back the video tape andframe-by-frame analysis. The extent of the prosthetic mitral valve regurgitation jet by transthoracic and transesophagealcolorjlow Doppler was semiquantitated by relating it to the left atria1 chamber.6 Transesophagealcolor flow Doppler demonstrated3 regurgitant jets (Figure 1) in all 28 normal functioning SJM mitral valves. The jet length varied from 1 to 3.5 cm and the width from 0.5 to 1.5 cm in awake patients andfrom 0.6 to 2.5 cm and 0.4 to 1 cm, respectively, in anesthetizedpatients. In all the patients, the regurgitant jet was holosystolic, centrally located and occupied <50% of the left atria1 chamber. Occasionalcolor flow reversal and mosaicpattern limited to a small area of the jet wasobserved.In awakepatients there wasvariation in the length, width and degreeof color flow reversal and turbulence within the samejet and in the samepersonsat different times of the procedure. Both transesophageal and transthoracic 2-dimensional echocardiography of normal functioning St. Jude mitral valves demonstrated multiple echoesemanating
FIGURE 1. Transesophageal color flow Doppler of a patient with ‘physiologic” mitral regurgitation. Note the 3 regurgitant jets (arrows), which are of narrow width, central, and have color flow reversal and mosaic features limited to only 1 of 3 jets. LA = left atrium; LV = left ventricle; MV = St. Jude mitral valve.
FIGURE 2. Transesophageal color flowDoppler of regurgitant St. Jude mitral valve (NIV). Note that the “pathologic” paravaivular regurgitant jet (arrow) is eccentric in its origin, occupies X0% of the left atrial chamber, and demonstrates a marked degree of color flow reversal and mosaic feature. LA = left atrium: LV = left ventricle; RA = right atrium.
872
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
66
FIGURE 3. Transesophageal color flow Doppler of a patient with regurgitant St. Jude mitrai valve (MV). Note that in this patient there are 2 pathologic regurgitant jets (arrows) filling the left atrium (LA). LV = left ventricle.
from the prosthetic disc masking the left ventricle and left atrium, respectively. All 8 patients with regurgitant SJM prostheses had holosystolic color flow Doppler regurgitant jet occupying 50 to 90% of the left atria1 chamber. The jet varied in length from 3 to 5 cm and in width from 3 to 4 cm. In all 8 patients, these jets were eccentric (paravalvular), shaped as a wide crescent or teardrop, with color flow reversal and mosaic pattern involving almost the entire jet (Figure 2). In 3 patients with previous endocarditis there were 2 sites of origin of the color flow regurgitant jet (Figure 3). Transthoracic color flow Doppler using multiple acoustic windows in these 8patients demonstrated either no regurgitation in 4 patients or only mild regurgitation (4 patients). It was not possible from transthoracic color flow Doppler to determine ifthe mild regurgitation seen in these 4 patients was physiologic or pathologic. At the time of surgery the site of valve regurgitation was paravalvular in all 5 instances. Both transesophageal and transthoracic 2-dimensional echocardiograms were normal in 7 of 8 regurgitant valves. Vegetations or mass echoes were observed in I patient who had a small mobile mass at the valve sewing ring demonstrable by transesophageal but not by transthoracic 2-dimensional echocardiography. At the time of surgery this patient had vegetations and dehiscence of the valve at its sewing ring.
Transesophageal color flow Doppler reveals “physiologic” holosystolic mitral regurgitation in all patients with normal functioning SJM prostheses in the mitral valve position. Variations in the extent and turbulence of physiologic mitral regurgitant jets during study may be
explained by fluctuations in systolic blood pressure that alter the left ventricular to left atria1 pressure gradient. This study demonstrated that it is possible by transesophageal color flow Doppler to differentiate “physiolog ic” mitral regurgitation from pathologic regurgitation by the characteristics of the color flow regurgitant jet. All our patients with pathologic mitral regurgitation had a more extensive crescent- or teardrop-shaped jet, which was eccentric (paravalvular), with color flow reversal and mosaic pattern encompassing most of the regurgitant jet. This study indicates that transesophageal color flow Doppler is a highly sensitive indicator of SJM prosthetic regurgitation. Therefore, we recommend this test in every symptomatic patient in whom this entity is suspected, even if transthoracic color flow Doppler is normal.
1. Alam M, Rosman HS, McBroom D, Graham L, Magilligan DJ Jr, Khaja F, Stein PD. Color flow Doppler evaluation of St. Judemedical prosthetic valves. Anz J Cardiol
1989;64:1387-1389.
2. Sprecher DL, Adamick A, Adams D, Kisslo J. In vitro color flow, pulsed and continuous wave Doppler ultrasound masking of flow by prosthetic valves. .I Am Cdl
Cardiol
1987:9:1306-l
310.
3. Nellessen U, Schnittger I, Appleton CP, Masuyama T, Bolger A, F&hell TA, Tye T, Popp RL. Transesophageal 2-dimensional echocardiography and color Doppler flow velocity mapping in the evaluation of cardiac valve prostheses. Circuhion
1988:78:848-855.
4. Van den Brink RBA, Visser CA, Basart DCG, Duren DR, de Jong AP, Dunning AJ. Comparison of transthoracic and transesophageal color Doppler flow imaging in patients with mechanical prostheses in the mitral valve position. Am J Cardiol
1989;63:1471-1474.
5. Steward JB, Khandheria BK, Oh JK, Abel MD, Hughes RW Jr, Edwards WD, Nichol BA, Freeman WK, Tajik AJ. Transesophageal echocardiography: technique, anatomic correlations, implementation, and clinical applications. Mayo
Clin
Proc
1988;63:649-680.
6. Helmcke F, Nanda NC, Hsiung MC, Soto B, Adey CK, Goyal RG, Gatewood RP. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulation
J987;75:175-183,
ansesophageal Color Flow Doppler and Echocardiographic Features Normal and Regurgitant St. Jude Medical Prostheses in th Valve Position Mohsin Alam, MD, Jeffrey B. Serwin, MD, Howard S. Rosman, MD, Mita Sheth, MD, Irene Sun, RN, RDMS, Norman A. Silverman, MD, and Sidney Goldstein, MD ransthoracic echocardiography and color flow DopT pler have been shown to be of value in evaluating regurgitant St. Jude Medical (SJM) prostheses in the aortic valve position.’ Transesophageal echocardiography and color fiow Doppler show promise in evaluating normal functioning and regurgitant SJM mitral valves.2y3 Recently transesophageal imaging has been shown to be superior to the transthoracic approach in demonstrating prosthetic valve vegetations4 This report describes our transesophageal ultrasound experience with 18 normal From the Henry Ford Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Anesthesia, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, Michigan 48202. Manuscript received May 3, 1990; revised manuscript received and accepted May 21, 1990.
functioning, 2 regurgitant and 1 infected SJM prostheses in the aortic valve position. Transthoracic and transesophageal echocardiography and colorflow Doppler studieswereperformed in 21 patients with SJM prosthesesin the aortic position. At the time of the transesophageal study, the valves had been in place from I day to 37 months (mean 10 months). Of the 21 transesophageal valve studies, 18 appeared normal and 2 had features of valve regurgitation and I was infected. All 3 abnormal valves resulted from bacterial endocarditis. Valve regurgitation and infection was substantiated by valve replacement surgery in 2 patients. The prosthetic valve replacement surgery was performed within 7 days of transesophagealstudy. Transthoracic and transesophageal echocardiography and color jlow Doppler studies were performed
THE AMERICAN
JOURNAL
OF CARDIOLOGY
OCTO5ER
1,
1990
Raw
LR+LS
Rw4wt
m SPEClFlClTY
El SENSKIVKY ity, specificity and accuracy of each cutoff point studied in the RV&RVs voltage ratio, and other measurements, are listed in Table I and shown in Figure 1. A comparisonamongR&RVs >0.65 and other criteria is shown in Figure 2. As the ratio RV6:RVs increases,the specificity increasesat the expenseof sensitivity. A ratio RV6:RVs >0.65 yields the best accuracy for thesepatients, for whom a techniquewith high sensitivity is needed.A ratio RV6:RVs >0.60 has the bestsensitivity but poorer specificity and a lesseraccuracy. The other criteria have a very high specificity but a sensitivity far less than the RVk:RVj voltage ratio.
According to our data, a ratio between the R-wave voltage of leads V6 and Vs X.65 is a simple and useful index of LV hypertrophy in the hypertensive patient, with a sensitivity of 8970, a specificity of 21% and an accuracy of 64%. This index is much better than most frequently
I ACCURACY
EC0
CRITERIA
used ones for the study of cardiac hypertrophy in systemic hypertension, given that a highly sensitive technique is needed for screening. This is more important if we realize that electrocardiographic LV hypertrophy has independent prognostic significance in hypertension5
1. Koito H, Spodick DH. Accuracy of the RV6:RV5 voltage ratio for increased left ventricular mass. Am J Cardioi 1988;62:986-987. 2. Spodick DH, Koito H. Differential sensitivity of the RV6:RV5 voltage ratio by pathogenesis of left ventricular hypertrophy and diagnostic cutpoint. Am J Cardial
1989;64:817-819.
3. Chou T-Ch. Left ventricular hypertrophy. In: Electrocardiography in Clinical Practice. 0rhtdo:Grune & Stratton, 1986;46-65. 4. Devereux RB, Philips MC, Casale PB, Eisenberg RR, Kligfield P. Geometric determination of electrocardiographic left ventricular hypertrophy. Circulation 1983;67:907-911.
5. Kannel WB, Dannenberg AL. Prevalence and natural history of electrocardiographic left ventricular hypertrophy. In: Messerli FH, ed. The Heart and Hypertension. New York:Yorke Medical Books, 1987;53-61.
ransesophageal Color Flow Doppler and Echocardiographic Features Of Normal and Regurgitant St. Jude Medical Prostheses in the Mitral Valve Position Mohsin Alam, MD, Jeffrey B. Serwin, MD, Howard S. Rosman, MD, Mita Sheth, MD, Irene Sun, RN, RDMS, Norman A. Silverman, MD, and Sidney Goldstein, MD ransthoracic echocardiography and color flow Doppler have been shown to be of value in evaluating regurgitant St. Jude Medical (SJM) prostheses in the From the Henry Ford Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Anesthesia, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, Michigan 48202. Manuscript received April 16,199O; revised manuscript received and accepted May 21, 1990.
aortic valve position.” These studies have emphasized the limitations of this technique in diagnosing SJM mitral regurgitation because of flow masking and signal attenuation produced by the echo-reflective metallic valves2 Transesophageal echocardiography and color flow Doppler overcome these problems and show promise in evaluating normal functioning and regurgitant SJM mitral valves.3,4This report describes our transesophageal ultra-
THE AMERICAN
JOIJRNAL
OF CARDIOLOGY
OCTOBER
1, 1990
sound experience with 28 normal functioning and 8 regurgitant SJM prostheses in the mitral valve position. Transthoracic and transesophageal echocardiography and colorpow Doppler studies were performed in 36 patients with SJMprostheses in the mitral position by previously reported techniques.’ At transesophageal study, the valves had been in place from I day to 42 months (mean 12 months). Of the 36 transesophageal valve studies, 28 appeared normal and 8 had features of valve regurgitation. In the 8 patients, regurgitation was substantiated by cardiac catheterization and angiography in 4, and valve replacement surgery in 5. The prosthetic valve replacement surgery was performed within 8
days of transesophagealstudy. In IZpatients the transesophageal study was performed in the operating room, whereasin 24 others the tests wereperformed on awake patients. All valves were evaluated by color flow Doppler for the presenceor absenceof valve regurgitation. The color flow gain and reject settings were adjusted to just below the level at which background noisewasseen.The color flow Doppler regurgitant jet length, width, duration, location, shapeand color characteristicswere evaluated by playing back the video tape andframe-by-frame analysis. The extent of the prosthetic mitral valve regurgitation jet by transthoracic and transesophagealcolorjlow Doppler was semiquantitated by relating it to the left atria1 chamber.6 Transesophagealcolor flow Doppler demonstrated3 regurgitant jets (Figure 1) in all 28 normal functioning SJM mitral valves. The jet length varied from 1 to 3.5 cm and the width from 0.5 to 1.5 cm in awake patients andfrom 0.6 to 2.5 cm and 0.4 to 1 cm, respectively, in anesthetizedpatients. In all the patients, the regurgitant jet was holosystolic, centrally located and occupied <50% of the left atria1 chamber. Occasionalcolor flow reversal and mosaicpattern limited to a small area of the jet wasobserved.In awakepatients there wasvariation in the length, width and degreeof color flow reversal and turbulence within the samejet and in the samepersonsat different times of the procedure. Both transesophageal and transthoracic 2-dimensional echocardiography of normal functioning St. Jude mitral valves demonstrated multiple echoesemanating
FIGURE 1. Transesophageal color flow Doppler of a patient with ‘physiologic” mitral regurgitation. Note the 3 regurgitant jets (arrows), which are of narrow width, central, and have color flow reversal and mosaic features limited to only 1 of 3 jets. LA = left atrium; LV = left ventricle; MV = St. Jude mitral valve.
FIGURE 2. Transesophageal color flowDoppler of regurgitant St. Jude mitral valve (NIV). Note that the “pathologic” paravaivular regurgitant jet (arrow) is eccentric in its origin, occupies X0% of the left atrial chamber, and demonstrates a marked degree of color flow reversal and mosaic feature. LA = left atrium: LV = left ventricle; RA = right atrium.
872
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
66
FIGURE 3. Transesophageal color flow Doppler of a patient with regurgitant St. Jude mitrai valve (MV). Note that in this patient there are 2 pathologic regurgitant jets (arrows) filling the left atrium (LA). LV = left ventricle.
from the prosthetic disc masking the left ventricle and left atrium, respectively. All 8 patients with regurgitant SJM prostheses had holosystolic color flow Doppler regurgitant jet occupying 50 to 90% of the left atria1 chamber. The jet varied in length from 3 to 5 cm and in width from 3 to 4 cm. In all 8 patients, these jets were eccentric (paravalvular), shaped as a wide crescent or teardrop, with color flow reversal and mosaic pattern involving almost the entire jet (Figure 2). In 3 patients with previous endocarditis there were 2 sites of origin of the color flow regurgitant jet (Figure 3). Transthoracic color flow Doppler using multiple acoustic windows in these 8patients demonstrated either no regurgitation in 4 patients or only mild regurgitation (4 patients). It was not possible from transthoracic color flow Doppler to determine ifthe mild regurgitation seen in these 4 patients was physiologic or pathologic. At the time of surgery the site of valve regurgitation was paravalvular in all 5 instances. Both transesophageal and transthoracic 2-dimensional echocardiograms were normal in 7 of 8 regurgitant valves. Vegetations or mass echoes were observed in I patient who had a small mobile mass at the valve sewing ring demonstrable by transesophageal but not by transthoracic 2-dimensional echocardiography. At the time of surgery this patient had vegetations and dehiscence of the valve at its sewing ring.
Transesophageal color flow Doppler reveals “physiologic” holosystolic mitral regurgitation in all patients with normal functioning SJM prostheses in the mitral valve position. Variations in the extent and turbulence of physiologic mitral regurgitant jets during study may be
explained by fluctuations in systolic blood pressure that alter the left ventricular to left atria1 pressure gradient. This study demonstrated that it is possible by transesophageal color flow Doppler to differentiate “physiolog ic” mitral regurgitation from pathologic regurgitation by the characteristics of the color flow regurgitant jet. All our patients with pathologic mitral regurgitation had a more extensive crescent- or teardrop-shaped jet, which was eccentric (paravalvular), with color flow reversal and mosaic pattern encompassing most of the regurgitant jet. This study indicates that transesophageal color flow Doppler is a highly sensitive indicator of SJM prosthetic regurgitation. Therefore, we recommend this test in every symptomatic patient in whom this entity is suspected, even if transthoracic color flow Doppler is normal.
1. Alam M, Rosman HS, McBroom D, Graham L, Magilligan DJ Jr, Khaja F, Stein PD. Color flow Doppler evaluation of St. Judemedical prosthetic valves. Anz J Cardiol
1989;64:1387-1389.
2. Sprecher DL, Adamick A, Adams D, Kisslo J. In vitro color flow, pulsed and continuous wave Doppler ultrasound masking of flow by prosthetic valves. .I Am Cdl
Cardiol
1987:9:1306-l
310.
3. Nellessen U, Schnittger I, Appleton CP, Masuyama T, Bolger A, F&hell TA, Tye T, Popp RL. Transesophageal 2-dimensional echocardiography and color Doppler flow velocity mapping in the evaluation of cardiac valve prostheses. Circuhion
1988:78:848-855.
4. Van den Brink RBA, Visser CA, Basart DCG, Duren DR, de Jong AP, Dunning AJ. Comparison of transthoracic and transesophageal color Doppler flow imaging in patients with mechanical prostheses in the mitral valve position. Am J Cardiol
1989;63:1471-1474.
5. Steward JB, Khandheria BK, Oh JK, Abel MD, Hughes RW Jr, Edwards WD, Nichol BA, Freeman WK, Tajik AJ. Transesophageal echocardiography: technique, anatomic correlations, implementation, and clinical applications. Mayo
Clin
Proc
1988;63:649-680.
6. Helmcke F, Nanda NC, Hsiung MC, Soto B, Adey CK, Goyal RG, Gatewood RP. Color Doppler assessment of mitral regurgitation with orthogonal planes. Circulation
J987;75:175-183,
ansesophageal Color Flow Doppler and Echocardiographic Features Normal and Regurgitant St. Jude Medical Prostheses in th Valve Position Mohsin Alam, MD, Jeffrey B. Serwin, MD, Howard S. Rosman, MD, Mita Sheth, MD, Irene Sun, RN, RDMS, Norman A. Silverman, MD, and Sidney Goldstein, MD ransthoracic echocardiography and color flow DopT pler have been shown to be of value in evaluating regurgitant St. Jude Medical (SJM) prostheses in the aortic valve position.’ Transesophageal echocardiography and color fiow Doppler show promise in evaluating normal functioning and regurgitant SJM mitral valves.2y3 Recently transesophageal imaging has been shown to be superior to the transthoracic approach in demonstrating prosthetic valve vegetations4 This report describes our transesophageal ultrasound experience with 18 normal From the Henry Ford Heart and Vascular Institute, Division of Cardiovascular Medicine, Department of Anesthesia, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, Michigan 48202. Manuscript received May 3, 1990; revised manuscript received and accepted May 21, 1990.
functioning, 2 regurgitant and 1 infected SJM prostheses in the aortic valve position. Transthoracic and transesophageal echocardiography and colorflow Doppler studieswereperformed in 21 patients with SJM prosthesesin the aortic position. At the time of the transesophageal study, the valves had been in place from I day to 37 months (mean 10 months). Of the 21 transesophageal valve studies, 18 appeared normal and 2 had features of valve regurgitation and I was infected. All 3 abnormal valves resulted from bacterial endocarditis. Valve regurgitation and infection was substantiated by valve replacement surgery in 2 patients. The prosthetic valve replacement surgery was performed within 7 days of transesophagealstudy. Transthoracic and transesophageal echocardiography and color jlow Doppler studies were performed
THE AMERICAN
JOURNAL
OF CARDIOLOGY
OCTO5ER
1,
1990