We used a pulsed Doppler technique to examine the flow velocity pattern in the right ventricular outflow tract in 33 adults. In the patients with normal pulmonary artery pressure (mean pressure < 20 mm Hg, 16 patients), ejection flow reached a peak level at midsystole (137 + 24 msec, mean + SD), producing a domelike contour of the flow velocity pattern during systole. In contrast, the flow velocity pattern in patients with pulmonary hypertension (mean pressure ¢ 20 mm Hg,17 patients) was demonstrated to accelerate rapidly and to reach a peak level sooner (97 + 20 msec, p < .01); in 10 of the pulmonary hypertensive patients a secondary slower rise in flow velocity was observed during a deceleration, resulting in the midsystolic notching. The time to peak flow (acceleration time, AcT) and right ventricular ejection time (RVET) were measured from the flow velocity pattern. Either AcT or AcT/RVET decreased with increase in mean pulmonary artery pressure, and a very high correlation (r = -.90) was found between AcT/RVET and log,0 (mean pulmonary artery pressure). The use of this technique permitted the noninvasive estimation of the pulmonary artery pressure. Circulation 68, No. 2, 302-309, 1983. NONINVASIVE evaluation of pulmonary hypertension has been an important clinical problem for many years. The presence of pulmonary hypertension has been assessed by abnormalities in heart sounds,' in electrocardiographic tracings, or in chest x-rays,2 but to date, the accurate measurement of the pulmonary artery pressure requires the use of cardiac catheterization procedures. The development of echocardiographic techniques has allowed the investigation of pulmonic valve motion,3 which represents some characteristic abnormalities associated with pulmonary hypertension, such as rapid opening slope in systole,j5 attenuation or absence of the "a" dip,' prolongation of the ratio of right ventricular preejection period (RPEP) to right ventricular ejection time (RVET),57 and midsystolic semiclosure of pulmonic valve.)6 A recent experimental study8 emphasized that these abnormalities of the pulmonic valve motion were determined by abnormal flow changes in the pulmonary artery. However, flow characteristics with regard to pulmonary artery pressure either in the pulmonary artery or in the right ventricular outflow tract have not been successfully studied in man. Our objectives were to study the blood flow characteristics in the right ventricular outflow tract in patients with pulmonary hypertension by a pulsed Doppler technique9-I and to develop an index that would permit quantitative evaluation of pulmonary hypertension by noninvasive methods. Materials and methodsPatient selection. Thirty-eight patients admitted for diagnostic catheterization were examined by a pulsed Doppler technique. Five patients were excluded in whom Doppler recordings of flow velocity in the right ventricular outflow tract were not satisfactorily obtained because of poor penetration of ultrasound through the chest wall. Doppler examination was perfor...

The ratio of pulmonary to systemic flow (Qp/Qs) was noninvasively evaluated by duplex Doppler echocardiography in 22 patients with atrial septal defects (ASDs). Right and left ventricular stroke volumes (RSV, LSV) were determined from the recordings of ejection blood flow velocity and diameter at the level of the pulmonary and aortic orifices in each ventricular outflow tract. The ratio RSV/LSV, determined by the duplex Doppler echocardiography, was compared with Qp/Qs by oximetry. The RSV/LSV for 10 normal subjects was 0.99 ± 0.05 (mean + SD), whereas the RSV/ LSV for patients with ASD, 2.26 ± 0.63, was significantly higher than that for normal subjects (p < .01). In patients with ASD, a fairly good correlation was found between RSV/LSV and Qp/Qs (r .92, p < .01; y = 1.1 lx -0.30), and this high correlation was found even in patients with complications such as pulmonary hypertension, mitral and tricuspid regurgitation, Eisenmenger complex, and ventricular septal defect. We also found that semilunar valve regurgitation modified the value of RSV/LSV in accordance with the degree of regurgitation. These findings indicate that, with a few limitations, the Doppler index RSV/LSV is clinically useful in the estimation of the magnitude of the shunt flow in patients with ASD and that the limitations could be overcome by additional Doppler examination.

An 8-year-old boy with scimitar syndrome, an accessory diaphragm and an absent right superior vena cava, underwent surgery on March 28, 1983. The scimitar vein was separated from an accessory diaphragm and cut just above the right diaphragm where the vein penetrated. The vein was re-implanted into the right lateral portion of the right atrium and a tunnel was made between the atrial septal defect created in the septum and the site of the implanted vein. The accessory diaphragm was not removed because of the lack of compression on the right lung. At cardiopulmonary bypass, venous cannulae were inserted into the persistent left superior vena cava and inferior vena cava. Because of the absence of the right superior vena cava, the right atrium was not fixed by both cavae so that there was difficulty in intracardiac maneuvers. The patient is doing well 32 months after this treatment.

DeVega, N. G.: La anuloplastia selectiva, regulabley permanente. Uta tecnica original para eltratamiento de la insuficiencia tricuspide. Rev. Esp. Cardiol. 25: 555-556, 1972. 3) Chalkley, H. W.: Method for the quantitative morphologic analysis of tissues.

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