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The Normal Vibrocardiogram

Physiologic Variations and Relation to Cardiodynamic Events*


CLARENCE M . AGREss, M .D ., F .A .C .C ., Louis G . FIELDS, STANLEY WEGNER, MORRIS WILBLRNE, M .D .,
MARTIN D . SIIICKMAN, M .D . and ROBERT M . MULLER, M.D .

Los Angeles, California

ADVANCES IN electronic technics have stim- the "kinetocardiogram ." Much useful data are
ulated exploration into the use of precordial currently being reported by this group .
vibrations for cardiac diagnosis . The earliest Mounsey,d6 Rosa, 3 7 Hollis 39,4p and our group41 are
records were obtained by Marey and Potain' all currently investigating the precordial vibro-
in 1885 . For the next fifty-five years direct cardiogram using modern electronic methods .
methods of recording apex pulsations were used
METHODS AND TECHNICS
by American and European investigators . -14
The vibrations of the thoracic wall, acting on a The electronic technics developed in this laboratory
for recording vibrations from the precordium have
sensitive membrane, produced oscillations which
been described in a previous publication 41
were magnified, usually by optical means, and
Patients are studied in a quiet room as free from
transmitted to a screen or passing film . Dietrich
noise as possible . Ordinary noise and vibrations,
and Dunker, 74 using an esophageal balloon however, do not distort the records . The bed used in
probe, found differences in the time intervals of these studies consists of a four-inch foam latex mat-
vibrocardiographic waves in pathologic states . tress supported on a canvas cot . This arrangement
Neither they nor other investigators'' 10 have has been selected on the basis of its tendency to
further evaluated this observation . eliminate directly conducted external vibrations .
With the adaptation of the cathode ray oscillo- A warm room and the foam rubber pad afford
scope for recording precordial vibration's--1s comfort to the patient and avoid muscle tremor .
Records arc taken at least one hour after a meal and
and the development of a linear recording micro-
after fifteen minutes of relaxation . Records are
phone21 detailed study of precordial vibrations
usually taken at the end of expiration, unless it is de-
became feasible. Groups of investigators 22,2 s be-
sired to note the effect of respiration, because at this
gan to assess changes in cardiac function point in the respiratory cycle the heart is closest to
through analysis of the subaudiblc frequencies . the chest wall and damping is at a minimum.
Kountz, Gilson and Smith," who coined the The transducer, an Altec-Lansing capacitance
term "vibrocardiogram," observed that in ab- microphone (model number 165A), is suspended
normal hearts the first vibrational complex from a horizontal bar over the bed and placed 2 cm .
was lengthened . Dunn and Rahm,24 in a study from the left sternal border at the fourth intercostal
of abnormal hearts, noted that the damaged space . 'I he use of lubricating jelly at the point of
pickup maintains good contact with the chest wall
myocardium could not produce the same
and eliminates skin friction . The polarity of the
vibrational pattern in successive beats .
transducer was standardized so that an outward
The modern period of vibrocardiography now
movement of the chest produced an upward deflec-
has an increasing number of active investigators .
tion of the tracing .
In 1956, Groom and Boone 26 introduced the The recording equipment consists of a four channel
General Motors capacitance microphone (2-500 direct writer and a four channel F .M . tape recorder,
c .p .s .) which recorded chest vibrations with a permitting a simultaneous recording of vibrocardio-
26-26 and
high degree of fidelity . Harrison gram, phonocardiogram, electrocardiogram and
Eddleman et al .R 9 -' 6 have been working with pulse wave .

From the Cardiovascular Laboratory, General Medical Research Service, Veterans Administration Center, and the
Department of Medicine, University of California, Los Angeles, California . This work was supported by funds from
the U . S . Public Health Service, (Grant No. H-3960) and in part by the U . S . Air Force (Contract No . AF 41(657)-265)
monitored by the School of Aviation Medicine, USAF, Randolph Air Force Base, Texas .

22 THE AMERICAN JOURNAL OF CARDIOLOGY


Normal Vibrocardiogram 23

Fifth Interspace
2 cm. from Left
Tricuspid Xiphoid Sternal Border

Fin_ 1 . Vbrocardiographic tracings over six precordial positions in four normal young adults recorded simulta-
neously with phonocardiogram and electrocardiogram .

The individual vibrocardiographie waves have for present analysis . Therefore, we have selected
been designated in accordance with the conventional an area 2 to 3 cm . from the left sternal border
ballistocardiygraphic system of lettcring .ss in the fourth interspace and have found, as have
others,sr - 's that shifts of I to 2 cm . do not mate-
EXPERIMENTAL STUDIES rially alter the character of the tracings . The
records are reproducible from hour to hour (Fig .
HUMAN 2) and, under basal conditions as herein de-
Position of Transducer : The character of the scribed, from day to day .
vibrocardiogram changes markedly with the Relationship of the Vibrocardiogram to the Fleclro-
variation of the position of the transducer on cardiogram : It was desired to correlate the
the chest wall . Figure 1 illustrates the changes vibrocardiogram with the electrocardiogram for
at the classic auscultatory areas . These areas the purpose of identifying the vibrocardiographie
may, in the future, have important applications ; waves . Table i shows the data obtained from
however, the variations in pattern are too great this study . Only those points which demon-

JULY 1961

24 Agress et al .

r
FIG, 2 . Consecutive tracings over a period of two hours in normal dog, showing reproducilibity
of tracings . A, phonocardiogram . B, vibrocardiogram . C, electrocardiogTam .

strated consistent close time relationships are (Fig . 4) . However, the waves maintain their
shown . Diastolic waves (those occurring be- sharpness and character . During both respira-
tween the N wave of the vibrocardiogram and P tory phases the H-J, interval maintains a con-
wave of the electrocardiogram) had no consistent stant time relationship to the electrocardiogram
time relationship . Figure 3 shows the time while the Jr-J2 interval is lengthened 0 .005 second
ranges of each wave with reference to the during the inspiratory phase . With the Mueller
electrocardiogram . The mean values are in- test, slight degrees of splitting of the second
dicated in the table . sound can easily be detected by the vibro-
Effects of Respiration : During the phase of cardiogram (Fig . 5) . In the fir_t vibrational
inspiration, damping of the waves is noted complex the H-1, interval lengthened 0 .01 second

TABLE I
Relation of the Vibrocardiogram to the Electrocardiogram before and after Master Two Step Test

After Exercise (Sec .)


Electrocar- Control (sec .)
Vibrocar-
diogram
diogram Immediate 15 Minutes after
Reference
Deflection
Point
Mean Range Mean Range Mean Range

H R 0 .01 0 .00-0 .02 0 .01 0 .00-0 .02 0 .01 0 .00-0 .02


II S 0 .00 0 .01-0 .02 0 .00 0 .02 0 .02 0 .00 0 .02-0 .02
J, S 0 .02 0 .01-0 .04 0 .02 0 .00-0 .04 0 .02 0 .01-0 .04
Is S 0 .05 0 .04-0 .06 0 .05 0 .03 0 .07 0 .05 0 .04-0 .07
Js s 0 .08 0 .06-0 .10 0 .08 0 .06-0 .10 0 .08 0 .05-0 .10
LI T* 0 .07 0 06-0 .09 0 .08 0 .06 0,10 0 .08 0 .06-0 .10
MI T* 0 .09 0 .08-0 .11 0 .09 0 .07-0 .12 0 .09 0 .08-0 .11
I's T* 0 .10 0 .09-0 .10 0 .11 0 .10-0 .12 0 .10 0 .09-0 .10
M, T* 0 .12 0 .12-0 .12 0 .12 0 .08-0 .14 0 .11 0 .10-0 .12
N T* 0 .13 0 .12-0 .14 0 .13 0 .12-0 .13 0 .13 0 .12-0 .14
0 T* 0 .16 0 .15-0 .18 0 .16 0 .14-0 .18 0 .16 0 .15-0 .16
W T* 0 .16 0 .15-0 .18 0 .16 0 .14-0 .18 0_16 0 .15-0 .16

* Midpoint,

THE AMERICAN JOURNAL OF CARDIOLOGY


Normal Vibrocardiogram 25

o e
Fme . 3 . The timing of the vibrocardiogram with reference to the electrocardio-
gram . The width of the blocks shows the normal range-variation .

FIG . 4. Respiratory variations . A, phonocardiogram. B, vibrocardiogram.


C, electrocardiogram .

~ms 1961

26 Agress et al .

Fic . 5 . Respiratory variations- A, phonocardiogram . B, ibrocardiogram . C, elec-


trocardiogram .

Fm . 6 . Respiratory variations. A, phonocardiogram. B diogram. C, elec-


trocardiogram .

THE AMERICAN JOURNAL OF CARDIOLOGY


Normal Vibrocardiogram 27

Pte . 7 . Influence of pulse rule change on vibrocardiogram . A,phonocardiogram, B,vibrocardio-


gram . C, .
electrocardiogram

A B C
Flo . 8 . Influence of blood pressure change .

and the J,-J2 interval remained constant ; in the M I -1 .,, which shortened by approximately 0 .005
second sound complex, L,-L3 lengthened 0 .03 second . The morphology and amplitude of the
second . waves were not materially altered in any of the
During the Valsalva test (Fig . 6), a shortening experiments .
of the H-I and J-J interval by 0 .01 second oc- Effect of Change in Blood Pressure : As illus-
curred . The L-M complex was not altered . trated in Figure 8, there is a marked reduction
in amplitude of the vibrocardiogram when a
ANIMAL fall in blood pressure to a mean level of 35 mm .
Influence of Heart Rate Change : Figure 7 illus- Hg occurred . The 1,-J, interval lengthened
trates the pulse rate changes in a typical experi- 0 .01 second . A further reduction in pressure
ment on a dog before and after freezing the vagi . to 25 nun . Hg produced lengthening of .f,-J, by
Although the pulse rates varied, the blood 0 .02 second and shortening of 12-J2 by 0 .02
pressure remained unchanged . The only inter- second . An increase in mean pressure to 68
val of the vibrocardiogram to change was the mm . produced further shortening of I s -J, (0 .01

JULY 1961
28 Agress et al .

a 0

AS

SA s S,

PROAOCARDIOGRAM

Ln .Ai .

A T M

ruRACAPDI OOAAM T

A V
R 1

SCALE

-~
0.01 SEC .
RLORROLA PClOGAAM

IAPUmi,
P P
I

Flc . 9 . Events of the cardiac cycle.

'T'HE AMERICAN JObRNAI . OF CARDIOLOGY


Normal Vibrocardiogram 29

second) and a slight increase in amplitude . As found with our tracing shown in Figure 9 . G
pressure increased to 105 mm ., the 1,-J, interval follows atrial contraction and H-J, corresponds
returned to its control values, as did the ampli- to isometric ventricular contraction . J,-J 2 oc-
tude . The entire tracing returned to the pre- curs simultaneously with rapid ventricular ejec-
occlusion level when a pressure of 125 mm . Hg tion, J2 peaking near the summit of right ventric-
was reached . ular ejection . L occurs simultaneously with
Relationship of Vibrocardiogram to the Events of the onset of the second heart sound or approxi-
Cardiac Cycle : The individual vibrocardio- mately at the inscription of the dicrotic notch
graphic waves have been considered to represent (closure of the semilunar valve) . N marks
the mechanical events of the heart cycle .as the end of rapid ventricular filling . We have
Figure 9 shows the general relationship of the vi- found, as did Rosa," that L,-L 2 gives better dif-
brocardiogram to the events of the cardiac cycle ferentiation of the elements of the second heart
in man . This chart has been constructed from sound .
the most appropriate curves obtainable from the Vibrocardiograms (precordial ballistocardio-
literature . 41-17 Although this is a composite grams) appear to have certain advantages over
graph, an accuracy of 0 .005 second per scale total body hallistocardiograms . Honig et aL 5
division was made possible by using a sirnultane- compared ectromelic to normal subjects using a
ously inscribed electrocardiogram as the time suhfrequency pendulum and found that in
base . normal subjects, the hallistocardiogram was
A series of experiments on dogs, in which distorted "due to inertia, complex mass and
intracardiac pressure, vibrocardiograts and loading effects of limb impedance ." Both
electrocardiograms have been recorded si- Honig60 and HollisAO found eetromelic subjects
multaneously, casts doubt upon this relationship free of this impedance, and Hollis'0 found that
in animals . The H wave of the vibrocardiogram such records resembled his precordial force-thrust
occurs simultaneously with the onset of left ven- tracings . The problem of damping when the
tricular isometric contraction ; J2 marks the body must be closely coupled to the bed has
opening of the semilunar valves, and L, marks always been a vexing one when the concern is to
the closure of the semilunar valve . The period record head to foot motions . Since precordial
of diastole is characterized by small, low fre- hallistocardiograms represent principally re-
quency vibrations or a nearly baseline tracing . flections of anterior-posterior motions, the prob-
No consistent pattern in these deflections has yet lem of coupling does not appear to have the
been found . Thus, in animal studies the vibro- same significance . An inexpensive, simple and
cardiographic intervals correlate well with the readily available bed is more acceptable than
following periods : isometric contraction (H-J 2), costly and complex systems designed to cir-
ejection (J 2 -L), Systole (H-L) and diastole (L-H) . cumvent damping . Again, vibrocardiographic
These studies, which are now in progress, will be recording is independent of ordinary floor vibra-
the subject of another report . tions and room noises, which makes it a more
practical procedure . Due to the inherently high
COMMENTS energy level of the vibrocardiogram, normal
Many studies have been undertaken to background vibrations interfere with the record
correlate ballistocardiographic waves with the very little as compared to the ballistocardio-
events of the heart cycle . 95,'s's There is still gram or phonocardiogram . The precordial
much controversy, however, as to the origin transducer can easily be attached to the patient
and significance of these ballistic waves . Some in the sitting or semireclining position, which
of this disagreement arises from the fact that makes it possible to monitor the heart heat dur-
inherent delays between cardiac contraction and ing many procedures, including air or space
graphic inscription of these forces, due in part flights .
to equipment and recording technic, are im-
possible to eliminate .* Hollis'y'i0 has recorded SUMMARY
vibrocardiograms on twenty subjects during The variations in the vibrocardiogram pro-
cardiac catheterization . If the timing of the duced by alteration of recording surface and
waves is studied substantial agreement will be position of the transducer of the precordium are
* Improved equipment in use since this paper was shown . The physiologic effects of respiration,
written has eliminated muchof the error . (H- .T,) in ani- forced breathing, change in heart rate and
mal corresponds to isometric contraction . change in pulse pressure are noted in normal

lut .v 1961

30 Agress et a] .

human subjects and dogs . A study of the char- branche . Sa demonstration au movers de 1'en-
acteristics of vibrocardiographic waves indicates registrement des phenomenes mecaniques de
1'aetive-eardiaquc . Arch. mat coeur, 31 :250,
that these waves have reproducible character- 1938 .
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The timing of the vibrocardiographic waves and caber die Schwingungsvorgange bei der Herzaction .
their relation to the electrocardiogram and to Arch . Kreislaujforsch ., 5 : 239, 1939 .
the events of the cardiac cycle are shown . 15 . KOUNTZ, W . B., GILSON, A . S . and SMITH, J. R.
The use of the cathode ray for recording heart
Precordial ballistocardiographic tracings sound and vibrations . I . Studies on the normal
(vibrocardiograms) have certain advantages over heart . Am . Heart J ., 20 : 667, 1940.
total body ballistocardiograms . Their relative 16 . SMrra, J . R., GILSON, A. S . and KOUNTZ, W . B .
freedom from limb impedance and damping The use of the cathode ray for recording heart
sounds and vibrations . n, Studies on the muscular
permits records to be taken upon inexpensive, element of the first heart sound . Am . Heart J.,
simple beds . Tracings can be recorded in any 21 :17, 1941 .
position and are not distorted by ordinary 17. SMITH, J . R., EDwARDS, J. C . and KOUNTZ, W. B.
floor vibrations or room noises . These records The use of the cathode ray for recording heart
are less distorted by artefacts and, since the sounds and vibrations . III . Total cardiac vibra-
tions in 100 normal subjects . Am . Heart J., 21 :
time lag is reduced, they closely follow the acti- 228, 1941 .
vity of the heart . 18 . KouNTZ, W . B, and SMITH, J . R. Total cardiac
vibrations in aged hearts and in coronary disease .
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THE AMERICAN JOURNAL OF CARDIOLOGY



Normal Vibrocardiogram 31

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JULY 1961

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