Augmentation of atrial contribution to left ventricular inflow with aging as assessed by intracardiac Doppler flowmetry

The assessment of left ventricular diastolic function: guidance and recommendations from the British Society of Echocardiography

Impairment of left ventricular (LV) diastolic function is common amongst those with left heart disease and is associated with significant morbidity. Given that, in simple terms, the ventricle can only eject the volume with which it fills and that approximately one half of hospitalisations for heart failure (HF) are in those with normal/'preserved' left ventricular ejection fraction (HFpEF) (Bianco et al. in JACC Cardiovasc Imaging. 13:258-271, 2020. 10.1016/j.jcmg.2018.12.035), where abnormalities of ventricular filling are the cause of symptoms, it is clear that the assessment of left ventricular diastolic function (LVDF) is crucial for understanding global cardiac function and for identifying the wider effects of disease processes. Invasive methods of measuring LV relaxation and filling pressures are considered the gold-standard for investigating diastolic function. However, the high temporal resolution of trans-thoracic echocardiography (TTE) with widely validated and reproducible measures available at the patient's bedside and without the need for invasive procedures involving ionising radiation have established echocardiography as the primary imaging modality. The comprehensive assessment of LVDF is therefore a fundamental element of the standard TTE (Robinson et al. in Echo Res Pract7:G59-G93, 2020. 10.1530/ERP-20-0026). However, the echocardiographic assessment of diastolic function is complex. In the broadest and most basic terms, ventricular diastole comprises an early filling phase when blood is drawn, by suction, into the ventricle as it rapidly recoils and lengthens following the preceding systolic contraction and shortening. This is followed in late diastole by distension of the compliant LV when atrial contraction actively contributes to ventricular filling. When LVDF is normal, ventricular filling is achieved at low pressure both at rest and during exertion. However, this basic description merely summarises the complex physiology that enables the diastolic process and defines it according to the mechanical method by which the ventricles fill, overlooking the myocardial function, properties of chamber compliance and pressure differentials that determine the capacity for LV filling. Unlike ventricular systolic function where single parameters are utilised to define myocardial performance (LV ejection fraction (LVEF) and Global Longitudinal Strain (GLS)), the assessment of diastolic function relies on the interpretation of multiple myocardial and blood-flow velocity parameters, along with left atrial (LA) size and function, in order to diagnose the presence and degree of impairment. The echocardiographic assessment of diastolic function is therefore multifaceted and complex, requiring an algorithmic approach that incorporates parameters of myocardial relaxation/recoil, chamber compliance and function under variable loading conditions and the intra-cavity pressures under which these processes occur. This guideline outlines a structured approach to the assessment of diastolic function and includes recommendations for the assessment of LV relaxation and filling pressures. Non-routine echocardiographic measures are described alongside guidance for application in specific circumstances. Provocative methods for revealing increased filling pressure on exertion are described and novel and emerging modalities considered. For rapid access to the core recommendations of the diastolic guideline, a quick-reference guide (additional file 1) accompanies the main guideline document. This describes in very brief detail the diastolic investigation in each patient group and includes all algorithms and core reference tables.

Echocardiographic findings in apparently healthy Czechoslovakian wolfdogs

INTRODUCTION

To echocardiographically evaluate a large number of apparently healthy Czechoslovakian wolfdogs (CWDs) to identify possible subclinical cardiac abnormalities and to generate reference intervals.

ANIMALS

One-hundred and seventeen apparently healthy client-owned CWDs.

MATERIALS AND METHODS

Standard two-dimensional, M-mode, and Doppler echocardiographic measurements were obtained on non-sedated, manually restrained standing dogs. Animals with no relevant echocardiographic abnormalities were used to generate reference intervals. Echocardiographic variables were compared between males and females and between dogs with and without mitral regurgitation (MR).

RESULTS AND DISCUSSION

Among the 117 CWDs, 103 dogs were used to generate reference intervals. The 14 dogs with abnormalities had more than trivial MR (12 dogs), subaortic stenosis (one dog), and equivocal subaortic stenosis (one dog). The 44 males were heavier than 59 females (P<0.001) and had a larger maximum left atrial dimension (P=0.015), left ventricular internal dimension at end-diastole (P<0.001) and systole (P<0.001), and thicker interventricular septum thickness at end-diastole (P=0.016). A positive linear correlation was identified between bodyweight and aortic root and left atrial diameters and left ventricular dimensions and between age and aortic root and left atrial diameter and peak late transmitral flow velocity. A negative linear correlation was identified between age and peak early transmitral flow velocity and the ratio between peak early and late transmitral flow velocities. No differences in echocardiographic-derived cardiac dimensions were detected between healthy dogs and dogs with more than trivial MR.

CONCLUSIONS

In this population of CWDs, subclinical cardiac abnormalities were uncommon, and they were mainly classified as MR.

Dobutamine effects on systolic and diastolic left ventricular long-axis excursion and timing - significance for the interpretation of s' and e'

BACKGROUND

Dobutamine effects on the relationships of the peak velocity of left ventricular (LV) long-axis systolic motion (s') with systolic excursion (SExc), systolic duration (SDur) and heart rate, of LV long-axis early diastolic excursion (EDExc) with SExc, and of the peak velocity of LV long-axis early diastolic motion (e') with EDExc, early diastolic duration (EDDur) and isovolumic relaxation time (IVRT') are unknown.

METHODS

Two groups of adult subjects, one young and healthy (n = 10), and one with impaired LV long-axis function (n = 10), were studied, with the aim of identifying consistent findings for the two groups and for the septal and lateral walls. Dobutamine was infused at doses of 5 and 10 µg/kg/min. The relationships between tissue Doppler imaging (TDI) variables acquired before and during dobutamine infusion were analysed using mixed effect multivariate regression modelling.

RESULTS

In both groups, heart rate increased and SDur decreased during dobutamine infusion, and there were independent inverse correlations of SDur with heart rate and dobutamine dose. In contrast, there was no change in EDDur during dobutamine infusion, and no consistent changes in IVRT' independent of heart rate. s' was positively correlated with SExc and inversely correlated with SDur, and there were positive correlations between EDExc and SExc and between e' and EDExc.

CONCLUSION

Dobutamine increases s' due to effects on both systolic excursion and duration and it increases e' due to the associated increases in systolic and early diastolic excursion. A lack of effect on diastolic times does not support the presence of a lusitropic effect of dobutamine.

Left Ventricular Diastolic Dysfunction in Patients with Subclinical Hypothyroidism: A Single South Indian Tertiary Care Centre Study

Context Subclinical hypothyroidism (SCH) has been implicated in left ventricular diastolic dysfunction (LVDD).

Aims To study the association between SCH and LVDD.

Objectives To analyze the association between SCH and LVDD. To correlate the amount of LVDD with the serum thyroid-stimulating hormone (TSH) levels.

Settings and Design Single-center case–control study.

Methods and Material A case–control study was conducted between January 2020 and June 2021. A total of 36 cases of SCH were enrolled in the study and 36 age- and gender-matched euthyroid controls were included. Each individual's LV diastolic functioning was assessed by 2D echocardiography. LVDD was graded and compared between cases and controls.

Statistical Analysis Used The sample size was calculated to be 72 based on previous studies. Statistical analysis was performed using the IBM SPSS software version 20. A p-value of less than 0.05 was considered significant.

Results SCH was more commonly seen among females (75%) as compared with males (25%). Among cases, a majority of them (75%) had grade 1 SCH (i.e., TSH < 10 mU/L) and 25% of them had grade 2 SCH (i.e., TSH ≥ 10 mU/L). Among all the parameters assessed for LV diastolic function, the isovolumetric relaxation time and septal E/e' ratio was found to be significantly higher in cases than in controls and mitral E wave deceleration time (DT) significantly lower in cases. A statistically significant majority (72.2%) of the patients with SCH had some form of LVDD as compared with controls (30.5%)

Conclusions Walk-in outpatient department patients who opt for health check-up packages should be screened for SCH. SCH is statistically significantly associated with higher grades of LVDD as compared with age- and gender-matched euthyroid controls.

Association between cortisol and left ventricular diastolic dysfunction in patients with diabetes mellitus

Aims/Introduction

Diabetes mellitus is a major risk factor for the development of cardiovascular diseases. Heart failure with preserved ejection fraction is characterized by left ventricular diastolic dysfunction (LVDD). It has been reported that excess cortisol found in patients with Cushing's syndrome was associated with the development of LVDD. However, the relationship between cortisol concentration and LVDD in patients with diabetes mellitus has not been addressed.

Materials and Methods

We enrolled 109 patients with diabetes mellitus and 104 patients without diabetes mellitus who had undergone echocardiographic examination at Kyushu University Hospital, Fukuoka, Japan, between November 2016 and March 2019. Left ventricular function was evaluated and the ratio of early diastolic velocity from transmitral inflow to early diastolic velocity (E/eʹ) was used as an index of diastolic function. Plasma cortisol concentrations, glycemic control, lipid profiles, treatment with antidiabetic drugs and other clinical characteristics were evaluated, and their associations with E/eʹ were determined using univariate and multivariate analyses.

Results

Multivariate linear regression analysis showed that log E/eʹ was positively correlated with age (P = 0.017), log systolic blood pressure (P = 0.004) and cortisol (P = 0.037), and negatively correlated with estimated glomerular filtration rate (P = 0.016) and the use of sodium–glucose cotransporter 2 inhibitors (P = 0.042) in patients with diabetes mellitus. Multivariate analysis showed that cortisol was positively correlated with age (P = 0.016) and glycated hemoglobin (P = 0.011). There was no association between E/eʹ and cortisol in patients without diabetes mellitus.

Conclusions

Increased cortisol levels might increase the risk of developing LVDD in diabetes mellitus patients.

Evaluation of echocardiographic parameters in Japanese patients aged over 90 years at a single institution

PURPOSE

The number of patients aged over 90 years undergoing transthoracic echocardiography (TTE) has increased. Normal echocardiographic measurement values in healthy Japanese aged 20-79 years have been reported by Daimon et al., and in those aged 10-89 years by Okura et al. To date, no researchers have published normal values in healthy Japanese aged  over 90 years. To understand the echocardiographic characteristics and establish the normal range, we evaluated patients aged  over 90 years who had preserved left ventricular (LV) ejection fraction without cardiovascular disease.

METHOD

Enrolled in the study were consecutive patients aged  over 90 years who were examined by TTE at the Ultrasound Imaging Center at Nagasaki University Hospital, Japan, between September 2009 and May 2016. We selected patients with LV ejection fraction > 55%, and without cardiac, renal, or aortic disease.

RESULTS

Among a total of 956 patients, 73 patients (19 males, 54 females) were admitted. Compared with females, males had significantly higher values of aortic diameter at the sinus of Valsalva and LV diastolic diameter and systolic diameter (P < 0.01), significantly lower E wave velocities (P < 0.01) and left ventricle mass (P < 0.01), and lower values of relative wall thickness (P < 0.01). Compared with subjects in their 70s and 80s in the studies by Daimon and Okura, the E and A wave velocities were higher.

CONCLUSION

We established the normal range of TTE parameters in elderly patients who had LV ejection fraction > 55% without cardiac, renal, or aortic disease. Sex differences were present as well as a tendency towards age-related changes in LV geometry and diastolic function. Most of the patients aged  over 90 years had LV hypertrophy and potential diastolic dysfunction.

Echocardiographic reference ranges for normal cardiac Doppler data in healthy Turkish population: ECHO-DOP-TR Trial

AIM

Doppler echocardiography has become the standard imaging modality for diastolic function and provides pathophysiological insight into systolic and diastolic heart failure. In this study, we aimed to obtain normal echocardiographic Doppler parameters of healthy Turkish population.

METHODS

Among 31 collaborating institutions from all regions of Turkey, 1154 healthy volunteers were enrolled in this study. Predefined protocols were used for all participants during echocardiographic examination and The American Society of Echocardiography and European Association of Cardiovascular Imaging recommendations were used for echocardiographic Doppler measurements.

RESULTS

A total of 967 healthy participants were enrolled in this study after applying exclusion criteria. Echocardiographic examination was obtained from all subjects following predefined protocols. Mitral E wave velocity and E/A ratio were higher in females and decreased progressively in advancing ages. E wave deceleration time and A wave velocity were increased with aging. Assessment of tissue Doppler velocities showed that left ventricular lateral e', septal e', and septal s' were higher in younger subjects and in females. E/e' ratio was increased progressively with advancing decades. Right ventricular e' and s' were decreased but a' was increased with increasing age. Septal e' lower than 8 cm/s was 1.9% in the fifth decade and 13.7% in ages older than 50 years. The E/e' ratio greater than 15 (and also 13) was not found.

CONCLUSION

This study, for the first time, provides echocardiographic reference ranges for normal cardiac Doppler data in healthy Turkish population which will be useful in routine clinical practice as well as in future clinical trials.

Transient atrial mechanical dysfunction assessed in acute phase of embolic stroke of undetermined source

BACKGROUND AND PURPOSE

Paroxysmal atrial fibrillation (PAF) has been suggested as a major cause of embolic stroke of undetermined source (ESUS). Transient atrial mechanical dysfunction (stunning) frequently occurs after conversion of atrial fibrillation to sinus rhythm. The study aim was to determine if reversible atrial mechanical dysfunction in ESUS could help elucidate the mechanism of stroke.

METHODS

Eighty-five consecutive patients with acute ischemic stroke were enrolled according to the following inclusion criteria: [1] ≥55 years old; [2] normal sinus rhythm upon admission; [3] no apparent embolic source; and [4] transthoracic echocardiographic evaluation had been performed in both the early phase (<72 h) and late phase (>7 days) after stroke onset. There were 27 patients in the lacunar or atherothrombotic infarction group (controls), 22 in the PAF group, and 36 in the ESUS group. To determine atrial stunning, transmitral flow velocity profiles (Doppler peak E- [early diastolic] and A- [atrial systolic] waves) were obtained.

RESULTS

In the early phase, an E/A velocity ratio ≥ 1.0 was less common in the control group (1 patient, 3.7%) than in the PAF group (19 patients, 86.4%; p < 0.001) and ESUS group (10 patients, 27.8%; p < 0.05). In the late phase, the E/A ratio decreased to less than 1.0 in six patients (31.6%) who had PAF and in eight patients (80.0%) who had ESUS.

CONCLUSION

Transient atrial mechanical dysfunction could be a helpful finding for elucidating the stroke mechanism in patients with ESUS, and early echocardiographic assessment could improve its detection.

Echocardiographic evaluation of cardiac function in cynomolgus monkeys over a wide age range

Various cardiovascular diseases can be detected and diagnosed using echocardiography. The demand for cardiovascular system research using nonhuman primates is increasing, but echocardiographic references for nonhuman primates are limited. This report describes the first comparison of echocardiographic reference values in 247 normal cynomolgus monkeys (135 females, 112 males) over a wide age range. Echocardiography, electrocardiography, blood pressure and chest X-ray images were acquired under immobilization with intramuscular ketamine hydrochloride, then cardiac structure, function, and flow velocity were assessed. Cardiac hormone levels were also tested. We found that cardiac structures positively correlated with weight, that the size of these structures stabilized after reaching maturity and that cardiac output increased according to heart size. In contrast, fractional shortening of the left ventricle, ejection fraction and flow velocity showed no significant correlations with weight or age, and age and E wave correlated negatively. These findings appear sufficiently similar to those in humans to suggest that cynomolgus monkeys can serve as a suitable model of human cardiac disease. Our data should also prove useful for surveying cardiac dysfunction in monkeys.

Divergent Effects of Hemodialysis and Continuous Ambulatory Peritoneal Dialysis on Cardiac Diastolic Function

Objective

To investigate the effects of dialysis procedures on cardiac diastolic function.

Design

Comparative, nonrandomized matched pair study.

Setting

Nephrology and cardiology departments at a university hospital.

Patients

Thirty-four patients on hemodialysis (HD) (n = 17) and continuous ambulatory peritoneal dialysis (CAPD) (n = 17), matched by sex, age, duration of dialysis treatment, and presence/absence of diabetes.

Measurements

Cardiac function was estimated by means of M-mode, two-dimensional, and spectral Dopplerechocardiography, and results were statisticallyevalu-ated by means of univariate and multivariate analytical procedures.

Results

Although not statistically significant, trends towards differences between the two patient groups were detected for left ventricular mass (p = 0.083) and parameters of diastolic function (p = 0.079). These differences in left ventricular performance and diastolic function between HD and CAPD patients were also evident when calculating Spearman rank correlation coefficients. Left ventricular mass and diastolic function were closely correlated to each other in all dialysis patients. Moreover, by means of a multivariate analytical procedure (Hotelling T square test), diversities in diastolic function between the two patient groups could be clearly established (p = 0.037), with more impaired diastolic function in HD patients. In addition, cardiac performance was shown to depend to a certain extent on hemoglobin concentration.

Conclusion

Clear differences in diastolic function and cardiac performance were evident between CAPD and HD patients. From the data of our pilot study, it may be speculated whether decrease of left ventricular mass could be beneficial for the improvement of diastolic function and cardiac hemodynamics in dialysis patients.

Increased atrial contraction contribution to left ventricular filling during early septic shock

PURPOSE

To assess the atrial systolic function and the contribution of atrial contraction to left ventricular (LV) filling in septic shock patients as compared with healthy volunteers.

METHODS

Twenty-seven septic patients evaluated during first 48 h of ICU admission and compared with 27 healthy volunteers. Left atrial (LA) contraction contribution to LV filling was calculated as the active emptying atrial volume/LV end-diastolic volume. Atrial systolic function was evaluated with the atrial kinetic force [LAKE = 0.5 × blood density × LVV_active × (peak A velocity)²] and atrial ejection force [LASF = 0.5 × blood density × mitral annulus area × (peak A velocity)²].

RESULTS

LV ejection fraction was lower in septic patients than in control group: 51 ± 14%vs 60 ± 6% (p < 0.01). Contribution of LA contraction to LV preload was greater in septic patients than in normal subjects (26.7 ± 11.3% vs 15.9 ± 5.9%, p < 0.001), even if adjusted for age (0.49 ± 0.19 vs 0.35 ± 0.13, p = 0.004). LAKE and LASF were also significantly larger in septic patients than in normal subjects (21.8 ± 9.1 vs 7.3 ± 3 kdynes·cm, p < 0.001; 16.1 ± 11.7 vs 9.8 ± 4.3 kdynes, p = 0.048, respectively), and remained unchanged during the next 48 h.

CONCLUSION

In septic shock patients, LA systolic function increased and greatly contributed to support LV filling. These results highlight the role of preserving atrial contraction on the hemodynamic resuscitation in early septic shock.

Aging and the relationships between long-axis systolic and early diastolic excursion, isovolumic relaxation time and left ventricular length-Implications for the interpretation of aging effects on e`

BACKGROUND

Both the left ventricular (LV) long-axis peak early diastolic lengthening velocity (e`) and long-axis early diastolic excursion (EDExc) decrease with age, but the mechanisms underlying these decreases are not fully understood. The aim of this study was to investigate the relative contributions to aging-related decreases in e`and EDExc from LV long-axis systolic excursion (SExc), isovolumic relaxation time (IVRT, as a measure of the speed of relaxation) and LV end-diastolic length (LVEDL).

METHODS

The study group was 50 healthy adult subjects of ages 17-75 years with a normal LV ejection fraction. SExc, EDExc, e`and IVRT were measured from pulsed wave tissue Doppler signals acquired from the septal and lateral walls. Multivariate modelling was performed to identify independent predictors of EDExc and e`which were consistent for the septal and lateral walls.

RESULTS

EDExc decreased with age and the major determinant of EDExc was SExc, which also decreased with age. There was also a decrease of e`with age, and the major determinant of e`was EDExc. IVRT decreased with age and on univariate analysis was not only inversely correlated with EDExc and e`, but also with SExc. IVRT was only a minor contributor to models of EDExc which included SExc, and was an inconsistent contributor to models of e`which included EDExc. LVEDL decreased with age independent of sex and body size, and was positively correlated with SExc, EDExc and e`.

CONCLUSION

Major mechanisms underlying the decrease in e`seen during aging are the concomitant decreases in long-axis contraction and early diastolic excursion, which are in turn related in part to long-axis remodelling of the left ventricle. After adjusting for the extent of systolic and early diastolic excursion, slowing of relaxation, as reflected in prolongation of the IVRT, makes no more than a minor contribution to aging-related decreases in EDExc and e`.

Coenzyme Q10 Modulates Remodeling Possibly by Decreasing Angiotensin-Converting Enzyme in Patients with Acute Coronary Syndrome

The study aims to examine the effects of coenzyme Q10, (a bioenergetic antioxidant), on the indexes of left ventricular remodeling, oxidative damage, and angiotensin-converting enzyme (ACE) level after acute myocardial infarction (AMI) with left ventricular dysfunction. In a double blind, randomized, placebo-controlled, parallel group study (a retrospective analysis of an earlier trial) in 55 patients with left ventricular ejection fraction <50% after AMI, the effects of coenzyme Q10 (120 mg/day) or placebo were studied for 24 weeks. Two-dimensional echocardiography was performed at discharge, (approximately 5–10 days after admission) and at 6 months after AMI. The results revealed that wall thickness opposite the site of infarction decreased from (mean ± standard deviation (SD)) 12.2 ± 2.0 mm to 10.0 ± 1.8 mm with coenzyme Q10 compared with 12.8 ± 2.2 mm to 13.3 ± 2.3 mm with placebo (p < 0.01). Left ventricular mass changed from 236 ± 72 g to 213 ± 61 g with coenzyme Q10 compared with 230 ± 77 g to 255 ± 86 g with placebo (p < 0.01). Treatment with coenzyme Q10 also prevented alteration of sphericity index which is a ratio of the long and short axis of the left ventricle (which changed from 1.61 ± 0.28 to 1.63 ± 0.30 with coenzyme Q10 compared with 1.61 ± 0.32 to 1.41 ± 0.31 with placebo (p < 0.05)). Coenzyme Q10 also prevented alteration of the wall thickening abnormality at the infarct site, which changed from 9.4 ± 3.0 cm² to 9.1 ± 2.8 cm² compared with 10.1 ± 3.1 to 13.7 ± 4.2 cm² with placebo (p < 0.05). End diastolic and systolic volumes also showed significant reduction with coenzyme Q10 compared to placebo. The serum level of ACE showed significant decline in the coenzyme Q10 group compared to the control group. Treatment with coenzyme Q10 early after AMI causes attenuation of left ventricular remodeling and decreases the serum ACE level in patients with left ventricular dysfunction.

Impact of age on the association between cardiac high-energy phosphate metabolism and cardiac power in women

OBJECTIVE

Diminished cardiac high-energy phosphate metabolism (phosphocreatine-to-ATP (PCr:ATP) ratio) and cardiac power with age may play an important roles in development of cardiac dysfunction and heart failure. The study defines the impact of age on PCr:ATP ratio and cardiac power and their relationship.

METHODS

Thirty-five healthy women (young≤50 years, n=20; and old≥60 years, n=15) underwent cardiac MRI with ³¹P spectroscopy to assess PCr:ATP ratio and performed maximal graded cardiopulmonary exercise testing with simultaneous gas-exchange and central haemodynamic measurements. Peak cardiac power output, as the best measure of pumping capability and performance of the heart, was calculated as the product of peak exercise cardiac output and mean arterial blood pressure.

RESULTS

PCr:ATP ratio was significantly lower in old compared with young age group (1.92±0.48 vs 2.29±0.55, p=0.03), as were peak cardiac power output (3.35±0.73 vs 4.14±0.81W, p=0.01), diastolic function (ie, early-to-late diastolic filling ratio, 1.33±0.54 vs 3.07±1.84, p<0.01) and peak exercise oxygen consumption (1382.9±255.0 vs 1940.3±434.4 mL/min, p<0.01). Further analysis revealed that PCr:ATP ratio shows a significant positive relationship with early-to-late diastolic filling ratio (r=0.46, p=0.02), peak cardiac power output (r=0.44, p=0.02) and peak oxygen consumption (r=0.51, p=0.01).

CONCLUSIONS

High-energy phosphate metabolism and peak power of the heart decline with age. Significant positive relationship between PCr:ATP ratio, early-to-late diastolic filling ratio and peak cardiac power output suggests that cardiac high-energy phosphate metabolism may be an important determinant of cardiac function and performance.

Comparison of Left Ventricular Relaxation and Left Atrial Function in Patients With Heart Failure and Preserved Ejection Fraction Versus Patients With Systemic Hypertension and Healthy Subjects

Heart failure with preserved ejection fraction (HFpEF) may be characterized as impaired left ventricular (LV) relaxation and/or left atrial (LA) function, both of which are age and gender dependent. The aim of this study was to investigate LV relaxation and the LA function in HFpEF. A total of 71 HFpEF (mean age 73 years, 38 men) were studied. Late transmitral flow velocity (A), late mitral annular velocity (a'), and early mitral annular velocity (e') were measured and compared with age- and gender-matched normal control subjects (CTL; n = 71) and hypertensive patients (HT; n = 71). To clarify prognostic impact of the LA function, cardiac event-free survival was compared between high a' (≥7.9 cm/s, n = 36) and low a' (<7.9 cm/s, n = 35) groups. Cardiac event was defined as a composite of all-cause death and hospitalization due to recurrent congestive heart failure. In both HFpEF and HT groups, e' was significantly and similarly decreased compared with CTL group (p = 0.005). Although A was similar among the 3 groups, a' was significantly lower in HFpEF group than in HT and CTL groups (7.9 ± 2.1 vs 9.0 ± 1.9 vs 9.3 ± 1.96 cm/s, p <0.0001). HFpEF with low a' showed significantly lower cardiac event-free survival than HFpEF with high a' (log rank, p = 0.02). By multivariate Cox proportional analysis, low a' was the only independent predictor of cardiac events (hazard ratio 2.896, 95% confidence interval 1.004 to 8.355, p = 0.049). Both LV relaxation and LA function are impaired in HFpEF. Impaired LA function may be associated with worse prognosis in HFpEF.

Challenges for 'diastology': contributions from Japanese researchers

Diastology is a study to treat diastole of the heart. Transmitral flow and pulmonary venous flow velocities recorded by pulsed Doppler echocardiography provide more important information about left ventricular (LV) diastolic dysfunction [left atrial (LA)-LV coupling] than cardiac catheterization in clinical practice; however, these waveforms are influenced by loading conditions, particularly preload. The early diastolic mitral annular and LV wall motion indices measured by tissue Doppler echocardiography can evaluate LV relaxation abnormality and filling pressure by being relatively preload independent. In addition, the role of concomitant systolic longitudinal dysfunction is well characterized in asymptomatic patients and in patients with heart failure and preserved ejection fraction. Two-dimensional speckle tracking echocardiography is an angle-independent method, and has the potential to evaluate the contraction and relaxation abnormalities in the longitudinal, circumferential, and radial directions of the LV myocardium as well as LV torsion/untwisting and, moreover, deformation of the LA myocardium and large arterial wall. As a result, this new technique can facilitate the early detection of impaired LA-LV-arterial coupling in patients before occurrence of overt heart failure symptoms.

Right and Left Ventricular Diastolic Filling Parameters in Essential Hypertension

Right and left ventricular filling parameters were compared in 118 hypertensive patients (mean age, 54.4 ± 10.3 years) and 50 normotensive controls (mean age, 51.6 ± 8 years). Diastolic filling parameters were obtained by pulsed Doppler echocardiography at the tricuspid and mitral annular levels. The tricuspid early to late filling velocity ratios and the normalized peak filling rates were significantly reduced, while the atrial filling fraction was increased and tricuspid deceleration time was prolonged in hypertensive patients compared to controls. Right ventricular diastolic filling parameters correlated significantly with septal and posterior diastolic wall thickness, while left ventricular mass index correlated significantly with right ventricular diastolic filling parameters and right ventricular diastolic wall thickness in hypertensive subjects. Right ventricular diastolic wall thickness correlated significantly with the tricuspid early to late filling velocity ratio, tricuspid inflow total velocity-time integral, normalized peak filling rate, and peak filling fraction. Right ventricular diastolic filling parameters were closely related to left ventricular diastolic filling parameters in both groups. It was concluded that right ventricular filling parameters undergo a series of changes in essential hypertension and these parameters are closely related to left ventricular filling parameters and correlate with right ventricular wall thickness and left ventricular mass index.

Hyperinsulinemia and sulfonylurea use are independently associated with left ventricular diastolic dysfunction in patients with type 2 diabetes mellitus with suboptimal blood glucose control

OBJECTIVE

Although diabetes mellitus is associated with an increased risk of heart failure with preserved ejection fraction, the underlying mechanisms leading to left ventricular diastolic dysfunction (LVDD) remain poorly understood. The study was designed to assess the risk factors for LVDD in patients with type 2 diabetes mellitus.

RESEARCH DESIGN AND METHODS

The study cohort included 101 asymptomatic patients with type 2 diabetes mellitus without overt heart disease. Left ventricular diastolic function was estimated as the ratio of early diastolic velocity (E) from transmitral inflow to early diastolic velocity (e') of tissue Doppler at mitral annulus (E/e'). Parameters of glycemic control, plasma insulin concentration, treatment with antidiabetic drugs, lipid profile, and other clinical characteristics were evaluated, and their association with E/e' determined. Patients with New York Heart Association class >1, ejection fraction <50%, history of coronary artery disease, severe valvulopathy, chronic atrial fibrillation, or creatinine clearance <30 mL/min, as well as those receiving insulin treatment, were excluded.

RESULTS

Univariate analysis showed that E/e' was significantly correlated with age (p<0.001), sex (p<0.001), duration of diabetes (p=0.002), systolic blood pressure (p=0.017), pulse pressure (p=0.010), fasting insulin concentration (p=0.025), and sulfonylurea use (p<0.001). Multivariate linear regression analysis showed that log E/e' was significantly and positively correlated with log age (p=0.034), female sex (p=0.019), log fasting insulin concentration (p=0.010), and sulfonylurea use (p=0.027).

CONCLUSIONS

Hyperinsulinemia and sulfonylurea use may be important in the development of LVDD in patients with type 2 diabetes mellitus.

Echocardiographic reference ranges for normal cardiac Doppler data: results from the NORRE Study

AIMS

Reference values for Doppler parameters according to age and gender are recommended for the assessment of heart physiology, specifically for left ventricular (LV) diastolic function. In this study, we report normal reference ranges for Doppler parameters obtained in a large group of healthy volunteers. Echocardiographic data were acquired using state-of-the-art cardiac ultrasound equipment following Doppler acquisition and measurement protocols approved by the European Association of Cardiovascular Imaging.

METHODS AND RESULTS

A total of 449 (mean age: 45.8 ± 13.7 years) healthy volunteers (198 men and 251 women) were enrolled at the collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study. A comprehensive echocardiographic examination was obtained from all subjects following predefined protocols. The majority of the Doppler diastolic parameters (e', E/e') as well as right ventricle systolic s' wave velocity were similar in men and women. Left ventricle s' wave velocity was higher in men than in women. E wave and e' were higher in younger subjects and decreased progressively in the older ones. E/e' ratio increased with ageing. Septal e' <8 cm/s was present in 19.7% of the subjects in the 40-60 year group and in 55% of those in the ≥60 year group. However, the cut-off value of average E/e' or lateral E/e' remained <15 or 13, respectively, in the majority of patients.

CONCLUSION

The NORRE study provides the reference values for the most useful Doppler parameters in the evaluation of heart physiology. These data highlight the need of using age-specific reference values especially for the diagnosis of LV systolic and diastolic dysfunction and for the estimation of LV filling pressures.

Assessment of normal left atrial appendage anatomy and function over gender and ages by dynamic cardiac CT

OBJECTIVES

The aim of this study was to evaluate variations in anatomy and function according to age and gender using cardiac computed tomography (CT) in a large prospective cohort of healthy patients.

BACKGROUND

The left atrial appendage (LAA) is considered the most frequent site of intracardiac thrombus formation. However, variations in normal in vivo anatomy and function according to age and gender remain largely unknown.

METHODS

Three-dimensional (3D) cardiac reconstructions of the LAA were performed from CT scans of 193 consecutive patients. Parameters measured included LAA number of lobes, anatomical position of the LAA tip, angulation measured between the proximal and distal portions, minimum (iVolmin) and maximum (iVolmax) volumes indexed to body surface area (BSA), and ejection fraction (LAAEF). Relationship with age was assessed for each parameter.

RESULTS

We found that men had longer and wider LAAs. The iVolmin and iVolmax increased by 0.23 and 0.19 ml per decade, respectively, while LAAEF decreased by 2% per decade in both sexes.

CONCLUSIONS

Although LAA volumes increase, LAAEF decreases with age in both sexes.

KEY POINTS

• Variations in normal left atrial appendage in vivo anatomy and function remain largely unknown. • Cardiac CT is reliable for left atrial appendage volume measurements. • Although LAA volumes increase, LAAEF decreases with age in both sexes.

Left atrial appendage flow velocity and time from P-wave onset to tissue Doppler-derived A' predict atrial fibrillation recurrence after radiofrequency catheter ablation

BACKGROUND

Atrial fibrillation (AF) is associated with atrial remodeling. We investigate the abilities of preprocedural echocardiographic parameters reflecting atrial remodeling to predict AF recurrence after radiofrequency catheter ablation (RFCA) for paroxysmal AF (PAF).

METHODS

Preprocedural echocardiographic parameters were measured during sinus rhythm in 105 patients with PAF undergoing RFCA. Electrical remodeling was assessed by the time from the onset of the P-wave to the peak A'-wave on the tissue Doppler imaging (PA-TDI), functional remodeling was assessed by the left atrial appendage flow velocity (LAAFV), and structural remodeling was assessed by the left atrial volume index (LAVI). PA-TDI, LAAFV, and LAVI values were divided into tertiles, and their abilities to predict AF recurrence were assessed using Cox regression analysis.

RESULTS

AF recurrence occurred in 39/105 (37.1%) patients. After adjustment for confounders, the rate of AF recurrence was significantly higher in the highest tertile of PA-TDI compared with the lowest tertile (≥151.3 msec vs. <131.0 msec; hazard ratio [HR]: 2.477, 95% confidence interval [CI]: 1.031-5.950; P = 0.042), and in the lowest tertile of LAAFV compared with the highest tertile (<48.5 cm/sec vs. ≥64.9 cm/sec; HR: 2.680, 95% CI: 1.136-6.318; P = 0.024). The risk of AF recurrence was also higher in the highest tertile of LAVI (≥34.2 mL/m(2) ) compared with the lowest tertile, but this difference was not significant (HR: 2.146, 95% CI: 0.834-5.523; P = 0.113).

CONCLUSIONS

LAAFV (reflecting functional remodeling) and PA-TDI (reflecting electrical remodeling) are independent predictors of AF recurrence after RFCA for PAF.

Decreased aorto-septal angle may contribute to left ventricular diastolic dysfunction in healthy subjects

BACKGROUND

Left ventricular (LV) diastolic dysfunction is often observed in healthy older subjects without structural heart disease, although its exact mechanisms have not been established. A decrease in the aorto-septal angle (ASA), an alteration of LV shape due to aortic elongation, is also frequently seen in elderly subjects. The objective of this study was to evaluate whether it can contribute to LV diastolic dysfunction in healthy subjects.

METHODS

Echocardiography was performed in 77 healthy subjects (42 men, mean age 43.2 ± 13.8 years) to measure the ASA, early diastolic transmitral flow velocity (E), isovolumic relaxation time (IRT), and early diastolic mitral annular velocity (e'). The LV peak early diastolic longitudinal strain rate (GSRE ) was measured using a two-dimensional speckle tracking imaging technique.

RESULTS

ASA was significantly correlated with E (r = 0.54, p < 0.001), IRT (r = -0.41, p < 0.001), e' (r = 0.57, p < 0.001), and GSRE (r = 0.63, p < 0.001) and shown by stepwise multivariate analysis to be the strongest independent determinant of E, IRT, and GSRE , and one of the independent determinants of e'.

CONCLUSIONS

The alteration of LV shape associated with reduced ASA may be one of the causes of LV diastolic dysfunction independently of age in otherwise healthy subjects.

Effect of mitral inflow pattern on diagnosis of severe mitral regurgitation in patients with chronic organic mitral regurgitation

BACKGROUND

To determine sensitivity and specificity of E wave velocity in patients with severe chronic organic mitral regurgitation (MR) and normal left ventricular ejection fraction (EF) and to evaluate prevalence of A wave dominance in patients with severe MR.

METHODS

We compared 35 patients with quantified severe, chronic, quantified, organic MR due to flail/prolapsed leaflets who had reparative surgery with 35 age-matched control subjects.

EXCLUSION CRITERIA

EF < 60%, atrial fibrillation, and more than mild aortic regurgitation.

RESULTS

Mean [standard deviation (SD)] age [70 (8) years vs. 69 (8) years; p = 0.94] and mean (SD) EF [66% (6%) vs. 65% (4%); p = 0.43] were not different between the two groups. Mean (SD) E wave velocity was greater in case patients than control subjects [1.2 (0.3) m/sec vs. 0.7 (0.15) m/sec; p < 0.001]. However, E wave velocity of 1.2 m/sec had a sensitivity of only 57% [95% confidence interval (CI), 41-7 and a specificity of 100% (95% CI, 90-100%) in identifying severe MR. E wave velocity of 0.9 m/sec had a more optimal combined sensitivity (89%; 95% CI, 74-95%) and specificity (86%; 95% CI, 71-94%). A wave dominance was seen in 18% of case patients and 66% of control subjects (p < 0.001).

CONCLUSION

E wave velocity of 1.2 m/sec is specific not sensitive for severe organic MR; E wave velocity of 0.9 m/sec has better sensitivity and specificity. A wave dominance pattern alone cannot exclude patients with severe organic MR. Our findings highlight the importance of a comprehensive echocardiographic exam rather than relying on a few Doppler parameters in diagnosing MR.

Effects of short-term nutritional interventions on right ventricular function in healthy men

BACKGROUND

A physiological model of increased plasma nonesterified fatty acid (NEFA) levels result in myocardial triglyceride (TG) accumulation, which is related to cardiac dysfunction. A pathophysiological model of increased plasma NEFA levels result in hepatic steatosis, which has been linked to abnormal myocardial energy metabolism. Hepatic steatosis is accompanied by hepatic inflammation, reflected by plasma cholesteryl ester transfer protein (CETP) levels. The current study aimed to investigate effects of these models via different nutritional interventions on right ventricular (RV) function.

METHODS

Fifteen men (age 25.0±6.6 years) were included and underwent magnetic resonance imaging and spectroscopy in this prospective crossover intervention study. RV function, myocardial and hepatic TG content, and CETP levels were assessed on three occasions: after normal diet, very low-calorie diet (VLCD, physiological model) and high-fat high-energy (HFHE, pathophysiological model) diet (all 3-days diets, randomly ordered, washout phase at least 14 days).

RESULTS

VLCD induced a decrease in mean E deceleration by 27%. Myocardial TG content increased by 55%, whereas hepatic TG content decreased by 32%. Plasma CETP levels decreased by 14% (all P<0.05). HFHE diet induced a decrease in E/A by 19% (P<0.05). Myocardial TG content did not change, whereas hepatic TG content increased by 112% (P<0.01). Plasma CETP levels increased by 14% (P<0.05).

CONCLUSIONS

These findings show that RV diastolic function is impaired after short-term VLCD and HFHE diet in healthy men, respectively a physiological and a pathophysiological model of increased plasma NEFA levels. After short-term VLCD, myocardial lipotoxicity may be of importance in decreased RV diastolic function. RV diastolic dysfunction is accompanied by increased hepatic TG content and plasma CETP levels after short-term HFHE diet, suggesting that systemic inflammation reflecting local macrophage infiltration in the heart may be involved in RV dysfunction.

Early subclinical left-ventricular dysfunction in obese nonhypertensive children: a tissue Doppler imaging study

A direct effect of obesity on myocardial function has not been not well established. Our aim was to investigate the effect of body mass index (BMI) and homeostatic model assessment of insulin resistance (HOMA-IR) on left-ventricular (LV) myocardial function in normotensive overweight and obese children by tissue Doppler imaging (TDI). We calculated the mitral annular displacement index (DI) and myocardial performance index (MPI) using TDI indices of systolic and diastolic LV function. In this hospital-based, prospective cross-sectional study, we studied 60 obese (mean age 13.2 ± 2.0 years) and 50 normal children. Subjects were divided into three groups: group 1 (BMI < 25, n = 50, control), group 2 (BMI 25-29.9 kg/m(2), n = 30, overweight), and group 3 (BMI ≥ 30 kg/m(2), n = 30, morbidly obese). Standard echocardiography showed increased LV diameters and LV mass/index and preserved ejection fraction in obese children. By TDI, LV systolic and diastolic function showed that peak late myocardial velocity (Em = 15.4 ± 2 cm/s), peak early myocardial velocity (Am = 8.7 ± 1.3 cm/s), Em/Am ratio (1.8 ± 0.3), isovolumetric relaxation time (IVRT = 59.2 ± 8.2 ms), MPI (0.39 ± 0.03), and DI (25.5 ± 3.2 %) of the lateral mitral annulus in the obese subgroups were significantly different from those of control subjects (18.2 ± 1.2 cm/sn, 6.9 ± 0.6 cm/sn, 2.6 ± 0.2, 51.2 ± 9.6 ms, 0.34 ± 0.03, and 33.13 ± 5.0 %, respectively; p < 0.001). These structural and functional abnormalities were significantly related to BMI. There were positive correlations between HOMA-IR, septal MPI, and LV mass. DI and MPI data indicated impaired subclinical LV function in all grades of isolated obesity at a preclinical stage. Insulin resistance and BMI correlated significantly with indices of LV function.

Overweight causes left ventricular diastolic asynchrony and diastolic dysfunction: a study based on speckle tracking echocardiography in healthy subjects

BACKGROUND

Left ventricular (LV) diastolic dysfunction is often observed in healthy subjects and can be a cause of heart failure with preserved ejection fraction (EF). We aimed to investigate the role of LV diastolic asynchrony as a cause of diastolic dysfunction in healthy subjects.

METHODS

In 40 healthy subjects, two-dimensional speckle tracking imaging (2DSTI) was performed to measure the peak early diastolic longitudinal strain rates (Esr) of the apical, mid-ventricular, and basal segments of the septum and posterior wall. A mean value of the Esr of the 6 segments (mEsr) was calculated. The time from aortic valve closure to the Esr was measured for each segment, and the standard deviation (SDTEsr) was calculated. The peak global early diastolic strain rate (gEsr) was measured with a region of interest (ROI) on the whole LV myocardium. LV flow propagation velocity (FPV) was measured using conventional Doppler techniques.

RESULTS

SDTEsr was not correlated with age, but was significantly correlated with body mass index (BMI) (r = 0.41, p < 0.01). Although no significant correlation was observed between mEsr and FPV, gEsr and SDTEsr significantly correlated with FPV (r = 0.41, p < 0.01; r = -0.54, p < 0.001). As a result of the multiple regression analysis, SDTEsr was the single determinant of FPV.

CONCLUSIONS

Diastolic asynchrony, associated with overweight but not with aging, may contribute to diastolic dysfunction in healthy subjects.

Aging-associated cardiovascular changes and their relationship to heart failure

Aging represents a convergence of declining cardioprotective systems and increasing disease processes that is fertile ground for the development of heart failure. Fifty percent of all heart failure diagnoses and 90% of all heart failure deaths occur in individuals older than 70. This article discusses the microscopic and macroscopic changes in cardiovascular structure, function, protective systems, and disease associated with aging. In addition to outlining important clinical considerations and conditions in older persons, the link between normal aging and the elevated risk for development of stage B heart failure is explained and potential therapeutic pathways are highlighted.

Left atrial function: physiology, assessment, and clinical implications

The interest in the left atrium (LA) has resurged over the recent years. In the early 1980s, multiple studies were conducted to determine the normal values of LA size. Over the past decade, LA size as an imaging biomarker has been consistently shown to be a powerful predictor of outcomes, including major public health problems such as atrial fibrillation, heart failure, stroke, and death. More recently, functional assessment of the LA has been shown to be, at least as, if not more robust, a marker of cardiovascular outcomes. Current available data suggest that the combined evaluation of LA size and LA function will augment prognostication. The aim of this review is to provide a critical appraisal of current echocardiographic techniques for the assessment of LA function and the implications of such assessment for prediction and disease prevention.

Transthoracic tissue Doppler assessment of left atrial appendage contraction and relaxation: their changes with aging

AIM

We assessed left atrial appendage (LAA) function using transthoracic tissue Doppler echocardiography (TDE), and examined the influence of aging on LAA contraction and relaxation.

METHODS

The subjects were 45 consecutive patients with heart disease and 110 healthy individuals. LAA wall motion velocity (LAAWV) at the tip of the LAA was measured using transthoracic echocardiography (TTE) and/or transesophageal echocardiography (TEE).

RESULTS

We successfully recorded and measured LAAWV using TTE in 105 (95%) of the 110 healthy subjects. When angle correction was applied for the Doppler beam in TTE, LAAWV during contraction (LAAWVc) measured by TTE closely correlated with that measured by TEE (r = 0.97), and LAAWV during relaxation (LAAWVr) measured by TTE closely correlated with that measured by TEE (r = 0.95). LAAWVc and LAAWVr measured by TTE correlated significantly with the LAA flow velocities during LAA contraction and LAA relaxation measured by TEE (r = 0.64, P < 0.001; r = 0.53, P = 0.001). In healthy subjects, although LAAWVc remained unchanged with aging, LAAWVr significantly declined with aging (r =-0.48, P < 0.001) and had a significant negative correlation with left atrial dimension and a significant positive correlation with transmitral flow and annulus velocity during early diastole.

CONCLUSION

Transthoracic TDE can provide information on LAA function. LAA relaxation may be impaired with aging and may be accompanied by early diastolic left ventricular dysfunction and chronic overload to the left atrium.

Doppler echocardiography in diastology: 35 years of Japanese contribution to its advancement and utility

Echocardiography is one of the most important and clinically useful techniques in the assessment of diastolic function. Because of the prevalence of this technique, "diastology" and even the concept of diastolic heart failure have become familiar to researchers and physicians. We believe the first description by Kitabatake and his colleagues in 1982 of the use of Doppler technique to assess the transmitral flow velocity pattern in various cardiac diseases was the beginning of this development. Since then, a number of excellent works regarding echocardiographic assessment of diastolic function have emerged from Japan. Here, we review the Japanese contributions to the development of the use of Doppler echocardiography in diastology.

Can an elderly woman's heart be too strong? Increased mortality with high versus normal ejection fraction after an acute coronary syndrome. The Global Registry of Acute Coronary Events

BACKGROUND

Coronary artery disease is the leading cause of death in women. We sought to validate previous clinical experience in which we have observed that elderly women with a very high left ventricular ejection fraction (LVEF) are at increased risk of death compared with elderly women with acute coronary syndromes with a normal LVEF.

METHODS

Data from 5,127 elderly female patients (age >65 years) enrolled in the Global Registry of Acute Coronary Events were collected. Patients were divided into 3 groups based on their LVEF: group I had a low ejection fraction (<55%), group II had a normal ejection fraction (55%-65%), and group III had a high ejection fraction (>65%). χ² test and multiple logistic regression analysis were performed. The main outcome measures were death in-hospital and death, stroke, rehospitalization, and myocardial infarction at 6-month follow-up.

RESULTS

Hospital mortality was 12% in group I. Patients in group III were more likely to die in-hospital than those in group II (P = .003). Multivariable logistic regression showed that high ejection fraction was an independent predictor of hospital death (odds ratio [OR] 2.5, 95% CI [CI] 1.2-5.2, P = .01), 6-month death (OR 2.0, 95% CI 1.1-3.4, P = .01), and cardiac arrest/ventricular fibrillation (OR 2.5, 95% CI 1.2-5.0, P = .01) compared with the normal ejection fraction group.

CONCLUSIONS

Having a very high LVEF (> 65%) is associated with worse survival and higher rates of sudden cardiac death than an LVEF considered to be in the reference range.

Age- and gender-specific changes in the left ventricular relaxation: a Doppler echocardiographic study in healthy individuals

BACKGROUND

Although left ventricular diastolic function has been shown to deteriorate with advancing age, its gender-specific change is unknown. The aim of this study was to investigate age- and gender-specific changes in tissue Doppler-derived left ventricular diastolic index, E'.

METHODS AND RESULTS

A total of 1333 healthy individual without known heart disease or hypertension (mean age, 55 years; range, 10 to 89) were enrolled and studied. Peak early mitral annular velocity (E') and peak late mitral annular velocity (A') were recorded and measured. As an index of the left ventricular relaxation, E' was used. As an index of the left ventricular filling pressure, E/E' was calculated. Although systolic indices poorly correlated with age, diastolic indices correlated well with age. Among those aged 30 to 39 and 40 to 49 years, E' was significantly lower in males than in females. In subjects aged 50 to 59 and 60 to 69 years, E' was similar in both genders. Among those aged 70 to 79 and 80 to 89 years, E' was significantly lower in females than in males. Predictors of the lowest quartile of E' among subjects aged >50 years were age (P<0.0001; chi(2)=66.11; odds ratio, 1.08; 95% CI, 1.058 to 1.097) and female gender (P=0.002; chi(2)=9.23; odds ratio, 1.68; 95% CI, 1.202 to 2.343).

CONCLUSIONS

Age-related changes in diastolic indices were gender specific. In the elderly population, diastolic function deteriorated more significantly in the female gender than in the male gender. These results may explain the relatively higher incidence in elderly females among patients with diastolic heart failure and higher cardiovascular mortality in the female gender.

The age dependence of left ventricular filling efficiency

Echocardiography has emerged as the preferred modality by which diastolic function (DF) is assessed for clinical or research purposes. Echocardiographic indexes and parameters of DF such as E/A, DT, E/E', etc., deteriorate with advancing age. Whether the efficiency of filling depends on age is unknown. To better characterize the filling process and DF in causal rather than correlative terms, we have previously modeled diastole kinematically. We introduced and validated a dimensionless measure of DF termed the kinematic filling efficiency index (KFEI). In the present study, we determined the effect of aging on DF in terms of KFEI in 72 control subjects without cardiovascular-related diseases or pathologies. We also evaluated the age dependence of other conventional parameters of DF. In concordance with other noninvasive DF measures known to decrease with age, KFEI decreases and correlates very strongly with age (R2=0.80). Multivariate analysis showed that age is the single most important contributor to KFEI (p=0.003). We conclude that KFEI provides novel insight into DF impairment mechanisms because of aging. These results support the clinical value of KFEI and advance our ability to characterize DF in mechanistic and quantitative terms based on the efficiency of filling.

The functional role of longitudinal, circumferential, and radial myocardial deformation for regulating the early impairment of left ventricular contraction and relaxation in patients with cardiovascular risk factors: a study with two-dimensional strain imaging

BACKGROUND

Two-dimensional strain imaging allows rapid and accurate analysis of regional left ventricular (LV) systolic and diastolic mechanics in the longitudinal, radial, and circumferential directions. The aim of this study was to assess precisely the differences in early impairment of LV myocardial contraction and relaxation among the 3 directions in 70 patients with cardiovascular risk factors and preserved LV pump function.

METHODS

The patients were classified into 2 groups according to the ratio of early diastolic to atrial systolic velocity (E/A) of transmitral flow: E/A > or = 1 (n = 35, 57 +/- 6.8 years) or E/A < 1 (n = 35, 60 +/- 4.9 years). The longitudinal strain and strain rate curves were determined in apical 2- and 4-chamber views, and radial and circumferential strain and strain rate curves and LV torsion curve were determined in the parasternal short-axis views.

RESULTS

The mean peak systolic longitudinal strain and strain rate were lower, whereas the mean peak systolic circumferential strain and strain rate were greater in the E/A < 1 group. There were no significant differences in the mean peak systolic radial strain and strain rate between the 2 groups. The mean peak early diastolic longitudinal strain rate was markedly lower in the E/A < 1 group. The mean peak LV strain rates during atrial systole in all 3 directions were greater in the E/A < 1 group. The mean peak LV systolic longitudinal strain and longitudinal strain rate during atrial systole were independent predictors related to E/A in all patients. There were no significant differences in torsion and torsional and untwisting rates between the 2 groups.

CONCLUSION

LV myocardial contraction and relaxation were first impaired in the longitudinal direction among the 3 directions in subclinical patients with cardiovascular risk factors. However, LV pump function and LV filling were compensated by circumferential shortening at ventricular systole and 3 directional lengthenings at atrial systole, respectively.

Determinants of enhanced left atrial active emptying with aging: left atrial preload, contractility or both?

OBJECTIVE

Senile persons have reduced left ventricular (LV) relaxation and increased late diastolic filling. However, the determinant factor of the enhanced active emptying of the left atrium has not been well established.

METHODS

Subjects were 62 healthy individuals with a mean age of 58+/-19 (21-85) years. The biplane modified Simpson's rule was applied to measure left atrial (LA) volume at pre-atrial contraction (LAVpre) as an index of LA preload and LA volume change during atrial contraction (LASV) as an index of active LA emptying. These values were divided by the body surface area and represented as LAVpreI and LASVI, respectively. Postero-basal (dorsal cranial) left atrial wall velocity (LAWV) during atrial contraction as an index of LA contractility was measured in the apical three-chamber view by two-dimensional tissue Doppler echocardiography.

RESULTS

Age significantly correlated with mitral flow velocity (TMA), velocity-time integral during atrial contraction (TMAVTI) and LASVI (r= 0.63, p<0.001 and r=0.71, p<0.001, r=0.21, p=0.049, respectively). LAVpreI was significantly correlated with age (r=0.44, p<0.001), LASVI (r=0.71, p<0.001), TMA (r=0.31, p=0.008) and TMAVTI (r=0.40, p<0.001). LAWV remained unchanged with aging and had no correlation with TMA, TMAVTI or LASVI.

CONCLUSION

The enlargement of the LA in senile persons may be a major determinant of enhanced active LA emptying and the increased LA contractility may be less contributory.

Acute respiratory failure in the elderly: diagnosis and prognosis

Acute respiratory failure (ARF) in patients over 65 years is common in emergency departments (EDs) and is one of the key symptoms of congestive heart failure (CHF) and respiratory disorders. Searches were conducted in MEDLINE for published studies in the English language between January 1980 and August 2007, using 'acute dyspnea', 'acute respiratory failure (ARF)', 'heart failure', 'pneumonia', 'pulmonary embolism (PE)' keywords and selecting articles concerning patients aged 65 or over. The age-related structural changes of the respiratory system, their consequences in clinical assessment and the pathophysiology of ARF are reviewed. CHF is the most common cause of ARF in the elderly. Inappropriate diagnosis that is frequent and inappropriate treatments in ED are associated with adverse outcomes. B-type natriuretic peptides (BNPs) help to determine an accurate diagnosis of CHF. We should consider non-invasive ventilation (NIV) in elderly patients hospitalised with CHF or acidotic chronic obstructive pulmonary disease (COPD) who do not improve with medical treatment. Further studies on ARF in elderly patients are warranted.

Heart failure in the "oldest old": clinical and echocardiographic insights

While the incidence and prevalence of heart failure (HF) increase markedly with age, few studies have included data on a large series of patients aged 85 years and older. Clinical and echocardiographic data from 533 patients admitted to a tertiary care hospital for acute HF were obtained. Data from the oldest old (>or=85 years; n=252; mean age, 91.9+/-3.6 years) were compared with data from those aged 65 to 74 years (n=123; mean age, 70.1+/-2.8 years) and 75 to 84 years (n=158; mean age, 79.4+/-2.9 years). Echocardiographic data were consistent with hypertensive remodeling. The proportion of patients with HF and a preserved left ventricular ejection fraction was greatest in the oldest patients (61%) in comparison to patients aged 65 to 74 years (48%) and 75 to 84 years (48%). Approximately three-fourths of the oldest patients were women, and two-thirds of women had a left ventricular ejection fraction >or=50%.

Effect of Age and Heart Rate on Atrial Mechanical Function Assessed by Doppler Tissue Imaging in Healthy Individuals

BACKGROUND

The potential usefulness of Doppler tissue imaging (DTI) to assess atrial mechanical function in cardiac disease has been demonstrated. However, there are few reports on normal values of atrial function by DTI analysis.

METHODS

Echocardiography with color-coded DTI was performed in 131 healthy control subjects. The peak atrial contraction velocity (V(A)) and the timing of mechanical events were assessed offline at the left atrial (LA) and right atrial (RA) free wall and interatrial septum.

RESULTS

V(A) was higher in the RA (9.0 +/- 2.6 cm/s) than the LA (7.5 +/- 2.4 cm/s, P < .001), and both sites were higher than the interatrial septum (5.6 +/- 1.3 cm/s, both P < .001). The interatrial delay was 24 +/- 21 milliseconds. V(A) at the LA was higher in the participants aged 60 years or older than those who were younger than 60 years (8.1 +/- 2.7 vs 6.7 +/- 1.4 cm/s, P < .001), as was the velocity at the RA (9.6 +/- 2.8 vs 8.0 +/- 2.1 cm/s, P < .01). V(A) at the LA was higher in the participants with heart rate of 60/min or higher than those with lower heart rate (7.9 +/- 2.5 vs 6.8 +/- 1.8 cm/s, P < .05). Sex difference had no effect on V(A) and timings of atrial events.

CONCLUSIONS

Assessment of atrial mechanical function by DTI is feasible in healthy individuals. The V(A) is the highest at the RA, followed by LA, and the lowest at the interatrial septum. Older age and faster heart rate seems to augment V(A) in the atrial walls.

A new Doppler tissue ratio to revisit systole: The pre-ejectional isovolumic to ejectional velocity ratio–application to aging

Most diagnostic applications of Doppler tissue echocardiography rely on peak (Pk) velocity (V) values of single variables or myocardial V gradient. Whereas age-related changes in diastolic V are well-known, previous Doppler tissue echocardiography studies of systolic function showed no age effect for pre-ejectional (Ej) isovolumic (PEI) and Ej inward wall motion Pk V. In addition to myocardial V gradient, ratios were calculated between PEI and Ej Pk V, and mean V averaged over systole (PEI/Ej V ratios) at each layer of the posterior wall using M-mode color on two control groups: A (27 +/- 5 years) and B (54 +/- 10 years). The only changes were for PEI/Ej V ratios (mean V endocardial 21 +/- 7% vs 34 +/- 20%, P = .01; mean V epicardial 27 +/- 8% vs 40 +/- 18%, P = .006; Pk epicardial V 21 +/- 10% vs 30 +/- 16%, P = .04 for groups A and B, respectively). Correlation versus age were r = 0.52 and P = .005 (mean V endocardial), r = 0.50 and P = .007 (mean V epicardial), and r = 0.32 and P = .03 (Pk epicardial V). PEI/Ej V ratios and mean V studied in separate layers showed that the new systolic approach had advantages over single variable or Pk V to study age-related changes.

Left ventricular diastolic function and carotid artery wall in elderly athletes and sedentary controls

Advancing age is characterized by structural and functional change of left ventricle (LV) and large elastic arteries. Recent advances in tissue Doppler imaging (TDI) and integrated backscatter (IBS), new ultrasound tools, have allowed non-invasive assessment of structural and functional characterization of myocardium and artery wall. Our aim was to compare LV diastolic function and carotid artery remodeling in elderly athletes and sedentary controls. Twenty-five elderly athletes (males, aged 68.6 +/- 4.2 years) were compared to 25 age-sex-matched sedentary controls. All the subjects underwent either conventional Doppler echocardiography with pulsed TDI to evaluate LV diastolic function, and conventional ultrasonography and integrated backscatter (IBS) analysis to evaluate the carotid wall. Corrected IBS values (C-IBS) were obtained by subtracting the IBS value of the adventitia. Body mass index and blood pressure were not different in the two groups; athletes showed lower heart rate (P < 0.0001) and, as expected, higher LV mass than sedentary subjects (P < 0.0001). Transmitral Doppler analysis showed in trained subjects a significantly lower peak A and a higher E/A ratio (P < 0.001). On regards to TDI measurements, athletes exhibited a higher Em, a lower Am, and, subsequently, an increased Em/Am ratio of both lateral wall and septum (P < 0.0001). The IVRTm was shorter in trained subjects (P < 0.001). Athletes showed a lower C-IBS (-26.8 +/- 2.9 vs. -23.4 +/- 3.8 dB, P < 0.001) and a smaller intima-media thickness (IMT: 0.66 +/- 0.14 vs. 0.80 +/- 0.18 mm, P < 0.001) respect to sedentary controls. Moreover, a significant direct correlation was found between Em/Am of LV septal and lateral wall and C-IBS values (respectively, r = 0.62 and r = 0.56, P < 0.001). Thus the aging heart manifests structural and functional changes in response to physical activity. The expected pattern of cardiac and arterial alterations normally seen in response to age is modified in the older athletes, suggesting the exercise training is an effective stimulus in shaping arterial structure and left ventricular function in older heart. It would appear that pulsed TDI and IBS analysis may play an important role in detecting training-induced LV and carotid artery structural and functional modifications.