Electrokyrnographic Studies in Insufficiency of

the Aortic and Pulionic Valves

By HOwARD E. HEYER, M.D., ERNEST POULOS, MI.D., AND JULIAN H. ACKER, \I.D.

The following paper (lescribes the results of electrokymographic studies performed on patientsvith l)roved aortic insufficiency. Alterations in the shape of the aortic ejection curve were foundand were accompanied by a diminution or absence of the incisura in the presence of insufficiencyof the aortic valves. Alterations in heart border motion of the ventricles Xwere also found. Thepossible dynamic factors responsible for these changes are discussed and the clinical al)plicationof the electrokymograph to aortic and pulmonic valvular disease is pointed out.

SINCE Corrigan's' description of thewater-hammer pulse of aortic insufficiencyin 1832, numerous studies of the altera-

tions in circulatory dynamics have been re-ported. In human beings, MacKenzie2 re-corded, by means of the polygraph, thecharacteristics of the peculiar pulse present inassociation with this disease. Feil,3 using opticalmethods of recording, has obtained recordingsof the arterial pulse wave in patients similarto those recorded by MacKenzie. By means ofthe roentgenkymograph, records of the bordermotion of the heart and great vessels have beenobtained in patients with aortic valvular dis-ease.5 The roentgenkymographic method hascertain inherent limitations, however, includingthe relative crudeness of the method of record-ing, and the difficulty of obtaining accuratemeasurements of the duration of various por-tions of the cardiac cycle for any given chamberor vessel. Although careful studies, utilizingoptical means of recording, have been madeof the pressure pulses in the ventricle and aortaof animals with artificially induced aortic in-sufficiency, such direct methods of recordinghave not been systematically recorded in thehuman patient.

Recently Henny, Boone, and Chamberlain'have introduced an accurate method of re-cording the border motion of the heart andgreat vessels by means of the electrokymo-graph. Tracings of the ventricular. border mo-tion recorded optically with this instrumenthave revealed a marked similarity to volume

From the Department of Internal Medicine, South-wcstern Medical College, Dallas, Texas.

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curves of the heart obtained in animals bymeans of the cardiometer. Records of bordermotion of the great vessels closely resemblethose obtained from intra-aortic pressure t rac-ings.

It is the purpose of the present study torecord the alterations from the normal in suchtracings, obtained by means of the elect roky-mograph, in a group of patients suffering frominsufficiency of the aortic and pulmonic valves.Evidence will be presented that tracings of thegreat vessels with insufficient valves reveal acharacteristic contour, and that the records ofventricular border movements in some patientsmay also show certain alterations. In addition,data indicative of alterations in the durationof certain portions of the cardiac cycle will bepresented. Finally, the ability to determinethe site or origin of a parasternal diastolic mur-mur (i.e., to ascertain whether insufficiency ofthe aortic or pulmonic valve exists) by meansof such electrokymographic tracings will be il-lustrated.

METHOD AND MATERIAL

The apparatus used consisted of the 931-A GECphoto-electLon multiplier tube and potentiomiieter(as described by Henny and co-workers6) Cam-blridge electrocardiograph (with sound an(1 p)ulserecorder.), and a fluoroscope with a tilting table.Eighty kilovolts and 4 milliamlperes were use(l, andthe electrocardiograph paper was run at 50 mimn. persecond. The. galvanometer string was standardizedso that 1 millivolt gave a 2-cm. deflection. Thecoarse adjustment of the potentiometer was set at5 while the setting of the fine adjustment was variedfor the individual. The tracings were recorded inthe posteroantelior, left anterior oblique, and right

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anterior oblique views. The 30 normal subjects weremedical students ranging from 19 to 30 years of age.Twenty-two patients with aortic insufficiency fromthe outpatient an(l ward services of Parkland Hos-pital were studied. The patients ianged from 14 to65 years of age. Of those with valvular disease, in6 the origin was rheumatic and in 16 syphilitic. Ineach patient with aortic disease, definite clinicalevi(lence of insufficiency was present, with charac-teristic blowing diastolic murmurs, frequently asso-ciated with evidence of alterations in the peripheralpulses, frequently with large pulse pressures, andwith signs of left ventricular enlargement in allpatients. Tracings of the aortic knob, ascendingaorta, p)ulmonary artery, pulmonary artery seg-ment, right and left auricles, and right and leftventricles were made.

RESULTS OF ELECTROKYMOGRAPHIC TRACINGS

Aortic Insufficiency

Ascending Aorta.. The tracings of the ascend-ing aorta were satisfactorily obtained in 15patients and are described in the followingparagraphs according to contour and to dura-tion of the ejection phase.The majority of the tracings showed a mod-

erately rapid, smooth, and continuous upswingof the first major upward deflection, followed bya rounded or somewhat flat peak, and ter-minating in a downward direction with thebeginning of the phase of reduced ejection (fig.1, C). The appearance of the early stages ofejection was, in many cases, not materiallydifferent from that of the normal tracing. How-ever, in four of the tracings the initial risinglimb was extremely thin and rose rapidly toa high summit (fig. 1, B).The most constant and striking finding noted

in these tracings was that there was markeddiminution (fig. 1, B) to complete absence(fig. 1, C) of the incisural notches in all in-stances. In most cases this vestigial incisuraoccurred farther down on the descending limbthan normally, as has been reported by othermethods of investigation in animals.9' 10 Inthose cases in which the incisura was markedlydiminished to absent, the descending limb ofthe aortic tracing revealed a rapid, smoothdescent to the base line, beginning with thephase of protodiastole (fig. 1, C). When therate of decline in aortic volume in diastolewas observed in various cases, it appeared that

the maximal decline occurred earlier in diastolein the phases of protodiastole and isometricrelaxation in the patients with valvular insuf-ficiency of the great vessels than in the normalsubjects. In the normal group, aortic volumeoften appeared to decline to a greater degreein later diastole than in those patients withaortic or pulmonic insufficiency.The phases studied were total, rapid, and

reduced ejection. Since the incisuras of theaortic tracings were diminished or absent, thislandmark for determining the end of systolewas often not available. Total ejection in theascending aorta, therefore, was determined bymeasuring the time consumed from the be-ginning of the rising limb of the tracing to thefirst vibration of the second sound. * Rapidejection was measured as the period from thebeginning of the rising limb to the summitof the tracing. Reduced ejection ws1as measuredfrom the summit to the second sound. It willbe seen from figure 2 that the duration of theperiod of total ejection was prolonged in amajority of the patients with aortic insuffi-ciency, Avhen compared with the normal sub-jects. Rapid and reduced ejection were notselectively increased, either or both being pro-longed in various instances.The above findings were true in patients

who had aortic insufficiency caused by eitherrheumatic fever or syphilis. There was no ap-parent close correlation with duration of thedisease process, age of the patient, pulse pres-

* We have found the heginning of the second soundusually to be coincident with the beginning of closureof the aortic valves, with the beginning of the phaseof protodiastole (the earliest phase of diastole), andthus with the end of ejection in the ascending aorta.Owing to ventricular asynchron.ism, in some patientsthe right ventricle may cease contraction first, andthus closure of the pulmonic valves would give riseto the earliest components of the second sound. Insuch cases the end of svstole in the left ventriclewould actually occur slightly later than the onset ofthe second sound would indicate. In such instances,however, measurements from the beginning of theejection limb to onset of the secon(l sound would givea' value which might, be slightly less than the trueduration of total ejection, but XN ould not give valuesthait were greater than the actual duration. Hencetotal ejection may be measurecl with a fairl- highd(egree of accuracy- by this method.

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A

Fi(;. 1.-Ilectrokvmogral)hic tracings of ascending aorta, with simultanieously recorded carotidpulse and sound tracing. Up)w~ard movement of ElKY tracing indicates an increase in volume, down-ward movements a decrease in volume. (In each tracing, the lowest curve is the ascending aortaEKY, the curve above it the carotid sphygmogram.)

A, Normal subject. There is a moderately fast upswing of the rising limb of EKY tracing, waitha well marked incisural notch (denoting closure of the aortic valves) followed b)v a large rel)ound wave,located high on the descending limh.

B, Patient with aortic insufficiency. Negro man, 45 years old, with evidence of marked left ventric-ular enlargement. Blood pressure 160/20, Corrigan type pulse. Loud, high pitched, blowing diastolicmurmur audible at left sternal border and at first and second right interspaces. Reactions to Kline,Wassermann and Alazzini tests positive for syphilis. Note sharp, rapid increase in volume in earlyejection phase, followed by a rapid decline in volume. There is a vestigial incisura located far down on

the descending limb of the tracing. The incisural notch of the carotid pulse, although diminishedin depth, is more easily distinguished than the incisura of the aorta in most Pulse waves.

C, Patient with aortic insufficiency.. Negro woman, 51 years old, with moderate left ventricularenlargement; vigorous, hyperactive carotid pulsations; moderately loud, high-pitchc(d blowingdiastolic murmur at left sternal border and at first and second right interspaces; rather harsh sys-tolic murmur at first and second right interspaces. Reactions to Kline and Wassermantii tests posi-tive. There is a rather gradual rise of the pulse wave, with a fairly rapid decline after the summit.There is no clearly distinguishable incisural notch, on either aortic EKY or carotid pulse, to denoteclosure of aortic valves. (In tracings 1, B and 1, C, as in subsequent tracings, the diaphragm of thesound recorder has been placed laterally, over the apex of the heart, rendering the diastolic aorticmurmur almost indistinguishable.)

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INSUFFICIENCY OF AORTIC AND PULMNONIC VALVES

sure, presence or absence of signs of congestivefailure, or with the ingestion of digitalis.

.4ortic Knob. The tracing of the aortic knobwas satisfactorily obtained in 20 patients andthese manifested definite changes from the nor-mal. As was the case in the ascending aorta,the incisural notches were remarkably di-minished (fig. 3, B) or entirely absent (fig. 3, C).The rising limb was not steep, as has been de-

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phases of rapid filling, diastasis, and auricularsystole (fig. 4, B and C). The phase of diastasiswas sometimes present provided the late wassufficiently slow. It should be noted that whilethe curves of the ascending aorta were diagnos-tic, those of the left ventricle were less so.Although these left ventricular tracings wereoften altered as described above, in some pa-tients their contour appeared normal.

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Duration of ejectionin patients with aorticinsufficiency = 0

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FIG. 2.-Electrokymographic tracings of ascending aorta. Duration of ejection phase in pa-

tients with aortic insufficiency (open circles) compared with that of normal subjects (solid blackcircles). The duration of ejection is longer in most patients with aortic insufficiency than in normalsubjects with comparal)le cycle lengths.

scribed above in several cases, but was as grad-ual as the normal. The peak was rounded butrarely flat as in some of the ascending aortatracings.

Ventricle. There were 16 left ventricular trac-ings which were susceptible to analysis. Thegeneral contour of the systolic portion of thetracing was not altered. However, the diastolicsection of the curves frequently showed aber-rations from the normal. The periods of iso-metric relaxation, rapid filling, and diastasisusually show well-defined changes in gradientin the electrokymographic tracings of the ven-

tricles of normal subjects (fig. 4, A). In placeof the normal contour of the ventricular curve,there was frequently a rather smooth con-

tinuous upswing with poor delineation of the

Carotid Artery. The tracings of the carotidartery, obtained by placing a cup against thevessel and utilizing a segment capsule withoptical recording, usually showed a contoursimilar to that of the aortie electrokymogram,with a diminished or absent incisura whichfrequently occurred low on the descending limbof the pulse wave. However, a point of some

interest was the finding that in a few patientswith aortic insufficiency incisural notches were

sometimes present on carotid tracings even

though they were completely absent on theelectrokymographic tracings of the aortic knob

(fig. 6, B). Although no explanation was ap-

parent to account for this persistence of the

carotid incisural notch under such condlitions,

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H. E1. H1E.\YER, 1E. POULOS, AND J. H. ACKER

1 2 1 2 1 2*,,1I.i~i.11m-A0j~i-_ss r__1, #., ,

FIG. 3.-Electrokvmographic tracings of aortic knob. (In each tracing, the lowest curve'is theaortic knob EKY, the curve above it the carotid sphygmogram.)

A, Normal subject with well marked incisura denoting aortic valve closure.B, Patient with aortic insufficiency; 58 year old woman. Blood pressure 140/62; marked left ven-

tricular enlargement with loud blowing diastolic murmur audible at first and second right inter-spaces and at left sternal border. Numerous previous arm and hip injections for syphilis; reactions toserologic tests at time of examination negative. There is a poorly marked vestigial incisura seen onIaortic knob EKY. The incisural notch is slightly better marked in the carotid pulse.

C, Patient with aortic insufficiency-; Negro man, age 47 years. Admitted with acute polyarthritisdiagnosedjas acute rheumatic fever; history of "leakage of heart" known for twenty years. Bloodpressure 180/80; diastolic blowing murmur at first and second right interspaces. Reaction to MIazzinitest negative. Descending limb of EKY shows marked and abrupt decline in aortic volume withpractically absent incisural notch. The greatest decline in aortic volume is seen to occur in earlydiastole. There is a well marked carotid incisura.

it would suggest that the aortic electrokymo-gram wvas a more reliable method of determin-ing alterations in the pulse wave contour thanwas the carotid artery tracing obtained by

these means. The periods of rapid ejection werevariable on the carotid artery records, and theircontour often differed considerably from thatof the aortic tracings.

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102INSUFFICI,'CMY OF AORTIC AND PULMONIC VALVES

1 2 1 2 1. 4 tt. ., 44

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FIG. 4. Electrokyrmographic tracings of left ventricle. Downward limb of EKY indicates a de-crease in volume accompanying systole, upward movement indicates an increase in volume in di-astole. (In each tracing, the lowest curve is the left ventricle EiKY, the curve above it the carotidsphygmogram.)

A, Normal subject. Arrow denotes sharp and well defined increase in volume in rapid-fillingphase of diastole, due to normal filling from auricle, followed by resting phase of diastasis and byterminal increase in ventricular volume probably due to auricular systole.

B, Patient with aortic insufficiency and previous congestive failure; Negro man, age 59 years.Moderate left ventricular enlargement, diastolic murmur audible at left sternal border and secondright interspace. Blood pressure 120/56. Reactions to Kline, Wassermann and Mazzini tests positive.Phases of rapid filling and diastasis are poorly delineated with a somewhat smooth, continuousupswing in diastole. Note well defined incisural notch of carotid pulse.

C, Patient with aortic insufficiency; Negro man, age 40 years. Marked left ventricular enlargement,hyperactive carotid pulsations, blood pressure 150/76. Loud, blowing diastolic murmur at left ster-nal border and upper right sternal margin. Wassermann reaction 4+. As in the previous patient,the rapid filling phase and phases of diastasis and auricular filling are poorly marked and replaced bya rather gentle upward gradient of filling of the ventricle.

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H. E. HEYER, E. POULOS, AND J. H. ACKIR1

Additional Findings.Pulmonary Insufficiency. In one patient

whose clinical diagnosis was tetralogy of Fal-

.1 2 1 2

a

murmur heard at the base of the heart andalong the left sternal border, with normal pulsepressure, and with no peripheral signs of aortic

1 .27

2

A

B

FIG. 5.-Electrokymograms of pulmonary artery. (In each tracing, the lowest curve is the pul-monary artery EKY, the curve above it the carotid sphygmogram.)A, Normal subject. Incisural notch, although normally located fairly far down on descending

limb, is well marked, indicating closure of pulmonic valves.B, Patient with congenital cyanotic heart disease. Clinical diagnosis: Tetralogy. of Fallot com-

plicated by pulmonary insufficiency. Cyanosis since infancy; patient frequently preferred squattingposition. Moderate clubbing of fingers. Heart globular, normal size; rough, very loud systolic mur-mur at left sternal border, transmitted widely. Moderately loud diastolic blowing murmur at secondleft interspace. Lung fields showed relative diminution of lung markings and angiocardiography re-vealed stenosis of pulmonary artery with evidence of poststenotic dilatation. (Subsequent Blalock-Taussig procedure performed, with marked improvement in cyanosis and well-being.) Note completeabsence of incisura on descending limb, with sharp and well defined incisura of carotid pulse. Theelectrokymographic tracings of the aorta in this patient (not shown) revealed a well defined incisuralnotch.

lot, angiocardiographic studies demonstrated astenosis of the pulmonary artery. The patientalso had a loud, well defined diastolic, blowing

insufficiency. Electrokymographic tracings ofthe pulmonary artery in this patient showedthe absence of an incisural notch (fig. 5, B)

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104INSUFFICIE\NCY OF AORTIC AND PULMONIC VALVE'ES

while the tracings obtained from the aortadefinitely exhibited these notches. Normal pul-monary artery tracings, as seen in figure 5, A,

Aortic Stenosis. In 2 patients there was (lefi-nite clinical evidence of aortic stenosis compli-cating the aortic insufficiency. In these two

1 2 AL C;0:~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~$F- ***0 ~ ~~ ~~~~~~~~~~~~ 1 l iM 1

A

B

FIG. 6.-Patients with aortic stenosis and aortic insufficiency. (In each tracing, the lowest curveis the ascending aorta EIKY, the curve above it the carotid sphVgmogram.)A, EKY of ascending aorta in 31 year old man with aortic stenosis. History of "inflammatory

rheumatism" at age 9 years. Marked cardiac enlargement; very loud harsh systolic murmur at firstright interspace transmitted into neck vessels, followed by blowing diastolic murmur in same area.After aln initial ejection phase of rapid increase in volume there is a well defined change in gradient(indicated by arrows) with more gradual increase in volume to the summit. The descending limbshows no definite incisural marking. Immediately following the larger pulse waves are smaller onesdue to premature ventricular contractions.

B, Patient with aortic stenosis and insufficiency-; 64 year old white woman. Acute rheumaticfever in early adult life, recent congestive failure. M\Iarked cardiac enlargement. Harsh systolicmurmur at first right interspace, transmitted into neck vessels; blowing diastolic murmur in samearea, also audible at left sternal margin. Separate harsh systolic and rumbling diastolic murmursat ipex. Reactions to serologic tests for syphilis negative. Note similar change in gradient of as-

cending ejection limb and l)oorly defined incisural notch of descenlding limb. In figure 6, B the in-cisural notch of carotid pulse is well defined.

show a definite incisural notch. There appearedto be no doubt, therefore, that the murmurnoted was due to insufficiency of the pulmonicrather than the aortic valves.

patients the rapid ejection period of the ascend-ing aorta was divided into two separate phases

an initial rapid upswing ending abruptly in amuch slower rise upwar(l (fig. 6, A and B).

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Tracings of the central arterial pulse, recordedoptically in patients with aortic stenosis, haveshown a strikingly similar contour.'-'

DIscussIoNThe electrokymograph has provided an easy

and accurate method of studying many aspectsof circulatory dynamics in patients. Many ofthese data are otherwise only obtainable bycomplicated procedures which are undesirableor involve some discomfort or hazard. Thus,although the registration of pressure pulsecurves from the aorta, via catheterization of aperipheral artery, has been found possible inhuman beings, it is a relatively dangerous pro-cedure.22

It should be realized that the electrokymo-gram provides information regarding the heartand great vessels through changes in volume,caused primarily by the movement of bloodthrough the chambers of the heart and thegreat vessels. The electrokymogram has beenshown to yield tracings closely resembling intra-aortic and intrapulmonic pressure curves ob-tained by the direct insertion of cannulas intothe great vessels in animals or by cardiac cathe-terization in human beings.7' ' Electrokymo-graphic tracings recorded from the ventricleshave been shown to resemble closely ventricu-lar volume curves provided by the cardiom-eter.7' 8 Although positional movements ofthe heart and great vessels interpose someartefacts in the tracings from both instruments,nevertheless the general resemblance to recordsobtained by more direct means is striking, andthe time relationships of the major events ofthe cardiac cycle are faithfully preserved.The most striking alteration in aortic trac-

ings obtained from patients with aortic insuf-ficiency was the abolition or marked diminutionin the incisural marking which normally ac-companies the closure of intact aortic valves.Although a close correlation between the esti-mated degree of valvular insufficiency and theextent of obliteration of incisural marking wasnot possible, in general the more severe theevidence of valvular incompetency, the morecompletely this normal landmark was obliter-ated. This Mwas accompanied by a rapid declinein aortic volume in the early phases of diastole.

The classic studies of Wiggers and his associ-ates9'-4 in animals, utilizing aortic pressurecurves, have shown similar findings in experi-mental aortic insufficiency in animals. Theirexperiments have shown that the early di-astolic decline in pressure increases significantlyin experimental aortic insufficiency, and thatthe abruptness of the pressure decline increaseswith the size of the leak. Furthermore, theseauthors have shown that with larger leaks aprogressively greater percentage of the regurgi-tated blood re-enters the ventricle earlier indiastole, in the protodiastolic phase. In thisconnection it should be pointed out that thepercentage of blood that regurgitates per beatvaries with the size of the leak, and estimatesbased on experimental data vary widely, rang-ing from an insignificant fraction to values ofover 50 per cent of the stroke volume.When the general contour of the aortic elec-

trokymographic curves is considered, it is prob-able that many factors influence their generalshape. In some instances the tracings revealeda sharp and abrupt discharge of blood in theearly phases of systole (as in fig. 1, B), with arather rapid decline in volume increase in latersystole. This rapid ejection of a large volume ofblood in early systole is due probably in part tothe presence of increased initial tension existingat the onset of systole within the ventricle inpatients with aortic insufficiency. However, asecond factor which probably explains the ra-pidity of ejection of blood in early systole, isthat ejection begins at a lower intraventricularpressure during systole, owing to the lowerdiastolic level of aortic pressure in mostcases.9' 10 In other instances (as in fig. 1, C)this early abrupt increase in volume was notnoted, and the curves rose more slowly and de-clined in a similar fashion. In this connectionit should be recognized that most of the pa-tients were studied in hospital or clinic practiceand revealed varying degrees of myocardial in-sufficiency, which probably influenced the veloc-ity and type of ejection that occurred. Anotherfactor which may determine the shape of suchcurves, and which Wiggers and MIaltby'0thought to be of great importance in determin-ing aortic pressure patterns, is the type ofventricular contraction exhibited by the ventri-

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cle. Thus, in milder degrees of aortic valvularincompetency, the heart contracted usually inan "after loaded" fashion, and the ventricularand aortic pressure curves mounted rapidly andto greatest height in early diastole. In largeratortic regurgitant leaks, however, the ventricu-lar pattern of response was of a "loaded" typewith a more gradual slope in ascent and descent,andwlithi the aortic pressure pulse strongly re-sembling the ventricular curves. This latterexplanation may be the fundamental cause ofthe variations seen in the aortic electrokymo-grams. llowever, the possibility of "positional"movements also influencing the shape of thesetracings cannot be excluded.When the data regarding the duration of

ejection are considered, although not finallyconclusive, they indicate that the period ofsystole in patients with aortic insufficiency isusually prolonged beyond that of normal sub-jects. This is probably due to the increasedvolume of blood which the ventricle must expel.The attendant increased initial tension of themuscle is also probably of great importance inthis connection. An increase in the duration ofsystole has been shown to accompany an in-creased initial intraventricular tension in ex-perimental studies in animals."5 Since the initialventricular tension is elevated in experimentalaortic insufficiency, a similar mechanism isprob-ably operative in prolonging the contractionphase in patients with such lesions. The possibleeffects of myocardial insufficiency in producingsuch a prolongation cannot be eliminated, how-ever.The most constant feature of the left ventric-

ular electrokymographic tracings was a tend-ency to smooth over or eliminate many of thephases of rapid volume change. Thus the rap-idly filling phase was not well marked in themajority of tracings of patients with aortic in-sufficiency. Similarly, even with slow rates thenormal plateau of diastasis and the increase inventricular volume due to auricular contractionwere often poorly marked or absent. Althoughsuch tracings are admittedly not diagnostic innature, they appear to be a deviation from thenormal pattern. While a sudden marked in-

crease in ventricular volume in early diastolemight have been anticipated in large leaks, thisfinding was not detectable in these tracings."Positional" movements at the apex of theheart are often marked early in diastole andthese may have obscured such a rapid increasein volume in some cases. However, it is moreprobable that the retention of residual blood ina dilated ventricle plus the early regurgitationof blood from the aorta has produced thesealterations. These factors would combine to fillthe ventricle to a considerable degree beforethe onset of rapid filling. In the case of achamber of greater volume, the increment of agiven amount of additional blood from theauricle would produce a smaller change in out-ward movement of the ventricular wall. Thereis reason to believe, from experimental wor k inanimals, that the existence of aortic insuffi-ciency, by filling the ventricle in the earliestphase of diastole, actually reduces the amountof blood which enters this chamber in the nor-mal rapid filling phase, which occurs somewhatlater.12 Hence the usual steep outward curveof movement normally seen in the rapid fillingphase would be considerably attenuated andits slope diminished, under these conditions.The same factors would tend to obliterate orobscure the normal plateau of diastasis andalso the terminal increase in volume due toauricular systole. This explanation appears tobe the most feasible one to explain the altera-tions produced in the ventricular electrokymo-gram.

In an individual in whom the origin of adiastolic murmur is in doubt, the electrokymo-gram may be of considerable help in determin-ing whether aortic or pulmonic valvular in-sufficiency exists. From the constancy withwhich variations in the electrokyymographictracings were obtained in patients with aorticinsufficiency, it is probable that they will be-come a laboratory aid of corroborative value inthe diagnosis of valvular insufficiency of thegreat vessels. No patient in the present groupwith definite signs of aortic insufficiency failedto show the characteristic alterations notedabove in the aortic electrokymogram. Since

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most of these patients manifested clinical signsof moderate to large regurgitant aortic leaks, itis possible that very slight degrees of aorticinsufficiency might fail to show such aberra-tions. It also appears that electrokymographictracings may be of aid in clarifying the diagnosisof aortic stenosis when systolic murmurs arefound at the base of the heart.

SUMMARY

1. Electrokymographic studies of the heartand great vessels were made in 22 patients withclinical signs of aortic insufficiency.

2. Variations from the normal were noted inall patients. These included: (a) A diminutionor absence of the normal aortic incisural mark-ings. This was a constant finding in all patients.(b) A rapid decline in volume in early diastole.(c) Alterations in the general shape and con-tour of the aortic tracings. (d) Prolongation ofthe duration of ejection (and hence systole) inmost patients, compared with normal subjects.(e) Variations in the normal ventricular fillingpattern of the left ventricle with a flatteningand decrease in the normal changes in gradientin many patients.

3. One patient with pulmonic insufficiencyrevealed abnormalities of the pulmonic andright ventricular electrokymograms which re-sembled those seen in association with aorticinsufficiency.

4. Two patients with aortic insufficiencycomplicated by aortic stenosis revealed definitealterations from the normal which are de-scribed.

5. The probable factors operative in causingthese changes in the electrokymogram, and thediagnostic value of these patterns in patientsare discussed.

REFERENCES

1CORRIGAN, D. J.: On permanent patency of themouth of the aorta, or inadequacy of the aorticvalves. Edinburgh M. J. 37: 225, 1832.

2 AMACKENZIE, J.: Diseases of the Heart, ed. 4.London Oxford University Press, 1925.

3 FEIL, H. S.: Subclavian pulse in aortic valve dis-ease. Am. Heart J. 6: 778, 1930.

4 KATZ, L. N., AND FEIL, H. S.: The transformation

of the central into the peripheral pulse inpatients with aortic stenosis. Am. Heart J.2: 12, 1926.

5 HIRSCH, J., AND GUBNER, R.: Application ofroentgenkymography to the study of normaland abnormal cardiac physiology. Am. HeartJ. 12: 413, 1936.

6 HENNYGEORGEC.,BOONE, BERT R., AND CHAM-BERLAIN, W. EDWARD: Electrokymiiograpl1)hv forrecording heart motion, imp)rove(l tyl)e. Am.J. Roentgenol. 57: 409, 1947.

7 BOO3NE, B. R., CHAMBERLAIN, W. l1DWARD, GILLICK, F. G., HENNY, G. C., AND OPPENHEIMElRM. J.: Interpreting the electrokymogranm ofheart and great vessel motion. Am. Heart J.34: 560, 1947.

8 LUISADA, A. A., FLEISCHNElR, F. (G., AND RAP-PAPORT, MI. B.: Fluorocardiography (eleetro-kymiography) II. Observations on normal sub-jects. Am. Heart J. 35: 348, 1948.

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HOWARD E. HEYER, ERNEST POULOS and JULIAN H. ACKERElectrokymographic Studies in Insufficiency of the Aortic and Pulmonic Valves

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