Shortened Doppler-derived mitral A wave deceleration time: an important predictor of elevated left ventricular filling pressure

Heart Failure due to High Degree Atrio-Ventricular Block: How Frequent is it and what is the cause?

BACKGROUND

The causes of heart failure (HF) during high-grade atrio-ventricular block (AVB) are poorly understood. This study assessed the mechanisms of HF in patients with AVB.

METHODS

We studied patients presenting (over the period 2012-2016) with high-grade AVB not related to acute myocardial infarction (MI). Patients with preexisting significant valvular heart disease were excluded. All patients underwent comprehensive echocardiographic evaluation during AVB, prior to pacemaker implantation. The diagnosis of HF was based on the Framingham criteria.

RESULTS

122 patients were included in the study, 50% male, average age 76+/-13 years. Twenty-eight (23%) patients with AVB presented with HF. Univariate correlates associated with HF were decrease in cardiac output (CO) [0.67 (95% confidence interval 0.49-0.9) per liter/min, p=0.007], measures of impaired left ventricular (LV) compliance and increase in diastolic mitral regurgitation (MR) volume [1.04 (1.01- 1.07), per cc, p=0.0016]. Ventricular rate during AVB and left-ventricular ejection fraction (LVEF) were not significantly associated with the presence of HF. By multivariate nominal logistic analysis, the best model associated with HF included diastolic MR volume [OR 1.03 (1.00-1.07), p=0.03], A-wave deceleration time [OR 0.96 (0.94-0.98), p=0.001], and CO [OR 0.72 (0.48-1.00), p=0.05], (X²= 30.6; AUC 0.84; p<0.0001 for the entire model).

CONCLUSIONS

In the setting of high-degree AVB, clinical HF occurrence correlates with impaired LV compliance and diastolic MR volume, but not with heart rate or LVEF. The cardiac performance of patients with poor LV compliance and high-volume diastolic MR may show maladjustment to slow heart rates, manifesting as low CO and HF.

Adjuvant radiotherapy-induced cardiac changes among patients with early breast cancer: a three-year follow-up study. Acta Oncol 2019;58:1250-1258. [PMID: 31219359 DOI: 10.1080/0284186x.2019.1630751]

Background: In this study, we evaluate the evolution of cardiac changes during a three-year follow-up after adjuvant breast radiotherapy (RT). Methods: Sixty patients with left-sided and 20 patients with right-sided early stage breast cancer without chemotherapy were included in this prospective study. Echocardiography and cardiac biomarkers were evaluated before, immediately after and 3 years after RT. Radiation doses to cardiac structures were calculated. Results: In echocardiography, left ventricle (LV) systolic measurements had impaired at 3 years compared to baseline: the mean global longitudinal strain (GLS) worsened from -18 ± 3 to -17 ± 3 (p = .015), LV ejection fraction from 62 ± 5% to 60 ± 4% (p = .003) and the stroke volume from 73 ± 16 mL to 69 ± 15 mL (p = .015). LV diastolic function was also negatively affected: the isovolumetric relaxation time was prolonged (p = .006) and the first peak of diastole decreased (p = .022). Likewise, left atrial (LA) measurements impaired. These changes in echocardiography were more prominent in left-sided than in right-sided patients. The concurrent aromatase inhibitor (AI) use was associated with GLS impairment. In all patients, the N-terminal pro-brain natriuretic peptide (proBNP) values were median (interquartile range) 74 (41-125) ng/L at baseline, 75 (41-125) ng/L at the end of RT and 96 (56-162) ng/L at 3 years (p < .001 from baseline to 3 years). However, proBNP did not increase in right-sided patients. Conclusion: During the 3-year follow-up after RT, negative subclinical changes in cardiac biomarkers and in LV systolic and diastolic function were observed. The measured changes were more pronounced in left-sided patients. In addition, AI use was associated with impaired cardiac systolic function.

Usefulness of tissue Doppler imaging to evaluate pulmonary capillary wedge pressure during exercise in patients with reduced left ventricular ejection fraction

The early diastolic transmitral velocity/tissue Doppler imaging mitral annular early diastolic velocity (E/e') ratio is used to estimate left ventricular (LV) filling pressures at rest. However, there are only limited data that validate its use during exercise. Accordingly, the aim of this study was to test the ability of E/e' to estimate pulmonary capillary wedge pressure (PCWP) during symptom-limited exercise in patients with LV systolic dysfunction. Forty patients with severe LV dysfunction and heart failure symptoms (54 ± 12 years, 28 men) underwent simultaneous Doppler assessment of E/e' and right-sided cardiac catheterization at rest and during a symptom-limited exercise test, at steady state levels of 30%, 60%, and 90% of their maximal exercise capacity. During exercise, all 40 patients successfully completed stage 1, yielding 40 pairs of data for comparison. Eighteen patients also successfully completed stage 2, and 5 patients also made it through stage 3, yielding 23 additional data pairs. In total, there were thus 63 pairs of data available during exercise. With exercise, heart rate increased from 77 ± 14 to 112 ± 21 beats/min. Septal E/e' at rest correlated well with PCWP at rest (r = 0.75, p <0.01). PCWP at rest also correlated with resting mitral deceleration time (r = 0.32, p <0.01) and with the transmitral E/A ratio (r = 0.74, p <0.01). During exercise, the correlation between septal E/e' and PCWP was weaker (r = 0.57, p <0.01) and was shifted to the right. This rightward shift was observed in patients with both separated or merged E and A velocities. In conclusion, in patients with severe LV dysfunction, although E/e' allows accurate estimation of PCWP at rest, it appears less reliable for estimating LV filing pressure during exercise.

The evolving concepts of haemodynamic support: from pulmonary artery catheter to echocardiography and theragnostics

Echocardiography is a non-invasive tool, aimed towards the anatomical and functional characterization of the heart. In Intensive Care it is considered nowadays as a necessary tool for patient evaluation. However, the information obtained using echocardiography is not the same as provided by other means, namely the invasive ones. In recent years there has been a significant evolution in the general concepts of haemodynamic support for the critically ill patient. In this new environment, echocardiography has gained particular relevance. In this text the new positioning of echocardiography in the light of the new concepts for hemodynamic support is described, as well as, the need for a specific formative program directed towards Intensive Care physicians. A new generation of biomarkers can also add relevant information and start a new era in haemodynamic support. They may help to further characterize the disease process, identifying patients at risk, as well as, characterize specific organ failure as well as monitoring therapy.

The clinical value of the Tei index among Nigerians with hypertensive heart failure: correlation with other conventional indices

BACKGROUND

Various conventional methods are used for functional evaluation and risk stratification in heart failure. A combined index of global myocardial performance called the Tei index has been described. The aim of this study was to evaluate the correlation of the Tei index with other conventional indices of systolic and diastolic function among Nigerians with hypertensive heart failure.

METHODS

Fifty-five subjects with hypertensive heart failure and 30 controls were examined, a clinical history was taken, and echocardiography was performed on them. The subjects were categorised into four groups based on their ejection fraction (normal ejection fraction, mild, moderate and severe heart failure). The Tei index was calculated as the sum of the isovolumic relaxation and contraction time, divided by the ejection time. Statistical analysis was done using SPSS 16.0.

RESULTS

The Tei index was significantly higher among subjects with hypertensive heart failure compared with the controls (0.91 ± 0.33 vs 0.28 ± 0.16, p < 0.005). The Tei index also increased with the severity of the heart failure and was inversely correlated with ejection fraction (r = -0.697, p < 0.001) and fractional shortening (r = -0.580, p = 0.001). It was directly correlated with mitral E/A ratio (r = 0.246, p = 0.030), left ventricular internal diastolic dimension (r = 0.414, p = 0.002), left ventricular internal systolic dimension (r = 0.596, p < 0.001) and deceleration time (r = 0.219, p = 0.032).

CONCLUSION

The Tei index correlated significantly with other conventional indices of systolic and diastolic function among Nigerians with hypertensive heart failure. It can be used as a risk-stratification index similar to other traditional indices of systolic and diastolic function.

Noninvasive assessment of left ventricular end-diastolic pressure with tissue Doppler imaging in patients with mitral regurgitation

BACKGROUND

The ratio of early transmitral flow velocity to mitral annulus early diastolic velocity (E/Ea) is a widely used noninvasive tool to estimate left ventricular end diastolic pressure (LVEDP). The aim of this study was to explore whether E/Ea ratio was a reliable index for the estimation of LVEDP in patients with mitral regurgitation (MR).

METHODS

Sixteen patients with nonischemic MR (primary MR group; 6 male, 58 ± 12 years) 51 patients with ischemic MR (secondary MR group; 29 male, 63 ± 9 years) and 29 patients without MR (control group; 19 male, 53 ± 10 years) were consecutively included. The peak transmitral flow and mitral annular velocities during early diastole were measured. LVEDP was determined invasively by left heart catheterization.

RESULTS

Primary and secondary MR groups had significantly higher E/Ea ratios and LVEDP than control group. LVEDP significantly correlated with E/Ea ratio in patients with primary MR, but not in patients with secondary MR. Multiple regression analysis revealed that E/Ea ratio was an independent predictor of LVEDP in patients with primary MR. Ten patients with primary MR had LVEDP ≥15 mmHg. ROC analysis demonstrated cutoff values for E/Ea ratios as >10.5 for lateral mitral annulus (sensitivity: 80%, specificity: 66%, PPV: 80%, NPV: 66%) and as >14 for medial mitral annulus (sensitivity: 90%, specificity: 83%, PPV: 90%, NPV: 83%) to predict primary MR patients with LVEDP ≥15 mmHg.

CONCLUSION

E/Ea ratio is still reliable in estimation of LVEDP in primary MR patients while it is not predictive for LVEDP in secondary MR patients.

The effect of cardiac fibrosis on left ventricular remodeling, diastolic function, and N-terminal pro-B-type natriuretic peptide levels in patients with nonischemic dilated cardiomyopathy

BACKGROUND

Cardiac fibrosis is common and associated with poor prognosis in patients with heart failure. We investigated the effect of cardiac fibrosis on the left ventricular (LV) diastolic function, functional capacity, LV remodeling, and biochemical parameters in patients with nonischemic dilated cardiomyopathy (NIDC). In addition, we investigated the biochemical and echocardiographic predictors of cardiac fibrosis in this group.

METHODS AND RESULTS

Forty patients with NIDC were enrolled. Cardiac fibrosis was evaluated according to the presence of late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) imaging. Nineteen patients had cardiac fibrosis (Group I) and 21 patients did not have cardiac fibrosis (Group II). LV systolic and diastolic parameters were assessed with conventional and tissue Doppler echocardiography. N-terminal pro-B-type natriuretic peptide (NT-pro BNP) levels of each patient were recorded. Patients with cardiac fibrosis had impaired diastolic function, higher functional class and NT-pro BNP levels, and significant LV remodeling than the patients without cardiac fibrosis. A correlation analysis revealed that the cardiac fibrosis severity was associated with functional class, cardiac chamber sizes, NT-pro BNP levels, diastolic parameters such as E/Se. A linear regression analysis demonstrated that NT-pro BNP and E/Se were the independent predictors of cardiac fibrosis.

CONCLUSION

Cardiac fibrosis correlates with impaired LV diastolic function and functional capacity, elevated NT-proBNP levels, and adverse cardiac remodeling in patients with NIDC. Therefore, the assessment of cardiac fibrosis can be useful in the management of these patients.

Right ventricular dysfunction in hypertrophic cardiomyopathy as evidenced by the myocardial performance index

BACKGROUND

Left ventricular function in hypertrophic cardiomyopathy (HCM) has been extensively studied, whereas right ventricular function is much less explored. The myocardial performance index (MPI) has been shown to be useful in functional assessment of both ventricles. Furthermore, right ventricular MPI was found to be of predictive value in heart failure due to dilated cardiomyopathy and ischemic heart disease. The aim of this study was, therefore, to evaluate the right ventricular MPI in patients with HCM.

METHODS

Fifty patients with HCM and 250 healthy controls were studied by conventional Doppler echocardiography and Doppler tissue imaging.

RESULTS

Patients showed increased global, 0.48 (0.15) vs. 0.21 (0.14), and regional, 0.71 (0.23) vs. 0.55 (0.17), right ventricular MPI, as compared to controls, p<0.001. Tricuspid annular plane systolic excursion and peak myocardial systolic velocities were also reduced. Patients with dyspnoea had increased global right ventricular MPI (0.53 vs. 0.36, p<0.05) as compared to those without dyspnoea.

CONCLUSION

In the present study, patients with HCM showed evidence of both global and regional right ventricular dysfunction. Previous studies of the right ventricle in HCM have only shown evidence of diastolic dysfunction, contrary to our results, showing impairment of both systolic and diastolic function. This study suggests that HCM should not only be regarded as an isolated disease of the left ventricle, but rather as a biventricular disease. The predictive value of our findings in HCM needs to be assessed in a separate study with special reference to those with and without dyspnoea.

Assessment of severity in aortic stenosis-incremental value of endocardial function parameters compared with standard indexes

Several studies have reported that patients (pts) with severe aortic stenosis and similar pressure gradients or even similar aortic valve areas may have quite different symptomatic status and clinical outcomes suggesting that other factors might have a significant impact on the pathophysiology of this disease. Our purpose was to assess the severity of subendocardial wall dysfunction in symptomatic and asymptomatic pts with aortic stenosis using tissue Doppler imaging (TDI), strain rate imaging (SRI) and cyclic variation of integrated backscatter (IB). We studied 68 pts with aortic valvar stenosis and 46 subjects with no signs of heart disease. SRI/IB indexes were calculated in the apical four chambers views at endocardial level. Early diastolic endocardial strain rate showed the best correlation with transvalvar pressure gradients and valve areas. Compared with controls, symptomatic pts showed a more marked decrease in endocardial strain, strain rate and cyclic variation of IB. Receiver operating characteristic (ROC) curves suggested that the thresholds offering an adequate compromise between sensitivity and specificity for the prediction of symptoms were >/=60 mm Hg for the pressure gradient, less than 0.60 cm(2)/m(2) for aortic valve area, less than 20% for strain, less than 2.0 s(-1) for strain rate and less than 3.0 dB for cyclic variation. The combination of pressure gradient, aortic valve area and SRI/IB parameters resulted in an improvement of the overall performance for predicting the symptomatic state. Thus, SRI/IB parameters have an incremental value in differentiating symptomatic and asymptomatic pts with aortic stenosis compared with conventional hemodynamic parameters.

[Evaluation of diastolic function in patients with constrictive pericarditis before and after pericardectomy]

PURPOSE

The aim of the study was to evaluate diastolic function in patients with constrictive pericarditis using velocity-encoded flow measurements before and after pericardectomy.

MATERIALS AND METHODS

Velocity-encoded flow measurements were performed at the atrioventricular valves in nine patients with constrictive pericarditis. The resulting flow curves were evaluated. For assessment of diastolic function the amplitudes of the E and A waves were measured and the E to A wave ratios calculated. Appearance of mid-diastolic flow, indicating diastolic dysfunction, was registered.

RESULTS

The measurements at the mitral valves prior to pericardectomy revealed diastolic dysfunction grade I in two patients, grade II in three patients, and grade III in three patients. Mid-diastolic flow was detected in two patients. At the tricuspid valves diastolic dysfunction grade I was present in two patients, grade II in four patients, and grade III in three patients. Improvement of diastolic function after pericardectomy was documented in five patients at the mitral valve and in two patients at the tricuspid valve.

CONCLUSION

Velocity-encoded flow measurements are feasible and a valuable tool for assessment of diastolic function in patients with constrictive pericarditis prior to and after pericardectomy.

Long-term prognostic value of an index of myocardial performance in patients with myocardial infarction

BACKGROUND

The Tei index of myocardial performance (IMP), which combines parameters of both systolic and diastolic ventricular function, is a useful prognostic factor in many clinical settings.

HYPOTHESIS

This study assessed the long-term prognostic value of IMP in patients discharged from hospital after acute myocardial infarction (AMI).

METHODS

Doppler/echocardiographic studies were recorded in 90 consecutive patients on Day 14 +/- 2 following an AMI. The IMP was calculated from the Doppler recordings, as a sum of isovolumetric contraction time and isovolumetric relaxation time, divided by the ejection time.

RESULTS

The patients were followed for an average (SD) of 57.8 (16.1) months. During this period there were 22 (24%) cardiac events, defined as cardiac deaths (10) or nonfatal recurrent myocardial infarctions (12). After multivariate Cox analysis, Tei index > 0.55 (relative risk [RR] 4.45; 95% confidence interval [CI] 1.28-15.45; p = 0.019), LV end-systolic volume > 65 ml (RR 3.23; 95% CI 1.34-7.79; p = 0.009), and mitral E wave deceleration time < or = 0.145 s (RR 2.94; 95% CI 1.24-6.92; p = 0.014) were the only independent predictors of cardiac events during the follow-up period. In a subgroup of patients with preserved LV systolic function (ejection fraction > 0.40), IMP was the only predictor of cardiac events (RR 6.37; 95% CI 1.32-30.77, p = 0.02).

CONCLUSIONS

The Tei index of myocardial performance, which is simple and easy to calculate, is a useful tool for risk assessment in patients following myocardial infarction, and in a subgroup of patients with normal or only mildly impaired systolic function.

Effects of losartan + L-arginine on nitric oxide production, endothelial cell function, and hemodynamic variables in patients with heart failure secondary to coronary heart disease

The purpose of the present study was to evaluate the effects of losartan and the combination of losartan and L-arginine on endothelial function and hemodynamic variables in patients with heart failure (HF). Endothelium-dependent vasodilation is impaired in patients with HF. It was hypothesized that the administration of losartan and the combination of losartan and L-arginine might increase nitric oxide production and have a beneficial additive effect on endothelial function and hemodynamic variables in patients with HF. Nine patients with HF (ejection fraction<35%) were given losartan 50 mg orally on 2 consecutive days. On the second day, 1 hour after losartan 50 mg administration, L-arginine 20 g was given by intravenous infusion. Endothelial function in the form of endothelium-dependent brachial artery flow-mediated vasodilation (FMV) was measured by ultrasound. Hemodynamic variables were estimated using Doppler echocardiography at baseline and at 2 and 4 hours after losartan alone and after combination therapy. Urinary levels of nitrite (NO2) or nitrate (NO3) were measured. Four hours after losartan administration, significant reductions in systemic vascular resistance and estimated end-systolic elastase were observed. On the second day, 1 hour after L-arginine infusion, an additive hemodynamic effect was observed, with significant increases in the cardiac index and stroke volume and significant reductions in systemic vascular resistance and calculated left ventricular end-diastolic pressure. A trend toward improved FMV was observed with losartan alone, but without statistical significance. Combination therapy significantly improved postintervention FMV compared with baseline. The increase in urinary nitric oxide excretion after losartan treatment and combination therapy was significantly correlated with improved hemodynamic variables and improved FMV. In conclusion, losartan induces significant afterload reduction, reduced contractility, and increased nitric oxide urinary excretion. The combination of L-arginine and losartan seems to have superior effects on hemodynamic variables and endothelium-dependent vasodilation compared with losartan alone.

The Utility of Pulsed Tissue Doppler Parameters for the Diagnosis of Advanced Left Ventricular Diastolic Dysfunction

OBJECTIVE

The evaluation of diagnostic value of pulsed tissue Doppler (TD) parameters (calculated from six points of mitral annulus and separately measured in the lateral part of mitral annulus) for the detection of pseudonormal mitral inflow pattern.

METHODS AND RESULTS

Among 200 persons examined by transthoracic echocardiography group with E/A value between 1 and 2 was selected and divided to normal (54 subjects, early wave deceleration time, Edt > or = 150 msec) and pseudonormal (23 patients, Edt < 150 msec together with prolonged difference between duration of atrial reversal flow in pulmonary vein and mitral flow in atrial phase, delta Ar > or = 20 msec) inflow. Wide spectrum of TD parameters was compared between the selected groups. In normal inflow, average peak velocities of early and atrial phase of diastolic mitral annulus motion were significantly higher: 11.0 +/- 2.6 versus 8.9 +/- 3.5 cm/sec; (P = 0.005) and 12.0 +/- 2.2 versus 10.0 +/- 3.0 cm/sec; (P = 0.002), respectively. Ratio of peak early mitral wave velocity to peak velocity of annulus motion in early phase (Ev/E'v avr) was higher in the pseudonormal pattern: 9.8 +/- 3.7 versus 7.0 +/- 2.0, respectively (P < 0.001). For the value of Ev/E'v avr > 10.2, 70% accuracy for the diagnosis of pseudonormalization was detected. For the parameters measured in the lateral part of mitral annulus similar relationships in the early filling phase were detected but did not reach statistical significance in the atrial phase.

CONCLUSIONS

Pulsed TD offers good accuracy for the diagnosis of pseudonormalization with increased ratio of peak early mitral wave velocity to peak velocity of mitral annulus being the optimal predictor of advanced diastolic dysfunction.

Quantitative assessment of systolic and diastolic ventricular function with tissue Doppler imaging after Fontan type of operation

BACKGROUND

There is evidence that "inappropriate hypertrophy" of the single left ventricle, which occurs as a result of acute preload reduction, leads to adverse consequences on ventricular function. However, a systematic study of the capability of tissue Doppler imaging (TDI) to assess systolic and diastolic ventricular functions after the Fontan procedure is still missing.

METHODS

Twenty-four postoperative patients aged 12-33 years were prospectively evaluated with two-dimensional echocardiography equipped with TDI capabilities. Nineteen age-matched normal subjects were selected as controls. Good-quality echoes for the measurement of ejection fractions were available in 21 patients. Ten patients (group 1) had systolic dysfunction (ejection fraction < 50%), and 11 patients (group 2) had normal systolic function. Peak systolic and diastolic wall velocities were acquired from the two-chamber view in the myocardia and mitral annulus.

RESULTS

Compared with controls, the Fontan patients had a significantly reduced peak systolic velocity at wall and annulus sites. A linear correlation existed between ejection fraction and systolic myocardial velocity from the annular sites. Group 1 patients had lower wall velocities and lower annulus velocities both in systole and diastole. Group 2 patients had preserved systolic velocities but decreased regional and annular early diastolic velocities, suggesting impaired filling. Multiple correlation analysis showed a relation between peak early diastolic mitral velocity and ventricular ejection fraction, mean mitral annular motion at systole, mass/volume ratio, and the number of years post Fontan revision.

CONCLUSIONS

Myocardial velocities recorded after the Fontan operation give insight into systolic and diastolic ventricular functions. The peak systolic mitral annular velocity correlated well with the ventricular ejection fraction. The peak early diastolic velocity and the ratio between the early and late diastolic mitral annular velocity are reduced and reflect diastolic dysfunction even in the presence of normal systolic ejection fraction.

Preload-adjusted right ventricular maximal power: concept and validation

Right ventricular (RV) maximal power (PWRmx) is dependent on preload. The objective of this study was to test our hypothesis that the PWRmx versus end-diastolic volume (EDV) relationship, analogous to the load-independent stroke work (SW) versus EDV relationship (preload-recruitable SW, PRSW), is linear, with the PWR x-axis intercept (V0PWR) corresponding to the PRSW intercept (V0SW). If our hypothesis is correct, the preload sensitivity of PWRmx could be eliminated by adjusting for EDV and V0PWR. Ten dogs were instrumented with a pulmonary flow probe, micromanometers, and RV conductance catheter. Data were obtained during bicaval occlusions under various conditions and fitted to PWRmx = a·(EDV − V0PWR)β, where a is the slope of the relationship. The PWRmx versus EDV relationship did not deviate from linearity (β = 1.09, P = not significant vs. 1), and V0PWR correlated with V0SW ( r = 0.93, P <0.0001). V0PRW was related to steady-state EDV and left ventricular end-diastolic pressure, allowing for estimation of V0PWR (V0Est) and single-beat PWRmx preload adjustment. Dividing PWRmx by the difference of EDV and V0PWR (PAMPV0PWR) eliminated preload dependency down to 50% of the baseline EDV. PWRmx adjustment using V0Est (PAMPV0Est) showed similar preload independency. Enhancing contractility increased PAMPV0PWR and PAMPV0Est from 176 ± 52 to 394 ± 205 W/ml × 104 and 145 ± 51 to 404 ± 261 W/ml × 104, respectively, accompanied by an increase of PRSW from 13.0 ± 4.5 to 29.7 ± 16.4 mmHg (all P <0.01). PAMPV0PWR and PAMPV0Est correlated with PRSW ( r = 0.85; r = 0.77; both P <0.001). Numerical modeling confirmed the accuracy of our experimental data. Thus preload adjustment of PWRmx should consider a linear PWRmx versus EDV relationship with distinct V0PWR. PAMPV0PWR is a preload-independent estimate of RV contractility that may eventually be determined noninvasively.

Usefulness of tissue Doppler imaging for estimation of filling pressures in patients with primary or secondary pure mitral regurgitation

Mitral annular velocities derived from tissue Doppler (S', E', A') and left ventricular (LV) end-diastolic pressures were obtained in 11 patients with significant primary mitral regurgitation (MR), 26 patients with significant MR secondary to ischemic or dilated cardiomyopathy, and in 29 asymptomatic controls. The mitral E/E' ratio was related significantly to LV end-diastolic pressure in patients with secondary, but not in patients with primary MR. In patients with secondary MR, a mitral E/E' ratio >15 predicted an elevated LV end-diastolic pressure with a sensitivity of 80% and a specificity of 100%. Thus, the mitral E/E' ratio is a reliable estimate of filling pressures only in subjects with significant secondary, but not with significant, primary MR.

Novel approach to measure myocardial performance index: pulsed-wave tissue Doppler echocardiography

A simple, reproducible, noninvasive myocardial performance index (MPI) for the assessment of overall cardiac function has been described previously. The purpose of this study was to compare the MPI obtained by pulse Doppler method with the MPI obtained by tissue Doppler echocardiography (TDE) in normal subjects and patients with dilated cardiomyopathy (DCMP). Fifteen patients with DCMP and 15 healthy subjects were included. In order to calculate MPI by TDE, isovolumetric contraction (IVCT), relaxation time (IVRT), and ejection time (ET) were measured at two different sites of mitral annulus: septum and lateral. MPI was calculated by dividing the sum of IVCT and IVRT by ET at each site of measurement. The mean MPI value was found by dividing the sum of these MPI values into two. The same parameters were measured using the mitral inflow and left ventricular outflow velocity time intervals in pulsed Doppler method. At all sites measured, MPI by TDE correlated well with conventional MPI both in healthy subjects and patients with DCMP. The highest correlation was observed in mean values of MPI by TDE:r = 0.94, P < 0.0001in healthy subjects; andr = 0.95, P < 0.0001in patients with DCMP. In conclusion, this study clearly demonstrated that MPI could be measured by TDE and it correlated well with conventional MPI in normal and diseased heart.

Doppler-derived left ventricular end-diastolic pressure prediction model using the combined analysis of mitral and pulmonary A waves in patients with coronary artery disease and preserved left ventricular systolic function

The aim of this study was to analyze the components of mitral and pulmonary A waves and to construct a Doppler-derived left ventricular (LV) end-diastolic pressure (EDP) prediction model based on the combined analysis of transmitral and pulmonary venous flow velocity curves. Combined analysis of transmitral and pulmonary venous flow velocity curves at atrial contraction is a reliable predictor of increased LV filling pressure. The duration of pulmonary and mitral A waves is determined by the sum of respective acceleration and deceleration time. Mitral flow and left upper pulmonary vein flow velocity curves were recorded simultaneously with LVEDP in 40 consecutive patients (aged 59 +/- 8 years) with coronary artery disease and preserved LV systolic function. Differences in all parameters represent values of pulmonary minus those of mitral A wave curve. The difference in deceleration time was the strongest candidate, being included in all models. After redundancy evaluation, we reached the following model: LVEDP = 20.61 + 0.229 x difference in deceleration time (r(2) = 0.80, p <0.001). In the entire study group, the difference in duration and in deceleration time of the A wave was highly correlated with LVEDP (r = 0.79, p <0.001, and r = 0.88, p <0.001, respectively). The entire study group was further divided according to whether LVEDP was above (group I, 20 patients) or below (group II, 20 patients) the median value (15.5 mm Hg). In group I, the difference in duration and in deceleration time correlated well (r = 0.62, p = 0.01, and r = 0.75, p = 0.001, respectively) with LVEDP, whereas in group II only the difference in deceleration time correlated well (r = 0.68, p = 0.005). In patients with coronary artery disease and preserved LV systolic function, the combined analysis of mitral and pulmonary A waves can predict LVEDP. The difference in deceleration time between pulmonary and mitral A waves can reliably evaluate high and normal LVEDP.

Severe aortic valve stenosis with preserved and reduced systolic left ventricular function: diagnostic usefulness of the Tei index

BACKGROUND

In patients with severe aortic valve stenosis (AS), the onset of heart failure is associated with increased mortality and higher operative risk. Heart failure may result from either systolic, diastolic, or "overall" left ventricular dysfunction. The index "isovolumic contraction time and isovolumic relaxation time divided by ejection time" was shown to be a sensitive indicator of "overall" cardiac dysfunction in patients with dilated cardiomyopathy and cardiac amyloidosis. We sought to define the role of the Tei index in patients with severe AS and to validate this index against conventional measures of systolic and diastolic LV function.

PATIENTS AND METHODS

Fifty-three participants underwent left heart catheterization for invasive measurement of LV end-diastolic pressure as a marker of diastolic function: 10 AS patients (valve orifice 0.6 +/- 0.2 qcm) with depressed systolic LV function (defined by LV ejection fraction < or = 45% [mean 32% +/- 8%], 7 male/3 female, 72 +/- 10 years old, DAS group), 22 AS patients (valve orifice 0.7 +/- 0.2 qcm) with preserved systolic LV function (ejection fraction > 45% [mean 55% +/- 6%], 13 male/9 female, 71 +/- 11 years old, PAS group) and 21 asymptomatic control participants (ejection fraction > 45% [mean 62% +/- 8%], 14 male/7 female, 66 +/- 8 years old, CON group). Within 24 hours from catheterization, conventional 2-dimensional and Doppler echocardiographic examination including measurement of the Tei index was performed.

RESULTS

LV end-diastolic pressure was elevated in the DAS and in the PAS group in comparison with control participants (32 +/- 6 mm Hg and 22 +/- 7 mm Hg vs 11 +/- 4 mm Hg, respectively, P <.01 for both comparisons). DAS patients were in a higher New York Heart Association functional class than PAS patients (3.2 +/- 0.4 vs 2.2 +/- 0.4, P <.001) The Tei index was easily and reproducibly obtained in all study participants. In the DAS group, isovolumic contraction time was prolonged and ejection time was shortened in comparison with the CON group (102 +/- 20 ms vs 52 +/- 15 ms, P <.01; and 235 +/- 44 ms vs 316 +/- 45 ms, P <.01), resulting in a significantly increased Tei index (0.78 +/- 0.28 vs 0.40 +/- 0.11, P <.01). In the PAS group, isovolumic relaxation time was shortened (62 +/- 18 ms vs 81 +/- 26 ms for the CON group, P <.01) and ejection time was prolonged (335 +/- 34 ms vs 316 +/- 45 ms for the CON group, P <.05), resulting in a decreased Tei index (0.29 +/- 0.12 vs 0.40 +/- 0.11, P <.05). Receiver operating characteristic curve analysis for the Tei index yielded an area under the curve of 0.98 +/- 0.03 for separating DAS and PAS patients. Using a Tei index greater than 0.42 as a cutoff, DAS patients were identified with a sensitivity of 100% and a specificity of 91%.

CONCLUSION

The Tei index is significantly increased in patients with severe AS and depressed overall cardiac LV function. In AS patients with predominant diastolic dysfunction, in whom systolic function is preserved, the index is decreased in comparison with control patients. The index differentiates between symptomatic AS patients with depressed and less symptomatic AS patients with preserved systolic LV function, and may thus provide relevant information in the work-up and care of such patients.

Impact of disease activity on left ventricular performance in patients with acromegaly

BACKGROUND

In patients with acromegaly, abnormalities of systolic and diastolic left ventricular (LV) performance, mostly associated with hypertension or LV hypertrophy, have been reported. We used 2-dimensional/Doppler echocardiographic methods and tissue Doppler imaging (TDI) to elucidate the impact of disease activity on LV function in patients with acromegaly.

METHODS

In a prospective study design, 15 patients with active acromegaly (AA group; mean age-adjusted serum insuline-like growth factor-I [IGF-I] level, 420 +/- 170 ng/mL, mean growth hormone nadir during 75-g oral glucose load, 12.3 +/- 30.1 microg/L), 18 patients with cured (n = 14, mean IGF-I level 205 +/- 115 ng/mL, mean growth hormone nadir during glucose load 0.72 +/- 0.34 microg/L) or well-controlled (n = 4, normal age-adjusted ranges of IGF-I levels with medication with somatostatin analogues 354 +/- 88 ng/mL) acromegaly (CA group), and 24 control subjects (control group) underwent 2-dimensional/Doppler echocardiographic measurements, including assessment of the Tei index (isovolumic contraction time and isovolumic relaxation time divided by ejection time). Systolic and diastolic mitral annular velocities (peak systolic velocity, peak early diastolic velocity [E'], peak late diastolic velocity [A'], E'/A' ratio) were derived from pulsed TDI.

RESULTS

No significant differences between study groups were observed with respect to muscle mass and systolic parameters, such as ejection fraction, fractional shortening, and peak systolic velocity. In patients with AA, E' and the E'/A' ratio were lower than in control and CA subjects (AA 6.8 +/- 1.7 cm/s, control 10.0 +/- 1.7 cm/s, CA 9.1+/- 3.0 cm/s, P <.01 AA vs control, P <.05 AA versus CA, AA 0.68 +/- 0.22, control 0.98 +/- 0.16, CA 0.89 +/- 0.37, P <.01 AA vs control and CA, respectively). In comparison with control subjects and patients with CA, patients with AA had a reduced mitral peak velocity of early/late filling ratio (AA 0.78 +/- 0.22 m/s, control 1.12 +/- 0.33 m/s, CA 1.11 +/- 0.36 m/s, P <.05 AA vs control and CA) and a prolonged deceleration time (AA 223 +/- 41 ms, control 188 +/- 26 ms, CA 185 +/- 25 ms, P <.05 AA vs control and CA). The Tei index was significantly elevated in patients with AA in comparison with control subjects and patients with CA (AA 0.54 +/- 0.13, control 0.40 +/- 0.09, CA 0.44 +/- 0.10, P <.05 AA vs control and CA). No significant differences were observed between control subjects and patients with CA with respect to mitral flow-derived variables, TDI parameters, and the Tei index.

CONCLUSION

Disease activity has a significant impact on LV performance in patients with acromegaly. In subjects with active disease, diastolic dysfunction and beginning impairment of overall LV performance are present. In patients with cured/well-controlled disease, systolic and diastolic function appear normal.

Acromegaly: evidence for a direct relation between disease activity and cardiac dysfunction in patients without ventricular hypertrophy

BACKGROUND AND AIMS

Cardiac abnormalities, such as cardiomegaly and congestive heart failure, occur frequently in advanced acromegaly. Abnormalities of systolic and diastolic function, mostly associated with left ventricular (LV) hypertrophy, have been reported. The impact of disease activity on LV performance in patients with normal or slightly elevated LV muscle mass has not been demonstrated.

PATIENTS AND METHODS

Conventional two-dimensional/Doppler echocardiography and tissue Doppler imaging (TDI) of the mitral annulus were performed in 13 patients with active acromegaly (AA) and normal or slightly elevated LV muscle mass (< 140 g/m2) and in 19 cured/well-controlled patients (CA). A group of 21 volunteers without symptoms or signs of cardiac disease served as controls (CON). The combined myocardial performance index (Tei-Index) was determined in all patients and controls.

RESULTS

Muscle mass index of the left ventricle, ejection fraction, fractional shorting, E/ET-ratio, systolic (ST) and late diastolic (AT) annular velocities did not differ significantly between the three groups. In the AA group, the early diastolic annular velocity ET[7.13 +/- 2.11 (AA); 9.83 +/- 3.29 (CA); 10.10 +/- 1.70 m/s (CON); P < 0.05 AA vs. CA, P < 0.005 AA vs. CON] and the ET/AT-ratio [0.71 +/- 0.26 (AA); 0.95 +/- 0.33 (CA); 1.00 +/- 0.15 m/s (CON); P < 0.05 AA vs. CA, P < 0.005 AA vs. CON] were significantly reduced. Patients with AA had a longer deceleration time [209 +/- 19 (AA); 179 +/- 22 (CA); 185 +/- 26 ms (CON); P < 0.05]. The Tei-Index was significantly higher in AA in comparison with CON [0.50 +/- 0.15 (AA); 0.48 +/- 0.12 (CA); 0.41 +/- 0.10 (CON); P < 0.05 AA vs. CON]. Subjects with CA did not differ significantly from controls with respect to 2-D/Doppler echo- and TDI-derived parameters.

CONCLUSION

The data demonstrate that diastolic dysfunction can be verified by tissue Doppler imaging in patients with active acromegaly with normal or slightly elevated muscle mass of the left ventricle and seems to be related to disease activity. The Tei-Index as a sensitive combined myocardial performance index can be used to complete the assessment of systolic and diastolic LV performance in acromegalic patients.

Chronic mitral regurgitation and Doppler estimation of left ventricular filling pressures in patients with heart failure

Previous studies relating Doppler parameters and pulmonary capillary wedge pressures (PCWP) typically exclude patients with severe mitral regurgitation (MR). We evaluated the effects of varying degrees of chronic MR on the Doppler estimation of PCWP. PCWP and mitral Doppler profiles were obtained in 88 patients (mean age 55 +/- 8 years) with severe left ventricular (LV) dysfunction (mean ejection fraction 23% +/- 5%). Patients were classified by severity of MR. Patients with severe MR had greater left atrial areas, LV end-diastolic volumes, and mean PCWPs and lower ejection fractions (each P <.01). In patients with mild MR, multiple echocardiographic parameters correlated with PCWP; however, with worsening MR, only deceleration time strongly related to PCWP. From stepwise multivariate analysis, deceleration time was the best independent predictor of PCWP overall, and it was the only predictor in patients with moderate or severe MR. Doppler-derived early mitral deceleration time reliably predicts PCWP in patients with severe LV dysfunction irrespective of degree of MR.

Feasibility and accuracy of transthoracic Doppler echocardiographic estimation of pulmonary capillary wedge pressure applying different methods

BACKGROUND

Pulmonary wedge pressure (PWP) is an established index of cardiac function and an essential component in the management of patients with congestive heart failure and in critically ill patients.

AIM

To evaluate feasibility and accuracy of non-invasive prediction of PWP by Doppler echocardiography in daily clinical practice.

METHODS

Agreement was assessed between values predicted by Doppler vs. invasively measured PWP. Forty-five consecutive patients [mean (S.D.) age 62 (10) years] with CAD (44%), DCMP (40%) and without structural heart disease (16%) were studied (EF< or =40% in 58% of the patients). Doppler transmitral and pulmonary venous flow velocity profiles were recorded. For binary and quantitative prediction of PWP, four different methods and five different linear equations, suggested previously in the literature, were evaluated.

RESULTS

Predictive values to identify elevated PWP were highest for pulmonary venous flow reversal exceeding the duration of forward mitral flow during atrial systole (PPV 1 and NPV 0.96). Likewise, agreement with measured PWP was highest for equations comprising both transmitral and pulmonary venous flow variables (relative mean difference 0.11, S.D.+/-4.01 mmHg for the most accurate equation). Feasibility was slightly, but not statistically, lower when pulmonary venous flow was considered vs. transmitral flow parameters alone for binary prediction (87 vs. 93%) as well as for quantitative assessment (82 vs. 93%).

CONCLUSION

Semiquantitative prediction of elevated PWP by Doppler echocardiography is feasible as well as accurate in daily clinical practice. However, accuracy of numeric estimates is limited. Hence, invasive measurement of PWP is still necessary in certain clinical settings.

Mitral regurgitation and left ventricular diastolic dysfunction similarly affect mitral and pulmonary vein flow Doppler parameters: the advantage of end-diastolic markers

Enhanced early mitral flow and reduced systolic pulmonary vein flow may be caused both by increased left ventricular pressure as the result of diastolic dysfunction and by increased transmitral flow as the result of mitral regurgitation. Nevertheless, Doppler parameters are widely used to predict left ventricular filling pressure. We aimed to analyze the interference of mitral regurgitation with Doppler parameters usually used to estimate left ventricular filling pressure and to identify markers independent of mitral regurgitation, which could reliably estimate increased left ventricular filling pressure. Eighty-four patients (age, 62 +/- 9 years; 82% men) had a complete echocardiographic Doppler examination. Transmitral E- and A-wave velocity, E deceleration time and A duration, pulmonary vein systolic and diastolic velocities, and reversal flow duration and maximal and minimal left atrial volumes were measured. The difference between the duration of pulmonary vein and mitral A waves was calculated (A'-A). Mitral regurgitant volume was quantitatively assessed by echocardiography. Left ventricular end-diastolic pressure was measured invasively. Patients had a wide range of left ventricular ejection fraction (14% to 70%), mitral regurgitant volume (0 to 94 mL), and left ventricular end-diastolic pressure (3 to 37 mm Hg). E velocity, E/A, pulmonary vein systolic and diastolic, and systo-diastolic ratios were significantly and independently correlated with both left ventricular end-diastolic pressure and mitral regurgitant volume. A'-A showed a strong correlation with left ventricular end-diastolic pressure (r = 0.70; P <.0001), but the relation with mitral regurgitant volume was not significant (r = 0.19; P =.08). Mitral regurgitation affects the majority of Doppler parameters widely used to predict filling pressure but does not influence Ad'-Ad, which proved to be the strongest predictor of left ventricular end-diastolic pressure.

The echo-Doppler evaluation of left ventricular diastolic function. A current perspective

The role of left ventricular (LV) diastolic function in health and disease is still incompletely understood and under appreciated by most primary care physicians and many cardiologists. Physical examination, electrocardiogram, and chest radiographs are unreliable in making the diagnosis of LV diastolic dysfunction in most individuals, and invasive measurements of cardiac pressures, rates of LV relaxation, and LV compliance are costly, clinically impracticable as they carry increased risk, and require special catheters and software analysis programs. The authors address the definition of LV diastolic dysfunction, history of diastole, LV filling patterns, pulmonary venous flow velocity variables, additional ancillary data, practical echo-Doppler evaluation of LV diastolic function, and limitations.

Noninvasive assessment of left ventricular end-diastolic pressure by the response of the transmitral a-wave velocity to a standardized Valsalva maneuver

Impaired relaxation is frequently masked by elevated filling pressures, resulting in a pseudonormal flow pattern (E/A >1.0). Because the E/A wave ratio increases as filling pressures rise, it is generally assumed that patients with an E/A ratio of <1.0 (impaired relaxation pattern) have relatively low filling pressures. Nevertheless, patients with an E/A ratio of <1.0 can have as profoundly elevated filling pressures as patients with a pseudonormal or restrictive filling pattern. Because left ventricular (LV) pressure during end-diastole essentially determines atrial afterload, the response of the A-wave velocity to a reduction of atrial afterload by a standardized Valsalva maneuver should allow estimation of LV end-diastolic pressure (LVEDP) regardless of the baseline Doppler flow pattern. This was tested in 20 consecutive patients who were studied by pulse-wave Doppler echocardiography during cardiac catheterization. There was a close correlation between LVEDP and the change in A-wave velocity during the Valsalva maneuver (r = 0.85, SEE 6.7 mm Hg) regardless of the baseline E/A ratio. In patients with a LVEDP of <15 mm Hg the A wave decreased by 21 +/- 15 cm/s. In patients with a LVEDP of >25 mm Hg the A wave increased by 18 +/- 13 cm/s. The change in the E/A ratio during Valsalva correlated fairly with LVEDP (r = -0.72, SEE 8.8 mm Hg), the baseline E/A ratio correlated poorly, and scatter was substantial (r = 0.46, SEE 11.2 mm Hg). Just as elevated filling pressures can mask impaired relaxation, the impaired relaxation pattern can mask the presence of elevated filling pressures. This can be revealed by testing the response of the A wave to the Valsalva maneuver, allowing estimation of LVEDP independent of the baseline E/A ratio.

Serial assessment of left ventricular diastolic function after Fontan procedure

OBJECTIVE

To assess longitudinal changes in systemic ventricular diastolic function late after the Fontan procedure.

DESIGN AND PATIENTS

Prospective study of 13 patients at 2.8 (2.0) years (early) and again at 11.4 (2.0) years (late) after the Fontan procedure by Doppler echocardiography with simultaneous ECG, phonocardiogram, and respirometer.

SETTING

Tertiary paediatric cardiac centre.

RESULTS

The isovolumic relaxation time (IVRT) was significantly longer, and E wave deceleration time, E and A wave velocities, and E:A velocity ratio were reduced compared to normal both early and late after the procedure. The mean (SD) z score of IVRT decreased significantly from +2.50 (1.00) to +1.24 (0.80) (p = 0.002), and the z score of the E wave deceleration time decreased from -1.69 (1.31) to -2.40 (1.47) (p = 0.03) during follow up. The A wave deceleration time also tended to decrease (early 80 (12) ms v late 73 (11) ms, p = 0.13) with increased follow up. There were no changes of the E and A wave velocities and E:A velocity ratio. The E wave velocity was inversely related to IVRT both early (r = -0.82, p = 0.001) and late (r = -0.59, p = 0.034) after the operation. The prevalence of diastolic flow during isovolumic relaxation decreased from 85% (11/13) to 38% (5/13) (p = 0.04), while that of mid diastolic flow increased from 23% (3/13) to 77% (10/13) (p = 0.02) between the two assessments.

CONCLUSIONS

Left ventricular diastolic function remains highly abnormal late after the Fontan procedure. The longitudinal changes demonstrated on follow up are compatible with reduction of left ventricular compliance in addition to persisting abnormalities of relaxation.

N-terminal proatrial natriuretic peptide correlates with systolic dysfunction and left ventricular filling pattern in patients with idiopathic dilated cardiomyopathy

OBJECTIVE

To investigate the diastolic Doppler filling pattern in patients with idiopathic dilated cardiomyopathy and its relation to N-terminal pro-atrial natriuretic peptide (NT-pro-ANP).

METHODS

32 patients (26 male, six female) with idiopathic dilated cardiomyopathy were investigated. All were in sinus rhythm. Conventional M mode echocardiography and Doppler echocardiography was done in each patient. Pulsed wave Doppler inflow signals were obtained and the following variables were measured: maximum E wave, maximum A wave, E/A ratio, E wave deceleration time, A wave deceleration time. NT-pro-ANP was measured using radioimmunoassay.

RESULTS

Mean (SD) left ventricular ejection fraction was 34 (7)% and mean left ventricular end diastolic diameter on M mode echocardiography was 69 (7) mm. Left ventricular filling indices were as follows: maximum E wave velocity, 0.86 (0.22) m/s; maximum A wave velocity, 0.71 (0.24) m/s; E/A ratio, 1.41 (0.65). Mean E wave deceleration time was 140 (50) ms; mean A wave deceleration time was 100 (20) ms. In a stepwise forward regression model, NT-pro-ANP correlated significantly with left atrial diameter (r = 0.603; p < 0. 001), left ventricular ejection fraction (r = -0.758; p < 0.001), and Doppler derived E/A ratio (r = 0.740; p < 0.001).

CONCLUSIONS

In patients with idiopathic dilated cardiomyopathy there is a relation between NT-pro-ANP and both systolic and diastolic variables. In a multivariate model NT-pro-ANP correlated with left atrial diameter, left ventricular ejection fraction, and Doppler derived E/A ratio on transmitral inflow.

M-mode analysis of mitral annulus motion for detection of pseudonormalization of the mitral inflow pattern

Left ventricular (LV) diastolic dysfunction is a frequent cause of heart failure. Doppler echocardiography has become the method of choice for the noninvasive evaluation of LV diastolic dysfunction. However, pseudonormalization of mitral inflow often presents a diagnostic problem in clinical practice. We sought to define the role of mitral annulus motion in this setting. We performed echocardiography in 36 consecutive subjects (age 59 +/- 10 years). Eighteen had recently (within 3 months) been diagnosed with coronary artery disease, 18 had clinical suspicion of coronary artery disease, and 15 had symptoms of heart failure (New York Heart Association class 2.4 +/- 0.5). The amplitude (E(M)) and the slope (slope E) of early diastolic motion of the septal mitral annulus were derived from M-mode analysis. Left heart catheterization was performed for direct measurement of LV end-diastolic pressure. Pseudonormalization defined by an E/A ratio > 1 and a LV end-diastolic pressure > or = 16 mm Hg was found in 9 patients. All patients with pseudonormalization were symptomatic (New York Heart Association class 2.8 +/- 0.5). Patients with and without pseudonormalization did not differ with respect to the E/A ratio (1.29 +/- 0.44 vs 1.16 +/- 0.23, p = NS), deceleration time (182 +/- 38 vs 205 +/- 42 ms, p = NS), and isovolumic relaxation time (88 +/- 24 vs 92 +/- 18 ms, p = NS). In the group with pseudonormalization, a significant reduction of E(M) (3.9 +/- 1.6 vs 5.7 +/- 1.5 mm, p = 0.008) and slope E (24.5 +/- 11.8 vs 43.9 +/- 7.7 mm/s, p <0.001) was detected. Using E(M) <4.3 mm and slope E <35 mm/s as cut points, sensitivity and specificity for the detection of pseudonormalization were 66% and 82% for E(M) and 77% and 87% for slope E, respectively. There was no significant relation between LV end-diastolic pressure as a measure of preload and either E(M) (r = 0.44, p >0.5) or slope E (r = 0.30, p >0.2). Thus, E(M) and slope E may be preload-independent tools for assessing LV diastolic dysfunction in symptomatic patients with a pseudonormal mitral inflow pattern and elevated filling pressures.

Noninvasive evaluation of hemodynamics by Doppler echocardiography

Doppler echocardiography plays an invaluable role in the diagnosis and management of patients with heart disease. Noninvasive measurements of cardiac output, pulmonary artery pressures, and left and right ventricular filling pressures can be obtained with reasonable accuracy at baseline and at intervals to assess the response to therapy. Furthermore, simple measurements of Doppler-acquired mitral inflow parameters provide independent and incremental prognostic data in patients with restrictive heart disease and in patients with left ventricular systolic dysfunction and heart failure.

Changes in left ventricular diastolic function 6 months after nonsurgical septal reduction therapy for hypertrophic obstructive cardiomyopathy

BACKGROUND

Nonsurgical septal reduction therapy (NSRT) decreases left ventricular outflow tract (LVOT) gradient and improves symptoms in patients with hypertrophic obstructive cardiomyopathy (HOCM). NSRT effects on LV/left ventricular diastolic function are currently unknown.

METHODS AND RESULTS

HOCM patients (n=29) had Doppler echocardiography at baseline and 6 months after NSRT to evaluate changes in LV volume, pre-A-wave pressure, early diastolic mitral annulus velocity (Ea) by tissue Doppler, and tau. At 6 months, a significant reduction in LVOT gradient (from 53.6+/-15 to 6+/-5 mm Hg; P<0.001) was accompanied by improvement in exercise duration (from 284+/-147 to 408+/-178 seconds; P=0.04) and New York Health Association class (from III to I; P<0.001). Pre-A pressure (18+/-6 to 14+/-5 mm Hg; P<0.01) and tau (62+/-8 to 51+/-8 ms; P<0.01) decreased, whereas Ea (5.8+/-1.8 to 8+/-1.8 cml/s; P<0.01) and LV end-diastolic volume (117+/-16 to 130+/-22 mL; P<0.01) increased.

CONCLUSIONS

NSRT improves LV relaxation and compliance, which contributes to the symptomatic relief seen at 6 months.

Doppler estimation of left ventricular filling pressures in patients with hypertrophic cardiomyopathy

BACKGROUND

Conventional Doppler parameters are unreliable for estimating left ventricular (LV) filling pressures in hypertrophic cardiomyopathy (HCM). This study was undertaken to evaluate flow propagation velocity by color M-mode and early diastolic annular velocity (Ea) by tissue Doppler 2 new indices of LV relaxation, combined with mitral E velocity for estimation of filling pressures in HCM.

METHODS AND RESULTS

Thirty-five HCM patients (52+/-15 years) underwent LV catheterization simultaneously with 2-dimensional and Doppler echocardiography. Pulsed Doppler echocardiography of mitral and pulmonary venous flows was obtained along with flow propagation velocity and Ea. LV preA pressure had weak or no relations with mitral, pulmonary venous velocities and atrial volumes. In contrast, preA pressure related strongly to E velocity/flow propagation velocity (r=0.67; SEE=4) and E/Ea (r=0.76; SEE=3.4). In 17 patients with repeat measurements, preA pressure changes were well detected by measuring E velocity/flow propagation velocity (r=0.68; P=0.01) or E/Ea (r=0.8; P<0.001). PreA pressure estimation with these 2 methods was tested prospectively in 17 additional HCM patients with good results (E velocity/flow propagation velocity, r=0.76; E/Ea, r=0.82).

CONCLUSIONS

LV filling pressures can be estimated with reasonable accuracy in HCM patients by measuring E velocity/flow propagation velocity or E/Ea. These ratios also track changes in filling pressures.

Decreased left atrial appendage function is an important predictor of elevated left ventricular filling pressure in patients with congestive heart failure

OBJECTIVE

The aim of this study was to investigate whether left atrial (LA) appendage function, as indicated by LA appendage blood flow velocities and its ejection fraction, could identify elevated left ventricular filling pressure in patients with chronic congestive heart failure.

METHODS

Using transesophageal echocardiography, adequate pulsed Doppler LA appendage active emptying and filling velocities could be recorded in 25 consecutive patients (16 men and 9 women, aged 57+/-10 years) with chronic congestive heart failure (symptom duration > or =1 year). LA appendage ejection fraction calculated as (LA appendage maximal area)-(LA appendage minimal area)/(LA appendage maximal area) x 100 was also determined in these patients. Left ventricular end-diastolic pressure was recorded during cardiac catheterization performed within 24 h of echocardiographic study.

RESULTS

Left ventricular end-diastolic pressure was 2 to 47 mm Hg. There were close negative correlations of LA appendage emptying velocity (r=-0.508; P<0.01), filling velocity (r=-0.429; P<0.05) and LA appendage ejection fraction (r=-0.523; P<0.005) with left ventricular end-diastolic pressure. LA appendage active emptying velocity <30 cm/s predicted left ventricular end-diastolic pressure >25 mm Hg with a sensitivity of 72.7%, a specificity of 92.9% and a positive and negative predictive value of 88.9 and 81.3%.

CONCLUSIONS

The findings suggest that measurement of LA appendage blood flow velocities and contractile function by transesophageal echocardiography can be used to predict elevated left ventricular filling pressure in patients with congestive heart failure.

Doppler estimation of left ventricular filling pressure in sinus tachycardia. A new application of tissue doppler imaging

BACKGROUND

Doppler echocardiography is frequently used to predict filling pressures in normal sinus rhythm, but it is unknown whether it can be applied in sinus tachycardia, with merging of E and A velocities. Tissue Doppler imaging (TDI) can record the mitral annular velocity. The early diastolic velocity (Ea) behaves as a relative load-independent index of left ventricular relaxation, which corrects the influence of relaxation on the transmitral E velocity.

METHODS AND RESULTS

We evaluated 100 patients 64+/-12 years old with simultaneous Doppler and invasive hemodynamics. Mitral inflow was classified into 3 patterns: complete merging of E and A velocities (pattern A), discernible velocities with A dominance (B), or E dominance (C). The Doppler data were analyzed at the mitral valve tips for E, acceleration and deceleration times of E, and isovolumic relaxation time. In patterns B and C, the A velocity, E/A ratio, and atrial filling fraction were derived. Pulmonary venous flow velocities were also measured, and TDI was used to acquire Ea and Aa. Weak significant relations were observed between pulmonary capillary wedge pressure (PCWP) and sole parameters of mitral flow, pulmonary venous flow, and annular measurements. These were better for patterns A and C. E/Ea ratio had the strongest relation to PCWP [r=0.86, PCWP=1.55+1.47(E/Ea)], irrespective of the pattern and ejection fraction. This equation was tested prospectively in 20 patients with sinus tachycardia. A strong relation was observed between catheter and Doppler PCWP (r=0.91), with a mean difference of 0.4+/-2.8 mm Hg.

CONCLUSIONS

The ratio of transmitral E velocity to Ea can be used to estimate PCWP with reasonable accuracy in sinus tachycardia, even with complete merging of E and A velocities.

Doppler tissue imaging: a noninvasive technique for evaluation of left ventricular relaxation and estimation of filling pressures

OBJECTIVES

This investigation was designed 1) to assess whether the early diastolic velocity of the mitral annulus (Ea) obtained with Doppler tissue imaging (DTI) behaves as a preload-independent index of left ventricular (LV) relaxation; and 2) to evaluate the relation of the mitral E/Ea ratio to LV filling pressures.

BACKGROUND

Recent observations suggest that Ea is an index of LV relaxation that is less influenced by LV filling pressures.

METHODS

One hundred twenty-five study subjects were classified into three groups according to mitral E/A ratio, LV ejection fraction (LVEF) and clinical symptoms: 34 asymptomatic subjects with a normal LVEF and an E/A ratio > or =1; 40 with a normal LVEF, an E/A ratio <1 and no heart failure symptoms (impaired relaxation [IR]); and 51 with heart failure symptoms and an E/A ratio >1 (pseudonormal [PN]). Ea was derived from the lateral border of the annulus. A subset of 60 patients had invasive measurement of pulmonary capillary wedge pressure (PCWP) simultaneous with Doppler echocardiographic DTI.

RESULTS

Ea was reduced in the IR and PN groups compared with the group of normal subjects: 5.8 +/- 1.5 and 5.2 +/- 1.4 vs. 12 +/- 2.8 cm/s, respectively (p < 0.001). Mean PCWP (20 +/- 8 mm Hg) related weakly to mitral E (r = 0.68) but not to Ea. The E/Ea ratio related well to PCWP (r = 0.87; PCWP = 1.24 [E/Ea] + 1.9), with a difference between Doppler and catheter measurements of 0.1 +/- 3.8 mm Hg.

CONCLUSIONS

Ea behaves as a preload-independent index of LV relaxation. Mitral E velocity, corrected for the influence of relaxation (i.e., the E/Ea ratio), relates well to mean PCWP and may be used to estimate LV filling pressures.