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Ultrasound cardiography
ULTRASOUND C A R D I O G R A P H Y I. Edler*
By m e a n s of u l t r a s o u n d , e c h o e s can be obtained f r o m a v a r i ety of h e a r t s t r u c t u r e s , so t h a t the m o v e m e n t s of t h e s e s t r u c t u r e s a r e r e c o r d e d a s a t r a c i n g , the u l t r a s o u n d c a r d i o g r a m , (UCG). T h e p a t t e r n of m o v e m e n t of the echo s i g n a l s v a r i e s a c c o r d i n g to the location of the c r y s t a l in the p r e c a r d i a l a r e a and the d i r e c t i o n of the b e a m . The m e t h o d h a s p r o v e d of value in e v a l u a t i n g the d e g r e e of s t e n o s i s in m i t r a l v a l v e d i s e a s e and {n d e t e c t i n g p e r i c a r d i a l effusion. U l t r a s o u n d c a r d i o g r a p h y is a l s o v a l u a b l e in d i f f e r e n t i a t i n g an a t r i a l s e p t a l defect f r o m m i t r a l valve d i s e a s e and f r o m p u l m o n a r y valve stenosis.
METHOD P u l s e s of u l t r a s o u n d a r e g e n e r a t e d by an e l e c t r i c a l l y e x c i t e d q u a r t z or b a r i u m t i t a n a t e c r y s t a l placed a g a i n s t the c h e s t . If sound i m p u l s e s p a s s i n g t h r o u g h the h e a r t i m p i n g e upon the l e a f l e t s of the v a l v e s or the h e a r t walls, p a r t of the p u l s e will * Dr. Inge E d l e r i s h e a d of the D e p a r t m e n t of C a r d i o l o g y , U n i v e r s i t y Hospital, Lund, Sweden.
be r e f l e c t e d . If the path of p r o p a g a t i o n of the p u l s e i s p e r p e n d i c u l a r to the r e f l e c t i n g s u r f a c e s t h e n the p u l s e will be r e f l e c t e d b a c k t o w a r d s the c r y s t a l , which a c t s a s a m i c r o phone f o r the d e t e c t i o n of t h e s e e c h o e s . T h e s o u n d g e n e r a ting and r e c e i v i n g e q u i p m e n t is c o n n e c t e d to a cathode r a y tube. At e a c h p u l s e the e l e c t r o n b e a m is s t a r t e d at the left s i d e of the s c r e e n and m o v e s to the r i g h t along the x - a x i s at c o n s t a n t s p e e d . W h e n an echo a r r i v e s back at the c r y s t a l it i s c o n v e r t e d to an e l e c t r i c a l s i g n a l , which i s then a m p l i f i e d and fed to the y - p l a t e s of t h e cathode r a y tube. T h i s r e s u l t s in a v e r t i c a l d e f l e c t i o n of the e l e c t r o n b e a m . T h e echo s i g n a l s a r e t h u s s e e n a s v e r t i c a l d e f l e c t i o n s on the o s c i l l o s c o p e s c r e e n , F i g 1. T h e h o r i z o n t a l d i s t a n c e b e t w e e n the left b o r d e r of t h e s c r e e n and the echo s i g n a l i s a m e a s u r e of the t i m e n e c e s s a r y f o r the p u l s e to t r a v e l f r o m the c r y s t a l to a r e f l e c t i n g s u r f a c e and b a c k again. If the v e l o c i t y of the sound i s the s a m e in all the m e d i a it t r a v e r s e s , the h o r i z o n t a l d i s t a n c e b e t w e e n the v e r t i c a l o s c i l l a t i o n s on the s c r e e n will be a m e a s u r e of the d i s t a n c e b e t w e e n d i f f e r e n t r e f l e c t i n g s u r f a c e s . T h e v e l o c i t y of s o u n d is about 1 5 0 0 m / s e c in both m u s c l e and blood. T h e p u l s e r a t e f r o m the c r y s t a l i s 2001000 p u l s e s / s e c which m e a n s that the d i s t a n c e between the c r y s t a l and t h e r e f l e c t i n g s u r f a c e s is m e a s u r e d 200-1000 t i m e s / s e c . If the e c h o - g i v i n g h e a r t s t r u c t u r e m o v e s t o w a r d s the c r y s t a l , the echo s i g n a l t r a v e l s along the h o r i z o n t a l a x i s t o w a r d s the l e f t - h a n d s i d e of the s c r e e n . A l t e r n a t i v e l y , if the e c h o - g i v i n g h e a r t s t r u c t u r e m o v e s away f r o m the c r y s t a l , the echo s i g n a l m o v e s to the r i g h t - h a n d s i d e of the s c r e e n (Fig 2). U l t r a s o u n d with a f r e q u e n c y of 2 . 5 M H z is g e n e r a l l y u s e d . The i m p u l s e d u r a t i o n can be v a r i e d o v e r (2-5) x 1 0 - 6 s e c .
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Fig 1
E c h o g r a m obtained on the o s c i l l o s c o p e s c r e e n . T h e s i g n a l r e p r e s e n t i n g the outgoing i m p u l s e f r o m the c r y s t a l is on the left. T h e o t h e r two p e a k s r e p r e s e n t the e c h o e s
Fig 2
(a) The echo s i g n a l s obtained on the o s c i l l o s c o p e s c r e e n m o v e t o w a r d s the r i g h t - h a n d s i d e of the s c r e e n , a s the e c h o - g i v i n g s t r u c t u r e s m o v e away f r o m the c r y s t a l (b) P h o t o g r a p h i c r e c o r d i n g of the e c h o g r a m shown in (a). See text and Fig 3. T h e m o v e m e n t s of the e c h o giving s t r u c t u r e s away f r o m the c r y s t a l a r e r e c o r ded a s i n c r e a s e d d i s t a n c e b e t w e e n the ' t r a n s m i s s i o n p u l s e ' s i g n a l and the echo s i g n a l s
T h e recording technique The m o v e m e n t patterns of various heart structures can be continuously recorded either with a photographic method z or via one of the channels of a direct-writing electrocardiograph. 2 For continuous photographic recording a c a m e r a is placed in front of the oscilloscope screen. Fig 3 is a sketch of the a r r a n g e m e n t . T h e f i l m is wound f o r w a r d s at a c o n s t a n t speed. Echoes from a motionless s t r u c t u r e are reproduced on the f i l m a s a s t r a i g h t line at a c o n s t a n t d i s t a n c e f r o m the e m i s s i o n s i g n a l . Echo s i g n a l s f r o m a s t r u c t u r e which m o v e s to and f r o m the c r y s t a l a r e r e p r o d u c e d on the f i l m a s a c u r v e . The f i l m s h o w s c u r v e s r e p r e s e n t i n g e a c h of the sound r e f l e c t i n g s t r u c t u r e s . By i n c r e a s i n g the s c a n n i n g s p e e d of the e l e c t r o n b e a m in the x - d i r e c t i o n a l i m i t e d a r e a of the o s c i l l o g r a m can be e n l a r g e d . In t h i s m a n n e r a m o r e d e t a i l e d i n s p e c t i o n of the m o v e m e n t s is p o s s i b l e . T h e e l e c t r o c a r d i o g r a m can be r e c o r d e d on the f i l m s i m u l t a n e o u s l y with the u l t r a s o u n d t r a c i n g .
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the P waves of the e l e c t r o c a r d i o g r a m in c a s e s of a c o m p l e t e h e a r t block. The peak of the A wave r e p r e s e n t s the position of m a x i m u m opening of the a n t e r i o r m i t r a l leaflet during atrial systole. P h a s e 2. Systolic wave p r o d u c e d by v e n t r i c u l a r c o n t r a c t i o n After the A wave the t r a c i n g develops a r a p i d downstroke B-C, which is a t t r i b u t e d to the m o v e m e n t of c l o s u r e of the a n t e r i o r m i t r a l leaflet. Point C coincides with the m i t r a l component (Mz) of the 1st h e a r t sound commonly r e g a r d e d to be due to m i t r a l valve c l o s u r e . C-D r e p r e s e n t s the c l o s e d position of the a n t e r i o r m i t r a l leaflet. The 2nd h e a r t sound just p r e c e d e s the point D, to be followed by the .rapid ups t r o k e D-E during v e n t r i c u l a r relaxation. P h a s e 3. Opening m o v e m e n t of t h e a n t e r i o r m i t r a l leaflet D-E r e p r e s e n t s the opening m o v e m e n t of the a n t e r i o r m i t r a l leaflet. Point E coincides with the opening sound of the m i t r a l valve. E r e p r e s e n t s the abrupt c e s s a t i o n of the opening m o v e m e n t of the a n t e r i o r m i t r a l leaflet: the valve is fully open at t h i s point. Fig 3
Continuous r e g i s t r a t i o n of h e a r t wall m o v e m e n t s by the photographic method. The film, F, m o v e s with constant velocity behind a slit, S, on which the echo s i g n a l s a r e p r o j e c t e d by the lens, O. The e l e c t r o c a r d i o g r a m is s i m u l t a n e o u s l y displayed on the c r t s c r e e n by the sling o s c i l l o g r a p h , M, and thus also r e c o r d e d on the film
P h a s e 4. E a r l y and r a p i d v e n t r i c u l a r filling wave P h a s e 4 begins at point E and ends at F. The downstroke E - F c o n s i s t s of an initial slow m o v e m e n t E- F o, followed by a rapid final downstroke F 0 - F . It r e p r e s e n t s the m o v e m e n t of the leaflet t o w a r d s c l o s u r e during the rapid inflow of blood into the v e n t r i c l e . The l e a f l e t s float t o w a r d s each other.
4 Direct recording of the ultrasound cardiogram via an electrocardiograph can be carried out by the method described by Effert, Hertz and BShme.2 This technique permits recording of the movements of only a single echo,but it is possible to correlate the ultrasound cardiogram with a simultaneously recorded electrocardiogram,phonocardiogram and intracardiac pressure recording.
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For a detailed study of the method and recording technique see Edler, 1961. 3
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U l t r a s o u n d c a r d i o g r a m (UCG) An ultrasound cardiogram can be obtained from various parts of the heart. The echo signals' pattern of movement varies with the location of the crystal in the precardial area and with the direction of the beam. If the heart is enlarged pulsating echo signals can be obtained over a significantly larger area than in normal cases. Certain conditions, such as obesity and severe emphysema, impair the quality of the ultrasound cardiogram. By applying the crystal to the fourth left interspace a tracing can be obtained which represents the motion of the posterior wall of the left ventricle. With the crystal applied over the third or fourth left interspace, l-4cm from the sternal border, echo s i g n a l s f r o m the a n t e r i o r and p o s t e r i o r m i t r a l l e a f l e t s a r e obtained. It is p o s s i b l e to make r e c o r d i n g s f r o m the left v e n t r i c u l a r outflow t r a c t and s o m e t i m e s f r o m the a o r t i c v a l v e - c u s p s . 4, 5
ULTRASOUND CARDIOGRAM FROM THE ANTERIOR MITRAL LEAFLETS. A normal ultrasound cardiogram of the movements of the anterior mitral leaflet is shown in Fig 4. Phase 1 represents the atrial systole; phase 2 the systolic wave; phase 3 the opening wave; phase 4 the movement towards closure during the early and rapid ventricular filling; phase 5 the slow ventricular filling. An upstroke of the ultrasound cardiogram represents a movement of the echo source towards the crystal on the anterior chest wall. A downstroke of the curve represents a movement of the echo source away from the crystal. E represents the most ventral position attained by the echo-source, and C represents the most dorsal position.
P h a s e II Fig 4
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The n o r m a l ultrasound c a r d i o g r a m of the m o v e m e n t s of the a n t e r i o r m i t r a l leaflet. Simultaneous r e c o r d ings of e l e c t r o c a r d i o g r a m , apex p h o n o c a r d i o g r a m (Phono-apex) and ultrasound c a r d i o g r a m (UCG). Upstroke of UCG-curve r e p r e s e n t s m o v e m e n t of e c h o s o u r c e t o w a r d s the c r y s t a l . Downstroke r e p r e s e n t s m o v e m e n t away f r o m the c r y s t a l . P a p e r s p e e d 100mm/sec M z = m i t r a l component of the f i r s t h e a r t sound. A = atrial wave. B-C = m o v e m e n t of the a n t e r i o r m i t r a l leaflet t o w a r d s c l o s e d position during e a r l y v e n t r i cular s y s t o l e . Point C coincides with M z. C-D = the c l o s e d position of the a n t e r i o r m i t r a l leaflet during v e n t r i c u l a r systole. D-E = opening m o v e m e n t of the a n t e r i o r m i t r a l leaflet. E - F = the r a p i d diastolic downstroke during the period of rapid v e n t r i cular filling. F o s e e text. P h a s e s 1-5, s e e text
In n o r m a l c a s e s and in c a s e s of h e a r t d i s e a s e without m i t r a l s t e n o s i s the m o v e m e n t of the a n t e r i o r m i t r a l leaflet after the m a x i m u m opening in e a r l y d i a s t o l e o c c u r s at a s p e e d of m o r e than 8 0 m m / s e c . 3 , 6-8 The s p e e d m e a s u r e m e n t s f r o m the r e c o r d s of 53 n o r m a l c a s e s ranged f r o m 9 0 - 1 9 0 m m / s e c , mean 1 4 0 m m / s e c (Table 1). The t i m e i n t e r v a l between point E and point F v a r i e d from 0. 105sec to 0 . 1 6 s e c , with a mean 0 . 1 3 s e c . 9, lo
P h a s e 1. A t r i a l w a v e .
P h a s e 5. Slow v e n t r i c u l a r filling p e r i o d
The A wave is c a u s e d by a t r i a l activity, which is shown by its d i s a p p e a r a n c e in a t r i a l fibrillation and its r e l a t i o n to
This phase r e p r e s e n t s the late p a s s i v e v e n t r i c u l a r filling, and ends at the next A wave, or at the onset of the next main ULTRASONICS A p r i l 1967
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s y s t o l i c wave. In s o m e c a s e s the t r a c i n g shows an u p s t r o k e of s h o r t duration and low amplitude i m m e d i a t e l y a f t e r point F.
Fig 6
The total amplitude of the m o v e m e n t of the a n t e r i o r m i t r a l leaflet between the c l o s e d position and the m a x i m u m opening in e a r l y diastole (the d i s t a n c e C - E on the tracing) v a r i e d f r o m 20mm to 33mm, with an a v e r a g e of 27mm. 9, lo
Relation b e t w e e n the s p e e d of diastolic d o w n s t r o k e E - F on the UCG t r a c i n g and the s i z e of the m i t r a l o r i f i c e , e s t i m a t e d at operation, in 84 c a s e s of pure m i t r a l s t e n o s i s without calcification. The s p e e d of d i a s t o l i c d o w n s t r o k e in 15 c a s e s of slight m i t r a l s t e n o s i s is shown at the r i g h t of the figure
ULTRASOUND CARDIOGRAM FROM THE ANTERIOR MITRAL L E A F L E T IN MITRAL STENOSIS. In m i t r a l s t e n o s i s the a p p e a r a n c e of the t r a c i n g of the ant e r i o r m i t r a l leaflet is e n t i r e l y different. The quick c o m p o nent, E - F , in e a r l y d i a s t o l e is lacking 11 (Fig 5). Point E indicating the abrupt c e s s a t i o n of the opening m o v e m e n t s of the a n t e r i o r m i t r a l leaflet c o i n c i d e s with the opening snap. F r o m point E the t r a c i n g shows a slow fall which, as a rule, continues as far as wave A o r point B (in c a s e s of a t r i a l fibrillation). Wave A is usually s m a l l and in m o s t c a s e s t h e r e is only the downstroke, A-B (Fig 5).
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Ultrasound c a r d i o g r a m of the m o v e m e n t s of the a n t e r i o r m i t r a l leaflet in a c a s e of pure m i t r a l s t e n o s i s with sinus rhythm. Simultaneous r e c o r d i n g s of e l e c t r o c a r d i o g r a m , apex p h o n o c a r d i o g r a m (Phono-apex) and ultrasound c a r d i o g r a m (UCG). P a p e r s p e e d 100mm/sec. 1 = f i r s t h e a r t sound. 2 = second h e a r t sound. ASM = a t r i a l s y s t o l i c m u r m u r . U p s t r o k e of the UCG-curve r e p r e s e n t s m o v e m e n t t o w a r d s the c r y s t a l . Downstroke r e p r e s e n t s m o v e ment away f r o m the c r y s t a l . A = a t r i a l wave. E = position of m a x i m a l opening in e a r l y diastole. E coincides with opening snap, OS. The n o r m a l r a p i d downstroke E - F is r e p l a c e d by a slow fall as far as wave A. The s p e e d of the diastolic downstroke is 26mm/sec. The downstroke A - B coincides with the a t r i a l s y s t o l i c m u r m u r , ASM
s u r e of the m i t r a l o r i f i c e . Fig 6 shows the r e l a t i o n between the s p e e d of the diastolic downstroke and the s i z e of the m i t r a l o r i f i c e e s t i m a t e d in 84 c a s e s of pure m i t r a l s t e n o s i s without calcification in the leaflets. T h e r e is also a group of 15 c a s e s with a s y m p t o m a t i c slight m i t r a l s t e n o s i s . In the m o s t tight m i t r a l s t e n o s i s the s p e e d of the diastolic downstroke, E - F , n e v e r e x c e e d s 1 4 m m / s e c . In the group without c a l c i f i c a t i o n s and with an o r i f i c e above 1 . 8 c m 2 the s p e e d of the d i a s t o l i c d o w n s t r o k e is n e v e r below 1 6 m m / s e c . 9, lo In m i t r a l s t e n o s i s , with a m o d e r a t e or high d e g r e e of c a l c i fication, the s p e e d of the diastolic downstroke is slow even in c a s e s with a m i t r a l o r i f i c e m e a s u r i n g 1 . 3 - 2 . 3 c m 2. The r e a son for this slow velocity is p e r h a p s a 'functional s t e n o s i s ' on account of the rigidity in the valve apparatus.
s t e n o s i s or m i t r a l s t e n o s i s a s s o c i a t e d with insignificant m i t r a l regurgitation, in 150 c a s e s of combined m i t r a l s t e n o s i s and regurgitation, and in 154 c a s e s of m i t r a l s t e n o s i s a s s o c i ated with aortic valve l e s i o n s . In only 13 c a s e s of m i t r a l s t e n o s i s was it i m p o s s i b l e to r e c o r d the typical t r a c i n g f r o m the a n t e r i o r roitral leaflet. Neither have we found this c h a r a c t e r i s t i c t r a c i n g in c a s e s other than m i t r a l s t e n o s i s .
R i g i d i t y o r c a l c i f i c a t i o n of t h e v a l v e
The degree of mitral stenosis
Ultrasound cardiogram after mitral commissurotomy
Since the introduction of ultrasound cardiography this method has been of value for the pre-operative evaluation of mitral stenosis. The speed of diastolic downstroke, E-F, is a m e a -
The ultrasound c a r d i o g r a m also p e r m i t s quantitative evaluation of the o p e r a t i v e r e s u l t s . The s p e e d of the diastolic downstroke, E - F , is m o r e rapid a f t e r m i t r a l c o m m i s s u r o -
74
ULTRASONICS April 1967
The total amplitude of the m o v e m e n t of the a n t e r i o r m i t r a l leaflet between the c l o s e d position during v e n t r l c u l a r s y s t o l e and the position of m a x i m u m opening in e a r l y d i a s t o l e (the d i s t a n c e C-E on the tracing) is a m e a s u r e of the rigidity of the valve. In c a s e s without calcification the total amplitude v a r i e s between 20mm and 30mm, which i s in the n o r m a l range. In c a s e s of a high d e g r e e of c a l c i f i c a t i o n the total amplitude is only 15mm or below.9, lo Fig 7.
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t o m y . Only in a few c a s e s , h o w e v e r , i s t h e p o s t o p e r a t i v e s p e e d e n t i r e l y n o r m a l . In the c a s e s without c a l c i f i c a t i o n t h e p o s t o p e r a t i v e s p e e d of the d i a s t o l i c d o w n s t r o k e i n c r e a s e s m o r e t h a n in the c a s e s with c a l c i f i c a t i o n . In 78 c a s e s w i t h out c a l c i f i c a t i o n , the m e a n p r e o p e r a t i v e s p e e d w a s 1 5 . 8 m m / s e c and the m e a n p o s t o p e r a t i v e s p e e d w a s 4 4 m m / s e c . In 18 c a s e s with e x t e n s i v e c a l c i f i c a t i o n and a total a m p l i t u d e of 15mm, or below, the m e a n p r e - o p e r a t i v e s p e e d w a s 10.3 m m / s e c with a p o s t o p e r a t i v e s p e e d of 2 9 . 9 m m / s e c .
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T r a c i n g s f r o m a c a s e of m i t r a l s t e n o s i s with e x t e n s i v e c a l c i f i c a t i o n c o n f i r m e d by s u r g e r y . S i m u l t a n e o u s r e c o r d i n g s of e l e c t r o c a r d i o g r a m , apex p h o n o c a r d i o g r a m ( P h o n o - a p e x ) and u l t r a s o u n d c a r d i o g r a m (UCG) of the m o v e m e n t of the a n t e r i o r m i t r a l leaflet. Paper speed 50mm/sec.
Fig 7
The total a m p l i t u d e of m o v e m e n t b e t w e e n c l o s e d p o s i tion (C) and the p o s i t i o n of m a x i m a l o p e n i n g (E) i s 13mm. A b b r e v i a t i o n s a s in F i g 4 and 5
Fig 8
In p u r e m i t r a l r e g u r g i t a t i o n the s p e e d of m o v e m e n t of the a n t e r i o r m i t r a l l e a f l e t d u r i n g the r a p i d left v e n t r i c u l a r f i l l ing p h a s e i s n o r m a l or i n c r e a s e d . 9 Fig 8 is a r e c o r d f r o m a p a t i e n t with p u r e m i t r a l r e g u r g i t a tion. In a g r o u p of 8 c a s e s of s e v e r e p u r e m i t r a l r e g u r g i t a t i o n the m e a n s p e e d of the a n t e r i o r m i t r a l l e a f l e t w a s 1 5 8 m m / s e c r a n g e 2 2 3 - 9 2 m m / s e c . T h e total a m p l i t u d e , C - E , w a s 30-39 mm, mean 34mm. In a n o t h e r g r o u p of 9 p a t i e n t s with s l i g h t or m o d e r a t e p u r e m i t r a l r e g u r g i t a t i o n the s p e e d of m o v e m e n t of the a n t e r i o r m i t r a l leaflet varied between 2 1 0 - 8 0 m m / s e c , mean 151ram/ s e c . The total a m p l i t u d e w a s 2 5 - 3 5 m m , m e a n 3 1 m m . Conclusions
T r a c i n g s f r o m a p a t i e n t with p u r e m i t r a l r e g u r g i t a tion. 1 = f i r s t h e a r t sound. 2 = s e c o n d h e a r t sound. 3 = t h i r d h e a r t sound. SM = s y s t o l i c m u r m u r . DM = d i a s t o l i c m u r m u r . A b b r e v i a t i o n s on the UCG t r a c i n g a s in F i g u r e s 4 and 5. The s p e e d of d i a s t o l i c downs t r o k e is l l 5 m m / s e c . T h e total a m p l i t u d e C - E is 33mm.
In p u r e m i t r a l r e g u r g i t a t i o n the s p e e d of m o v e m e n t of the a n t e r i o r m i t r a l l e a f l e t d u r i n g the v e n t r i c u l a r filling p e r i o d is n o r m a l or s l i g h t l y i n c r e a s e d . T h e m a x i m u m a m p l i t u d e b e t w e e n the c l o s e d p o s i t i o n and the m a x i m u m opening in e a r l y d i a s t o l e i s in m a n y c a s e s g r e a t e r t h a n n o r m a l . In c a s e s with s e v e r e m i t r a l r e g u r g i t a t i o n the total a m p l i t u d e i s 3 0 m m or m o r e . 9
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In c a s e 1 t h e r e w a s no e n d - d i a s t o l i c p r e s s u r e g r a d i e n t a c r o s s the m i t r a l valve. In c a s e s 2-6 the d i a s t o l i c p r e s s u r e g r a d i e n t b e t w e e n the left a t r i u m and the left v e n t r i c l e indic a t e s only a s l i g h t o r m i l d s t e n o s i s . In c a s e s 7-8 the high d i a s t o l i c p r e s s u r e g r a d i e n t i n d i c a t e s p r e d o m i n a t i o n of mitral stenosis. T h e s e d a t a t o g e t h e r with the r e s u l t of left v e n t r i c u l o g r a p h y and the d i a g n o s i s c o n f i r m e d at o p e r a t i o n (in 7 c a s e s ) show the r e l a t i o n b e t w e e n r e g u r g i t a t i o n and s t e n o s i s . UCG fiDdings
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Tracings from a patient with combined mitral sienaFig 10 Tracings from a patient with combined mitral stenosis and regurgitation with atrial fibrillation. Case no 3 sis and regurgitation with atrial fibrillation. Case table 1 no 8 table i. Symptomsclassified to group IV. Clinical and haemodynamic data are shown in table I. (a) Simultaneous recordings of electrocardiogram (ECG), apex phonocardiogram (Phone-apex), and (a) Simultaneous recordings of electrocardiogram and ultrasound cardiogram (UCG). Paper speed 50mm/ apex phonocardiogram (Phone-apex). SM = holosyssec. relic murmur, DM -- mitral diastolic murmur, aS = SM = holosystolic murmur, DM = mitral diastolic opening snap. Paper speed 100mm/see. murmur during rapid flow phase, aS -- opening snap, and 3 -- third heart sound. 1 = first heart sound. 2 = Ist -- first heart sound. 2nd = second heart sound second heart sound. (b) Simultaneous recordings of electrocardiogram, Ultrasound cardiogram: the speed of diastolic downphonocardiogram and ultrasound cardiogram (UCG) stroke is 33mm/sec. There is a slight degree of of the movement of the anterior mitral leaflet. Paper stenosis. Total amplitude C-E is 27ram. speed 50ram/see. The speed of diastolic downstroke (b) Simultaneously recorded left atrial and left venis 9mm/sec. Total amplitude 17ram tricular pressure pulses. The left atrial pressure (c) Simultaneously recorded left atrial (LA) and left pulse shows characteristics of both stenosis and reventricular (LV) pressure pulses shows a high presgurgitation. During short cycle lengths the pressure sure gradient across the mitral valve during diastole gradient (shaded area) between the atrium and ventri(shaded area). End-diastolic pressure gradient is cle continues throughout diastole, whereas during 32mmHg. Paper speed 40mm/sec long cycle lengths (>0.4sec) there is no end-diastolic gradient, but there is a high peaked V-wave. The period without an end-diastolic gradient corresponds Summary to the phase F-B of the UCG-curve. Auscultation: m i t r a l s t e n o s i s and m i t r a l r e g u r g i t a t i o n P r e s s u r e r e c o r d i n g s : c h a r a c t e r i s t i c for m i t r a l s t e n o s i s Left v e n t r i c u l o g r a p h y : s l i g h t r e g u r g i t a t i o n The clinical and haemodynamic data for this patient are shown in table i. Left ventricular angiogram UCG: tight m i t r a l s t e n o s i s , 9 m m / s e c . Rigidity, the showed a moderate regurgitation. At operation fitotal amplitude is 1Tmm brotic leaflets were found with shortened and At o p e r a t i o n the o r i f i c e was open for t w o - t h i r d s of thickened chordae tendineae. The orifice was open a f i n g e r - t i p . C a l c i f i c a t i o n s of the l e a f l e t s for 2 I/2 fingers
ULTRASONICS A p r i l 1967
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Fig 11 T r a c i n g s r e p r e s e n t i n g the action of the m i t r a l and t r i c u s p i d v a l v e s in a c a s e of a t r i a l septal defect. The c r y s t a l was applied to the f o u r t h left i n t e r s p a c e 5cm f r o m the m i d s t e r n a l line Ca) and (b) A n t e r o p o s t e r i o r beam d i r e c t i o n . (a) S m a l l s c a l e p i c t u r e . AM = a n t e r i o r cusp of the m i t r a l valve. The m i n i m u m and m a x i m u m d i s t a n c e s between AM and C ( r e p r e s e n t i n g the c r y s t a l on the a n t e r i o r c h e s t wall) a r e 8 . 0 c m and 10.3cm, r e s p e c t i v e l y . IVS = i n t e r v e n t r i c u l a r s e p t u m . (b) T r a c i n g AM to b i g g e r s c a l e (c) While the r e c o r d i n g of t r a c i n g AM is in p r o g r e s s , the d i r e c t i o n of the beam is a l t e r e d so as to d i v e r g e 15-20 ° medially f r o m the a n t e r o p o s t e r i o r line. At t h i s point t r a c i n g AM d i s a p p e a r s to be r e p l a c e d by t r a c i n g T r e p r e s e n t i n g the a n t e r i o r leaflet of the t r i c u s p i d valve. The m i n i m u m and m a x i m u m d i s t a n c e between T and C a r e 4 . 5 c m and 8cm, r e s p e c t i v e l y
6
(d) T r a c i n g T to g r e a t e r s c a l e
In c a s e s no 2-6, with a slight e n d - d i a s t o l i c p r e s s u r e g r a d i ent the s p e e d of the diastolic downstroke on the UCG t r a c i n g r a n g e d f r o m 20-43 m m / s e c , mean 3 3 m m / s e c . The two c a s e s (7, 8) with p r e d o m i n a n t m i t r a l s t e n o s i s , showed a s p e e d of only 1 1 m m / s e c and 9 m m / s e c r e s p e c t i v e l y . The total amplitude was n o r m a l in c a s e s 1-4, without c a l c i fication. In c a s e s no 5, 7-9, with a high d e g r e e of c a l c i f i c a tion, the total amplitude r a n g e d between 10mm and 17mm, with a m e a n of 14mm. The r e m a i n i n g 6 c a s e s (no 10-15) w e r e a s y m p t o m a t i c . The s p e e d of m o v e m e n t of the a n t e r i o r m i t r a l leaflet during the left v e n t r i c u l a r filling p e r i o d v a r i e d between 3 5 m m / s e c and 7 0 m m / s e e , mean 4 9 m m / s e c .
The total amplitude in t h e s e c a s e s was 22-32mm, with a mean of 27ram. F i g s 9 and 10 show two c a s e s of c o m b i n e d m i t r a l s t e n o s i s and r e g u r g i t a t i o n .
Conclusions In combined mitral stenosis and regurgitation the ultrasound cardiogram from the anterior mitral leaflet shows the degree of stenosis. As a high degree of regurgitation cannot be combinedwith a high degree of stenosis the ultrasound cardiogram is a valuable parameter for differentiatingbetweenpredominant mitral regurgitation and predominant mitral stenosis.
Fig 12 P e r i c a r d i t i s with effusion Ca) Before a s p i r a t i o n . Distance between p e r i c a r d i u m and a n t e r i o r wall of v e n t r i c l e as s e e n in UCG is due to accumulation of fluid (b) A f t e r a s p i r a t i o n . D i s t a n c e r e d u c e d a f t e r a s p i r a t i o n .
a Pericardium Ant. w a l l of t h e ventricle
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RIGHT VENTRICULAR DILATATION In n o r m a l c a s e s a c o m p l e t e p a t t e r n of t r i c u s p i d motion is difficult to obtain. However in p a t i e n t s with right v e n t r i c u l a r dilatation t r a c i n g s r e p r e s e n t i n g the a n t e r i o r t r i c u s p i d leaflet a r e r e c o r d e d without difficulty. This c u r v e is r e c o r d e d with the t r a n s d u c e r placed in the fourth or fifth left i n t e r s p a c e , 4 - 5 c m f r o m the m i d s t e r n a l line, and the beam d i r e c t e d tow a r d the spine. 3-5 The configuration of the t r i c u s p i d p a t t e r n is s i m i l a r to that e s t a b l i s h e d as the n o r m a l configuration of the a n t e r i o r m i t r a l leaflet. The t r i c u s p i d t r a c i n g r e p r e s e n t s a s t r u c t u r e lying a n t e r i o r and medial to the m i t r a l echo. The t r a c i n g s of the i n t e r v e n t r i c u l a r septum and the a n t e r i o r m i t r a l leaflet a r e in t h e s e c a s e s situated d e e p e r than n o r mal 3-5 Fig II. T h e s e s i g n s of r i g h t v e n t r i c u l a r dilatation and a s a t i s f a c t o r y t r i c u s p i d c u r v e can usually be obtained f r o m patients with pulmonary hypertension; an a t r i a l septal defect, with or without pulmonary hypertension; and m i t r a l s t e n o s i s with pulm o n a r y h y p e r t e n s i o n . In m i t r a l s t e n o s i s with pulmonary h y p e r t e n s i o n the typical c u r v e of m i t r a l s t e n o s i s is r e c o r d e d t o g e t h e r with the s i g n s of right v e n t r i c u l a r dilatation. It s e e m s i m p o s s i b l e to obtain continuous r e c o r d i n g s of the m o v e m e n t of the t r i c u s p i d ' l e a f l e t f r o m p a t i e n t s with pulmona r y valve s t e n o s i s .
78
ULTRASONICS A p r i l 1967
In t r i c u s p i d s t e n o s i s the s p e e d of d i a s t o l i c d o w n s t r o k e of the m o v e m e n t of the a n t e r i o r t r i c u s p i d l e a f l e t is r e s t r i c t e d in the s a m e m a n n e r a s the m i t r a l m o v e m e n t in m i t r a l s t e n o s i s . 1 3
4
Edler, I., 'The diagnostic u s e of u l t r a s o u n d in h e a r t d i s e a s e ' in ' U l t r a s o n i c e n e r g y ' (edited by Kelly, E.) Chicago (1965) U n i v e r s i t y of Illinois
U l t r a s o u n d c a r d i o g r a p h y is v a l u a b l e for d e t e c t i n g r i g h t v e n t r i c u l a r dilatation, for d i f f e r e n t i a t i n g an a t r i a l s e p t a l defect f r o m p u l m o n a r y valve s t e n o s i s or f r o m m i t r a l s t e n o s i s and f o r diagnosing t r i c u s p i d s t e n o s i s .
5
Edler, I., ' C a r d i a c s t u d i e s by u l t r a s o u n d s ' in ' C a r d i o logy. An encyclopedia of the c a r d i o v a s c u l a r s y s t e m ' (edited by Luisada, Aldo A.) Supplement i, 4, 410. M c G r a w - H i l l , New York (1962)
6
Edler, I. and Gustafson, A., ' U l t r a s o n i c c a r d i o g r a m in mitral stenosis', Acta Medica Scandinavica, 159, 85 (1957)
THE DIAGNOSIS OF PERCARDIAL EFFUSION.
7
Effert, S., ' D e r d e r z e i t i g e Stand d e r U 1 t r a s c h a l l k a r d i o g r a p h i e ' , A r c h i v fur K r e i s l a u f f o r s c h u n g , 214 (1959)
U l t r a s o u n d is a v a l u a b l e method of d e t e c t i n g o r excluding p e r i c a r d i a l effusion. In 22 c a s e s we have been able to dem o n s t r a t e the p r e s e n c e of p e r i c a r d i a l fluid in the a n t e r i o r r e g i o n of the p e r i c a r d i u m . Normally, the echo s i g n a l s f r o m the c h e s t wall, f r o m the p e r i c a r d i u m , and f r o m the a n t e r i o r wall of the r i g h t v e n t r i c l e m e r g e into one. In the p r e s e n c e of effusion t h e r e is a c l e a r a r e a between the echo r e f l e c t e d f r o m the p e r i c a r d i u m and the echo r e f l e c t e d f r o m the a n t e r i o r wall. 4, s, 14- 16 (Fig 12). The i n t e r v e n i n g i n t e r v a l between the two s e p a r a t e d e c h o e s is a m e a s u r e of the amount of fluid in the p e r i c a r d i u m .
8
J o y n e r , C. R., Reid, J. M. and Bond, J. P., ' R e f l e c t e d u l t r a sound in the a s s e s s m e n t of m i t r a l valve d i s e a s e ' , C i r culation 27, 503 (1963)
9
Edler, I., ' M i t r a l valve function studied by the u l t r a sound echo method' in ' D i a g n o s t i c u l t r a s o u n d ' , P r o c e e d ings of the I s t I n t e r n a t i o n a l C o n f e r e n c e (edited by G r o s s m a n , C. C. et al), P l e n u m P r e s s , New York (1966) 198
10
Edler, I., ' U l t r a s o u n d c a r d i o g r a p h y in m i t r a l valve s t e n o s i s ' , A m e r i c a n J o u r n a l of Cardiology, 19, 18 (1967)
11
Edler, I., ' U 1 t r a s o u n d c a r d i o g r a m in m i t r a l v a l v u l a r d i s e a s e ' , Acta C h i r u r g i c a Scandinavica, 3, 230 (1956)
12
M a r s h a l l , H. W., Woodward, E. and Wood, E. H., ' H e m o dynamic methods for d i f f e r e n t i a t i o n of m i t r a l s t e n o s i s and r e g u r g i t a t i o n ' , A m e r i c a n J o u r n a l of Cardiology, 2, 24 (1958)
13
Joyner, C. R., 'Reflected ultrasound in the diagnosis of tricuspid stenosis', American Journal of Cardiology, 19, 66 (1967)
14
Edler, I., 'The diagnostic use of ultrasound in heart disease', Acta Medica Scandinavica Supplement, 308, 32 (1955)
15
Effert, S. and Bleifeld, W. 'Diagnostic value of ultrasound reflection procedures in cardiology' in 'Diagnostic ultrasound', Proceedings of the Ist International Conference (edited by Grossman, C. C. et al) Plenum Press, New York (1966) 299
16
Joyner, C. R., 'Experience with ultrasound in the study of heart disease and the production of intracardiac sound' in 'Diagnostic ultrasound', Proceedings of the Ist International Conference (edited by Grossman, C. C. et al) Plenum Press, New York (1966) 237
17
Feigenbaum, H., Zaky, A. and Waldhausen, J. A., 'Use of reflected ultrasound in detecting pericardial effusion', American Journal of Cardiology, 19, 84 (1967)
Some a u t h o r s have d i a g n o s e d p e r i c a r d i a l fluid by d e m o n s t r a ting a c l e a r a r e a p o s t e r i o r to the moving p a t t e r n r e f l e c t e d f r o m the r e g i o n of the p o s t e r i o r v e n t r i c u l a r wall. 17 However, two s e p a r a t e d e c h o e s f r o m the p o s t e r i o r r e g i o n of the h e a r t a r e often obtained in n o r m a l c a s e s . This is the c a u s e of r e p o r t e d ' f a l s e p o s i t i v e ' r e c o r d i n g s . We have n e v e r obtained 'false positive' in looking for fluid anterior to the heart.
REFERENCES
1
Edler, I. and Hertz, C. H., ' T h e use of u l t r a s o n i c r e f l e c t o s c o p e for the continuous r e c o r d i n g of m o v e m e n t s of the h e a r t w a l l s ' , Kungliga F y s i o g r a f i s k a S~illskapets i Lund, F S r h a n d l i n g a r , 24, 5 (1954)
2
Effert, S., Hertz, C. H. and Bohme, W., ' D i r e k t e R e g i s t r i e r u n g d e s U l t r a s c h a l l k a r d i o g r a m m e s m i t dem E l e k t r o k a r d i o g r a p h e n ' , Z e i t s c h r i f t fiir K r e i s l a u f f o r s c h u n g , 48, 230 (1959)
3
Edler, I., Gustafson, A., K a r l e f o r s , T. and C h r i s t e n s s o n , B., ' U l t r a s o u n d c a r d i o g r a p h y ' , Acta M e d i c a Scandinavica, Supplement 370 (1961)
ULTRASONICS A p r i l 1967
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By m e a n s of u l t r a s o u n d , e c h o e s can be obtained f r o m a v a r i ety of h e a r t s t r u c t u r e s , so t h a t the m o v e m e n t s of t h e s e s t r u c t u r e s a r e r e c o r d e d a s a t r a c i n g , the u l t r a s o u n d c a r d i o g r a m , (UCG). T h e p a t t e r n of m o v e m e n t of the echo s i g n a l s v a r i e s a c c o r d i n g to the location of the c r y s t a l in the p r e c a r d i a l a r e a and the d i r e c t i o n of the b e a m . The m e t h o d h a s p r o v e d of value in e v a l u a t i n g the d e g r e e of s t e n o s i s in m i t r a l v a l v e d i s e a s e and {n d e t e c t i n g p e r i c a r d i a l effusion. U l t r a s o u n d c a r d i o g r a p h y is a l s o v a l u a b l e in d i f f e r e n t i a t i n g an a t r i a l s e p t a l defect f r o m m i t r a l valve d i s e a s e and f r o m p u l m o n a r y valve stenosis.
METHOD P u l s e s of u l t r a s o u n d a r e g e n e r a t e d by an e l e c t r i c a l l y e x c i t e d q u a r t z or b a r i u m t i t a n a t e c r y s t a l placed a g a i n s t the c h e s t . If sound i m p u l s e s p a s s i n g t h r o u g h the h e a r t i m p i n g e upon the l e a f l e t s of the v a l v e s or the h e a r t walls, p a r t of the p u l s e will * Dr. Inge E d l e r i s h e a d of the D e p a r t m e n t of C a r d i o l o g y , U n i v e r s i t y Hospital, Lund, Sweden.
be r e f l e c t e d . If the path of p r o p a g a t i o n of the p u l s e i s p e r p e n d i c u l a r to the r e f l e c t i n g s u r f a c e s t h e n the p u l s e will be r e f l e c t e d b a c k t o w a r d s the c r y s t a l , which a c t s a s a m i c r o phone f o r the d e t e c t i o n of t h e s e e c h o e s . T h e s o u n d g e n e r a ting and r e c e i v i n g e q u i p m e n t is c o n n e c t e d to a cathode r a y tube. At e a c h p u l s e the e l e c t r o n b e a m is s t a r t e d at the left s i d e of the s c r e e n and m o v e s to the r i g h t along the x - a x i s at c o n s t a n t s p e e d . W h e n an echo a r r i v e s back at the c r y s t a l it i s c o n v e r t e d to an e l e c t r i c a l s i g n a l , which i s then a m p l i f i e d and fed to the y - p l a t e s of t h e cathode r a y tube. T h i s r e s u l t s in a v e r t i c a l d e f l e c t i o n of the e l e c t r o n b e a m . T h e echo s i g n a l s a r e t h u s s e e n a s v e r t i c a l d e f l e c t i o n s on the o s c i l l o s c o p e s c r e e n , F i g 1. T h e h o r i z o n t a l d i s t a n c e b e t w e e n the left b o r d e r of t h e s c r e e n and the echo s i g n a l i s a m e a s u r e of the t i m e n e c e s s a r y f o r the p u l s e to t r a v e l f r o m the c r y s t a l to a r e f l e c t i n g s u r f a c e and b a c k again. If the v e l o c i t y of the sound i s the s a m e in all the m e d i a it t r a v e r s e s , the h o r i z o n t a l d i s t a n c e b e t w e e n the v e r t i c a l o s c i l l a t i o n s on the s c r e e n will be a m e a s u r e of the d i s t a n c e b e t w e e n d i f f e r e n t r e f l e c t i n g s u r f a c e s . T h e v e l o c i t y of s o u n d is about 1 5 0 0 m / s e c in both m u s c l e and blood. T h e p u l s e r a t e f r o m the c r y s t a l i s 2001000 p u l s e s / s e c which m e a n s that the d i s t a n c e between the c r y s t a l and t h e r e f l e c t i n g s u r f a c e s is m e a s u r e d 200-1000 t i m e s / s e c . If the e c h o - g i v i n g h e a r t s t r u c t u r e m o v e s t o w a r d s the c r y s t a l , the echo s i g n a l t r a v e l s along the h o r i z o n t a l a x i s t o w a r d s the l e f t - h a n d s i d e of the s c r e e n . A l t e r n a t i v e l y , if the e c h o - g i v i n g h e a r t s t r u c t u r e m o v e s away f r o m the c r y s t a l , the echo s i g n a l m o v e s to the r i g h t - h a n d s i d e of the s c r e e n (Fig 2). U l t r a s o u n d with a f r e q u e n c y of 2 . 5 M H z is g e n e r a l l y u s e d . The i m p u l s e d u r a t i o n can be v a r i e d o v e r (2-5) x 1 0 - 6 s e c .
.
. . . .
Fig 1
E c h o g r a m obtained on the o s c i l l o s c o p e s c r e e n . T h e s i g n a l r e p r e s e n t i n g the outgoing i m p u l s e f r o m the c r y s t a l is on the left. T h e o t h e r two p e a k s r e p r e s e n t the e c h o e s
Fig 2
(a) The echo s i g n a l s obtained on the o s c i l l o s c o p e s c r e e n m o v e t o w a r d s the r i g h t - h a n d s i d e of the s c r e e n , a s the e c h o - g i v i n g s t r u c t u r e s m o v e away f r o m the c r y s t a l (b) P h o t o g r a p h i c r e c o r d i n g of the e c h o g r a m shown in (a). See text and Fig 3. T h e m o v e m e n t s of the e c h o giving s t r u c t u r e s away f r o m the c r y s t a l a r e r e c o r ded a s i n c r e a s e d d i s t a n c e b e t w e e n the ' t r a n s m i s s i o n p u l s e ' s i g n a l and the echo s i g n a l s
T h e recording technique The m o v e m e n t patterns of various heart structures can be continuously recorded either with a photographic method z or via one of the channels of a direct-writing electrocardiograph. 2 For continuous photographic recording a c a m e r a is placed in front of the oscilloscope screen. Fig 3 is a sketch of the a r r a n g e m e n t . T h e f i l m is wound f o r w a r d s at a c o n s t a n t speed. Echoes from a motionless s t r u c t u r e are reproduced on the f i l m a s a s t r a i g h t line at a c o n s t a n t d i s t a n c e f r o m the e m i s s i o n s i g n a l . Echo s i g n a l s f r o m a s t r u c t u r e which m o v e s to and f r o m the c r y s t a l a r e r e p r o d u c e d on the f i l m a s a c u r v e . The f i l m s h o w s c u r v e s r e p r e s e n t i n g e a c h of the sound r e f l e c t i n g s t r u c t u r e s . By i n c r e a s i n g the s c a n n i n g s p e e d of the e l e c t r o n b e a m in the x - d i r e c t i o n a l i m i t e d a r e a of the o s c i l l o g r a m can be e n l a r g e d . In t h i s m a n n e r a m o r e d e t a i l e d i n s p e c t i o n of the m o v e m e n t s is p o s s i b l e . T h e e l e c t r o c a r d i o g r a m can be r e c o r d e d on the f i l m s i m u l t a n e o u s l y with the u l t r a s o u n d t r a c i n g .
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ULTRASONICS A p r i l 1967
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the P waves of the e l e c t r o c a r d i o g r a m in c a s e s of a c o m p l e t e h e a r t block. The peak of the A wave r e p r e s e n t s the position of m a x i m u m opening of the a n t e r i o r m i t r a l leaflet during atrial systole. P h a s e 2. Systolic wave p r o d u c e d by v e n t r i c u l a r c o n t r a c t i o n After the A wave the t r a c i n g develops a r a p i d downstroke B-C, which is a t t r i b u t e d to the m o v e m e n t of c l o s u r e of the a n t e r i o r m i t r a l leaflet. Point C coincides with the m i t r a l component (Mz) of the 1st h e a r t sound commonly r e g a r d e d to be due to m i t r a l valve c l o s u r e . C-D r e p r e s e n t s the c l o s e d position of the a n t e r i o r m i t r a l leaflet. The 2nd h e a r t sound just p r e c e d e s the point D, to be followed by the .rapid ups t r o k e D-E during v e n t r i c u l a r relaxation. P h a s e 3. Opening m o v e m e n t of t h e a n t e r i o r m i t r a l leaflet D-E r e p r e s e n t s the opening m o v e m e n t of the a n t e r i o r m i t r a l leaflet. Point E coincides with the opening sound of the m i t r a l valve. E r e p r e s e n t s the abrupt c e s s a t i o n of the opening m o v e m e n t of the a n t e r i o r m i t r a l leaflet: the valve is fully open at t h i s point. Fig 3
Continuous r e g i s t r a t i o n of h e a r t wall m o v e m e n t s by the photographic method. The film, F, m o v e s with constant velocity behind a slit, S, on which the echo s i g n a l s a r e p r o j e c t e d by the lens, O. The e l e c t r o c a r d i o g r a m is s i m u l t a n e o u s l y displayed on the c r t s c r e e n by the sling o s c i l l o g r a p h , M, and thus also r e c o r d e d on the film
P h a s e 4. E a r l y and r a p i d v e n t r i c u l a r filling wave P h a s e 4 begins at point E and ends at F. The downstroke E - F c o n s i s t s of an initial slow m o v e m e n t E- F o, followed by a rapid final downstroke F 0 - F . It r e p r e s e n t s the m o v e m e n t of the leaflet t o w a r d s c l o s u r e during the rapid inflow of blood into the v e n t r i c l e . The l e a f l e t s float t o w a r d s each other.
4 Direct recording of the ultrasound cardiogram via an electrocardiograph can be carried out by the method described by Effert, Hertz and BShme.2 This technique permits recording of the movements of only a single echo,but it is possible to correlate the ultrasound cardiogram with a simultaneously recorded electrocardiogram,phonocardiogram and intracardiac pressure recording.
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For a detailed study of the method and recording technique see Edler, 1961. 3
2.
U l t r a s o u n d c a r d i o g r a m (UCG) An ultrasound cardiogram can be obtained from various parts of the heart. The echo signals' pattern of movement varies with the location of the crystal in the precardial area and with the direction of the beam. If the heart is enlarged pulsating echo signals can be obtained over a significantly larger area than in normal cases. Certain conditions, such as obesity and severe emphysema, impair the quality of the ultrasound cardiogram. By applying the crystal to the fourth left interspace a tracing can be obtained which represents the motion of the posterior wall of the left ventricle. With the crystal applied over the third or fourth left interspace, l-4cm from the sternal border, echo s i g n a l s f r o m the a n t e r i o r and p o s t e r i o r m i t r a l l e a f l e t s a r e obtained. It is p o s s i b l e to make r e c o r d i n g s f r o m the left v e n t r i c u l a r outflow t r a c t and s o m e t i m e s f r o m the a o r t i c v a l v e - c u s p s . 4, 5
ULTRASOUND CARDIOGRAM FROM THE ANTERIOR MITRAL LEAFLETS. A normal ultrasound cardiogram of the movements of the anterior mitral leaflet is shown in Fig 4. Phase 1 represents the atrial systole; phase 2 the systolic wave; phase 3 the opening wave; phase 4 the movement towards closure during the early and rapid ventricular filling; phase 5 the slow ventricular filling. An upstroke of the ultrasound cardiogram represents a movement of the echo source towards the crystal on the anterior chest wall. A downstroke of the curve represents a movement of the echo source away from the crystal. E represents the most ventral position attained by the echo-source, and C represents the most dorsal position.
P h a s e II Fig 4
2
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5
i
The n o r m a l ultrasound c a r d i o g r a m of the m o v e m e n t s of the a n t e r i o r m i t r a l leaflet. Simultaneous r e c o r d ings of e l e c t r o c a r d i o g r a m , apex p h o n o c a r d i o g r a m (Phono-apex) and ultrasound c a r d i o g r a m (UCG). Upstroke of UCG-curve r e p r e s e n t s m o v e m e n t of e c h o s o u r c e t o w a r d s the c r y s t a l . Downstroke r e p r e s e n t s m o v e m e n t away f r o m the c r y s t a l . P a p e r s p e e d 100mm/sec M z = m i t r a l component of the f i r s t h e a r t sound. A = atrial wave. B-C = m o v e m e n t of the a n t e r i o r m i t r a l leaflet t o w a r d s c l o s e d position during e a r l y v e n t r i cular s y s t o l e . Point C coincides with M z. C-D = the c l o s e d position of the a n t e r i o r m i t r a l leaflet during v e n t r i c u l a r systole. D-E = opening m o v e m e n t of the a n t e r i o r m i t r a l leaflet. E - F = the r a p i d diastolic downstroke during the period of rapid v e n t r i cular filling. F o s e e text. P h a s e s 1-5, s e e text
In n o r m a l c a s e s and in c a s e s of h e a r t d i s e a s e without m i t r a l s t e n o s i s the m o v e m e n t of the a n t e r i o r m i t r a l leaflet after the m a x i m u m opening in e a r l y d i a s t o l e o c c u r s at a s p e e d of m o r e than 8 0 m m / s e c . 3 , 6-8 The s p e e d m e a s u r e m e n t s f r o m the r e c o r d s of 53 n o r m a l c a s e s ranged f r o m 9 0 - 1 9 0 m m / s e c , mean 1 4 0 m m / s e c (Table 1). The t i m e i n t e r v a l between point E and point F v a r i e d from 0. 105sec to 0 . 1 6 s e c , with a mean 0 . 1 3 s e c . 9, lo
P h a s e 1. A t r i a l w a v e .
P h a s e 5. Slow v e n t r i c u l a r filling p e r i o d
The A wave is c a u s e d by a t r i a l activity, which is shown by its d i s a p p e a r a n c e in a t r i a l fibrillation and its r e l a t i o n to
This phase r e p r e s e n t s the late p a s s i v e v e n t r i c u l a r filling, and ends at the next A wave, or at the onset of the next main ULTRASONICS A p r i l 1967
73
s y s t o l i c wave. In s o m e c a s e s the t r a c i n g shows an u p s t r o k e of s h o r t duration and low amplitude i m m e d i a t e l y a f t e r point F.
Fig 6
The total amplitude of the m o v e m e n t of the a n t e r i o r m i t r a l leaflet between the c l o s e d position and the m a x i m u m opening in e a r l y diastole (the d i s t a n c e C - E on the tracing) v a r i e d f r o m 20mm to 33mm, with an a v e r a g e of 27mm. 9, lo
Relation b e t w e e n the s p e e d of diastolic d o w n s t r o k e E - F on the UCG t r a c i n g and the s i z e of the m i t r a l o r i f i c e , e s t i m a t e d at operation, in 84 c a s e s of pure m i t r a l s t e n o s i s without calcification. The s p e e d of d i a s t o l i c d o w n s t r o k e in 15 c a s e s of slight m i t r a l s t e n o s i s is shown at the r i g h t of the figure
ULTRASOUND CARDIOGRAM FROM THE ANTERIOR MITRAL L E A F L E T IN MITRAL STENOSIS. In m i t r a l s t e n o s i s the a p p e a r a n c e of the t r a c i n g of the ant e r i o r m i t r a l leaflet is e n t i r e l y different. The quick c o m p o nent, E - F , in e a r l y d i a s t o l e is lacking 11 (Fig 5). Point E indicating the abrupt c e s s a t i o n of the opening m o v e m e n t s of the a n t e r i o r m i t r a l leaflet c o i n c i d e s with the opening snap. F r o m point E the t r a c i n g shows a slow fall which, as a rule, continues as far as wave A o r point B (in c a s e s of a t r i a l fibrillation). Wave A is usually s m a l l and in m o s t c a s e s t h e r e is only the downstroke, A-B (Fig 5).
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Ultrasound c a r d i o g r a m of the m o v e m e n t s of the a n t e r i o r m i t r a l leaflet in a c a s e of pure m i t r a l s t e n o s i s with sinus rhythm. Simultaneous r e c o r d i n g s of e l e c t r o c a r d i o g r a m , apex p h o n o c a r d i o g r a m (Phono-apex) and ultrasound c a r d i o g r a m (UCG). P a p e r s p e e d 100mm/sec. 1 = f i r s t h e a r t sound. 2 = second h e a r t sound. ASM = a t r i a l s y s t o l i c m u r m u r . U p s t r o k e of the UCG-curve r e p r e s e n t s m o v e m e n t t o w a r d s the c r y s t a l . Downstroke r e p r e s e n t s m o v e ment away f r o m the c r y s t a l . A = a t r i a l wave. E = position of m a x i m a l opening in e a r l y diastole. E coincides with opening snap, OS. The n o r m a l r a p i d downstroke E - F is r e p l a c e d by a slow fall as far as wave A. The s p e e d of the diastolic downstroke is 26mm/sec. The downstroke A - B coincides with the a t r i a l s y s t o l i c m u r m u r , ASM
s u r e of the m i t r a l o r i f i c e . Fig 6 shows the r e l a t i o n between the s p e e d of the diastolic downstroke and the s i z e of the m i t r a l o r i f i c e e s t i m a t e d in 84 c a s e s of pure m i t r a l s t e n o s i s without calcification in the leaflets. T h e r e is also a group of 15 c a s e s with a s y m p t o m a t i c slight m i t r a l s t e n o s i s . In the m o s t tight m i t r a l s t e n o s i s the s p e e d of the diastolic downstroke, E - F , n e v e r e x c e e d s 1 4 m m / s e c . In the group without c a l c i f i c a t i o n s and with an o r i f i c e above 1 . 8 c m 2 the s p e e d of the d i a s t o l i c d o w n s t r o k e is n e v e r below 1 6 m m / s e c . 9, lo In m i t r a l s t e n o s i s , with a m o d e r a t e or high d e g r e e of c a l c i fication, the s p e e d of the diastolic downstroke is slow even in c a s e s with a m i t r a l o r i f i c e m e a s u r i n g 1 . 3 - 2 . 3 c m 2. The r e a son for this slow velocity is p e r h a p s a 'functional s t e n o s i s ' on account of the rigidity in the valve apparatus.
s t e n o s i s or m i t r a l s t e n o s i s a s s o c i a t e d with insignificant m i t r a l regurgitation, in 150 c a s e s of combined m i t r a l s t e n o s i s and regurgitation, and in 154 c a s e s of m i t r a l s t e n o s i s a s s o c i ated with aortic valve l e s i o n s . In only 13 c a s e s of m i t r a l s t e n o s i s was it i m p o s s i b l e to r e c o r d the typical t r a c i n g f r o m the a n t e r i o r roitral leaflet. Neither have we found this c h a r a c t e r i s t i c t r a c i n g in c a s e s other than m i t r a l s t e n o s i s .
R i g i d i t y o r c a l c i f i c a t i o n of t h e v a l v e
The degree of mitral stenosis
Ultrasound cardiogram after mitral commissurotomy
Since the introduction of ultrasound cardiography this method has been of value for the pre-operative evaluation of mitral stenosis. The speed of diastolic downstroke, E-F, is a m e a -
The ultrasound c a r d i o g r a m also p e r m i t s quantitative evaluation of the o p e r a t i v e r e s u l t s . The s p e e d of the diastolic downstroke, E - F , is m o r e rapid a f t e r m i t r a l c o m m i s s u r o -
74
ULTRASONICS April 1967
The total amplitude of the m o v e m e n t of the a n t e r i o r m i t r a l leaflet between the c l o s e d position during v e n t r l c u l a r s y s t o l e and the position of m a x i m u m opening in e a r l y d i a s t o l e (the d i s t a n c e C-E on the tracing) is a m e a s u r e of the rigidity of the valve. In c a s e s without calcification the total amplitude v a r i e s between 20mm and 30mm, which i s in the n o r m a l range. In c a s e s of a high d e g r e e of c a l c i f i c a t i o n the total amplitude is only 15mm or below.9, lo Fig 7.
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In t h e s e l a t t e r c a s e s of m i t r a l s t e n o s i s , with a total a m p l i tude of 1 5 m m or below, a c o n v e n t i o n a l c o m m i s s u r o t o m y by the c l o s e d t e c h n i q u e h a s not b e e n effective. Open h e a r t s u r g e r y i s r e c o m m e n d e d in t h e s e c a s e s .
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t o m y . Only in a few c a s e s , h o w e v e r , i s t h e p o s t o p e r a t i v e s p e e d e n t i r e l y n o r m a l . In the c a s e s without c a l c i f i c a t i o n t h e p o s t o p e r a t i v e s p e e d of the d i a s t o l i c d o w n s t r o k e i n c r e a s e s m o r e t h a n in the c a s e s with c a l c i f i c a t i o n . In 78 c a s e s w i t h out c a l c i f i c a t i o n , the m e a n p r e o p e r a t i v e s p e e d w a s 1 5 . 8 m m / s e c and the m e a n p o s t o p e r a t i v e s p e e d w a s 4 4 m m / s e c . In 18 c a s e s with e x t e n s i v e c a l c i f i c a t i o n and a total a m p l i t u d e of 15mm, or below, the m e a n p r e - o p e r a t i v e s p e e d w a s 10.3 m m / s e c with a p o s t o p e r a t i v e s p e e d of 2 9 . 9 m m / s e c .
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ULTRASOUND CARDIOGRAM FROM THE ANTERIOR M I T R A L L E A F L E T IN PURE M I T R A L REGURGITATION.
T r a c i n g s f r o m a c a s e of m i t r a l s t e n o s i s with e x t e n s i v e c a l c i f i c a t i o n c o n f i r m e d by s u r g e r y . S i m u l t a n e o u s r e c o r d i n g s of e l e c t r o c a r d i o g r a m , apex p h o n o c a r d i o g r a m ( P h o n o - a p e x ) and u l t r a s o u n d c a r d i o g r a m (UCG) of the m o v e m e n t of the a n t e r i o r m i t r a l leaflet. Paper speed 50mm/sec.
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The total a m p l i t u d e of m o v e m e n t b e t w e e n c l o s e d p o s i tion (C) and the p o s i t i o n of m a x i m a l o p e n i n g (E) i s 13mm. A b b r e v i a t i o n s a s in F i g 4 and 5
Fig 8
In p u r e m i t r a l r e g u r g i t a t i o n the s p e e d of m o v e m e n t of the a n t e r i o r m i t r a l l e a f l e t d u r i n g the r a p i d left v e n t r i c u l a r f i l l ing p h a s e i s n o r m a l or i n c r e a s e d . 9 Fig 8 is a r e c o r d f r o m a p a t i e n t with p u r e m i t r a l r e g u r g i t a tion. In a g r o u p of 8 c a s e s of s e v e r e p u r e m i t r a l r e g u r g i t a t i o n the m e a n s p e e d of the a n t e r i o r m i t r a l l e a f l e t w a s 1 5 8 m m / s e c r a n g e 2 2 3 - 9 2 m m / s e c . T h e total a m p l i t u d e , C - E , w a s 30-39 mm, mean 34mm. In a n o t h e r g r o u p of 9 p a t i e n t s with s l i g h t or m o d e r a t e p u r e m i t r a l r e g u r g i t a t i o n the s p e e d of m o v e m e n t of the a n t e r i o r m i t r a l leaflet varied between 2 1 0 - 8 0 m m / s e c , mean 151ram/ s e c . The total a m p l i t u d e w a s 2 5 - 3 5 m m , m e a n 3 1 m m . Conclusions
T r a c i n g s f r o m a p a t i e n t with p u r e m i t r a l r e g u r g i t a tion. 1 = f i r s t h e a r t sound. 2 = s e c o n d h e a r t sound. 3 = t h i r d h e a r t sound. SM = s y s t o l i c m u r m u r . DM = d i a s t o l i c m u r m u r . A b b r e v i a t i o n s on the UCG t r a c i n g a s in F i g u r e s 4 and 5. The s p e e d of d i a s t o l i c downs t r o k e is l l 5 m m / s e c . T h e total a m p l i t u d e C - E is 33mm.
In p u r e m i t r a l r e g u r g i t a t i o n the s p e e d of m o v e m e n t of the a n t e r i o r m i t r a l l e a f l e t d u r i n g the v e n t r i c u l a r filling p e r i o d is n o r m a l or s l i g h t l y i n c r e a s e d . T h e m a x i m u m a m p l i t u d e b e t w e e n the c l o s e d p o s i t i o n and the m a x i m u m opening in e a r l y d i a s t o l e i s in m a n y c a s e s g r e a t e r t h a n n o r m a l . In c a s e s with s e v e r e m i t r a l r e g u r g i t a t i o n the total a m p l i t u d e i s 3 0 m m or m o r e . 9
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ULTRASOUND CARDIOGRAM FROM THE ANTERIOR M I T R A L L E A F L E T IN COMBINED M I T R A L STENOSIS AND REGURGITATION W h e n m i t r a l s t e n o s i s and i n s u f f i c i e n c y c o e x i s t it i s difficult to e s t i m a t e the dordinant l e s i o n f r o m the a u s c u l t a t o r y s i g n s . In t h e s e c a s e s the u l t r a s o u n d c a r d i o g r a m f r o m the a n t e r i o r m i t r a l l e a f l e t is v a l u a b l e . 9 T a b l e 1 s h o w s the data of a g r o u p of 15 c a s e s with c o m b i n e d m i t r a l s t e n o s i s and r e g u r g i t a t i o n .
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In c a s e 1 t h e r e w a s no e n d - d i a s t o l i c p r e s s u r e g r a d i e n t a c r o s s the m i t r a l valve. In c a s e s 2-6 the d i a s t o l i c p r e s s u r e g r a d i e n t b e t w e e n the left a t r i u m and the left v e n t r i c l e indic a t e s only a s l i g h t o r m i l d s t e n o s i s . In c a s e s 7-8 the high d i a s t o l i c p r e s s u r e g r a d i e n t i n d i c a t e s p r e d o m i n a t i o n of mitral stenosis. T h e s e d a t a t o g e t h e r with the r e s u l t of left v e n t r i c u l o g r a p h y and the d i a g n o s i s c o n f i r m e d at o p e r a t i o n (in 7 c a s e s ) show the r e l a t i o n b e t w e e n r e g u r g i t a t i o n and s t e n o s i s . UCG fiDdings
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Tracings from a patient with combined mitral sienaFig 10 Tracings from a patient with combined mitral stenosis and regurgitation with atrial fibrillation. Case no 3 sis and regurgitation with atrial fibrillation. Case table 1 no 8 table i. Symptomsclassified to group IV. Clinical and haemodynamic data are shown in table I. (a) Simultaneous recordings of electrocardiogram (ECG), apex phonocardiogram (Phone-apex), and (a) Simultaneous recordings of electrocardiogram and ultrasound cardiogram (UCG). Paper speed 50mm/ apex phonocardiogram (Phone-apex). SM = holosyssec. relic murmur, DM -- mitral diastolic murmur, aS = SM = holosystolic murmur, DM = mitral diastolic opening snap. Paper speed 100mm/see. murmur during rapid flow phase, aS -- opening snap, and 3 -- third heart sound. 1 = first heart sound. 2 = Ist -- first heart sound. 2nd = second heart sound second heart sound. (b) Simultaneous recordings of electrocardiogram, Ultrasound cardiogram: the speed of diastolic downphonocardiogram and ultrasound cardiogram (UCG) stroke is 33mm/sec. There is a slight degree of of the movement of the anterior mitral leaflet. Paper stenosis. Total amplitude C-E is 27ram. speed 50ram/see. The speed of diastolic downstroke (b) Simultaneously recorded left atrial and left venis 9mm/sec. Total amplitude 17ram tricular pressure pulses. The left atrial pressure (c) Simultaneously recorded left atrial (LA) and left pulse shows characteristics of both stenosis and reventricular (LV) pressure pulses shows a high presgurgitation. During short cycle lengths the pressure sure gradient across the mitral valve during diastole gradient (shaded area) between the atrium and ventri(shaded area). End-diastolic pressure gradient is cle continues throughout diastole, whereas during 32mmHg. Paper speed 40mm/sec long cycle lengths (>0.4sec) there is no end-diastolic gradient, but there is a high peaked V-wave. The period without an end-diastolic gradient corresponds Summary to the phase F-B of the UCG-curve. Auscultation: m i t r a l s t e n o s i s and m i t r a l r e g u r g i t a t i o n P r e s s u r e r e c o r d i n g s : c h a r a c t e r i s t i c for m i t r a l s t e n o s i s Left v e n t r i c u l o g r a p h y : s l i g h t r e g u r g i t a t i o n The clinical and haemodynamic data for this patient are shown in table i. Left ventricular angiogram UCG: tight m i t r a l s t e n o s i s , 9 m m / s e c . Rigidity, the showed a moderate regurgitation. At operation fitotal amplitude is 1Tmm brotic leaflets were found with shortened and At o p e r a t i o n the o r i f i c e was open for t w o - t h i r d s of thickened chordae tendineae. The orifice was open a f i n g e r - t i p . C a l c i f i c a t i o n s of the l e a f l e t s for 2 I/2 fingers
ULTRASONICS A p r i l 1967
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Fig 11 T r a c i n g s r e p r e s e n t i n g the action of the m i t r a l and t r i c u s p i d v a l v e s in a c a s e of a t r i a l septal defect. The c r y s t a l was applied to the f o u r t h left i n t e r s p a c e 5cm f r o m the m i d s t e r n a l line Ca) and (b) A n t e r o p o s t e r i o r beam d i r e c t i o n . (a) S m a l l s c a l e p i c t u r e . AM = a n t e r i o r cusp of the m i t r a l valve. The m i n i m u m and m a x i m u m d i s t a n c e s between AM and C ( r e p r e s e n t i n g the c r y s t a l on the a n t e r i o r c h e s t wall) a r e 8 . 0 c m and 10.3cm, r e s p e c t i v e l y . IVS = i n t e r v e n t r i c u l a r s e p t u m . (b) T r a c i n g AM to b i g g e r s c a l e (c) While the r e c o r d i n g of t r a c i n g AM is in p r o g r e s s , the d i r e c t i o n of the beam is a l t e r e d so as to d i v e r g e 15-20 ° medially f r o m the a n t e r o p o s t e r i o r line. At t h i s point t r a c i n g AM d i s a p p e a r s to be r e p l a c e d by t r a c i n g T r e p r e s e n t i n g the a n t e r i o r leaflet of the t r i c u s p i d valve. The m i n i m u m and m a x i m u m d i s t a n c e between T and C a r e 4 . 5 c m and 8cm, r e s p e c t i v e l y
6
(d) T r a c i n g T to g r e a t e r s c a l e
In c a s e s no 2-6, with a slight e n d - d i a s t o l i c p r e s s u r e g r a d i ent the s p e e d of the diastolic downstroke on the UCG t r a c i n g r a n g e d f r o m 20-43 m m / s e c , mean 3 3 m m / s e c . The two c a s e s (7, 8) with p r e d o m i n a n t m i t r a l s t e n o s i s , showed a s p e e d of only 1 1 m m / s e c and 9 m m / s e c r e s p e c t i v e l y . The total amplitude was n o r m a l in c a s e s 1-4, without c a l c i fication. In c a s e s no 5, 7-9, with a high d e g r e e of c a l c i f i c a tion, the total amplitude r a n g e d between 10mm and 17mm, with a m e a n of 14mm. The r e m a i n i n g 6 c a s e s (no 10-15) w e r e a s y m p t o m a t i c . The s p e e d of m o v e m e n t of the a n t e r i o r m i t r a l leaflet during the left v e n t r i c u l a r filling p e r i o d v a r i e d between 3 5 m m / s e c and 7 0 m m / s e e , mean 4 9 m m / s e c .
The total amplitude in t h e s e c a s e s was 22-32mm, with a mean of 27ram. F i g s 9 and 10 show two c a s e s of c o m b i n e d m i t r a l s t e n o s i s and r e g u r g i t a t i o n .
Conclusions In combined mitral stenosis and regurgitation the ultrasound cardiogram from the anterior mitral leaflet shows the degree of stenosis. As a high degree of regurgitation cannot be combinedwith a high degree of stenosis the ultrasound cardiogram is a valuable parameter for differentiatingbetweenpredominant mitral regurgitation and predominant mitral stenosis.
Fig 12 P e r i c a r d i t i s with effusion Ca) Before a s p i r a t i o n . Distance between p e r i c a r d i u m and a n t e r i o r wall of v e n t r i c l e as s e e n in UCG is due to accumulation of fluid (b) A f t e r a s p i r a t i o n . D i s t a n c e r e d u c e d a f t e r a s p i r a t i o n .
a Pericardium Ant. w a l l of t h e ventricle
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RIGHT VENTRICULAR DILATATION In n o r m a l c a s e s a c o m p l e t e p a t t e r n of t r i c u s p i d motion is difficult to obtain. However in p a t i e n t s with right v e n t r i c u l a r dilatation t r a c i n g s r e p r e s e n t i n g the a n t e r i o r t r i c u s p i d leaflet a r e r e c o r d e d without difficulty. This c u r v e is r e c o r d e d with the t r a n s d u c e r placed in the fourth or fifth left i n t e r s p a c e , 4 - 5 c m f r o m the m i d s t e r n a l line, and the beam d i r e c t e d tow a r d the spine. 3-5 The configuration of the t r i c u s p i d p a t t e r n is s i m i l a r to that e s t a b l i s h e d as the n o r m a l configuration of the a n t e r i o r m i t r a l leaflet. The t r i c u s p i d t r a c i n g r e p r e s e n t s a s t r u c t u r e lying a n t e r i o r and medial to the m i t r a l echo. The t r a c i n g s of the i n t e r v e n t r i c u l a r septum and the a n t e r i o r m i t r a l leaflet a r e in t h e s e c a s e s situated d e e p e r than n o r mal 3-5 Fig II. T h e s e s i g n s of r i g h t v e n t r i c u l a r dilatation and a s a t i s f a c t o r y t r i c u s p i d c u r v e can usually be obtained f r o m patients with pulmonary hypertension; an a t r i a l septal defect, with or without pulmonary hypertension; and m i t r a l s t e n o s i s with pulm o n a r y h y p e r t e n s i o n . In m i t r a l s t e n o s i s with pulmonary h y p e r t e n s i o n the typical c u r v e of m i t r a l s t e n o s i s is r e c o r d e d t o g e t h e r with the s i g n s of right v e n t r i c u l a r dilatation. It s e e m s i m p o s s i b l e to obtain continuous r e c o r d i n g s of the m o v e m e n t of the t r i c u s p i d ' l e a f l e t f r o m p a t i e n t s with pulmona r y valve s t e n o s i s .
78
ULTRASONICS A p r i l 1967
In t r i c u s p i d s t e n o s i s the s p e e d of d i a s t o l i c d o w n s t r o k e of the m o v e m e n t of the a n t e r i o r t r i c u s p i d l e a f l e t is r e s t r i c t e d in the s a m e m a n n e r a s the m i t r a l m o v e m e n t in m i t r a l s t e n o s i s . 1 3
4
Edler, I., 'The diagnostic u s e of u l t r a s o u n d in h e a r t d i s e a s e ' in ' U l t r a s o n i c e n e r g y ' (edited by Kelly, E.) Chicago (1965) U n i v e r s i t y of Illinois
U l t r a s o u n d c a r d i o g r a p h y is v a l u a b l e for d e t e c t i n g r i g h t v e n t r i c u l a r dilatation, for d i f f e r e n t i a t i n g an a t r i a l s e p t a l defect f r o m p u l m o n a r y valve s t e n o s i s or f r o m m i t r a l s t e n o s i s and f o r diagnosing t r i c u s p i d s t e n o s i s .
5
Edler, I., ' C a r d i a c s t u d i e s by u l t r a s o u n d s ' in ' C a r d i o logy. An encyclopedia of the c a r d i o v a s c u l a r s y s t e m ' (edited by Luisada, Aldo A.) Supplement i, 4, 410. M c G r a w - H i l l , New York (1962)
6
Edler, I. and Gustafson, A., ' U l t r a s o n i c c a r d i o g r a m in mitral stenosis', Acta Medica Scandinavica, 159, 85 (1957)
THE DIAGNOSIS OF PERCARDIAL EFFUSION.
7
Effert, S., ' D e r d e r z e i t i g e Stand d e r U 1 t r a s c h a l l k a r d i o g r a p h i e ' , A r c h i v fur K r e i s l a u f f o r s c h u n g , 214 (1959)
U l t r a s o u n d is a v a l u a b l e method of d e t e c t i n g o r excluding p e r i c a r d i a l effusion. In 22 c a s e s we have been able to dem o n s t r a t e the p r e s e n c e of p e r i c a r d i a l fluid in the a n t e r i o r r e g i o n of the p e r i c a r d i u m . Normally, the echo s i g n a l s f r o m the c h e s t wall, f r o m the p e r i c a r d i u m , and f r o m the a n t e r i o r wall of the r i g h t v e n t r i c l e m e r g e into one. In the p r e s e n c e of effusion t h e r e is a c l e a r a r e a between the echo r e f l e c t e d f r o m the p e r i c a r d i u m and the echo r e f l e c t e d f r o m the a n t e r i o r wall. 4, s, 14- 16 (Fig 12). The i n t e r v e n i n g i n t e r v a l between the two s e p a r a t e d e c h o e s is a m e a s u r e of the amount of fluid in the p e r i c a r d i u m .
8
J o y n e r , C. R., Reid, J. M. and Bond, J. P., ' R e f l e c t e d u l t r a sound in the a s s e s s m e n t of m i t r a l valve d i s e a s e ' , C i r culation 27, 503 (1963)
9
Edler, I., ' M i t r a l valve function studied by the u l t r a sound echo method' in ' D i a g n o s t i c u l t r a s o u n d ' , P r o c e e d ings of the I s t I n t e r n a t i o n a l C o n f e r e n c e (edited by G r o s s m a n , C. C. et al), P l e n u m P r e s s , New York (1966) 198
10
Edler, I., ' U l t r a s o u n d c a r d i o g r a p h y in m i t r a l valve s t e n o s i s ' , A m e r i c a n J o u r n a l of Cardiology, 19, 18 (1967)
11
Edler, I., ' U 1 t r a s o u n d c a r d i o g r a m in m i t r a l v a l v u l a r d i s e a s e ' , Acta C h i r u r g i c a Scandinavica, 3, 230 (1956)
12
M a r s h a l l , H. W., Woodward, E. and Wood, E. H., ' H e m o dynamic methods for d i f f e r e n t i a t i o n of m i t r a l s t e n o s i s and r e g u r g i t a t i o n ' , A m e r i c a n J o u r n a l of Cardiology, 2, 24 (1958)
13
Joyner, C. R., 'Reflected ultrasound in the diagnosis of tricuspid stenosis', American Journal of Cardiology, 19, 66 (1967)
14
Edler, I., 'The diagnostic use of ultrasound in heart disease', Acta Medica Scandinavica Supplement, 308, 32 (1955)
15
Effert, S. and Bleifeld, W. 'Diagnostic value of ultrasound reflection procedures in cardiology' in 'Diagnostic ultrasound', Proceedings of the Ist International Conference (edited by Grossman, C. C. et al) Plenum Press, New York (1966) 299
16
Joyner, C. R., 'Experience with ultrasound in the study of heart disease and the production of intracardiac sound' in 'Diagnostic ultrasound', Proceedings of the Ist International Conference (edited by Grossman, C. C. et al) Plenum Press, New York (1966) 237
17
Feigenbaum, H., Zaky, A. and Waldhausen, J. A., 'Use of reflected ultrasound in detecting pericardial effusion', American Journal of Cardiology, 19, 84 (1967)
Some a u t h o r s have d i a g n o s e d p e r i c a r d i a l fluid by d e m o n s t r a ting a c l e a r a r e a p o s t e r i o r to the moving p a t t e r n r e f l e c t e d f r o m the r e g i o n of the p o s t e r i o r v e n t r i c u l a r wall. 17 However, two s e p a r a t e d e c h o e s f r o m the p o s t e r i o r r e g i o n of the h e a r t a r e often obtained in n o r m a l c a s e s . This is the c a u s e of r e p o r t e d ' f a l s e p o s i t i v e ' r e c o r d i n g s . We have n e v e r obtained 'false positive' in looking for fluid anterior to the heart.
REFERENCES
1
Edler, I. and Hertz, C. H., ' T h e use of u l t r a s o n i c r e f l e c t o s c o p e for the continuous r e c o r d i n g of m o v e m e n t s of the h e a r t w a l l s ' , Kungliga F y s i o g r a f i s k a S~illskapets i Lund, F S r h a n d l i n g a r , 24, 5 (1954)
2
Effert, S., Hertz, C. H. and Bohme, W., ' D i r e k t e R e g i s t r i e r u n g d e s U l t r a s c h a l l k a r d i o g r a m m e s m i t dem E l e k t r o k a r d i o g r a p h e n ' , Z e i t s c h r i f t fiir K r e i s l a u f f o r s c h u n g , 48, 230 (1959)
3
Edler, I., Gustafson, A., K a r l e f o r s , T. and C h r i s t e n s s o n , B., ' U l t r a s o u n d c a r d i o g r a p h y ' , Acta M e d i c a Scandinavica, Supplement 370 (1961)
ULTRASONICS A p r i l 1967
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