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Use of Ultrasound to Measure Left Ventricular Stroke Volume By HARVEY FEIGENBAUM, M.D., ADIB ZAKY, M.B., AND WILLIAM K. NASSER, M.D. With the technical assistatuce of Charles L. Hainie Downloaded from http://circ.ahajournals.org/ by guest on April 28, 2017 SUMMARY Several empirical observations made during ultrasound examinations for pericardial effusion have led to the possibility that this diagnostic technique might be used to measure left ventricular stroke volume in man. The hypothesis that left ventricular stroke volume was proportional to the amplitude of an echo originating from a portion of the left ventricle near the mitral ring (MREa) times the distance between the echoes from the anterior and posterior ventricular walls (LVD) lhas been validated. Ultrasoutnd examiniation.s were performed simultaneously with cardiac output determinations using the direct Fick method on 16 patients proven to have competent mitral and aortic valves. Correlation between the two methods of measuring left ventricular stroke volume was excellent (r = 0.973; P < 0.001). WVhen ultrasound measurements were used in the regression equation to predict stroke volume, the calculated values were within 11 ml or 15% of those determined by the Fick method. The fact that an ultrasound examination is simple, can be done as a bedside determination in a matter of minutes, and is totally harmless to the patient make it a promising diagnostic procedure. The measurement of left ventricular stroke volume represents another addition to the growing list of medical uses for this intriguing technique. Additional Indexing Words: Cardiac outptut Ultrasouin(d myocardial function Echographv when we were attempting to diagnose pericardial effusion.2 On correlating the location and pattern of this echo with those of echoes originating from the cage of Starr-Edwards mitral valves,4 this echo appeared to be originating from a portion of the left ventricle near the mitral ring or annulus and, thus for convenience, was designated as the mitral ring echo (MRE)." A similar echo has been recognized by other investigators, and they too believed that it originated from an area near the mitral ring or atrioventricular wvall.. Upon further investigation of the MRE, it was noted that the curve which it inscribed was surprisingly similar to known left ventricular volume curves with the amplitude varying directly with left ventricular stroke volume and inversely with left ventricular volume." Edler5 likewise noted that the amplitude of the atrioventricular wall echo varied with different disease states. It thus seemed pos- IN THE COURSE of earlier studies using diagnostic ultrasound to detect the presence of pericardial effusion,1 2 several observations were made which suggested the possibility of using this technique to measure left ventricular stroke volume. The first of these observations was the finding of a consistent and strong ultrasound signal or echo near the echo from the anterior leaflet of the mitral valve' :1 (fig. 1D). This new echo was initially of interest because it was confused with the true mitral valve echo.Secondly, this echo offered some difficulty From the Departmient of Medicine, Indiana University School of Medicine, and the Krannert Heart Research Institute, Marion County General Hospital, Indianapolis, Indiana. This investigation was supported in part by the Hermian C. Krannert Fund, U. S. Public Health Service Grants HE-09815-02, HE-6308, HTS-5363, anid HE-5749, and the Indiana Heart Association. 1092 Circulation. Volune XXXV, June 1967 LEFT VENTRICULAR STROKE V OOLUME 10)93 there is some functional relationship of MREa to left ventricular stroke volume and left ventricular volume, this ventricular dimension possibly could be substituted for left ventricular volume, and thereby MREa could be used to calculate left ventricular stroke volume. This study attempts to test the validity of these observations and assumptions by using the amplitude of the mitral ring echo and the distance between the anterior and posterior heart wall echoes to calculate left ventricuilar stroke volume in the intact hulman sull)ject. Downloaded from http://circ.ahajournals.org/ by guest on April 28, 2017 Method Stuidies wer e donie oni 16 patienits uniildergoinig diagnostic heart catheterizationi. The patients inchlidled botlh nmales awl females, aniid their ages ranged firom 15 to 61 years. No patienit lhad any eviden-ice of mitr-al or aortic inisuifficiency. In 15 of the patients valvuilair insuifficienicy was excluded by left hear-t catheterization aind selective cineFigure I Fourt cardiac echoes in a nonimal indiividuial. Aniterior is at the top of eaclh tiracing A and B illu-strate echloes froml the poster ior- hleart wall, the echo in C is frontI the ainterior leaflet of the mitral valve, andl the strong in1ovin1g ech1o in D i.s front a portion of the lef tventr-icle near th7e mnitydl ring (AIRE). (FrJ omtI Feigen1batmttn, II., Zaky, A., anid Waldhatusen, J. A.: Anni IniternlMeci 65: 443, 1966, bl) periniission of the Ametican College of Ph ysicia its.) sible that then '- miglht be some fiunctional relationiship amonig the MRE amplitude (MREa ), left venitricuilar voluime, anid left ventricuilar stroke volume. The seconid observation which made this sttidy feasible was that the distance between the anterior chest wvall anid the echo originating from the posterior xvall of the heart wa.s rouighly proportional to the size of the left ventricle (fig. 2). The correlation betwveen this tiltrasouind measurement and the clinical estimation of left ventricular volume improved eveIn fuirther when a more accurcate left ventricular dimenision was obtained by learning how to record the faint aniterior heart wall echo in most patieiIts wvith or without pericardial effusion" (fig. 3). Thuis, asstuming that 2 Circulation, Volume XXXV, June 1967 angiocardiography. The one patient who lhad only riglt lheart cathleterization had nio heart muirmul.urs and was beinig stuidiedI to evaluate a recent ptulmoar-y einbolus. Thie principles of diagnostic tultrasotunid lIave leen reviewed in previouis papers.7-10 The uiltrasouniid exatminiation-s were perfofrmed with a comm-tercially available uiltrasonioscope utilizing a 2.25mc, 0.75-inichl transducer withl a repetitioni rate of 1,000 imptulses per secon-id. For recordinig the echoes, the "slow sweep" or "time-motion" presenitatioIn was used whlereby dlistanice is plotted against time and mllovinig echloes are plotted as wavvy lines. The patients wveie examined in the recumbent positionl and AqLuasonic gel was used as a} coupling medliuim to enisuir-e airless conitact between the trainsduceI and the skin. To record the anterior anidl posterior lheart wall eclhoes, the transducer was placed alonig the left sternal bordler at the four-th in-tercostal space anid pointed (dir-ectlv posteriorly (fig. 4). Jtust as is done when excimininig for per icardial effusion, the gain, clamping, and reject modalities, as well as the exact positioining of the tran-sducer-, were adjusted to record the sin-gle most dominan-t echo originatinig from the viciniity of the posterior wall of the heart. In addition, the gaini conitrolling the iiear field was adjusted to record the nonimoving aniterior clhest wall eclhoes plus the fuizzy tlhin echo juist immediately posterior to the chlest wall echoes. In maiiy patienits, despite its somewhat inidistinct chiaracter, this anter-ior heart wall echo couild be seeni to move in a directioni opposite to the posterior lieaut wall (fig. 3). 1094 FEIGENBAUM ET AL. T Downloaded from http://circ.ahajournals.org/ by guest on April 28, 2017 P Figure 2 ch (F) in a 110a1001 subject (A) and in a patient twith a dilated left Posteil hteai watll f clif centr-iclc (13). T t pi-esents tlhe ccho originating fr-onti the tt-ansdtcer. (A) The posterior hieart naill echo (FP) is 10 cot frorn the transAdcer. (B) The ce/Io P is nicarly 14 crtt fronti ecllo T. (I"tI out Jcigenbanitn II., Zakoy, A., and Waldhatsicn,' J. A.: Ann Itntern Mecd 65: 443, 1966, b1)1 pO tnitsusiott of the Antet-io-an Co/lage of Physicians.) The echo originiatinig from the mitral rinlg (NIRE) was obtain-ed by placinig the transducer _s_s_ ~~AW_ Pw. Figure 3 Anttcrito (AW) t(d po)sterni(r (PW1) lIcart trall eclcoe.s in a tItorttIal stbiject. The ciho ftom tite aniterior heart a trall is faittt arndl jitst posterior to the ec/Ioes origirnalt- frottl te ah tteti ioI chtest waill. (Fr1omti Feigernbantn, H., Zakil, A., at(l (Girabhottn, L. L.: Circttdationt 34: 6i11, 1966, bhy' peitmission of Atterican Heart A.sns., itig 1Inc.) over the apex of the heart an2d pointing the transducer posteriorly, mediallv, anid a little superiorly (fig. 5 ) The exact direction was adjitsted to recor-d the strong echo wlich was just posterior to the imnitral valve eeho and which hadl a characteristic patterin of motion. The MRE inove(l toward the tr-anisduticer witl-h ventricular svstole an(d away from the t -anisduicer- with diastole. The diastolic motioni was divided inito three plases: rapid iiovement eairly in diastole, eitlher less rapid or no motioni in mid-diastole, and theni a-pidI movemeent following atrial systole (fig. 5). A simuiltaneous electrocardiogram aided in identificationi of all eclhoes. B3y placinig the transduicer over the apex of the heart, the maximal aimiplitudle of the MRE was recorded." This appr-oach also lhelped to standardize the examination by allowinig for dillerences in. heart size fr-om one patienit to) another. The uiltrasouniid recor-dings were obtained simutltaneously with the determiniation of cardiac output ais ml-easuri-ed by the direct Fick method. A simultatneouls electrocardiogranm oni a standard( strip-chart recorlder was use(l to ineasuire the Circultion, Volumie XXXV, June 1967 LEFT VENTRICULAR STROKE VOLUME 01()95 Downloaded from http://circ.ahajournals.org/ by guest on April 28, 2017 ): Figure 4 Diagramit oar! actu1al u-iltrasountdftracing illu,strfatiiig the mitetIodi byl whlich the left ventricular C and posterior wealls diareter (LVD) is obtainiedl. CWV = ch5est twall; AWV antd PW1 = anterior of left venitricle; TI- echo froni transducer. heart rate. In the thlree patients witlh aitriIa] fibrillatioIn, ain effor-t waVis miale to utilize those ultrasouind measurements wlhich followed anm B-B interval corresponding to the averalge hear t rate during the determination- of cardliac outpuit. Results The ultrasound measurements which vere uised to determine left ventricullar stroke volume (LVSV) vere left ventricular diameter (LVD), which wvas the distance betveen the echoes from the anterior and posterior lheart xvalls duiring diastole (fig. 4), and the mitral ring echo amplitude (MREa), which wits the total amplitude of motion inscribed by thc mitral ring echo from the beginning of systole to the beginninig of diastole (fig. 5). The formula used to calculate LVSV was derived primarily from empirical findings. As stated before, MRlEa seemed to vary with stroke volume for a given left ventricuilar Circulalion, Volumue XXXV, June 1967 end-diastolic volume (LVV). If LVV were increased an1d LVSV were niot chaiiged, then MREa decrease-J. Thus, MLIEa appeared to vary directly with LVSV and iniversely with oV r LVSV-MIEa LVV, that is, M IEa- L'NV x LVV. By using LVD as a function of LVV, the relatively simple formula IVSV-MREa x LVD xxwas employed. Whien M I x x D xvas plotted against the stroke voltume, as determine(l by the Fick method, tlere was a straight line relationship betxveen the txvo valuies (fig. 6). The correlation coefficient xvas r 0.973 (P <0.091) xvith a regression ecqtiatiunvi = 87.5 + 10.40 (x 8.9). Table 1 shoxvs the results of uisinag this regression equiation to predict stroke volume from the ultrasound measurements (SV,,). The greatest disc repancy between the stroke volu-mes Downloaded from http://circ.ahajournals.org/ by guest on April 28, 2017 sS_^;~ FEIGENBAUM ET AL. 1096 t- J~~~~~~~~~g A~~~~~~~~~A, Figure 5 ho I)iagran and tiltrasountld recorlin, demonstatinlgio aimiplittide (AIREa) is obtainiedl. V9. M.0 ,E s.ol LVD x MREa Figure 6 Stroke volulme as determined byl the Fick mnethod plotted against the prodtuct of tire tultrasouind mleastrem?wents, LVD X MREa. calculated by the Fick and the tiltrasotind methods was 11 ml or 15%. Discussion Many attempts have been made to measure left ventricular stroke voluime by utilizing theinitral ring e((ho (AIR1 ) and( its Various (liagniostic procedures. Probably the most widely accepted methodl is measturing the cardiac otutput by either tlhe Fick6X or the indicator-diluition- technique and theni dividing the cardiac outpuit by the heart rate. This method has mainy obvious disadvantages. First, right heart catheterization is niecessary. Secondly, this technique caininot l)e used to measure truie stroke volume in the Presence of mitral in.suifficiency or aortic insufficiency. Thirdly, this teclhniqtue (loes niot allow for heat to beat measurements of stroke volume. Direct measuirements of left ventricular volume by either the angiographic' I 1 2 or inr dicator-dilution techniquies1; are more recent procedures uised to measiure left ventricular stroke volume. These techniques again require cardiac catheteriizatioD. The anigiographic proceduire possesses severail inherent objections. It introduces a foreign substance which may alter the hemodynamic situation; the technique offer.s som-ne risk to the patient; (rculhaion, Vo/lume XXXV. June 1967 LEFT VENTRICULAR STROKE VOLUME I'l --o 1097 co 't o- c X i In CS -o oo ++++++++I 10 I 10 10 co r- I- c 00 *li' 00 'I" t- oo OO N N +++++++I +± -f c ++I iD_co I>t > 10 't 0 1 r-Kt cscs ao +tl CZ 00CD - cs UC Cl) > :rA O)10 M 00 -- t m 5 ta- _- -- *0 Downloaded from http://circ.ahajournals.org/ by guest on April 28, 2017 N Iin 00 CO 0 Co 00 m -_ ._ 10 ° 'It )n in C CS oo t :0oob b o cr t- aQ I'l 0 O E cCC :6 10 00 +1 CO ~6 1 CZ 1-- "-. . x . 1)'t c VO . . c r- 1- +1 . "t1 )1 cor 00 0~ U co a 11CZ o6 CO r--l CZ P-10010)0)1~cq-00 0. cu CZ 00 - s>E 04 C) 't O CO . 1 . . C) "t C0 . -0t-N -t -- +1-0 -,t o6 6 t- Ct t0 CZ coC 000 00 0001 CS O o6 o6 o6 c6 Ci) CA CO ozQ._ E m CZ E. t ¢ * C ,.O . S X c C o 0 n t cs cs _cs CZ b C cO ;Z 0 _ K t CZ00 C")CIDin 0O= 0C, -0 0 c: CA CZ 10 'C 01C)-"T Clo co:) H- CIO Circulation, Volume XXXV, June 1967 ' 01 oot_nm m .0 1CbO C _t r rn cO 0) Cc r- c / Uw=P4P ;4 ; 00 O0)0~= -C01Nco "t10CC0 -,uw-~~-; ,- -- r-q r-q r-- r- O FEIGENBAUM ET AL. 1098 Downloaded from http://circ.ahajournals.org/ by guest on April 28, 2017 it does not lend itself to many repeated examinations, and the actual calculations are tedious and time consuming.4 In addition, both the angiographic and indicator-dilution techniques are still being questioned as to their accuracy in truly measuring left ventricular volume.-' The results of the present study indicate that diagnostic ultrasound with its many inherent advantages may provide another way of measuring left ventricular stroke volume. As stated in many previous publications,7 10 ultrasound in the power ranges used for diagnostic purposes is entirely innocuous to the patient. The technique used in this study is simple and the equipment is portable. Thus, the examination can be performed as a bedside procedure in a short time. The ease of the examination is borne out by the fact th-at for each patient in this study the ultrasound recordings were obtained within the 4 minuites it took to measure the cardiac output by the Fick method. The close correlation between the calculated left ventricular stroke volume and the expected left ventricular stroke volume as measured by the Fick method indicates that the accuracy of this ultrasound technique is probably as good as, if not better than, any of the other currently available methods. The advantages of a simple, accurate method for measuring left ventricular stroke volume are numerous. First of all, when such a technique is combined with a Fick cardiac output, theoretically a quantitative measure of mitral or aortic insufficiency can be ob- does represent some function of left ventricular volume and might prove to be of value as a qualitative or semiquantitative measure of left ventricular volume. It is somewhat difficult to explain entirely why these two relatively simple ultrasound measurements should be directly related to left ventricular stroke volume. The logical tendency is to try to fit the measurements into some mathematical formula used to measure left ventricular volume. Obviously there are too few data to justify such an attempt. In fact, one cannot entirely justify placing cm" or ml after the ultrasound calculations. Left ventricular diameter is actually measured in cm, as is MREa, thus the answer should really be in cm.2 The only justification one might have to use ml is that LVD supposedly represents a function of left ventricular volume in ml, and MREa is a function of how much left ventricular volume changes with ventricular systole. In any case, for the time being the findings must be considered entirely empirical. It is possible that future attempts to explain these findings may yield valuable information concerning the shape of the left ventricle and the manner in which this chamber ejects blood. tained. In patients without mitral or aortic valvular incompetence, this technique provides a bedside method for measuring cardiac output. In addition, since the formula LVSVMREa x LVD seems to be valid, the fact that the curve inscribed by the MRE is similar to left ventricular volume curves is probably more than coincidental. Thus, the recording of this echo may lend itself to hemodynamic studies involving changes in left ventricular volume. The validation of this formula also indicates that the ultrasound measurement of left ventricular diameter (LVD) probably 3. ZAKY, A., GRABHORN, L., ANDI) FEIGENBAUM, H.: Movenment of the mitral ring: Study in References 1. FEIGENBAUM, H., WALDHAUSEN, J. A., AND HYDE, L. P.: Ultrasouind diagnosis of pericardial effu- s,ion. JAMA 191: 107, 1965. 2. FEIGENBAUm, H., ZAKY, A., AND WVALDHAUSEN, J. A.: Use of ultrasound in the diagnosis of pericardial effusion. Ann Intern Med 65: 443, 1966. ultrasoundcardiograpby. Cardiov Res Cen Bull. In press. 4. GIMENEZ, J. L., WINTERS, V. L., JR., DAVILA, J. C., CONNELL, J., AND KLEIN, K. S.: Dynamiies of the Starr-Edwards ball valve prosthesis: A cinefluorographic and ultrasonic study in humans. Amer J Med Sci 250: 652, 1965. 5. EDLER, I.: Examination of the Cardiac Patient, edited by A. A. Luisada. New York, McCrawHill Book Co., 1965, p. 4. 6. FEIGENBAUM, H., ZAKY, A., AND GRABHOIR, L.: Cardiac motion in patients with pericardial effusion: A study using reflected ultrasound. Circulation 34: 611, 1966. (irculation, VZolime XXXV. !nne I96- LEFT VENTRICULAR STROKE VOLUME 1099 7. EDLER, I., GUSTOFSoN, A., KARLEFORS, T., AND 12. CHAPMAN, C. B., BAKER, O., MITCHEL, J. A., AND COLLIER, R. G.: Experiences with a cinefluorographic method for measuring ventricular volume. Amer J Cardiol 18: 25, 1966. 13. HOLT, J. P.: Indicator-dilution methods: Indicators, injection, sampling and mixing problems in measurement of ventricular volume. Amer J Cardiol 18: 208, 1966. 14. DODGE, H. T., SANDLER, H., BAXLEY, W. A., AND HAWLEY, R. R.: Usefulness and limitations of radiographic methods for determining left ventricular volume. Amer J Cardiol 18: 10, 1966. 15. SOLOFF, L. A.: On measuring left ventricular volume. Amer J Cardiol 18: 2, 1966. CHRISTENSON, B.: Ultrasound cardiography. Acta Med Scand 170 (suppl 370): 67, 1961. 8. JOYNER, C. R., AND REID, J. M.: Application of ultrasound in cardiology and cardiovascular physiology. Progr Cardiov Dis 5: 482, 1963. 9. FEIGENBAUM, H.: Diagnostic ultrasound. Ann Intern Med 65: 185, 1966. 10. SEGAL, B. L., LixOFF, W., AND KINGSLEY, B.: Echocardiography: Clinical application in mitral stenosis. JAMA 195: 161, 1966. 1 1. DODGE, H. T., HAY, R. E., AND SANDLER, H.: Angiocardiographic method for directly determining left ventricular stroke volume in man. Circulation Research 11: 739, 1962. Downloaded from http://circ.ahajournals.org/ by guest on April 28, 2017 Elementary Approaches to Thrombosis Various medical scientists look at thrombosis from different points of view. Only one, the clinician, studies the whole patient in whom a symptomatic clot resides.... The pathologist notes that when a vessel is injured, a clumping of platelets quickly develops at the site of injury. Under the electron microscope, he can see that the clumped platelets tend to lose their "dense granules," perhaps releasing their clotpromoting contents. The biochemist is interested in the chemical attraction between platelets and injured intima and the subjacent collagen; he tends to implicate the chemical, adenosine diphosphate. The biochemist has made significant advances in the chemistry of prothrombin and its active enzyme, thrombin, as well as in the biochemistry of the fibrinogen-fibrin reaction. The physiologist is interested in clots that form in living vessels. He notes that undamaged vascular intima is electrically negatively charged, repelling platelets that are similarly charged. When a vessel is damaged, its electronegativity disappears or may be replaced by an electropositivity, which tends to attract platelets to the injured site. The biophysicist is concerned with two rheologic principles as they may relate to vascular thrombi. First, fluid moving through a tube generates a negative "streaming" potential at the surface of the tube. This exaggerates the normal negative charge of the intima and is dependent upon the flow rate of the blood. Further, the flow rate in very small tubes, such as capillaries, varies with the fourth power of the caliber of the tube. If the diameter of a tube is reduced by one half, the flow rate diminishes to one sixteenth.-CHARLEs A. OWEN, JR.: Hypercoagulability and Thrombosis. In Proc Mayo Clin 40: 830, 1965. Circulation, Volume XXXV, June 1967 Use of Ultrasound to Measure Left Ventricular Stroke Volume HARVEY FEIGENBAUM, ADIB ZAKY, WILLIAM K. NASSER and Charles L. Haine Downloaded from http://circ.ahajournals.org/ by guest on April 28, 2017 Circulation. 1967;35:1092-1099 doi: 10.1161/01.CIR.35.6.1092 Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Copyright © 1967 American Heart Association, Inc. All rights reserved. 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