Comparison of transthoracic Doppler echocardiography and natriuretic peptides in predicting mean pulmonary capillary wedge pressure in patients with chronic atrial fibrillation.

The purpose of this study was to assess whether transthoracic Doppler echocardiography and serum natriuretic peptide levels could predict mean pulmonary capillary wedge pressure (PCWP) in patients with chronic atrial fibrillation. We examined mitral flow velocity and pulmonary venous flow (PVF) velocity patterns in 32 patients with chronic atrial fibrillation. Plasma A-type and B-type natriuretic peptide (ANP, BNP, respectively) levels in the peripheral vein were measured. Significant correlations were observed between mean PCWP and the following: peak velocity (r = 0.51) and deceleration time (r = -0.65) of the mitral flow; peak velocity (r = 0.64) and deceleration time (r = -0.80) of the PVF; BNP (r = 0.60); and ANP (r = 0.36). Stepwise multiple linear regression analysis selected PVF deceleration time and mitral flow deceleration time as independent predictors of PCWP. A cutoff value of PVF deceleration time of < or =150 ms and a mitral flow deceleration time of < or =100 ms predicted a mean PCWP of > or =18 mm Hg, with a sensitivity of 100% and 80% and a specificity of 96% and 85%, respectively. In conclusion, PVF deceleration time and mitral flow deceleration time obtained from transthoracic Doppler echocardiography are more accurate predictors of mean PCWP than values obtained with natriuretic peptides in patients with chronic atrial fibrillation.

Repeated thermal therapy improves impaired vascular endothelial function in patients with coronary risk factors.

OBJECTIVES: We sought to determine whether sauna therapy, a thermal vasodilation therapy, improves endothelial function in patients with coronary risk factors such as hypercholesterolemia, hypertension, diabetes mellitus and smoking. BACKGROUND: Exposure to heat is widely used as a traditional therapy in many different cultures. We have recently found that repeated sauna therapy improves endothelial and cardiac function in patients with chronic heart failure. METHODS: Twenty-five men with at least one coronary risk factor (risk group: 38 +/- 7 years) and 10 healthy men without coronary risk factors (control group: 35 +/- 8 years) were enrolled. Patients in the risk group were treated with a 60 degrees C far infrared-ray dry sauna bath for 15 min and then kept in a bed covered with blankets for 30 min once a day for two weeks. To assess endothelial function, brachial artery diameter was measured at rest, during reactive hyperemia (flow-mediated endothelium-dependent dilation [%FMD]), again at rest and after sublingual nitroglycerin administration (endothelium-independent vasodilation [%NTG]) using high-resolution ultrasound. RESULTS: The %FMD was significantly impaired in the risk group compared with the control group (4.0 +/- 1.7% vs. 8.2 +/- 2.7%, p < 0.0001), while %NTG was similar (18.7 +/- 4.2% vs. 20.4 +/- 5.1%). Two weeks of sauna therapy significantly improved %FMD in the risk group (4.0 +/- 1.7% to 5.8 +/- 1.3%, p < 0.001). In contrast, %NTG did not change after two weeks of sauna therapy (18.7 +/- 4.2% to 18.1 +/- 4.1%). CONCLUSIONS: Repeated sauna treatment improves impaired vascular endothelial function in the setting of coronary risk factors, suggesting a therapeutic role for sauna treatment in patients with risk factors for atherosclerosis.

Transthoracic Doppler echocardiographic assessment of left anterior descending coronary artery and intramyocardial small coronary artery flow in patients with hypertrophic cardiomyopathy.

OBJECTIVES: Transthoracic Doppler echocardiography with a high frequency transducer can visualize blood flow velocities in the left anterior descending coronary artery (LAD) and the intramyocardial small coronary artery in humans. However, the clinical utility for coronary circulation has not been established. To evaluate the reliability of transthoracic Doppler echocardiography for measuring coronary flow velocity, we firstly evaluated the coronary flow velocity and coronary flow reserve in the LAD in patients with coronary artery disease, and secondly evaluated the flow velocity in the intramyocardial small coronary artery in patients with hypertrophic cardiomyopathy. METHODS: Transthoracic Doppler echocardiographic LAD flow velocity was simultaneously recorded with Doppler guide wire before and after papaverin or adenosine triphosphate (ATP) infusion in 18 patients with coronary artery disease (mean age 61 years) during cardiac catheterization. Intramyocardial small coronary artery flow velocity by transthoracic Doppler echocardiography was examined in another 51 patients (mean age 53 years) with hypertrophic cardiomyopathy and 31 normal subjects (mean age 62 years). RESULTS: There were good correlations of coronary flow reserve measured by papaverin (r = 0.87) and ATP (r = 0.80) administration between the transthoracic Doppler echocardiography and Doppler flow wire methods in patients with coronary artery disease. Averaged diastolic peak flow velocity [77 +/- 36 (mean +/- SD) cm/sec] and time velocity integral (27 +/- 11 cm) in the small coronary artery in patients with hypertrophic cardiomyopathy were significantly higher (p < 0.05) than those in the LAD (46 +/- 20 cm/sec and 19 +/- 11 cm), respectively. However, there were no significant differences of flow velocities in the control subjects between averaged diastolic peak flow velocity (31 +/- 10 cm/sec) and time velocity integral (11 +/- 5 cm) in the small coronary artery and those in the LAD (32 +/- 11 cm/sec and 12 +/- 5 cm), respectively. Systolic reversal flow in the small coronary artery was observed in 41 patients with hypertrophic cardiomyopathy, but not in the controls. CONCLUSIONS: Transthoracic Doppler echocardiography using a high frequency transducer is a useful technique for noninvasive investigation of flow velocity dynamics in the LAD and intramyocardial small coronary artery in patients with hypertrophic cardiomyopathy.

Monophasic transmitral flow pattern with less increase in heart rate indicates left ventricular dysfunction.

When heart rate (HR) increases, mitral flow can become monophasic. Prolonged isovolumic contraction and relaxation time (ICT and IRT), directly related to left ventricular (LV) function, can potentially influence the HR with monophasic mitral flow. The present study investigated the relation between HR that causes monophasic flow and LV function. During diagnostic catheterization, HR was increased using right atrial pacing by 2 beats/min every 2 min in a stepwise manner until the development of monophasic mitral flow in 17 patients with normal sinus rhythm. ICT, IRT, end-diastolic and end-systolic LV volumes, LV ejection fraction, LV peak + and -dP/dt, peak (+dP/dt)/P, and the relaxation time constant (tau) were measured by Doppler echocardiography or catheterization when monophasic mitral flow developed. The monophasic HR varied from 74 to 106 beats/min. By univariate analysis, ICT (p<0.01, r2=0.73), LV peak +dP/dt (p<0.05, r2=0.37), peak (+dP/dt)/P (p<0.01, r2=0.71), peak -dP/dt (p<0.05, r2=0.25), and tau (p<0.05, r2=0.33) had a significant correlation with monophasic HR. By multivariate analysis, prolonged ICT and reduced LV peak -dP/dt independently contributed to monophasic mitral flow with less increase in HR. Monophasic mitral flow with less increase in HR indicates impaired LV systolic and diastolic function during isovolumic contraction and relaxation.

Imbalance of plasminogen activator inhibitor-I/ tissue plasminogen activator and tissue factor/tissue factor pathway inhibitor in young Japanese men with myocardial infarction.

To evaluate the association between haemostatic parameters and increased risk of myocardial infarction (MI) at a young age, we measured fibrinogen, factor VII, antithrombin III, protein C, protein S, tissue factor (TF), free form tissue factor pathway inhibitor (TFPI), plasminogen, alpha2-antiplasmin, tissue plasminogen activator (tPA), plasminogen activator inhibitor-I (PAI-I), and lipoprotein (a) in 140 young men with MI before age 45 and 150 age-matched healthy men. TF, TF/TFPI ratio, PAI-I, PAI-I/tPA ratio, plasminogen, and lipoprotein (a) in young MI patients were all significantly higher than controls, while TFPI, antithrombin II, and tPA were significantly lower (P <0.001 of each). Significant determinants of MI risk were PAI-I/tPA ratio (R2 = 0.300, P <0.001), TF/TFPI ratio (R2 = 0.049, P <0.001), antithrombin III (R2 = 0.034, P <0.001), hyperlipidaemia (R2 = 0.019, P = 0.004), diabetes (R2 = 0.014, P = 0.015), lipoprotein (a) (R2 = 0.012, P = 0.023), alpha2-antiplasmin (R2= 0.014, P = 0.012), and protein C (R2= 0.012, P = 0.018). We conclude that the imbalances of PAI-I/tPA and TF/TFPI are significantly associated with MI at a young age, perhaps mediated via impaired fibrinolytic activity.

Plasma level of triglyceride-rich lipoprotein remnants is closely associated with the activation of coagulation factor VII in patients with myocardial infarction.

Remnant-like particles, which have been recognized to be atherogenic derivatives of chylomicrons and very low density lipoproteins, can be measured using a new assay kit. The purpose of the present study was to investigate the association of remnant-like particles with the coagulation system that has an important role in the pathogenesis of myocardial infarction. We assayed blood levels of total cholesterol, triglyceride, HDL-cholesterol, apolipoproteins, remnant-like particles-cholesterol, remnant-like particles-triglyceride, fibrinogen, factor VII antigen, activated factor VII, and tissue factor in 111 patients with a history of myocardial infarction and 128 control subjects. In simple regression analysis, plasma levels of remnant-like particles-cholesterol and remnant-like particles-triglyceride showed a significant positive correlation with the levels of activated factor VII (r=0.319, p<0. 001, and r=0.286, p=0.002, respectively) and the activated factor VII/factor VII antigen ratio (r=0.241, p=0.011, and r=0.249, p=0.008, respectively) in patients with myocardial infarction. In contrast, there were no significant differences between remnant-like particles and activated factor VII in control subjects. In stepwise multivariate regression analysis, the significant determinants of activated factor VII were remnant-like particles-cholesterol (10.2%), apolipoproteins A-I (5.1%), and E (7.1%); for the activated factor VII/factor VII antigen ratio, remnant-like particles-triglyceride (6. 2%), age at blood sampling (5.1%), and apolipoprotein A-I (4.0%) in patients with myocardial infarction. However, the significant determinants of activated factor VII and the activated factor VII/factor VII antigen ratio were HDL-cholesterol (9.9% and 9.2%, respectively) in control subjects. It is concluded that remnant-like particles may be a risk factor for myocardial infarction by activating the extrinsic coagulation pathway.

[Transthoracic Doppler echocardiographic detection of intramyocardial coronary artery flow in humans using high frequency transducer].

The use of transthoracic color and pulsed Doppler echocardiography to detect intramyocardial coronary artery flow in humans was evaluated in 18 normal healthy subjects (mean age 54 years) and in 16 patients with hypertrophic cardiomyopathy (HCM; mean age 59 years) to measure the intramyocardial coronary artery flow velocity at the ventricular septum and the apex using a 10-5 or 7-4 MHz transducer. Linear inflow color Doppler signals which passed the interventricular septum were demonstrated in 15 of 18 normal subjects (83%) and 15 of 16 patients with HCM (94%). The phasic flow velocities measured by pulsed Doppler echocardiography consisted of two forward flow signals in mid-systole (S-wave) and holodiastole (D-wave), and were obtained in 11 of 18 in normal subjects (61%) and 14 of 16 patients with HCM (88%). The mean peak velocities of the S- and D-waves in patients with HCM (mean [+/-SD] 27 +/- 9 and 86 +/- 23 cm/sec, respectively) were significantly (p < 0.05) higher than those in normal subjects (18 +/- 4 and 54 +/- 11 cm/sec, respectively). At the apex, linear inflow color Doppler signals which passed the myocardium perpendicularly during the whole diastole were demonstrated in 14 of 18 normal subjects (78%) and all 16 patients with HCM (100%). The phasic flow velocities were measured by pulsed Doppler echocardiography in 10 of 18 normal subjects (56%) and 15 of 16 patients with HCM (94%). The mean peak velocities in patients with HCM (74 +/- 27 cm/sec) were significantly (p < 0.05) higher than those in normal subjects (33 +/- 13 cm/sec). Transthoracic color and pulsed Doppler echocardiography can detect intramyocardial coronary artery flow in humans at the interventricular septum and the apex noninvasively.

[Change in mitral valve area after percutaneous transvenous mitral commissurotomy: prediction of mitral valve restenosis].

Factors indicating changes in mitral valve area after single-balloon percutaneous transvenous mitral commissurotomy (PTMC) were evaluated in 53 patients receiving PTMC by follow up for 3-48 months (mean 18 +/- 12 months) using serial transthoracic echocardiography to measure mitral valve area by planimetry. The echocardiographic scores of the mitral commissures and mitral valve, and other clinical variables were assessed. Mitral valve area showed an immediate increase from 1.1 +/- 0.3 to 1.8 +/- 0.3 cm2 (p < 0.01). There was a small but significant decrease in mitral valve area at follow-up to 1.6 +/- 0.4 cm2 (p < 0.01). Restenosis (a decrease in mitral valve area of more than 25% from immediately after PTMC to follow-up) occurred in nine patients (17%). There was no significant correlation between clinical or echocardiographic features and an increase in mitral valve area immediately after PTMC. The total echocardiographic score of the mitral commissures correlated with the decrease in mitral valve area at follow-up (r = 0.42, p = 0.002). Multiple regression analysis showed the total echocardiographic score of the mitral commissures was the best indicator of a decrease in mitral valve area at follow-up (p = 0.0059). Six of nine patients with restenosis had a commissure score of more than 3, while only five of 44 patients without restenosis had a commissure score of more than 3 (p < 0.01). Mitral valve area increases significantly immediately after PTMC, and decreases significantly at follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

[Relationship between early peaking of serum myosin light chain 1 level and washout phenomenon of creatine kinase in acute myocardial infarction].

To investigate the serum levels of myosin light chain 1 (MLC1) during the acute phase of myocardial infarction, the MLC1 and creatine kinase (CK) levels were measured in samples from 59 consecutive patients with acute myocardial infarction. The serum concentration of MLC1 increased rapidly, reaching an early peak in 22 of the 59 patients (the MLP + group). Fifteen patients showed rapid increases in MLC1 levels without an early peak (the MLP - group). Serum MLC1 levels remained within normal limits (the MLN group) 10 hours after the onset of symptoms in the remaining 22 patients (but in eight of these serum MLC1 levels were abnormal 16-39 hours after the onset of symptoms). Serum level curves of CK showed a single episode of acute myocardial infarction in all patients. The patterns of MLC1 levels correlated with the washout phenomenon of CK (p < 0.001) and the maximum MLC1 level (p < 0.05). The ratio of serum MLC1 level during the early phase to the maximum level (EMR) decreased in the order of groups MLP+, MLP-, MLN (0.54 +/- 0.28, 0.31 +/- 0.22, 0.13 +/- 0.09, respectively). The EMR was correlated with the washout phenomenon of CK (p < 0.001), but not with the maximum MLC1 level which might reflect the size of the infarction. The patterns of neither MLC1 nor EMR were correlated with the administration of urokinase or the patency of the infarct-related artery at the early phase (within 10 hours of onset).(ABSTRACT TRUNCATED AT 250 WORDS)

[Quantification of mitral regurgitant stroke volume by the proximal isovelocity surface area method].

Although color Doppler flow mapping has been used to quantitate the severity of mitral regurgitation, this approach has various limitations. Doppler color flow mapping of a proximal isovelocity surface area (PISA), defined by a blue-red aliasing interface, has been shown in vitro to be accurate for estimating volume flow rate across an orifice. Volume flow rate can be calculated as PISA x aliasing velocity. To evaluate the clinical applicability of the PISA method, we compared the regurgitant stroke volume estimated by the PISA method with the conventional pulsed wave Doppler method in 18 patients with mitral regurgitation. The mean systolic aliasing radius was calculated from color overlayed M-mode (Q/M-mode) images. The mitral regurgitant stroke volume calculated by the PISA method correlated well with that calculated by the pulsed Doppler method (r = 0.89, SEE = 6.0 ml). Thus, the color Doppler PISA method can be applicable to calculating the regurgitant volume in patients with mitral regurgitation.

[Reliability of biplane transesophageal color Doppler echocardiography in evaluating mitral valve prolapse: comparison with surgical findings].

The reliability of biplane transesophageal color Doppler echocardiography for the evaluation of mitral valve prolapse was assessed by comparison with surgical findings in 27 patients. The mitral valve prolapse site was classified as the medial, central, and lateral portions of the anterior leaflet, and medial, middle, and lateral scallops of the posterior leaflet. The prolapsed sites were determined by the site of systolic displacement using two-dimensional echocardiography, the site of flow acceleration and the direction of the mitral regurgitant jet using color Doppler echocardiography. The sensitivity of transesophageal echocardiography for detecting prolapse at the medial, central, and lateral portions of the anterior leaflet, and the medial, middle and lateral scallops of the posterior leaflet was 91, 100, 86, 83, 100, and 80%, respectively. The specificity was 100, 100, 96, 100, 89, and 100%, respectively. Biplane transesophageal echocardiography is a reliable method for detecting the site of mitral valve prolapse.

Obstruction of inferior vena caval orifice by giant left atrium in patients with mitral stenosis. A Doppler echocardiographic study from the right parasternal approach.

BACKGROUND: To examine whether an extremely enlarged left atrium (giant left atrium) obstructs the venous return from the inferior vena cava (IVC), the velocity of IVC flow was measured at its junction with the right atrium (IVC orifice) in patients with mitral stenosis by use of color and pulsed-wave Doppler echocardiography from a right parasternal longitudinal plane. METHODS AND RESULTS: The maximum dimension of the IVC orifice by two-dimensional echocardiography and the maximum IVC orifice flow velocity by pulsed-wave Doppler echocardiography were measured in 74 patients with mitral stenosis and atrial fibrillation (mean age, 59 years). The control population consisted of 16 subjects with atrial fibrillation alone (mean age, 61 years). Flow velocities in the superior vena cava and hepatic vein were also obtained by pulsed-wave Doppler echocardiography from the supraclavicular and subcostal views, respectively. Fifty-one mitral stenosis patients without severe tricuspid regurgitation were divided into two groups according to the left atrial dimension (LAD), which was measured by the standard left parasternal long-axis view (group A: n = 33, LAD less than 65 mm; group B: n = 18, LAD greater than or equal to 65 mm). Peak inspiratory and expiratory velocities of IVC orifice flow in diastole averaged over three consecutive inspirations in group B (mean +/- SD, 93.4 +/- 32.0 and 47.6 +/- 19.8 cm/sec) were significantly greater (p less than 0.01) than in the control subjects (67.9 +/- 12.8 and 34.5 +/- 7.0 cm/sec) and in group A (70.2 +/- 18.4 and 38.1 +/- 11.5 cm/sec, respectively). However, there were no significant differences in superior vena caval and hepatic vein flow velocities among the three groups. The maximum IVC orifice dimension in group B (11.4 +/- 4.4 mm) was significantly smaller than in the control subjects (20.1 +/- 2.1 mm) and in group A (18.6 +/- 5.4 mm) because of displacement of the atrial septum into the right atrium. There were significant negative correlations between the IVC orifice dimension and the peak IVC orifice flow velocity (r = -0.62, SEE = 0.33 cm/sec, n = 67, y = e(-0.01x + 3.6), p less than 0.01) as well as the left atrial dimension (r = -0.71, SEE = 0.32 mm, n = 67, y = e(-0.02x + 3.8), p less than 0.01) in these 51 patients and control subjects. In the remaining 23 patients with severe tricuspid regurgitation, the peak inspiratory IVC orifice velocity (n = 9, 88.6 +/- 30.0 cm/sec) was significantly greater (p less than 0.05) and the IVC orifice dimension (23.8 +/- 9.7 mm) significantly smaller (p less than 0.05) in patients with a giant left atrium than in those without (n = 14, 69.9 +/- 15.3 cm/sec and 30.5 +/- 9.6 mm, respectively); in the latter, the IVC orifice dimension was significantly (p less than 0.05) greater than in the controls. CONCLUSIONS: A giant left atrium in patients with mitral stenosis obstructs venous return at the IVC orifice by marked displacement of the atrial septum toward the right atrium.

Value of acceleration flow signals proximal to the leaking orifice in assessing the severity of prosthetic mitral valve regurgitation.

To test the value of acceleration flow signals proximal to the leaking orifice in assessing the severity of prosthetic mitral valve regurgitation, 39 consecutive patients undergoing left ventriculography were examined by Doppler color flow imaging. Acceleration flow signals proximal to the regurgitant orifice were detected in 27 of the 31 patients who had prosthetic mitral regurgitation by left ventriculography (sensitivity 87%). All four patients without acceleration flow signals had mild prosthetic mitral regurgitation by angiography. No acceleration flow signals were detected in any patient without prosthetic regurgitation by left ventriculography (specificity 100%). Individual values of the maximal area of acceleration flow signals obtained from three orthogonal planes in seven patients with mild prosthetic mitral regurgitation by angiography ranged from 0 to 17 mm2 (mean 4 +/- 6). In 8 patients with moderate prosthetic mitral regurgitation by angiography, the maximal area of acceleration flow signals ranged from 21 to 58 mm2 (mean 33 +/- 15), whereas the maximal area of acceleration flow signals in 16 patients with severe prosthetic regurgitation ranged from 20 to 173 mm2 (mean 102 +/- 41). The maximal area of the acceleration flow signals from three planes correlated well with the angiographic grade of prosthetic mitral regurgitation. There was a significant difference in the maximal area of acceleration flow signals between mild and moderate (p less than 0.001), moderate and severe (p less than 0.001) and mild and severe (p less than 0.001) prosthetic mitral regurgitation. Thus, measurement of acceleration flow signals by Doppler color flow imaging is useful in assessing the severity of prosthetic mitral regurgitation.

Assessment of aortic regurgitation by the acceleration flow signal void proximal to the leaking orifice in cinemagnetic resonance imaging.

BACKGROUND: The proximal acceleration flow region is a laminar flow field that is located immediately upstream from the leaking orifice. The purpose of this study was to evaluate whether cinemagnetic resonance imaging can provide information regarding the proximal acceleration flow region in patients with aortic regurgitation and to analyze the relation between the area of the proximal acceleration flow delineated by cinemagnetic resonance imaging and the severity of aortic regurgitation delineated by angiography. METHODS AND RESULTS: Thirty-eight consecutive patients who underwent aortography were examined by cinemagnetic resonance imaging. The region of proximal flow acceleration was identified as a semicircular-shaped signal void in the aorta during diastole. Cinemagnetic resonance imaging detected the proximal acceleration flow region in 26 of the 30 patients who were proved to have this lesion (sensitivity, 87%). In eight patients without aortic regurgitation according to aortography, no proximal acceleration flow region was detected (specificity, 100%). The area of the acceleration flow signal void from the long-axis view was well correlated with angiographic degree of aortic regurgitation. CONCLUSIONS: Cinemagnetic resonance imaging is useful in detecting the proximal acceleration flow region and permits noninvasive assessment of the severity of aortic regurgitation.

Surgery for total anomalous pulmonary venous drainage in adults. Case reports and review of eight Japanese patients over 40 years of age.

In the majority of cases, total anomalous pulmonary venous drainage (TAPVD) results in death in infancy or early childhood, with very few cases surviving until adulthood. We report here the surgical correction of TAPVD in two adult patients, a 43-year-old male and 51-year-old female. The postoperative course was uneventful in the two patients, both of whom showed marked improvement of clinical features. The six other surgical corrections of TAPVD in patients over 40 years of age that have been reported in Japan are also reviewed. The favorable results in these cases were associated with the following common factors: 1) unobstructed forms with large drainage veins, 2) large interatrial communication, 3) normal pulmonary vascular resistance with normal or slightly elevated pulmonary artery pressure, 4) low grade, delayed cyanosis, and 5) the supracardiac type of TAPVD.

Significance of laminar systolic regurgitant flow in patients with tricuspid regurgitation: a combined pulsed-wave, continuous-wave Doppler and two-dimensional echocardiographic study.

To define the significance of laminar systolic tricuspid regurgitant (TR) flow, pulsed-wave and continuous-wave Doppler (PWD, CWD), and two-dimensional and M-mode echocardiography (2-DE, M-mode) were performed in 68 patients with TR, which included five patients with tricuspid valvectomy. The pattern of TR flow (laminar versus turbulent), TR severity (the distance that the regurgitant flow extended into the right atrium [1+ to 4+ as measured by PWD]), the peak flow velocity of TR by CWD, the presence or absence and the amount of systolic tricuspid cusp separation by 2-DE, and the dimension of the right ventricle and the inferior vena cava by M-mode, were assessed. A laminar pattern of TR flow in systole was obtained in 21 patients, five of whom had undergone tricuspid valvectomy. Fourteen of 21 had visible tricuspid cusp separation in systole on 2-DE; of the seven who had no visible tricuspid cusp separation during systole, five had undergone tricuspid valvectomy. All 47 patients with a turbulent pattern of TR flow had no visible systolic tricuspid cusp separation. Severe 4+ TR was present in 14 of 21 (67%) patients with laminar TR flow and in 4 of 47 (9%) patients with turbulent TR flow (p less than 0.001). The peak flow velocity of TR in patients with laminar TR flow (2.0 +/- 0.7 m/sec) was lower (p less than 0.001) than in those with turbulent TR flow (3.1 +/- 0.7 m/sec).(ABSTRACT TRUNCATED AT 250 WORDS)

[Exercise capacity in coronary artery disease evaluated by continuous wave Doppler flowmetry].

In this study the effects of exercise on peak aortic flow velocity (PFV), and the relationship between the maximum change in PFV and the extent of ischemia or infarction were examined. In 16 normal controls (NC) and 83 patients (pts) with documented coronary artery disease, continuous wave Doppler echocardiography and thallium-201 scintigraphy were performed simultaneously during supine bicycle exercise. The patients were grouped according to their results of thallium perfusion imaging: Group (G) 1 (10 pts) = normal; G-2 (30 pts) = ischemia without old infarction, G-3 (23 pts) = old infarction without angina, and G-4 (20 pts) = angina with old infarction. Three different PFV responses to exercise were observed. In NC, PFV increased progressively with exercise. In 28 pts (G-1 = 10, G-2 = 2, G-3 = 11, G-4 = 5), PFV increased as in NC (Type I). In 43 pts (G-2 = 24, G-3 = 9, G-4 = 10), PFV increased at the initial stage but was unchanged or decreased at the final stage (Type II). In 12 pts (G-2 = 4, G-3 = 3, G-4 = 5), PFV decreased progressively with exercise (Type III). The incidence of acute ischemia was 25% (7/28) in Type I, 79% (34/43) in Type II and 75% (9/12) in Type III. Furthermore, Doppler and scintigraphic studies were repeated during exercise in 16 pts (Type II = 14, Type III = 2) who underwent percutaneous transluminal coronary angioplasty (PTCA). After PTCA, in 11 of the 16 pts, the images of acute ischemia nearly resolved and profile of the PFV changed from Type II or III to Type I. In the remaining five patients, the results of both studies were unchanged. Finally, the maximum change of PFV showed good correlation with the extent of ischemia and/or prior infarction (in G-2, r = -0.50, p less than 0.01; in G-3 except for 11 pts of Type I, r = -0.76, p less than 0.01; in G-4, r = -0.80, p less than 0.001). The extents of ischemia and infarction in each group were considered to be far greater in Type III than those in the other Types. These results show that changing of PFV during exercise are related with the presence and extent of acute ischemia and/or infarction.