Echocardiographic Studies of Stented Fascia Lata Grafts in the Mitral Position

Transcription

1 Echocrdiogrphic Studies of Stented Fsci Lt Grfts in the Mitrl Position By DAvD A. S. MARY, M.B., CH.B., M.R.C.P., BROJESH C. PAKRASHI, M.B., B.S., M.R.C.P., ROGER W. CATCHPOLE, AND MARIAN I. IONESCU, M.D., F.A.C.S. SUMMARY Nineteen ptients with stented fsci lt grfts in the mitrl position were studied by the reflected ultrsound technique. Eleven of these hd competent grfts, two hd miniml regurgittion nd six hd severe grft incompetence s judged by ventriculogrphy nd during surgery. The distolic closure rte (E-F speed) of the cusps reveled significnt correltion with the effective grft re derived by clcultions from crdic ctheteriztion dt (P <.1), nd indicted only mild to moderte stenosis. The exhibited cusp mobility reveled n mplitude which ws comprble with nd similr to tht mesured in cusps from freshly prepred fsci lt vlves. The demonstrted cusp mobility nd E-F speed did not show sttisticlly significnt difference between competent nd incompetent grfts (P>.7 nd P>.4 respectively). Further evidence is presented supporting the role plyed by the mitrl nnulus mobility in the production of echocrdiogrphic distolic movement of the leflet. Additionl Indexing Words: Effective grft re Distolic mitrl ring mobility Grft distolic closure Amplitude of cusp opening movement rte Downloded from by on October 1, 218 ECHOCARDIOGRAPHY hs become estblished s noninvsive technique for the dignosis nd ssessment of mitrl vlve stenosis.1-5 The sme technique cn lso be used to demonstrte prolpse of vlve leflets with or without mitrl incompetence.6-8 Studies with reflected ultrsound in ptients with mitrl prostheses hve been found useful for the detection of perivlvulr lek' nd dysfunction of the occluder device,1 11 nd for the investigtion of the mitrl ring movement.'2 13 There is no published report on the ppliction of echocrdiogrphy to the ssessment of mitrl stented tissue grfts. The technique of mitrl vlve replcement with stented fsci lt grfts hs been pioneered in the Generl Infirmry t Leeds,'4 nd its clinicl nd hemodynmic results hve been reported'5 16 The present echocrdiogrphic study From the Deprtment of Crdio-thorcic Surgery nd Crdiology, The Generl Infirmry t Leeds nd Leeds University, Leeds, Gret Britin. This work ws supported by the British Hert Foundtion. Address for reprints: Mrin I. Ionescu, M.D., F.A.C.S., Deprtment of Crdio-thorcic Surgery, The Generl Infirmry, Leeds, Gret Britin. Received August 21, 1973; revision ccepted for publiction October 1, Circultion. Volume XLIX, Februry 1974 ws performed in ptients who underwent postopertive crdic ctheteriztion. The im of the investigtion ws to seek correltions between the hemodynmic dt nd the ultrsonic distolic closure rte (E-F speed) of grft leflets, to study the reltionship between the distolic movements of the mitrl grft ring nd leflets, to detect grft incompetence, nd to define the mobility of the ultrsoniclly demonstrted cusps in reltion to tht mesured in freshly prepred fsci lt vlves. Mteril nd Method A totl of 19 ptients were studied by reflected ultrsound. Group A (tble 1) comprised 13 ptients, 11 with competent grfts nd two with miniml regurgittion. The ptients were investigted 1.5 to 3.5 yers (men 2.9 yers) postopertively. There were seven mles nd six femles with n ge rnge from 31 to 54 yers (men 44 yers). Group B (tble 2) comprised six ptients with incompetent mitrl grfts who were studied two to four yers (men 2.5 yers) postopertively. Their ges rnged between 35 nd 57 yers (men 45 yers). Three of these ptients were mles nd three were femles. Echocrdiogrphic studies were performed the dy before crdic ctheteriztion. An Ekoline 2 ultrsonoscope ws employed using 2.25 MHz (13/12 inich fce dimeter) trnsducer probe, whiclh trnsmits nid receives pulsed echoes t frequency of 1 pulses/sec. Echocrdiogrms were obtinied by Polroid 237

2 238 MARY, PAKRASHI, CATCHPOLE, IONESCU Tble I Detils of 13 Ptients Comprising Group A nd Fresh Grft Mesurements Downloded from by on October 1, 218 Internl dimeter of grfts used (mm) Dt Totl Grft no Yers since implnttion Echocrdiogrphic dt E-F speed (mm/sec) Totl grft mplitude (mmi) Amplitude of opening movement (mm) , Hemodynmic dt Hert rte (bet/min) Effective grft re (cm2) Men distolic grdient (mm Hg) Crdic output (L/min) Men left tril pressure (mm Hg) ) 2 1i Men pulmonry rtery pressure (mm Hg) Fresh grft mesurements Cusps number Opening mplitude (mm) Dt re expressed s rnge, men nd stndrd error. photogrphy from the oscilloscope of the instrument. The position of the mitrl grft ws predetermined by thorcic roentgenogrphy nd ws found in the mjority of ptients to ly t the level of the 4th to 5th intercostl spce. To obtin mitrl grft echocrdiogrms, the ultrsonic probe ws pplied to the nterior chest wll of the ptients, who were in supine position, 1 to 3 cm to the left of the midsternl line. The grft ring echoes were obtined first nd were confirmed by ngultion of the probe to define the reltion of the nterior edge of the grft to the posterior wll of the ortic root superomedilly. The interventriculr septum becomes the nterior wll of the ortic root.17 By further chnge in ngultion of the probe, echogrms were obtined demonstrting the mximl nd fstest movements of n nteriorly plced leflet with nd without grft ring or prong echoes (fig. 1). It ws not possible to obtin stisfctory mitrl grft echocrdiogrms in two ptients, one of whom hd kyphoscoliosis. The dt obtined from these two ptients were rejected. The hemodynmic dt were obtined by right nd left hert ctheteriztion with the zero level set t reference point 5 cm posterior to the sternl ngle. Crdic output ws mesured by the Fick method. Men distolic pressure grdient cross the mitrl grft ws obtined by plnimetry of simultneously recorded left ventriculr nd left tril or pulmonry wedge pressure t rest. Grft orifice re in cm2 ws obtined by using Gorlin nd Gorlin's hydrulic formul nd employing simultneous left ventriculr nd left tril or pulmonry wedge pressure trcings.18 Selective left ventriculr cinengiocrdiogrphy ws used in every ptient from group A nd in five ptients from group B in order to ssess the competence nd function of the vlve grft nd, when present, to grde the degree of regurgittion. In the remining ptient from group B nd in three others from the sme group, grft ppernce during re-opertion confirmed the severity of incompetency noted cliniclly nd ngiocrdiogrphiclly, nd provided informtion regrding the mechnism of incompetence nd grft leflet mobility. Mesurements An verge of t lest four crdic cycles ws used s mesure of every prmeter. In the mitrl grft echocrdiogrms, n nteriorly plced leflet is the expected reflecting interfce (fig. le). The demonstrtion of two leflets, however, ws chieved in four ptients (figs. 1, 2, 6). Totl mplitude of grft leflet excursions were mesured s the mximl verticl distnce between point C nd point E in mm, the mplitude of opening movement of the cusp s the verticl distnce between point D nd E in mm, nd Circultion, Volume XLIX, Februry 1974

3 Downloded from by on October 1, 218 ULTRASOUND STUDIES OF MITRAL GRAFTS pg.z. ;1 z U tz C. g.. z U CID C-.1_ IN1.j 91.4 r- 't, Co.).C.1 ti S.Q. C. 1 S, rc sq bi). >, r. A. 4. :I P. bel cc It G) u.c St oi WC p, 5 c_ ^s COO N N co Iz Hs Xo t-r. "-._ --- Cc Circultion. Volume XLIX, Februry 1974 o._ z CD t1..j C C: t v c 1 s tcv c cg t-.!4 - o - cd CMS r- -W. 1i.- 1 NqN t- - O.~ t- to ci CYID~~~~~~~~~~~~~~~~~~~~~~~,, N1-ev 1DS> -~. : -H 239 tht of mitrl grft ring excursions s the mximl verticl displcement of ring echogrm in mm. The distolic closure rte of the cusp (E-F speed) nd the distolic receding rte of the grft ring (H-I slope) were mesured s the rte of posterior movements of the echoes from point E nd point H, respectively, nd expressed in mm/sec (fig. 1). The mplitude of cusp opening movement ws mesured in freshly prepred fsci lt vlves. Six vlves with ring dimeter of 24 mm, four vlves with ring dimeter of 26 mm nd two vlves with ring dimeter of 28 mm were studied. The movement of the cusps on opening inscribe n rc bordering sector of circle. The chords joining the two ends of the rcs inscribed by the free mrgin of the cusps during opening were mesured in mm. This ws possible by stnding the vlve with its ring t right ngles on flt surfce nd mesuring the chords of ech cusp from the point of closed to tht of n open position. Results Reproducibility of Results All the ultrsonic studies were performed by one observer. The vlues obtined from two consecutive pplictions of the probes for the totl mplitude, opening movement of the cusp nd E-F speed, were tested by Student's t-test for pired vrints nd reveled no significnt difference (P >.4, P >.3, P >.5, respectively). The stndrd errors between the determintions were 2.5, 2.7, nd 6.7 mm/sec, respectively. Mitrl Grft Echocrdiogrm The ventriculr rtes of 18 ptients during echocrdiogrphic studies, the dy before, nd during crdic ctheteriztion t rest were essentilly the sme (P >.3). The ventriculr rtes during echocrdiogrphy of the 13 ptients belonging to group A rnged from 7 to 12 (men + SE 87 ± 4) bets/min. Seven of these ptients were in tril fibrilltion nd the remining six in sinus rhythm. In nine ptients utologous, nd in four homologous fsci lt were used. The internl dimeter of the grft ring ws 24 mm in three ptients, 26 mm in eight nd 28 mm in the remining two ptients (tble 1). In ll ptients from group A, the levels of left ventriculr enddistolic pressure ttined during submximl supine leg exercise rnged from 1 to 18 mm Hg (men ± SE mm Hg). On cine ventriculogrphy, the wlls of the left ventricle reveled good movements during ejection, nd there ws no evidence of kinesi or neurysm formtion. There ws sttisticlly significnt correltion (fig. 3) between clculted grft re nd E-F speed (-r =.6841, P <.1) in ptients from group A.

4 MARY, PAKRASHI, CATCHPOLE, IONESCU 24.. {. ER E.CG.G A.A.W. Ao.C. A. G..V.S PA.W. e E.C.G. L.A.W. L.VYW WA.P UJf'~L.JA.G.C. N ~P.G.F%PG.F E.CGG. A.TL. E.C.G A.G.C. P.G.F. -.9 Figure 1 ptient with size 26 mrm competent utologous fsci lt mitrl fter insertion. The sme clibrtions were used in every photogrph. Frmes to c represent selections of n M-mode scn from the bse of the hert () to the left ventricle just below the mitrl grft (c), nd demonstrting the reltionship between the mitrl grft frme, ortic root nd posterior left tril nd left ventriculr wlls. Frme b shows the box-like ppernce of n nterior nd posterior cusp), both enclosed by the grft frme. The echo in between the two cusps represents either the third cusp or prong of the grft. Frmre e nd the corresponding line drwing to the right demonstrte the ultrsonic lndmrks used in the text. The E-F speed nd the distolic receding rte of the grft ring (H-I slope) were mesured s the slope of line joining point E nd H with point F nd I respectively. The mximl verticl distnces between point C nd E nd point D nd E were used to mesure totl grft mplitude nd the mplitude of opening movement of the cusp respectively. The mximl verticl displcement of the frnme echo ws used to mesure the mplitude of ring excursions. Frme d shows discontinuous prts of the echoes obtined from the nterior tricuspid leflet,, which re indequte for ssessment of E-F speed or mplitude of this vlve, but will llow ide of the comprtive thickness of the leflets. Abbrevitions: E.C.G. = Electrocrdiogrm, A.A.W. -Anterior ortic root wll, Ao.C. = Aortic cusp, P.A.W. - Posterior ortic root wll, L.A. Left trium, Echocrdiogrm obtined from grft, 3.5 yers Downloded from by on October 1, 218 n = L.A,W. Posterior wll of the left trium, of grft frme I.V.S._- Interventriculr sept terior leflet of the trictuspid vlve, A.G.C. A.F. = Anterior edge um, L.V.W. Anterior The significnt correltion ws mintined when the two ptients with the miniml grft incompetence were excluded (r =.77, P <.2). Grft res rnged from.88 to 3. ( ) cm2, nd the E-F speed between 21 nd 47 (37± 2) mm/sec. The E-F speeds nd effective grft res 6 mm/sec, cm2 for grft size were 33 of 24 mm, 37 2 mm/sec, cm2 for grft size of 26 mm, nd 43 5 mm/sec, for grft size of 28 mm (fig. 4). Correltions between grft clculted re nd either totl mplitude or opening movement of the cusp of grft frme, P.F. = Posterior edge Posterior left ventricutlr wll A.T.L.- Anof the mitrl grft. cusp ws insignificnt (P >.1, P >.1). The ltter txvo prmeters rnged from 16 to 28 (21 ± 1) mm nd from 1 to 23 (16 1) mm, respectively. In eight ptients with grft size of 26 mm, the mplitude of the opening movements of the cusps ( 17 1 mm) were sttisticlly similr (P >.5) to tht obtined from 26 mm fresh grfts ( mm). A smller number of ptients with the remining two sizes of grfts (24 nd 28 mm) re depicted in tble 1. There ws no sttisticlly significnt correltion between the internl dimeter of the grft ring nd Circultion, Volume XLIX, Februry 1974

5 241 ULTRASOUND STUDIES OF MITRAL GRAFTS Figure 2 Echocrdiogrm obtined from ptient with size 24 mm E ;G.G AAW Ao.C, PAW AG F A.G.C. PG.F PG.E either the E-F speed (P>.1) or the opening leflets (P >.1). In one ptient grft, studied two nd three yers postopertively, the E-F speed hs chnged from 36 to 32 mm/see, while the mplitude hs remined unchnged. Such reduction of the E-F speed ws movement of the with competent Downloded from by on October 1, 218 so s. 4 e 3 3 E ene 2 s 2 r= P=. 81 PCo 5 11 p<o.o t 2 1 GRAFT AREA cm? W W MEAN DIASTOLIC GRADIENT mrn.hg o 4l C) 3 2~~~~ 2 1 r=1272 p).1 1 r=.222 p)oi MEAN L.A.P. mm.ng MEAN P.A.P. mm.hg. Figure 3 Demonstrtes the reltionship between the distolic closure rte of the nterior cusp of the mitrl grfts (E-F speed) nd the clculted effective grft re (top left); the men distolic grdient cross the mitrl grft (top right); the men left tril pressure (bottom left); nd the men pulmonry rteril pressure (bottom right). L.A.P. Left tril pressure, P.A.P. Pulmonry rtery pressure. = Circultion, Volume XLIX, Februry 1974 minimlly incompetent utcolov.s. gous fsci bt mitrl grft, 1.5 yers fter insertion. The sme clibrtions were used in every photogrph. As in figure 1, LtV,W frmes to c re selections of n M-mode scn f rom the bse towrd the pex of the hert. Frme d shows n nterior (A.G.C.) nd posterior (P.G.C.) grft cusp within the grft frme. The nterior (A.G.F.) nd posterior (P.G.F.) edges of the ltter re demonstrted. Frme e shows the expected pttern of movement of the nterior cusp of the mitrl grft. The echocrdiogrphic A wve is bsent becuse of tril fibrilltion. Abbrevitions s in figure 1. within the limits of repetbility of this technique. The crdic output nd stroke volume (fig. 5) correlted significntly with totl grft mplitude (.6896,.759, P <.1, respectively) but not with the mplitude of cusp opening movement. No significnt correltion ws found between the E-F speed nd either the men left tril pressure, men pulmonry rtery pressure or end-distolic grdient cross the mitrl grft. Significnt correltion ( r =.581, P <.5) ws found between the men distolic grdient nd E-F speed (fig. 3). The ventriculr rtes during echocrdiogrphy of the six ptients belonging to group B rnged from 75 to 19 (89 + 5) bets/min. Three ptients were in tril fibrilltion nd the remining three in sinus rhythm. In five ptients grft incompetence ws grded s severe on ngiocrdiogrphy nd in the remining ptient the insufficiency observed t reoperti.on ws considered severe. The internl dimeters of the grfts used were 24 mm in one ptient, 26 mm in three ptients nd 28 mm in the remining two ptients. The totl grft mplitude rnged from 19 to 25 (22 ±1) mm nd the E-F speed from 27 to 66 (41+6) mm/sec. The corresponding hemodynmic dt re shown in tble 2. The difference of the mplitudes of totl grft, culsp openiing movement nd E-F speed between (r P <.1, r competent nd incompetent grfts ws nlot sttisticlly significnt (P>.7, P>.6 nd P>.4,

6 242 MARY, PAKRASHI, CATCHPOLE, IONESCU Downloded from by on October 1, (. (C32 E In v U. ~16 WI ~~~~ ~~~~4 ++ of C4 LL 1 c cc GRAFT DIAMETER mm. Figure 4 Depicts the influence of the internl dimeter of grft rings t insertion on the postopertive grft cusp E-F speed nd the postopertive clculted effective re of the grfts. The men nd SE re shown in ech column. o = distolic closure rte (E-F speed); = effective grft re. respectively). In one ptient with grft incompetence who ws studied twice t two nd t three yers postopertively, the E-F speed hs incresed from 39 mm/sec to 53 mm/sec while the totl grft mplitude hs remined the sme t 19 mm. During re-opertion, the mechnism of grft incompetence ws found to be due to vrible shrinkge of posteriorly plced cusps in three ptients nd torn cusp ttchments in fourth ptient. The ltter ptient hd the highest vlues of totl mplitude (25 mm), opening movement of cusp (19 mm) nd E-F speed (66 mm/sec). In one ptient with incompetent grft, two cusps were demonstrted echocrdiogrphiclly (fig. 6). Both cusps ppered thickened, nd the nteriorly sited one hd smll opening movement of 13 mm. Mitrl Grft Ring Echocrdiogrm In ptients from group A, the ring mplitude rnged from 4 to 11 (7 + 1) mm nd the receding rte rnged between 22 nd 41 (34 + 2) mm/sec. Significnt correltion (fig. 7) ws found between E-F speed nd ring receding rte (r =.7151, P <.1). No correltion ws found between the ring mplitude or the receding rte nd either the crdic output, (P>.1, P>.1), stroke volume (P>.1, P >.1), internl ring dimeter (P>.1, P >.1), or men distolic grdient cross the grft (r =.736, P>.1; r =.3165, P >.1, respectively). 1:4 1^ m 8 w 6 -J > 4 2 D I- ^1 1.2, c _ X 4.8 I m 2.4 9, 1.2 C., 11 r=.759 p<o.o1 r=.6896 P<O.O1... v TOTAL GRAFT AMPLITUDE mm. Figure 5 Shows correltions between totl grft mplitude nd both the stroke volume (top) nd the crdic output (bottom). Discussion Hemodynmic studies in ptients with mitrl stented fsci lt grfts hve reveled the presence of only mild to moderte obstruction to blood flow Using experimentl studies with pulse duplictors, such obstruction to flow ws ttributed to stiffness nd sequentil opening of the cusps.2 The presence of residul left ventriculr myocrdil disese,21 22 nd the incresed left ventriculr volume,23 re expected to produce further impednce to blood flow. A reltionship between the distolic closure rte of stenosed nturl mitrl vlves nd numericlly suitble representtive vlue of the effective vlve re hs been sought. A significnt correltion ws found between the E-F speed in mm/sec nd the mitrl vlve re clculted by Gorlin's method.24 In the present study, similr correltion ws obtined between the effective grft re nd E-F speed. The coefficient of correltion obtined here ws not, however, very high, nd nlysis ccording Circultion, Volume XLIX, Februry 1974

7 ULTRASOUND STUDIES OF MITRAL GRAFTS EE.C.G. _ FRAME s.; W WCUSPS Figure 6 Echocrdiogrm obtined from ptient with size 28 mm, severely incompetent utologous fsci lt mitrl grft, four yers fter insertion. The grft ctusps pper thickened compred with those shown in figures 1 nd 2. A nd P-nterior nd posterior grft cusps, respectively. when Downloded from by on October 1, 218 to the size of effective grft re leves smll nuimber of ptients for vlid nlysis. As in previous reports on steniosed nturl vlves,3 5) 24, 2.5r vlues of E-F speed slower thn 35 mm/sec indicted signiificnt obstructioni to blood flow. Our results therefore confirm the usefulness of mitrl echocrdiogrphy in the detection nd ssessment of grft stenlosis cn -. E 3 E XW2 c LL X1 El U v r=.7151 p<o(.o DIASTOLIC RING RATE mm./sec. Figure 7 Shows the reltionship between the distolic closure rte of the nterior cusp of the mitrl grft (E-F speed) nd grft ring distolic receding rte. Circulnon, Volurne XLIX, Februry The E-F speed nd effective re did not correlte with the grft size s obtined from its internl dimeter t insertion. The slowest E-F speed nd smllest effective re were, however, obtined from ptient with grft dimeter of 24 mm. In ll the ptients with competent grfts, the clculted re ws smller thn the ctul primry grft re s mesured t the bse of the frme. In one ptient in whom n initil hemodynmic study ws vilble, the E-F speed becme slightly slower on re-exmintion one yer lter, lthough the mobility of the demonstrted cusp hs remined unchnged. It is probble tht these results together re consistent with previously reported mechnisms which my produce grft stenosis such s ltertion of cusp opening chrcteristics2 nd development of cusp stiffness."" 2 The size of the supporting frme of the grft should of course be tken into considertion.'9 Although there ws no significnt sttisticl correltion when ll the ptients from group A were tested, the sizes of the grft rings when looked t s subgroups (fig. 4) ppered to influence the effective grft re nd E-F speed. However, the number of ptients within the subgroups ws very smll for meningful sttisticl comprison. In study on recovered grfts t utopsy or t re-opertion, up to 38 months fter insertion, it ws found tht there ws no reduction in the primry or secondry orifice re due to clot deposition, tissue ingrowth or commissurl dhesions. Such fctors re known to cuse obstruction to blood flow cross mitrl vlve substitutes,27 nd to influence the E-F speed in disesed nturl mitrl vlves.2-4 Leflet stiffness of the disesed nturl mitrl vlve hs been shown to influence the E-F speed.2 Anterior leflet mobility below 15 mm s inferred fromn the echocrdiogrphic totl vlve mplitude, hs been found to indicte severe leflet disese.2 4 The ultrsonic mobility of n nteriorly plced grft cusp in this series ws comprble to tht mesured in vitro in freshly prepred fsci lt vlves. The mplitude of cusp movements obtined from otur ptients did not correlte with grft ring size, nd in few instnces the mplitude in vivo ws smller thn the mobility mesured in grfts in vitro. Mesurement of the ctul thickness of vlve leflet by reflected ultrsonic techniques is not precise, but mrked thickening or clcifiction my be detected.28 In this series only one ptient with severe grft incompetence ws shown to hve similr ultrsonic criteri which indicted mrked thickening or clcifiction of the demonstrted

8 Downloded from by on October 1, MARY, PAKRASHI, CATCHPOLE, IONESCU cusps (fig. 6). The grft is still in situ s the ptient ws not in need of re-opertion. Furthermore, echocrdiogrphic A wves were demonstrted in ptienits following tril systole (fig. Id, 8), nid iil one ptient xvith grde II ortic incompetence, s determinied by ortogrphy,29 fst echocrdiogrplhic oscilltions (fig. 9) of cusp echoes were seen. Both the A wve nd the oscilltions re usully bsenit in echocrdiogrms from ptients with severe mitrl stenosis nd disesed leflets.3 3 Echoes from only one or occsionlly two cusps could be obtined, however, in the sme ptient, nd the chnges in the opening chrcteristics of the cusps hve been shown to be limited to one or two cusps only, regrdless of their circumferentil orienttion.2 The demonstrtion of cusps which hve retined good mobility chrcteristics nevertheless will serve s senisitive indictor of reduced rte of ventriculr filling cused by chnges in the remining cusps. The significnt correltion seen in this study between the E-F speed nd effective re or the meni distolic grdient cross the grft corrobortes this finding. In the two ptients with grft ring dimeter of 28 mm who were studied 3.5 yers fter insertion, the reduction of mobility of the demonstrted cusps would suggest either tht the visulized cusps were those with chnged opening chrcteristics or tht the influence of lrge grft size plys role in mintining good flow cross the grft. In disese of the nturl mitrl vlve, echocrdiogrphic vlve mplitude nd E-F speed re not lwys helpful in the detection or ssessment of incompetence.5-! 3', 31 Systolic leflet prolpse into the left trium my however be demonstrted.7' 8 Echocrdiogrms in this series demonstrted nite- rior cusp prolpse beyond grft frme in ptients with competent vlves. In one ptient with grft incompetence (group B, ptient 1, tble 2), repet echocrdiogrphy one yer lter showed significnt increse in the E-F speed, but not in vlve mplitude. In this ptient, recovery of the grft t re-opertion reveled retrction nd shrinkge of the two posteriorly plced cusps but not of the niterior one which ws demonstrted echocrdiogrphiclly. In nother ptient (group B, ptient 3, tble 2), whose grft incompetence ws found to be due to detchlment of the nterior cusps from the frme, the E-F speed ws the fstest in this series nd vlve mplitude ws lrge. In third ptient (group B, ptient 5, tble 2, fig. 6) with severe grft incompetence, cusp thickening ws demonstrted xvith reduced opening movement mplitude, probbly suggesting disesed cusp s the cuse of inicomipetence. These fetures nd their progress in time my help to detect significnt grft incompetence if they re further confirmed by studying lrger series. Our dt reveled no significnt sttisticl difference between grft or cusp opening mplitudes or E-F speed of severely incompetent grfts when compred with competent ones. In this stuidy significnt correltion ws found between the E-F speed of the grft cusp nd the distolic receding rte of the grft ring. The former E.C.G. CUSP EC.G AAW >FRAME Ao.C. POG.c PA.W. P G.E. LAW. Figure 8 Echocrdiogrms obtined from ptient with size 26 mm, competent utologous fsci lt mitrl grft, three yers fter insertion. Frme shows ortic root echocrdiogrm in reltion to frme b demonstrting mitrl grft echocrdiogrm. Echocrdiogrphic A wve cn be seen in frme b. Abbrevitions s in figures 1 nd 2. Figure 9 Mitrl grft echocrdiogrm from ptient with size 28 mm competent homologous fsci lt mitrl grft, 3.5 yers fter insertion. IThis ptient lso hd orttc incompetence. Fine rpid oscilltion cn be seen on the demonstrted cusp echo. Circultion, Volunme XLIX, Februry 1974

9 Downloded from by on October 1, 218 ULTRASOUND STUDIES OF MITRAL GRAFTS hs exceeded the ltter in the mjority of the ptients. These results confirm previous works suggesting tht mitrl ring movement nd ring vortex formtion beneth the vlve cusps re the mechnisms of the distolic closure movement.12' 23, 32 Echocrdiogrphy of the stented fsci lt grfts ws found useful in the ssessment of the effective vlve re nd its chnges in time. Cusp retrction nd stiffness which subsequently give rise to incompetence ws demonstrted. Furthermore, individul observtions suggest tht when n unffected cusp is visulized ultrsoniclly, the development of fster E-F speed would indicte progression of grft incompetence. A single determintion of the E-F speed, however, did not pper to be helpful in detecting incompetence. References 1. EDLER I: Ultrsoundcrdiogrphy in mitrl vlve stenosis. Am J Crdiol 19: 18, GUSTAFSON A: Ultrsoundcrdiogrphy in mitrl stenosis. Act Med Scnd 461 (suppl): 69 & 87, SEGAL BL, LIKOFF W, KINGSLEY B: Echocrdiogrphy. Clinicl ppliction in mitrl stenosis. JAMA 195: 99, WHARTON CFP, LOPEZ BEscos L: Mitrl vlve movement: A study using n ultrsound technique. Br Hert J , WINTERS WL, RJCCE1Tro A, GIMENEZ J, McDONOUGH M, SOULEN R: Reflected ultrsound s dignostic instrument in study of mitrl vlve disese. Br Hert J 29: 788, DILLON JC, HAINE CL, CHANG S, FEIGENBAUM H: Use of echocrdiogrphy in ptients with prolpsed mitrl vlve. Circultion 43: 53, JOHNSON ML, HOLMES JH, SPANGLER RD, PATON BC: Usefulness of echocrdiogrphy in ptients undergoing mitrl vlve surgery. J Thorc Crdiovsc Surg 64: 922, MARY DAS, PAKRASHI BC, WOOLER GH, IONESCU MI: Study with reflected ultrsound of ptients with mitrl vlve repir. Br Hert J 35: 48, MILLER HC, STEPHENS J, GIBSON D: Echocrdiogrphic fetures of mitrl Strr-Edwrds prprosthetic regurgittion. Br Hert J 35: 56, JOHNSON ML, PATON BC, HOLMES JH: Ultrsonic evlution of prosthetic vlve motion. Circultion 39 nd 4 (suppl II): II-3, OLIVA PB, JOHNSON ML, POMERANTZ M, LEVENE A: Dysfunction of the Bell mitrl prosthesis nd its detection by cinefluoroscopy nd echocrdiogrphy. Am J Crdiol 31: 393, CHAKORN SA, SIGGERS DC, WHARTON CFP, DEUCHAR DC: Study of norml nd bnorml movements of mitrl vlve ring using reflected ultrsound. Br Hert J 34: 48, SIGGERS DC, SRIVONCSE SA, DEUCHAR D: Anlysis of dynmics of mitrl Strr-Edwrds vlve prosthesis using reflected ultrsound. Br Hert J 33: 41, IONESCU MI, Ross DN: Hert vlve replcement with utologous fsci lt. Lncet 2: 335, IONESCU MI, MARY DAS, PAKRASHI BC: Hert vlve replcement with stented tissue vlves. Crdiology digest: in press 16. IONESCU MI, PAKRASHI BC, MARY DAS, BARTEK IT, WOOLER GH: Replcement of hert vlves with frme-mounted tissue grfts. Thorx: in press 17. FEIGENBAUM H: Clinicl ppliction of echocrdiogrphy. Progr Crdiovsc Dis 14: 531, GORLIN R, GORLIN SC: Hydrulic formul for clcultion of the re of the stenotic mitrl vlve, other crdic vlves, nd centrl circultory shunts. Am Hert J 41: 1, TALAVLIKAR PH, WALBAUM PR, KITCHEN AH: Hemodynmic results of replcement of mitrl nd ortic vlves with utologous fsci lt prostheses. Thorx 28: 169, SWALES PD, HOLDEN MP, DOWSON D, IONESCU MI: Opening chrcteristics of three-cusp tissue hert vlves. Thorx 28: 286, SHAH PM, GRAMIAK R, KRAMMER DH, Yu PN: Determinnts of tril (S4) nd ventriculr (S3) gllop sounds in primry myocrdil disese. N Engl J Med 278: 753, HULTGREN H, HUBIS H, SHUMWAY N: Crdic function following mitrl vlve replcement. Am Hert J 75: 32, BELLHOUSE BJ: Fluid mechnics of model mitrl vlve nd left ventricle. Crdiovsc Res 6: 199, EFFERT S: Pre- nd post-opertive evlution of mitrl stenosis by ultrsound. Am J Crdiol 19: 59, GRAMIAK R, SHAH PM: Crdic ultrsoundcrdiogrphy. A review of current pplictions. Rdiol Clin North Am 9: 469, IONESCU MI, PAKRASHI BC, MARY DA, WOOLER GH: Results of hert vlve replcement with frme mounted tissue vlves. II Symposium Interncionl sobre Protesis e Injertos de Ls Vlvuls Crdics. Mdrid, Spin, Mrch 29-3, GLANCY DL, O'BRIEN KP, REIS RL, EPSTEIN SE, MORROW AG: Hemodynmic studies in ptients with 2M nd 3M Strr-Edwrds prosthesis: Evidence of obstruction to left tril emptying. Circultion 39 nd 4 (suppl I): I-113, PRIDIE RB, BEHNAM R, WILD J: Ultrsound in crdic dignosis. Clin Rdiol 23: 16, BRANDT PWT, ROCHE AHG, BARRATT-BOYES BG, LOWE JB: Rdiology of homogrft ortic vlve. Thorx 24: 129, WINSBERG F, MERCER EN: Echocrdiogrphy in combined vlve disese. Rdiology 15: 45, JOYNER CR JR, REID JM, BoND JP: Reflected ultrsound in the ssessment of mitrl vlve disese. Circultion 27: 53, ZAKY A, NASSER WK, FEIGENBAUM H: A study of mitrl vlve ction recorded by reflected ultrsound nd its ppliction in the dignosis of mitrl stenosis. Circultion 37: 789, 1968 Circultion, Volume XLIX, Februry 1974