- Email: [email protected]
Upstroke time ratio in valvular aortic insufficiency
Upstroke
Time
Aortic GUY
M.
BOITEAU,
M.D.,?
Ratio
Insufficiency*
ALBERT
J. LIBANOFF, Duarte,
W
still
HILE
assessment
sufficiency inaccurate,
validate
pre-
concept
progress and
insufficiency,
measure
is
aortic
stenosis
has
to The
stenosis been
time
ratio
Observed
de-
secondary
in valvular
U.l’.
U.T. is the measured upstroke time on the pressure tracing, and RI-R2 is the measured interval between peaks of successive R waves in the electrocardiogram. The normal upstroke time is 0.10 to 0.16 sec. in the systemic artery, and 0.18 to 0.24 sec. in the central aorta. s The @stroke time ratio was calculated as follows:
and as a myocardial
involvement. MATERIALS
M.D.
dR-2
as an indirect
of regurgitation,
in evaluating
J. ALLENSTEIN,
Calif.
we seek to demonstrate
particularly
of the degree
is
made
results.
~I.D. and BERTRAM
“upstroke time.” The systolic ejection time was measured from the onset of the pulse pressure after the isometric contraction to the dicrotic notch.sJO Corrected aortic and radial artery upstroke times were calculated from the following formula:
in-
methods
being
valvular
aortic
of the upstroke
useful index
valvular
time ratio as a means for
In this paper
the value
aortic
postoperative
between
subvalvular
scribed.’ aortic
of
hemodynamic
of the upstroke
differentiating and
by
in Valvular
AND METHOD
‘These studies were made during diagnostic catheterization of the left side of the heart by percutaneous femoral puncture2 (retrograde) and/or by the transseptal route3 (forward). The patients were supine, fasting and premeditated with 100 mg. of intramuscular hydroxyzine hydrochloride. Pressures were recorded by means of a Statham strain gauge,4 P23AA, and multichannel photographic DR-8 recorder. Radial artery pressures were secured in the following manner : An indwelling 19-T gauge needle was advanced percutaneously into the radial artery under oscilloscopic observation. The needle was attached to 32 cm. of polyethylene tubing (1.77 mm. inside diameter) which was connected to a hypodermic string gauge manometer system described previously.5 Intermittent flushing of the manometer system was carried out to prevent formation of clots in the needle and catheter by means of a pressure bottle filled with sterile saline solution containing heparin. A 125 cm., No. 7, NIH catheter was used to obtain the central aortic pressures (retrograde femoral puncture). Cardiac output was calculated by the Fick method” and from indicator dilution curves by the methods of Stewart’ and Hami1ton.s The time elapsing from the onset of the pulse after isometric contraction to the peak of the curve was called “build-up time” or
Corrected
U.T.
Radial
Artery
Corrected
U.T.
Central
Aorta
when both arterial curves were recorded taneously at a speed of 50 and 75 mm. /sec. CLASSIFICATION
simul-
OF PATIENTS
Forty-six subjects were studied, 15 normal and 31 with the diagnosis of pure aortic valvular regurgitation. These patients were chosen under the following conditions: (1) There was no systolic pressure gradient across the aortic valve or the left ventricular outflow area; (2) no significant involvement of an)other cardiac valve was present as determined by electrocardiogram, vectorcardioclinica findings, gram, phonocardiogram and a combined right and left heart catheterization, including indicator-dilution curves; (3) patients with significant cardiac arrhythsuch as atria1 fibrillation, were excluded mias, and (4) 8 patients with inadequate from this study; tracings, artefacts or damping were rejected. There is no completely reliable method for measuring valvular regurgitation in man. To determine aortic regurgitant flow, Indocyanine-Green was in.jected at various levels in the descending aorta, as described previously, when recording at the right
* From the Elsinore and George Machris Cardiac Hospital and Department Center, Duarte, Calif. f Present address: Institut de Cardiologie, H&pita1 La&, Quebec, Canada. 162
THE
of Cardiology,
AMERICAN
City of Hope Medical
JOURNAL
OF CARDIOLOGY
Upstroke
Time
Ratio
in Aortic
163
Insufficiency
ir
I
FIG. 1. Case 6 (Table I). Normal subject. All figures show prototype tracings of simultaneous recording of the radial artery (a) and ascending aorta (b) pressures. Corrected
upstroke time radial artery
Corrected upstroke time ascending aorta 0 12 sec. -~= 0.50 = 0.24 sec. radial artery. Patients were graded from 0 to IV as follows: Grade O-dye did not appear at right radial artery when injected into the descending aorta. Grade I-dye appeared at right radial artery when injected at 1 tb 5 cm. into the descending aorta. Grade n-dye appeared at right radial artery when injected at 5 to 10 cm. into the descending aorta. Grade m-dye appeared at right radial artery when injected at 10 to 15 cm. into the descending aorta. Grade Iv-dye appeared at right radial artery when injected at the diaphragmatic level, 15 cm. or more.
RESULTS NORMALSUBJECTS Seven male and eight female subjects ranging in age from 16 to 53 years, were studied (Table I). The corrected radial artery upstroke time varied from 0.11 to 0.16 sec.; corrected ascending aorta upstroke time, from 0.20 to 0.24 sec. (Fig. 1). The upstroke time ratio varied from 0.50 to 0.66 sec. Cardiac output ranged from 3.5 to 5.6 L./min., and cardiac index from 2.5 to 3.9 L./min./M2. Radial and central artery ejection time varied from 0.28 to 0.34 sec. (Fig. 1). PATIENTS WITH AORTIC INSUFFICIENCY Thirty-one VOLUME
14,
patients
AUGUST
1964
were
divided
into
two
FIG. 2.
o-
Case 8 (Table
t
Aortic insufficiency with low cardiac index and anacrotism on the radial pulse ascent (arrow). IIA).
Corrected upstroke time radial artery Corrected upstroke time ascending aorta 0.20 sec.
=
o,74
0.27 sec.
groups, one with low cardiac index, the other with normal cardiac index. (A) Patients with Low Cardiac Index (Table IIA) : There were 4 men and 5 women ranging in age from 36 to 57 years. The corrected upstroke time at the radial artery varied from 0.11 to 0.20 sec., and at the ascending aorta, from 0.21 to 0.31 sec. The upstroke time ratio ranged from 0.50 to 0.80. The cardiac output varied from 3.0 to 4.6 L./min., and the cardiac index from 1.5 to 2.5 L./min./M2. The radial and central artery ejection time ranged from 0.31 to 0.42 sec. In 4 patients, an anacrotic notch seen on the pulse ascent accounted for a higher upstroke time ratio (Fig. 2). Two patients (2a & 5a) had intermittent left bundle branch block during the cardiac study. (B) Patients with Normal Cardiac Index (Table IIB) : Twenty-two patients, 10 female and 12 male, ranging in age from 15 to 52 years, were studied. The radial artery corrected upstroke time varied from 0.08 to 0.14 sec., and the central aorta corrected upstroke time from 0.18
~‘patroh< Time Ralio
cue
Age
&
Sex
(yr.1
1F
16
-.
_~
22
2M
23
3M 4F
25 25
5F
25
6M 7F
31 31
9F
35
10M
35
1lF
40
12M 13F
50
14F
120
120
o-4
78
130
130
2-6
80
115
115
3-8
85
100
102
Z-9
56
117 S-10
117
51
55
125 O-14
125
53
13x
(96)
110
110 74
102
100
4-8
60
140
(94)
r3
105 4-l 5
5
110
108
(‘JO)
0 22
0.12
(1 54
0 2s
5X
37
(94!
0 20
0 1.3
n 65
0 31
48
3.0
(88)
(1 22
0.11
0 50
0 31
4.6
3 .(I
(66)
0.21
0 I2
0 55
n 33
5.6
33
(69)
0 21
0.12
0 55
0 33
3.5
25
(66)
0 24
0.12
0.50
0.32
4.4
3 1
(92)
0.23
0.15
0.66
0.30
4.6
3.1
(84)
0.21
0.14
0.66
0.30
5.2
3.3
(76)
0 23
0.14
0.61
0.32
5.2
3.4
(75)
0 22
0.13
0.59
0.34
4.8
3.3
(77)
0.24
0.16
0 66
0.34
4.1
2.6
(84)
0.21
0.13
0.62
0.28
5.5
3.9
(97)
0.20
0.12
0 60
0 31
4.8
3.2
(82)
0.22
0.13
0.59
0.32
3.6
2.6
(96)
0.22
0.13
0.59
0.28
5 .O
3.2
70 102
(6%
51 122
(72)
48 110
(70)
56 130
(98)
80 112
(87)
64 110
(80)
60
100
100 O-10
115
(76)
53
105
110
(82)
SO
4-b
65
140
140
O-8
70
118
117
110
(88)
63 144
(98)
68 120
(87)
68
64
150
145
9-l 5
78
150
(100)
67
TABLE Aortic
Case & SW
Agt: (yr.)
.-----Pressures Left Ventricle
(mm. Central .4orta
(86)
Radial Artery
42
2a .SM
43
110
108
4-24
70
92
90
4-22
54
130 9z13
4M 5F 5a
45 4s
147
131
(80)
With Low Card&
Ejection Time (s@=.) Radial Artery
Cardiac output (L./min.)
Cardiac Index (L./min./ M’.)
Grades o AWtiC hufficiency
Index
(8.3)
0.28
0 16
0 57
0.35
36
2.0
2
130
(72)
0 21
0.11
0.55
0 35
3.7
22
2
(65)
0.22
0.12
0.55
0 37
3.5
1.7
(76)
0.31
0.23*
0.74
0 36
3.2
1.5
3
(80)
0 28
0.19*
0 70
0.42
3.1
1.6
4
(70)
0 22
0 11
0 50
0.31
3.0
1.9
2
(67)
0 24
0.12
0.50
0.34
52 (70)
110 _ 48
(82)
x
135 3
150
lo-25
44
118
118
528
4R
110
110
5 120
Upstroke Time Ratio Radial Artery/ Central Aorta
-50
55 2M
140
II
Insufficiency
Corrected Upstroke Time (sec.) Central Radial Aorta Artery
Hg)v
A. 135
Cardiac Index (L./m&’ M*.)
76
85
o-5
Cardiac Output (L./min.)
76
96
O-8
o-9 15M
12s
(92)
48
96
29
8M
R:ididl Artrry
Left Ventricle
Rndhl Artzry,’ Central AW1.l
46
(85)
I60 40
(72)
124 48
(70)
118 4
THE
AMERICAN
JOURNAL
OF CARDIOLOGY
Upstroke
Time
Ratio
in Aortic
TABLE
II (cwztinw~)
Aortic
Insufficiency
Corrected Upstroke Time Case & Sex 6F 7F
Age (yr.) 49 50
-_-----Pressures Left Ventricle
(mm. CeIltKil Aorta
120
120
5-12
54
154
154
4-l 8 8F 9F
57 52
145
145
-5-16
ro
115
115
1lF 12M 13F 14M 15F 16F 17M 18F 19M 20F
15 15 16 16 18 21 22 22 24 26 27 29
23F 24F 25M 26M 27M 28F 29M 3bM 31F
31 32 33 34 38 39 41 52 58 58
100 O-10
86
14,
104 5-15
104
100
96
o-5
50
(86)
104 -z
(84)
0.24
0.12
(85)
0.27
(65)
0.24
B.
With Normal -
(87)
0.27
(55)
0.34
3.8
2.3
1
0.50
0.34
4.6
2.4
1
155
0.20*
0.74
0.42
3.8
2.2
3
(69)
123
0 20*
0.80
0.38
4.1
2.5
3
0.11
0.40
0.32
6.0
3.1
3
0.30
0.12
0.40
0.36
6.6
3.6
4
(65)
0.22
0.11
0.48
0.40
6.0
3.3
2
(64)
0.20
0.08
0.40
0.33
4.2
3.5
3
(68)
0.25
0.11
0.42
0.31
5.6
3.0
3
(80)
0.34
0.13
0.38
0.33
4.7
2.9
2
(70)
0.23
0.08
0.34
0.35
5.8
3.4
4
(76)
0.28
0.11
0.39
0.37
7.0
3.8
3
(80)
0.20
0.10
0.50
0.31
5.0
3.2
0
(68)
0.28
0.11
0.39
0.36
6.2
3.5
3
(76)
0.25
0.09
0.36
0.31
4.3
2.5
3
(70)
0.27
0.10
0.37
0.40
7.6
4.1
4
(62)
0.24
0.11
0.45
0.32
4.2
3.0
2
(87)
0.25
0.08
0.30
0.28
4.9
2.5
3
(90)
0.28
0.14
0.50
0.28
7.6
4.2
0
(72)
0.30
0.12
0.40
0.38
5.4
2.7
2
(70)
0.28
0.09
0.32
0.34
5.3
2.8
4
(93)
0.28
0.14
0.50
0.34
7.3
4.0
1
(94j
0.20
0.08
0.35
0.32
6.9
4.3
3
(67)
0.22
0.10
0.45
0.33
4.2
3.1
3
(80)
D.27
0.11
0.40
0.36
5.7
3.2
2
(90)
0.26
0.11
0.42
0.35
4.0
2.6
2
z
(92)
140
Cardiac Index
-
(60)
104 38
(70)
136
(70)
130 4s
(75)
135 0
135
135
2-10
55
130 8-12
130
(82)
140 0
(78)
135 44
52 120
(78)
140 40
io
112 4-8
112
(84)
130 60
65
133
135
4-14
-5i,
120
120
(70)
125
150 38
(80)
165 42
50 (77)
132 40
45
100
100
5-11
Ti
124
124
4-l 3
6
130 O-6
130
(64)
114 39
(88)
155 3
(98)
135 70
80 120
120 7-12
Xi
130
130
2-12
45
165
165
3-10
s
132 04
7
(76)
130 7
(75)
150 40
(98)
165 60
134
(95)
170 50
95
95
?il
50 120
3-8
rs
130
132
4-10
52
1964
0.12
Grades of Aortic I nsufficiency
s
104
120
0.21
Cardiac Index (L./min./ M2.J
48
0
4-24
AUGUST
168
44
125
(81)
Cardiac output (L&in.)
46
*All anacmtic notch present. 2a and 5a: with intermittent left bundle Figures in parenthexs = mean pressure.
VOLUME
124
Ejection Time (sec.) Radial Artery
s
10-15 22M
(90)
0
120 O-l 3
(sec.1 Radial hrtery
Upstroke Time Ratio Radial Artery/ Central Aorta
50
120
4-l 1 21M
(82)
40
120 O-6
Central Aorta
Radial Artery
50
IO-25
10M
Hg.)--
Insufficiency
(721
100 47
(85)
125 50
(92)
150 s
branch
block.
166
Boiteau,
Libanoti
and Allenstein
Y
0 75
Y \
0 70
\
0 65
0 60 0 c 2
0 55
$ c
0 50
lI_ z c
0.45
: 3 040
0
035
I
FIG. 3. Case 17 (Table IIB). normal cardiac index.
Aortic insufficiency with
0.30
\.
r.
Corrected upstroke time ascending aorta 0.11 sec. = ~ = 0.39 0.28 sec.
to 0.34 sec. The upstroke time ratio ranged from 0.32 to 0.50 sec. Cardiac output varied from 4.0 to 7.6 L./min., and cardiac index, from 2.5 to 4.3 L./min./M2. Central and radial systolic ejection time ranged from 0.28 The contour of the peripheral to 0.40 sec. pulse showed a sharp anacrotic rise to an early systolic peak with a decreased amplitude of the dicrotic wave (Fig. 3). COMMENTS Arterial pulse contour has been well studied in the past, particularly with aortic stenosis,“-l5 but simultaneous recording and comparative analysis of the central aorta and peripheral artery pressure is still not in routine use in many cardiac laboratories. ARTERIAL UPSTROKE STUDIES Peripheral arterial studies noting the pulse pressure, the diastolic pressure, or rapidity of the upstroke time frequently will not reveal a true picture of aortic regurgitation. Most of our patients had a normal upstroke time by Wide arterial pulse pressure Wood’s criteria.g
I
2
of Al CHF)
Grades (with
of AI CHF)
-* _-.
Grades of AI _-x with CHF ond macrofic nolch
0
I 0
Corrected upstroke time radial artery
0
Grades lwifhout
:
t
3
4
GRADE
FIN. 4. Upstroke time ratio scale in patients with different grades of aortic insufficiency (AI), with no evidence of congestive heart failure (CHF) and normal cardiac index. and with cardiac decompensation. See text.
is often seen in dynamic normal individuals, or those with hypertension or hyperthyroidism, and is not necessarily a stigma of aortic regurgitation. Diastolic pressure below 50 mm. Hg at the peripheral artery is usually seen in aortic insufficiency and often with arterial hypotension occurring during cardiac catheterization. Therefore, we feel that a combined study of central and peripheral pulses, such as upstroke time ratio, has more clinical value than that of perrpheral pulse alone. For example, in Figure 4, patients with grades III and IV regurgitant index are in the lower area of the upstroke time ratio scale, except for those in This is consistent with congestive heart failure. an increased myocardial contraction and a good ventricular compliance with an increased it sugejection ; consequently, ventricular gests good myocardial reserve. A patient with a ratio near 0.75 and no systolic pressure gradient across the aortic valve should be suspected of myocardial insufficiency because it reflects poor myocardial contraction and deTIIR AMERICANJOURNAL OF CARDIOLOGY
Upstroke
Time
Ratio
creased ventricular ejection. Cases with grades I and II regurgitant index have usually a ratio between 0.40 and 0.50, in keeping with a milder degree of valvular aortic insufliciency. Systolic ejection time is usually prolonged in both central and peripheral artery pressures in aortic stenosis and insufficiency. Diastolic overloading in aortic insufficiency increases the left ventricular work which results in prolongation of left ventricular systole and a delay in total systolic ejection time. In valvular aortic stenosis, left ventricular pressure is increased due to significant reduction of the aortic valve orifice ; this also increases left ventricular work and the total systolic ejection time. A prolonged total ejection time, caused by myocardial failure, seems to be a natural consequence of poor myocardial reserve. The mean value is slightly lower in our series of patients without clinical evidence of decompensation (0.36 sec.) than in those with decompensation (0.38 sec.). Benchimol et al.,lO expected the opposite phenomenon, i.e., decrease of the total ejection time. They stated that left heart failure of any cause, by decreasing the cardiac output and left ventricular stroke volume, tends to decrease the duration of ventricular systole. CLINICAL
SIGNIFICANCE
OF
UPSTROKE
TIME
RATIO
The importance of the simultaneous examination of aortic and peripheral pulses in health has been shown by Kroeker and Woodi and with aortic valvular stenosis by others.‘6 The comparative study of both pulses in aortic valvular insufficiency is also important, adding value to the other hemodynamic findings of this disease. Clinical aortic insufficiency is not a simple syndrome.17 Progressive changes in the myocardium, such as hypertrophy of the left ventricle or myocardial fibrosis, cause alterations in pulse contour which have no direct relations to the regurgitant valve. From Table II and Figure 4 we can review the influence of heart failure and bundle branch block on the upstroke time ratio in valvular aortic insufficiency. Heart Failure: The 9 patients in congestive heart failure, as reflected by low cardiac index, observed a strict cardiac regimen. Moderate to marked cardiomegaly was found by chest roentgenogram. Four of these patients showed an anacrotic notch near the systolic peak, without systolic pressure gradient across the aortic valve. The upstroke time ratio was then elevated and ranged from 0.70 to 0.80. The VOLUME
14,
AUGUST
1964
in Aortic
Insufficiency
167
other 5 patients showed a ratio within the lower limits of normal, from 0.50 to 0.57 (normal: 0.50 to 0.70). The left ventricular end-diastolic pressures were elevated in all these cases. High upstroke time ratio occurred because of the alterations in the pressure volume relationship of the ventricle due to marked diastolic overload and increased diastolic volume. Serial follow-up chest roentgenograms of these patients over the years showed gradual enlargement or dilatation of the left ventricle consistent with stretch or loss of elasticity of the myocardial fibers. Perhaps not only the diastolic overload but also chronic rheumatic fever may play a role in the alterations of the mechanical properties of the left ventricle. Autopsy data may reveal signs of chronic active rheumatic fever even without any clinical or laboratory findings during the patient’s life. Bundle Branch Block: Two patients were found to have intermittent left bundle branch block. One has already been described.‘* Autopsy revealed a markedly dilated left ventricle, with myocardial fibrosis but little coronary artery disease. In both patients the upstroke time ratio was higher than the usual range for significant aortic insufficiency. The arterial upstroke time was slightly higher with bundle branch block than with normal conduction, but was still in the normal range for both central and peripheral artery pulse. This suggests an important aspect of left bundle branch block, i.e., that slowing of intraventricular conduction and prolonged isometric contraction of the left ventricle result in decreased force and efficiency of the contraction. The systolic pressure of the central and peripheral pulses during isometric contraction of the left ventricle rises to a lower level with left bundle branch block than with left ventricular hypertrophy. This demonstrates that delay of conduction in the left ventricle results in a less effective myocardial contraction and a small stroke output. Consequently, the decreased amount and velocity of flow into the central aorta explains the more normal appearance of the pulse curve as compared to the pulse contour typical of aortic insufficiency. Prognostic Value: The upstroke time ratio as an isolated observation may also have significant prognostic value. For example, only 1 of the 4 patients with aortic insufficiency and a ratio near 0.75 is alive 16 months after completion of the hemodynamic study. An elevated upstroke time ratio indicates poor myocardial re-
Boitcau,
168 serve, and, therefore. be a grave risk.
Libanoti
and
open heart surgery would
%JMMARY
The upstroke time ratio has been studied in 15 normal controls and in 31 patients with pure aortic regurgitation and varying stages of myocardial involvement. The upstroke time ratio results were as follows: 15 normal subjects, 0.50 to 0.70; 31 patients with rheumatic aortic valvular insufficiency, of whom 9 had cardiac decompensation, 0.50 to 0.80; and 22 with no evidence of myocardial failure, 0.31 to 0.50. These patients were graded from 0 to IV, depending upon the degree of aortic regurgitation by the Braunwald method. Those with lower ratio had grade III and IV regurgitant index and were found to have good myocardial reserve. Others with grade III and IV and elevated ratio were classified as having poor myocardial reserve, and should be high surgical risks if open heart surgery is performed. The upstroke time ratio is an indirect measurement of aortic valvular regurgitation and is a useful index in evaluating secondar!. myocardial involvement.
4. i.
6.
7.
8.
9. 10.
11.
12. 13. 14.
ACKNOWLEDGMENT We gratefully acknowledge the technical assistance of Mr. Dick Ray, medical photographer, Mr. Curt Smolen, medical artist and Miss Vi Calzarett, medical secretary.
15.
16.
REFERENCES 1. BOITEALJ, G. M., BOURASSA, M. G. and ALL~NSTEIN, B. J. Upstroke time ratio. New concept in differentiating aortic and subaortic stenosis. :Zm. J. Cardiol., 11: 319: 1963. 2. SELDINGER, S. I. Catheter replacement of the needle in percutaneous arteriography. New technique. Acta radio/., 39: 368, 1953. 3. Ross, .I.. JR., BRAUNWALD,E. and MORROW, A. G.
17.
18.
Allenstein I‘ransseptal left atria1 puncture. New techniqut for the measurement of left atria1 pressure in man. .lm. -1. &r&o/., 3: 653, 1959. GLASSER, 0. Medical Physics, Vol. III. p. 641. Chicago. 1960. Yrar Book Publishers. \Vooo. 1:. H. and SUTTERER. \V. improved resistance wire strain-gauge manometers adaptable for biologic instruments. ./. Lab. & C/in. Mpd., 45: 153.1955. FICK. .4. Uber die Messung des Blut @anturns in den Herzventrikeln. Cited by HOFF, H. E. and SCOT?., .J. .I. Physiology (continued). .v
THE AMERICAN JOURNAL OF CARDIOLOGY
Time
Aortic GUY
M.
BOITEAU,
M.D.,?
Ratio
Insufficiency*
ALBERT
J. LIBANOFF, Duarte,
W
still
HILE
assessment
sufficiency inaccurate,
validate
pre-
concept
progress and
insufficiency,
measure
is
aortic
stenosis
has
to The
stenosis been
time
ratio
Observed
de-
secondary
in valvular
U.l’.
U.T. is the measured upstroke time on the pressure tracing, and RI-R2 is the measured interval between peaks of successive R waves in the electrocardiogram. The normal upstroke time is 0.10 to 0.16 sec. in the systemic artery, and 0.18 to 0.24 sec. in the central aorta. s The @stroke time ratio was calculated as follows:
and as a myocardial
involvement. MATERIALS
M.D.
dR-2
as an indirect
of regurgitation,
in evaluating
J. ALLENSTEIN,
Calif.
we seek to demonstrate
particularly
of the degree
is
made
results.
~I.D. and BERTRAM
“upstroke time.” The systolic ejection time was measured from the onset of the pulse pressure after the isometric contraction to the dicrotic notch.sJO Corrected aortic and radial artery upstroke times were calculated from the following formula:
in-
methods
being
valvular
aortic
of the upstroke
useful index
valvular
time ratio as a means for
In this paper
the value
aortic
postoperative
between
subvalvular
scribed.’ aortic
of
hemodynamic
of the upstroke
differentiating and
by
in Valvular
AND METHOD
‘These studies were made during diagnostic catheterization of the left side of the heart by percutaneous femoral puncture2 (retrograde) and/or by the transseptal route3 (forward). The patients were supine, fasting and premeditated with 100 mg. of intramuscular hydroxyzine hydrochloride. Pressures were recorded by means of a Statham strain gauge,4 P23AA, and multichannel photographic DR-8 recorder. Radial artery pressures were secured in the following manner : An indwelling 19-T gauge needle was advanced percutaneously into the radial artery under oscilloscopic observation. The needle was attached to 32 cm. of polyethylene tubing (1.77 mm. inside diameter) which was connected to a hypodermic string gauge manometer system described previously.5 Intermittent flushing of the manometer system was carried out to prevent formation of clots in the needle and catheter by means of a pressure bottle filled with sterile saline solution containing heparin. A 125 cm., No. 7, NIH catheter was used to obtain the central aortic pressures (retrograde femoral puncture). Cardiac output was calculated by the Fick method” and from indicator dilution curves by the methods of Stewart’ and Hami1ton.s The time elapsing from the onset of the pulse after isometric contraction to the peak of the curve was called “build-up time” or
Corrected
U.T.
Radial
Artery
Corrected
U.T.
Central
Aorta
when both arterial curves were recorded taneously at a speed of 50 and 75 mm. /sec. CLASSIFICATION
simul-
OF PATIENTS
Forty-six subjects were studied, 15 normal and 31 with the diagnosis of pure aortic valvular regurgitation. These patients were chosen under the following conditions: (1) There was no systolic pressure gradient across the aortic valve or the left ventricular outflow area; (2) no significant involvement of an)other cardiac valve was present as determined by electrocardiogram, vectorcardioclinica findings, gram, phonocardiogram and a combined right and left heart catheterization, including indicator-dilution curves; (3) patients with significant cardiac arrhythsuch as atria1 fibrillation, were excluded mias, and (4) 8 patients with inadequate from this study; tracings, artefacts or damping were rejected. There is no completely reliable method for measuring valvular regurgitation in man. To determine aortic regurgitant flow, Indocyanine-Green was in.jected at various levels in the descending aorta, as described previously, when recording at the right
* From the Elsinore and George Machris Cardiac Hospital and Department Center, Duarte, Calif. f Present address: Institut de Cardiologie, H&pita1 La&, Quebec, Canada. 162
THE
of Cardiology,
AMERICAN
City of Hope Medical
JOURNAL
OF CARDIOLOGY
Upstroke
Time
Ratio
in Aortic
163
Insufficiency
ir
I
FIG. 1. Case 6 (Table I). Normal subject. All figures show prototype tracings of simultaneous recording of the radial artery (a) and ascending aorta (b) pressures. Corrected
upstroke time radial artery
Corrected upstroke time ascending aorta 0 12 sec. -~= 0.50 = 0.24 sec. radial artery. Patients were graded from 0 to IV as follows: Grade O-dye did not appear at right radial artery when injected into the descending aorta. Grade I-dye appeared at right radial artery when injected at 1 tb 5 cm. into the descending aorta. Grade n-dye appeared at right radial artery when injected at 5 to 10 cm. into the descending aorta. Grade m-dye appeared at right radial artery when injected at 10 to 15 cm. into the descending aorta. Grade Iv-dye appeared at right radial artery when injected at the diaphragmatic level, 15 cm. or more.
RESULTS NORMALSUBJECTS Seven male and eight female subjects ranging in age from 16 to 53 years, were studied (Table I). The corrected radial artery upstroke time varied from 0.11 to 0.16 sec.; corrected ascending aorta upstroke time, from 0.20 to 0.24 sec. (Fig. 1). The upstroke time ratio varied from 0.50 to 0.66 sec. Cardiac output ranged from 3.5 to 5.6 L./min., and cardiac index from 2.5 to 3.9 L./min./M2. Radial and central artery ejection time varied from 0.28 to 0.34 sec. (Fig. 1). PATIENTS WITH AORTIC INSUFFICIENCY Thirty-one VOLUME
14,
patients
AUGUST
1964
were
divided
into
two
FIG. 2.
o-
Case 8 (Table
t
Aortic insufficiency with low cardiac index and anacrotism on the radial pulse ascent (arrow). IIA).
Corrected upstroke time radial artery Corrected upstroke time ascending aorta 0.20 sec.
=
o,74
0.27 sec.
groups, one with low cardiac index, the other with normal cardiac index. (A) Patients with Low Cardiac Index (Table IIA) : There were 4 men and 5 women ranging in age from 36 to 57 years. The corrected upstroke time at the radial artery varied from 0.11 to 0.20 sec., and at the ascending aorta, from 0.21 to 0.31 sec. The upstroke time ratio ranged from 0.50 to 0.80. The cardiac output varied from 3.0 to 4.6 L./min., and the cardiac index from 1.5 to 2.5 L./min./M2. The radial and central artery ejection time ranged from 0.31 to 0.42 sec. In 4 patients, an anacrotic notch seen on the pulse ascent accounted for a higher upstroke time ratio (Fig. 2). Two patients (2a & 5a) had intermittent left bundle branch block during the cardiac study. (B) Patients with Normal Cardiac Index (Table IIB) : Twenty-two patients, 10 female and 12 male, ranging in age from 15 to 52 years, were studied. The radial artery corrected upstroke time varied from 0.08 to 0.14 sec., and the central aorta corrected upstroke time from 0.18
~‘patroh< Time Ralio
cue
Age
&
Sex
(yr.1
1F
16
-.
_~
22
2M
23
3M 4F
25 25
5F
25
6M 7F
31 31
9F
35
10M
35
1lF
40
12M 13F
50
14F
120
120
o-4
78
130
130
2-6
80
115
115
3-8
85
100
102
Z-9
56
117 S-10
117
51
55
125 O-14
125
53
13x
(96)
110
110 74
102
100
4-8
60
140
(94)
r3
105 4-l 5
5
110
108
(‘JO)
0 22
0.12
(1 54
0 2s
5X
37
(94!
0 20
0 1.3
n 65
0 31
48
3.0
(88)
(1 22
0.11
0 50
0 31
4.6
3 .(I
(66)
0.21
0 I2
0 55
n 33
5.6
33
(69)
0 21
0.12
0 55
0 33
3.5
25
(66)
0 24
0.12
0.50
0.32
4.4
3 1
(92)
0.23
0.15
0.66
0.30
4.6
3.1
(84)
0.21
0.14
0.66
0.30
5.2
3.3
(76)
0 23
0.14
0.61
0.32
5.2
3.4
(75)
0 22
0.13
0.59
0.34
4.8
3.3
(77)
0.24
0.16
0 66
0.34
4.1
2.6
(84)
0.21
0.13
0.62
0.28
5.5
3.9
(97)
0.20
0.12
0 60
0 31
4.8
3.2
(82)
0.22
0.13
0.59
0.32
3.6
2.6
(96)
0.22
0.13
0.59
0.28
5 .O
3.2
70 102
(6%
51 122
(72)
48 110
(70)
56 130
(98)
80 112
(87)
64 110
(80)
60
100
100 O-10
115
(76)
53
105
110
(82)
SO
4-b
65
140
140
O-8
70
118
117
110
(88)
63 144
(98)
68 120
(87)
68
64
150
145
9-l 5
78
150
(100)
67
TABLE Aortic
Case & SW
Agt: (yr.)
.-----Pressures Left Ventricle
(mm. Central .4orta
(86)
Radial Artery
42
2a .SM
43
110
108
4-24
70
92
90
4-22
54
130 9z13
4M 5F 5a
45 4s
147
131
(80)
With Low Card&
Ejection Time (s@=.) Radial Artery
Cardiac output (L./min.)
Cardiac Index (L./min./ M’.)
Grades o AWtiC hufficiency
Index
(8.3)
0.28
0 16
0 57
0.35
36
2.0
2
130
(72)
0 21
0.11
0.55
0 35
3.7
22
2
(65)
0.22
0.12
0.55
0 37
3.5
1.7
(76)
0.31
0.23*
0.74
0 36
3.2
1.5
3
(80)
0 28
0.19*
0 70
0.42
3.1
1.6
4
(70)
0 22
0 11
0 50
0.31
3.0
1.9
2
(67)
0 24
0.12
0.50
0.34
52 (70)
110 _ 48
(82)
x
135 3
150
lo-25
44
118
118
528
4R
110
110
5 120
Upstroke Time Ratio Radial Artery/ Central Aorta
-50
55 2M
140
II
Insufficiency
Corrected Upstroke Time (sec.) Central Radial Aorta Artery
Hg)v
A. 135
Cardiac Index (L./m&’ M*.)
76
85
o-5
Cardiac Output (L./min.)
76
96
O-8
o-9 15M
12s
(92)
48
96
29
8M
R:ididl Artrry
Left Ventricle
Rndhl Artzry,’ Central AW1.l
46
(85)
I60 40
(72)
124 48
(70)
118 4
THE
AMERICAN
JOURNAL
OF CARDIOLOGY
Upstroke
Time
Ratio
in Aortic
TABLE
II (cwztinw~)
Aortic
Insufficiency
Corrected Upstroke Time Case & Sex 6F 7F
Age (yr.) 49 50
-_-----Pressures Left Ventricle
(mm. CeIltKil Aorta
120
120
5-12
54
154
154
4-l 8 8F 9F
57 52
145
145
-5-16
ro
115
115
1lF 12M 13F 14M 15F 16F 17M 18F 19M 20F
15 15 16 16 18 21 22 22 24 26 27 29
23F 24F 25M 26M 27M 28F 29M 3bM 31F
31 32 33 34 38 39 41 52 58 58
100 O-10
86
14,
104 5-15
104
100
96
o-5
50
(86)
104 -z
(84)
0.24
0.12
(85)
0.27
(65)
0.24
B.
With Normal -
(87)
0.27
(55)
0.34
3.8
2.3
1
0.50
0.34
4.6
2.4
1
155
0.20*
0.74
0.42
3.8
2.2
3
(69)
123
0 20*
0.80
0.38
4.1
2.5
3
0.11
0.40
0.32
6.0
3.1
3
0.30
0.12
0.40
0.36
6.6
3.6
4
(65)
0.22
0.11
0.48
0.40
6.0
3.3
2
(64)
0.20
0.08
0.40
0.33
4.2
3.5
3
(68)
0.25
0.11
0.42
0.31
5.6
3.0
3
(80)
0.34
0.13
0.38
0.33
4.7
2.9
2
(70)
0.23
0.08
0.34
0.35
5.8
3.4
4
(76)
0.28
0.11
0.39
0.37
7.0
3.8
3
(80)
0.20
0.10
0.50
0.31
5.0
3.2
0
(68)
0.28
0.11
0.39
0.36
6.2
3.5
3
(76)
0.25
0.09
0.36
0.31
4.3
2.5
3
(70)
0.27
0.10
0.37
0.40
7.6
4.1
4
(62)
0.24
0.11
0.45
0.32
4.2
3.0
2
(87)
0.25
0.08
0.30
0.28
4.9
2.5
3
(90)
0.28
0.14
0.50
0.28
7.6
4.2
0
(72)
0.30
0.12
0.40
0.38
5.4
2.7
2
(70)
0.28
0.09
0.32
0.34
5.3
2.8
4
(93)
0.28
0.14
0.50
0.34
7.3
4.0
1
(94j
0.20
0.08
0.35
0.32
6.9
4.3
3
(67)
0.22
0.10
0.45
0.33
4.2
3.1
3
(80)
D.27
0.11
0.40
0.36
5.7
3.2
2
(90)
0.26
0.11
0.42
0.35
4.0
2.6
2
z
(92)
140
Cardiac Index
-
(60)
104 38
(70)
136
(70)
130 4s
(75)
135 0
135
135
2-10
55
130 8-12
130
(82)
140 0
(78)
135 44
52 120
(78)
140 40
io
112 4-8
112
(84)
130 60
65
133
135
4-14
-5i,
120
120
(70)
125
150 38
(80)
165 42
50 (77)
132 40
45
100
100
5-11
Ti
124
124
4-l 3
6
130 O-6
130
(64)
114 39
(88)
155 3
(98)
135 70
80 120
120 7-12
Xi
130
130
2-12
45
165
165
3-10
s
132 04
7
(76)
130 7
(75)
150 40
(98)
165 60
134
(95)
170 50
95
95
?il
50 120
3-8
rs
130
132
4-10
52
1964
0.12
Grades of Aortic I nsufficiency
s
104
120
0.21
Cardiac Index (L./min./ M2.J
48
0
4-24
AUGUST
168
44
125
(81)
Cardiac output (L&in.)
46
*All anacmtic notch present. 2a and 5a: with intermittent left bundle Figures in parenthexs = mean pressure.
VOLUME
124
Ejection Time (sec.) Radial Artery
s
10-15 22M
(90)
0
120 O-l 3
(sec.1 Radial hrtery
Upstroke Time Ratio Radial Artery/ Central Aorta
50
120
4-l 1 21M
(82)
40
120 O-6
Central Aorta
Radial Artery
50
IO-25
10M
Hg.)--
Insufficiency
(721
100 47
(85)
125 50
(92)
150 s
branch
block.
166
Boiteau,
Libanoti
and Allenstein
Y
0 75
Y \
0 70
\
0 65
0 60 0 c 2
0 55
$ c
0 50
lI_ z c
0.45
: 3 040
0
035
I
FIG. 3. Case 17 (Table IIB). normal cardiac index.
Aortic insufficiency with
0.30
\.
r.
Corrected upstroke time ascending aorta 0.11 sec. = ~ = 0.39 0.28 sec.
to 0.34 sec. The upstroke time ratio ranged from 0.32 to 0.50 sec. Cardiac output varied from 4.0 to 7.6 L./min., and cardiac index, from 2.5 to 4.3 L./min./M2. Central and radial systolic ejection time ranged from 0.28 The contour of the peripheral to 0.40 sec. pulse showed a sharp anacrotic rise to an early systolic peak with a decreased amplitude of the dicrotic wave (Fig. 3). COMMENTS Arterial pulse contour has been well studied in the past, particularly with aortic stenosis,“-l5 but simultaneous recording and comparative analysis of the central aorta and peripheral artery pressure is still not in routine use in many cardiac laboratories. ARTERIAL UPSTROKE STUDIES Peripheral arterial studies noting the pulse pressure, the diastolic pressure, or rapidity of the upstroke time frequently will not reveal a true picture of aortic regurgitation. Most of our patients had a normal upstroke time by Wide arterial pulse pressure Wood’s criteria.g
I
2
of Al CHF)
Grades (with
of AI CHF)
-* _-.
Grades of AI _-x with CHF ond macrofic nolch
0
I 0
Corrected upstroke time radial artery
0
Grades lwifhout
:
t
3
4
GRADE
FIN. 4. Upstroke time ratio scale in patients with different grades of aortic insufficiency (AI), with no evidence of congestive heart failure (CHF) and normal cardiac index. and with cardiac decompensation. See text.
is often seen in dynamic normal individuals, or those with hypertension or hyperthyroidism, and is not necessarily a stigma of aortic regurgitation. Diastolic pressure below 50 mm. Hg at the peripheral artery is usually seen in aortic insufficiency and often with arterial hypotension occurring during cardiac catheterization. Therefore, we feel that a combined study of central and peripheral pulses, such as upstroke time ratio, has more clinical value than that of perrpheral pulse alone. For example, in Figure 4, patients with grades III and IV regurgitant index are in the lower area of the upstroke time ratio scale, except for those in This is consistent with congestive heart failure. an increased myocardial contraction and a good ventricular compliance with an increased it sugejection ; consequently, ventricular gests good myocardial reserve. A patient with a ratio near 0.75 and no systolic pressure gradient across the aortic valve should be suspected of myocardial insufficiency because it reflects poor myocardial contraction and deTIIR AMERICANJOURNAL OF CARDIOLOGY
Upstroke
Time
Ratio
creased ventricular ejection. Cases with grades I and II regurgitant index have usually a ratio between 0.40 and 0.50, in keeping with a milder degree of valvular aortic insufliciency. Systolic ejection time is usually prolonged in both central and peripheral artery pressures in aortic stenosis and insufficiency. Diastolic overloading in aortic insufficiency increases the left ventricular work which results in prolongation of left ventricular systole and a delay in total systolic ejection time. In valvular aortic stenosis, left ventricular pressure is increased due to significant reduction of the aortic valve orifice ; this also increases left ventricular work and the total systolic ejection time. A prolonged total ejection time, caused by myocardial failure, seems to be a natural consequence of poor myocardial reserve. The mean value is slightly lower in our series of patients without clinical evidence of decompensation (0.36 sec.) than in those with decompensation (0.38 sec.). Benchimol et al.,lO expected the opposite phenomenon, i.e., decrease of the total ejection time. They stated that left heart failure of any cause, by decreasing the cardiac output and left ventricular stroke volume, tends to decrease the duration of ventricular systole. CLINICAL
SIGNIFICANCE
OF
UPSTROKE
TIME
RATIO
The importance of the simultaneous examination of aortic and peripheral pulses in health has been shown by Kroeker and Woodi and with aortic valvular stenosis by others.‘6 The comparative study of both pulses in aortic valvular insufficiency is also important, adding value to the other hemodynamic findings of this disease. Clinical aortic insufficiency is not a simple syndrome.17 Progressive changes in the myocardium, such as hypertrophy of the left ventricle or myocardial fibrosis, cause alterations in pulse contour which have no direct relations to the regurgitant valve. From Table II and Figure 4 we can review the influence of heart failure and bundle branch block on the upstroke time ratio in valvular aortic insufficiency. Heart Failure: The 9 patients in congestive heart failure, as reflected by low cardiac index, observed a strict cardiac regimen. Moderate to marked cardiomegaly was found by chest roentgenogram. Four of these patients showed an anacrotic notch near the systolic peak, without systolic pressure gradient across the aortic valve. The upstroke time ratio was then elevated and ranged from 0.70 to 0.80. The VOLUME
14,
AUGUST
1964
in Aortic
Insufficiency
167
other 5 patients showed a ratio within the lower limits of normal, from 0.50 to 0.57 (normal: 0.50 to 0.70). The left ventricular end-diastolic pressures were elevated in all these cases. High upstroke time ratio occurred because of the alterations in the pressure volume relationship of the ventricle due to marked diastolic overload and increased diastolic volume. Serial follow-up chest roentgenograms of these patients over the years showed gradual enlargement or dilatation of the left ventricle consistent with stretch or loss of elasticity of the myocardial fibers. Perhaps not only the diastolic overload but also chronic rheumatic fever may play a role in the alterations of the mechanical properties of the left ventricle. Autopsy data may reveal signs of chronic active rheumatic fever even without any clinical or laboratory findings during the patient’s life. Bundle Branch Block: Two patients were found to have intermittent left bundle branch block. One has already been described.‘* Autopsy revealed a markedly dilated left ventricle, with myocardial fibrosis but little coronary artery disease. In both patients the upstroke time ratio was higher than the usual range for significant aortic insufficiency. The arterial upstroke time was slightly higher with bundle branch block than with normal conduction, but was still in the normal range for both central and peripheral artery pulse. This suggests an important aspect of left bundle branch block, i.e., that slowing of intraventricular conduction and prolonged isometric contraction of the left ventricle result in decreased force and efficiency of the contraction. The systolic pressure of the central and peripheral pulses during isometric contraction of the left ventricle rises to a lower level with left bundle branch block than with left ventricular hypertrophy. This demonstrates that delay of conduction in the left ventricle results in a less effective myocardial contraction and a small stroke output. Consequently, the decreased amount and velocity of flow into the central aorta explains the more normal appearance of the pulse curve as compared to the pulse contour typical of aortic insufficiency. Prognostic Value: The upstroke time ratio as an isolated observation may also have significant prognostic value. For example, only 1 of the 4 patients with aortic insufficiency and a ratio near 0.75 is alive 16 months after completion of the hemodynamic study. An elevated upstroke time ratio indicates poor myocardial re-
Boitcau,
168 serve, and, therefore. be a grave risk.
Libanoti
and
open heart surgery would
%JMMARY
The upstroke time ratio has been studied in 15 normal controls and in 31 patients with pure aortic regurgitation and varying stages of myocardial involvement. The upstroke time ratio results were as follows: 15 normal subjects, 0.50 to 0.70; 31 patients with rheumatic aortic valvular insufficiency, of whom 9 had cardiac decompensation, 0.50 to 0.80; and 22 with no evidence of myocardial failure, 0.31 to 0.50. These patients were graded from 0 to IV, depending upon the degree of aortic regurgitation by the Braunwald method. Those with lower ratio had grade III and IV regurgitant index and were found to have good myocardial reserve. Others with grade III and IV and elevated ratio were classified as having poor myocardial reserve, and should be high surgical risks if open heart surgery is performed. The upstroke time ratio is an indirect measurement of aortic valvular regurgitation and is a useful index in evaluating secondar!. myocardial involvement.
4. i.
6.
7.
8.
9. 10.
11.
12. 13. 14.
ACKNOWLEDGMENT We gratefully acknowledge the technical assistance of Mr. Dick Ray, medical photographer, Mr. Curt Smolen, medical artist and Miss Vi Calzarett, medical secretary.
15.
16.
REFERENCES 1. BOITEALJ, G. M., BOURASSA, M. G. and ALL~NSTEIN, B. J. Upstroke time ratio. New concept in differentiating aortic and subaortic stenosis. :Zm. J. Cardiol., 11: 319: 1963. 2. SELDINGER, S. I. Catheter replacement of the needle in percutaneous arteriography. New technique. Acta radio/., 39: 368, 1953. 3. Ross, .I.. JR., BRAUNWALD,E. and MORROW, A. G.
17.
18.
Allenstein I‘ransseptal left atria1 puncture. New techniqut for the measurement of left atria1 pressure in man. .lm. -1. &r&o/., 3: 653, 1959. GLASSER, 0. Medical Physics, Vol. III. p. 641. Chicago. 1960. Yrar Book Publishers. \Vooo. 1:. H. and SUTTERER. \V. improved resistance wire strain-gauge manometers adaptable for biologic instruments. ./. Lab. & C/in. Mpd., 45: 153.1955. FICK. .4. Uber die Messung des Blut @anturns in den Herzventrikeln. Cited by HOFF, H. E. and SCOT?., .J. .I. Physiology (continued). .v
THE AMERICAN JOURNAL OF CARDIOLOGY