Prognostic value of pulmonary venous flow Doppler signal in left ventricular dysfunction: contribution of the difference in duration of pulmonary venous and mitral flow at atrial contraction

New perspectives in the echocardiographic hemodynamics multiparametric assessment of patients with heart failure

International Guidelines consider left ventricular ejection fraction (LVEF) as an important parameter to categorize patients with heart failure (HF) and to define recommended treatments in clinical practice. However, LVEF has some technical and clinical limitations, being derived from geometric assumptions and is unable to evaluate intrinsic myocardial function and LV filling pressure (LVFP). Moreover, it has been shown to fail to predict clinical outcome in patients with end-stage HF. The analysis of LV antegrade flow derived from pulsed-wave Doppler (stroke volume index, stroke distance, cardiac output, and cardiac index) and non-invasive evaluation of LVFP have demonstrated some advantages and prognostic implications in HF patients. Speckle tracking echocardiography (STE) is able to unmask intrinsic myocardial systolic dysfunction in HF patients, particularly in those with LV preserved EF, hence allowing analysis of LV, right ventricular and left atrial (LA) intrinsic myocardial function (global peak atrial LS, (PALS)). Global PALS has been proven a reliable index of LVFP which could fill the gaps "gray zone" in the previous Guidelines algorithm for the assessment of LV diastolic dysfunction and LVFP, being added to the latest European Association of Cardiovascular Imaging Consensus document for the use of multimodality imaging in evaluating HFpEF. The aim of this review is to highlight the importance of the hemodynamics multiparametric approach of assessing myocardial function (from LVFP to stroke volume) in patients with HF, thus overcoming the limitations of LVEF.

Predictors of Exercise Capacity in Dilated Cardiomyopathy with Focus on Pulmonary Venous Flow Recorded with Transesophageal Eco-Doppler

The aim of this study was to clarify the relative contribution of elevated left ventricle (LV) filling pressure (FP) estimated by pulmonary venous (PV) and mitral flow, transesophageal Doppler recording (TEE), and other extracardiac factors like obesity and renal insufficiency (KI) to exercise capacity (ExC) evaluated by cardiopulmonary exercise testing (CPX) in patients with dilated cardiomyopathy (DCM). During the CPX test, 119 patients (pts) with DCM underwent both peak VO₂ consumption and then TEE with color-guided pulsed-wave Doppler recording of PVF and transmitral flow. In 78 patients (65%), peak VO₂ was normal or mildly reduced (>14 mL/kg/min) (group 1) while it was markedly reduced (≤14 mL/kg/min) in 41 (group 2). In univariate analysis, systolic fraction (S Fract), a predictor of elevated pre-a LV diastolic FP, appeared to be the best diastolic parameter predicting a significantly reduced peak VO₂. Logistic regression analysis identified five parameters yielding a unique, statistically significant contribution in predicting reduced ExC: creatinine clearance < 52 mL/min (odds ratio (OR) = 7.4, p = 0.007); female gender (OR = 7.1, p = 0.004); BMI > 28 (OR = 5.8, p = 0.029), age > 62 years (OR = 5.5, p = 0.03), S Fract < 59% (OR = 4.9, p = 0.02). Conclusion: KI was the strongest predictor of reduced ExC. The other modifiable factors were obesity and severe LV diastolic dysfunction expressed by blunted systolic venous flow. Contrarily, LV ejection fraction was not predictive, confirming other previous studies. This has important clinical implications.

Prognostic value of an echocardiographic index reflecting right ventricular operating stiffness in patients with heart failure

PURPOSE

We recently reported a noninvasive method for the assessment of right ventricular (RV) operating stiffness that is obtained by dividing the atrial-systolic descent of the pulmonary artery-RV pressure gradient (PRPGD_AC) derived from the pulmonary regurgitant velocity by the tricuspid annular plane movement during atrial contraction (TAPM_AC). Here, we investigated whether this parameter of RV operating stiffness, PRPGD_AC/TAPM_AC, is useful for predicting the prognosis of patients with heart failure (HF).

METHODS

We retrospectively included 127 hospitalized patients with HF who underwent an echocardiographic examination immediately pre-discharge. The PRPGD_AC/TAPM_AC was measured in addition to standard echocardiographic parameters. Patients were followed until 2 years post-discharge. The endpoint was the composite of cardiac death, readmission for acute decompensation, and increased diuretic dose due to worsening HF.

RESULTS

58 patients (46%) experienced the endpoint during follow-up. Univariable and multivariable Cox regression analyses demonstrated that the PRPGD_AC/TAPM_AC was associated with the endpoint. In a Kaplan-Meier analysis, the event rate of the greater PRPGD_AC/TAPM_AC group was significantly higher than that of the lesser PRPGD_AC/TAPM_AC group. In a sequential Cox analysis for predicting the endpoint's occurrence, the addition of PRPGD_AC/TAPM_AC to the model including age, sex, NYHA functional classification, brain natriuretic peptide level, and several echocardiographic parameters including tricuspid annular plane systolic excursion significantly improved the predictive power for prognosis.

CONCLUSION

A completely noninvasive index of RV operating stiffness, PRPGD_AC/TAPM_AC, was useful for predicting prognoses in patients with HF, and it showed an incremental prognostic value over RV systolic function.

Comprehensive data integration-Toward a more personalized assessment of diastolic function

BACKGROUND AND AIM

The main challenge of assessing diastolic function is the balance between clinical utility, in the sense of usability and time-efficiency, and overall applicability, in the sense of precision for the patient under investigation. In this review, we aim to explore the challenges of integrating data in the assessment of diastolic function and discuss the perspectives of a more comprehensive data integration approach.

METHODS

Review of traditional and novel approaches regarding data integration in the assessment of diastolic function.

RESULTS

Comprehensive data integration can lead to improved understanding of disease phenotypes and better relation of these phenotypes to underlying pathophysiological processes-which may help affirm diagnostic reasoning, guide treatment options, and reduce limitations related to previously unaddressed confounders. The optimal assessment of diastolic function should ideally integrate all relevant clinical information with all available structural and functional whole cardiac cycle echocardiographic data-envisioning a personalized approach to patient care, a high-reaching future goal in medicine.

CONCLUSION

Complete data integration seems to be a long-lasting goal, the way forward in diastology, and machine learning seems to be one of the tools suited for the challenge. With perpetual evidence that traditional approaches to complex problems may not the optimal solution, there is room for a steady and cautious, and inherently very exciting paradigm shift toward novel diagnostic tools and workflows to reach a more personalized, comprehensive, and integrated assessment of cardiac function.

Ultrasound guidance for volume management in patients with heart failure

Congestion is one of the most prominent characteristics of patients presented with decompensated heart failure and it implies unfavorable prognosis for the heart failure patient. Neurohumoral and immuno-inflammatory activation secondary to cardiac dysfunction constitute the pivotal mechanisms driving the heart failure syndrome that results in progressive fluid accumulation. In addition, fluid redistribution between different vascular compartments in human body guided from sympathetic activity constitutes another mechanism for heart failure decompensation. Ultrasound applied in the form of echocardiography provides invaluable data for the assessment of intracardiac filling pressures. The type of renal venous flow can provide the degree of renal congestion and probably insight into the pathophysiology of the decompensation of heart failure. Assessment of lung congestion in the patient with heart failure can be accomplished by lung ultrasonography. Additionally, clinical studies on the role of ultrasound in the management and prognosis of the congested patient are reviewed. Special heart failure population supported with left ventricular assist devices and extracorporeal membrane oxygenation support constitute an area where ultrasound guidance of fluid management has gained important role.

Optimizing Management of Heart Failure by Using Echo and Natriuretic Peptides in the Outpatient Unit

Chronic heart failure (HF) is an important public health problem and is associated with high morbidity, high mortality, and considerable healthcare costs. More than 90% of hospitalizations due to worsening HF result from elevations of left ventricular (LV) filling pressures and fluid overload, which are often accompanied by the increased synthesis and secretion of natriuretic peptides (NPs). Furthermore, persistently abnormal LV filling pressures and a rise in NP circulating levels are well known indicators of poor prognosis. Frequent office visits with the resulting evaluation and management are most often needed. The growing pressure from hospital readmissions in HF patients is shifting the focus of interest from traditionally symptom-guided care to a more specific patient-centered follow-up care based on clinical findings, BNP and echo. Recent studies supported the value of serial NP measurements and Doppler echocardiographic biomarkers of elevated LV filling pressures as tools to scrutinize patients with impending clinically overt HF. Therefore, combination of echo and pulsed-wave blood-flow and tissue Doppler with NPs appears valuable in guiding ambulatory HF management, since they are potentially useful to distinguish stable patients from those at high risk of decompensation.

Combining echo and natriuretic peptides to guide heart failure care in the outpatient setting: A position paper

BACKGROUND

Chronic heart failure (HF) is a relevant and growing public health problem. Although the prognosis has recently improved, it remains a lethal disease, with a mortality that equals or exceeds that of many malignancies. Furthermore, chronic HF is costly, representing a large and growing drain on healthcare resources.

METHODS

This narrative review is based on the material searched for and obtained via PubMed up to May 2017. The search terms we used were as follows: "heart failure, echocardiography, natriuretic peptides" in combination with "treatment, biomarkers, guidelines."

RESULTS

Recent studies have supported the value of natriuretic peptides (NPs) and Doppler echocardiographic biomarkers of increased left ventricular (LV) filling pressures or pulmonary congestion as tools to scrutinize patients with impending clinically overt HF. Therefore, combination of pulsed-wave tissue and blood flow Doppler with NPs appears valuable in guiding HF management in the outpatient setting. In as much as both the echo and the plasma levels of NPs may reflect the presence of fluid overload and elevations of LV filling pressures, integrating NP and echocardiographic biomarkers with clinical findings may help the cardiologist to identify high-risk patients, that is to recognize whether a patient is stable or the condition is likely to evolve into decompensated HF, to optimize treatment, to improve the prognosis and to reduce rehospitalization.

CONCLUSION

We discussed the rationale and the clinical significance of combining follow-up echo and NP assessment to guide management of ambulatory patients with chronic HF.

Echocardiographic evaluation of left ventricular diastolic function in cats: Hemodynamic determinants and pattern recognition

Left ventricular (LV) diastolic dysfunction is highly prevalent in cats and is a functional hallmark of feline cardiomyopathy. The majority of cats with hypertrophic, restrictive, and dilated cardiomyopathy have echocardiographic evidence of abnormal LV filling, even during the occult (preclinical) phase. Moderate and severe diastolic dysfunction is an indicator of advanced myocardial disease, is associated with clinical signs including exercise intolerance and congestive heart failure, affects outcome, and influences therapeutic decisions. Therefore, identification and quantification of LV diastolic dysfunction are clinically important. Surrogate measures of diastolic function determined by transthoracic two-dimensional, M-mode, and Doppler echocardiographic (DE) methods have been used widely for such purpose. Major functional characteristics of LV diastole, including global function, relaxation and untwist, chamber compliance, filling volume, and the resultant filling pressures can be semi-quantified by echocardiographic methods, and variables retrieved from transmitral flow, pulmonary vein flow, and tissue Doppler recordings are most frequently used. Although there is still a critical lack of well-designed studies in the field, knowledge has steadily accumulated over the past 20 years, reference ranges of diastolic echocardiographic variables have been determined, epidemiological studies have been conducted, and new treatments of diastolic dysfunction in cats have been evaluated. This report will give the reader a summary of the current status in the field of feline diastology with focus on the noninvasive diagnostic methods and interpretation of echocardiographic surrogate measures of LV diastolic function. Lastly, a grading system using a composite of left atrial size and various DE variables potentially useful in the functional classification of LV diastole in cats is introduced.

Quantification and significance of diffuse myocardial fibrosis and diastolic dysfunction in childhood hypertrophic cardiomyopathy

The purpose of this study was to evaluate the presence of diffuse myocardial fibrosis in children and adolescents with hypertrophic cardiomyopathy (HCM) and to assess associations with echocardiographic and clinical parameters of disease. While a common end point in adults with HCM, it is unclear whether diffuse myocardial fibrosis occurs early in the disease. Cardiac magnetic resonance (CMR) estimation of myocardial post-contrast longitudinal relaxation time (T1) is an increasingly used method to estimate diffuse fibrosis. T1 measurements were taken using standard multi-breath-hold spoiled gradient echo phase-sensitive inversion-recovery CMR before and 15 min after the injection of gadolinium. The tissue-blood partition coefficient was calculated as a function of the ratio of T1 change of myocardium compared with blood. An echocardiogram and blood brain natriuretic peptide (BNP) levels were obtained on the day of the CMR. Twelve controls (mean age 12.8 years; 7 male) and 28 patients with HCM (mean age 12.8 years; 21 male) participated. The partition coefficient for both septal (0.27 ± 0.17 vs. 0.13 ± 0.09; p = 0.03) and lateral walls (0.22 ± 0.09 vs. 0.07 ± 0.10; p < 0.001) was increased in patients compared with controls. Eight patients had overt areas of late gadolinium enhancement (LGE). These patients did not show increased partition coefficient compared with those without LGE (0.27 ± 0.15 vs. 0.27 ± 0.19 and 0.22 ± 0.09 vs. 0.22 ± 0.09; p = 0.95 and 0.98, respectively). However, patients who were symptomatic (dyspnea, arrhythmia and/or chest pain) had higher lateral wall partition coefficient than asymptomatic HCM patients (0.27 ± 0.08 vs. 0.17 ± 0.08; p = 0.006). Similarly, patients with raised BNP (>100 pg/ml) had raised lateral wall coefficients (0.27 ± 0.07 vs. 0.20 ± 0.07; p = 0.03), as did those with traditional risk factors for sudden death (0.27 ± 0.06 vs. 0.18 ± 0.08; p = 0.007). Diffuse fibrosis, measured by the partition coefficient technique, is demonstrable in children and adolescents with HCM. Markers of fibrosis show an association with symptoms and raised serum BNP. Further study of the prognostic implication of this technique in young patients with HCM is warranted.

Left ventricular diastolic function in hypertension: methodological considerations and clinical implications

The assessment of left ventricular (LV) diastolic function should be an integral part of a routine examination of hypertensive patient; indeed when LV diastolic function is impaired, it is possible to have heart failure even with preserved LV ejection fraction. Left ventricular diastolic dysfunction (LVDD) occurs frequently and is associated to heart disease. Doppler echocardiography is the best tool for early LVDD diagnosis. Hypertension affects LV relaxation and when left ventricular hypertrophy (LVH) occurs, it decreases compliance too, so it is important to calculate Doppler echocardiography parameters, for diastolic function evaluation, in all hypertensive patients. The purpose of our review was to discuss about the strong relationship between LVDD and hypertension, and their relationship with LV systolic function. Furthermore, we aimed to assess the relationship between the arterial stiffness and LV structure and function in hypertensive patients.

The prognostic impact of diastolic dysfunction in patients with chronic heart failure and post-acute myocardial infarction: Can age-stratified E/A ratio alone predict survival?

OBJECTIVE

To determine the prognostic implications of diastolic filling grades and identify whether age-stratified E/A ratio alone can identify patients at high risk of death post-AMI and HF. We hypothesized that in response to ageing and pathology, a normal E/A (>1) could be considered abnormal in patients post-AMI older than 65years, and that in patients with symptomatic HF, a normal E/A always represents advanced diastolic dysfunction.

METHODS AND RESULTS

This is a sub-analysis of the Meta-analysis Research Group in Echocardiography (MeRGE) which combined individual patient data from 30 prospective studies and demonstrated that restrictive filling was an important and independent predictor of all-cause mortality. This sub-analysis is restricted to those studies in which continuous E/A data were available (20 studies) and includes a total of 3082 AMI and 2321 HF patients. Patients were classified at the time of echocardiography into four filling patterns: normal, abnormal relaxation, pseudonormal, and restrictive filling. Post-AMI patients were divided into four groups on the basis of age and E/A, while patients with HF were classified into three groups, based on only E/A. Mortality across groups was compared using Kaplan-Meier survival analysis and Cox proportional hazards. In multivariable analyses in the AMI patients, age-stratified E/A was an independent predictor of outcome (HR 1.43 (95% CI: 1.31-1.56)), and in the HF cohort, E/A was confirmed as an independent predictor of mortality (HR 1.12 (95% CI 1.09-1.16)) alongside age and ejection fraction.

CONCLUSIONS

Age-stratified E/A is an independent predictor of mortality after AMI and in HF patients, regardless of left ventricular ejection fraction, age and gender. E/A ratio could be a first step echocardiographic risk stratification, which could precede and indicate the need for more advanced diagnostic and prognostic considerations in high-risk AMI and HF patients.

The role of echocardiography in the diagnosis and prognosis of patients with heart failure

The number of patients with congestive heart failure has increased in epidemic proportions. Echocardiography plays an important role in the diagnosis and management of these patients. Recent studies have also confirmed the independent prognostic information of the echocardiographic findings.

Role of echocardiography in the contemporary management of chronic heart failure

Echocardiography is an excellent noninvasive tool for the assessment of ventricular size and both systolic and diastolic function, and it is routinely used in patients with heart failure. This review will discuss the role of echocardiography in heart failure diagnosis, prognostic assessment and in the management of heart failure patients.

Clinical utility and prognostic value of left atrial volume assessment by cardiovascular magnetic resonance in non-ischaemic dilated cardiomyopathy

AIMS

Echocardiographic studies have shown that left atrial volume (LAV) predicts adverse outcome in small heart failure (HF) cohorts of mixed aetiology. However, the prognostic value of LAV in non-ischaemic dilated cardiomyopathy (DCM) is unknown. Cardiovascular magnetic resonance (CMR) allows accurate and reproducible measurement of LAV. We sought to determine the long-term prognostic significance of LAV assessed by CMR in DCM.

METHODS AND RESULTS

We measured LAV indexed to body surface area (LAVi) in 483 consecutive DCM patients referred for CMR. Patients were prospectively followed up for a primary endpoint of all-cause mortality or cardiac transplantation. During a median follow-up of 5.3 years, 75 patients died and 9 underwent cardiac transplantation. After adjustment for established risk factors, LAVi was an independent predictor of the primary endpoint [hazard ratio (HR) per 10 mL/m(2) 1.08; 95% confidence interval (CI) 1.01-1.15; P = 0.022]. LAVi was also independently associated with the secondary composite endpoints of cardiovascular mortality or cardiac transplantation (HR per 10 mL/m(2) 1.11; 95% CI 1.04-1.19; P = 0.003), and HF death, HF hospitalization, or cardiac transplantation (HR per 10 mL/m(2) 1.11; 95% CI 1.04-1.18; P = 0.001). The optimal LAVi cut-off value for predicting the primary endpoint was 72 mL/m(2). Patients with LAVi >72 mL/m(2) had a three-fold elevated risk of death or transplantation (HR 3.00; 95% CI 1.92-4.70; P < 0.001). LAVi provided incremental prognostic value for the prediction of transplant-free survival (net reclassification improvement 0.17; 95% CI 0.05-0.29; P = 0.002).

CONCLUSIONS

LAVi is a powerful independent predictor of transplant-free survival and HF outcomes in DCM. Assessment of LAV improves risk stratification in DCM and should be incorporated into routine CMR examination.

The etiology-filling pattern-pulmonary artery pressure score: a simple tool for risk stratification of patients with systolic heart failure

Heart failure (HF) is a leading cause of morbidity and mortality. The detection of patients at high risk for death is a major challenge in HF management. The authors compared the prognostic value of 23 clinical Doppler echocardiography and cardiopulmonary exercise indexes in a stable, moderately symptomatic, systolic HF outpatient population receiving optimal medical therapy. The end point was the incidence of overall mortality. Between January 2002 and December 2008, a total of 146 patients with left ventricular (LV) ejection fraction 0.31±0.8 and New York Heart Association functional class II or III were enrolled. The prognostic power of single variables was assessed using chi-square test for categoric variables and t test for continuous variables. Variables associated with the prespecified end point were included as predictors in a binary logistic regression multivariate model. At multivariate analysis, "restrictive" LV filling pattern (P=.004), ischemic etiology (P=.022), pulmonary artery systolic pressure (PASP) ≥50 mm Hg (P=.027), and peak oxygen uptake (VO(2) ) <15.9 mL/kg/min (P=.046) resulted independent predictors of the outcome. A simple risk score was then obtained using these significant independent variables, excluding peak VO(2) because of only borderline significance. Patients with ischemic etiology, restrictive LV filling pattern, and PASP ≥50 mm Hg have a very high risk of death (odds ratio, 33.77; 95% confidence interval, 5.74-198.8; P<.001, compared with patients with no risk factors). In this high-risk group, evaluation of peak VO(2) could be superfluous. A very simple clinical echocardiographic model based on etiology-LV filling and pulmonary pressure is a powerful tool for risk stratification of systolic HF in ambulatory patients.

Failure to Unmask Pseudonormal Diastolic Function by a Valsalva Maneuver

Background—

For the clinical assessment of patients with dyspnea, the inversion of the early (E) and late (A) transmitral flow during Valsalva maneuver (VM) frequently helps to distinguish pseudonormal from normal filling pattern. However, in an important number of patients, VM fails to reveal the change from dominant early mitral flow velocity toward larger late velocity.

Methods and Results—

From December 2009 to October 2010, we selected consecutive patients with abnormal filling with (n=25) and without E/A inversion (n=25) during VM. Transmitral, tricuspid, and pulmonary Doppler traces were recorded and the degree of insufficiency was estimated. After evaluating all standard echocardiographic morphological, functional, and flow-related parameters, it became evident that the failure to unmask the pseudonormal filling pattern by VM was related to the degree of the tricuspid insufficiency (TI). TI was graded as mild in 24 of 25 patients in the group with E/A inversion during VM, whereas TI was graded as moderate to severe in 24 of the 25 patients with pseudonormal diastolic function without E/A inversion during VM.

Conclusions—

Our data suggest that TI is a major factor to prevent E/A inversion during a VM in patients with pseudonormal diastolic function. This probably is due to a decrease in TI resulting in an increase in forward flow rather than the expected decrease during the VM. Thus, whenever a pseudonormal diastolic filling pattern is suspected, the use of a VM is not an informative discriminator in the presence of moderate or severe TI.

A comparison of echocardiographic measures of diastolic function for predicting all-cause mortality in a predominantly male population

BACKGROUND

Prior studies demonstrating the prognostic value of echocardiographic measures of diastolic function have been limited by sample size, have included only select clinical populations, and have not incorporated newer measures of diastolic function nor determined their independent prognostic value. The objective of this study is to determine the independent prognostic value of established and new echocardiographic parameters of diastolic function.

METHODS

We included 3,604 consecutive patients referred to 1 of 3 echocardiography laboratories over a 2-year period. We obtained measurements of mitral inflow velocities, pulmonary vein filling pattern, mitral annulus motion (e'), and propagation velocity (V(p)). The primary end point was 1-year all-cause mortality.

RESULTS

The mean age of the patients was 68 years, and 95% were male. There were 277 deaths during a mean follow-up of 248 ± 221 days. For patients with reduced left ventricular ejection fraction (LVEF), all measured parameters except for e' were associated with mortality (P < .05) on univariate analysis. For patients with preserved LVEF, the E-wave velocity was significantly associated with mortality (P < .05) on univariate analysis. The deceleration time/E-wave velocity ratio, V(p), and pulmonary vein filling pattern were borderline significant (P < .10). With multivariate analysis, only V(p) was associated with survival for both reduced (P = .02) and preserved LVEF groups (P = .01).

CONCLUSION

In a large, clinically diverse population, most measures of diastolic function were predictive of all-cause mortality without adjustment for patient characteristics. On multivariate analysis, only V(p) was independently associated with total mortality. This association with mortality may be related to factors other than diastolic function and warrants further investigation.

Diastolic dysfunction: improved understanding using emerging imaging techniques

Diastolic heart failure is increasing in prevalence. Although the pathophysiology is incompletely understood and current therapeutic strategies are limited, identification of diastolic dysfunction is important. We review the role of contemporary techniques with echocardiography and cardiac magnetic resonance imaging (CMRI) in the assessment of diastolic dysfunction. Cardiac catheterization is the criterion standard for demonstrating impaired relaxation and filling by making direct measurements; however, echocardiography has replaced it as the most clinically used tool. By evaluating mitral inflow pulsed-wave Doppler with and without the Valsalva maneuver, isovolumetric relaxation time, pulmonary venous flow Doppler, color M-mode velocity propagation, tissue Doppler imaging, and speckle tracking, echocardiography is considered an accurate method for diagnosis and grading diastolic dysfunction. Evaluation of diastolic function can also be performed by CMRI. Mitral valve inflow velocities, early deceleration time, and pulmonary vein flow velocities are diastolic parameters that can be measured by phase-contrast CMRI. Cardiac magnetic resonance imaging steady-state gradient echo can evaluate functional dimensions for time-volume curves; and myocardial tagging can assess ventricular diastolic "untwisting," which may be important for improved pathophysiologic understanding. Studies have compared echocardiography and CMRI for diagnosing diastolic dysfunction in small patient groups with similar results. Cardiac magnetic resonance imaging can now provide clinically relevant data regarding the underlying cause of diastolic dysfunction and offers promise to gain mechanistic insights for therapeutic strategy development and clinical trial planning.

Prevalence of left ventricular diastolic dysfunction in a general population

BACKGROUND

Because the process of myocardial remodelling starts before the onset of symptoms, recent heart failure (HF) guidelines place special emphasis on the detection of subclinical left ventricular (LV) systolic and diastolic dysfunction and the timely identification of risk factors for HF. Our goal was to describe the prevalence and determinants (risk factors) of LV diastolic dysfunction in a general population and to compare the amino terminal probrain natriuretic peptide level across groups with and without diastolic dysfunction.

METHODS AND RESULTS

In a randomly recruited population sample (n=539; 50.5% women; mean age, 52.5 years), we measured early and late diastolic peak velocities of mitral inflow (E and A), pulmonary vein flow by pulsed-wave Doppler, and the mitral annular velocities (Ea and Aa) at 4 sites by tissue Doppler imaging. A healthy subsample of 239 subjects (mean age, 43.7 years) provided age-specific cutoff limits for normal E/A and E/Ea ratios and the differences in duration between the mitral A and the reverse pulmonary vein flows during atrial systole (DeltaAd-ARd). The number of subjects in diastolic dysfunction groups 1 (impaired relaxation), 2 (elevated LV end-diastolic filling pressure), and 3 (elevated E/Ea and abnormally low E/A) were 53 (9.8%), 76 (14.1%), and 18 (3.4%), respectively. We used Delta(Ad<ARd+10) to confirm possible elevation of LV filling pressures in group 2. Compared with subjects with normal diastolic function (n=392, 72.7%), group 1 (209 versus 251 pmol/L; P=0.015) and group 2 (209 versus 275 pmol/L; P=0.0003) but not group 3 (209 versus 224 pmol/L; P=0.65) had a significantly higher adjusted NT-probrain natriuretic peptide. Higher age, body mass index, heart rate, systolic blood pressure, serum insulin, and creatinine were significantly associated with a higher risk of LV diastolic dysfunction.

CONCLUSIONS

The overall prevalence of LV diastolic dysfunction in a random sample of a general population, as estimated from echocardiographic measurements, was as high as 27.3%.

Stratification of impaired relaxation filling patterns by passive leg lifting in patients with preserved left ventricular ejection fraction

METHODS

We evaluated diastolic functional reserve in 108 patients with normal left ventricular ejection fraction (LVEF)> or =50% but abnormal relaxation (ratio of transmitral peak velocity of early and late diastolic flow (E/A)<1) using passive leg lifting. We calculated the pulmonary venous systolic to diastolic flow ratio (S/D) as a marker of left atrial reservoir function, and the time difference between the duration of pulmonary venous retrograde flow (PVAd) and the duration of the mitral A wave (PVAd-Ad) as a marker of left ventricular end-diastolic pressure (LVEDP).

RESULTS

During leg lifting, the E/A was > or =1 in 39 patients (the inverted group); the remaining 69 patients comprised the stable group. Comparing the inverted group with the stable group at baseline, S/D was smaller (1.5+/-0.4 vs. 1.8+/-0.5, P=0.002) and PVAd-Ad greater (11+/-23 ms vs. -23+/-28 ms, P<0.001). Multiple logistic regression analysis revealed that PVAd-Ad and S/D predicted E/A inversion with leg lifting after adjustment for age, LV wall thickness, LV dimension, LVEF, deceleration time of E, and E/E'.

CONCLUSION

In patients with preserved LVEF but early diastolic dysfunction, passive leg lifting may identify patients having a less compliant left ventricle and impaired left atrial reservoir function.

Independence of restrictive filling pattern and LV ejection fraction with mortality in heart failure: an individual patient meta-analysis

BACKGROUND

The Doppler echocardiographic restrictive mitral filling pattern (RFP) is an important prognostic indicator in patients with heart failure (HF), but the interaction between RFP, left ventricular ejection fraction (LVEF) and filling pattern remains uncertain.

AIMS

To determine whether the RFP is predictive of mortality independently of LVEF in patients with HF.

METHODS

Online databases were searched to identify studies assessing the relationship between prognosis and LV filling pattern in patients with HF. Individual patient data from 18 studies (3540 patients) were extracted and collated at the MeRGE Coordinating Centre (The University of Auckland).

RESULTS

Overall, RFP was associated with higher all-cause mortality than the non-restrictive filling pattern: hazard ratio 2.42 (95% CI 2.06, 2.83). In multivariable analysis the RFP, LVEF, NYHA class and age were independent predictors of mortality. The prevalence of the RFP was inversely related to LVEF but remained a predictor of mortality even in those patients with preserved LVEF.

CONCLUSIONS

The restrictive mitral filling pattern is a powerful predictor of mortality, independent of LVEF and age, in patients with HF. Doppler-derived LV filling patterns are an accessible marker from echocardiography that can readily be incorporated in risk stratification of all patients with HF.

Assessing diastolic function with Doppler echocardiography using a novel index: ratio of the transmitral early diastolic velocity to pulmonary diastolic velocity

We developed a novel index to assess left ventricular (LV) relaxation as the ratio of transmitral early diastolic velocity to pulmonary diastolic velocity (E/D ratio). Mixed breed dogs (n=7) were anesthetized and their respiration was controlled. A 3.5-Fr micromanometer-tipped catheter was placed into the left ventricle. Dobutamine (5.0 or 10 microg/kg/min) or esmolol (100 or 500 microg/kg/min) was administered via the cephalic vein. The transmitral flow (TMF) and pulmonary venous flow (PVF) were recorded using transthoracic echocardiography from the apical long-axis view. The heart rate, systolic LV pressure, +dP/dt, and -dP/dt were significantly elevated by dobutamine, but significantly reduced by esmolol. Dobutamine significantly decreased tau, whereas esmolol significantly increased tau. The TMF-derived E and PVF-derived D wave velocities increased significantly with dobutamine, but decreased significantly with esmolol. A significant correlation was detected between the E and D wave velocities (r=0.92). Consequently, the E/D ratio was decreased significantly with dobutamine, and increased significantly with esmolol. Furthermore, the E/D ratio was significantly correlated with -dP/dt (r= -0.64) and tau (r=0.84). Our results suggest that the E/D ratio reflects LV relaxation, and may potentially provide further information on LV relaxation.

Individual patient meta-analyses of restrictive diastolic filling pattern and mortality in patients post acute myocardial infarction and in patients with chronic heart failure

BACKGROUND AND OBJECTIVE

Doppler echocardiographic assessment of diastolic filling provides a non-invasive estimate of left ventricular (LV) filling pressure and the most advanced diastolic filling grade, the restrictive filling pattern (RFP), has been linked to prognosis in patients post acute myocardial infarction (AMI) and with heart failure (HF). There remains some uncertainty about the prognostic role of RFP in patients with varied levels of systolic function. The objective of this collaboration is to determine whether the presence of RFP offers additional prognostic information over LV systolic function, symptoms or other clinical factors in patients post AMI or with HF.

METHODS

The Meta-analysis Research Group in Echocardiography (MeRGE) has been established in order to test this through two individual patient meta-analyses. Prospective studies that enrolled patients with either established HF or post AMI and included Doppler-echocardiography and outcome data will be merged into two large datasets (3739 AMI patients and 3540 HF patients) in order to evaluate the independent effects of RFP upon total and cardiovascular mortality using Kaplan-Meier survival analysis methods and Cox proportional hazards model for multi-variate analysis. Survival will be examined within different bands of LV systolic function based upon ejection fraction (EF).

IMPLICATIONS

This unique dataset will provide a very large cohort of patients, which will be adequately powered to provide new and prognostically important information to further aid risk stratification in these two high-risk patient groups.

Left ventricular diastolic function

Cardiovascular morbidity and mortality resulting from congestive heart failure are major concerns for the critical care physician. Although heart failure is commonly associated with impaired systolic function, in up to one half of cases, heart failure occurs exclusively on the basis of an impairment of diastolic function. Diastole is the summation of processes by which the heart loses its ability to generate force and shorten and returns to its precontractile state. The two principal processes responsible for diastole are relaxation and passive pressure-volume properties of the ventricle. Echocardiography provides a comprehensive, noninvasive evaluation of diastolic filling of the ventricle, myocardial relaxation, and ventricular stiffness; the information obtained by echocardiography has prognostic value and is a guide to proper therapy. This article reviews the physiology of diastole, the pathogenesis of diastolic heart failure, and the diagnosis of diastolic dysfunction, with a focus on the diagnostic utility of echocardiography and an emphasis on those areas of greatest interest to the critical care physician.

Impact of mitral E/A ratio on the accuracy of different echocardiographic indices to estimate left ventricular end-diastolic pressure

The objective was to determine the influence of left ventricular (LV) inflow pattern on the accuracy of different echocardiographic indices for estimation of LV end-diastolic pressure (LVEDP). Echocardiography with color tissue Doppler imaging (TDI) and LVEDP measurements using fluid-filled catheters were performed in 176 consecutive patients on the same day. Mitral peak diastolic velocities (E, A) and the difference in duration between pulmonary venous retrograde velocity and mitral A-velocity (PV(R)-A) were recorded by pulsed Doppler. Propagation velocity of the early mitral inflow (V(P)) was assessed using color M-mode. Early diastolic longitudinal (E'(lat)) and radial (E'(radial)) velocities of mitral annulus were measured by TDI. Area under ROC curve (AUC) for prediction of elevated LVEDP (> or =15 mm Hg) was computed for each parameter. For E/A > or =1 (98 patients, 46 with elevated LVEDP), the AUC values were: PV(R)-A: 0.914; E/E'(lat): 0.780; E/E'(radial): 0.729; E/V(P): 0.712 (p < 0.001). When E/A <1 (78 patients, 26 with elevated LVEDP), only PV(R)-A reached statistical significance (AUC = 0.893, p < 0.001). The conclusions were: PV(R)-A enabled the most accurate noninvasive estimation of LVEDP irrespective of LV filling profile and combined indices E/V(P), E/E'(lat) and E/E'(radial) represent more feasible alternatives for patients with mitral E/A-1.

How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology

Diastolic heart failure (DHF) currently accounts for more than 50% of all heart failure patients. DHF is also referred to as heart failure with normal left ventricular (LV) ejection fraction (HFNEF) to indicate that HFNEF could be a precursor of heart failure with reduced LVEF. Because of improved cardiac imaging and because of widespread clinical use of plasma levels of natriuretic peptides, diagnostic criteria for HFNEF needed to be updated. The diagnosis of HFNEF requires the following conditions to be satisfied: (i) signs or symptoms of heart failure; (ii) normal or mildly abnormal systolic LV function; (iii) evidence of diastolic LV dysfunction. Normal or mildly abnormal systolic LV function implies both an LVEF > 50% and an LV end-diastolic volume index (LVEDVI) <97 mL/m(2). Diagnostic evidence of diastolic LV dysfunction can be obtained invasively (LV end-diastolic pressure >16 mmHg or mean pulmonary capillary wedge pressure >12 mmHg) or non-invasively by tissue Doppler (TD) (E/E' > 15). If TD yields an E/E' ratio suggestive of diastolic LV dysfunction (15 > E/E' > 8), additional non-invasive investigations are required for diagnostic evidence of diastolic LV dysfunction. These can consist of blood flow Doppler of mitral valve or pulmonary veins, echo measures of LV mass index or left atrial volume index, electrocardiographic evidence of atrial fibrillation, or plasma levels of natriuretic peptides. If plasma levels of natriuretic peptides are elevated, diagnostic evidence of diastolic LV dysfunction also requires additional non-invasive investigations such as TD, blood flow Doppler of mitral valve or pulmonary veins, echo measures of LV mass index or left atrial volume index, or electrocardiographic evidence of atrial fibrillation. A similar strategy with focus on a high negative predictive value of successive investigations is proposed for the exclusion of HFNEF in patients with breathlessness and no signs of congestion. The updated strategies for the diagnosis and exclusion of HFNEF are useful not only for individual patient management but also for patient recruitment in future clinical trials exploring therapies for HFNEF.

The prognostic significance of restrictive diastolic filling associated with heart failure: A meta-analysis

BACKGROUND

Several studies have reported that the presence of a restrictive filling pattern (RFP) is associated with poor outcome in patients with heart failure (HF). These studies, of variable sample size, have involved different HF patient groups with variable associated mortality rates and follow-up times, and while powered for effects on combined end-points such as death or hospital admission, many were underpowered to reliably determine the overall effect of the RFP on total mortality. Consequently, we performed a meta-analysis to determine the mortality associated with RFP in patients with HF.

METHODS

We searched several online medical databases for prospective studies of patients with HF. All authors were requested to confirm their data. All-cause mortality was compared between RFP and non-restrictive filling patterns (Non-RFP). Review Manager version 4.2.7 software was used for the analysis.

RESULTS

3024 patients in 27 studies were identified (379 idiopathic cardiomyopathy, 2645 mixed aetiology HF). Average follow-up was between 3 months and 5 years. 1284 (42%) patients had RFP at baseline. 688 deaths occurred and the overall odds ratio for death was 4.36 (CI 3.60, 5.04); idiopathic group: 6.65 (CI 3.86, 11.47); mixed aetiology group: 4.10 (CI 3.34, 5.04). The overall odds ratio for death/transplantation was 4.87 (CI 4.04, 5.86); idiopathic group: 7.62 (CI 4.50, 12.92); mixed aetiology group: 4.56 (CI 3.74, 5.56).

CONCLUSIONS

Restrictive filling pattern is associated with a four-fold increase in mortality in patients with HF and thus should be an important part of the echocardiographic assessment of such patients.

Significance of left atrial contractile function in asymptomatic subjects with hereditary hemochromatosis

Patients with hereditary hemochromatosis (HH) have been reported to develop diastolic functional abnormalities detectable by echocardiography, but it is unknown whether these occur in asymptomatic subjects. Thus, this study tested whether echocardiographic left ventricular (LV) relaxation abnormalities are detectable in subjects with asymptomatic HH. Forty-three asymptomatic subjects with HH (C282Y homozygosity in the HFE gene) and 21 age- and gender-matched control subjects without known HFE mutations underwent echocardiography with comprehensive diastolic functional evaluations. Subjects with HH were in New York Heart Association functional class I and consisted of 22 newly diagnosed patients (group A) and 21 chronically phlebotomized subjects with stable iron levels (group B). Group A subjects showed significant iron overload compared with group B subjects and controls (group C) (ferritin 1,164 +/- 886 [p <0.05 vs groups B and C], 128 +/- 262, and 98 +/- 76 microg/L and transferrin saturation 79 +/- 19% [p <0.05 vs groups B and C], 42 +/- 21%, and 26 +/- 10% for groups A, B, and C, respectively). Echocardiographic evaluation revealed (1) no statistically significant abnormalities of Doppler LV relaxation in HH groups; (2) significant augmentation of atrial contractile function in subjects with HH compared with controls, which was not correlated with iron levels and treatment status; and (3) the preservation of overall LV systolic function in HH groups. In conclusion, the results of this study suggest that the augmentation of atrial contraction appears to be an early detectable echocardiographic cardiac manifestation of abnormal diastolic function in asymptomatic subjects with HH, which may reflect undetectable subclinical LV relaxation abnormalities.

Restrictive diastolic filling predicts death after acute myocardial infarction: systematic review and meta-analysis of prospective studies

OBJECTIVE

To determine, through a systematic review and meta-analysis, the magnitude of the survival deficit associated with a restrictive filling pattern after acute myocardial infarction (AMI).

METHODS

Online databases were searched for prospective echocardiography outcome studies of patients after AMI. All authors were contacted to seek confirmation of their data. Restrictive filling was compared with all non-restrictive filling patterns. Review Manager Version 4.2.7 software was used for analysis.

RESULTS

3855 patients in 16 studies were identified. Follow up varied from two weeks to five years (> 1 year, 10 studies; and > 4 years, four studies). 776 (20%) of patients had a restrictive filling pattern at baseline. 580 patients died (247 in the restrictive group), and the overall odds ratio for death (restrictive filling worse) was 4.10 (95% confidence interval 3.38 to 4.99).

CONCLUSIONS

Mortality is about four times higher in patients with a restrictive filling pattern than in those with non-restrictive filling patterns after AMI. Echocardiographic assessment of diastolic filling pattern is an important part of the echocardiographic assessment of patients after myocardial infarction and provides important prognostic information about such patients.

Effects of Levosimendan on Restrictive Left Ventricular Filling in Severe Heart Failure

BACKGROUND

A restrictive pattern of left ventricular filling is often present in patients with severe heart failure. Although the hemodynamic effects of levosimendan have been studied, the effects of levosimendan on LV filling pattern have not been investigated.

METHODS

Pulsed-wave Doppler mitral (transthoracic) and pulmonary venous flow (transesophageal) velocity curves were recorded in 30 patients with a restrictive pattern of left ventricular filling with New York Heart Association class III or IV heart failure who had a documented left ventricular ejection fraction < 30% by echocardiography and received a 0.1 microg/kg/min infusion of levosimendan for 24 h.

RESULTS

Levosimendan caused significant (p < 0.001) increases in stroke volume (from 46 +/- 4 to 57 +/- 4 mL) and decreases in pulmonary capillary wedge pressure (from 21 +/- 1 to 15 +/- 1 mm Hg). The E wave decreased (from 96 +/- 7 to 71 +/- 5 cm/s), and the A wave increased (from 40 +/- 4 to 46 +/- 4 cm/s). Moreover, deceleration time was increased (from 112 +/- 7 to 189 +/- 14 ms). The S wave of pulmonary venous flow was increased (from 38 +/- 3 to 60 +/- 3 cm/s), and atrial reversal was decreased (from 36 +/- 2 to 29 +/- 2 cm/s). All changes were significant (p < 0.001). Using stepwise linear regression analysis, we found that the percentage changes of the early/late transmitral diastolic peak flow velocity (E/A) ratio and the percentage changes of the isovolumetric relaxation time were independent predictors of the increase in cardiac output. Furthermore, the percentage changes of the systolic/diastolic ratio and the percentage changes of the E/A ratio were independent predictors of the decrease in pulmonary capillary wedge pressure.

CONCLUSIONS

Treatment with levosimendan improved measures of left ventricular diastolic function. Consequently, left ventricular stroke volume was increased.

Doppler tissue imaging: a reliable method for estimation of left ventricular filling pressure in patients with mitral regurgitation

BACKGROUND

Doppler of mitral and pulmonary vein flows are used to estimate left ventricular (LV) filling pressure. Mitral regurgitation (MR) makes unreliable these parameters by inducing changes of both mitral inflow and pulmonary vein flow.

OBJECTIVES

To evaluate whether Doppler tissue imaging (DTI) diastolic indices obtained at the level of LV lateral mitral annulus can provide accurate estimation of LV filling pressure in patients with MR.

METHODS

Forty-three patients (age 55 +/- 11 years) with severe MR and mean LV ejection fraction (EF) 58 +/- 13 were enrolled, 10 (23%) with LV EF < 50% and 33 (77%) with LV EF > 50%. Doppler signals from the mitral inflow, pulmonary venous flow, and DTI indices of the lateral mitral annulus were obtained. LV end-diastolic pressure (LVEDP) was measured invasively with fluid-filled catheter.

RESULTS

In the overall population, the majority of standard Doppler and DTI indices correlated with LVEDP, but the multivariate analysis showed that the ratio of mitral velocity to early diastolic velocity of the mitral annulus (E/Em ratio) (beta = .87, P = .0001) was independent predictor of LVEDP (R2 = 0.74, SE = 4, P = .0001). An E/Em ratio > 10 predicted an LVEDP > 15 mm Hg (sensitivity 90%, specificity 83%). In both groups with LV EF > 50% (beta = .77, P = .005; cumulative R2 = 0.73, SE = 2.5, P = .0001) and < 50% (beta = .89, P = .002; cumulative R2 = 0.77, SE = 2.1, P = .002), multivariate analysis underscored again only E/Em ratio as independent predictor of LVEDP.

CONCLUSIONS

The combination of DTI indices of the mitral annulus and mitral inflow velocities provides reliable parameters to predict LV filling pressure in patients with MR both in patients with LV EF > 50% and < 50%.

Prognostic value of tissue Doppler imaging in patients with chronic congestive heart failure

BACKGROUND

The prognostic value of tissue Doppler imaging (TDI) in patients with chronic congestive heart failure (CHF) has not been compared against conventional measures of systolic, diastolic and overall left ventricular LV performance. The aim of this study was to assess the prognostic value of TDI-derived parameters in patients with CHF.

METHODS

One hundred thirty-two subjects with chronic CHF [due to ischemic (n=82) or dilated (n=50) cardiomyopathy, 101 males, mean age 57+/-11 years] underwent conventional two-dimensional/Doppler echocardiography and assessment of the Tei-index (isovolumic contraction time and isovolumic relaxation time divided by ejection time). Systolic, early and late diastolic mitral annular velocities (S', E' and A') were derived from pulsed TDI. A cardiac event (cardiac death, urgent cardiac transplantation or hospitalization due to decompensated CHF) was defined as the combined study endpoint.

RESULTS

The patients were followed for a mean of 224+/-123 days. Thirty-one patients suffered an event (cardiac death, n=5; urgent cardiac transplantation, n=2; hospitalization due to CHF, n=24). In patients with event, ejection fraction was lower (25+/-10 vs. 32+/-9%), mitral deceleration time was shorter (138+/-58 vs. 193+/-72 ms), and the peak mitral E/E'-ratio (16.1+/-6.6 vs. 10.6+/-5.0) was significantly elevated as compared to patients free of events (p<0.001 for all comparisons). In those patients, the Tei-index was elevated (1.09+/-0.39 vs. 0.86+/-0.26, p<0.01), and a restrictive mitral filling pattern was more frequent (51.6 vs. 17.5%, p<0.001). Stepwise multivariate analysis identified the mitral E/E'-ratio (p<0.001) and the Tei-index (p=0.019) as the only independent predictors of a combined event. E/E'-ratio was the best predictor of hospitalization due to CHF also. In patients with mitral E/E'-ratio>12.5 or Tei-index>0.90, outcome was poor.

CONCLUSIONS

In subjects with chronic CHF, the mitral E/E'-ratio is a stronger predictor of future cardiac events than conventional parameters of systolic, diastolic or overall LV performance. The E/E'-ratio may be a useful addition in the routine follow-up of such patients.