[Calculation of the arterial pulmonary pressure by using phonomechanocardiography. Correlation with the measurement by catheterization]. / Cálculo de la presión arterial pulmonar por fonomecanocardiografía. Correlación con la medición por cateterismo.

We are presenting a phonomechanographic study for the calculation of sytolic pressure of the pulmonary artery, following the method proposed by Burstin & Fishleder. Correlation is made of 287 patients with the pressure obtained from the registration of direct-catheterism in the pulmonary artery. We insist on the advantages of this method such as quicker accomplishment, easier calculation and harmless for the patient, and we are analyzing some of the physiologic mechanisms which participate in the calculation of the pulmonary systolic pressure. We concluded that it is a reliable method of a high degree of correlation uith the hemodynamic research, specially when both studies are contemporary.

[Electro-echocardiographic correlation in mitral valve prolapse]. / Correlación electro-ecocardiografía en el prolapso de la válvula mitral.

The study was performed in 33 patients with echocardiographic diagnosis of mitral valve prolapse (PVM), without any other associated heart disease. A 19 derivations electrocardiogram (ECG) was performed a direct inscription 4 channel Samborns 150 machine at 25 and 50 mm/sec. The purpose of the study was determine the alterations in ventricular depolarization and repolarization, and to correlate them with valve prolapse, as well as with cavitary and parietal dimensions, as measured by M mode and/or two-dimensional echocardiography. Left ventricular hypertrophy detected by ECG agreed with the ECO test in 77%; the sensitivity was of 86% and specificity of 67.5%. Left ventricular hypertrophy detected by ECG was not related with the type of prolapse. Ventricular repolarization alteration was very frequent (84.8%). Association of this parameter with initial notch of R in a VF becomes important for diagnosis suspicion (p less than 0.01). When the abnormal repolarization affected the anterolateral wall, posterior valve prolapse was frequent; when the posteroinferior region was the affected one, the prolapse occurred more frequently in both valves. An important correlation (p less than 0.01) was found between left ventricular dilatation detected by ECO and the abnormal ventricular repolarization.

[Echocardiographic evaluation of the tricuspid valve in rheumatic mitral valvulopathy]. / Valoración ecocardiográfica de la valvula tricúspide en la vavulopatía mitral reumática.

The recognition of tricuspid valve involvement in presence of rheumatic mitral valve disease is important when surgery is contemplated. At the National Institute of Cardiology in Mexico City, we studied 57 patients with preoperative echocardiogram and catheterisation on whom the tricuspid valve (TV) was explored during surgical repair of mitral valve disease. TV was normal in 17 patients (group I), 28 had functional tricuspid insufficiency (group II) and 12 had rheumatic involvement (group III). Surgical treatment over TV was required in 22 (20 annuloplasty, 1 comissurotomy and 1 homograft valve replacement). We found pure mitral stenosis in 15, mitral stenosis and regurgitation in 36 and 6 with pure mitral insufficiency; the surgical repair over the mitral valve consisted in: 4 comissurotomies and 53 prosthetic valve replacement. At catheterisation, no significant pressure differences were found among the groups (right atrium, end diastolic of right ventricle, systolic pulmonary artery and capillary wedge). Echocardiogram showed E-F slope velocity diminished in group III (P less than 0.01), a diastolic anterior motion of septal leaflet of TV was found in 22 patients. No significant differences in the right ventricle measurements were found. In 7 patients a systolic anterior motion of interventricular septum was observed, all had mitral stenosis, 6 from group II and 1 from group III. We conclude that: echocardiogram study is a useful tool for the evaluation of TV involvement in patients with rheumatic mitral valve disease.

[Echocardiography in the evaluation and pre- and postoperative follow-up of chronic aortic insufficiency]. / La ecocardiografía en la valoración y seguimiento pre y postoperatorio de la insuficiencia aórtica crónica.

In chronic aortic regurgitation (CAoR) is difficult to determine the moment in which volume overload produces the myocardial deterioration which originates symptoms. We pretend to demonstrate the utility of echocardiography in defining the correct timing of operative correction in CAoR with pre- and post-operative comparison. Thirteen patients with CAoR (systolic ventricular-aortic gradient less than 20 mmHg) in whom the aortic valve was replaced were studied with an average of 13.7 months of follow-up. Two patients died immediately after surgery. Those remaining had a decrease in cardiomegaly grade and moved into functional class I. The echocardiogram revealed a significant reduction (P less than 0.01) in diameters of the left ventricle. The ejection fraction increased (P less than 0.05) in the post-operative period. Fractional shortening (FS) and mean velocity of circumferential shortening showed no significant change. The index end-systolic diameter over normalized velocity of the posterior wall IESD/NVPW) decreased considerably and the mean velocity of circumferential relaxation (Vcfr) increased (P less than 0.001) after surgical treatment. The preoperative ESD/NVPW index and Vcfr correlated well with the left ventricular end-diastolic pressure (r = 0.891 and r = -0.885, respectively). There was no difference in the course of those patients with diminished FS. The ESD/NVPW index and the Vcfr allowed a better evaluation of the residual volume, of the Frank-Starling law and of distensibility as an expression of the ventricular function. Consequently we conclude these indices are useful to establish the best moment for pre-operative catheterization in patients with CAoR.

[Phonomechanocardiography in the evaluation of the functional status of valvular prosthesis]. / El estudio fonomecanocardiográfico en la valoración del estado funcional de las prótesis valvulares

The FMCG in 22 patients with valvular prosthesis is analyzed and its clinical, hemodynamic and surgical correlation are established (11 from the I.N.C. and 11 from the Hospital Infantil I.M.A.N.). The average age of the patients was 15 years old, 18 had a mitral and six aortic valvulopathy, and they all required a valvular replacement. Of the mitral prosthesis, 14 were Starr-Edwards (13 of ball valve and one of disc), three Lillehei-Kaster and one Börck-Shiley. In 5 patients, the FMCG suspected disfunction that was later corroborated by catheterism in three patients and by surgery in all of them. The important differences of the FMCG between the group with good and the one with bad function were: the aparition of a rumble, a decrease in the amplitud of the closing snap, index of closing snap opering snap of less than one, lenghtening of fases PFVP and IVCP, and shortening of IVDRP. In the patients with auricular fibrilation, after long dyastoles; that would represent an adequate atrial emptying; the closing snap was more intense, the PFVP was lennthened the IVDRP was shortened when the prosthesis was not properly functioning. All the aortic prosthesis were ball valve Starr-Edwards type; in one the FMCG suspected disfunction and the patient had a sudden death outside of the Hospital. The significant differences of the FMCG were the decrease in the intensity of the opening snap, with a Hylen index of less than one, lengthening of the PFVP, IVCP and of the expulsive period (EP). The authors conclude that the FMCG is a good method for an early detection of the disfunctions of valvular prosthesis.

[Apical hypertrophic myocardiopathy: presentation of 3 cases and review of the literature]. / Miocardiopatía hipertrófica apical: presentación de tres casos y revisión de la literatura.

Apical hypertrophic myocardiopathy (AHM) is an entity less frequently reported in our country than in Japan. We studied only three patients between 1980 and 1987. Their age varied from 26 to 40 years. Other studies included vectorcardiograms, Holter monitoring, exercise stress testing, phonocardiograms and cardiac catheterization; only one case had a genetic study, program atrial stimulation and technetium-99m pyrophosphate scintigraphy. All patients underwent echocardiographic study. The clinical features had great variations, from asymptomatic cases to the presence of important left ventricular failure and brain embolism. Electrocardiogram was characteristic in two patients; in one, cardiac catheterization showed an intraventricular pressure gradient of 19 mmHg explained by trapping of the catheter and in the other one, the end-diastole pressure of left ventricle was 22 mmHg; in both, the left ventriculogram showed the characteristic spade image. In all of them the echocardiogram showed segmentary left apical ventricular hypertrophy similar to the angiographic image; one patients had mitral regurgitation. This study demonstrates the usefulness of echocardiogram in this pathology.

[Phonomechanocardiographic study of innocent murmurs in children]. / Estudio fonomecanocardiográfico de los soplos inocentes en niños.

At the National Institute of Pediatrics DIF (formerly IMAN), a comparative study was performed in 157 healthy children. Ninety four (59.8%), had an innocent cardiac murmur, and 63 children (40.1%) had no heart murmur detectable. The presence of innocent murmurs was more frequent in pre-school and school age; murmurs of basal location were predominant. The murmurs were brief midsystolic and of the ejective type. All of them had the characteristics of a vibratory murmur of sinusoidal type, with diagonal radiation and low frequency. One more dynamic of pharmacological tests were performed in 60 children. In 88.5% of the cases, the murmur showed left behavior during the Valsalva monouver. Only in 15.7% during the Azoulay maneuver suggested right origin of the murmur. In 70% the murmur decreased with orthostatism and in the children who inhaled amyl nitrite, the murmur showed a behavior suggestive of aortic ejective origin. The comparison between the groups with and without murmurs showed that the heart rate was lower for those children with murmurs (P less than 0.05), the left ventricle ejection time was shorter in children with murmurs (P less than 0.01), but instead the preejection period was longer in children with murmurs (P less than 0.05). These differences let us point out that in children with murmurs the blood flow during the early systole is higher than in those without murmurs. This conditions probably a determinant in the origin of the innocent murmur.

[Chronodynocardiometry in healthy children. 1: Systolic times]. / Cronodinocardiometría en niños sanos. Primera parte: tiempos sistólicos.

At the National Institute of Pediatry (IMAN) were studied the phonomechanocardiographic recorders obtained of 125 children, all were eutrophic and healthy. The measure of the systolic time intervals were the purpose of the study. Children's age varied from 2 months old to 18 years old; 82 boys and 43 girls. The duration of the R-R space increased according to age (P less than 0.001), the electroacoustic systole and the ejection time showed more duration in older children (r = 0.61 and 0.77 respectively). In opposite, the pre-ejection time as well as its phases, had a similar duration in all ages. Tables of values and ranges of the systolic time intervals according to age are presented. The systolic time intervals were correlated to the R-R space duration, and showed a direct proportion with the electroacoustic systole (r = 0.76) and ejection time (r = 0.83), but the pre-ejection time had not significant changes. The electroacoustic diastole duration was proportional to the R-R space (r = 0.96). The regression equations were calculated to evaluate the normal range of the systolic time intervals in children, obviously in accordance to cardiac frequency.

[Chronocardiometry in healthy children. II. Diastolic time intervals]. / Cronodinocardiometría en niños sanos. Segunda parte: Tiempos diastólicos.

At the National Institute of Pediatrics DIF (called before IMAN) a prospective study of diastole time intervals (DTI) was performed on 138 healthy children by phonomechanocardiography. The correlation of the DTI with age and heart rate (HR) was studied. Also the relationship of the DTI with systolic times intervals (STI) was studied. The age of children did not show significant correlation with the DTI. Isovolumic relaxation phase (IVRP), tachydiastolic phase (TDP) and presystolic phase (PSP) were slightly modified by HR and obviously, without significance. But instead, the bradidiastolic phase (BDP), effective diastole (ED) or the time on which the mitral valve is opened and total diastole (D) showed directly proportional relation with R-R interval of the ECG (P less than 0.001). The left ventricular ejection time (LVET) was longer according to the ED duration (r = 0.818). The ejection fraction (EF) showed proportional increase to the ED duration, but without statistics significance. The influence of the DTI that have upon STI is important.

[Echocardiographic study of corrected transposition (author's transl)]. / Estudio ecocardiográfico de la transposición corregida.

We studied patients with corrected transposition of the great arteries by M and bidimensional echocardiography. Three patients in situs solitus and one in atrial situs inversus. The characteristics of the atrio-ventricular valves, and it's relation with other heart structures was determined, as well as the ventriculo-arterial connections and the presence of associated defects. The approximations employed were parasternal and suprasternal. The cases of discordant ventriculo-arterial connection in atrial situs solitus showed mitro-pulmonary continuity. In these cases the pulmonary artery, located in a right posterior situation with respect to the aorta, became intensely opaque when contrast material was injected in a peripheral vein. In atrial situs inversus, the aorta had a right and anterior position. We conclude that it is possible to establish the diagnosis of atrioventricular discordance by an adequate systematization of the echocardiographic recordings.

[New echocardiographic (M-mode) index for evaluation of left ventricular end-diastolic pressure in chronic aortic regurgitation (author's transl)]. / Nuevo índice for ecocardiografía modo-m para la evaluación de la presión diastólica final del ventrículo izquierdo en la insuficiencia aórtica crónica.

The clinical evaluation of the best time for the surgical treatment of chronic aortic insufficiency is difficult to be assessed. Several invasive and non invasive procedures had been used, but there is no definitive solution yet. At the National Institute of Cardiology Ignacio Chávez, 13 patients wih pure, chronic and isolated cortic regurgitation (AR) were studied by echocardiography M mode (Echo M) to determine the state of left ventricular performance and the correlation with the valves of the end diastolic pressure of left ventricle (LVEDP). Besides catheterism of the left side, aortography and ventriculography were performed to all the patients. Catheterism, X-nay and electrocardiogram were done within a period no longer than 24 hours after the Echo M record. The function of the left ventricle (LV) was evaluated by measures and calculations published by other authors. With the purpose of integrating the functional characteristics of the LV in one expression, the indices left ventricle and systolic diameter divided by left ventricular normalized velocity of posterior wall (LVESD/LVPWNV) was created. It showed good correlation with LVEDP (r = 0.92). The index also had good correlation with the cardiothoracic ratio (r = 0.86) and the mean velocity of circumferential shortening of the LV by Echo M (r = 0.91). We consider important the LVESD/LVPWNV index proposed here, to determine the LVEDP of these patients; together with the whole clinical information, it makes easier the identification of the most appropriate time for surgical treatment making possible to evade the phase of myocardial damage which is risky to patients with chronic aortic insufficiency.

[Evaluation of pulmonary valve stenosis by means of phonomechanocardiography]. / Valoración de la estenosis pulmonar valvular por fonomecanocardiografía.

At the DIF Children's Hospital, 12 patients with pulmonary stenosis (PS) were studied. The values of the systolic pressure of right ventricle (SPRV) varied between 69 to 300 mmHg, showing a direct relationship with age. Weight and height were not related to the degree of PS. Five patients presented dyspnea and 3 of them also presented cyanosis, but seven were asymptomatic. Symptoms appeared in those patients with higher systolic and end diastolic pressure of RV, although the correlation was not significant. The phonocardiogram (PCG) showed a correlation between the duration of the systolic ejective murmur (SEM) and the degree of increase SPRV. The presence of an ejection click did not show a significant correlation with the severity of PS. Furuta's index, the IIA-IIP interval and the IIP/IIA index indicated a substantial corresponding between the SPRV and the transpulmonary gradient, both measured by catheterization. The "a" wave of phlebogram was giant in patients with high SPRV. The calculation of the SPRV by PCG showed a strong correlation with the determination made by catheterization. After surgery the duration of the SEM and Furuta's index decreased in all patients. The ejection click disappeared in 3 patients, becoming apparent in one. The IIA-IIP interval was shorter than before the operation and the phlebogram "a" wave of was reduced, except in one patient. The PCG is a reliable method of great utility for the evaluation of PS.

[Evaluation of the electrocardiogram in tricuspid atresia]. / Valoración del electrocardiograma de la atresia tricuspídea.

Due to the broad behaviour variability of the tricuspid atresia by the defects to which it is associated, the authors propose another classification, based on the position of the great vessels and the characteristics of the pulmonary flow, in addition to the extent of the intracardiac septal defects (atrial septal defect and ventricular septal defect) and the presence of patent ductus arterious. Eleven patients with tricuspid atresia with situs solitus and heart normo-placed are studied for diagnosis confirmation by catheterism or autopsy. Electrocardiograms are studied and observed in two patients with transposition of the great vessels and pulmonary oligohemia, a more evident right auricular enlargement (P of greater voltage in DII and AP heading right in the front plane), the AQRS deviated to the right, up and backwards, with less evidence of the left ventricular power than in other varieties of tricuspid atresia. These characteristics gave a diagnosis useful for this variation. On those patients without transposition and pulmonary flow increase, it is observed that growing appearance of the left auricle is more evident and so is the power of the free wall of the right ventricle (high R in right precordial deviations), the AQRS heads left as in most of the cases, but forward and upwards also. This electrocardiographic information is considered to have great importance to establish a diagnosis of the variations of tricuspid atresia due to associated malformations. Common varieties have already been extensively described by other authors and are not subject to special study. Bibliography on this matter is reviewed.

[Segmental echocardiographic analysis of congenital cardiopathies]. / Análisis ecocardiográfico segmentario de las cardiopatías congénitas.

The usefulness of M mode and two-dimensional echocardiography in the segmental localization of the cardiac chambers in congenital heart disease was studied. Nineteen patients with congenital heart disease and various possibilities of conexion of the different segments of the heart were diagnosed by angiocardiography and in some cases by surgical treatment. The echocardiographic diagnosis in these cases was based in the analysis of the spatial position of the heart chambers, atrio-ventricular, aortic and pulmonary valves. The results obtained are presented and the differential diagnosis is discussed. We conclude that in the majority of these patients with complex congenital heart disease, the diagnosis can be suggested by echocardiography, or at least, this procedure can guide us to program the angiocardiographic studies.

[Echocardiographic study of chronic aortic insufficiency. Hemodynamic, angiographic and total clinical correlates. II. Evaluation of left ventricular function]. / Estudio ecocardiográfico de la insuficiencia aortica crónica. Correlacion hemodinámica, angiográfica y clínica integral. Segunda parte: evaluación de la funcion ventricular izquierda.

An important point in the evolution of chronic aortic insufficiency (CAI) is the degree of disturbance of left ventricular performance (LVP), from which the surgical risk and the prognosis depend. Is possible by M mode Echocardiography (M-Echo) to evaluate the different elements that regulate the LVP, with the known measurements and by ratios of integral appraisal that are described here. We studied 14 patients with pure CAI at the National Institute of Cardiology, all of them had left catherization, ventriculography aortography, M-Echo, Chest X ray and EKG. The end systolic diameter (ESD) of the left ventricle (LV) and the fractional shortening (FS) showed good correlation with the end diastolic pressure (EDP) of the LV (r = 0.86 and -0.74 respectively). The percentage of aortic regurgitation (%AR) did not show significative correlation with the parameters of LV function. The ratios of integral appraisal showed good correlation with the EDP of the LV, the left atrium diameter over ejection fraction ratio (LAD/EF) was r = 0.764; the E point-septum separation over the fractional shortening ratio (E-S/FE) was r = 0.776, and for the ESD over the normalized velocity of the posterior wall of the LV ratio (ESD/NVPW) was r = 0.85. The relationship of the ESD/NVPW ratio with the EF was good (r = 0.95), with the mean velocity of circunferential shortening (r = -0.94) and with the cardiothoracic index (r = 0.88). We did not find a relationship between the functional class (NYHA) and the LVP, evaluated hemodynamic and echocardiographic methods used here. The M-Echo is an useful procedure for the sequential study of CAI, that permits recognition of the initiation and severity of the LV dysfunction, and it is of great help to signal the right moment for the surgical treatment.

[Echocardiographic study of congenital mitral valvulopathy]. / Estudio ecocardiográfico de la valvulopatía mitral congénita.

M mode, two dimensional and Doppler echocardiographic findings of eleven patients with congenital abnormalities of mitral valve are described. Nine of them had mitral stenosis and two had predominant regurgitation. Six of our patients had other associated cardiovascular malformations (3 coarctation of the aorta, two tetralogy of Fallot and one patent ductus arteriosus). In none of them, there was demonstration of abnormal echoes in the left atrium. In patients with congenital mitral stenosis the M mode echocardiographic findings were indistinguishable of those present in rheumatic mitral stenosis. With two dimensional echocardiography the anatomy was determined from the subvalvular characteristics and the mitral valve diastolic area. The Doppler study showed increase of the peak velocity of the mitral flow in all cases. We conclude that the M mode and two dimensional-Doppler echocardiography are helpful in the recognition of the isolated congenital mitral pathology or when it is associated to other malformations.

[Tetralogy of Fallot associated with supravalvular mitral membrane]. / Tetralogía de Fallot asociada a membrana supravalvular mitral.

Two children with tetralogy of Fallot and supravalvular mitral membrane are reported. In both, the diagnosis was established before surgery. In the first case, clinical data suggested the associated mitral lesion and a two-dimensional echocardiogram demonstrated a supravalvular membrane. In the second patient, mitral obstruction was diagnosed by Doppler echocardiography and the supravalvular membrane was visualized by means of the angiographic study. Despite the rare association of both malformation, the importance of its clinical recognition is mainly related to the surgical correction of both lesions.

[Study of the left coronary trunk by 2-dimensional echocardiography in ischemic cardiopathy]. / Estudio del tronco de la coronaria izquierda por ecocardiografía bidimensional en la cardiopatía isquemica.

The study of the left main coronary artery (LMCA) obstruction is very important in view of the risk that it represents for coronarography, the high mortality that it has and its indication of early surgical treatment. For these reasons we studied LMCA obstruction by two-dimensional echocardiography (2-D Echo). The study was blind, prospective and included of 50 unselected patients with coronary artery disease proved by coronarography. The LMCA obstruction was recognized in 5 patients (10%) by 2-D Echo, in two of them it was seen as non-obstructive atheroma and in 3 as a significant obstruction. This LMCA correlated with angiographic findings. We had not false negatives. The patients with LMCA obstruction had higher frequency of positive treadmill test and anteroseptal myocardial infarction. Three patients had bypass surgery with good results. Two had not surgery, one of them died and the other one has angina and heart failure. The 2-D Echo is a useful procedure in the study of LMCA obstruction.