Mitral stenosis with posterior diastolic movement of posterior leaflet Neil D. Berman, md; Brian W.
Gilbert, md; Peter R. McLaughlin,
Summary: The echocardiographic diagnosis of mitral stenosis depends
in part on the demonstration of abnormal posterior leaflet movement to distinguish it from other conditions that similarly affect anterior leaflet motion. In mitral stenosis the posterior leaflet has been shown to move anteriorly in diastole rather than in the normal posterior direction. A patient presented with clinical evidence of moderate mitral stenosis. The anterior leaflet echo was typical but the posterior leaflet showed posterior diastolic movement. At catheterization moderate mitral stenosis was confirmed. To our knowledge this is the first report of the echocardiographic demonstration of posterior diastolic movement of the posterior mitral leaflet in documented mitral stenosis.
Resume: Ste nose mitrale
avec
diastolique posterieur du feuillet posterieur L'echodiagnostic de la stenose mitrale depend partieJIement de la mouvement
demonstration d'un mouvement anormal du feuillet posterieur pour le distinguer d'autres pathologies qui affectent egalement le mouvement du feuillet valvulaire anterieur. Dans la stenose mitrale le feuillet posterieur se meut anterieurement dans la diastole plutdt que dans la direction posterieure normale. Un malade presenta it des signes cliniques d'une stenose mitrale moderee. L'echo du feuillet anterieur etait typique de cette cardiopathie mais le feuillet posterieur avait un mouvement
diastolique posterieur.
Le catheterisme a confirme mitrale moderee.
md; John E.
Morch,
md
she was referred to our hos¬ Historically, the first significant ap¬ heparin3 and weeks later for assessment and plication of cardiac ultrasound was in pital the diagnosis of mitral stenosis.1,2 With further therapy. The positive physical findings were con¬ further experience echocardiography to the cardiovascular system. Atrial has been shown to be useful not only fined fibrillation was still present, with a ventri¬ for diagnosis but also for assessment cular response of 130 to 140 beats/min. of severity of mitral stenosis.3"6 In the The blood pressure was 130/80 mm Hg.
presence of stenosis the anterior mitral leaflet shows a decreased rate of closure during early diastole (reduced EF slope*). Because the EF slope is often difficult to evaluate in the presence of tachycardia7 or aortic in¬ sufficiency,8 other criteria for the diagnosis of mitral stenosis were es¬ tablished. These include decreased am¬ plitude of excursion of the anterior leaflet or abnormal thickness of the valve as indicated by multiple thick echoes. All these abnormalities of the anterior leaflet can be produced by other cardiac abnormalities, particu¬ larly those associated with slow dia¬ stolic filling of the left ventricle or abnormal compliance.9"11 Thus, atten¬ tion shifted to the posterior leaflet, which normally moves in a direction opposite to that of the anterior leaflet. In mitral stenosis the posterior leaflet was shown to move in the same direc¬ tion as the anterior leaflet.12 This ab¬ normal movement of the posterior leaf¬ let became the essential criterion for distinguishing mitral stenosis from other causes of abnormal anterior leaf¬ let movement. We recently studied a patient in whom the clinical diagnosis of mitral stenosis was contradicted by the nor¬ mal direction of movement of the pos¬ terior mitral leaflet, as determined by
echocardiography.
Case report
The jugular venous pressure was normal. The first heart sound (SO was palpable at the apex. There was a slight right ven¬ tricular heave. On auscultation Si was loud and P2 moderately increased. An opening snap was heard at the apex 0.08 seconds after S2 but no diastolic rumble was audible. The arterial pulses in the legs were present but diminished. Additional digoxin further decreased the apical rate and a brief diastolic rumble (2/6) could be clearly heard after the
opening
snap.
A chest radiograph showed moderate left atrial enlargement and slight prominence of the upper pulmonary veins. An electrocardiogram showed atrial fibrilla¬ tion with an rSR1 pattern in lead Vi.
Echocardiography Echocardiograms were recorded with the patient in both the supine and left lateral positions. For this a Smith Kline Ekoline 20 Ultrasonoscope producing 1000 pulses per second was interfaced with a Cambridge recorder; a 2.25-MHz transducer of 1.5-cm diameter was used. Optimal echoes were recorded from the fourth left interspace. M-mode scanning was performed, sweeping from the aortic root towards the apex. All measurements were averaged over five cycles. The echocardiogram is shown in Fig. 1. The opening amplitude of the anterior leaflet was reduced to 8 mm. The EF slope was decreased at 14.8 mm/s. The posterior leaflet moved in a direction op¬ posite to the movement of the anterior leaflet; that is, the direction of movement of the posterior leaflet was normal. Angulation of the transducer confirmed that was a posterior leaflet echo, not a 10-year this chordal echo.
A 56-year-old woman with a history of mild hypertension and no other The septum showed normal thickness known heart disease presented with a A notre avis c'est le premier rapport and movement. The right ventricular end2-week of on exertion and history dyspnea d'echodiagnostic cardiographique qui She was hospitalized with diastolic diameter was increased at 31 mm ait demontre un mouvement diastolique fatigability. atrial fibrillation and digitalization and the left was normal at 39 mm. rapid post6rieur du feuillet mitral posterieur was begun. Six days later she complained dans un cas de stenose mitrale bien of coldness and numbness of her legs. The Cardiac catheterization documente. legs were cool and pale, with absent popRight and left heart catheterization were liteal pulses and diminished femoral performed via the right femoral artery and pulses. Heparinization rapidly improved From the department of medicine, University the peripheral perfusion. An oral anti¬ vein using standard techniques. Left atrial of Toronto and the cardiovascular unit, through a 2.5-cm Toronto General Hospital coagulant was gradually substituted for pressures were measured Brockenbrough catheter introduced by Supported in part by Ontario and Canadian une
stenose
heart foundations
Reprint requests to: Dr. J. E. Morch, Cardiovascular unit, Toronto General Hospital, 101 College St., Toronto, Ont. M5G 1L7
*EF slope is the standard designation for the slope of a line joining the point of peak anterior motion (E) with the point of maximum posterior motion (F) on the echocardiogram.3,12
976 CMA JOURNAL/APRIL 19, 1975/VOL. 112
needle puncture of the intra-atrial septum. Pressures were recorded with Statham P23Db transducers and an Electronics for Medicine recorder. Pressures were as fol-
pulmonary arterial (mean), 30 mm Hg; right ventricular (end-diastolic), 10 mm Hg; left atrial (mean), 24 mm Hg; and left ventricular (end-diastolic), 14 mm Hg. Cardiac output was determined by the Fick principle to be 2.2 1/min (1.4 1/min .m2). Pulmonary vascular re¬ sistance was 253 dynes/sec .cm'5. The mit¬ ral gradient was assessed by simultaneous left atrial and ventricular pressures (Fig. 2). The mean integrated mitral gradient was 4 mm Hg. The calculated mitral valve area was 1.3 cm2 (Gorlin formula13). A left atrial injection performed with 35 ml of Renografin-76 at 6 ml/min showed an enlarged left atrium without a filling defect and a thickened and stiff mitral valve (Fig. 3). lows:
ualized through the left atrium, was stiff and mildly calcified, with an orifice of approximately 1 cm. The valve was suc¬ cessfully split without the creation of any
insufficiency.
Postoperative echocardiography An echocardiogram was performed postoperatively. The calculated EF slope (average of 5 cycles) was now within the normal range at 36.8 mm/s and the am-
1P
Mitral
commissurotomy Subsequently an open mitral commis¬ surotomy was performed on total cardio¬ pulmonary bypass. The mitral valve, vis-
RV
l'iyi^0^^M^^:''-
:^'-:/ >'-"^ -)¦' '^
'^SS^^mlSS^Q
§pSi:
FIG. 2.Simultaneous left atrial (LA) and left ventricular (LV) pressure tracings and standard electrocardiogram lead I (L,). 0 = 0 mm Hg.
^%NV1mk,
PML"
ENDO FIG. 1.Echocardiogram at level of mitral leaflets. Reduced amplitude of opening of anterior leaflet and reduced EF slope. Posterior leaflet moves in normal direction. L2 == standard lead II; RV = right ventricular cavity; S = interventricular septum; AML = anterior mitral leaflet; PML = posterior mitral leaflet; ENDO =. endocardium.
FIG. 3.Left atrial (LA) angiogram in 30° right anterior Arrow indicates thick, stiff, ballooning mitral valve.
oblique projection.
CMA JOURNAL/APRIL 19, 1975/VOL. 112 977
Specially tailored to pregnancy
plitude of opening of the anterior leaflet was improved, though still reduced at 15 mm. The movement of the posterior leaflet was unchanged. Discussion
Slow-I. folk Brief Prescribing Information Formula: Each SLOW-Fe folic tablet contains 160mg dried ferrous sulfate (equivalent to 50 mg of elemental iron) and 400 micrograms folic acid in a specially formulated slow release base. The iron content is released evenly over an average period of.hours, optimum time for maximum effective absorption. The tablets are film coated.
indications Prophylaxis of iron and folic acid deficiencies and treatment of megaloblastic anemia, during pregnancy, puerperium and lactation.
Dosage and Administration Prophylaxis: One tablet daily throughout pregnancy, puerperium and lactation. To be swallowed whole at any time of day regardless of meal times. Treatment of megaloblastic anemia: during pregnancy, puerperium and lactation; and, in multiple pregnancy: two tablets, in a single dose, should be swallowed daily.
Side Effects
The incidence of gastro-intestinal side effects such as nausea and gastro-intestinal irritation is extremely low.
Treatment of Overdosage Signs of toxicity from folic acid have not been observed even with doses several times higher than the usual therapeutic levels. Care has been taken to minimize the risk of accidental consumption of SLOW-Fe folic in children by making the tablets a relatively unattractive offwhite colour with an almost tasteless film coat. Moreover the push-through type of foil packaging makes the extraction of any tablets difficult and tedious for children. However, in the event of overdosage the usual treatment for iron poisoning should be instituted. Because the iron is only slowly released, the risk of toxic levels of ionic iron being absorbed is less and there is a wider time margin in which to carry out stomach washouts; also the use of an iron-chelating agent such as DESFERAL® (deferoxamine CIBA) is likely to be more effective. The treatment of iron poisoning is described in detail in the CIBA literature on DESFERAL®.
Contraindications Hemochromatosis, hemosiderosis, and hemolytic anemia.
Warnings Keep out of reach of children.
References 1. EoLER I: Diagnostic use of ultrasound in heart disease. Ada Med Scand 308: 32, 1955 2. JOYNER CP JR. REID TM, BOND JP: Reflected ultrasound in the assessment of mitral valve disease. Circulation 27: 503, 1963 3. FEIGENBAUM H: Echocardiography. Philadelphia, Lea and Febiger, 1973, p 50 4. EDLER I: Ultrasoundcardiography in mitral valve stenosis. Am I Cardiol 19: 18, 1967 5. GusTAFsoN A: Correlation between ultrasoundcardiography, hemodynamics and surgical findings in mitral stenosis. Ibid, p 32 6. EFFERT S: Pre- and postoperative evaluation of mitral stenosis by ultrasound. Ibid, p 59 7. FEIGENBAUM H: Echocardiographj'. Philadelphia, Lea and Febiger, 1973, p 54 8. wIN SHERO F, GABOR GE, HERNBERG JG, et
Precautions The use of Folic acid in the treatment of pernicious (Addisonian) anemia, in which vitamin B12 is deficient, may return the peripheral blood picture to normal while neurological manifestations remain progressive. Oral iron preparations may aggravate existing peptic ulcers, regional enteritis and ulcerative colitis. Iron when given with tetracyclines, binds in the equimolecular ratio thus lowering the absorption of tetracyclines.
Supplied SLOW-Fe folic tablets are packaged in pushthrough packs containing 30 tablets per sheet and are available in units of 30 and 120 tablets.
CIBA Dorval, Ouebec H95 iBi
Echocardiography has become a useful noninvasive diagnostic technique in cardiology. With increased application its potential is being defined. Its limitations will be disclosed more gradually. In our patient peripheral embolization was considered an indication for surgery.14 It was anticipated that confirmation of the diagnosis by echocardiography would have permitted surgery without the need for invasive studies. In view of the atypical echocardiogram the diagnosis was clarified invasively. Since the movement of the posterior leaflet was first defined in mitral stenosis'2 it has been a consistent finding. To our knowledge this is the first well documented case of moderate mitral stenosis in which posterior diastolic motion of the posterior leaflet has been demonstrated echocardiographically. The basis for the normal direction of movement of the posterior leaflet in this case is unclear. Technical errors are unlikely because the transducer was applied in various positions and at various angles and the pattern was consistent. The posterior movement may represent a large, mobile posterior leaflet that is abnormal only along its line of closure. We anticipate that further examples will help clarify the factors that influence the movement of the posterior leaflet in mitral stenosis, perhaps with the additional application of multicrystal ultrasound techniques.
at: Fluttering of the mitral valve in sonic insufficiency. Circulation 41: 225, 1970 9. FEIGENBAUM H: Echocardiography. Philadelphia, Lea and Febiger, 1973, p 51
10. SMITH w. JR, FRANEL wS: Ultrasound in
clinical practice. Med Clin North An, 57: 959, 1973 II. QUINoNEs MA, GAASCH wH, wAIssER E, et at: Reduction in the rate of diastolic
descent of the mitral valve echogram in patients with altered left ventricular diastolic
pressure-volume
246, 1974
relations.
Circulation
49:
12. DUCHAK JM, CHANG S. FEIGENBAUM H: The posterior mitral valve echo and the echocardiographic diagnosis of mitral stenosis.
Am J Cardiol 29: 628, 1972 13. GORLIN R, GORuN SG: Hydraulic formula for calculation of the area of the stenotic mitral valve, other cardiac valves and central circulatory shunts. Am Heart 1 41: 1, 1951 14. GREENWOOD WF, ALDRIDGE HE, MCKELvEY AD: Effect of mitral commissurotomy on duration of life, functional capacity, hemop-
C-4052
tysis and systemic embolism. Ani I Cardiol II: 348, 1963
POSTGRADUATE COURSES continued from page 928 PHYSICAL ILLNESS AND FAMILY THERAPY. Clarke Institute of Psychiatry, Toronto. May 3031, 1975. Information: Director, Division of postgraduate medical education, University of Toronto, Toronto, Ont. M5S lAB TREATMENT OF THE SERIOUSLY INJURED OR ILL IN THE EMERGENCY DEPARTMENT. The Montreal General Hospital, June 4-6, 1975. Information: Secretary, Postgraduate board, MGH, 1650 Cedar Ave., Montreal, Que. H3G 1A4 PEDIATRIC METABOLIC BONE DISEASE. Royal Victoria Hospital, Montr6al, June 4-6, 1975. Information: The Secretary, Postgraduate board, RVH, 687 Pine Ave. W, Montreal, Ou.. H3A lAl GENERAL THORACIC SURGERY. Mount Sinai Hospital, Toronto. June 5-6, 1975. Information: Director, Division of postgraduate medical education, University of Toronto, Toronto, Ont. MSS lAB HEINZ SEMINAR IN PEDIATRICS. Royal York Hotel, Toronto. June 9-10, 1975. Sponsored by Canadian Paediatric Society and Centre Hospitaher Universitaire de Sherbrooke. Information: Dr Roger R. Dufresne, D6partement d.ducation medicale permanente, CHUS, Sherbrooke, Que. J1H 5N4 NEUROLOGY CLINICAL DAY. Royal Victoria Hospital, Montreal. June 11, 1975. Information: Secretary, Postgraduate board, RVH, 687 Pine Ave. W, Montreal, Que, H3A lAl POSTGRADUATE SEMINAR IN DIAGNOSTIC UL. TRASOUND. The Montreal General Hospital, June 12-14, 1975. Information: Dr. F, Winsberg, Director, Division of diagnostic ultrasound, Department of diagnostic radiology, MGH, 1650 Cedar Ave., Montreal, Que. H3G 1A4 ALLERGY AND CLINICAL IMMUNOLOGY. Featured as part of the annual meeting of the Canadian Society of Allergy and Clinical Immunology, London, Ont. June 13, 1975. Information: Mrs. B.J. McGlynn, Executive secretary, The Canadian Society of Allergy and Clinical Immunology, 1390 Sherbrooke St. W, Montreal, Que. CONTACT LENS FITTING. Chateau Laurier, Ottawa. June 14-15, 1975. Held by Contact Lens Association of Ophthalmologists (Canada) in conjunction with the annual meeting of the Canadian Ophthalmological Society. Information: Dr. G. Nason, COS, P0 Box 8650, Ottawa, Ont. KiG 0G8 38TH ANNUAL MEETING OF THE CANADIAN OPHTHALMOLOGICAL SOCIETY. Chateau Laurier, Ottawa. June 15-18, 1975. Research sessions: June 15. Scientific meetings: June 16-18. Glaucoma symposium: June 18. Information: Dr, G. Nason. COS, P0 Box 8650, Ottawa, Ont. KiG 0GB INTERNATIONAL SYMPOSIUM ON SAFETY OF DRUGS. Government Conference Centre, Ottawa. June 17-18, 1975. Sponsored by drugs directorate of health protection branch of Health and Welfare Cenada. Theme: development and use of safe and effective drugs. Information: Mrs. Jean Anderson, A/Head. Technical secretariat, Rm. 1-12. Health Protection Branch Building, Health and Welfare Canada, Ottawa. Ont. KIA 0L2 CODING AND ABSTRACTING INSTITUTES. Calgary. June 17-19, 1975. Review of basic principles of H-ICDA coding; discussion of methods of PAS abstracting. Open to all medical record personnel using H-ICDA. Information: Commission on Professional and Hospital Activities. 1968 Green Rd., Ann Arbor. Ml 48105, USA ADVANCES IN INTERNAL MEDICINE. The Banff Centre for Continuing Education and School of Fine Arts, Banff, Alta. June 23-27, 1975. Information: Director, Division of continuing medical education, The University of Alberta, Edmonton, Alta. T6G 2G3 ANNUAL MEETING OF THE CANADIAN ASSOCIA. TION OF PATHOLOGISTS. Calgary, June 25-29, 1975. Scientific sessions: June 25-27. Workshops: June 28-29. Information: Dr. D.P. Hill, Department of laboratory medicine, Ottawa General Hospital, Ottawa. Ont. KiN 5C8 ANNUAL MEETING. CANADIAN DERMATOLOG. ICAL ASSOCIATION. Banff, Alta. July 2-6, 1975. Information: Dr. W.T.R. Linton, Secretary treasurer, CDA. 22 Richmond St., Richmond Hill, Ont. INTRODUCTORY SEMINAR ON ACUPUNCTURE. Holiday Inn, Yorkdale, Toronto. July 4-6, 1975. Information: Dr. Elie Cass, President, Acupuncture Foundation of Canada, Ste. 228, 730 Younge St. Toronto. Ont. M4Y 2B7 SPORTS MEDICINE SYMPOSIUM. Regina. Aug. 7-8, 1975. Information: Mrs. M.P. Sarich, Administrative assistant, Continuing medical education, 408 Ellis Hall, University of Saskatchewan, Saskatoon. Sask. 57N OWB
CMA JOURNAL/APRIL 19. 1975/VOL. 112 979
Gilbert, md; Peter R. McLaughlin,
Summary: The echocardiographic diagnosis of mitral stenosis depends
in part on the demonstration of abnormal posterior leaflet movement to distinguish it from other conditions that similarly affect anterior leaflet motion. In mitral stenosis the posterior leaflet has been shown to move anteriorly in diastole rather than in the normal posterior direction. A patient presented with clinical evidence of moderate mitral stenosis. The anterior leaflet echo was typical but the posterior leaflet showed posterior diastolic movement. At catheterization moderate mitral stenosis was confirmed. To our knowledge this is the first report of the echocardiographic demonstration of posterior diastolic movement of the posterior mitral leaflet in documented mitral stenosis.
Resume: Ste nose mitrale
avec
diastolique posterieur du feuillet posterieur L'echodiagnostic de la stenose mitrale depend partieJIement de la mouvement
demonstration d'un mouvement anormal du feuillet posterieur pour le distinguer d'autres pathologies qui affectent egalement le mouvement du feuillet valvulaire anterieur. Dans la stenose mitrale le feuillet posterieur se meut anterieurement dans la diastole plutdt que dans la direction posterieure normale. Un malade presenta it des signes cliniques d'une stenose mitrale moderee. L'echo du feuillet anterieur etait typique de cette cardiopathie mais le feuillet posterieur avait un mouvement
diastolique posterieur.
Le catheterisme a confirme mitrale moderee.
md; John E.
Morch,
md
she was referred to our hos¬ Historically, the first significant ap¬ heparin3 and weeks later for assessment and plication of cardiac ultrasound was in pital the diagnosis of mitral stenosis.1,2 With further therapy. The positive physical findings were con¬ further experience echocardiography to the cardiovascular system. Atrial has been shown to be useful not only fined fibrillation was still present, with a ventri¬ for diagnosis but also for assessment cular response of 130 to 140 beats/min. of severity of mitral stenosis.3"6 In the The blood pressure was 130/80 mm Hg.
presence of stenosis the anterior mitral leaflet shows a decreased rate of closure during early diastole (reduced EF slope*). Because the EF slope is often difficult to evaluate in the presence of tachycardia7 or aortic in¬ sufficiency,8 other criteria for the diagnosis of mitral stenosis were es¬ tablished. These include decreased am¬ plitude of excursion of the anterior leaflet or abnormal thickness of the valve as indicated by multiple thick echoes. All these abnormalities of the anterior leaflet can be produced by other cardiac abnormalities, particu¬ larly those associated with slow dia¬ stolic filling of the left ventricle or abnormal compliance.9"11 Thus, atten¬ tion shifted to the posterior leaflet, which normally moves in a direction opposite to that of the anterior leaflet. In mitral stenosis the posterior leaflet was shown to move in the same direc¬ tion as the anterior leaflet.12 This ab¬ normal movement of the posterior leaf¬ let became the essential criterion for distinguishing mitral stenosis from other causes of abnormal anterior leaf¬ let movement. We recently studied a patient in whom the clinical diagnosis of mitral stenosis was contradicted by the nor¬ mal direction of movement of the pos¬ terior mitral leaflet, as determined by
echocardiography.
Case report
The jugular venous pressure was normal. The first heart sound (SO was palpable at the apex. There was a slight right ven¬ tricular heave. On auscultation Si was loud and P2 moderately increased. An opening snap was heard at the apex 0.08 seconds after S2 but no diastolic rumble was audible. The arterial pulses in the legs were present but diminished. Additional digoxin further decreased the apical rate and a brief diastolic rumble (2/6) could be clearly heard after the
opening
snap.
A chest radiograph showed moderate left atrial enlargement and slight prominence of the upper pulmonary veins. An electrocardiogram showed atrial fibrilla¬ tion with an rSR1 pattern in lead Vi.
Echocardiography Echocardiograms were recorded with the patient in both the supine and left lateral positions. For this a Smith Kline Ekoline 20 Ultrasonoscope producing 1000 pulses per second was interfaced with a Cambridge recorder; a 2.25-MHz transducer of 1.5-cm diameter was used. Optimal echoes were recorded from the fourth left interspace. M-mode scanning was performed, sweeping from the aortic root towards the apex. All measurements were averaged over five cycles. The echocardiogram is shown in Fig. 1. The opening amplitude of the anterior leaflet was reduced to 8 mm. The EF slope was decreased at 14.8 mm/s. The posterior leaflet moved in a direction op¬ posite to the movement of the anterior leaflet; that is, the direction of movement of the posterior leaflet was normal. Angulation of the transducer confirmed that was a posterior leaflet echo, not a 10-year this chordal echo.
A 56-year-old woman with a history of mild hypertension and no other The septum showed normal thickness known heart disease presented with a A notre avis c'est le premier rapport and movement. The right ventricular end2-week of on exertion and history dyspnea d'echodiagnostic cardiographique qui She was hospitalized with diastolic diameter was increased at 31 mm ait demontre un mouvement diastolique fatigability. atrial fibrillation and digitalization and the left was normal at 39 mm. rapid post6rieur du feuillet mitral posterieur was begun. Six days later she complained dans un cas de stenose mitrale bien of coldness and numbness of her legs. The Cardiac catheterization documente. legs were cool and pale, with absent popRight and left heart catheterization were liteal pulses and diminished femoral performed via the right femoral artery and pulses. Heparinization rapidly improved From the department of medicine, University the peripheral perfusion. An oral anti¬ vein using standard techniques. Left atrial of Toronto and the cardiovascular unit, through a 2.5-cm Toronto General Hospital coagulant was gradually substituted for pressures were measured Brockenbrough catheter introduced by Supported in part by Ontario and Canadian une
stenose
heart foundations
Reprint requests to: Dr. J. E. Morch, Cardiovascular unit, Toronto General Hospital, 101 College St., Toronto, Ont. M5G 1L7
*EF slope is the standard designation for the slope of a line joining the point of peak anterior motion (E) with the point of maximum posterior motion (F) on the echocardiogram.3,12
976 CMA JOURNAL/APRIL 19, 1975/VOL. 112
needle puncture of the intra-atrial septum. Pressures were recorded with Statham P23Db transducers and an Electronics for Medicine recorder. Pressures were as fol-
pulmonary arterial (mean), 30 mm Hg; right ventricular (end-diastolic), 10 mm Hg; left atrial (mean), 24 mm Hg; and left ventricular (end-diastolic), 14 mm Hg. Cardiac output was determined by the Fick principle to be 2.2 1/min (1.4 1/min .m2). Pulmonary vascular re¬ sistance was 253 dynes/sec .cm'5. The mit¬ ral gradient was assessed by simultaneous left atrial and ventricular pressures (Fig. 2). The mean integrated mitral gradient was 4 mm Hg. The calculated mitral valve area was 1.3 cm2 (Gorlin formula13). A left atrial injection performed with 35 ml of Renografin-76 at 6 ml/min showed an enlarged left atrium without a filling defect and a thickened and stiff mitral valve (Fig. 3). lows:
ualized through the left atrium, was stiff and mildly calcified, with an orifice of approximately 1 cm. The valve was suc¬ cessfully split without the creation of any
insufficiency.
Postoperative echocardiography An echocardiogram was performed postoperatively. The calculated EF slope (average of 5 cycles) was now within the normal range at 36.8 mm/s and the am-
1P
Mitral
commissurotomy Subsequently an open mitral commis¬ surotomy was performed on total cardio¬ pulmonary bypass. The mitral valve, vis-
RV
l'iyi^0^^M^^:''-
:^'-:/ >'-"^ -)¦' '^
'^SS^^mlSS^Q
§pSi:
FIG. 2.Simultaneous left atrial (LA) and left ventricular (LV) pressure tracings and standard electrocardiogram lead I (L,). 0 = 0 mm Hg.
^%NV1mk,
PML"
ENDO FIG. 1.Echocardiogram at level of mitral leaflets. Reduced amplitude of opening of anterior leaflet and reduced EF slope. Posterior leaflet moves in normal direction. L2 == standard lead II; RV = right ventricular cavity; S = interventricular septum; AML = anterior mitral leaflet; PML = posterior mitral leaflet; ENDO =. endocardium.
FIG. 3.Left atrial (LA) angiogram in 30° right anterior Arrow indicates thick, stiff, ballooning mitral valve.
oblique projection.
CMA JOURNAL/APRIL 19, 1975/VOL. 112 977
Specially tailored to pregnancy
plitude of opening of the anterior leaflet was improved, though still reduced at 15 mm. The movement of the posterior leaflet was unchanged. Discussion
Slow-I. folk Brief Prescribing Information Formula: Each SLOW-Fe folic tablet contains 160mg dried ferrous sulfate (equivalent to 50 mg of elemental iron) and 400 micrograms folic acid in a specially formulated slow release base. The iron content is released evenly over an average period of.hours, optimum time for maximum effective absorption. The tablets are film coated.
indications Prophylaxis of iron and folic acid deficiencies and treatment of megaloblastic anemia, during pregnancy, puerperium and lactation.
Dosage and Administration Prophylaxis: One tablet daily throughout pregnancy, puerperium and lactation. To be swallowed whole at any time of day regardless of meal times. Treatment of megaloblastic anemia: during pregnancy, puerperium and lactation; and, in multiple pregnancy: two tablets, in a single dose, should be swallowed daily.
Side Effects
The incidence of gastro-intestinal side effects such as nausea and gastro-intestinal irritation is extremely low.
Treatment of Overdosage Signs of toxicity from folic acid have not been observed even with doses several times higher than the usual therapeutic levels. Care has been taken to minimize the risk of accidental consumption of SLOW-Fe folic in children by making the tablets a relatively unattractive offwhite colour with an almost tasteless film coat. Moreover the push-through type of foil packaging makes the extraction of any tablets difficult and tedious for children. However, in the event of overdosage the usual treatment for iron poisoning should be instituted. Because the iron is only slowly released, the risk of toxic levels of ionic iron being absorbed is less and there is a wider time margin in which to carry out stomach washouts; also the use of an iron-chelating agent such as DESFERAL® (deferoxamine CIBA) is likely to be more effective. The treatment of iron poisoning is described in detail in the CIBA literature on DESFERAL®.
Contraindications Hemochromatosis, hemosiderosis, and hemolytic anemia.
Warnings Keep out of reach of children.
References 1. EoLER I: Diagnostic use of ultrasound in heart disease. Ada Med Scand 308: 32, 1955 2. JOYNER CP JR. REID TM, BOND JP: Reflected ultrasound in the assessment of mitral valve disease. Circulation 27: 503, 1963 3. FEIGENBAUM H: Echocardiography. Philadelphia, Lea and Febiger, 1973, p 50 4. EDLER I: Ultrasoundcardiography in mitral valve stenosis. Am I Cardiol 19: 18, 1967 5. GusTAFsoN A: Correlation between ultrasoundcardiography, hemodynamics and surgical findings in mitral stenosis. Ibid, p 32 6. EFFERT S: Pre- and postoperative evaluation of mitral stenosis by ultrasound. Ibid, p 59 7. FEIGENBAUM H: Echocardiographj'. Philadelphia, Lea and Febiger, 1973, p 54 8. wIN SHERO F, GABOR GE, HERNBERG JG, et
Precautions The use of Folic acid in the treatment of pernicious (Addisonian) anemia, in which vitamin B12 is deficient, may return the peripheral blood picture to normal while neurological manifestations remain progressive. Oral iron preparations may aggravate existing peptic ulcers, regional enteritis and ulcerative colitis. Iron when given with tetracyclines, binds in the equimolecular ratio thus lowering the absorption of tetracyclines.
Supplied SLOW-Fe folic tablets are packaged in pushthrough packs containing 30 tablets per sheet and are available in units of 30 and 120 tablets.
CIBA Dorval, Ouebec H95 iBi
Echocardiography has become a useful noninvasive diagnostic technique in cardiology. With increased application its potential is being defined. Its limitations will be disclosed more gradually. In our patient peripheral embolization was considered an indication for surgery.14 It was anticipated that confirmation of the diagnosis by echocardiography would have permitted surgery without the need for invasive studies. In view of the atypical echocardiogram the diagnosis was clarified invasively. Since the movement of the posterior leaflet was first defined in mitral stenosis'2 it has been a consistent finding. To our knowledge this is the first well documented case of moderate mitral stenosis in which posterior diastolic motion of the posterior leaflet has been demonstrated echocardiographically. The basis for the normal direction of movement of the posterior leaflet in this case is unclear. Technical errors are unlikely because the transducer was applied in various positions and at various angles and the pattern was consistent. The posterior movement may represent a large, mobile posterior leaflet that is abnormal only along its line of closure. We anticipate that further examples will help clarify the factors that influence the movement of the posterior leaflet in mitral stenosis, perhaps with the additional application of multicrystal ultrasound techniques.
at: Fluttering of the mitral valve in sonic insufficiency. Circulation 41: 225, 1970 9. FEIGENBAUM H: Echocardiography. Philadelphia, Lea and Febiger, 1973, p 51
10. SMITH w. JR, FRANEL wS: Ultrasound in
clinical practice. Med Clin North An, 57: 959, 1973 II. QUINoNEs MA, GAASCH wH, wAIssER E, et at: Reduction in the rate of diastolic
descent of the mitral valve echogram in patients with altered left ventricular diastolic
pressure-volume
246, 1974
relations.
Circulation
49:
12. DUCHAK JM, CHANG S. FEIGENBAUM H: The posterior mitral valve echo and the echocardiographic diagnosis of mitral stenosis.
Am J Cardiol 29: 628, 1972 13. GORLIN R, GORuN SG: Hydraulic formula for calculation of the area of the stenotic mitral valve, other cardiac valves and central circulatory shunts. Am Heart 1 41: 1, 1951 14. GREENWOOD WF, ALDRIDGE HE, MCKELvEY AD: Effect of mitral commissurotomy on duration of life, functional capacity, hemop-
C-4052
tysis and systemic embolism. Ani I Cardiol II: 348, 1963
POSTGRADUATE COURSES continued from page 928 PHYSICAL ILLNESS AND FAMILY THERAPY. Clarke Institute of Psychiatry, Toronto. May 3031, 1975. Information: Director, Division of postgraduate medical education, University of Toronto, Toronto, Ont. M5S lAB TREATMENT OF THE SERIOUSLY INJURED OR ILL IN THE EMERGENCY DEPARTMENT. The Montreal General Hospital, June 4-6, 1975. Information: Secretary, Postgraduate board, MGH, 1650 Cedar Ave., Montreal, Que. H3G 1A4 PEDIATRIC METABOLIC BONE DISEASE. Royal Victoria Hospital, Montr6al, June 4-6, 1975. Information: The Secretary, Postgraduate board, RVH, 687 Pine Ave. W, Montreal, Ou.. H3A lAl GENERAL THORACIC SURGERY. Mount Sinai Hospital, Toronto. June 5-6, 1975. Information: Director, Division of postgraduate medical education, University of Toronto, Toronto, Ont. MSS lAB HEINZ SEMINAR IN PEDIATRICS. Royal York Hotel, Toronto. June 9-10, 1975. Sponsored by Canadian Paediatric Society and Centre Hospitaher Universitaire de Sherbrooke. Information: Dr Roger R. Dufresne, D6partement d.ducation medicale permanente, CHUS, Sherbrooke, Que. J1H 5N4 NEUROLOGY CLINICAL DAY. Royal Victoria Hospital, Montreal. June 11, 1975. Information: Secretary, Postgraduate board, RVH, 687 Pine Ave. W, Montreal, Que, H3A lAl POSTGRADUATE SEMINAR IN DIAGNOSTIC UL. TRASOUND. The Montreal General Hospital, June 12-14, 1975. Information: Dr. F, Winsberg, Director, Division of diagnostic ultrasound, Department of diagnostic radiology, MGH, 1650 Cedar Ave., Montreal, Que. H3G 1A4 ALLERGY AND CLINICAL IMMUNOLOGY. Featured as part of the annual meeting of the Canadian Society of Allergy and Clinical Immunology, London, Ont. June 13, 1975. Information: Mrs. B.J. McGlynn, Executive secretary, The Canadian Society of Allergy and Clinical Immunology, 1390 Sherbrooke St. W, Montreal, Que. CONTACT LENS FITTING. Chateau Laurier, Ottawa. June 14-15, 1975. Held by Contact Lens Association of Ophthalmologists (Canada) in conjunction with the annual meeting of the Canadian Ophthalmological Society. Information: Dr. G. Nason, COS, P0 Box 8650, Ottawa, Ont. KiG 0G8 38TH ANNUAL MEETING OF THE CANADIAN OPHTHALMOLOGICAL SOCIETY. Chateau Laurier, Ottawa. June 15-18, 1975. Research sessions: June 15. Scientific meetings: June 16-18. Glaucoma symposium: June 18. Information: Dr, G. Nason. COS, P0 Box 8650, Ottawa, Ont. KiG 0GB INTERNATIONAL SYMPOSIUM ON SAFETY OF DRUGS. Government Conference Centre, Ottawa. June 17-18, 1975. Sponsored by drugs directorate of health protection branch of Health and Welfare Cenada. Theme: development and use of safe and effective drugs. Information: Mrs. Jean Anderson, A/Head. Technical secretariat, Rm. 1-12. Health Protection Branch Building, Health and Welfare Canada, Ottawa. Ont. KIA 0L2 CODING AND ABSTRACTING INSTITUTES. Calgary. June 17-19, 1975. Review of basic principles of H-ICDA coding; discussion of methods of PAS abstracting. Open to all medical record personnel using H-ICDA. Information: Commission on Professional and Hospital Activities. 1968 Green Rd., Ann Arbor. Ml 48105, USA ADVANCES IN INTERNAL MEDICINE. The Banff Centre for Continuing Education and School of Fine Arts, Banff, Alta. June 23-27, 1975. Information: Director, Division of continuing medical education, The University of Alberta, Edmonton, Alta. T6G 2G3 ANNUAL MEETING OF THE CANADIAN ASSOCIA. TION OF PATHOLOGISTS. Calgary, June 25-29, 1975. Scientific sessions: June 25-27. Workshops: June 28-29. Information: Dr. D.P. Hill, Department of laboratory medicine, Ottawa General Hospital, Ottawa. Ont. KiN 5C8 ANNUAL MEETING. CANADIAN DERMATOLOG. ICAL ASSOCIATION. Banff, Alta. July 2-6, 1975. Information: Dr. W.T.R. Linton, Secretary treasurer, CDA. 22 Richmond St., Richmond Hill, Ont. INTRODUCTORY SEMINAR ON ACUPUNCTURE. Holiday Inn, Yorkdale, Toronto. July 4-6, 1975. Information: Dr. Elie Cass, President, Acupuncture Foundation of Canada, Ste. 228, 730 Younge St. Toronto. Ont. M4Y 2B7 SPORTS MEDICINE SYMPOSIUM. Regina. Aug. 7-8, 1975. Information: Mrs. M.P. Sarich, Administrative assistant, Continuing medical education, 408 Ellis Hall, University of Saskatchewan, Saskatoon. Sask. 57N OWB
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