Color M-mode and pulsed wave tissue Doppler echocardiography: powerful predictors of cardiac events after first myocardial infarction

Prior Beta-Blocker Therapy for Hypertension and Sex-Based Differences in Heart Failure Among Patients With Incident Coronary Heart Disease

The usefulness of β-blockers has been questioned for patients who have hypertension without a prior manifestation of coronary heart disease or heart failure. In addition, sex-based differences in the efficacy of β-blockers for prevention of heart failure during acute myocardial ischemia have never been evaluated. We explored whether the effect of β-blocker therapy varied according to the sex among patients with hypertension who have no prior history of cardiovascular disease. Data were drawn from the ISACS (International Survey of Acute Coronary Syndromes)-Archives. The study population consisted of 13 764 patients presenting with acute coronary syndromes. There were 2590 patients in whom hypertension was treated previously with β-blocker (954 women and 1636 men). Primary outcome measure was the incidence of heart failure according to Killip class classification. Subsidiary analyses were conducted to estimate the association between heart failure and all-cause mortality at 30 days. Outcome rates were assessed using the inverse probability of treatment weighting and logistic regression models. Estimates were compared by test of interaction on the log scale. Among patients taking β-blockers before admission, there was an absolute difference of 4.6% between women and men in the rate of heart failure (Killip ≥2) at hospital presentation (21.3% versus 16.7%; relative risk ratio, 1.35 [95% CI, 1.10-1.65]). On the opposite, the rate of heart failure was approximately similar among women and men who did not receive β-blockers (17.2% versus 16.1%; relative risk ratio, 1.09 [95% CI, 0.97-1.21]). The test of interaction identified a significant (P=0.034) association between sex and β-blocker therapy. Heart failure was predictive of mortality at 30-day either in women (odds ratio, 7.54 [95% CI, 5.78-9.83]) or men (odds ratio, 9.62 [95% CI, 7.67-12.07]). In conclusion, β-blockers use may be an acute precipitant of heart failure in new-onset coronary heart disease among women, but not men. Heart failure increases the risk of death. Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT04008173.

Association of the low e' and high E/e' with long-term outcomes in patients with normal ejection fraction: a hospital population-based observational cohort study

OBJECTIVE

We aimed to evaluate the association of the severity of left ventricular (LV) diastolic dysfunction with long-term outcomes in patients with normal ejection fraction.

DESIGN

Retrospective study.

SETTING

A single centre in Japan.

PARTICIPANTS

We included 3576 patients who underwent both scheduled transthoracic echocardiography and ECG between 1 January and 31 December 2013, in a hospital-based population after excluding valvular diseases or low ejection fraction (<50%) or atrial fibrillation and categorised them into three groups: septal tissue Doppler early diastolic mitral annular velocity (e')≥7 (without relaxation disorder, n=1593), e'<7 and early mitral inflow velocity (E)/e'≤14 (with relaxation disorder and normal LV end-diastolic pressure, n=1337) and e'<7 and E/e'>14 (with relaxation disorder and high LV end-diastolic pressure, n=646).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was a composite of all-cause death and major adverse cardiac events (MACE). The secondary outcome measure were all-cause death and MACE, separately.

RESULTS

The cumulative 3-year incidences of the primary outcome measures were significantly higher in the e'<7 and E/e'≤14 (19.0%) and e'<7 and E/e'>14 group (23.4%) than those for the e'≥7 group (13.0%; p<0.001). After adjusting for confounders, the excess 3-year risk of primary outcome for the groups with e'<7 and E/e'≤14 related to e'≥7 (HR: 1.24; 95% CI 1.02 to 1.52) and e'<7 and E/e'>14 related to e'<7 (HR: 1.57; 95% CI 1.28 to 1.94) were significant. The severity of diastolic dysfunction was associated with incrementally higher risk for primary outcomes (p<0.001).

CONCLUSION

The severity of LV diastolic dysfunction using e'<7 and E/e'>14 was associated with the long-term prognosis in patients with normal ejection fraction in an incremental fashion.

Advances in Echocardiographic Imaging in Heart Failure With Reduced and Preserved Ejection Fraction

Echocardiography, given its safety, easy availability, and the ability to permit a comprehensive assessment of cardiac structure and function, is an indispensable tool in the evaluation and management of patients with heart failure (HF). From initial phenotyping and risk stratification to providing vital data for guiding therapeutic decision-making and monitoring, echocardiography plays a pivotal role in the care of HF patients. The recent advent of multiparametric approaches for myocardial deformation imaging has provided valuable insights in the pathogenesis of HF, elucidating distinct patterns of myocardial dysfunction and events that are associated with progression from subclinical stage to overt HF. At the same time, miniaturization of echocardiography has further expanded clinical application of echocardiography, with the use of pocket cardiac ultrasound as an adjunct to physical examination demonstrated to improve diagnostic accuracy and risk stratification. Furthermore, ongoing advances in the field of big data analytics promise to create an exciting opportunity to operationalize precision medicine as the new approach to healthcare delivery that aims to individualize patient care by integrating data extracted from clinical, laboratory, echocardiographic, and genetic assessments. The present review summarizes the recent advances in the field of echocardiography, with emphasis on their role in HF phenotyping, risk stratification, and optimizing clinical outcomes.

Prognostic importance of tissue velocity imaging during exercise echocardiography in patients with systolic heart failure

Resting echocardiography measurements are poor predictors of exercise capacity and symptoms in patients with heart failure (HF). Stress echocardiography may provide additional information and can be expressed using left ventricular ejection fraction (LVEF), or diastolic parameters (E/E'), but LVEF has some major limitations. Systolic annular velocity (S') provides a measure of longitudinal systolic function, which is relatively easy to obtain and shows a good relationship with exercise capacity. The objective of this study was to investigate the relationship among S', E/E' and LVEF obtained during stress echocardiography and both mortality and hospitalisation. A secondary objective was to compare S' measured using a simplified two-wall model. A total of 80 patients with stable HF underwent exercise stress echocardiography and simultaneous cardiopulmonary exercise testing. Volumetric and tissue velocity imaging (TVI) measurements were obtained, as was peak oxygen uptake (VO2 peak). Of the total number of patients, 11 died and 22 required cardiac hospitalisation. S' at peak exertion was a powerful predictor for death and hospitalisation. Cut-off points of 5.3 cm/s for death and 5.7 cm/s for hospitalisation provided optimum sensitivity and specificity. This study suggests that, in patients with systolic HF, S' at peak exertion calculated from the averaged spectral TVI systolic velocity of six myocardial segments, or using a simplified measure of two myocardial segments, is a powerful predictor of future events and stronger than LVEF, diastolic velocities at rest or exercise and VO2 peak. Results indicate that measuring S' during exercise echocardiography might play an important role in understanding the likelihood of adverse clinical outcomes in patients with HF.

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.

Frequent premature ventricular complex is associated with left atrial enlargement in patients with normal left ventricular ejection fraction

BACKGROUND

Premature ventricular complex (PVC) has been regarded as benign; however, when frequent, the arrhythmia can induce left ventricular (LV) systolic dysfunction. Meanwhile, the influence of PVCs on cardiac structural remodeling and functional change before occurrence of overt systolic heart failure has not been fully described. In this study, we attempted to identify early cardiac structural/functional manifestations of frequent PVCs in patients with normal LV systolic function.

METHODS

A total of 146 patients (age: 55 ± 15 years, 48 males) with frequent PVCs observed on 24-hour Holter monitoring (>10/h) and normal LV ejection fraction (LV EF ≥ 55% on echocardiography) were enrolled. Clinical characteristics and echocardiographic parameters of the patients were compared with those of an age-/sex-matched control group (n = 292, age: 55 ± 15 years, 96 males).

RESULTS

Patients with frequent PVCs had significantly larger left atrial volume index (LAVI [28 ± 9 mL/m(2) vs. 24 ± 7 mL/m(2) ]), along with larger LV end-diastolic dimension (49.4 ± 4.4 mm vs. 48.5 ± 3.9 mm), lower LV EF (63 ± 7% vs. 66 ± 6%), and lower peak systolic mitral annular velocity (7 ± 2 cm/s vs. 8 ± 2 cm/s; P < 0.05 for all), whereas other clinical characteristics were similar. In particular, in patients with frequent PVCs, LAVI showed linear correlation with PVC burden (R = 0.30, P < 0.001), and, in a multiple regression model, PVC burden independently estimated LAVI, even after controlling for age, sex, comorbidities, and systolic function (β = 0.309, P < 0.001).

CONCLUSION

Frequent PVC is associated with LA enlargement in patients with normal LV EF. Atrial anatomical remodeling may precede LV geometry change and systolic dysfunction in patients with frequent PVCs.

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.

Detection of left ventricular dysfunction using early diastolic mitral annular velocity in patients undergoing mitral valve repair for mitral regurgitation

OBJECTIVES

Ejection fraction (EF) is considered an unreliable index in patients with mitral regurgitation (MR). Left ventricular dysfunction (LVD) frequently occurs after mitral valve repair (MVR), with the incidence being 15% to 34%. This study aimed at investigating whether preoperative early diastolic mitral annular velocity (E') is associated with LVD after MVR.

DESIGN

Retrospective study.

SETTING

University hospital.

PARTICIPANTS

Sixty-three patients undergoing MVR for severe MR.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

LVD was defined by a postoperative EF of<50%. Receiver operating characteristic (ROC) analysis and separate multivariate logistic regression models were used to examine the independent effects of echocardiographic variables on LVD risk. LVD occurred in 20 patients (31.7%). E' was correlated significantly with perioperative EF change (p = 0.019, r = 0.293). The area under the ROC curve was 0.777 (95% confidence interval [CI]: 0.644-0.911) for E', and the optimal threshold value of E' for predicting LVD was 6.5 cm/s (sensitivity, 80%; specificity, 67.4%). The frequency of LVD was 33.3% for a preoperative EF< 65%; 44.4% for preoperative EF< 65% and left ventricular end-systolic diameter>32 mm; and 88.9% for preoperative EF< 65%, left ventricular end-systolic diameter>32 mm, and E'< 6.5 cm/s (p = 0.006). Multivariate logistic regression models analysis revealed that E' was an independent risk factor for LVD (odds ratio: 1.98, 95% CI: 1.22-3.22).

CONCLUSIONS

Preoperative E' value was an independent risk factor of LVD after mitral valve repair in patients with severe MR.

The pulsed Doppler and tissue Doppler-derived septal E/e' ratio is significantly related to invasive measurement of ventricular end-diastolic pressure in biventricular rather than univentricular physiology in patients with congenital heart disease

OBJECTIVES

The value of conventional non-invasive Doppler parameters to predict ventricular end-diastolic pressure (EDP) and diastolic function in congenital heart diseases is limited. The aim of our prospective study was to investigate whether the ratio of mitral early blood inflow velocity to early diastolic velocity of the mitral annulus (E/e') as assessed by pulsed tissue Doppler is related to EDP in patients with different congenital heart disease (CHD) undergoing left heart catheterization.

METHODS

A total of 115 hospital inpatients (64 male) with different CHD referred for cardiac catheterization were simultaneously examined by echocardiography for non-invasive estimation of ventricular EDP during heart catheterization. The mean age at catheterization was 8.71 years (range 3 days to 18 years). These patients were divided into two groups according to the different hemodynamic and morphology conditions: group A consisted of patients with biventricular heart and group B of patients with univentricular heart.

RESULTS

For all the studied patients, a significant positive correlation was found between E/e' and EDP (r = 0.54, P < 0.001). EDP correlated rather weakly with combined measurements E/global LV early diastolic velocity (r = 0.27, P = 0.02). A significant relationship was also found between ventricular EDP and early mitral inflow velocity E (r = 0.36, P = 0.001). The ratio of pulmonary venous flow velocities s/d was not found to be related to invasively measured EDP (r = -0.16, P = 0.13). Group A (n = 96) had similar results, but for group B (n = 19), these parameters did not show a relationship to EDP. The analysis of these parameters showed that the larger area under the curve (AUC) was found for the ratio of E/e' (AUC = 0.77) compared with E/global e' (AUC = 0.57). E/e' > 10.7 had 69 % sensitivity and 81 % specificity for EDP > 10 mmHg.

CONCLUSION

Doppler and tissue Doppler-derived E/e' ratio is related to simultaneous invasive measurement of EDP in a heterogeneous group of patients with CHD and may provide an additional surrogate non-invasive estimation of ventricular diastolic performance in the routine follow-up of these patients.

Tissue Doppler imaging in coronary artery diseases and heart failure

Recent studies have explored the prognostic role of TDI-derived parameters in major cardiac diseases, such as coronary artery disease (CAD) and heart failure (HF). In these conditions, myocardial mitral annular systolic (S’) and early diastolic (E’) velocities have been shown to predict mortality or cardiovascular events. In heart failure non invasive assessment of LV diastolic pressure by transmitral to mitral annular early diastolic velocity ratio (E/E’) is a strong prognosticator, especially when E/E’ is > or =15. Moreover, other parameters derived by TDI, as cardiac time intervals and Myocardial Performance Index, might play a role in the prognostic stratification in CAD and HF. Recently, a three-dimensional (3-D) TDI imaging modality, triplane TDI, has become available, and this allows calculation of 3-Dvolumes and LV ejection fraction. We present a brief update of TDI.

Prediction of hospital outcome in septic shock: a prospective comparison of tissue Doppler and cardiac biomarkers

Introduction

Diastolic dysfunction as demonstrated by tissue Doppler imaging (TDI), particularly E/e' (peak early diastolic transmitral/peak early diastolic mitral annular velocity) is common in critical illness. In septic shock, the prognostic value of TDI is undefined. This study sought to evaluate and compare the prognostic significance of TDI and cardiac biomarkers (B-type natriuretic peptide (BNP); N-terminal proBNP (NTproBNP); troponin T (TnT)) in septic shock. The contribution of fluid management and diastolic dysfunction to elevation of BNP was also evaluated.

Methods

Twenty-one consecutive adult patients from a multidisciplinary intensive care unit underwent transthoracic echocardiography and blood collection within 72 hours of developing septic shock.

Results

Mean ± SD APACHE III score was 80.1 ± 23.8. Hospital mortality was 29%. E/e' was significantly higher in hospital non-survivors (15.32 ± 2.74, survivors 9.05 ± 2.75; P = 0.0002). Area under ROC curves were E/e' 0.94, TnT 0.86, BNP 0.78 and NTproBNP 0.67. An E/e' threshold of 14.5 offered 100% sensitivity and 83% specificity. Adjustment for APACHE III, cardiac disease, fluid balance and grade of diastolic function, demonstrated E/e' as an independent predictor of hospital mortality (P = 0.019). Multiple linear regression incorporating APACHE III, gender, cardiac disease, fluid balance, noradrenaline dose, C reactive protein, ejection fraction and diastolic dysfunction yielded APACHE III (P = 0.033), fluid balance (P = 0.001) and diastolic dysfunction (P = 0.009) as independent predictors of BNP concentration.

Conclusions

E/e' is an independent predictor of hospital survival in septic shock. It offers better discrimination between survivors and non-survivors than cardiac biomarkers. Fluid balance and diastolic dysfunction were independent predictors of BNP concentration in septic shock.

(123)I-BMIPP and (99m)Tc-TF discordance on myocardial scintigraphy and it's correlation with functional recovery following acute myocardial infarction: role of conventional echocardiography

(123)I-beta-methyl-iodophenyl pentadecanoic acid (BMIPP) and (99m)Tc-Tetrofosmin (TF) mismatch designated as stunned myocardium having both systolic and diastolic components. The degree of mismatch might reflect subsequent functional improvement, and this study was designed to unravel the impact of mismatched defect score (MMDS) on recovery of both systolic and diastolic function following acute myocardial infarction (AMI). Forty patients with recent AMI were recruited, and all of them underwent emergency percutaneous coronary intervention. Echocardiography and BMIPP and TF cardiac scintigraphy were performed on 7 +/- 3 days of admission. Follow up echocardiography was performed after 3 months. MMDS were compared with the systolic [ejection fraction (EF) and wall motion score index (WMSI)] and diastolic [peak velocity of early diastolic filling of mitral inflow/peak early diastolic velocity of the mitral annulus(E/E') and left atrial volume index(LAVI)] parameters. BMIPP defect score was significantly higher than the TF defect score and there was a strong positive correlation between them (r = 0.90, P < 0.00001). Thirty-two (80%) patients showed mismatched defect and rest 8(20%) showed matched defect. Of 32 patients 24(75%), 22(69%), 19(59%), and 20(62.5%) showed improved EF, WMSI, E/E' and LAVI respectively. Conversely out of 8 only 2(25%), 1(12.5%), and 2(25%) patients showed improvement of EF, WMSI and LAVI, respectively. E/E' was not improved in patients with matched defect. MMDS were significantly correlated with the improvement of EF (r = -0.46, P = 0.002), WMSI (r = 0.41, P = 0.007), E/E' (r = 0.56, P < 0.0002), and LAVI (r = 0.44, P = 0.004). Mismatched defect score could predict the approximate amount of viable dysfunctional myocardium, and the degree of mismatch showed a significant correlation with the improvement of both systolic and diastolic function.

Tissue Doppler in critical illness: a retrospective cohort study

BACKGROUND

There is a paucity of published data on tissue Doppler imaging (TDI) in the critically ill. In a critically ill cohort, we studied the distribution of TDI and its correlation with other echocardiographic indices of preload. To aid hypothesis generation and sample size calculation, associations between echocardiographic variables, including the ratio of peak early diastolic transmitral velocity (E) to peak early diastolic mitral annular velocity (E'), and mortality were also explored.

METHODS

This retrospective study was performed in a combined medical/surgical, tertiary referral intensive care unit. Over a 2-year period, 94 consecutive patients who underwent transthoracic echocardiography with E/E' measurement were studied.

RESULTS

Mean Acute Physiology and Chronic Health Evaluation III score was 72 +/- 25. Echocardiography was performed 5 +/- 6 days after intensive care unit admission. TDI variables exhibited a wide range (E' 4.7-18.2 cm/s and E/E' 3.3 to 27.2). E' below 9.6 cm/s was observed in 63 patients (rate of myocardial relaxation below lower 95% confidence limit of normal individuals). Fourteen patients had E/E' above 15 (evidence of raised left ventricular filling pressure). E/E' correlated with left atrial area (r = 0.27, P = 0.01) but not inferior vena cava diameter (r = 0.16, P = 0.21) or left ventricular end-diastolic volume (r = 0.16, P = 0.14). In this cohort, increased left ventricular end-systolic volume, but not E/E', appeared to be an independent predictor (odds ratio 2.1, P = 0.007) of 28-day mortality (31%; n = 29).

CONCLUSION

There was a wide range of TDI values. TDI evidence of diastolic dysfunction was common. E/E' did not correlate strongly with other echocardiographic indices of preload. Further evaluation of echocardiographic variables, particularly left ventricular end-systolic volume, for risk stratification in the critically ill appears warranted.

Utility of Doppler echocardiography and tissue Doppler imaging in the estimation of diastolic function in heart failure with normal ejection fraction: a comparative Doppler-conductance catheterization study

BACKGROUND

Various conventional and tissue Doppler echocardiographic indexes were compared with pressure-volume loop analysis to assess their accuracy in detecting left ventricular (LV) diastolic dysfunction in patients with heart failure with normal ejection fraction (HFNEF).

METHODS AND RESULTS

Diastolic dysfunction was confirmed by pressure-volume loop analysis obtained by conductance catheter in 43 patients (19 men) with HFNEF. Their Doppler indexes were compared with those of 12 control patients without heart failure symptoms and with normal ejection fraction. Invasively measured indexes for diastolic relaxation (tau, dP/dt(min)), LV end-diastolic pressure, and LV end-diastolic pressure-volume relationship (stiffness, b [dP/dV], and stiffness constant, beta) were correlated with several conventional mitral flow and tissue Doppler imaging indexes. Conventional Doppler indexes correlated moderately with the degree of LV relaxation index, tau (E/A: r=-0.36, P=0.013; isovolumic relaxation time: r=0.31, P=0.040) and b (deceleration time: r=0.39, P=0.012) but not with beta, in contrast to the tissue Doppler imaging indexes E'/A'(lateral) (r=-0.37, P=0.008) and E/E'(lateral) (r=0.53, P<0.001). Diastolic dysfunction was detected in 70% of the HFNEF patients by mitral flow Doppler but in 81% and 86% by E'/A'(lateral), and E/E'(lateral), respectively.

CONCLUSIONS

Of all echocardiographic parameters investigated, the LV filling index E/E'(lateral) was identified as the best index to detect diastolic dysfunction in HFNEF in which the diagnosis of diastolic dysfunction was confirmed by conductance catheter analysis. We recommend its use as an essential tool for noninvasive diagnostics of diastolic function in patients with HFNEF.

Echocardiography in Heart Failure

Echocardiography is well qualified to meet the growing need for noninvasive imaging in the expanding heart failure (HF) population. The recently-released American College of Cardiology/American Heart Association guidelines for the diagnosis and management of HF labeled echocardiography "the single most useful diagnostic test in the evaluation of patients with HF...," because of its ability to accurately and noninvasively provide measures of ventricular function and assess causes of structural heart disease. It can also detect and define the hemodynamic and morphologic changes in HF over time and might be equivalent to invasive measures in guiding therapy. In this article we will discuss: 1) the clinical uses of echocardiography in HF and their prognostic value; 2) the use of echocardiography to guide treatment in HF patients; and 3) promising future techniques for echocardiographic-based imaging in HF. In addition, we will highlight some of the limitations of echocardiography.

Validity of Revised Doppler Echocardiographic Algorithms and Composite Clinical and Angiographic Data in Diagnosis of Diastolic Dysfunction

BACKGROUND

Commonly used echocardiographic indices for grading diastolic function predicated on mitral inflow Doppler analysis have a poor diagnostic concordance and discriminatory value. Even when combined with other indices, significant overlap prevents a single group assignment for many subjects. We tested the relative validity of echocardiographic and clinical algorithms for grading diastolic function in patients undergoing cardiac catheterization.

METHOD

Patients (n = 115), had echocardiograms immediately prior to measuring left ventricular (LV) diastolic (pre-A, mean, end-diastolic) pressures. Diastolic function was classified into the traditional four stages, and into three stages using a new classification that obviates the pseudonormal class. Summative clinical and angiographic data were used in a standardized fashion to classify each patient according to the probability for abnormal diastolic function. Measured LV diastolic pressure in each patient was compared with expected diastolic pressures based on the clinical and echocardiographic classifications.

RESULT

The group means of the diastolic pressures were identical in patients stratified by four-stage or three-stage echocardiographic classifications, indicating that both classifications schemes are interchangeable. When severe diastolic dysfunction is diagnosed by the three-stage classification, 88% and 12%, respectively, were clinically classified as high and intermediate probability, and the mean LV pre-A pressures was >12 mmHg (P < 0.005). Conversely, the mean LV pre-A pressure in the clinical low probability or echocardiographic normal groups was <11 mmHg.

CONCLUSION

Use of a standardized clinical algorithm to define the probability of diastolic function identifies patients with elevated LV filing pressure to the same extent as echocardiographic methods.

Tissue Doppler imaging in patients with advanced heart failure: relation to functional class and prognosis

BACKGROUND

Tissue Doppler imaging (TDI) provides rapid assessment of systolic and diastolic myocardial function. However, the added value of TDI to standard Doppler echocardiographic measurements in predicting symptoms and outcome of advanced heart failure remains unknown.

METHODS

The study cohort comprised 45 patients with congestive heart failure, defined as New York Heart Association functional class III and IV, who were referred to our department for evaluation for heart transplantation. Twenty healthy subjects were the controls. Conventional echo Doppler was used to assess left ventricular (LV) ejection fraction, peak velocities of transmitral early and late diastolic LV filling, the ratio of transmitral early to late LV filling velocity, and E-deceleration time. TDI measurements recorded at the mitral annulus included systolic velocity, early and late diastolic velocities, and the ratio of early to late diastolic velocity. The ratio of transmitral early LV filling velocity to early diastolic TDI velocity of the mitral annulus (E/E') was calculated. All patients were followed for cardiac-related death and hospitalization for heart failure.

RESULTS

Patients with functional class IV had a significantly higher E/E' ratio than did patients with functional class III (12.9 +/- 2.8 vs 8.3 +/- 1.7, p < 0.001) and the controls (5.4 +/- 1.3, p < 0.001). Except for transmitral late filling velocity, all conventional echo Doppler parameters and TDI variables significantly correlated with functional class. On multivariate stepwise analysis, however, the E/E' ratio was the only independent predictor of functional class (p = 0.003). E/E' also correlated with cardiac mortality and hospitalization.

CONCLUSION

Conventional Doppler indices and TDI parameters correlated with functional class in patients with advanced heart failure. The E/E' ratio, which probably reflects high LV end-diastolic pressure, was the best measure for differentiating patients with functional class III and IV, and it also correlated with cardiac mortality and hospitalization for worsening heart failure, thereby providing additional value to standard echocardiographic measures.

Comparison of usefulness of echocardiographic Doppler variables to left ventricular end-diastolic pressure in predicting future heart failure events

We sought to determine whether the echocardiographic Doppler parameters of left ventricular diastolic dysfunction predict future heart failure (HF) events and, if so, which parameters best predict HF. We also examined whether the predictive ability of echocardiographic Doppler parameters was related to their prediction of left ventricular end-diastolic pressure (LVEDP). We studied patients who underwent cardiac catheterization and echocardiography performed within a 30-day period. The end point was HF, defined as new-onset or recurrent HF diagnosed by a physician and requiring the initiation or modification of treatment of HF. We identified 289 patients (mean age 63.5 +/- 12.6 years) with a mean follow-up of 10.9 +/- 10.2 months. A total of 24 HF events occurred. LVEDP was a significant predictor of HF univariately and independently in multiple regression models after adjustment for ejection fraction. In Cox models adjusted for age, gender, LVEDP, and ejection fraction, only the left atrial volume index and early mitral inflow to early diastolic tissue velocity (E/e') ratio remained predictive of HF. A multiple regression model, including all echocardiographic variables, showed a persistent, although attenuated, relation of early to late mitral inflow velocity (E/A) ratio and E/e' with LVEDP (p = 0.06 and p = 0.002, respectively). The addition of E/e' or the left atrial volume indexed to body surface area, but not E/A, to the clinical history and left ventricular ejection fraction provided incremental prognostic information. A LVEDP of > or =20 mm Hg, E/e' ratio of > or =15, and left atrial volume index of > or =23 ml/m(2) identified those with a higher risk of HF. In conclusion, invasively determined LVEDP is an independent predictor of future HF events. E/e' and the left atrial volume indexed to body surface area are the best independent predictors of future HF and provide prognostic information incremental to the clinical history and left ventricular ejection fraction.

Color M-mode flow propagation velocity: is it really preload independent?

OBJECTIVE

This study investigates the change in flow propagation velocity (FPV) in uremic patients who undergo regular hemodialysis (H/D).

MATERIALS AND METHODS

We studied 93 uremic patients (44 men and 49 women; 59 +/- 14-years-old) receiving regular hemodialysis. Patients were separated by baseline left ventricular ejection fraction (LVEF): 71 patients with LVEF > 50% (group 1), 13 patients with LVEF 35-50% (group 2), 7 patients with LVEF < 35% (group 3). All patients were in sinus rhythm before H/D. They received complete transthoracic echocardiographic examinations. Flow propagation velocity was measured by color M-mode echocardiography in apical four chambers view. All these parameters were obtained before and after H/D. Paired data were compared. According to different H/D amounts, we viewed the FPV response after H/D in variant baseline LVEF groups.

RESULT

The baseline FPV became lower in patients with low LVEF. After H/D, obvious decrement of FPV occurred in group 1, but there were no obvious changes in groups 2 and 3. In fact, a slight increment of FPV was found in group 3. In patients with baseline LVEF > 50%, FPV after H/D was almost always lower, regardless of H/D amount. But there was different response in patients with baseline LVEF < 50%.

CONCLUSION

Flow propagation velocity is preload independent in patients with LVEF < 50%, but it is preload-dependent in patients with LVEF > 50%.

Prognostic value of systolic mitral annular velocity measured with Doppler tissue imaging in patients with chronic heart failure caused by left ventricular systolic dysfunction

OBJECTIVE

To assess the prognostic value of various conventional and novel echocardiographic indices in patients with chronic heart failure (CHF) caused by left ventricular (LV) systolic dysfunction.

METHODS

185 patients with a mean (SD) age of 67 (11) years with CHF and LV ejection fraction < 45% despite optimal pharmacological treatment were prospectively enrolled. The patients underwent two dimensional echocardiography with tissue harmonic imaging to assess global LV systolic function and obtain volumetric data. Transmitral flow was assessed with conventional pulse wave Doppler. Systolic (Sm), early, and late diastolic mitral annular velocities were measured with the use of colour coded Doppler tissue imaging.

RESULTS

During a median follow up of 32 months (range 24-38 months in survivors), 34 patients died and one underwent heart transplantation. Sm velocity (hazard ratio (HR) 0.648, 95% confidence interval (CI) 0.463 to 0.907, p = 0.011), diastolic arterial pressure (HR 0.965, 95% CI 0.938 to 0.993, p = 0.015), serum creatinine (HR 1.006, 95% CI 1.001 to 1.011, p = 0.023), LV ejection fraction (HR 0.945, 95% CI 0.899 to 0.992, p = 0.024), age (HR 1.035, 95% CI 1.000 to 1.071, p = 0.052), LV end systolic volume index (HR 1.009, 95% CI 0.999 to 1.019, p = 0.067), and restrictive pattern of transmitral flow (HR 0.543, 95% CI 0.278 to 1.061, p = 0.074) predicted the outcome of death or transplantation on univariate analysis. On multivariate analysis, only Sm velocity (HR 0.648, 95% CI 0.460 to 0.912, p = 0.013) and diastolic arterial pressure (HR 0.966, 95% CI 0.938 to 0.994, p = 0.016) emerged as independent predictors of outcome.

CONCLUSIONS

In patients with CHF and LV systolic dysfunction despite optimal pharmacological treatment, the strongest independent echocardiographic predictor of prognosis was Sm velocity measured with quantitative colour coded Doppler tissue imaging.

Tissue Doppler imaging in the evaluation of left ventricular diastolic function

PURPOSE OF REVIEW

Describe the rationale behind, and clinical use of, tissue Doppler (TD) imaging in the assessment of left ventricular (LV) diastolic function, with a focus on recent developments.

RECENT FINDINGS

Tissue Doppler imaging is a novel echocardiographic technique that directly measures myocardial velocities. Systolic TD measurements assess left and right ventricular myocardial contractile function. Diastolic TD values reflect myocardial relaxation, and in combination with conventional Doppler measurements, ratios (E/Ea) have been developed to estimate LV filling pressures. TD values and derived ratios have been demonstrated to be valuable in the diagnosis of elevated LV filling pressures, clinical congestive heart failure (CHF), and the prognosis of patients with cardiac disease and CHF. New TD indices have now been developed to assess myocardial relaxation and LV filling pressures, and the impact of LV systolic function on the use of TD imaging has recently been described. TD echocardiography is being used in an ever-widening group of patients for the assessment of LV diastolic function, and its correlation to, and comparison with, B-type natriuretic peptide is an active area of current investigation.

SUMMARY

This review focuses on new developments in the clinical use of TD echocardiography in the evaluation of left ventricular diastolic function.

Colour M-mode velocity propagation: a glance at intra-ventricular pressure gradients and early diastolic ventricular performance

The physiology of early-diastolic filling comprises ventricular performance and fluid dynamical principles. Elastic recoil and myocardial relaxation rate determine left ventricular early diastolic performance. The integrity of left ventricular synchrony and geometry is essential to maintain the effect of their timely action on early diastolic left ventricular filling. These factors not only are prime determinants of left ventricular pressure decay during isovolumic relaxation and immediately after mitral valve opening; they also instigate the generation of a sufficient intra-ventricular pressure gradient, which enhances efficient early diastolic left ventricular filling. Accurate assessment of diastolic (dys)function by non-invasive techniques has important therapeutic and prognostic implications but remains a challenge to the cardiologist. The evaluation of left ventricular relaxation by the standard Doppler echocardiographic parameters is hindered by their preload dependency. The colour M-mode velocity propagation of early diastolic inflow (Vp) correlates with intra-ventricular pressure gradients and is a largely preload independent index of ventricular diastolic performance. In this article, the physiologic background, utility and limitations of this promising new tool for the study of early diastolic filling are reviewed.

Noninvasive prediction of complications with anteroseptal acute myocardial infarction by left ventricular Tei index

BACKGROUND

Tei index has been proposed as a noninvasive and simple index that enables the evaluation of global left ventricular (LV) function and prediction of patient prognosis. However, its use to predict complications with acute myocardial infarction (AMI) is not fully investigated. Therefore, the purpose of this study was to investigate whether or not LV Tei index allows noninvasive prediction of complications with AMI.

METHODS

In all, 80 consecutive patients with anteroseptal AMI were enrolled. LV Tei index was measured at the time of admission as (a - b)/ b , where a is the interval between cessation and onset of mitral filling flow and interval b is the aortic flow ejection time. Subsequent complications including cardiac death, shock, congestive heart failure, ventricular tachycardia/fibrillation, paroxysmal atrial fibrillation/flutter, advanced atrioventricular block requiring pacing, pericardial effusion, and LV aneurysm during the 30 days after the onset of AMI were prospectively evaluated and compared with the initial Tei index at admission.

RESULTS

Complications developed in 31 of 80 (39%) patients with AMI. The Tei index was significantly increased for patients with complications compared with those without them (0.69 +/- 0.16 vs 0.50 +/- 0.11, P < .0001). When Tei index > or = 0.59 was used for the criteria, the sensitivity, specificity, and overall accuracy to predict subsequent complications were 77%, 86%, and 85%, respectively.

CONCLUSION

In patients with anteroseptal AMI, LV Tei index at arrival to the hospital in the acute phase allows noninvasive prediction of subsequent complications.

Association of left ventricular filling parameters assessed by pulsed wave Doppler and color M-mode Doppler echocardiography with left ventricular pathology, pulmonary congestion, and left ventricular end-diastolic pressure

Among 90 consecutive patients with various degrees of left ventricular (LV) dysfunction (normal patients, LV hypertrophy, LV ejection fraction <50%, and <30%), the mitral valve pulse-wave E/A ratio showed a characteristic U-shaped curve with increasing severity of LV dysfunction. In contrast, there was a significant progressive decrease in flow propagation velocity of the E-wave (Vp) and a significant increase in E/Vp values with increasing severity of LV dysfunction. The E/Vp ratio was the best predictor of pulmonary congestion, and in a subgroup of patients who underwent cardiac catheterization, it was the only significant predictor of LV end-diastolic pressure.

Peak early diastolic mitral annulus velocity by tissue Doppler imaging adds independent and incremental prognostic value

OBJECTIVES

The aim of this study was to ascertain if left ventricular mitral annulus velocities measured by tissue Doppler imaging (TDI) are more powerful predictors of outcome compared with clinical data and standard Doppler-echocardiographic parameters.

BACKGROUND

Tissue Doppler imaging of basal or mitral annulus velocities provides rapid assessment of ventricular long axis function. But it is not known if TDI-derived velocities in systole and diastole add incremental value and are superior to the standard Doppler-echocardiographic measurements as a predictor of outcome.

METHODS

The study population consisted of 518 subjects, 353 with cardiac disease and 165 normal subjects who had full Doppler two-dimensional-echocardiographic studies with measurement of mitral inflow velocities in early and late diastole, E-wave deceleration time (DT), peak systolic mitral annular velocity (Sm) early and late diastolic mitral annular velocity (Em and Am) by TDI, early diastolic flow propagation velocity, and standard chamber dimensions. All subjects were followed up for two years. The end point was cardiac death.

RESULTS

Tissue Doppler imaging mitral annulus systolic and diastolic velocities were all significantly lower in the non-survivors (all p < 0.05) as was DT (p = 0.024). In the Cox model the best predictors of mortality were Em, Sm, Am, left ventricular ejection fraction, left ventricular mass, and left atrial diameter in systole (LADs). By backward stepwise analysis Em and LADs were the strongest predictors. After forcing the TDI measurements into the covariate model with clinical and mitral DT <0.16 s, Em provided significant incremental value for predicting cardiac mortality (p = 0.004).

CONCLUSIONS

Mitral annulus velocity measured by TDI in early diastole gives incremental predictive power for cardiac mortality compared to clinical data and standard echocardiographic measurements. This easily available measurement adds significant value in the clinical management of cardiac patients.

Echocardiography and prognosis of heart failure

Echocardiography plays an important role in the diagnosis of patients with congestive heart failure (CHF). It determines the cause and readily provides a reliable noninvasive assessment of left and right ventricular function and filling pressures. This technique also has a tremendous potential in guiding therapy and tracking the clinical response. This review focuses on its prognostic power.