Echocardiographic assessment of left ventricular diastolic function and filling pressure in atrial fibrillation

Validation of E/e' Using the Index-Beat Method as an Estimate of Left Atrial Pressure in Patients with Atrial Fibrillation

INTRODUCTION

Echocardiographic assessment of diastolic function during atrial fibrillation (AF) remains challenging due to the irregular cardiac cycle length. We sought to assess whether the index-beat method, the beat following two preceding cardiac cycles of equal duration, could provide a more reliable measurement of E/e' (mitral E wave/diastolic tissue Doppler velocity) than the conventional averaging of consecutive beats and hence facilitate the noninvasive estimation of elevated left atrial pressure (LAP) in patients with AF.

METHODS

We prospectively studied 35 patients with persistent AF who had preserved left ventricular ejection fraction and underwent radiofrequency ablation. LAP was measured in conjunction with transseptal puncture during catheter ablation. Echocardiography was performed 24 h before ablation and E/e' was determined using the recommended averaging of 10 beats and the index-beat method, with the observers blinded to the clinical details and LAP measurements.

RESULTS

Correlation analysis showed a strong positive correlation between two methods in terms of both septal E/e' (r = 0.841, p < 0.001) and lateral E/e' (r = 0.930, p < 0.001). Bland-Altman analysis also showed a good agreement between the two measurement methods in terms of E/e'. E/e' determined using both conventional averaging and the index-beat method was significantly correlated with LAP (p < 0.05). After Fisher Z transformation, we found that the index-beat septal E/e' had a better correlation with LAP than did the conventional averaging E/e' (r = 0.736 vs. r = 0.392, Zr = -2.110, p = 0.035). Furthermore, the index-beat method took significantly less time to measure E/e' (mean 33.6 s; 95% confidence intervals [CIs]: 32.1 s-36.2 s) than did conventional averaging method (mean 96.2 s; 95% CI: 90.2 s-102.3 s; p < 0.001). Receiver operating characteristic curve analysis revealed that the optimal cut-off for predicting mean LAP >12 mm Hg was 11 (sensitivity 100%; specificity 77.3%) for index-beat septal E/e' and 16 (sensitivity 61.5%; specificity 95.5%) for index-beat lateral E/e'.

CONCLUSIONS

Good correlations were found between E/e' and LAP in patients with AF, particularly with the index-beat method. Moreover, the index-beat method can easily measure E/e' at an accuracy similar to that for the conventional averaging of consecutive beats, which can therefore be applied to assess the diastolic dysfunction and potentially improve the diagnosis of heart failure in patients with AF.

Role of Echocardiography in Diabetic Cardiomyopathy: From Mechanisms to Clinical Practice

It has been well established that diabetes mellitus (DM) is considered as a core risk factor for the development of cardiovascular diseases. However, what is less appreciated is the fact that DM may affect cardiac function irrespective of cardiac pathologies to which it contributes, such as coronary artery disease and hypertension. Although echocardiography provides accurate and reproducible diagnostic and prognostic data in patients with DM, its use in these patients is still underappreciated, resulting in progression of DM-related heart failure in many patients. Hence, in the present review, we aimed to discuss the role of echocardiography in the contemporary management of diabetic cardiomyopathy (DCM), as well as the role of emerging echocardiographic techniques, which may contribute to earlier diagnosis and more appropriate management of this complication of DM. In order to improve outcomes, focus must be placed on early diagnosis of this condition using a combination of echocardiography and emerging biomarkers, but perhaps the more important thing is to change perspective when it comes to the clinical importance of DCM.

Predictive power of diastolic parameters on medical cardioversion success in acute atrial fibrillation

BACKGROUND

Diastolic function assessment has been reported to provide valuable data in patients with atrial fibrillation (AF). The purpose of this study was to evaluate the effects of diastolic parameters on predicting the effectiveness of medical cardioversion in restoring sinus rhythm among patients with acute AF.

METHODS

40 non-valvular, new onset AF patients were included. All participants received an intravenous infusion of amiodarone. In patients whom sinus rhythm could not be restored with amiodarone, an electrical cardioversion was performed. Two groups, patients who achieved sinus rhythm with amiodarone (Group-1) and who failed to achieve sinus rhythm with amiodarone (Group-2) were compared with respect to initial echocardiographic measurements.

RESULTS

Group-1 patients were younger comparing with Group-2 (mean age; 54.4 ± 13.9 years vs 63.3 ± 10.3 years, p = 0.028). Comparing with Group-1, Group-2 patients had; a higher left atrium volume index (17.1 ± 4.8 cm³ / m² vs 22.6 ± 6.6 cm³ / m² , p = 0.03); a shorter pulmonary vein S (49.6 ± 3.8 cm/sec vs 41.1 ± 3.0 cm/sec, p < 0.001); and a shorter pulmonary vein D peak velocity (55.9 ± 2.4 cm/sec vs 52.3 ± 1.8 cm/sec, p < 0.001). Moreover, both IVRT and DT were significantly shorter in Group-2, comparing with Group-1 (45.1 ± 2.1 msec vs 51.1 ± 2.5 msec, p < 0.001 and 51.3 ± 2.4 msec vs 56.5± 3.2 msec, p < 0.001, respectively).

CONCLUSION

The present study revealed that admission pulmonary vein S and D wave peak velocities, IVRT, DT, and Pro-BNP levels could be predictors of failure of medical cardioversion among AF patients.

Effect of systolic dysfunction and elevated left ventricular end diastolic pressure on 3-year clinical outcomes in patients with atrial fibrillation

OBJECTIVES

Systolic and diastolic dysfunctions are related to adverse clinical outcomes in patients with sinus rhythm. The aim of this study was to clarify the prognostic significance of systolic and diastolic dysfunctions in patients with persistent atrial fibrillation (AF).

METHODS

We evaluated the data of 114 consecutive patients with persistent AF who underwent measurement of LVEDP at our hospital between March 1, 2011 and December 31, 2014. The patients were divided into two groups according to the left ventricular ejection fraction (LVEF): LVEF < 50 (reduced ejection fraction, REF group) and LVEF ≥50 (preserved EF, PEF group). The PEF group was further divided into two subgroups according to the left ventricular end-diastolic filling pressure (LVEDP): LVEDP > 15 mm Hg and LVEDP ≤ 15 mm Hg subgroups. The 3-year clinical outcomes were compared between the PEF and REF groups and the LVEDP ≥15 mm Hg and LVEDP < 15 mm Hg groups.

RESULTS

During the 3-year follow-up period, the rate of heart failure (HF) hospitalization and incidence of AF with rapid ventricular rhythm (RVR) were higher in the REF group than in the PEF group. Multivariate analysis revealed that REF was the only significant predictor of HF hospitalization (hazard ratio, 4.71; 95% confidence interval, 1.48-15.02; p = 0.009).

CONCLUSIONS

Our mid-term follow-up data demonstrated that systolic dysfunction was an important predictor of HF hospitalization in patients with AF. However, elevated LVEDP may not be associated with adverse mid-term clinical outcomes in patients without systolic dysfunction.

The relation between left ventricular systolic function parameters and preceding or prepreceding beat-to-beat distance in patients with atrial fibrillation: an echocardiographic study

We aimed at investigating the relation between left ventricle (LV) systolic parameters and beat-to-beat distances and also whether this relation is different in heart failure with reduced ejection fraction (HFrEF) patients with atrial fibrillation (AF). The relation between peak velocity in left ventricular outflow (V_LVOT), left atrioventricular plane displacement (LAVPD) or peak systolic tissue Doppler velocity of lateral mitral annulus (Lateral S') and preceding beat-to-beat distance (RR₁) or prepreceding beat-to-beat distance (RR₂) were analyzed by linear regression analysis. From this analysis, three parameters were obtained: slope of regression line, constant of regression line, and square of regression coefficient (r²) of linear relation. In the group with HFrEF, the slope and r² values of the regression line showing the relationship between the RR₁ interval and V_LVOT, LAVPD, and Lateral S' values were higher and the constants were lower. In the Kendall rank correlation analysis, the slope, constant, and r² values of the regression analysis between RR₁ interval and V_LVOT or Lateral S' were in significant correlation with LVEF. The r² of V_LVOT-RR₁ analysis, slope of this analysis, and slope of Lateral S'-RR₁ regression line values were mostly predictive for detecting HFrEF. It was concluded that the novel parameters obtained by linear regression analysis between LV systolic function parameters and RR₁ interval, but not RR₂, might be beneficial for evaluating systolic heart failure in patients with AF. They might have potential for future research about the physiopathology of heart and prognosis in patient with AF.

Risk factors and survival analysis of arrhythmia following lung cancer surgery: a retrospective study

Background

Surgical treatment of lung cancer is one of the important treatments for early-stage non-small cell lung cancer (NSCLC). However, arrhythmia, especially atrial fibrillation (AF) and supraventricular arrhythmia, are quite common among patients after surgical treatment of lung cancer. The impact of postoperative arrhythmia (PA) on survival is rarely reported. Our aim was to evaluate the risk factors of PA and its impact on overall survival (OS) after lung cancer surgery.

Methods

A total of 344 patients diagnosed with NSCLC who underwent lung cancer surgery were enrolled in this study. These patients were divided into two groups based on the occurrence of PA. Univariate and multivariate logistic regression analyses were conducted to identify the risk factors of PA. The Kaplan-Meier method was applied to show the OS differences between the two groups.

Results

The incidence of PA was 16% (55/344). Among these 55 patients, 20 had AF, 30 had sinus tachycardia, and 5 had premature beats. A total of 332 patients underwent lung cancer radical resection. Operation type (P<0.001), preoperative abnormal ECG (P=0.032), transfusion (P=0.016), postoperative serum potassium concentration (P=0.001) and clinical stage (P<0.05) were risk factors for PA. PA (HR 2.083, 95% CI, 1.334–3.253; P=0.001), age (HR 1.543, 95% CI, 1.063–2.239; P=0.025) and mediastinal lymph node metastasis (HR 2.655, 95% CI, 1.809–3.897; P<0.001) were independent prognostic risk factors for OS by multivariate cox analysis.

Conclusions

We identified PA as an independent prognostic risk factor to predict poor OS in patients who underwent lung cancer surgery and had risk factors for PA. We therefore provides guidance for PA in improving the prognosis of lung cancer patients.

Feasibility of weight loss in obese atrial fibrillation patients attending a specialist arrhythmia clinic and its impact on ablation outcomes

BACKGROUND

The feasibility of significant weight reduction in a specialist arrhythmia service, and its impact on atrial fibrillation (AF) ablation outcomes are unclear. We aimed to assess these factors in a real-world cohort in the United Kingdom.

METHODS

Patients from one specialized arrhythmia clinic were instructed to follow the "Intermittent Fasting 5:2 diet" ("diet group", n = 50), and their outcomes were compared to a propensity matched cohort who received no specific dietary advice ("control group", n = 42). The primary outcome was recurrence of AF or atrial tachycardia (AT) at 12 months postablation, with or without drugs.

RESULTS

Body weight and body mass index (BMI) at baseline were 105.0 (±15.3) kgs and 36.0 (±4.0), respectively. Baseline characteristics between the two groups were comparable. Patients in diet group experienced a mean weight loss of 8.2 (±7.1) kgs prior to AF ablation (P < .01 for comparison to baseline and control group). About 14 (28%) patients in the diet group lost >10% of their body weight. Overall, 11 (22%) patients in the diet group and five (12%) in the control group had AF recurrence at 1 year, P = .21. AF recurrence was similar in patients with BMI ≥ 35 (15%) as compared to BMI < 35 (19%), P = .60. There was one procedural complication (pulmonary edema) in the diet group.

CONCLUSION

It is feasible to achieve significant weight reduction in obese AF patients in a specialist arrhythmia clinic setting with unsupervised dietary advice. Low rates of procedural complications and excellent medium-term success rates were observed in this traditionally challenging population. Additional improvements in outcomes were not demonstrable in patients who exhibited significant weight loss.

Left ventricular overloading identified by critical care echocardiography is key in weaning-induced pulmonary edema

Purpose

To assess the role of left ventricular overload and cumulated fluid balance in the development weaning-induced pulmonary edema (WIPO).

Methods

Ventilated patients in sinus rhythm with COPD and/or heart failure (ejection fraction ≤ 40%) were studied. Echocardiography was performed immediately before and during a 30-min spontaneous breathing trial (SBT) using a T-tube. Patients who failed were treated according to echocardiography results before undergoing a second SBT.

Results

Twelve of 59 patients failed SBT, all of them developing WIPO. Patients who succeeded SBT had lower body weight (− 2.5 kg [− 4.8; − 1] vs. + 0.75 kg [− 2.95;  + 5.57]: p = 0.02) and cumulative fluid balance (− 2326 ml [− 3715;  + 863] vs. + 143 ml [− 2654; + 4434]: p = 0.007) than those who developed WIPO. SBT-induced central hemodynamic changes were more pronounced in patients who developed WIPO, with higher E wave velocity (122 cm/s [92; 159] vs. 93 cm/s [74; 109]: p = 0.017) and E/A ratio (2.1 [1.2; 3.6] vs. 0.9 [0.8; 1.4]: p = 0.001), and shorter E wave deceleration time (85 ms [72; 125] vs. 147 ms [103; 175]: p = 0.004). After echocardiography-guided treatment, all patients who failed the first SBT were successfully extubated. Fluid balance was then negative (− 2224 ml [− 7056; + 100] vs. + 146 ml [− 2654; + 4434]: p = 0.005). Left ventricular filling pressures were lower (E/E′: 7.3 [5; 10.4] vs. 8.9 [5.9; 13.1]: p = 0.028); SBT-induced increase in E wave velocity (+ 10.6% [− 2.7/ + 18] vs. + 25.6% [+ 12.7/ + 49]: p = 0.037) and of mitral regurgitation area were significantly smaller.

Conclusion

In high-risk patients, WIPO appears related to overloaded left ventricle associated with excessive fluid balance. SBT-induced central hemodynamic changes monitored by CCE help in guiding therapy for successful weaning.

Electronic supplementary material

The online version of this article (10.1007/s00134-020-06061-y) contains supplementary material, which is available to authorized users.

Impact of stand-alone minimally invasive radiofrequency ablation with left atrial appendectomy on left atrial function assessed by echocardiography

BACKGROUND

Stand-alone minimally invasive radiofrequency (RF) ablation with left atrial (LA) appendectomy has been an effective surgical intervention for non-paroxysmal atrial fibrillation (AF) (NPAF) in patients with a medical history of thromboembolism for secondary stroke prevention. This study sought to assess the impact of this surgery on LA function.

METHODS

A total of 37 NPAF patients with a medical history of stroke or thromboembolism were enrolled in this prospective observational study, all of whom underwent stand-alone minimally RF ablation with LA appendectomy. Echocardiography was used to evaluate LA function preoperatively and 1 week and 3 months postoperatively. All patients were divided into two groups (Group AF and Group SR) according to whether sinus rhythm (SR) was restored after the surgery.

RESULTS

The surgery had no impact on LA function in Group AF. Once NPAF patients were restored to SR, LA minimal volume (LAVmin) decreased immediately compared with pre-operation (22.98±13.76 vs. 17.68±9.52 mL; P<0.05) and consequently LA reservoir function increased, including LAEF (37.69%±12.53% vs. 46.71%±8.53%, P<0.05) and LAEI (66.54%±34.39% vs. 92.15%±31.37%, P<0.05). PA-TDI of Group SR, indicating LA electromechanical coupling, were improved at three months of follow-up because of atrial stunning after the surgery (160.55±26.19 vs. 143.82±20.923 ms, P<0.05). LA contractile function was also improved at three months of follow-up (A-TVI: 2.95±1.16 vs. 5.10±1.85 cm, P<0.05).

CONCLUSIONS

Stand-alone minimal invasive RF ablation with LA appendectomy had no impact on LA function in AF patients who could not be restored to SR. However, once AF patients were restored to SR after the surgery, LA function could recover better. Meanwhile, thromboembolic events could also be reduced after the surgery.

Management of pulmonary arterial hypertension in patients aged over 65 years

Historically, pulmonary arterial hypertension (PAH) has been considered a disease of young adults, but over the last three decades, the average age at diagnosis has increased, presenting clinicians with some unique challenges. Clinical symptoms of PAH, including shortness of breath and reduced functional capacity, are not specific for the disease and may be present in older patients because of their age or as a result of comorbid conditions. Eliminating other causes for these symptoms can delay PAH diagnosis and initiation of PAH-specific treatment compared with younger patients. Currently, there are no specific guidelines relating to PAH in older patients and existing guidelines for identifying patients at potential risk of PAH may not be appropriate for patients aged over 65 years. Even though older patients tend to be diagnosed with more advanced symptoms, and evidence suggests that they are less responsive to PAH-specific therapies, treatment is often less aggressive than in younger patients. Even after adjusting for age, survival rates remain disproportionately lower in the older vs. younger PAH populations. Specific guidelines for diagnosis and treatment of older patients with PAH are needed to improve care and outcomes in this growing population. This review aims to assess the challenges associated with diagnosing and managing PAH in older patients, based on literature searches, authors' experiences, and expert opinions.

Value of dual Doppler echocardiography for prediction of atrial fibrillation recurrence after radiofrequency catheter ablation

BACKGROUND

Increasing evidence has been presented which suggests that left ventricular (LV) diastolic dysfunction may play an important role in the development of atrial fibrillation (AF). However, the potential for LV diastolic dysfunction to serve as a predictor of AF recurrence after radiofrequency catheter ablation remains unresolved.

METHODS

Dual Doppler and M-PW mode echocardiography were performed in 67 patients with AF before ablation and 47 patients with sinus rhythm. The parameters measured within identical cardiac cycles included, the time interval between the onset of early transmitral flow peak velocity (E) and that of early diastolic mitral annular velocity (e') (TE-e'), the ratio of E to color M-mode Doppler flow propagation velocity (Vp)(E/Vp), the Tei index, the ratio of E and mitral annular septal (S) peak velocity in early diastolic E/e'(S) and the ratio of E and mitral annular lateral (L) peak velocity E/e'(L). A follow-up examination was performed 1 year after ablation and patients were divided into two groups based on the presence or absence of AF recurrence. Risk estimations for AF recurrence were performed using univariate and multivariate logistic regression.

RESULTS

TE-e', E/Vp, the Tei index, E/e'(S) and E/e'(L) were all increased in AF patients as compared with the control group (p <  0.05). At the one-year follow-up examination, a recurrence of AF was observed in 21/67 (31.34%) patients. TE-e' and the Tei index within the recurrence group were significantly increased as compared to the group without recurrence (p <  0.001). Results from multivariate analysis revealed that TE-e' can provide an independent predictor for AF recurrence (p = 0.001).

CONCLUSIONS

Dual Doppler echocardiography can provide an effective and accurate technique for evaluating LV diastolic function within AF patients. The TE-e' obtained within identical cardiac cycles can serve as an independent predictor for the recurrence of AF as determined at 1 year after ablation.

A Test in Context: E/A and E/e' to Assess Diastolic Dysfunction and LV Filling Pressure

Diastolic dysfunction represents a combination of impaired left ventricular (LV) relaxation, restoration forces, myocyte lengthening load, and atrial function, culminating in increased LV filling pressures. Current Doppler echocardiography guidelines recommend using early to late diastolic transmitral flow velocity (E/A) to assess diastolic function, and E to early diastolic mitral annular tissue velocity (E/e') to estimate LV filling pressures. Although both parameters have important diagnostic and prognostic implications, they should be interpreted in the context of a patient's age and the rest of the echocardiogram to describe diastolic function and guide patient management. This review discusses: 1) the physiological basis for the E/A and E/e' ratios; 2) their roles in diagnosing diastolic dysfunction; 3) prognostic implications of abnormalities in E/A and E/e'; 4) special scenarios of the E/A and E/e' ratios that are either useful or challenging when evaluating diastolic function clinically; and 5) their usefulness in guiding therapeutic decision making.

Prognostic Importance of Diastolic Dysfunction in Relation to Post Procedural Aortic Insufficiency in Patients Undergoing Transcatheter Aortic Valve Replacement

OBJECTIVES

We sought to examine whether baseline diastolic dysfunction (DD) is associated with increased mortality in patients who develop aortic insufficiency (AI) after transcatheter aortic valve replacement (TAVR).

BACKGROUND

Significant post-TAVR AI is associated with increased mortality, likely secondary to adverse hemodynamics secondary to volume overload and decreased LV compliance from chronic pressure overload. However, the effect of baseline DD on outcomes of patients with post-TAVR AI has not been studied.

METHODS

A total of 195 patients undergoing TAVR were included in the study. Patients with moderate-to-severe mitral stenosis, prior mitral valve replacement or atrial fibrillation were excluded. DD was classified at baseline by a 2-step approach as recommended by the American Society of Echocardiography while AI was evaluated 30 days post-TAVR. Follow up data up to 2 years post-TAVR was used in survival analysis.

RESULTS

Patients with severe baseline DD who developed ≥mild post-TAVR AI had increased mortality compared to all other patients (HR = 3.89, CI: 1.76-8.6, P = 0.001), which remained significant after adjusting for post-TAVR AI, pre-TAVR AI, baseline mitral regurgitation, ejection fraction, pulmonary artery pressure, creatinine clearance and history of stroke.

CONCLUSIONS

Even mild post-TAVR AI may have a negative impact on outcomes of patients with underlying severe DD. © 2016 Wiley Periodicals, Inc.

The use of echocardiography in acute cardiovascular care: Recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association

Echocardiography is one of the most powerful diagnostic and monitoring tools available to the modern emergency/critical care practitioner. Currently, there is a lack of specific European Association of Cardiovascular Imaging/Acute Cardiovascular Care Association recommendations for the use of echocardiography in acute cardiovascular care. In this document, we describe the practical applications of echocardiography in patients with acute cardiac conditions, in particular with acute chest pain, acute heart failure, suspected cardiac tamponade, complications of myocardial infarction, acute valvular heart disease including endocarditis, acute disease of the ascending aorta and post-intervention complications. Specific issues regarding echocardiography in other acute cardiovascular care scenarios are also described.

Left ventricular diastolic function and dysfunction: Central role of echocardiography

Comprehensive and precise assessment of left ventricular (LV) systolic and diastolic function is necessary to establish, or exclude, heart failure as a cause or component of dyspnea. Echocardiography with Doppler readily assesses LV diastolic function; advantages include that echocardiography is non-invasive, does not require radiation, is portable, rapid, readily available, and in competent hands, can provide an accurate and comprehensive assessment of LV systolic and diastolic function. Correct assessment of LV diastolic function is relevant in patients with both depressed and preserved LV ejection fraction (EF ≥ 50%, and < 50%, respectively). Tissue Doppler (TD) imaging has been useful in demonstrating impaired LV relaxation in the setting of preserved LVEF, which, in the setting of increased cardiac volume, can result in elevated LV filling pressures, and dyspnea due to diastolic heart failure. TD imaging is not always critical in patients with depressed LVEF, since such patients by definition have impaired LV relaxation, and thus significant increases in volume will result in increases in LV filling pressure due to impaired LV compliance. Thus, in depressed LVEF, transmitral flow velocities (E and A, and E/A) and deceleration time, pulmonary venous Doppler, left atrial volume, and pulmonary artery (PA) pressures suffice for the accurate assessment of LV filling pressures. Overall, diastolic assessment by echo-Doppler can be readily achieved in by using a comprehensive diastolic assessment—incorporating many 2-dimensional, conventional and tissue Doppler variables—as opposed to relying on any single, diastolic parameter, which can lead to errors.

Diagnostic performance of cardiopulmonary ultrasound performed by the emergency physician in the management of acute dyspnea

OBJECTIVE

The etiologic diagnosis of acute dyspnea in the emergency department (ED) remains difficult, especially for elderly patients or those with previous cardiorespiratory medical history. This may lead to inappropriate treatment and potentially a higher mortality rate. Our objective was to evaluate the performance of cardiopulmonary ultrasound compared with usual care for the etiologic diagnosis of acute dyspnea in the ED.

METHODS

Patients admitted to the ED for acute dyspnea underwent upon arrival a cardiopulmonary ultrasound performed by an emergency physician, in addition to standard care. The performances of the clinical examination, chest x-ray, N-terminal brain natriuretic peptide (NT-proBNP), and cardiopulmonary ultrasound were compared with the final diagnosis made by 2 independent physicians.

RESULTS

One hundred thirty patients were analyzed. For the diagnosis of acute left-sided heart failure, cardiopulmonary ultrasound had an accuracy of 90% (95% confidence interval [CI], 84-95) vs 67% (95% CI, 57-75), P = .0001 for clinical examination, and 81% (95% CI, 72-88), P = .04 for the combination "clinical examination-NT-proBNP-x-ray". Cardiopulmonary ultrasound led to the diagnosis of pneumonia or pleural effusion with an accuracy of 86% (95% CI, 80-92) and decompensated chronic obstructive pulmonary disease or asthma with an accuracy of 95% (95% CI, 92-99). Cardiopulmonary ultrasound lasted an average of 12 ± 3 minutes.

CONCLUSIONS

Cardiopulmonary ultrasounds performed in the ED setting allow one to rapidly establish the etiology of acute dyspnea with an accuracy of 90%.

The use of echocardiography in acute cardiovascular care: recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association

Echocardiography is one of the most powerful diagnostic and monitoring tools available to the modern emergency/ critical care practitioner. Currently, there is a lack of specific European Association of Cardiovascular Imaging/Acute Cardiovascular Care Association recommendations for the use of echocardiography in acute cardiovascular care. In this document, we describe the practical applications of echocardiography in patients with acute cardiac conditions, in particular with acute chest pain, acute heart failure, suspected cardiac tamponade, complications of myocardial infarction, acute valvular heart disease including endocarditis, acute disease of the ascending aorta and post-intervention complications. Specific issues regarding echocardiography in other acute cardiovascular care scenarios are also described.

Comparison between ivabradine and low-dose digoxin in the therapy of diastolic heart failure with preserved left ventricular systolic function

Multicenter trials have demonstrated that in patients with sinus rhythm ivabradine is effective in the therapy of ischemic heart disease and of impaired left ventricular systolic function. Ivabradine is ineffective in atrial fibrillation. Many patients with symptomatic heart failure have diastolic dysfunction with preserved left ventricular systolic function, and many have asymptomatic paroxysmal atrial fibrillation. Ivabradine is not indicated in these conditions, but it happens that it is erroneously used. Digoxin is now considered an outdated and potentially dangerous drug and while effective in the mentioned conditions, is rarely used. The aim of the study was to compare the therapeutic effects of ivabradine in diastolic heart failure with preserved left ventricular systolic function. Patients were assigned to ivabradine or digoxin according to a randomization cross-over design. Data were single-blind analyzed. The analysis was performed using an intention-to-treat method. Forty-two coronary patients were selected. In spite of maximally tolerated therapy with renin-antagonists, diuretics and β-blockers, they had congestive diastolic heart failure with preserved systolic function. Both ivabradine and digoxin had positive effects on dyspnea, Nterminal natriuretic peptide, heart rate, duration of 6-min. walk-test and signs of diastolic dysfunction, but digoxin was high-statistically more effective. Side-effects were irrelevant. Data were obtained in a single-center and from 42 patients with ischemic etiology of heart failure. The number of patients is small and does not allow assessing mortality. In coronary patients with symptomatic diastolic heart failure with preserved systolic function low-dose digoxin was significantly more effective than ivabradine and is much cheaper. One should be more critical about ivabradine and low-dose digoxin in diastolic heart failure. To avoid possible negative effects on the cardiac function and a severe reduction of the cardiac output the resting heart rate should not be decreased to <65 beats/min.

Changes in left ventricular filling in patients with persistent atrial fibrillation

BACKGROUND

Former studies showed possible interrelationship between altered ventricular filling patterns and atrial fibrillation (AF).

HYPOTHESIS

Long term persistent AF has a negative impact on left ventricular filling in patients with preserved ejection fraction of left ventricle.

METHODS

Our study was designed as a prospective case control study. We included 40 patients with persistent AF and preserved ejection fraction after successful electrical cardioversion and 43 control patients. Persistent AF was defined as AF lasting more than 4 weeks. Cardiac ultrasound was performed in all patients 24 hours after the procedure. Appropriate mitral flow and tissue Doppler velocities as well as standard echocardiographic measurements were obtained.

RESULTS

There were no significant differences between both groups' parameters regarding age, sex, commorbidities or drug therapy. Analysis of mitral flow velocities showed significant increase of E value in AF group (0.96±0.27 vs.0.70±0.14; p = 0.001). Tissue Doppler measurements didn't reveal any differences in early diastolic movement, however there was a statistically significant difference in E/Em values of both groups, respectively (12.0±4.0 vs. 9.0±2.1; p= 0.001).

CONCLUSION

Our study shows that in patients with preserved systolic function and persistent AF shortly after cardioversion diastolic ventricular filling patterns are altered mainly due to increased left atrial pressure and not due to impaired diastolic relaxation of left ventricle. Further studies are needed in order to define the interplay between diminished atrial function and impaired ventricular filling.

Relation Between RR Intervals and Early Diastolic Mitral Annular Velocities in Atrial Fibrillation

Background and Objectives

Irregular RR intervals in atrial fibrillation (AF) make beat-to-beat changes in left ventricular (LV) systolic performance. Early diastolic mitral annular velocity (E') is one of the well-established parameters for evaluating LV diastolic function. The relation between RR intervals and E's is unknown. The aim of this study was to observe the influence of continuous changes in RR interval on the parameter for diastolic function in AF.

Subjects and Methods

Echocardiography was performed in 117 patients with AF. E' was adjusted for the effect of pre-preceding RR interval (RR-2) using the logarithmic equation between RR-2 and E'. The logarithmic equation between adjusted E' and preceding RR interval (RR-1) was calculated.

Results

The slope in the relation between RR-1 and E' varied from -2.5 to 2.6. The slope was lower (more likely negative) in patients with higher ratio of early diastolic mitral flow velocity (E) to E' (r=-0.21, p=0.023), ischemic heart disease (IHD, r=0.21, p=0.026), and higher systolic blood pressure (r=-0.19, p=0.046). When patients were divided into these 3 groups on the basis of slope, the lowest slope group (<-0.55, n=39) was associated with higher E'/E (p=0.004) and IHD (p=0.018) compared with the highest slope group (>0.57, n=39). The slope with regards to the relationship between RR-2 and E' also varied from -3.4 to 3.1.

Conclusion

Changes in RR intervals had variable effects on E's according to clinical variables in AF.

Prevalence of left ventricular dysfunction in a UK community sample of very old people: the Newcastle 85+ study

Objective

Heart failure (HF) prevalence rises sharply among those aged 85 years and over. Previous population based echocardiographic studies of left ventricular (LV) dysfunction, the substrate for HF, have included only small numbers in this age group. We used domiciliary echocardiography to estimate the prevalence of LV systolic and diastolic dysfunction in 87–89 year olds and the proportion remaining undiagnosed.

Design

Cross sectional analysis of data from Newcastle 85+ Study.

Setting

Primary care, North-East England.

Participants

376 men and women aged 87–89 years.

Measures

Domiciliary echocardiography was performed and LV systolic and diastolic function was graded. The presence of limiting dyspnoea was assessed by questionnaire. Previous diagnoses of HF were abstracted from general practice (GP) records.

Results

32% of participants (119/376) had LV systolic dysfunction (ejection fraction (EF) ≤50%) and a further 20% (75/376) had moderate or severe LV diastolic dysfunction with preserved EF. Both echocardiographic assessment of LV function and dyspnoea status were available in 74% (278/376) of participants. Among these participants, limiting dyspnoea was present in approximately two thirds of those with significant (systolic or isolated moderate/severe diastolic) LV dysfunction. 84% (73/87) of participants with significant LV dysfunction and limiting dyspnoea did not have a pre-existing HF diagnosis in their GP records. Overall, 26% (73/278) of participants with both echocardiographic and dyspnoea data had undiagnosed, symptomatic, significant LV dysfunction.

Conclusion

Significant systolic and diastolic LV dysfunction is much commoner in community dwelling 87–89 year olds than previous studies have suggested. The majority are both symptomatic and undiagnosed.

Heart failure with normal left ventricular ejection fraction: role of echocardiography

PURPOSE OF REVIEW

Nearly half of patients presenting with heart failure have a preserved left ventricular ejection fraction (LVEF), previously known as diastolic heart failure. The diagnosis requires fulfillment of three criteria: signs or symptoms of heart failure, presence of a normal LVEF, and evidence of diastolic dysfunction. Two of the criteria can be evaluated by echocardiography. This article reviews the echocardiographic approach to the patient with suspected heart failure with a normal left ventricular ejection fraction (HFNEF).

RECENT FINDINGS

Echocardiography is the primary modality for evaluating left ventricular (LV) systolic and diastolic function in heart failure patients. Measurements of LVEF from two-dimensional echocardiography can have significant variability despite the use of quantitative methods. The use of contrast agents and three-dimensional echocardiography can improve the accuracy. Newer modalities of tissue Doppler imaging and deformation imaging are challenging the concept that systolic function is preserved in HFNEF. Evaluation of diastolic function with echocardiography requires a comprehensive approach using multiple modalities to quantitate transmitral flow, pulmonary venous flow, mitral annular motion, myocardial deformation, and cardiac structure. The clinical applicability of parameters used for evaluating diastolic function and filling pressures is dependent on the LVEF, necessitating a unique approach in patients with suspected HFNEF.

SUMMARY

A comprehensive examination with knowledge of the potential limitations of echocardiography is required to accurately interpret LV systolic and diastolic function in patients with suspected HFNEF.

Myocardial performance index derived from preejection period: a novel and feasible parameter in evaluation of cardiac performance in patients with permanent atrial fibrillation

BACKGROUND

Using tissue Doppler echocardiography, we can measure preejection period (PEPa), defined as the interval measured from the onset of QRS to the onset of the systolic mitral annular velocity pattern, isovolumic relaxation time (IVRTa), defined as the interval measured from the end of systolic mitral annular velocity pattern to the onset of diastolic mitral annular velocity pattern, and ejection time (ETa), defined as the interval measured from the onset to the end of systolic mitral annular velocity pattern on the same cardiac cycle. The aim of this study is to test the applicability of PEPa-derived myocardial performance index (MPI), defined as the ratio of PEPa + IVRTa to ETa, as an indicator of combined left ventricular systolic and diastolic function in patients with permanent atrial fibrillation.

METHODS

Echocardiographic examination was performed in 54 consecutive patients with permanent atrial fibrillation. Clinical and echocardiographic parameters were compared and analyzed.

RESULTS

After a multivariate analysis, the average RR interval on the tissue Doppler image (β=-0.328, P = 0.002), left ventricular ejection fraction (β=-0.260, P = 0.024), and early diastolic mitral annular velocity (β=-0.408, P < 0.001) were the major determinants of PEPa-derived MPI.

CONCLUSIONS

PEPa-derived MPI had a significant correlation with echocardiographic left ventricular diastolic and systolic function. It may be a novel and feasible indicator in assessment of global left ventricular function in patients with permanent atrial fibrillation.

The diastolic stress test: a new approach to an old problem

The evaluation of ischemic heart disease is the cornerstone of clinical Cardiology. Although there are many means of ischemic evaluation, all are with their own limitations. While perfusion-based studies are highly sensitive, they lack specificity. Conversely, systolic wall motion analysis with echocardiography tends to have high specificity; however, the sensitivity may be limited by short duration of systolic abnormalities when present. With the advent of Doppler echocardiography, and more specifically tissue Doppler imaging, and strain and strain rate imaging, a more comprehensive evaluation of the left ventricular function is available, including diastole. Diastolic abnormalities in the setting of ischemia are now being studied using these new parameters and have been suggested as a reliable marker of ischemia. Exercise-induced abnormalities in diastolic parameters have improved sensitivities and specificities over traditional stress testing and persist longer than systolic abnormalities. A review of the medical literature regarding the subject will be discussed here.

Effect of catheter ablation on the left ventricular mass index and other echocardiograph parameters in atrial fibrillation patients: comparison with antiarrhythmic drug treatment

BACKGROUND

Catheter ablation (CA) is reported to improve left ventricular (LV) function in patients with atrial fibrillation (AF). This study compared the effects of CA and antiarrhythmic drug treatment (AT) on LV remodeling and other echocardiography parameters in AF.

METHODS

We performed a non-randomized prospective study involving 72 drug-resistant AF patients who were treated with either CA (n = 42) or who declined CA and continued on AT (n = 30). Baseline and follow-up (mean 20.7 ± 7.5 months) echocardiography was performed in all patients. The maintenance of sinus rhythm was determined based on clinical interview, electrocardiography, and 24-h Holter and event recording.

RESULTS

There were no significant differences between the two groups in regard to demographic features, blood pressure, and medication. CA was superior to AT with respect to sinus rhythm maintenance, LV ejection fraction, left atrium (LA) diameter, and LA volume index. In addition, CA resulted in decreases in the LV mass [from 190.5 ± 36.1 to 179.3 ± 32.4 g (p = 0.02)] and the LV mass index [from 104.2 ± 20.5 to 98.2 ± 18.3 g/m(2) (p = 0.03)]. No parameter improved in AT patients. These improved echocardiographic parameters were observed in both groups with maintained sinus rhythm.

CONCLUSION

Reverse LV remodeling after CA may include a reduction in the LV mass index, which appears to be associated with sinus rhythm maintenance.

Is the E/V p index useful for evaluating prognosis in chronic heart failure with atrial fibrillation? A pilot study

BACKGROUND

The ratio of transmitral peak E wave velocity to color flow propagation velocity (E/V p index) has proved to be a significant predictor of prognosis in cardiac diseases with sinus rhythm. However, its usefulness in patients with atrial fibrillation (AF) and heart failure has not yet been established. The aim of this study was to determine the feasibility of using the E/V p index for the prediction of mortality and heart failure hospitalization in this group.

METHODS

We studied 66 ambulatory patients with stable congestive heart failure (CHF) functional class I-III and AF. Patients were divided into group A and B according to an E/V p index <1.5 and ≥1.5, respectively.

RESULTS

During follow-up (average 430 days) events were more common in group B (75 vs. 17%, log rank test; hazard ratio (HR)  = 6.8). By means of multivariate logistic regression analysis, E/V p proved to be an independent predictor of events (p = 0.0012).

CONCLUSIONS

In our patients with stable CHF and AF the E/V p index is a significant predictor of clinical outcome.

Association of the parameters derived from the relation between RR intervals and left ventricle performance with a history of heart failure in patients with atrial fibrillation

Parameters derived from the relation between RR intervals and left ventricular (LV) performance in atrial fibrillation (AF) have been useful to evaluate systolic LV function. This study investigated the association of these parameters with a history of heart failure. Echocardiography was performed in 107 patients with AF. LV outflow peak ejection velocity (Vpe) was adjusted for the effect of pre-preceding RR interval (RR-2) using the logarithmic equation between RR-2 and Vpe. The logarithmic equation between adjusted Vpe and preceding RR interval (RR-1) was calculated in the co-ordinates with RR-1 from 0.6 to 1 second. From this equation, the ratio of slope to Vpe at RR-1 = 1 second (slope/Vpe-1) was obtained. When patients were divided into 2 groups according to a history of heart failure, old age, high slope/Vpe-1, mitral regurgitation, and left atrial enlargement independently predicted the occurrence of heart failure. Fractional shortening was not different between the 2 groups. In patients with normal LV size and without significant regurgitation (n = 69), old age and high slope/Vpe-1 independently predicted the occurrence of heart failure. Areas under the receiver operating characteristics curve of slope/Vpe-1 for identifying heart failure were 0.72 (p <0.000) and 0.74 (p <0.001) in all patients and in patients with normal LV size, respectively. In conclusion, the new parameter, slope/Vpe-1, was one of the most useful predictors for the occurrence of heart failure in AF and was superior to the classic hemodynamic parameters. This parameter might be determined not only by systolic function but also by diastolic function of the left ventricle.

Echo Doppler guidance for atrial fibrillation ablation: recognition of primary electropathy

Atrial fibrillation (AF) is a multivariable disease. Young patients with paroxysmal AF without structural cardiac abnormality ("lone AF") likely have a primary electropathy with excellent results from radiofrequency ablation. However, with persistent AF with cardiac abnormalities, including left atrial enlargement and systolic ventricular dysfunction (ejection fraction percent), the electropathy is considered secondary and ablation results poor. We describe a case with persistent AF, depressed systolic function, and marked left atrial enlargement but without echo Doppler evidence of diastolic dysfunction. At electrophysiology study, findings were consistent with a primary electropathy, and the patient did well following ablation.

Atrial fibrillation and amino-terminal pro-brain natriuretic peptide as independent predictors of prognosis in systolic heart failure

BACKGROUND

Survival of patients with systolic heart failure (HF) may be influenced by the presence of chronic atrial fibrillation (AF) and circulating concentrations of B-type natriuretic peptides. In this study, we sought to assess the prognostic value of chronic AF in comparison to those of amino-terminal pro-brain natriuretic peptide (NT-proBNP) plasma levels and of echocardiographic parameters among HF patients of the entire study population and in those with AF.

METHODS

Plasma NT-proBNP levels and echocardiography were prospectively assessed in 489 patients with chronic systolic HF (LV ejection fraction <or=45%) in sinus rhythm or AF (16%). Follow-up duration was 26+/-15 months.

RESULTS

Patients with AF were older (p<0.0001), had a worse NYHA class (p=0.002) and higher NT-proBNP levels (p<0.0001) than those in sinus rhythm. Presence of AF (HR [hazards ratio]: 2.01, p=0.013) and plasma NT-proBNP (HR: 3.05, p<0.0001) were the only independent predictors of all-cause mortality. At receiver operating characteristic analyses, the threshold level for outcome prediction of NT-proBNP was higher in patients with AF (3883 pg/ml) than in patients in sinus rhythm (1653 pg/ml). Multivariate analysis performed in patients with HF and AF showed that plasma NT-proBNP was the most important predictor of death after statistic adjustment for age.

CONCLUSIONS

Chronic AF and NT-proBNP independently predicted the outcome of patients with HF. The threshold level of NT-proBNP for outcome prediction was different in patients with AF with respect to those in sinus rhythm. NT-proBNP was the most important independent predictor of all-cause mortality in HF patients with AF.