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Echocardiographic tracings of posterior left atrial wall motion were examined in 30 normal subjects, 17 patients of mitral stenosis with sinus rhythm and 31 coronary patients with elevated left ventricular end-diastolic pressure. Because of the plane of the posterior left atrial wall motion and the angle of the sound beam, usually the postero-inferior portion of the left atrial wall was recorded. In normal subjects, there were 3 positive waves (A,C,V waves) and 2 negative waves (X and Y waves). The A wave during atrial contraction period occurred in the closing motion of the mitral valve and was initiated by a slight negative wave. The fourth heart sound was consistent with the ascending limb of the A wave. The C wave coincided with the first heart sound followed by the pronounced negative depression (X wave). The X trough coincided with the beginning of the mitral valve opening in early diastole and was the deepest point in the motion curve. The V wave was a peaked anterior motion during rapid filling period and followed by the third heart sound. The Y wave was a slight negative depression following the V wave, and its trough occurred when the both leaflets of the mitral valve assumed a semiclosed position. In both mitral stenosis and coronary artery disease, significant increase (p less than 0.01) of the A wave excursion and significant decrease (p less than 0.01) of the V wave excursion were observed, resulting in marked increase (p less than 0.01) of the A/V ratio. The slope of the ascending limb of the V wave was also decreased apparently in both conditions. These findings might reflect increased resistance to left atrial emptying in mitral stenosis and decreased left ventricular filling rate in coronary artery disease. This study shows that echocardiographic examination of the posterior left atrial wall motion is feasible and useful in estimating the presence of either mitral stenosis or decreased left ventricular filling rate.

The echocardiographic, scintigraphic, angiocardiographic and autopsy correlations in a patient with left ventricular pseudoaneurysm are presented. Interruption of the echo of the left ventricular wall and radioisotope image of pseudoaneurysm and its communication channel are demonstrated for the first time. The striking similarity of the radioisotope image to the angiographic image is noted. This study suggests that echocardiography has capability to visualize left ventricular wall defects, such as the perforation seen in this case and radioisotope ventriculography is equivalent to the invasive contrast technique. Both of the methods seem to be safe and specific for the diagnosis of left ventricular pseudoaneurysm.

Fifteen patients with ventricular aneurysm were selected based on the following 3 criteria: 1) electrocardiographic evidence of old myocardial infarction, 2) presence of abnormal precordial impulse, 3) presence of dyskinesis or akinesis with diastolic bulging of the ventricular cavity by angiocardiogram. Eight patients had anterior left ventricular aneurysm and 7 apical aneurysm. The characteristic abnormal precordial impulse was diminished or absent A wave, pre-upstroke retraction, late systolic bulge, and diminished rapid filling wave, all of which were recorded over the restricted area of the broad precordial impulse. M-mode echocardiogram revealed increased or normal excursion of the posterior left ventricular wall. However, abnormal motion of the anterior left ventricular wall was detected in all, if the transducer was located over the abnormal precordial impulse or slightly inside of it. Compound M-mode echocardiographic scan toward the abnormal precordial impulse was able to detect asynergy of the anterior left ventricular wall and the apex, and distinguish it from motions of the interventricular septum and the anterior right ventricular wall. Abnormal motion of the anterior left ventricular wall was paradoxical in 13 patients and flat in the others. Systolic posterior mortion of the posterior left ventricular wall was detected in 2 patients with apical aneurysm. Cardiac ultrasonogram scanning over the abnormal precordial impulse demonstrated the bulging of the ventricular cavity in either systole or diastole depending on the site of lesion. There was a good correlation between cardiac ultrasonography and angiocardiography with respect to the site of lesion. Our study indicates that this method is useful in the diagnosis of anterior and apical aneurysm which ordinary technique failed to detect.

Eight patients with congenital pulmonary regurgitation documented by cardiac catheterization and angiography were studied by echocardiography. Echocardiographic features of the pulmonary valve observed in this condition included a) diastolic fluttering (5 cases), b) diastolic separation (2 cases), and c) increase of posterior motion during atrial systole (a wave). Maximum a wave depth exceeded the upper limit of the normal value in 2 cases and averaged 6.1 +/- 0.7 (standard error of the mean) mm. In addition, d) diastolic fluttering of the anterior tricuspid valve was seen in 5 cases and e) abnormal interventricular septal motion in 2 cases (one, paradoxical and the other, flat). Of these findings, the diastolic fluttering of the pulmonary valve, which results from the turbulent stream of blood in the outflow of the right ventricle striking the pulmonary valve, is pathognomonic for pulmonary regurgitation. Although the other findings are nonspecific, all patients had at least 1 of these 5 findings. Echocardiography, therefore, provides useful clues to the diagnosis of pulmonary regurgitation. Furthermore, echocardiography should be of use in differentiating congenital from functional pulmonary regurgitation and from aortic regurgitation.

Two cases of anomalous origin of the left coronary artery from the pulmonary artery with and without marked dilatation of the right coronary artery were studied by M-mode echocardiography and cross-sectional echocardiography. The M-mode echocardiogram obtained from the case with the dilated right coronary artery demonstrated an abnormal structure anterior to the aortic root. The cross-sectional echocardiogram of the same case visualized the origin of the dilated right coronary artery. In addition, echocardiographic abnormalities suggesting the ischemia of the left ventricle were observed in both cases. Although many of the ultrasonic features are nonspecific, the combination of ultrasonic technique provides useful clues to the diagnosis of anomalous origin of the left coronary artery from the pulmonary artery.

Little information is available concerning the relationship between the pattern of the jugular phlebogram and interventricular septal motion. We studied 250 patients with various conditons. Abnormal septal motion was observed in only 33% of the patients with tricuspid regurgitation. All the patients having abnormal septal motion and 66% of those having normal septal motion had the jugular pattern of tricuspid regurgitation. After cardiac operation with the incision of cardiac chambers and pericardiotomy, abnormal septal motion was seen from 40 to 89% at early postoperative period. Of the patients studied approximately 1 year after operation, there was reduced incidence of septal abnormality. Septal motion was normal in all the patients who had ligation of a patent ductus arteriosus and who underwent Blalock's operation. Of these, all having paradoxical motion which occurred in the mid-septum at least had the jugular pattern of tricuspid regurgitation. On the other hand, only 20 to 30% of the patients whose septal motion was normal had the jugular pattern of tricuspid regurgitation. Furthermore, all of the 3 patients with coronary artery disease having paradoxical motion of the entire septum had the jugular pattern of tricuspid regurgitation, as well. We conclude that the jugular pattern of tricuspid regurgitation and echocardiographic septal motion abnormality are related to each other and that tricuspid regurgitation should not be diagnosed by jugular phlebogram unless echocardiographic septal motion is examined.

Sixteen patients with endocardial cushion defects were studied by echocardiography and ultrasonocardiotomography. Three characteristic findings, common to both complete and partial forms, were observed. They were the ostium primum defect of the interatrial septum, the left ventricular outflow narrowing and the atrioventricular valve abnormalities which are the anatomic bases of endocardial cushion defects. Several additional findings were observed in patients with complete form. Most strikingly, the anterior leaflet echo locating in the left ventricle had the direct connection to that in the right ventricle without the interposition of the interventricular septum by echocardiogram. Ultrasonocardiotomogram, on the other hand, demonstrated beautifully the common anterior leaflet and the high inteventricular septal defect. There were, in addition, the absence of the paradoxical motion of the interventricular septum and the diffuculty in detecting the interatrial septum. The intact interatrial septum continuous with the anterior mitral leaflet was demonstrated in patients with the interventricularseptal defect of atrioventricular canal type, in which there were the typical abnormalities in the atrioventricular valves and the left ventricular outflow narrowing as well. This study indicates that ultrasonic examination may provide a direct, yet noninvasive method in the diagnosis of various types of endocardial cushion defects.