[Iatrogenic coronary stenosis after angioplasty]. / Sténoses coronaires iatrogènes après angioplastie.

Restenosis is the usual mechanism of recurrent myocardial ischaemia in the months following successful percutaneous transluminal coronary angioplasty (PTCA). Control coronary arteriography may occasionally show another cause: the constitution of a new stenosis near the dilated segment or in the left main coronary stem after angioplasty in a branch of this artery. The authors report 4 cases of patients who developed new coronary stenoses within a few weeks of PTCA, interpreted as traumatic complications of the initial procedure due to a lesion of the intima with a secondary fibrotic reaction and luminal narrowing. The guiding catheter was probably responsible for the trauma to the left main coronary stem whereas the tips of either the balloon catheter or the guide wire were thought to have been responsible for the endothelial effraction of the dilated vessels.

[Coronary angioplasty and electric alternans of the ST segment]. / Angioplastie coronaire et alternance électrique du segment ST.

Alternans of the ST segment is a rare phenomenon during coronary angioplasty. The authors report three cases. It is usually observed in left anterior descending arteries without collateral circulation. Alternans is not accompanied by haemodynamic changes and does not initiate malignant ventricular arrhythmias. It is a transient phenomenon. Electrical alternans is thought to be due to changes in the configuration of the transmembrane action potential and modifications of calcium exchanges.

[Variations in the amplitude of the Q wave at V5 during computerized exercise test. Value in the diagnosis of coronary insufficiency]. / Etude des variations d'amplitude de l'onde Q en V5 au cours de l'épreuve d'effort informatisée. Valeur dans le diagnostic de l'insuffisance coronaire.

The aim of this study was to evaluate the diagnostic value of changes in Q wave amplitude in the V5 chest lead in coronary artery disease, especially for the detection of significant (greater than or equal to 75% narrowing) left interior descending disease. The stress tests of 227 patients were reviewed and confronted with the results of coronary angiography in 93 patients with angiographically normal arteries, and 134 patients with left anterior descending disease of the latter, 37 had single vessel disease, 38 had double vessel disease and 59, triple vessel disease. The average values of the Q wave amplitude in V5 at the peak of effort were 0.97 +/- 1.04 mm in the control group; 0.53 +/- 0.65 mm (p less than 0.01) in the group with single vessel disease; 0.46 +/- 0.66 mm (p less than 0.01) in the group with double vessel disease and 0.64 +/- 0.9 mm (p = 0.04) in the group with triple vessel disease. The mean variations of the amplitude of the Q wave in lead V5 on effort in the same group of patients were: +0.55 +/- 0.73 mm (p less than 0.001); + 0.11 +/- 0.66 mm (NS); + 0.02 +/- 0.5 mm (NS) and + 0.05 +/- 0.53 mm (NS), respectively. The Q wave in lead V5 was generally deeper on effort in the control group and the average variation in its amplitude was statistically significant only in this group. In the coronary patients, the Q wave in lead V5 was generally smaller and its amplitude did not change significantly on effort.(ABSTRACT TRUNCATED AT 250 WORDS)

[Left ventricular function and secondary angioplasty after anterior infarction in simple coronary vessel disease]. / Fonction ventriculaire gauche et angioplastie secondaire après un infarctus antérieur chez le monotronculaire.

Arterial patency is a good prognostic factor in terms of survival and left ventricular function after myocardial infarction. The aim of this prospective study was to evaluate the benefit of secondary angioplasty of the infarct-related artery in single vessel, left anterior descending disease, on regional and global left ventricular function. Initial coronary angiography was undertaken at the 7th +/- 2 days after the onset of infarction. Arterial patency was assessed by the TIMI criteria and by percentage stenosis on quantitative angiography. Forty consecutive patients (Group I) underwent conventional angioplasty of the left anterior descending artery at the 9th +/- 2 days. Twelve consecutive patients (Group II) did not undergo angioplasty. A repeat coronary angiographic study was performed at 3 months. The results showed no difference between the two groups of patients in base line values. A significant improvement in arterial patency was observed in Group I (TIMI Grades II or III) and in residual stenosis at 3 months (54.7 +/- 13% versus 80.6 +/- 13%, p < 0.05). In addition, a significant improvement in ejection fraction of +4.7% (p < 0.02), of left anterior descending myocardial regional wall motion of +7.6 (p < 0.02) and a reduction of induced left ventricular end systolic volume of -2.2 ml/m2 (p < 0.05) were observed in Group I. Initial segmental hypokinesia or akinesia improved in 67.5% of patients. However, 50% of patients in Group II improved their segmental wall motion abnormalities at 3 months.(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of the negative U wave during exercise test in the diagnosis of coronary insufficiency]. / Intérêt de l'onde U négative au cours de l'épreuve d'effort dans le diagnostic de l'insuffisance coronaire.

In order to determine the value of inversion of the U wave during exercise for the diagnosis of coronary insufficiency, the stress tests of 227 patients were reviewed and confronted with the results of coronary angiography which showed 93 subjects with angiographically normal arteries and 134 subjects with left anterior descending disease; 37 patients had single vessel disease (Group I), 38 had double vessel disease (Group II) and 59 had triple vessel disease (Group III). When compared to the two classical criteria, anginal pain and less than or equal to 1 mm ST depression, inversion of the U wave was more specific: 82.8 +/- 7.6 p. 100 vs 77.4 p. 100 for anginal pain, and 66.7 +/- 9.6 p. 100 for ST depression. The sensitivity of this new sign for the detection of coronary insufficiency was 26.9 +/- 7.5 p. 100 vs 80.6 +/- 6.7 p. 100 for ST depression and 56.7 +/- 8.4 p. 100 for anginal pain. The positive predictive value of U wave inversion on effort was 70.9 +/- 12 p. 100 compared to 77.7 +/- 6.9 p. 100 for ischaemic ST depression and 78.3 +/- 8.2 p. 100 for induced anginal pain. Conversely, in angiographically normal coronary arteries, the absence of U wave inversion had a negative predictive value of 44.8 +/- 7.4 p. 100 compared to 70.5 +/- 9.5 p. 100 for the absence of ischaemic ST changes and 55.4 +/- 8.5 for the absence of anginal pain. These results confirm previously published data.(ABSTRACT TRUNCATED AT 250 WORDS)

[Compared validity of the criteria of quantification of aortic insufficiency using pulsed and continuous Doppler]. / Validité comparée des critères de quantification de l'insuffisance aortique en doppler pulsé et continu.

In order to evaluate the severity of aortic valve regurgitation (AVR) by means of simple criteria, we compared the feasibility and reliability of two methods: (1) pulsed doppler ultrasound suprasternal recording in the aortic sinus area, with calculation of the regurgitation fraction by planimetry of the systolic and diastolic curves, and with measurement of end-diastolic velocity, or end-diastolic doppler effect (EDDE); this was done in 114 subjects (84 patients with AVR and 30 controls); (2) continuous wave doppler ultrasound apical recording of the left intraventricular jet, with measurement of the velocity decrease slope (S) and of the velocity half-decrease time (T 1/2); this was done in 46 patients with AVR. Doppler results were compared with Seller's angiographic classification of AVR in 4 grades. Planimetry could be performed in only 41% of patients in this series. This measurement seems to be feasible only when perfect recording of an increased systolic flow (peak velocity higher than 1.2 m/s) can be performed, which is usually limited to cases with major regurgitation. EDDE was easier to record (84/84 patients). When above 5 cm/s it is a good reflection of AVR severity, and when above 20 cm/s it indicates a major AVR (3/4 or 4/4 at angiography), with an 81% sensitivity and a 91% specificity. Continuous wave doppler ultrasound apical recording could be used in 80% of the cases (37/46 patients). With this method, a more than 3 m/s slope is a highly specific (8/8) but not very sensitive (8/13) sign of major AVR. A T 1/2 value lower than 650 ms is a specific (12/12) and sensitive (12/13) sign of severe AVR.(ABSTRACT TRUNCATED AT 250 WORDS)

[Noninvasive measurement of cardiac output by pulsed Doppler echocardiography. Correlation with thermodilution]. / Mesure non invasive du débit cardiaque par échocardiographie Doppler pulsé. Corrélation avec la thermodilution.

Cardiac output was measured simultaneously by pulsed Doppler echocardiography and thermodilution in 22 patients, 18 of whom also underwent atrial pacing at different rates to give a total of 42 different measurements. The aortic diameter was measured firstly at the aortic ring at the level of insertion of the aortic cusps and then at the point of maximum separation of the valve cups in the left parasternal long-axis view. The aortic velocities were recorded in the apical 5-chamber view immediately below the level of the aortic valve. The correlations obtained at the aortic ring (R1) and at the point of maximum separation of the valve cusps (R2) were 0.77 (y = 0.67x + 1.17: standard error = 0.81 l/m) and 0.64 (y = 0.56x + 0.87; standard error = 1.01 l/mn) respectively. The correlations were much better when 7 technically unsatisfactory measurements were excluded (R2 = 0.76: y = 0.59x + 0.74: standard error = 0.79 l/mn) (R1 = 0.87: y = 0.72x + 1.04: standard error = 0.65 l/mn). THe correlations of stroke volume measured at aortic ring level also improved from r = 0.82 (y = 0.75x + 7.29: standard error = 8.9 ml) to r = 0.89 (y = 0.78x + 7.38: standard error = 7.3 ml). The measurement of cardiac output by pulsed Doppler echocardiography in the aortic root seems to be reliable. The correlations of the values of stroke volume and cardiac output with the thermodilution method are good, allowing detection of beat-to-beat variations of cardiac output, in suitable patients in the hands of experienced operators.

[Value and limits of the determination of aortic output by Doppler echocardiography in the quantification of aortic valve insufficiencies]. / Intérêt et limites de la détermination du débit aortique par échographie Doppler dans la quantification des insuffisances aortiques.

The aim of this study was to assess the value and limitations of Doppler echocardiographic measurement of aortic flow in the quantification of aortic regurgitation. Sixty-one patients were examined by Doppler echocardiography within 48 hours of cardiac catheterisation. There were 9 Grade I, 18 Grade II, 18 Grade III and 16 Grade IV angiographic aortic regurgitations. The mean aortic blood flow in angiographic Grades I and II (p less than 0.01). A correlation was observed between Doppler aortic flow and the angiographic grade of regurgitation (r = 0.66, p less than 0.001) and between aortic flow and regurgitant fraction (r = 0.68, p less than 0.001). Aortic flow greater than 10 l/mn identified angiographic Grades III or IV regurgitation with a sensitivity and specificity of 73.5% and 92.5% respectively and a positive and negative predictive values of 92.5% and 73.5% respectively. Aortic regurgitation with a regurgitant fraction greater than 40% was identified by a pulsed Doppler aortic blood flow greater than 10 l/mn with a sensitivity and specificity of 70% and 93% respectively, and positive and negative predictive values of 95% and 61% respectively. The sensitivity of this criterion is relatively poor as some severe aortic regurgitations have aortic flows of less than 10 l/mn: these patients have low outputs because of left ventricular dysfunction which is apparent from measurement of left ventricular fractional shortening.

[Postoperative iatrogenic left coronaroventricular fistula. Demonstration by color two-dimensional Doppler]. / Fistule coronaroventriculaire gauche iatrogène postopératoire. Mise en évidence par le Doppler bidimensionnel à codage couleur.

The authors report the case of an asymptomatic 67 year old patient, in whom, 6 years after aortic valve replacement, Doppler color flow mapping showed the presence of a coronary artery--left ventricular fistula. The normality of preoperative coronary angiography suggested that this fistula was created during peroperative left ventricular purging: the implantation of a needle through the right ventricle and interventricular septum. A iatrogenic lesion of a septal branch probably caused the communication between the left anterior descending artery and the left ventricle. Postoperative normalisation of the left ventricular end diastolic dimension, the absence of dilatation of the left main coronary on 2D echocardiography, the narrowness of the Doppler color jet and the absence of a significant end diastolic Doppler signal in the aortic isthmus indicated a fistula of small size and simple Doppler echocardiographic follow-up was decided upon.

[Delayed angioplasty of residual coronary stenosis after thrombolysis of myocardial infarction: prognostic factors of left ventricular function]. / Angioplastie différée de la sténose résiduelle après thrombolyse de l'infarctus du myocarde: facteurs déterminant l'évolution de la fonction ventriculaire gauche.

The aim of this study was to analyse the prognostic factors of long term left ventricular function after successful delayed angioplasty of residual coronary stenosis after thrombolysis for myocardial infarction. The left ventricular function of fifty patients, aged 54 +/- 10 years, who underwent intravenous thrombolysis 2.9 +/- 1.3 hours after the onset of myocardial infarction (28 anterior, 22 inferior wall) was assessed by angiography at the 6.1 +/- 1.7th day and 6.1 +/- 2.5 months after successful angioplasty undertaken on the 8.3 +/- 5.2nd day. In cases without reocclusion (n = 44), the ejection fraction and the wall motion of the infarcted region improved significantly from 56.8 +/- 12.2% to 59.5 +/- 15.4% (p < 0.002) and from 8.4 +/- 14.8% to 18.3 +/- 24.3% (p = 0.0001), respectively. These parameters did not change in cases with reocclusion (n = 6). When the dilated artery remained patent, an improvement in motion of the infarcted region was observed in 69.5% of hypokinesis (n = 23), 50% of akinesis (n = 10) and 9.1% of dyskinesis (n = 11) (p < 0.005). The improvement in motion of the infarcted zone was negatively correlated with the delay of thrombolysis (r = 0.36; p < 0.02) and peak CPK levels (r = 0.31; p < 0.04). Over 60% restenosis on digitalised densitometry (n = 11) did not compromise the possibilities of improvement, the evolution of wall motion of the infarcted zone and volumes with respect to cases without restenosis (n = 33).(ABSTRACT TRUNCATED AT 250 WORDS)

[Free-wall rupture during the acute phase of myocardial infarction. Apropos of 2 cases surgically treated with success]. / Rupture pariétale à la phase aiguë de l'infarctus du myocarde. A propos de 2 cas opérés avec succès.

The authors report two cases of cardiac rupture during acute myocardial infarction successfully treated surgically. In the first case, rupture occurred 7 days after hospital admission for anteroseptal myocardial infarction. The patient developed sudden cardiogenic shock with signs of venous hypertension without left ventricular failure. The second patient was admitted for syncopal chest pain with transient hypotension which regressed after volume repletion and pressor amine therapy. On admission, the patient had signs of cardiac tamponade. The ECG showed recent inferolaterobasal myocardial infarction. In both cases the diagnosis was made by 2D echocardiography which showed voluminous circumferential pericardial effusions probably due to haemorrage, with an image very suggestive of a blood clot in the effusion of the second patient. The two patients underwent emergency cardiac surgery and both survived with a 4 and 1.5 month follow-up respectively. These two cases confirm the value of 2D echocardiography as an emergency bedside procedure for the diagnosis of cardiac rupture, especially when images of intrapericardial thrombosis are observed, as in our second patient. In addition, the first case raises once again the question of the role of late thrombolysis as a predisposing factor of cardiac rupture at a time when this technique is proposed up to 24 hours after the onset of symptoms.

[Doppler echocardiographic study of mitral and aortic flow at various rates and atrioventricular intervals in patients with dual chamber pacemakers]. / Etude par doppler des flux mitral et aortique à fréquences et délais auriculo-ventriculaires différents chez des patients ayant un stimulateur double-chambre.

The aim of this study was to measure the changes in mitral and aortic blood flow induced by rate changes and different atrioventricular intervals in dual chamber pacemaker patients. Ten totally pacemaker dependant patients were studied under basal conditions, in double atrial and ventricular stimulation mode, by pulsed Doppler recordings of mitral and aortic flow, at three different pacing rates (80, 100 and 120/mn) and with three different atrioventricular intervals at each rate (short, 90 or 115 ms; medium, 165 or 190 ms; and long, 240 ms). The increase in pacing rate and prolongation of the atrioventricular interval significantly shortened the duration of mitral flow. Increasing the pacing rate induced a significant fall in stroke volume measured from the aortic flow. The optimal atrioventricular interval tended to shorten when the pacing rate was increased; a long atrioventricular interval had a deleterious effect on stroke volume compared with medium and short atrioventricular intervals; however, the difference between the short and medium atrioventricular intervals was not statistically significant even at 120 mn. These observations emphasise the hemodynamic advantages of shortening of the atrioventricular interval of dual chamber pacemakers when the pacing rate increases.

[Massive poisoning by naftidrofuryl with severe disorders of rhythm and conduction]. / Intoxication massive par le naftidrofuryl avec troubles sévères du rythme et de la conduction.

The authors report the case of a 35-year old woman with normal heart who voluntarily poisoned herself by swallowing 6 grams of naftidrofuryl. She developed disorders of atrioventricular conduction and a ventricular-like arrhythmia with collapse which resolves after mechanical ventilation. Data from the literature indicate that naftidrofuryl possesses class I electrophysiological properties which must not be ignored and which account for the cardiac effects observed in this particular case and in cases of parenteral overdosage already reported. By analogy with class I antiarrhythmic agents, treatment of naftidrofuryl poisoning with disorders of conduction could include the administration of molar sodium lactate.

[Spontaneous and isolated dissection of the coronary arteries, apropos of 8 cases with favourable outcome]. / Dissection spontanée et isolée des artères coronaires, à propos de 8 observations d'évolution favorable.

Spontaneous coronary artery dissection is rare compared with the high incidence of atheromatous coronary artery disease. Eight new clinical and angiographic cases diagnosed between 1984 and 1990 are reported. The patients were 6 men and 2 women with an average age of 44.1 +/- 10.7 years. The initial presentation is angina in half the cases, and myocardial infarction in the other half. Clinical signs and the results of non-invasive investigations are non-specific. Diagnosis is made by coronary angiography. The dissection is usually observed on a proximal segment of one of the main coronary arteries. In 5 cases, the disease was confined to a single vessel left anterior descending (3) and right coronary arteries (2). One patient had double vessel disease (left anterior descending and left retroventricular arteries); one patient had triple vessel disease (left anterior descending left circumflex and right coronary arteries), and finally, one patient had left main stem disease extending to the left anterior descending and first diagonal arteries. There was no aetiological factor in 5 cases whereas 3 had coronary atherosclerosis. After a period of 25 months all patients are alive. Five have drug therapy and 3 have undergone coronary bypass surgery. Six patients are asymptomatic and 2 have mild angina. One patient's coronary circulation has returned to normal. The extension of the indication of coronary angiography explains the diagnosis of an increasing number of spontaneous coronary artery dissection. The condition is serious but there are more and more long-term survivors as in our series.

[Doppler-ultrasonic diagnosis of tricuspid insufficiency]. / Le diagnostic écho Doppler des insuffisances tricuspidiennes (IT).

The positive diagnosis of tricuspid insufficiency is simple: it consists in demonstrating in pulsated Doppler, the presence of retro-tricuspid systolic turbulence in the right atrium. The best views for this diagnosis are the 4 cavities apical section and the mitro-tricuspid section. This criterion appears to be extremely specific and only exceptional left ventricle-right atrium communications are capable to also generate right intra-atrial turbulences. In our experiment the sensitivity is close to 93%. The advantage of the continuous Doppler is to permit the measurement of the maximal velocity of the regurgitating tricuspid flow and the evaluation of the right ventricular pressure and the pulmonary artery pressure. The best criteria of gravity of tricuspid insufficiency are: the acoustical and graphic intensity of the Doppler signal, the spatial extension of systolic turbulences within the right atrium, the velocity of the anterograde tricuspid flow which reaches and exceeds lm/sec in severe tricuspid insufficiencies, and the laminar nature of the regurgitating flow, a sign of great value in favor of a massive tricuspid insufficiency. The color Doppler represents the future.

[Infectious endocarditis on permanent endocavitary pacemakers: value of echocardiography and review of the literature]. / Endocardites infectieuses sur sondes de stimulation endocavitaire permanentes: intérêt de l'échocardiographie et revue de la littérature.

Infectious endocarditis around indwelling pacemakers is rare (0.15% of all implantations). They have a gloomy prognosis with a global mortality rate of nearly 34% as emerges from this review of the literature concerning 58 cases of infectious endocarditis published within the past 16 years. On the basis of the 6 cases which the authors report, they stress the importance and sometimes difficulty of using ultrasound in a positive diagnosis. Cardiographic ultrasound, which can determine the size and emboligenic nature of vegetations is capital in choosing how to remove the pacemakers. Percutaneous ablation by simply pulling or by catheterization currently gives the best results, but it may be necessary to resort to surgery involving right atriotomy if emboligenic vegetations are present. By combining antibiotic treatment and ablation of the intracavitary material, a cure is obtained in 92% of cases. These figures should be compared with the lack of success of using antibiotic treatment alone which results in a high level of mortality (84%).

[Thrombolysis and intravenous beta-blockaders in the acute phase of myocardial infarction]. / Thrombolyse et bêtabloquant intraveineux à la phase aiguë de l'infarctus du myocarde.

Since proof exists of the individual efficacy of thrombolytics and intravenous beta-blockers in the acute phase of myocardial infarction (MI), it seemed to us logical and interesting to combine them. The aim of this retrospective study was to evaluate the safety and potential benefit of this drug combination for left ventricular function. We compared 40 patients (group I) of mean age 53.9 +/- 8.5 years admitted for MI in the six hours following the onset of symptoms treated by thrombolysis and intravenous beta-blockers (metoprolol or atenolol), with 27 patients (group II) of mean age 57.1 +/- 9.4 years treated within the same time lapse by thrombolysis alone. All patients underwent coronary arteriography and only two in group I were not examined by ventriculography. The two groups were comparable in terms of age, coronary history, localization of MI, clinical status at the outset, and time lapse before administration of the thrombolytic. Only heart rate differed at the outset (lower in group II; p = 0.05). A significant reduction in heart rate of 18% was seen in group I. When administration of the two drugs was simultaneous (less than or equal to 30-min lapse between each drug) this reduction was greater (22%) than when they were given separately (13%). In group II, the drop in heart rate was not significant (63%). In contrast, the decrease in systolic pressure in both groups was significant and comparable (group I: 16.6%; group II: 14.5%) even in the case of simultaneous administration (22%). There was no between-group difference in left ventricular ejection fraction (LVEF).(ABSTRACT TRUNCATED AT 250 WORDS)

[Myocardial infarction caused by closed thoracic injury: pathogenic and angiocoronarographic aspects. Apropos of 4 cases and review of the literature]. / Infarctus du myocarde par traumatisme fermé du thorax: aspects angiocoronarographiques et pathogéniques. A propos de quatre observations et revue de la littérature.

The 4 cases of transmural myocardial infarction by closed chest trauma reported by the authors bring the number of angiographically documented and published cases to 52. This group serves as a basis for a detailed review of coronary and myocardial anatomical lesions and their pathophysiological mechanism is suggested. Long controversial, direct traumatic coronary damage has been confirmed by coronary angiography and is the essential mechanism of transmural infarctions. Myocardial contusion, much commoner, is responsible for non transmural lesions which remain difficult to diagnose. The authors stress the twin value of coronary arteriography: pathophysiological with its medicolegal consequences, and also therapeutic since a revascularisation procedure may be particularly beneficial in situations where thrombolysis is generally contraindicated.

[Infarction with angiographically normal coronary vessels. (20 cases)]. / Infarctus à coronaires angiographiquement normales. 20 observations.

Over 8 years, 20 cases of infarction with normal coronary angiography have been reported, representing 0.9% of the patients who underwent a coronary angiography after a myocardial infarction. The main characteristics of these patients are compared with those taken from the literature. The occurrence of this disease mainly depends on the age: especially higher when the patients are younger, ranging between 1 and 4% in major series, but it may reach 25% in case of infarction occurring before the age of 30. Therefore, this entity mainly affects young patients (mean age in the literature: 34.3 years), with a large proportion of women (27%). The main risk factor is smoking, found in 3 out of 4 men an more than half of the women; on the contrary, hypercholesterolemia and arterial hypertension are only seldom found. In women, administration of estro-progestative medications in mentioned in almost every other case. Coronary heredity is mentioned in one out of 3 cases. In 68% of the cases, the infarction is the original manifestation and frequently occurs during stress: 60 p. cent of the cases. The site of the necrosis is insignificant. Mortality is low: 2 p. cent but in 5 p. cent of the cases, the course may be complicated by recurrence or heart failure. According to recent findings on coronary angiography during the acute phase, the pathogenesis could involve an arterial coronary thrombosis, perhaps developing on minimal coronary lesions, caused by a spasm and/or a platelets hyperaggregation; then this coronary thrombosis is revascularized.

End diastolic flow velocity just beneath the aortic isthmus assessed by pulsed Doppler echocardiography: a new predictor of the aortic regurgitant fraction.

End diastolic flow velocity just beneath the aortic isthmus was measured within 72 hours of cardiac catheterisation by pulsed Doppler echocardiography in 30 controls and 61 patients with aortic regurgitation. The end diastolic flow velocity was determined at the peak R wave on a simultaneously recorded electrocardiogram. In all controls there was no reverse flow at the end diastole beneath the aortic isthmus. In patients with aortic regurgitation the end diastolic flow velocity correlated well with the angiographic grade of regurgitation (r = 0.81) and regurgitant fraction (r = 0.82). The mean (SD) values were 6.3 (5.2), 12.2 (4.3), 22.1 (5.7), and 34.3 (9.3) cm/s for patients with regurgitant fraction of less than 20%, between 20% and 40%, between 41% and 60%, and greater than 60%, respectively. An end diastolic flow velocity of greater than 18 cm/s predicted a regurgitant fraction of greater than or equal to 40% with a sensitivity of 88.5% and a specificity of 96%. The study suggests that the pulsed Doppler derived end diastolic flow velocity is a useful index in the routine non-invasive assessment of the severity of aortic regurgitation.