The purpose of this study is to explore the value of intracardiac sound recordings for the verification of subaortic stenosis. Intracardiac sound was measured in ten patients with subaortic obstructions. Seven had idiopathic hypertrophic subaortic stenosis, two had a subvalvular membrane, and one had a subvalvular tunnel. In each patient, a systolic murmur was recorded within the left ventricle distal to the obstruction. The murmur was of lower amplitude distal to the aortic valve, and it was of even lower amplitude or absent proximal to the obstruction. In the presence of entrapment, no intraventricular murmur occurred although an apparent subvalvular pressure gradient was observed. The identification and localization of the maximal intensity of a systolic murmur in the ventricular outflow tract may assist in the verification of a subvalvular obstruction and help distinguish between artifactual pressure gradients and gradients indicative of subvalvular stenosis

Anbe, Daniel T.

Folger, Gordon M., Jr.

Khaja, Fareed

Sabbah, Hani N.

Stein, Paul D.

English

Henry Ford Health System Scholarly Commons

Henry Ford Hospital Medical Journal Volume 26 Number 2 Article 7 6-1978 Intracardiac Phonocardiography in Subaortic Stenosis Paul D. Stein Hani N. Sabbah Daniel T. Anbe Fareed Khaja Gordon M. Folger Jr. Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal  Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Stein, Paul D.; Sabbah, Hani N.; Anbe, Daniel T.; Khaja, Fareed; and Folger, Gordon M. Jr. (1978) "Intracardiac Phonocardiography in Subaortic Stenosis," Henry Ford Hospital Medical Journal : Vol. 26 : No. 2 , 35-40. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol26/iss2/7 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp Med Journal Vol 26, No 2, 1978 Intracardiac Phonocardiography in Subaortic Stenosis Paul D. Stein, MD,* Hani N. Sabbah, BS,** Daniel T. Anbe, MD,** Fareed Khaja, MD,^ and Gordon M. Folger, Jr, MD*** The purpose of this study is to explore the value of intracar-diac sound recordings for the verification of subaortic stenosis. Intracardiac sound was measured in ten patients with subaortic obstructions. Seven had idiopathic hyper-trophic subaortic stenosis, two had a subvalvular mem-brane, and one had a subvalvular tunnel. In each patient, a systolic murmur was recorded within the left ventricle distal to the obstruction. The murmur was of lower amplitude distal to the aortic valve, and it was of even lower amplitude or absent proximal to the obstruction. In the presence of entrapment, no intraventricular murmur occurred although an apparent subvalvular pressure gradient was observed. The identification and localization of the maximal intensity of a systolic murmur in the ventricular outflow tract may assist in the verification of a subvalvular obstruction and help distinguish between artifactual pressure gradients and gradients indicative of subvalvular stenosis. Introduction T H E interpretation ofan apparent intraventricular pressure gradient in subvalvular stenosis sometimes may be difficult because of the possibility of catheter whip or, in rare instances, entrapment of the tip of the catheter.^ Many diagnostic tests are usually required to diagnose various types of subaortic stenosis, including clinical features,^ the ventriculogram,^'^ and the e c h o c a r d i o g r a m . N o single diagnostic procedure has been found to be adequate for all patients. The clinical features may be nonspecific^ and the ventriculogram may be misinterpreted if it simulates an obstructive defect by showing an hour-glass silhouette during early diastole.^ The echocardiogram has several limitations. In idiopathic hypertrophic subaorfic stenosis (IHSS), ft may fail to show systolic anterior motion of the mitral valve ifthere is no significant subaortic obstruction during the time of study.^ Asymmetric septal hypertrophy may also be present without obstruction.^'"^ In addition, membranous subaortic stenosis or tunnel subaortic stenosis sometimes may not be apparent on echocardiograms. Therefore, the diagnosis of a subvalvular obstruction, even during cardiac catheterization, may pose a problem. Any ancillary or supportive information would be of value. The purpose of this study is to determine if intracardiac pho-nocardiography may assist in verifying the presence of a subvalvular obstruction. Submitted for publication: May 22, 1978 Accepted for publication: June 16, 1978 'Departments of Medicine and Surgery, Henry Ford Hospital ' "Department of Medicine, Henry Ford Hospital *** Department of Pediatrics, Henry Ford Hospital This study was supported under project No. R38820 by the Henry Ford Hospital through a Ford Foundation grant. Address reprint requests to Dr. Stein, Cardiovascular Research Laboratory, Henry Ford Hospital, 2799 W Grand Blvd, Detroit, Ml 48202 Methods Pressure and intracardiac sound were measured during cardiac catheterization in ten patients with left ventricular outflow tract obstructions (see the accompanying table). Seven patients had IHSS as shown by echocardiography, ventriculograms, and pressure gradients across the outflow tract of the left ventricle. Two of these were treated sur-gically. Two ofthe ten (Patients 6 and 10) had a subvalvular membrane, and their diagnosis of subaortic stenosis was confirmed at surgery. In the one case of tunnel subaortic stenosis (Patient 7), the resected muscle showed normally arranged cardiac muscle with no fibrosis or disorganization. 35 stein, Sabbah, Anbe, Khaja, and Folger DIAGNOSTIC INDICATIONS OF LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTIONS Rest ing Pressure Pressure Grad ient Grad ient F ind ings Ac ross Fol lowing at Pat ient D iagnos is Echocard iog ram Out f low Tract Isopro tereno l Vent r icu logram Surgery (mm Hg) (mm Hg) 1 IHSS ASH, SAM 88 Out f low obst ruct ion IHSS by MV and septum 2 IHSS ASH, SAM 48 — Hyperkinet ic ventr ic le not done 3 IHSS ASH, SAM 42 192 Out f low obst ruct ion not done by MV and septum 4 IHSS ASH, SAM 8 50 Outf low obst ruct ion not done by MV and septum 5 IHSS ASH, SAM 100 — Thickened septum IHSS 6 Membranous subaort ic Not d iagnost ic 32 — Discrete subaort ic Subvalvular stenosis stenosis membrane 7 Tunnel subaort ic Not d iagnost ic 29 36 Subaort ic tunnel Subvalvular stenosis tunnel 8 IHSS ASH, SAM 20 80 Thickened septum not done 9 IHSS ASH, SAM 120 — Out f low obst ruct ion not done by MV and septum 10 Membranous subaort ic Early AV closure 20 — Discrete subaort ic not done stenosis stenosis ASH = asymmetric septal hypertrophy IHSS = idiopathic hypertro phic subaortic stenosis SAM = systolic anterior motion o f the m itral valve AV = aortic valve MV = mitral valve Entrapmentof the catheter occurred in one patient who was catheterized because of symptoms of angina. This resulted in an apparent pressure gradient across the outflow tract even though he had no clinical, echocardiographic, or ventriculographic evidence of outflow tract obstruction. Pressure and intracardiac sound were measured with a catheter-tip micromanometer (Millar instruments, Houston, TX) and recorded on a VR-6 photographic recorder (Electronics for Medicine, White Plains, NY), at paper speeds of 25 to 200 mm/sec, during multiple pullbacks of the micromanometer from the apex of the left ventricle to 1 8 0 i -the aorta. Particular care was taken to keep the gain of the sound amplifier constant during all recordings in order to compare the amplitude of murmurs recorded in various regions of the heart. Ventriculograms in the right anterior oblique projection were obtained on 35 mm cine in all patients; in nine cases, both the left anterior oblique and right anterior oblique views were obtained. In three of these patients, a simul-taneous injection was made in the left and right ventricles to show the thickness of the septum; none showed mitral regurgitation on the ventriculogram. P R E S S U R E (MM HG) 1 | LV sq i 1 ND ll L v] 1 L * -J 1 SEC Fig.1 Intracardiac sound, aortic (Ao) pressure, and left ventricular (LV) pressure ina patient w i th IHSS (Patient 3). Left: LV catheter was in the apex. Center: LV catheter was within the outf low tract. Right: Both micromanometers were within the aorta. The maximal intensity of the murmur occurred wi th in the outf low tract. 36 Subaortic Stenosis LV PRESSURE (MM HG) LV PRESSURE (MM HG) ECG Ao SOUND 1 OOt-Ao PRESSURE (MM HG) >^ | 0.5 SEC 1 ^ Fig. 2 Intracardiac pressure and sound in a patient wi th tunnel subaortic stenosis (Patient 7). Top: Left ventricular (LV) pressure and sound recorded proximal to the obstruction. Center: Pressure and sound recorded within the outf low tract, distal to the obstruction. Bottom: Aortic (Ao) pressure and sound. The murmur was of greatest amplitude within the outf low tract. Results In all patients wfth subaortic obstruction, irrespective of the cause (IHSS, a subvalvular membrane, or subvalvular tun-nel), a systolic murmur of greatest amplitude was recorded within the outflow tract of the left ventricle (Figures 1-3). The murmur was of lower amplitude distal to the aortic valve and even lower or absent proximal to the obstruction. One patient with IHSS (Patient 1) was catheterized before and after surgical correction. Prior to surgery, a pressure gradient was measured across the left ventricular outflow tract, and the ventriculogram and echocardiogram showed evidence of an intraventricular obstruction. A systolic mur-murwas shown in theoutflow tract of the left ventricle. After surgical correction, intracardiac sound showed no murmur within the left ventricle during multiple withdrawals ofthe micromanometer from the apex of the left ventricle to the aorta. No pressure gradient was measured across the out-flow tract, and the ventriculogram and echocardiogram showed no evidence of obstruction. The patient with en-trapment of the catheter showed no systolic murmur within the outflow tract ofthe left ventricle (Figure 4). Discussion Identification of an ejection murmurwithinthe left ventricu-lar outflow tract and of an absent or lower amplitude murmur at the apex and distal to the aortic valve implies the presence of an intraventricular obstruction sufficient to cause a disturbance of flow. Turbulent eddies picked up by a phonocatheter do not propagate well upstream from a stenofic orifice.'' Therefore, no murmur or only a faint murmur would be expected wfthin the ventricle proximal to the subaortic obstruction. Within the outflow tract, an ejection murmur would be expected due to the local occurrence of a turbulent jet.^° Distal to the point of peak turbulence, the murmur would gradually diminish in inten-sity as the magnftude of turbulence diminished. In spite of the reliable nature of cardiac catheterization for the diagnosis of subaortic stenosis, there frequently is an element of uncertainty about the validity of an apparent pressure gradient measured across the ventricular outflow tract. Entrapment of the catheter or catheter whip may simulate a pressure gradient Measurement of intraventricu-lar sound may validate the authenticity of a subvalvular gradient. The demonstration of an intracardiac murmur may also call attention to a subvalvular obstruction which is not severe enough to cause a prominent gradient Intracardiac phonocardiograms in patients with IHSS have been recorded by other investigators,^although their interpretation of the significanceof the intracardiac murmur differed. Some believe, aswe do, that a murmur of maximal 37 Stein, Sabbah, Anbe, Khaja, and Folger 1 O O i -P R E S S U R E (MM HQ) ECG 1 ll I'i li ' ' LV S O U N D l t ' - i " i 0 . 5 SEC Fig. 3 Intracardiac pressure and sound recorded in a patient wi th a subvalvular membrane (Patient 6). Recordings are from the apex of the left ventricle (LV) (left), outf low tract (center), and aorta (Ao) (right), just distal to the aortic valve. The murmur was of greatest amplitude within the LV outf low tract. P R E S S U R E (MM HG) LV SOUND A o SOUND » * « . | l Fig. 4 Intracardiac pressure and sound in a patient in whom catheter entrapment occurred, resulting in an apparent intraventricular pressure gradient. No systolic murmur was recorded wi th in the outf low tract of the left ventricle. amplitude in the ventricular outfiow tract and of lower amplitude in the aorta indicate that the murmur was ven-tricular in origin.12 Others, whose patients with IHSS also had mitral regurgitation, indicated that the recorded intra-ventricular murmur was the regurgitant murmur, which was recorded wfth greater amplitude in the left atrium. Despite these differing results, intracardiac phonocardiogra-phy has been shown to be a useful diagnostic technique in a variety of cardiac diseases, as it enables murmurs to be detected wfth greater intensity distal to a lesion." Summary Intracardiac phonocardiograms were recorded in patients with various types of subaortic stenosis. In all cases, the systolic murmur was shown to be of greatest amplitude within the outflow tract of the left ventricle distal to the obstruction. Occasionally, such a murmur was recorded even in the absence o fa prominent pressure gradient. In the presence of an apparent gradient caused by entrapment of the catheter, no murmur was recorded within the ventricular outflow tract It appears, therefore, that intracardiac pho-nocardiography may assist in the verification ofthe presence of a subvalvular obstruction. 38 Subaortic Stenosis References 1. CrileyJM, Lewis KB, White Rl, and Ross RS: Pressure gradients without obstruction: A new concept of "hyptertrophic subaortic stenosis". Circulation 32:881-887,1965. 2. Braunwald E, Lambrew CT, Rockoff SD, Ross J Jr, and Morrow AG: Idiopathic hypertrophic subaortic stenosis: I. A description of the disease based upon an analysis of 64 patients. Circulation 29 (Suppl. IV):3-119, 1964, 3. Adelman AG, McLoughlin MJ, Marquis Y, Auger P and Wigle ED: Left ventricular cineangiographic observations in muscular subaortic ste-nosis. Am / Cardiol 24:689-697, 1969. 4. Shah PM, Gramiak R, Adelman AG, and Wigle ED: Role of echocar-diography in diagnostic and hemodynamic assessment of hypertrophic subaortic stenosis. Circulation 44:891-898, 1971. 5. Henry WL, Clark CE, and Epstein SE: Asymmetric septal hypertrophy: Echocardiographic identification of the pathognomonic anatomic abnormality of IHSS. Circulation 47:225-233, 1973. 6. Popp RL, Silverman JF, French JW, Stinson EB, and Harrison DC: Echocardiographic findings in discrete subvalvular aortic stenosis. Circulation 49:226-231, 1974. 7. Maron BJ, Redwood DR, Roberts WC, Henry WL, Morrow AG, and Epstein SE: Tunnel subaortic stenosis. Left ventricular outflow tract obstruction produced by fibromuscular tubular narrowing. Circulation 54:404-416, 1976, 8. Henry WL, Clark CE, Clancy DL, and Epstein SE: Echocardiographic measurement of the left ventricular outflow gradient in idiopathic hypertrophic subaortic stenosis. New England I Med 288:989-993, 1973. 9. Yellin EL: Hydraulic noise in submerged and bounded liquid jets. In Biomed Fluid Mech Symposium, New York, Amer Soc Mechanical Engineers, 1966, pp. 209-221. 10. Sabbah HN and Stein PD: Turbulent blood flow in humans: Its primary role inthe production of ejection murmurs. Circ Res 38:513-525,1976. 11. Stein PD and Sabbah H N : Turbulent blood flow in the ascending aorta of humans with normal and diseased aortic valves, Circ Res 39:58-65, 1976. 12. Soulie P, Joly F, and Carlotti J: Les stenoses iodpath iques de lachambre de chasse du ventricule gauche. Acta Cardiol 17:357-378, 1962. 13. Feruglio GA: Intracardiac phonocardiography: A valuable diagnostic technique in congenital and acquired heart disease. Am Heart ; 58:827-848, 1959. 39 40 

Intracardiac Phonocardiography in Subaortic Stenosis

https://scholarlycommons.henryford.com/cgi/viewcontent.cgi?article=2000&amp;context=hfhmedjournal

Intracardiac Phonocardiography in Subaortic Stenosis

Abstract

Similar works

Full text

Available Versions

Henry Ford Health System Scholarly Commons