Noninvasive assessment of left ventricular diastolic function: comparative analysis of pulsed Doppler ultrasound and digitized M-mode echocardiography

Arterial and cardiac disease in young adults with childhood-onset end-stage renal disease—impact of calcium and vitamin D therapy

BACKGROUND

Studies in patients with childhood-onset end-stage renal disease (ESRD) provide a diagnostic window to the evolution of cardiovascular disease (CVD) in this population. Hyperphosphataemia and renal osteodystrophy are particularly difficult to treat in paediatric patients, but there is only limited information regarding the effect of calcium-containing phosphate binders and vitamin D preparations on the development of CVD in the young.

METHODS

We studied 40 adult patients (mean age 23.6 years) who developed ESRD at the age of 11.5 +/- 4 years and 40 matched healthy control subjects. Nine patients were on dialysis and 31 had a functioning kidney transplant. Measurements included intima-media thickness (IMT) of the common carotid artery, electron beam computed tomography (EBCT) for the detection of coronary artery calcifications (CAC), echocardiography and post-ischaemic arterial blood flow by venous occlusion plethysmography. Patient characteristics, atherosclerotic risk factors and a complete account of prescribed medications were analysed for correlations with arterial and cardiac changes.

RESULTS

The IMT was not significantly different in patients and controls; four patients (10%) had coronary calcifications on EBCT. Twenty-five patients (62.5%) had left ventricular hypertrophy. Patients had a 40% reduction of post-ischaemic arterial flow. Morphological alterations of the heart and arteries were significantly correlated with the duration of ESRD and dialysis time, and with the cumulative intake of calcium-containing phosphate binders and active vitamin D preparations. Functional changes (vascular reactivity) were correlated with duration of ESRD and non-traditional risk factors.

CONCLUSIONS

Young adults with ESRD since childhood have systemic CVD characterized by a decrease in arterial elasticity, the occurrence of CAC and changes in left ventricular morphology. Treatment with calcium-containing phosphate binders and active vitamin D preparations is independently associated in a dose-dependent manner with surrogate markers for CVD.

Assessment of cardiac function in iron-deficient children without anemia

Iron deficiency anemia may lead to impairment of many vital functions, including those in the cardiovascular system. However, the effects of iron depletion on cardiac function in the absence of anemia are not well known. In this study the authors examined the effects of iron deficiency without overt anemia on cardiac function in 59 children. Complete blood count, serum iron, serum iron-binding capacity, and serum ferritin levels were measured in all children. The children were divided into two groups according to serum ferritin levels: an iron-depleted group (n = 28) and a non-iron-depleted control group (n = 31). Echocardiographic examinations were performed using M mode and Doppler echocardiographic methods in all children to assess cardiac function. No statistically significant difference was found between the two groups in terms of echocardiographic indices. Although the number of subjects in this study was small, the authors conclude that iron deficiency in the absence of overt anemia does not lead to important changes in cardiac function.

Early changes in left ventricular function in chronic asymptomatic alcoholics: relation to the duration of heavy drinking

OBJECTIVES

This study sought to assess preclinical cardiac abnormalities in chronic alcoholic patients and possible differences among alcoholics related to the duration of heavy drinking.

BACKGROUND

Chronic excessive alcohol intake has been reported as a possible cause of dilated cardiomyopathy. However, before the appearance of severe cardiac dysfunction, subtle signs of cardiac abnormalities may be identified.

METHODS

We studied 30 healthy subjects (age 44 +/- 8 years) and 89 asymptomatic alcoholics (age 45 +/- 8 years, p = NS) divided into three groups, with short (S, 5-9 years, n = 31), intermediate (I, 10-15 years, n = 31) and long (L, 16-28 years, n = 27) duration of alcoholism. Transmitral early (E) and late (A) Doppler flow velocities, E/A ratio, deceleration time of E (DT) and isovolumic relaxation time (IVRT) were obtained. Left ventricular (LV) wall thickness and volumes were also determined by echocardiography, and LV mass and ejection fraction (EF) were calculated.

RESULTS

The alcoholics had prolonged IVRT (92 +/- 11 vs. 83 +/- 7 ms, p < 0.001), longer DT (180 +/- 20 vs. 170 +/- 10 ms, p < 0.01), smaller E/A (1.25 +/- 0.34 vs. 1.40 +/- 0.32, p < 0.05), larger LV volumes (73 +/- 8 vs. 65 +/- 7 ml/m2, p < 0.001 for end-diastolic volume index; 25 +/- 4 vs. 21 +/- 2 ml/m2, p < 0.001 for end-systolic volume index), higher LV mass index (92 +/- 14 vs. 78 +/- 8 g/m2, p < 0.001) and thicker posterior wall (9 +/- 1 vs. 8 +/- 1 mm, p < 0.001). Ejection fraction did not differ between the two groups (66 +/- 4 vs. 67 +/- 2%). Deceleration time of the early transmitral flow velocity was longer in groups L (187 +/- 18 ms) and I (185 +/- 16 ms) compared with group S (168 +/- 17 ms, p < 0.001 for L and I vs. S), whereas A was higher in group L compared with S (43 +/- 10 vs. 51 +/- 10 cm/s, p < 0.005). Multiple regression analysis identified duration of heavy drinking as the most important variable affecting DT and A.

CONCLUSIONS

Left ventricular dilation with preserved EF and impaired LV relaxation characterized LV function in chronic asymptomatic alcoholic patients. It appeared that the progression of abnormalities in LV diastolic filling related to the duration of alcoholism.

Quantitative evaluation of global and regional left ventricular diastolic function with color kinesis

BACKGROUND

Diastolic wall motion asynchrony is a major determinant of impaired left ventricular (LV) filling in patients with concentric hypertrophy and coronary artery disease. We evaluated the ability of Color Kinesis, a new echocardiographic technique that color-encodes endocardial motion, to quantitatively assess global and regional LV filling properties.

METHODS AND RESULTS

Color Kinesis images and mitral and pulmonary vein flow Doppler data were acquired in 29 patients with LV hypertrophy and 29 age-matched control subjects. In addition, Color Kinesis data were correlated to coronary angiographic findings in 15 patients with suspected coronary artery disease. Segmental analysis of Color Kinesis images was used to obtain time histograms of regional diastolic fractional area change, wherein early and late peaks (peaks 1 and 2) reflected rapid LV filling and atrial contraction, respectively. Regional mean LV filling time and filling curves were used to objectively identify diastolic endocardial motion asynchrony in patients with LV hypertrophy and coronary artery disease. None of the mitral and pulmonary vein Doppler indices differentiated patients with normalized mitral Doppler profile (n=13) from control subjects, whereas reduced peak1/peak2 ratio and prolonged mean filling time indicated augmented contribution of atrial contraction toward LV filling (P<.05). In 22 of 25 patients with LV hypertrophy and preserved systolic function and in all patients with coronary artery disease, delayed diastolic endocardial motion was observed in at least one segment.

CONCLUSIONS

Analysis of Color Kinesis images provides objective assessment of global and regional LV filling properties and allows identification of both diastolic dysfunction in patients with normalized Doppler indices and wall motion asynchrony.

Blood pressure, insulin resistance and left ventricular function in alcoholics

OBJECTIVE

To estimate the arterial blood pressure, left ventricular function and insulin secretion in alcoholics.

DESIGN

We examined hospitalized patients between the second and seventh day of acute alcohol withdrawal and after a month of abstinence by 24 h ambulatory blood pressure monitoring, a standard oral glucose-tolerance test with determination of insulinaemia, two-dimensional and M-mode echocardiography and pulsed-wave Doppler statistical analysis was performed using Student's t test P < 0.05 was considered statistically significant

PATIENTS

Fifty alcoholics aged 36.3 +/- 5.4 years with a history of alcohol abuse for a mean of 12 years.

MAIN OUTCOME

We expected the cessation of drinking to exert an influence by lowering the blood pressure and left ventricular function with a concomitant lowering of the insulin resistance.

RESULTS

During acute alcohol withdrawal the systolic (121.6 +/- 7.7 versus +115.8 +/- 8.7 mmHg) and diastolic blood pressures (74.5 +/- 6.3 versus 72.0 +/- 7.9 mmHg) were significantly higher. The nocturnal fall in blood pressure was smaller and the variability of the blood pressure was blunted. This period was characterized by hyperinsulinaemia detected by the glucose-tolerance test [In (SUMins) 8957 +/- 0.47 versus 8558 +/- 0.651] correlated to hyperdynamic circulation (cardiac index 3.38 +/- 0.86 versus 3.09 +/- 0.69 I/min per m2). The early: late atrial filling ratio had increased significantly after 1 month of abstinence (1.98 +/- 0.43 versus 2.08 +/- 0.50).

CONCLUSIONS

One month of abstinence from drinking decreases the blood pressure and improves the diurnal profile of the blood pressure and the left ventricular diastolic function. Hyperinsulinaemia, which is observed during acute restriction of alcohol consumption, could be one of the causes responsible for hyperdynamic circulation.

Spectrum of alcohol-induced myocardial damage detected by indium-111-labeled monoclonal antimyosin antibodies

OBJECTIVES

We sought to determine the prevalence, intensity and evolving changes of myocardial damage detected by myocardial uptake of antimyosin antibodies in patients with alcohol-induced dilated cardiomyopathy, alcohol addicts attending a detoxification unit and healthy subjects with short-term alcohol consumption.

BACKGROUND

Evidence of alcohol-induced myocardial damage may be provided by myocardial uptake of indium-111-labeled monoclonal antimyosin antibodies. The spectrum of such damage in patients who are heavy drinkers (> 100 g for > 10 years), with or without cardiomyopathy, and the impact of short-term alcohol ingestion on antimyosin antibody uptake have not been adequately explored.

METHODS

One hundred twenty antimyosin studies were performed in 56 patients with dilated cardiomyopathy (group I), 15 alcohol addicts attending a detoxification unit (group II) and 6 volunteers for short-term alcohol ingestion (group III). Estimation of antibody uptake was calculated through a heart/lung ratio (HLR) (normal < 1.55).

RESULTS

The 56 patients in group I (54 men, 2 women; mean [+/-SD] age 46 +/- 11 years) had consumed 123 +/- 60 g/day of alcohol for 21 +/- 9 years, for a cumulative intake of 914 +/- 478 kg. Mean duration of symptoms was 46 +/- 49 months. Mean left ventricular end-diastolic diameter was 71 +/- 10 mm, and mean ejection fraction was 28 +/- 12%. No differences in New York Heart Association functional class, ventricular size or ejection fraction were noted between 28 active and 28 past consumers, except for the prevalence and intensity of antibody uptake (75% vs. 32%, p < 0.001) and HLR (1.75 +/- 0.26 vs. 1.49 +/- 0.17, p = 0.0001). In 19 patients in the active group restudied after alcohol withdrawal, antibody uptake decreased (from 1.76 +/- 0.17 to 1.55 +/- 0.19, p < 0.001), and ejection fraction improved (from 30 +/- 12% to 43 +/- 16%, (p < 0.001). No changes occurred in the 15 past consumers restudied. The 15 male patients in group II (mean age 36 +/- 4 years) had consumed 156 +/- 59 g/day for 17 +/- 5 years, for a cumulative alcohol intake of 978 +/- 537 kg, an amount similar to that in patients in group I, but antimyosin antibody uptake was detected in only 3 (20%) of 15 patients. None of six group III subjects developed antibody uptake after short-term ethanol ingestion. Despite the small sample size, the power to detect clinically relevant differences in most variables that did not reach statistical significance was amply sufficient.

CONCLUSIONS

In alcohol-induced dilated cardiomyopathy, alcohol withdrawal is associated with the reduction or disappearance of myocardial damage and improvement of function. The difference in prevalence of antimyosin antibody uptake in patients with and without cardiac disease who consume similar amounts of alcohol suggests the presence of those with different myocardial susceptibilities to alcohol. Short-term ethanol ingestion in healthy subjects does not induce detectable uptake of antimyosin antibodies.

Newer Doppler measures of left ventricular diastolic function

Left ventricular (LV) diastolic dysfunction is an important cause of heart failure, and recent advances in the application of Doppler techniques allow a semiquantitative assessment of LV diastolic performance. This review discusses the use of Doppler echocardiography in the comprehensive assessment of LV diastolic function and performance in terms of the normal mitral and pulmonary venous flow profiles, their physiologic basis, and alterations in diseased states. There is also a discussion on the newer aspects of mitral flows such as relative durations of mitral A and pulmonary vein AR waves, E- and A- wave propagation inside the LV with their hemodynamic correlates, and derivation of ventricular dP/dt and Tau from the mitral regurgitation velocity profile. Analysis of these flow profiles and the other Doppler measures alluded to above allow one to make a fairly precise hemodynamic assessment of a patient in terms of left atrial pressure, LV relaxation and stiffness and the profile of LV diastolic pressure in terms of pre- 'a' wave and 'a' wave pressures and ventricular end-diastolic pressure.

Left ventricular diastolic Doppler characteristics in beta-thalassemia major

BACKGROUND

Diastolic left ventricular function expressed by diastolic Doppler characteristics of the left ventricle has never been properly investigated.

METHODS AND RESULTS

Left ventricular inflow and pulmonary vein flow patterns were assessed by Doppler echocardiography in 88 beta-thalassemia major patients with normal left ventricular systolic function; 34 were young (age, 15.1 +/- 3.2 years) and 54 were adults (age, 25.1 +/- 3.6 years). The findings were compared with those obtained from 22 young (age, 13.8 +/- 2.4 years) and 24 adult (age, 25.3 +/- 4.1 years) normal individuals. In both groups of patients, peak flow velocities in early (E) and late (A) diastole were higher than in the control subjects (young E: P < .01; adult E: P < .001; young A: P < .05; adult A: P < .05), whereas no difference was found in the E/A ratio, deceleration time, or isovolumic relaxation time. Pulmonary vein systolic (S) and diastolic (D) velocities were also higher in beta-thalassemia major patients compared with the control subjects (young S: P < .05; adult S: P < .05; young D: P < .05; adult D: P < .05). Restrictive left ventricular abnormalities were only found in 7 patients who were among the oldest beta-thalassemia major population of the adult group (P < .01) with highly elevated mean serum ferritin. In comparison to the remaining adult patients, interventricular septum and left ventricular posterior wall thickness were increased (P < .01 and P < .01, respectively). The left atrium and right ventricle were dilated (P < .05 and P < .01, respectively).

CONCLUSIONS

Doppler diastolic indexes in beta-thalassemia major patients with normal left ventricular systolic function are similar to those seen in conditions with an increased preload, probably because of chronic anemia. Only severe iron loading and deposition in the myocardium leads to the restrictive abnormalities of left ventricular filling.

Early changes in left ventricular subendocardial function after successful coronary angioplasty

OBJECTIVE

To study the early effects of coronary angioplasty on resting left ventricular long axis function, reflecting that of the subendocardium.

DESIGN

Prospective echocardiographic and Doppler examination of patients with coronary artery disease, before and after single vessel coronary angioplasty.

SETTING

A tertiary referral centre for cardiac diseases with facilities for invasive and non-invasive investigation.

PATIENTS

23 patients with significant left coronary disease being considered for coronary angioplasty.

RESULTS

Before angioplasty the mean (SD) isovolumic relaxation time was longer than normal (75(19) ms v 55 (10), p < 0.001) with a significant increase in transverse dimension change before mitral valve opening, and peak rate of early diastolic thinning (8(3) v 10.4 (2.6) cm/s (p < 0.001)) was reduced. Long axis motion was frequently abnormal. The interval from the onset of the Q wave to the onset of shortening was prolonged (118 (30) ms v 90 (19) at the left site and 115 (26) ms v 81 (9) at the septal site, p < 0.001) and the onset of early diastolic rapid lengthening delayed with respect to the aortic valve closure sound (A2) by 85 (34) ms v 58 (11) at the left site and 88 (33) ms v 60 (9) at the septal site (p < 0.001). Although overall amplitude was reduced at the septal site only (1.23 (0.3) cm v 1.5 (0.4), p < 0.05), the extent (0.8 (0.2) cm v 1.04 (0.3) at the left site and 0.66 (0.2) cm v 0.9 (0.3) at the septal site, p < 0.001) and peak rate (6.2 (2) cm/s v 10 (2.5) at the left site and 5.4 (2.3) cm/s v 8.5 (2) at the septal site, p < 001) of early diastolic lengthening were both much lower than normal. The E/A ratio on transmitral Doppler was modestly reduced (1.0 (0.7) v 1.4 (0.4), p < 0.05). After angioplasty: isovolumic relaxation time shortened to 64 (18) ms (p < 0.001) and left ventricular incoordination regressed. Long axis shortening with respect to Q (98 (32) ms v 118 (30) at the left site and 94 (23) ms v 115 (26) at the septal site, p < 0.01) and that of lengthening with respect to A2 both normalised. Early diastolic peak lengthening rate increased (7.5 (2.1) cm/s v 6.2 (2) at the left site, and 6.3 (2.4) cm/s v 5.4 (2.3) at the septal site, p < 0.001). The early diastolic peak thinning rate of the posterior wall significantly increased (10 (3.5) cm/s v 8 (3), p < 0.005) as did mitral E/A ratio 1.2 (0.7) v 1.0 (0.7), p < 0.05).

CONCLUSION

Long axis motion, representing the function of longitudinally arranged subendocardial fibres, is consistently abnormal in the resting state in coronary artery disease. These systolic and diastolic abnormalities return towards normal after successful angioplasty, suggesting that they are the direct effect of coronary artery stenosis.

Noninvasive assessment of systolic and diastolic left ventricular function in patients with chronic severe anemia: a combined M-mode, two-dimensional, and Doppler echocardiographic study

Thirty-one patients with chronic severe anemia of more than 3 months' duration (hemoglobin less than 7 gm/dl) and no underlying heart disease were studied by means of M-mode, two-dimensional, and Doppler echocardiography; an equal number of normal control subjects was also studied. There are conflicting reports regarding the influence of chronic severe anemia on systolic myocardial function, but diastolic function has not been systematically assessed. It is also uncertain whether anemia alone can cause heart failure in a structurally normal heart. We therefore performed a detailed study of echocardiographic indexes of systolic and diastolic left ventricular function in these patients. We found that patients with anemia have significantly faster heart rates and lower diastolic and mean blood pressures than normal subjects. They also have a significantly elevated cardiac output and stroke volume and larger left ventricles. Left ventricular contractility, assessed by the end-systolic stress-dimension relationship, was enhanced. There was no systematic evidence of diastolic dysfunction by Doppler assessment of mitral inflow. There was also no clinical evidence of congestive heart failure. We conclude that chronic severe anemia leads to a hyperdynamic state with systolic hyperfunction and no impairment of diastolic function. Anemia does not lead to congestive heart failure in the absence of underlying heart disease.

Diastolic left ventricular function after renal transplantation in patients with normal and hypertrophied myocardium

While diastolic left ventricular (LV) dysfunction is frequent and associated with cardiovascular complications in end-stage renal disease treated with dialysis, controversial information exists on diastolic LV function after renal transplantation. Therefore, Doppler echocardiographic parameters of LV diastolic filling were analyzed in 17 transplanted patients with normal LV mass (< 150 g/m2; mean: 128 +/- 17 g/m2) and 24 transplanted patients with LV hypertrophy (> 150 g/m2; mean: 197 +/- 36 g/m2) and compared with 28 normal controls without and 11 controls with LV hypertrophy. Mean age (normal vs. increased LV mass: 46 +/- 13 vs. 48 +/- 11 years; p = NS) and transplantation duration (60 +/- 35 vs. 50 +/- 37 months; p = NS) were comparable between renal patients, while systolic blood pressure (136 +/- 12 vs. 149 +/- 14 mmHg; p < 0.02) and serum creatinine (1.55 +/- 0.45 vs. 1.98 +/- 0.76 mg/dl; p < 0.05) were higher in patients with than without LV hypertrophy. In transplanted patients with LV hypertrophy, peak early/atrial filling velocity ratios were decreased (1.17 +/- 0.34 vs. 0.94 +/- 0.34; p < 0.05), mean atrial filling fractions were increased (37 +/- 7% vs. 42 +/- 7%; p < 0.05), and isovolumic relaxation periods were prolonged (86 +/- 23 vs. 106 +/- 26 ms; p < 0.02) compared with transplanted patients with normal LV mass. The frequency of pathologic peak early/atrial filling velocity ratios (12 vs. 42%; p < 0.05), atrial filling fractions (12 vs. 25%; p = NS) and isovolumic relaxation periods (6 vs. 29%; p = NS) was higher in transplanted patients with than without LV hypertrophy. Individual ratios of peak early/atrial filling velocity were inversely correlated with age in transplanted patients with normal LV mass (p < 0.002), and atrial filling fractions were correlated with LV mass index in transplanted patients with LV hypertrophy (p < 0.01). Diastolic LV function was comparable in both groups of transplanted patients with their corresponding non-renal controls. It is concluded that, in transplanted patients, diastolic LV filling is comparable to nonrenal controls; it is age-dependent in patients with normal LV mass and mass-dependent in those with LV hypertrophy.

Transesophageal Echo-doppler evaluation of the hemodynamic effects of positive-pressure ventilation after coronary artery surgery

Transesophageal echocardiography was used to extend knowledge about the impact of positive end-expiratory pressure (PEEP) during mechanical ventilation on right and left ventricular function and right ventricular impedance. At 20 cmH2O PEEP, a progressive increase of right ventricular end-diastolic area was seen (27%) that coincided with a reduction of early left ventricular filling velocity (25%) across the mitral valve, and a decrease of both pulmonary artery flow velocity (end-expiration 27% and end-inspiration 42%) and time-velocity index (end-inspiration 25%). As these changes were not accompanied by a change of the fractional area of contraction, the increase of the right ventricular diameter might be explained by right ventricular compensation due to an imbalance between augmented right ventricular impedance and reduced venous return.

Pulsed Doppler echocardiographic indices of left ventricular diastolic function in normal subjects

To establish the normal limits for various pulsed Doppler echocardiographic indices of left ventricular diastolic function, 92 healthy volunteers aged from 5 to 75 years were prospectively studied. The influence of various variables including age, gender, body surface area, fractional shortening, and left ventricular mass on these parameters was also assessed. Mean (2SD) values for 15 direct and 11 derived parameters were analyzed from transmitral inflow velocity waveform. No statistically significant differences were observed between males and females for any of these parameters. On stepwise multivariate linear regression analysis, age was found to be an independent strong determinant (p less than 0.001) of peak velocity of early diastolic filling wave, area of atrial filling period, deceleration slope, normalized peak filling rate, and early filling fraction. There was a significant correlation between heart rate and time to peak early diastolic velocity, total diastolic time period, early diastolic period, atrial filling period, and atrial filling fraction. It was further observed that a significant correlation (p less than 0.001) persisted between both age and heart rate with area of early filling period, one-third filling area, one-half filling area, ratio of early to atrial peak velocity and area, atrial filling fraction, and one-third filling fraction. None of the parameters were found to correlate with fractional shortening or left ventricular mass. Thus an effort was made to establish normal limits for various Doppler-derived parameters in healthy volunteers for future comparison in diseased states.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular factors influencing survival in end-stage renal disease treated by continuous ambulatory peritoneal dialysis

To determine whether hemodynamic advantages of continuous ambulatory peritoneal dialysis (CAPD) over intermittent hemodialysis are associated with improved survival and identify cardiac risk factors for early death, 55 patients on CAPD (age 58 +/- 11 years; CAPD duration: 29 +/- 25 months) were followed in a noninvasive prospective analysis over 35 months. At follow-up, 25 patients had died; 16 deaths were related to cardiovascular causes. Nonsurvivors were older (62 +/- 8 vs 55 +/- 12 years; p less than 0.015) and had more angina pectoris (40 vs 20%; p less than 0.05) than survivors, but had comparable CAPD duration, arterial blood pressure, hemoglobin, serum creatinine, urea and parathyroid hormone concentrations. On echocardiography, nonsurvivors had a lower mean left ventricular (LV) ejection fraction (59 +/- 15 vs 66 +/- 9%; p less than 0.03), higher LV end-systolic volume indexes (49 +/- 31 vs 36 +/- 13 ml/m2; p less than 0.03) and a shorter mean LV ejection time (371 +/- 41 vs 390 +/- 22 ms; p less than 0.03). LV muscle mass, LV diastolic and left atrial dimensions, stroke volume and cardiac index were comparable. On pulsed Doppler analysis of a subgroup of 48 patients in sinus rhythm and without valve disease, nonsurvivors (n = 23) had more severely decreased ratios of peak early/atrial filling velocities (0.66 +/- 0.18 vs 0.81 +/- 0.24; p less than 0.03) and increased atrial filling fractions (52 +/- 11 vs 46 +/- 9%; p less than 0.03) than survivors. Mean isovolumic relaxation periods were increased in both groups (135 +/- 39 vs 129 +/- 33 ms; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Correlation of quantitative angiographic parameters with changes in left ventricular diastolic function after angioplasty of the left anterior descending coronary artery

This study evaluates the changes in left ventricular (LV) diastolic filling after percutaneous transluminal coronary angioplasty and the relation of such changes to quantitative angiographic measurements of the severity of coronary narrowings. Pulsed Doppler echocardiographic measurements were performed in 40 patients with single left anterior descending artery narrowing before, and 10 and 30 days after angioplasty. Minimal luminal diameter and percent diameter stenosis of coronary lesions were measured by computer-assisted quantitation. The ratio of early to late diastolic flow velocities (E/A ratio), time velocity integral of early diastolic filling period (Ei) and the ratio of early and late diastolic filling periods (Ei/Ai ratio) increased gradually after angioplasty. Minimal luminal diameter correlated significantly with the percent changes in E/A ratio (r = 0.59 at 10 days, r = 0.57 at 30 days), Ei (r = 0.53 at 10 days, r = 0.55 at 30 days) and Ei/Ai ratio (r = 0.41 at 10 days, r = 0.49 at 30 days). Percent diameter stenosis showed overall weaker correlations than minimal diameter with the percent changes in E/A ratio (r = 0.39 at 10 days, r = 0.32 at 30 days) and Ei (r = 0.38 at 10 days, r = 0.31 at 30 days). Thus, LV diastolic filling improves serially after coronary angioplasty in patients with 1-vessel disease. The magnitude of improvement in diastolic filling correlates better with minimal luminal diameter than percent diameter stenosis. Therefore, minimal luminal diameter is a better predictor of changes in Doppler transmitral flow parameters after angioplasty than percent diameter stenosis.

Evaluation of left ventricular filling in dilated cardiomyopathy using digitized M-mode echocardiograms

Digital M-mode echocardiography describes a characteristic alteration in the pattern of left ventricular filling when a dilated cardiomyopathy is present. The peak rates of early diastolic dimension change (dD/dt and dD/dt/D) are uniformly reduced but remain unchanged in time of occurrence (time to dD/dt). The rapid filling period is slightly shortened compared to normals, but the %deltaD taking place during rapid filling is not different than normals. This pattern is distinct from characteristic alterations seen in other cardiac diseases that have preserved systolic performance. While M-mode indices of left ventricular filling may be altered by several factors, the most significant factors in dilated cardiomyopathy are the severity of systolic dysfunction and preload. Left-sided conduction delays and associated right ventricular enlargement have no demonstrable effect on very early portions of diastole, but the conduction delay does prolong the rapid filling period and reduce the extent of filling during this period. Combined use of digitized M-mode echocardiograms and Doppler analysis of transmitral flow may allow a more complete description of left ventricular filling in future studies.

Left ventricular muscle mass and diastolic function in patients with essential hypertension under long-term clonidine monotherapy

To determine whether alterations of left ventricular (LV) structure are associated with improved LV function under chronic clonidine monotherapy (300-450 g/day) of essential hypertension, 11 male patients (age range 47-61 years) were followed for 5.4 +/- 0.9 months using echocardiography and Doppler echocardiography. Blood pressure decreased from a mean of 168/105 to 150/96 mmHg (p less than 0.01), heart rate remained unchanged (73 +/- 10 vs. 71 +/- 10 beats/min). LV muscle mass decreased from 350 +/- 73 to 297 +/- 56 g (p less than 0.02), LV volume/muscle mass ratio increased from 0.58 +/- 0.13 to 0.69 +/- 0.12 ml/g (p less than 0.005). Ejection time increased from 276 +/- 17 to 296 +/- 17 ms (p less than 0.01), whereas no significant change was found for pre-ejection period, ejection fraction, cardiac index and LV dimensions. Doppler analysis revealed improved isovolumic relaxation time (116 +/- 17 vs. 84 +/- 28 ms; p less than 0.05), but no change in isovolumic contraction duration, maximal inflow velocities, time-velocity integrals and their duration, rate of acceleration and deceleration of early and atrial filling, and of their ratios. It is concluded that no reliable improvement in diastolic or systolic LV function is observed in chronic clonidine monotherapy of essential hypertension despite a normalization of blood pressure and a regression of LV hypertrophy.

Left ventricular filling impairment in asymptomatic chronic alcoholics

Systolic left ventricular dysfunction is relatively common in even asymptomatic alcoholics, but whether diastolic function is also altered is much less well-studied. We used M-mode and Doppler echocardiography to study left ventricular size, mass, systolic function and diastolic filling in 32 alcoholics free of clinically detectable heart disease and in 15 healthy control subjects. Left ventricular mass index and posterior wall thickness were higher in alcoholics than in controls, but there was no statistically significant difference either in end-diastolic size or in systolic ventricular function. More abnormalities were found in the Doppler indexes of diastolic function, however. The alcoholics had a prolonged relaxation time (200 +/- 6 vs 184 +/- 5 ms [mean +/- standard error], p less than 0.05), a decreased peak early diastolic velocity (52 +/- 2 vs 60 +/- 3 cm/s, p less than 0.05), a slower acceleration of the early flow (410 +/- 18 vs 552 +/- 43 cm/s2, p less than 0.01), and a higher atrial-to-early peak velocity ratio (0.74 +/- 0.04 vs 0.60 +/- 0.05, p less than 0.05). This pattern of changes suggests a primary abnormality in the relaxation of the left ventricle. In multivariate analyses, the abnormalities in the Doppler indexes were independent of the duration of alcoholism, the quantity of the most recent ethanol exposure and the increased mass of the left ventricle. Impaired early filling of the left ventricle due to delayed relaxation is common in asymptomatic alcoholics and may in fact be the earliest functional sign of preclinical alcoholic cardiomyopathy.

Effects of nifedipine on left ventricular diastolic function in hypertension; echo Doppler study

Hypertensive cardiac disease shows early alteration of left ventricular diastolic filling, characterized by a longer isovolumetric relaxation period and by an altered E/A ratio on the mitral spectral Doppler. We chose ten hypertensive patients who had left ventricular hypertrophy, but no left ventricular dilatation or mitral valve insufficiency and had a good left ventricular shortening fraction (greater than 26%). After the washout period we studied each of the above-mentioned parameters before and after the acute administration of nifedipine, dinitrate isosorbide, and captopril. While captopril and dinitrate isosorbide induced a prolongation of the isovolumic relaxation time and an impairment of the E/A ratio in mitral spectral Doppler (i.e., left ventricular filling), nifedipine induced an improvement in both parameters. The three drugs also induced a similar reduction in systemic blood pressure values (i.e., similar afterload). We therefore suggest that changes in diastolic function in hypertrophied cardiac fibers, induced by nifedipine, may be the result of a double action: one mediated by hemodynamic changes, the other directly affecting the cellular calcium ion exchange.

Restrictive diastolic abnormalities identified by Doppler echocardiography in patients with thalassemia major

The consequences of transfusional iron overload on left ventricular diastolic filling have never been investigated systematically in patients with thalassemia major. In the present study, the pattern of left ventricular filling was assessed by Doppler echocardiography in 32 patients with thalassemia major (age, 17 +/- 5 years) who had not experienced symptoms of heart failure and had normal left ventricular systolic function. Data were compared with those obtained in 32 age-matched and sex-matched normal subjects. An abnormal Doppler pattern of left ventricular filling with increased flow velocity at mitral valve opening followed by an abrupt and premature decrease of flow velocity in early diastole was identified in the patients with thalassemia. Peak flow velocity in early diastole was increased in patients compared with controls (90 +/- 10 vs. 81 +/- 15 cm/sec; p less than 0.01), and rate of deceleration of flow velocity after the early diastolic peak and the ratio between the early and late (atrial) peaks of flow velocity were also increased (1,050 +/- 325 vs. 762 +/- 193 cm/sec2 and 2.7 +/- 0.7 vs. 2.2 +/- 0.5, respectively; p less than 0.001), whereas flow velocity deceleration time was reduced (97 +/- 22 vs. 119 +/- 19 msec; p less than 0.001). This Doppler pattern of diastolic filling is usually described as "restrictive" and reflects a decrease in left ventricular chamber compliance. A restrictive pattern of left ventricular filling was also identified in the subgroup of 16 study patients who had undergone optimal iron chelation therapy with deferoxamine.(ABSTRACT TRUNCATED AT 250 WORDS)

Doppler echocardiographic evaluation of left ventricular diastolic function in patients with systemic lupus erythematosus

Subclinical myocardial involvement frequently occurs in patients with systemic lupus erythematosus (SLE). In this study, left ventricular diastolic function was assessed in 58 patients (54 female and 4 male; mean age 32 +/- 11 years) and in 40 sex-matched and age-matched healthy control subjects (37 female and 3 male; mean age 33 +/- 9 years) by means of pulsed Doppler echocardiography. All subjects had no clinical evidence of overt myocardial disease or abnormal left ventricular systolic function. Compared with the control group, patients with SLE had significantly prolonged isovolumic relaxation time (62 +/- 12 vs 80 +/- 14 msec; p less than 0.01), reduced peak early diastolic flow velocity (peak E) (82 +/- 18 vs 76 +/- 16 cm/sec; p less than 0.05), increased peak late diastolic flow velocity (peak A) (45 +/- 7 vs 53 +/- 8 cm/sec; p less than 0.01), reduced E/A ratio (1.81 +/- 0.32 vs 1.46 +/- 0.29; p less than 0.001), and lower deceleration rate of early diastolic flow velocity (EF slope) (489 +/- 151 vs 361 +/- 185 cm/sec2; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Improved diastolic LV filling after acute application of ajmaline in patients with coronary artery disease and normal systolic LV function

To determine whether ajmaline (A) can be safely applied in coronary artery disease (CAD), changes of left ventricular (LV) function after acute ajmaline application were analyzed by pulsed Doppler echocardiography in 10 CAD patients. LV pressures in systole and end-diastole and LVEF remained normal and comparable. Doppler normalized peak filling rate (p less than 0.02), peak early/atrial filling velocity (E/A) ratio (p less than 0.01) and E-deceleration (p less than 0.05) increased. The increase in E/A and in E-deceleration relative to base values was directly correlated (p less than 0.001). PEP increased, LVET remained unchanged. LV diastolic filling is improved after acute application of ajmaline in patients with CAD and normal systolic function; its application may be advised not only for therapy of arrhythmia but also to improve left ventricular diastolic mechanics in these patients.

Effect of age on diastolic left ventricular filling at rest and during inotropic stimulation and acute systemic hypertension: experimental studies in conscious beagles

"Pharmacologic" stress testing with inotropic stimulation is useful in the detection of coronary artery disease when ventricular dysfunction is provoked. However, abnormal diastolic filling may be masked or mimicked because of the influence of aging, heart rate, and loading conditions. We evaluated age effects on left ventricular filling at rest in young (n = 5) and old (n = 6) purebred beagles that were free of occlusive coronary disease and left ventricular hypertrophy, and we also evaluated age-related differences in left ventricular filling velocities in response to dobutamine and phenylephrine. Pulsed Doppler echocardiography of left ventricular filling velocities was performed at baseline and then after the administration of dobutamine (10 to 20 micrograms/kg/min) infusion. Repeat baseline recordings were obtained and then phenylephrine was administered intravenously in doses of 5 to 25 micrograms/kg/min until systolic arterial pressure increased by at least 30 mm Hg above baseline. At baseline, Doppler echocardiography revealed that there were no significant differences in the early (E) velocity or velocity time interval (VTI), and atrial (A) velocity or the A/E velocity ratio between the young and old groups. However, the A VTI and the A/(A + E) VTI ratio were significantly increased in the old group. With dobutamine administration, the E velocity did not significantly increase from baseline in either group. The E VTI, A velocity and A VTI increased significantly in both groups, but the increases were not different between groups. With phenylephrine infusion there was a significant decrease in the E VTI in the old group but neither the A/E velocity or the A/(A + E) VTI ratio significantly changed from baseline.(ABSTRACT TRUNCATED AT 250 WORDS)

Relation between blood pressure, left ventricular mass and pulsed Doppler parameters in healthy school children

We analyzed the relations between blood pressure in sitting and supine positions, left ventricular mass (LVM) and Doppler aortic, pulmonary and mitral flow velocity measurements in 163 healthy school children. Systolic blood pressure in a supine position correlated significantly with aortic acceleration (ATc) and ejection time (ETc), corrected by the square of R-R interval, pulmonary AT and peak flow velocities. Moreover, the systolic blood pressure in a sitting position correlated with pulmonary AT and LVM. LVM correlated with pulmonary ATc, the ratio of AT to ET and average acceleration, and aortic ETc and peak flow velocity. These data suggest the following: (1) the posture influences the relation between blood pressure and flow velocity, (2) pulmonary hemodynamics are influenced by systemic blood pressure in healthy children and (3) the development of LVM may be dependent not only on blood pressure but also on cardiac work in childhood.

Relation between extent of left ventricular hypertrophy and diastolic filling abnormalities in hypertrophic cardiomyopathy

In hypertrophic cardiomyopathy, the relation between left ventricular diastolic impairment and magnitude of left ventricular hypertrophy has not been clearly defined. In the present study, Doppler echocardiographic indexes of left ventricular diastolic filling were compared in 78 patients with hypertrophic cardiomyopathy and in 72 normal control subjects of similar age, and the relation between abnormalities of diastolic filling and magnitude of left ventricular hypertrophy was assessed. In patients with hypertrophic cardiomyopathy, isovolumic relaxation was prolonged (94 +/- 25 ms); peak early diastolic flow velocity (53 +/- 18 cm/s), deceleration of flow velocity in early diastole (341 +/- 142 cm/s2) and the ratio between early and late peaks of flow velocity (1.6 +/- 0.9) were reduced; and peak late diastolic flow velocity was increased (38 +/- 15 cm/s) compared with values in control subjects (76 +/- 12 ms, 65 +/- 12 cm/s, 512 +/- 131 cm/s2, 2.3 +/- 0.8 and 30 +/- 7 cm/s, respectively; p less than 0.001). Individual patient analysis showed that diastolic filling was abnormal in 52 (67%) of the 78 patients with hypertrophic cardiomyopathy. However, within the patient group, none of the Doppler diastolic indexes showed a significant correlation with maximal left ventricular wall thickness or the wall thickness index (correlation coefficients ranged from -0.15 to 0.10).(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical course and prognosis of hypertrophic cardiomyopathy in an outpatient population

Hypertrophic cardiomyopathy has been investigated mainly at referral institutions. Thus, the clinical history of the disease that emerges from published studies could be influenced by a bias in patient selection. In the present study, we compared the clinical features of an outpatient population of 25 patients who had hypertrophic cardiomyopathy with those reported in 78 studies published during the past five years. In the 25 study patients, age, sex, and the extent of left ventricular hypertrophy, as well as the prevalence of diastolic filling abnormalities, subaortic obstruction, and ventricular arrhythmias, were similar to those in patients described in the literature. Cardiac symptoms, however, were much less severe in the study patients. Eighteen patients (72 percent) were asymptomatic, six (24 percent) had mild symptoms, and only one (4 percent) had moderate-to-severe symptoms. Of 24 patients followed for a mean period of 4.4 years (range, 2.9 to 5.7), none died or had clinical deterioration. Of 3404 patients described in the 78 studies we reviewed, 2483 (73 percent) came from only two referral institutions. Of the 1721 patients in whom severity of symptoms was reported, 757 (44 percent) had moderate-to-severe symptoms. However, 727 (96 percent) of these patients were studied at one of the same two referral institutions. We conclude that the natural history of hypertrophic cardiomyopathy may be more benign than can be inferred from published reports.

Alterations in diastolic function in response to progressive left ventricular hypertrophy

To examine the time course of the functional consequences of progressive left ventricular hypertrophy, diastolic left ventricular inflow and wall thinning variables were analyzed in 13 dogs before and 2, 4, 8 and 12 weeks after creation of perinephritic hypertension. Left ventricular echocardiograms were digitized for dimensions, mass and peak rates of wall thinning (-dh/dt/h) and cavity enlargement (dD/dt/D). Doppler recordings of left ventricular inflow were analyzed for peak early (E) and late (A) diastolic inflow velocities, their ratio and atrial filling fraction. At 2 weeks, systolic blood pressure increased from 151 to 233 mm Hg, wall stress from 52 to 80 kdynes/cm2 and posterior wall thickness from 0.68 to 0.84 cm (all p less than 0.05). Left ventricular mass increased from 90 to 115 g over 12 weeks (p less than 0.05). Heart rate, cavity size and systolic shortening were unchanged at all data points. Diastolic abnormalities accompanied the developing hypertrophy and included impairment of early function, as demonstrated by a peak rate of wall thinning, from -13.4 to -8.9 l/s at 2 weeks (p less than 0.05), increased dependence on atrial systolic filling, a decrease in E/A from 1.68 to 1.29 at 4 weeks (p less than 0.05) and an increase in atrial filling fraction from 30% to 43% at 8 weeks (p = NS). Thus, diastolic dysfunction is an early consequence of experimental left ventricular hypertrophy. Different aspects of diastolic impairment are sensitively reflected by echocardiographic Doppler recordings, suggesting that these methods should be useful for the detection of diastolic dysfunction in human patients.

Doppler echocardiography for the diagnosis of acute cardiac allograft rejection

To evaluate the changes in left ventricular filling associated with acute cardiac rejection, serial Doppler echocardiographic examinations were prospectively performed on the same day as endomyocardial biopsy in 55 consecutive patients who successfully underwent orthotopic transplantation and were free of a previous episode of rejection. On average, 8.6 Doppler studies per patient were performed within a 6 month period after transplantation. Recordings of mitral flow were made with pulsed Doppler and two-dimensional echocardiography from an apical four chamber view; isovolumic relaxation time, peak early mitral flow velocity and pressure half-time were measured. The patients were classified into two groups on the basis of the histopathologic findings: group I (25 patients with at least one episode of mild or moderate rejection) and group II (30 patients without rejection). In group I, rejection was associated with a significant decrease of isovolumic relaxation time (p less than 0.005) and especially pressure half-time (p less than 0.0005) with no change in heart rate and peak early mitral flow velocity. In group II, Doppler indexes remained unchanged. These changes were not associated with alterations in left ventricular systolic function assessed by echocardiography. Isovolumic relaxation time and pressure half-time both returned to values similar to baseline values after immunosuppressive therapy (p less than 0.05 and p less than 0.0005, respectively). With 20% decrease in pressure half-time as a criterion for acute rejection, sensitivity was 88%, specificity 87% and positive predictive value 85%. Thus, Doppler echocardiographic evaluation of left ventricular diastolic function provides an excellent tool for early detection of acute rejection and noninvasive monitoring of the cardiac transplant recipient.

Influence of aging on Doppler echocardiographic indices of left ventricular diastolic function

The influence of age on six Doppler echocardiographic indices of left ventricular diastolic function was assessed in 86 normal volunteers aged from 20 to 74 years (mean 36). Five of the six indices showed a linear relation with age. Duration of isovolumic relaxation and maximal late diastolic (atrial) flow velocity increased significantly with age (r = 0.34 and r = 0.69), respectively). Conversely, maximal early diastolic flow velocity, the rate of decrease (deceleration) of flow velocity in early diastole, and the ratio between maximal early and late diastolic flow velocities decreased significantly with age (r = -0.30, r = -0.40, and r = -0.63, respectively). Duration of the early diastolic flow velocity peak did not show a linear relation with age (r = 0.04). Comparison of Doppler indices of diastolic performance among different age groups (20 to 29 years, 30 to 49 years, and 50 to 74 years) also showed an influence of aging on these diastolic variables. Isovolumic relaxation was significantly longer in older subjects than in either the intermediate or the younger age groups. In addition, both the rate of decrease of flow velocity in early diastole and the ratio between maximal early and late diastolic flow velocities were significantly reduced in older subjects. Multivariate linear regression analysis showed that after adjustment for left ventricular wall thickness and cavity dimension, percentage systolic shortening, and heart rate, age continued to correlate significantly with most Doppler indices of diastolic function. The isovolumic relaxation phase and the early and late filling phases of diastole, as assessed by Doppler echocardiography, are importantly and independently affected by aging. Hence the effects of age should be taken into account when the normal limits for Doppler indices of left ventricular diastolic function are defined.

Quantitative applications of Doppler cardiography in congenital heart disease

Doppler ultrasound has rapidly become a valuable tool in the noninvasive investigation of cardiac hemodynamics. Although based on secure principles, accurate application of this methodology to quantitative measurements necessitates a thorough understanding of both Doppler physics and instrumentation. Over the past several years a large body of clinical and animal data verifying the accuracy of Doppler determination of pressure and flow data at various sites in the cardiovascular system, as well as the potential sources of error in acquisition and interpretation of blood velocity recordings, has been published. Quantitative use of Doppler in congenital heart disease, with emphasis on limitations of existing studies and issues particular to this patient population, is reviewed.

Noninvasive assessment of left ventricular diastolic function by pulsed Doppler echocardiography in patients with hypertrophic cardiomyopathy

Hypertrophic cardiomyopathy is a primary myocardial disease in which symptoms may frequently result from impaired left ventricular relaxation, filling and compliance. In the present investigation, Doppler echocardiography was utilized to measure transmitral flow velocity and thereby assess left ventricular diastolic performance noninvasively in a group of 111 patients representative of the broad clinical spectrum of hypertrophic cardiomyopathy. In patients with hypertrophic cardiomyopathy, all Doppler indexes of diastolic relaxation and filling differed significantly (p less than 0.001) from those obtained in 86 control subjects without heart disease, namely, prolongation of isovolumic relaxation (94 +/- 24 versus 78 +/- 12 ms) and of the early diastolic peak of flow velocity (244 +/- 55 versus 220 +/- 28 ms), as well as slower deceleration (3.4 +/- 1.4 versus 4.9 +/- 1.3 m/s2) and reduced maximal flow velocity in early diastole (0.5 +/- 0.2 versus 0.6 +/- 0.1 m/s). As an apparent compensation for impaired relaxation and early diastolic filling, the atrial contribution to left ventricular filling was increased, as shown by increased late diastolic flow velocity (0.4 +/- 0.3 versus 0.3 +/- 0.1 m/s) and reduced ratio of maximal flow velocity in early diastole to that in late diastole (1.4 +/- 0.8 versus 2.1 +/- 0.9). The vast majority of patients with hypertrophic cardiomyopathy (91 [82%] of 111) showed evidence of impaired left ventricular diastolic performance, as assessed from the Doppler waveform. Abnormal Doppler diastolic indexes were identified with similar frequency in patients with (78%) or without (83%) left ventricular outflow obstruction, as well as in patients with (84%) or without (80%) cardiac symptoms. However, patients with nonobstructive hypertrophic cardiomyopathy showed more severe alterations in the Doppler indexes of diastolic function than did patients with obstruction. Thus, abnormal diastolic performance as assessed by Doppler echocardiography was apparent in the vast majority of the study patients with hypertrophic cardiomyopathy, independent of the presence or absence of cardiac symptoms or a subaortic pressure gradient. The high frequency with which diastolic abnormalities are identified in asymptomatic patients with hypertrophic cardiomyopathy suggests that impaired diastolic performance may be present at a time in the natural history of the disease when functional limitation is not yet evident.