during 24-hour electrocardiographic monitoring and exercise testing in patients withobstructive and non-obstructive hypertrophic cardiomyopathy . Circulation 1979 ;59 :866-75 .
DIASTOLIC ABNORMALITIES OF FLAIL MITRALLEAFLETS IN THE TWO DIMENSIONAL
ECHOCARDIOGRAM
Mintz et al.' provide significant and dramatic evidence of theability of the two dimensional echocardiogram to diagnose flailmitral leaflets. In their study loss of systolic mitral leafletcoaptation was the sole criterion for establishment of the di-agnosis. Although this criterion is essentially defining and themost direct, technical problems can occasionally obscure themitral leaflets during systole during maximal motion of theheart.
We have found that the diastolic appearance of the mitralvalve can also provide valuable information . Three patientswhose mitral leaflets were obscured in systole were prospec-tively diagnosed as possessing a flail anterior leaflet becauseof a commonly shared diastolic appearance . During the min-imal flow period of mid diastole, lack of chordal support to thefree edge of the mitral anterior leaflet was evidenced by adistinctive "sagging" appearance (Fig . 1) . This appearanceis not seen in leaflets with normal diastolic chordal support .There is also a characteristic motion of this untethered portionof the leaflet identifying a hinge point between supported andunsupported leaflet segments.
The high diagnostic sensitivity obtained by Mintz et al . intheir series may not be attained in all laboratories practicingthis technique-dependent procedure . This additional criterionin the less artifact-prone diastolic phase of the cardiac cyclemay be helpful .
Thomas G . Steffens, MAEdgar C. Schick, Jr., MDSection of CardiologyBoston University HospitalBoston, Massachusetts
Reference1 . MIMz Ga. Kotler MN. Parry Will, Spat SL . Statistical comparison of M mode and two
dimensional echocardlognphic diagnosis of flail mitral leaflets . Am J Cardlol 1980;45 :253-9 .
REPLY
We have seen this "sagging" of the leaflet not only during middiastole, but also during end-diastole as the mitral leafletbegins to close . The sign does not occur in all patients with flailmitral valve; in particular, we have never seen it in patients
902
FIGURE 1 . Two dimensional echocardlogam ; parasternal. long axle view obtained in middiastole. Arrow Indicates the sagging bee edge of the anterior mkral leaflet .
November 1980 The American Journal of CARDIOLOGY Volume 46
with a flail posterior leaflet . Furthermore, if diastasis does notoccur (for example, in patients with significant tachycardia),diastolic sagging may not occur . Other causes of mitral in-sufficiency can give a similar appearance to the anterior mitralleaflet during diastole: endocarditis (with a vegetation, butwithout flail leaflet), possibly rheumatic mitral valve diseaseand possibly mitral valve prolapse (because of the thickenedleaflet or localized chordal elongation) . This interesting ob-servation, like all proposed diagnostic criteria, requires sta-tistical analysis to determine its true significance.
Gary S. Mintz, MDLikoff Cardiovascular InstituteHahnemann Medical College and HospitalPhiladelphia, Pennsylvania
EFFECT OF HANDGRIP ON SYSTOLIC ANTERIORMOTION OF THE MURAL VALVE: AN
ECHOCARDIOGRAPHIC FINDING IN HYPERTROPHICOBSTRUCTIVE CARDIOMYOPATHY
To the seven echocardiographic features of hypertrophiccardiomyopathy described by Doi et al.,' one should add aneighth: the effect of handgrip on the systolic anterior motionof the mitral valve .
The isometric effort results in an important pressor re-sponse with elevation of afterload. 2 This, in turn, causes anattenuation or diminution of the systolic anterior motion inthe echocardiogram and a concomitant softening of the ac-companying murmur (Fig. 1). A similar maneuver performedduring cardiac catheterization results in a reduction of the leftventricular outflow gradient (Fig . 2) and its reappearancealmost instantaneously, as the handgrip is released (Fig. 3) .The three figures were obtained from three different patients .This response resembles that observed during squatting' andis, I believe, an additional important diagnostic sign that iseasily elicited and reproduced at the bedside or in the courseof invasive cardiac investigation .
R . J . VechtClinical Cardiovascular LaboratoryAcademic Surgical UnitSt. Mary's Hospital Medical SchoolLondon, England
References1 . Dol YL, McKenna WJ, Geleke J, Oakley CM, Goodwin JF . M mode echocardiography
In hypertrophic cardiomyopathy: diagnostic criteria and prediction of obstruction . AmJ Cardlol 1980;45 :6-14.
2. Yacht IN, Graham 0, Saver P. Plasma noradreneline concentrations during Isometricexercise . Br Hesrt J 1975 :40 :1216-20 .
3 . Nail M, Beck W, VogSIpwl I. Sekrln V. Atscunatory phenomena In hypertrophlcobstructive cardiomyopadhy . In: Hypemophlo Obstructive Cardlomyopalhy : CibaFoundation Study Group No. 37 . London : J & A Churchill, 1971 :77-102 .
REPLY
In hypertrophic cardiomyopathy the physiologic response toan increase in afterload induced pharmacologically or byisometric exercise is a decrease in left ventricular outflowgradient, a decrease in the duration and intensity of a systolicmurmur and, apparently, a reduction in systolic anteriormotion of the mitral valve . Patients who show true systolicanterior motion of the mitral valve usually have classic signsof hypertrophic cardiomyopathy with a left ventricular gra-dient and do not pose a diagnostic problem. A maneuver that
FIGU1ic 1(loptwo pawn). Above, the characteristicsystolic anterior motion (SAM) with a late systolic
a
mums. Below, after 35 setups of isometricand isthe
exercise(0 .3 1,91c.21 . the n1 rrv has aolante systolicn i ncr motion has been s es
dimensionThis also Illustrates
crease in lair ventricular mension at end-sys-tote .
FIGURE 2 (pawl 3). Pressure tracing . There is aresting gradient between the apex of the left ventricleand root of the ascending aorta . Shortly after the startof handgip (1), the aortic measure increases and thegadient is reduced.
FIGURE 3 (botlea panel). Pressure tracing. Lan, asmall testing gradient is evident. RIgM, at the end of 1 .5minutes of fandgip, there is no gradient. Both leftventricular and aortic pressures have increased. Theheart rate has increased from 66 to 93 beats/min . Asthe handgrip is stopped (1) there Is an immediate re-duction in both left ventricuar and aortic pressures. andafter a few beats the gradient reappears as the Murmurincreases in intensity.
LETTERS TO THE EDITOR
November 1980 The American Journal of CARDIOLOGY Volume 46
903
LETTERS TO THE EDITOR
removes one of the moat important of the echo abnormalitiesin hypertrophic cardiomyopathy would be diagnosticallyuseful only if it made it more specific . Systolic anterior motionof the mitral valve is seen in other conditions, but the responseto an induced increase in afterload may be similar to thatdescribed in hypertrophic cardiomyopathy .
William McKenna, MDYoshinori Doi, MDCelia Oakley MD, FRCP, FACCJohn Goodwin MD, FRCP, FACCRoyal Postgraduate Medical SchoolLondon, England
classification by M mode echocardiography . Am J candid 1980 :45 :861-71 .
FEVER IN AORTIC DISSECTION
Ruderman et al .' in their letter emphasize the occurrence andimportance of fever as a manifestation of dissecting aneurysmof the aorta. This relation, of course, has been documentedpreviously . 2. 3 In the patient presented by Ruderman et al ., ahistory of chest pain and abnormal chest X-ray findings ledto cardiac catheterization and aortography . However, evenin the absence of pain or an abnormal chest X-ray film, onemust still entertain the diagnosis of aortic dissection andmaintain a high index of suspicion when fever occurs in as-sociation with other manifestations of aortic dissection .
Case report: A 48 year old man had a severe flu-like syn-drome and was found to have a loud murmur of aortic in-competence. He was admitted to a referral hospital with afever of 39 .5 0 C and severe congestive heart failure . There wasno history of chest pain. Blood cultures were negative and hewas transferred to our institution when congestive heartfailure proved refractory to medical therapy . He underwentcardiac catheterization which demonstrated severe aorticinsufficiency. A supravalvular aortogram was performed butusual cineangiographic views failed to demonstrate dissection,focusing on the proximal ascending aorta and left ventricle .Seven days after catheterization, blood cultures remainednegative. Because of severe congestive failure, the patientunderwent operation. At operation, the ascending aorta wasfound to have dissected, was paper-thin and measured 10 cmin width. The aortic valve was resuspended and the ascendingaorta replaced with a 26 mm Dacrone graft . The patient'spostoperative course was entirely uncomplicated and he wasdischarged on the 7th postoperative day with normal hemo-dynamics and no diastolic murmur .Comment: In this patient, no chest pain was present and
no radiologic abnormalities of dissection were present. Anaortogram would have been diagnostic and outlined the ana-tomic defect. In a patient with negative blood cultures andaortic valve incompetence of recent onset, we believe an aor-togram is indicated to evaluate the possibility of aortic dis-section. We certainly agree with Ruderman et al . that cathe-terization should not be delayed by the presence of fever .
Grant V.S. Parr, MDJohn M. Field, MD, FACCDepartments of Surgery and MedicineThe Milton S. Hershey Medical CenterThe Pennsylvania State UniversityHershey, Pennsylvania
904 NDwmber 1980 The American Journal of CARDIOLOGY Volume 48
References1 . Ruclarman A, Mackmalals PA, Smith JW. Fever as a manifestation of dissecting aneu
rysm of aorta lletterl . Am J Cardlol 1979;44:581-2 .2 Mackowlak PA, Upecomb KM, Mills W, Smith JS. Dissecting aortic aneurysm mani-
fested as fever of unknown origin. JAM 1976 :236 :1725-27 .3 . Murray NW, Mean JJ, console A, Mdrualek VA . Fever with dissecting aneurysm of
the aorta . Am J Mad 1976;61 :140-4.
COMPLICATIONS OF INTRAAORTICBALLOON COUNTERPULSATION
Isner et al.' indicate a 36 percent rate of complications relatedto the use of the intraaortic balloon counterpulsation devicein 45 patients studied at necropsy . They further state that thenumber of complications has been underestimated untilnow .
The statement may be misleading, in that the authors donot include pertinent data to permit the true incidence ofcomplications to be assessed more accurately . They do notreport how the study group was selected from patients whounderwent the treatment, the total number of the latter or thenumber of patients who died but who did not undergo ne-cropsy. No adequate clinical data are included to indicate acause and effect relation between the complications and thedeath of the patients in most of the cases . Thus, an unfairopinion may be formed of the complications of the method,which has undoubtedly helped to keep alive patients whoprobably could not have been salvaged by conventional meansonly.
Spyridon D. Moulopoulos, MDDepartment of TherapeuticsAthens University School of MedicineAthens, Greece
Reference1 . laner JUL Cohan $R, Vkmani R, Lawrlrrnn W, Roberts WC. Complications of the in-
traaortic balloon counterpulaatlon device : clinical and morphologic observations In 45necropsy patients . Am J Cardiol 1980 ;45 :260-8 .
REPLY
Our paper concerned the frequency of complications observedin a necropsy group of patients who had had the intraaorticballoon inserted shortly before death . Among these necropsypatients, the percent who had complications from insertionof the balloon was surprisingly high. We have no informationon complications from this device in patients who died but didnot undergo autopsy. There are numerous reports describingvarious frequencies of complications of this device in patientswho are alive or have died and no autopsies have been done .Our presentation was not an epidemiologic type or study butsimply a study of necropsy patients. The message neverthelessis quite clear: among necropsy patients who have had the in-traaortic balloon device inserted shortly before death, thefrequency of complications is much higher than that predictedfrom purely clinical studies. Our study was not an attempt tocriticize the intraaortic balloon device but simply to point outthat it carries with it a relatively high frequency of compli-cations, some of which are important clinically and some ofwhich are not .
William C. Roberts, MD, FACCPathology BranchNational Heart, Lung, and Blood InstituteNational Institutes of HealthBethesda, Maryland
