[Two-dimensional and Doppler echocardiographic studies of the genesis of a high-pitched diastolic rumble in mitral stenosis: contribution of the deformed mitral orifice and eccentric mitral inflow jet].

To clarify the genesis of a high-pitched diastolic rumble in mitral stenosis, 51 patients with mitral stenosis were studied. They were subdivided into two groups based on the pitch of a rumble; six patients with a high-pitched rumble and 45 patients with an ordinary low-pitched rumble. Phonocardiography, and M-mode and two-dimensional (2-D) echocardiography were performed in all patients. Color and continuous wave Doppler echocardiography were performed in four patients with a high-pitched rumble and in 13 with a low-pitched rumble. Results obtained were as follows: 1. Points of the maximum intensity of a rumble: A low-pitched rumble was best heard at the apex in all patients. A high-pitched rumble was best heard at the mesoapical area, except in one patient who had an oval mitral orifice by 2-D echocardiography. 2. Correlation between the pitch of rumble and the shape of the mitral orifice: In five of the six patients with a high-pitched rumble, the mitral orifice had a tadpole-shaped deformity, in which commissural fusion and valvular thickening were more marked anterolaterally than posteromedially. Among 45 patients with oval, slit or pinhole-like valve orifices, only one had a high-pitched rumble. 3. Direction of the left ventricular (LV) inflow jet as observed by color Doppler echocardiography: On the short-axis view at the level of the papillary muscles, the inflow jet was directed toward the medial portion of the LV cavity in the patients with a high-pitched rumble. However, it was directed towards the central portion of the LV cavity in all patients with a low-pitched rumble. On the apical long-axis view, no distinct difference was detected in the direction of the LV inflow jet between the two groups. 4. Other findings: There were no significant differences between the two groups in the mitral orifice area, the peak velocity of LV inflow, fractional shortening of the LV, dimension of the left atrium, Wells' index and the degree of organic change in the subvalvular structures. These results suggest that the deformity of the mitral valve and resultant changes in the direction of the LV inflow jet may play an important role in the mechanism of producing a high-pitched diastolic rumble in mitral stenosis.

[Musical systolic murmur produced by oscillation of the systolic anterior motion of the mitral apparatus: relation to the genesis of Still's murmur].

The genesis of a musical systolic murmur produced by systolic anterior motion (SAM) of the mitral apparatus was investigated in four patients using phonocardiography and echocardiography. Two patients (Case 1 and 3) had hypertrophic cardiomyopathy (one, the obstructive type; the other, the nonobstructive type) and the remaining two (Case 2 and 4) had redundant chordae tendineae. 1. In every patient, regular oscillation of the SAM was observed, coinciding in time with the musical systolic murmur, which was simultaneously recorded. The fundamental frequency of the musical systolic murmur was recorded as integrally multiplied numbers of the SAM. Such regular oscillation was not observed in the echograms of other cardiac structures. In a patient with hypertrophic obstructive cardiomyopathy (Case 1), both the amplitude and oscillation of the SAM were increased by amyl nitrite inhalation, and were decreased by angiotensin II infusion. Correspondingly, the intensity of the musical murmur showed similar reaction. No findings suggestive of mitral valve prolapse or mitral regurgitation were found in any patients. Therefore, the oscillation of the SAM produced by blood ejected from the left ventricle was considered the source of the musical systolic murmur in these patients. 2. Two patients with redundant chordae tendineae had no clinical abnormalities except for chordal redundancy; therefore, the musical murmur in these cases was considered to be functional. Particularly, one of them was compatible in character with the so-called Still's murmur. In conclusion, the regular oscillation of the SAM may be the source of the musical systolic murmur, and they must be taken into consideration as part of the genesis of Still's murmur.

[Mitral regurgitation in mitral valve prolapse: its mechanisms and time course].

To clarify the mechanisms and time course of mitral regurgitation (MR) in mitral valve prolapse (MVP), the relationship between the timing of MR flow patterns on pulsed Doppler echocardiography and phase of mitral valve prolapse on two-dimensional echocardiography was investigated. 1. Thirty-seven patients with MVP were followed by pulsed Doppler echocardiography for one to six years with an average of 2.5 years. At the initial examination, the patients were classified in five subsets on the basis of the presence or timing of MR: 10 without MR, five with early systolic MR, one with mid-systolic MR, 15 with late systolic MR and six with pansystolic MR. During the follow-up period, the timing of MR did not change in 21 patients (three with no MR, five with early systolic MR, seven with late systolic MR and six with pansystolic MR). Various changes were observed in 16 patients, i.e., developments of late systolic MR from no MR in four, of pansystolic from no MR in three, from late systolic MR in five and from mid-systolic MR in one, and disappearing late systolic MR in three. 2. Mitral annular diameter and the prolapsing phase of 118 patients with MVP (44 without MR, eight with early systolic MR, 30 with late systolic MR and 36 with pansystolic MR) were examined by long-axis two-dimensional echocardiography. The mitral annular diameter in patients with early systolic MR was significantly less than that of other MR groups, and the diameter in patients with pansystolic MR was markedly increased. The timing of MR was determined according to the prolapsing phase and the grade of the prolapse and the systolic size of the mitral annulus. Six of the eight patients with early systolic MR first had early systolic prolapse of either mitral leaflet, and then the regurgitant gap of the mitral valve orifice was plugged by the prolapsing leaflet and/or the narrowed mitral annulus during mid-to-late systole. In 18 of the 30 patients with late systolic MR, the grade of prolapse of the mitral valve during mid-to-late systole was more severe, compared with that of early systole. The results of the present study indicated that the occurrence of MR in MVP is various in timing (early, mid-, late or pansystole) and shows various changes the during follow-up study, and that pulsed Doppler echocardiography allows phase analysis of MR in MVP.

[Correlations between the features of first heart sound and opening snap and the shape and motion of the anterior mitral leaflet in patients with mitral stenosis].

To evaluate the relationship between the motion pattern and degree of organic change of the anterior mitral leaflet (AML) and the features of the mitral component of the first heart sound (M1) or the opening snap (OS), 37 patients with mitral stenosis (MS) were studied by auscultation, phonocardiography and echocardiography. Based on the features of M1 and OS according to auscultation and phonocardiography, the patients were categorized as group I, 18 patients with loud and snappy M1 and OS; group II, 12 patients with snappy M1 but small and dull OS; and group III, seven patients with small and dull M1 and OS. Intensities of M1 and OS were calculated by the ratios of their amplitudes to the aortic component of the second heart sound on the high frequency phonocardiograms recorded at points of the maximum intensities, respectively. Echocardiographic parameters related to productions of M1 and OS were obtained from M-mode and two-dimensional echograms of the AML; they were amplitudes and velocities on closing and opening, M1 area defined as that between end-diastolic and systolic echoes, OS area between systolic and early diastolic echoes, the doming area between the trailing edge of an early diastolic echo and a line projected from the anterior annulus to the tip of the leaflet, and the degree of systolic ballooning. Results were as follows: 1. Significant differences in the area of the mitral valve orifice were found among three groups. The area was maximum in group II, minimum in group III and intermediate in group I. 2. In group I, the body of the AML was pliable, resulting in a ballooning into the left atrium in systole and a marked doming toward the left ventricle in early diastole. Various parameters related to the production of M1 and OS in group I were significantly increased as compared with those of the other two groups. 3. In group II, the body of the AML was not pliable in spite of mild organic changes in the valve. The degree of early diastolic doming was mild. Compared to group III, the intensity of M1 in group II was significantly larger, but no significant difference was observed in the parameters related to the production of M1 between the two groups.(ABSTRACT TRUNCATED AT 400 WORDS)

[Mitral component of the first heart sound in complete left bundle branch block: the mechanism of the decreased intensity].

To clarify the mechanism of the reduced intensity of the mitral component of the first heart sound (IM) in complete left bundle branch block (LBBB), electrocardiograms, phonocardiograms, apexcardiograms and mitral valve echograms of 12 patients with LBBB (LBBB group) and 13 normal subjects (normal group) were simultaneously recorded. The first derivative of the apexcardiogram was also studied. One of the 12 patients had an intermittent LBBB. There was no significant difference in the P-Q interval between the two groups. The following results were obtained: 1. In the LBBB group; 1) The intensity of the IM, expressed as a ratio of the amplitude of the IM to that of the aortic component of the second heart sound (IIA) on the apical phonocardiograms, was significantly reduced except in one patient who had a relatively short P-Q interval. 2) The timings of the onset of the upstroke of the apexcardiogram and mitral valve closure were significantly and equally delayed. 3) The amplitude of the mitral valve echogram at the onset of the upstroke of the apexcardiogram (end-diastolic amplitude of the mitral valve) was significantly decreased. The closing velocity of the mitral valve was also decreased. 4) The amplitude ratio (H2/H1) and the rate of rise (A) of the apexcardiogram at the onset of the IM were significantly decreased. 2. The intensity of the IM, H2/H1 and A of the apexcardiogram at the onset of the IM were compared for three cases with nearly equal end-diastolic mitral valve amplitudes in each group. The intensity of the IM was apparently reduced in the LBBB group, compared with that of the normal group, and its intensity correlated inversely with H2/H1 and A. These results indicate that the reduced intensity of the IM in LBBB is caused mainly by the decreased amplitude of the mitral valve excursion at the onset of left ventricular contraction. An additional cause is the decreased tension on the closed mitral valve resulting from the slow rate of left ventricular pressure rise at the onset of the IM.

[Mode of left ventricular diastolic filling in hypertrophic cardiomyopathy as studied by pulsed Doppler echocardiography and multigated blood pool scan].

The clinical significance of the mode of left ventricular (LV) diastolic filling in hypertrophic cardiomyopathy was studied by the LV inflow velocity patterns (LVIF) of pulsed Doppler echocardiography and LV early diastolic filling rates (V2) of radionuclide (RI) angiography. The relationship between the deceleration time (DT) obtained from LVIF and the V2 was evaluated in 34 patients with nonobstructive hypertrophic cardiomyopathy (HCM) and in nine with obstructive hypertrophic cardiomyopathy (HOCM), and the results were compared with those of 10 patients with dilated cardiomyopathy (DCM), of two with restrictive cardiomyopathy (RCM), and of 19 normal subjects. HCM was subdivided into the following groups according to V1-DT relationships: Group 1 with prolonged DT and decreased V1, Group 2 with normal or short DT and normal V1, and Group 3 with normal or short DT and decreased V1. There were significant negative correlations between V2 and DT in Groups 1 and 2 of HCM, normal and HOCM. However, there were significant positive correlations in Group 3 of HCM, DCM and RCM. Nearly all patients in Group 3 had decreased LV ejection fraction and % fractional shortening, distinct B-B' step formation of the mitral valve echogram, and huge A wave of the apexcardiogram. These findings suggested that the LV rapid filling interval gradually became shorter because the LV contraction is decreased as myocardial fibrosis develops in HCM, and that we must pay attention to the diagnosis of such abnormalities, similar to those of DCM or RCM.

[Apical mid-diastolic rumble in hypertrophic cardiomyopathy: a pulsed Doppler echocardiographic study].

To investigate the mechanism of an apical mid-diastolic rumble in hypertrophic cardiomyopathy (HCM), we recorded left ventricular (LV) inflow velocity patterns using pulsed Doppler echocardiography and apexcardiography for 10 HCM patients with rumble and 20 HCM patients without rumble. Controls consist of 17 normal subjects, three patients with complete atrioventricular block and two patients with artificial right ventricular pacemakers. The LV inflow velocity profiles were analyzed in terms of acceleration time (AT) and deceleration time (DT) of the rapid filling wave, and the ratio of peak velocity of the atrial contraction wave to that of the rapid filling wave (A/D ratio). The results were as follows: The apical mid-diastolic murmur in HCM had a crescendo-decrescendo character mainly of medium frequency, and increased in intensity after the inhalation of amyl nitrite. All patients with rumble had asymmetric septal hypertrophy and the five of these had LV outflow obstruction. In six of the 10 patients with rumble, mild mitral regurgitation was detected. In HCM with rumble, the AT tended to be shorter than that of HCM without rumble, but it was significantly longer than the AT of normal subjects. In HCM with rumble, the DT was significantly shorter than that of HCM without rumble, but it was significantly longer than the DT of normal subjects. There was no significant difference in the A/D ratio between the HCM with rumble and the normal subjects, but the A/H ratio of the apexcardiogram was significantly increased in HCM with rumble as compared with those of HCM without rumble and of the normal subjects. The LV dimension was significantly decreased in HCM with rumble as compared with those of HCM without rumble and the normal subjects. Peak negative VCF was significantly decreased in HCM with rumble as compared with that of HCM without rumble. But there was no significant difference in this parameter between HCM with rumble and the normal subjects. In simultaneous recordings of apical mid-diastolic rumble and LV inflow velocity patterns, the rumble appeared to start after the beginning of the diastolic rapid filling wave and to stop before or at the end of the diastolic rapid filling wave. In patients with complete atrioventricular block and with artificial right ventricular pacemakers, the apical mid-diastolic rumble appeared when the P wave was during the rapid filling phase of the left ventricle.(ABSTRACT TRUNCATED AT 400 WORDS)

[Genesis of protodiastolic extra heart sound in mitral stenosis: a phono-, apex-, echo- and cineangiographic study].

To clarify the genesis of a protodiastolic extra heart sound (S3') which was occasionally recorded at about the beginning of a diastolic rumble in mitral stenosis (MS), phono-, apex- and echocardiography were performed for 33 patients with MS, and left ventricular (LV) cineangiography was performed for eight of them. The patients were classified as S3'(+) and S3'(-) groups, according to whether they had S3'. Results were as follows: The S3' was synchronous with the rapid filling (RF) wave of the apexcardiogram (ACG). Its amplitude was proportional to the size of the RF wave. The RF wave was significantly sharper in the S3'(+) group as compared with that of the S3'(-) group. The S3' always appeared after onset of dispersion of dots in the velocity pattern of blood flow at the mitral valve orifice according to pulsed Doppler echocardiography. There was no significant difference between the S3'(+) and S3'(-) groups in the region of the mitral valve orifice according to two-dimensional echocardiography, and at the peak rate of change of the LV dimension during diastole as determined by M-mode echocardiography. The peak rate of change of the long-axis dimension of the LV during diastole as determined by cineangiography was significantly greater in the S3'(+) group than in the S3'(-) group. However, there was no significant difference between the two groups regarding the peak rate of change in the short-axis dimension of the LV during diastole as determined by cineangiography. The amplitude of the early diastolic dip of the interventricular septum (IVS) was significantly greater in the S3'(+) group as compared with that of the S3'(-) group. The amplitude of the S3' and the size of the RF wave correlated positively with the amplitude of the early diastolic dip of the IVS in pts with atrial fibrillation. Fractional shortening of the LV ascertained by M-mode echocardiography was significantly greater in the S3'(+) group than in the S3'(-) group. The end-systolic dimension of the LV tended to be less in the former than in the latter group. In conclusion, the S3' in MS was considered to be a third heart sound. Expansion along the long-axis of the LV and its sudden change in early diastole may account for the genesis of the S3', and this expansion may be accentuated by restoring force and active diastolic suction of the LV, and by velocity, direction and spread toward the cardiac apex of the stenotic mitral jet flow.

[Phono- and echocardiographic studies of the genesis of mitral valve prolapse in patients with funnel chest].

Two-dimensional echocardiograms (2-DE) and phonocardiograms (PCG) were used to clarify the genesis of mitral valve prolapse (MVP) and mitral regurgitation (MR) in 44 patients with funnel chest. These patients were categorized in three groups on the basis of the fronto-sagittal index (FSI) as determined from chest radiographs; 17 as mild, 15 as moderate and 12 as severe funnel chest. Their ages ranged from 5 to 65 years and averaged 24 years. MVP was diagnosed using the long-axis view of the 2-DE, and MR was diagnosed phonocardiographically including provocative test using angiotensin II. The results were as follows: In 44 patients with funnel chest, 20 (45%) had MVP and 15 (34%) had MR, respectively. The incidence of MVP increased directly in proportion to the severity of index, but the incidence of MR did not. In the short-axis view of the left ventricle at the level of the papillary muscles, there was more marked flattening of the interventricular septum than of the left ventricular posterior wall, resulting in deformity of the left ventricular geometry. A distortion index (DI) was used to quantify the degree of distortion of left ventricular shape, calculated as follows: DI = (R-r)/r, where R and r were radii of the curvatures of the interventricular septum and the left ventricular posterior wall, respectively. The DI in end-diastole (DId) and end-systole (DIs) increased in proportion to the severity of funnel chest. Patients were subdivided into four groups on the basis of DId. Incidence of MVP increased in proportion to the degree of distortion of the left ventricular shape. There was, however, no significant difference in the incidence of MR among the four groups. Patients were subdivided; one group of 13 under 14 years of age; another, 31 over 15 years old. The incidence was much higher in the latter than the former, but the incidence of MVP increased in proportion to the severity of funnel chest in both groups. MR was complicated by MR in nearly all cases in the latter group, but none had MR in the former. The DI of patients, whose FSI improved with surgery, apparently improved in addition to the disappearance and/or improvement of their MVP and MR. However, patients whose FSI did not improve with surgery showed little change in DI and persistence of MVP and/or MR.(ABSTRACT TRUNCATED AT 400 WORDS)

[Noninvasive studies of dynamic left ventricular outflow obstruction in patients with sigmoid septum].

In order to evaluate the clinical significance of the markedly protruding interventricular septum into the left ventricular (LV) cavity (sigmoid septum), we performed non-invasive studies including amyl nitrite (AN) inhalation in 21 patients (pts) with two-dimensional echocardiographic (2DE) documentations. LV outflow tract (LVOT) obstruction was determined by the presence at least three of the following findings at rest or during AN inhalation: 1) a loud apical ejection systolic murmur (ESM), 2) a midsystolic dip in the carotid pulse, 3) systolic anterior motion (SAM) of the mitral valve (MV) or chordae tendineae, and 4) systolic semiclosure of the aortic valve (AV). The 21 pts were subdivided into six pts (group I) with resting (two pts) or provocative (four) obstruction, and 15 pts (group II) without obstruction. Their ages ranged from 40 to 85 years with an average of 65. No pt had evidence of hypertrophic cardiomyopathy. Results were as follows: In five pts of group I a long ESM with a mid-systolic peak was recorded near the apex. After AN inhalation, this murmur was markedly intensified. On the contrary, all pts of group II had a short and early systolic murmur, which was not markedly intensified by AN. In contrast to group II, group I pts had a significantly smaller LV end-diastolic dimension, a smaller LVOT dimension, higher percent thickening of the LV posterior wall, higher fractional shortening and decreased aorto septal angle (the angle between the anterior aortic wall and the interventricular septum by 2DE). On 2DE, each pt of group I showed significant narrowing between the protruded septum and the hypercontractile LV posterior wall with the papillary muscle. Anteriorly shifted chordae tendineae noted as the SAM on the M-mode echocardiogram might also play an important role on the genesis of obstruction. The signs of LVOT obstruction at rest disappeared following oral administration of propranolol in two pts of group I. These observations suggested that LVOT obstruction might occur in some pts with sigmoid septum and the hypercontractile state, and that a systolic murmur observed in this condition should be differentiated from a functional murmur in the aged or a systolic murmur in hypertrophic obstructive cardiomyopathy.

[Left ventricular diastolic filling patterns in hypertrophic cardiomyopathy and myocardial infarction: studies by pulsed doppler echocardiography and multi-gated blood pool scans].

Relationship between various parameters of the left ventricular inflow velocity patterns by pulsed Doppler echocardiography and the early diastolic mean filling rate (V1) by multi-gated blood pool scans was evaluated. The materials consist of 26 patients with hypertrophic cardiomyopathy (HCM), 24 with old myocardial infarction (MI), seven with hypertensive heart disease (HHD), seven with dilated cardiomyopathy (DCM), seven with ischemic heart disease (IHD), and 16 normal subjects (N). The results were as follows: 1. Acceleration time (AT) and deceleration time (DT) were significantly prolonged in HCM (120 +/- 20 msec, 147 +/- 23 msec), MI (102 +/- 17 msec, 124 +/- 21 msec), HHD (105 +/- 11 msec, 141 +/- 17 msec) and IHD (111 +/- 16 msec, 122 +/- 20 msec) compared with those of normals (89 +/- 20 msec, 106 +/- 18 msec). 2. V1 was significantly decreased in HCM (1.14 +/- 0.28 sec-1), MI (0.68 +/- 0.24 sec-1), HHD (0.73 +/- 0.12 sec-1), DCM (0.67 +/- 0.30 sec-1) and IHD (1.03 +/- 0.29 sec-1) compared with that of normals (1.48 +/- 0.28 sec-1). 3. There were significant negative correlations between V1 and AT or DT in HCM, IHD with slightly impaired diastolic filling and normals. However, there were significant positive correlations between V1 and AT or DT in MI and DCM. These findings suggested that left ventricular diastolic filling is impaired in both HCM and MI, and that DT-V1 relationship is useful for differentiating HCM characterized by the "chamber stiffness" from MI characterized by the "myocardial stiffness".

[Mechanism of an early diastolic posterior motion of the interventricular septum in patients with mitral stenosis: with special reference to left ventricular inflow velocity pattern].

The mechanism of an early diastolic posterior motion of the interventricular septum (IVS) was investigated by means of M-mode, two-dimensional and pulsed Doppler echocardiographies in 53 patients with pure mitral stenosis (MS). Velocity patterns of the blood flow at the inflow tract of the left ventricle (LVIT) were classified into three types as previously reported (cf. Fig.3). The results obtained were as follows: The mitral valve orifice area (MVA) was significantly smaller in patients with type III of the LVIT flow velocity pattern than in patients with type I (p less than 0.001). An amplitude ("a") of the posterior IVS motion in systole (P1) was significantly diminished in type III (4.2 +/- 1.1 mm) than in type I (6.6 +/- 1.5 mm) (p less than 0.001). An amplitude ("b") of the posterior IVS motion in early diastole (P3) showed a significant increase in type III (7.5 +/- 1.2 mm) than in type I (5.2 +/- 1.5 mm) (p less than 0.001). Difference of the amplitude between P1 and P3 ("a-b") was significantly greater in type III (-3.4 +/- 1.1 mm) than in type I (1.4 +/- 0.9 mm) (p less than 0.0001). MVA was correlated statistically with "a" (r = 0.58, p less than 0.001), "b" (r = -0.38, p less than 0.01) and "a-b" (r = 0.80, p less than 0.0001). Deformity of the left ventricular cavity due to the flattened IVS in early diastole was observed in severe MS with an augmented septal P3 dip. A case of severe MS with type III velocity pattern and an augmented P3 dip showed type II velocity pattern and a decreased P3 dip after the attack of acute myocardial infarction. These findings suggested a close relationship between type III of the LVIT flow velocity pattern and the prominent septal P3 dip. The importance of diastolic suction of the left ventricle in producing an early diastolic posterior motion of IVS (P3) was discussed.

[Mode of production of the splitting of the second heart sound in post-extrasystolic beats].

The changes in left and right ventricular systolic time intervals (LV- and RVSTIs) and split interval of the second heart sound (IIA-IIP interval) associated with post-extrasystolic potentiation were studied in 48 patients including 37 without a significant intracardiac shunt or valvular regurgitation or pulmonary hypertension, 7 with aortic stenosis (AS) and 4 with hypertrophic obstructive cardiomyopathy (HOCM). In 19 out of 37 patients mentioned above, LV- and RVSTIs were measured from carotid pulse and pulmonary arterial pulse waves, and IIA-IIP interval of post-extrasystolic beat with a compensatory pause was compared to that of the preceding sinus beat. In the other 29 patients including AS and HOCM, LVSTI, total electromechanical systole of the right ventricle (Q-IIP) and IIA-IIP interval were compared. There was no significant difference in the coupling index [(compensatory pause-coupling interval)/preceding RR interval X 100(%)] among three groups. The following results were obtained: In all patients without HOCM, post-extrasystolic beats showed wider IIA-IIP interval than the control beats independent upon the diseased entity and severity of cardiac function. In pts with HOCM, a IIA-IIP interval was shortened in post-extrasystolic beats. A IIA-IIP interval at post-extrasystolic beats was prolonged in proportion to the augmentation of coupling index. However, this finding was no longer observed in cases with the coupling index of more than 80%. LVSTI: In patients without HOCM, almost no change or prolongation of left ventricular ejection time (LVET) and shortening of left ventricular preejection period (LPEP) were observed in post-extrasystolic beats. The degree of changes in LVET and LPEP was greater in patients with the abnormal left-sided PEP/ET than in patients with the normal PEP/ET. The degree of changes in LPEP was always greater than that in LVET, therefore, total electromechanical systole of the left ventricle (Q-IIA) was shortened in all patients. In HOCM, a marked prolongation of LVET and a shortening of LPEP were observed. The degree of changes in LVET was greater than that in LPEP, therefore, Q-IIA was prolonged in all patients. RVSTI: Prolongation of right ventricular ejection time (RVET) and shortening of right ventricular preejection period (RPEP) were observed in all patients in post-extrasystolic beats. The degree of changes in RVET and RPEP was increased in patients with the increased right-sided PEP/ET. The degree of changes in RVET was greater than or equal to that in LPEP, therefore, Q-IIP showed slight prolongation or no change.(ABSTRACT TRUNCATED AT 400 WORDS)