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Biomedical subjects

E D Folland

Publications and source records attributed to E D Folland.

At least 19 recordsLinked to original sources
PubMed1992

Implications of third heart sounds in patients with valvular heart disease. The Veterans Affairs Cooperative Study on Valvular Heart Disease.

BACKGROUND: The presence of third heart sounds in patients with valvular heart disease is often regarded as a sign of heart failure, but it may also depend on the type of valvular disease. METHODS: We assessed the prevalence of third heart sounds and the relation between third heart sounds and cardiac function in 1281 patients with six types of valvular heart disease. RESULTS: The prevalence of third heart sounds was higher in patients with mitral regurgitation (46 percent) or aortic regurgitation (28 percent) than in those with aortic stenosis (11 percent) or mitral stenosis (8 percent). The left ventricular ejection fraction was significantly lower (P less than 0.001) when a third heart sound was detected in patients with aortic stenosis (0.38, vs. 0.56 in those without third heart sounds) or mixed aortic valve disease (0.40 vs. 0.55). However, the ejection fraction was only slightly lower in patients with mitral regurgitation and third heart sounds (0.51 vs. 0.57, P = 0.03). The pulmonary-capillary wedge pressure was higher (P less than 0.001) when a third heart sound was detected in patients with aortic stenosis (18.6 mm Hg, vs. 12.1 mm Hg in those without third heart sounds). There was no association between the wedge pressure and third heart sounds in patients with mitral regurgitation. The prevalence of third heart sounds increased with the severity of mitral regurgitation. CONCLUSIONS: In patients with mitral regurgitation, third heart sounds are common but do not necessarily reflect left ventricular systolic dysfunction or increased filling pressure. In patients with aortic stenosis, third heart sounds are uncommon but usually indicate the presence of systolic dysfunction and elevated filling pressure.

Adult↗
PubMed1992

A comparison of angioplasty with medical therapy in the treatment of single-vessel coronary artery disease. Veterans Affairs ACME Investigators.

BACKGROUND: Despite the widespread use of percutaneous transluminal coronary angioplasty (PTCA), only a few prospective trials have assessed its efficacy. We compared the effects of PTCA with those of medical therapy on angina and exercise tolerance in patients with stable single-vessel coronary artery disease. METHODS: Patients with 70 to 99 percent stenosis of one epicardial coronary artery and with exercise-induced myocardial ischemia were randomly assigned either to undergo PTCA or to receive medical therapy and were evaluated monthly. The patients assigned to PTCA were urged to have repeat angioplasty if their symptoms suggested restenosis. After six months, all the patients had repeat exercise testing and coronary angiography. RESULTS: A total of 107 patients were randomly assigned to medical therapy and 105 to PTCA. PTCA was clinically successful in 80 of the 100 patients who actually had the procedure, with an initial reduction in mean percent stenosis from 76 to 36 percent. Two patients in the PTCA group required emergency coronary-artery bypass surgery. By six months after the procedure, 16 patients had had repeat PTCA. Myocardial infarction occurred in five patients assigned to PTCA and in three patients assigned to medical therapy. At six months 64 percent of the patients in the PTCA group (61 of 96) were free of angina, as compared with 46 percent of the medically treated patients (47 of 102; P less than 0.01). The patients in the PTCA group were able to increase their total duration of exercise more than the medical patients (2.1 vs. 0.5 minutes, P less than 0.0001) and were able to exercise longer without angina on treadmill testing (P less than 0.01). CONCLUSIONS: For patients with single-vessel coronary artery disease, PTCA offers earlier and more complete relief of angina than medical therapy and is associated with better performance on the exercise test. However, PTCA initially costs more than medical treatment and is associated with a higher frequency of complications.

Adrenergic beta-Antagonists↗
PubMed1992

Accelerated coronary artery stenosis at a site proximal to coronary angioplasty.

Rapid progression of coronary stenosis has been described in patients undergoing percutaneous transluminal coronary angioplasty (PTCA), typically resulting in symptomatic angina 3 to 30 months postprocedure. We report a case of accelerated coronary stenosis in the instrumented vessel resulting in angina 3 days post-PTCA.

Aged↗
PubMed1991

Left ventricular function in rheumatic mitral stenosis.

Haemodynamic factors contributing to clinical disability in patients with rheumatic mitral stenosis have been under discussion and investigation for decades. Prior to the development of left heart catheterization, a low cardiac output in the presence of little or no pulmonary hypertension was taken as evidence for a myocardial 'insufficiency'. With the use of left heart catheterization, it was possible to exclude the presence of coronary artery disease and to assess directly the size and function of the left ventricle. Such studies indicate a tendency toward low-normal left ventricular end-diastolic volumes and low-normal ejection fractions. Modest reductions in the ejection fraction may be due to: (1) a restriction or tethering of posterobasal myocardium by the scarred mitral apparatus, or (2) abnormal interventricular septal motion related to right ventricular overload and unequal filling of the two ventricles. These and other factors, such as limited LV distensibility and variable diastolic suction, may affect ventricular function in rheumatic mitral stenosis. Thus, left ventricular dysfunction can generally be explained without implicating a rheumatic myocardial factor.

Cineangiography↗
PubMed1990

Simplified method for estimating true aortic valve mean gradient from simultaneous left ventricular and peripheral arterial pressure recordings.

Estimation of the aortic valve gradient by simultaneous recording of left ventricular and peripheral arterial pressures is subject to error due to delay and modulation of the arterial pressure contour as it propagates from the ascending aorta. This error can be corrected by averaging the mean gradients derived from unaltered and temporally aligned simultaneous left ventricular-peripheral arterial pressure tracings. In 26 patients with aortic stenosis and simultaneous recordings of ascending aortic and femoral arterial pressure we compared this method with a simplified approach in which the peripheral arterial pressure is partially aligned by advancing it against the left ventricular pressure by 50% of the time delay of the simultaneously recorded upstrokes. Gradients measured this way predicted the true aortic valve gradients (left ventricular-ascending aortic) with a mean difference of +1.1 mm Hg (range = +10 to -5 mm Hg). We recommend use of this simplified method of correction because it predicts true aortic valve gradient equally well as the averaging technique (r = 0.977 vs. 0.979) and requires half the time and effort.

Aortic Valve↗
PubMed1990

Routine electrocardiograms after cardiac catheterization. Are they useful?

In order to assess the value of routine electrocardiograms after cardiac catheterization (ECGs), 150 consecutive patients undergoing diagnostic cardiac catheterization were studied prospectively. The physician performing each catheterization was asked to rate his or her clinical index of suspicion that the electrocardiogram would be changed as a result of events during the procedure. Clinical index of suspicion and electrocardiograms were then compared for their ability to predict outcomes. Urgent clinical events within 24 hours of cardiac catheterization were defined as (1) new intensive care unit admission; (2) myocardial infarction; (3) coronary artery bypass graft surgery; (4) percutaneous transluminal coronary angioplasty; or (5) death. Chi square analysis demonstrated that neither ECGs (x2 = 2.12, p greater than 0.1) nor clinical index of suspicion (x2 = 2.43, p greater than 0.1) was better than chance alone in predicting urgent clinical events. The addition of ECGs to positive clinical index of suspicion did not increase the ability to predict urgent clinical events (x2 = 2.38, p greater than 0.1). Both ECGs and clinical index of suspicion were found to be relatively insensitive tests (sensitivity = 29% for ECGs, 43% for clinical index of suspicion). While both tests demonstrated high specificity, (89% for ECGs, 79% for clinical index of suspicion), their predictive value was equally poor (21% for ECGs, 17% for clinical index of suspicion). The addition of ECGs to clinical index of suspicion marginally increased the sensitivity of both tests to 50%. We conclude that routine postcatheterization electrocardiograms are no better at predicting urgent clinical events than clinical observation during catheterization alone, and should be performed only when index of suspicion dictates.

Angioplasty, Balloon, Coronary↗
PubMed1989

Complications of cardiac catheterization and angiography in patients with valvular heart disease. VA Cooperative Study on Valvular Heart Disease.

Complications were surveyed prospectively in 2,029 catheterizations performed on 1,483 patients from the 13 centers participating in the VA Cooperative Study on Valvular Heart Disease. Complications were reported in 6.9% of 1,559 preoperative procedures of which 2.6% were major and 0.2% fatal. Clinical predictors of complications were hypertension and the precatheterization diagnosis of aortic stenosis. Nevertheless, patients with aortic stenosis successfully tolerated left ventriculography, which was routinely performed regardless of the magnitude of gradient. Procedural predictors of complication were brachial arteriotomy (vascular occlusion) and transseptal catheterization (tamponade). Among the 470 postoperative catheterizations performed solely for research purposes, there were six complications, of which five were bleeding events in patients taking warfarin. Transseptal catheterization was safer in postoperative patients with no cases of tamponade in 125 procedures.

Cardiac Catheterization↗
PubMed1989

Analysis of aortic valve gradients by transseptal technique: implications for noninvasive evaluation.

The peak instantaneous aortic valve gradient derived from Doppler echocardiography is commonly used to predict the severity of aortic stenosis. Peak instantaneous gradient should not be equated with the mean gradient or "peak to peak" gradient measured at cardiac catheterization. The primary purpose of this study is to assess the relationship between the aortic valve gradients, using a two-catheter transseptal technique in 102 patients with aortic stenosis, mixed aortic stenosis and regurgitation, and following aortic valve replacement. These cases were drawn from a series of 111 consecutive transseptal procedures for patients with isolated aortic valve disease. No major complications occurred, and the most common reason for technical failure was inability to engage the atrial septum in postoperative patients. Although the peak instantaneous gradient correlates well with the mean gradient in aortic stenosis (r = .94, P less than .001), mixed stenosis and regurgitation (r = .95, P less than .001), and after aortic valve replacement (r = .86, P less than .001), it systematically overestimates both the mean gradient and the peak to peak gradient. Neither the peak instantaneous nor the mean gradient correlates highly with aortic valve area in aortic stenosis (r = -.48, P less than .01 peak; r = -.58, P less than .001 mean gradient), mixed aortic stenosis and regurgitation (r = -.39, P NS peak; r = -.42, P NS mean gradient) or following aortic valve replacement (r = -.26, P NS peak; r = -.53, P less than .01 mean gradient). Systolic time intervals also were analyzed from the simultaneous left ventricular and ascending aortic pressure tracings.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic Valve↗
PubMed1988

Inadequacy of the Gorlin formula for predicting prosthetic valve area.

A total of 135 patients with normally functioning prosthetic aortic valves who were catheterized 6 months after placement of Hancock, modified Hancock or Bjork-Shiley prostheses were studied to determine the magnitude of error in Gorlin formula estimates of prosthetic aortic valve area. All patients were male, selected from 13 participating hospitals and routinely followed after valve replacement for 5 years. Hemodynamically determined Gorlin valve areas were compared with independently verified actual valve areas. Actual Hancock areas were measured from videotapes of valves exercised in a pulse duplicator flow model. Actual Bjork-Shiley areas were calculated directly from the valves' inner ring radius. Gorlin valve areas correlated poorly with actual valve areas (r = 0.39). The mean Gorlin formula error was 0.36 cm2 (standard deviation = 0.32). Gorlin areas overestimated actual areas by greater than 0.25 cm2 in 43 patients (32%) and underestimated actual areas by greater than 0.25 cm2 in 29 (21%). It was concluded that the Gorlin formula inaccurately predicts prosthetic valve area in the aortic position. Overreliance on this formula in assessing aortic stenosis could lead to errant clinical decisions.

Aortic Valve↗
PubMed1988

Six month postoperative hemodynamics of the Hancock heterograft and the Björk-Shiley prosthesis: results of a Veterans Administration cooperative prospective randomized trial.

In a Veterans Administration Cooperative Study involving 13 medical centers, 575 patients undergoing single valve replacement were prospectively randomized to receive either the standard Björk-Shiley prosthesis or the Hancock porcine heterograft (with a modified orifice for sizes 23 and smaller). The hemodynamic data in the 268 patients who underwent cardiac catheterization an average of 6 months (range 3 to 12) postoperatively are reported. Statistical analyses were performed on valve sizes 23, 25 and 27 in the aortic position, and 29, 31 and 33 in the mitral position. A wide variation was observed in mean pressure gradient and calculated orifice area in both valve types within all sizes in both the aortic and the mitral positions. In the aortic position, the Björk-Shiley prosthesis tended to have a lower pressure gradient and larger calculated orifice area than the Hancock heterograft, but the differences in gradient between the two valve types were significant only in the larger-sized valves. The difference in calculated area between the two valve types was not significant within each valve size. In the mitral position, there were no differences in gradient and calculated orifice area between the two types of prostheses. The postoperative cardiac index, regurgitant volume, pulmonary artery systolic and mean pressures, left ventricular end-diastolic pressure, left ventricular ejection fraction and left ventricular end-diastolic volume index did not differ in patients receiving the Björk-Shiley prosthesis from values in patients receiving the Hancock heterograft. Hence, the overall hemodynamic performance of both types of valves is remarkably similar. The choice between these two prostheses should, therefore, be governed not by the hemodynamic performance, but by other factors such as valve durability, risk of anticoagulation and incidence of valve-related complications.

Aortic Valve↗
PubMed1988

Documented symptomatic bradycardia and symptom relief in patients receiving permanent pacemakers: an evaluation of the joint ACC/AHA pacing guidelines.

Recently, emphasis has been placed on documenting symptomatic bradycardia (DSB) before pacemaker placement can be justified in some patients. This study was designed to judge whether DSB improved the likelihood of symptom relief after pacing in 93 patients who had symptoms prior to pacing. Patients with complete heart block (Group A) had excellent symptomatic relief with or without pre-pacemaker DSB (100% vs 94%, P = NS). Patients with other diagnoses (Group B) also had a high incidence of symptomatic relief after pacing, regardless of whether or not DSB was present pre-implant (28/30 (93%) vs 23/28 (82%) P = NS). When evaluated as a test to predict the response to pacing for Group B patients, spontaneously occurring symptomatic bradycardia was neither highly sensitive (55%) nor highly specific (71%). Moreover, while the ability of a positive test to predict resolution of symptoms after pacing was high (93%), the ability of a negative test to predict a poor outcome after pacing was low (18%). The absence of DSB should not rule out permanent pacing for symptomatic patients in any diagnostic group. Future pacing guidelines should be revised to offer additional detail regarding the influence of symptoms, extent of asymptomatic bradycardia, and results of provocative tests in determining which implants should be classified as definitely indicated.

Bradycardia↗
PubMed1985

Intraaortic balloon counterpulsation as a temporary support measure in decompensated critical aortic stenosis.

Intraaortic balloon counterpulsation was instituted in two adult patients whose condition was rapidly deteriorating because of critical decompensated valvular aortic stenosis. The acute hemodynamic effect of counterpulsation in these patients was compared with the effect of counterpulsation in three control patients with unstable angina and no aortic valve disease. Augmentation of aortic diastolic pressure was similar in both groups; however, in contrast to the patients with unstable angina, the patients with aortic stenosis had no decrease in left ventricular systolic pressure. Counterpulsation resulted in an increase in the transvalvular pressure gradient, which was associated with a slight increase in stroke volume. In both patients with aortic stenosis, the institution of counterpulsation resulted in marked clinical improvement, which facilitated successful valve replacement surgery. The benefit from counterpulsation in critically decompensated aortic stenosis appears to be derived almost entirely from augmentation of the diastolic coronary filling gradient. The improvement that results from counterpulsation suggests that ischemia is the major cause of decompensation.

Acute Disease↗
PubMed1979

Approaches to determination of left ventricular volume and ejection fraction by real-time two-dimensional echocardiography.

Left ventricular volumes and ejection fraction were derived from real time two-dimensional echocardiographic images (2 DE) and single plane (RAO) left ventricular cineangiograms in a series of 50 patients. Prospective application of a series of 6 alternate algorithms showed that a modified Simpson's rule approach using mitral and papillary muscle cross sections and an apical four chamber view provided the best 2 DE - angiographic correlations: for end-diastolic volume r = 0.82, SEE = 39 ml; for end-systolic volume r = 0.90, SEE = 29 ml and for ejection fraction r = 0.80, SEE = 0.09. The large SEE for volume determination indicates that further refinements are necessary to predict left ventricular volumes adequately; however, ejection fraction can be derived with an accuracy which allows practical clinical decisions in patients with satisfactory 2 DE images.

Cardiac Output↗
PubMed1979

Assessment of left ventricular ejection fraction and volumes by real-time, two-dimensional echocardiography. A comparison of cineangiographic and radionuclide techniques.

Five different algorithms for determining left ventricular (LV) ejection fraction (EF) and volumes from two-dimensional echocardiographic examination (TDE) were compared with standard methods for obtaining EF and volume from x-ray cineangiography (cine) and EF from radionuclide ventriculography (RVG) in 35 patients. Although all methods correlated positively, the degree of correlation varied with the algorithm used. For EF determination, TDE algorithms (especially those using multiple planes of section) were superior to unidimensional algorithms commonly used with M-mode echocardiography. The best algorithm (modified Simpson's rule) correlated well enough with cine EF (r = 0.78; SEE 0.097) and RVG EF (r = 0.75; SEE 0.087) to make clinically useful estimates. TDE volumes also correlated meaningfully with cine end-diastolic and end-systole volumes (r = 084; n = 70) but were associated with a large standard error of the estimate (43 ml) and offered less advantage over unidimensional volume estimates. Quantitative application of TDE appears to be a useful noninvasive method of evaluating LVEF, but is not as useful for estimating LV volumes.

Cineangiography↗
PubMed1978

Echocardiographic features of constrictive pericarditis.

The most characteristic echocardiographic features of 12 patients with constrictive pericarditis were compared with the findings in 10 normal volunteers. Left ventricular posterior wall (LVPW) "flatness" was quantified by measuring the diastolic change in distance from the crystal artifact to the LVPW endocardium. In 11 of 12 patients the net diastolic LVPW endocardial movement was less than 1 mm. In 10 normal volunteers LVPW endocardium moved posteriorly in diastole from 1.5 to 4 mm (mean 2.2 +/- 0.8). Abnormal septal motion was present in five of 12 patients with constriction. Pericardial thickness measured using standard damping techniques for both cnstriction and normal population did not distinguish the two groups. The "flattening" of the left ventricular endocardium as quantified above verifies earlier qualitative observations and was the most consistent finding in this series of patients with constrictive pericarditis.

Aged↗
PubMed1978

Radionuclide angiography for the evaluation of anthracycline therapy.

A sensitive and reproducible method to noninvasively monitor cardiac function in patients receiving anthracycline therapy is badly needed. The radionuclide ejection fraction (EFrn) appears to be a suitable technique to provide this hemodynamic information. This paper describes the technique for determining the left ventricular EFrn with the use of technetium99m-labeled rbcs, a gamma scintillation camera, and a dedicated computer. The comparison of radionuclide and radiographic contrast EFrn showed a high correlation ( r = 0.84) in 30 patients.

Angiography↗