Article

Clinical Utility of Doppler Echocardiography and Tissue Doppler Imaging in the Estimation of Left Ventricular Filling Pressures : A Comparative Simultaneous Doppler-Catheterization Study

November 2000
Circulation 102(15):1788-94

November 2000
102(15):1788-94

DOI:10.1161/01.CIR.102.15.1788

Source
PubMed

Authors:

Fletcher Miller

Mayo Foundation for Medical Education and Research

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Noninvasive assessment of diastolic filling by Doppler echocardiography provides important information about left ventricular (LV) status in selected subsets of patients. This study was designed to assess whether mitral annular velocities as assessed by tissue Doppler imaging are associated with invasive measures of diastolic LV performance and whether additional information is gained over traditional Doppler variables. One hundred consecutive patients referred for cardiac catheterization underwent simultaneous Doppler interrogation. Invasive measurements of LV pressures were obtained with micromanometer-tipped catheters, and the mean LV diastolic pressure (M-LVDP) was used as a surrogate for mean left atrial pressure. Doppler signals from the mitral inflow, pulmonary venous inflow, and TDI of the mitral annulus were obtained. Isolated parameters of transmitral flow correlated with M-LVDP only when ejection fraction <50%. The ratio of mitral velocity to early diastolic velocity of the mitral annulus (E/E') showed a better correlation with M-LVDP than did other Doppler variables for all levels of systolic function. E/E' <8 accurately predicted normal M-LVDP, and E/E' >15 identified increased M-LVDP. Wide variability was present in those with E/E' of 8 to 15. A subset of those patients with E/E' 8 to 15 could be further defined by use of other Doppler data. The combination of tissue Doppler imaging of the mitral annulus and mitral inflow velocity curves provides better estimates of LV filling pressures than other methods (pulmonary vein, preload reduction). However, accurate prediction of filling pressures for an individual patient requires a stepwise approach incorporating all available data.

Diagnostic Value of Serum Procalcitonin and Diastolic Dysfunction for Evaluating the Mortality of Sepsis Patients Admitted in the Intensive Care

Article

Full-text available

Oct 2023

Background: Sepsis is a serious condition that can be fatal and has become more common in recent times. The impact of diastolic dysfunction on the early mortality rate of septic patients has not been extensively researched. This study aimed to assess the accuracy of serum procalcitonin (PCT) levels and diastolic dysfunction in predicting the mortality rate of patients diagnosed with sepsis and admitted to the intensive care unit. Methods: In this cross-sectional study, 40 sepsis patients admitted to the ICU were examined. Their characteristics were meticulously recorded using the APACHE II and SOFA score questionnaires, and only those who met the criteria underwent echocardiography. In order to evaluate the serum levels of PCT, it was required to take 40 ml of venous blood samples from the patients on the first and fifth days of admission. Results: Out of 40 patients, the average age was 63±17 years. Of these patients, 23 (57.5%) were discharged, while 17 (42.5%) unfortunately passed away. Results showed a notable correlation between diastolic dysfunction, CRP, SOFA score on days 1 and 2, APACHE II score, and PCT on day 5 (P˂0.05). However, when analyzed using logistic regression, only PCT on day 5 showed a significant association with mortality. Conclusion: Based on our research, we found that PCT is an essential indicator in predicting the mortality rate of sepsis patients. While there was no significant correlation between diastolic dysfunction and mortality, it should still be considered a critical factor in determining the mortality rate.

Echocardiographic estimation of left ventricular filling pressures in heart transplant recipients

Article

Full-text available

Jan 2024

Background Echocardiographic estimation of left ventricular filling pressure in heart transplant (HTx) recipients is challenging. The ability of echocardiography to detect elevated left ventricular end-diastolic pressure (LVEDP) in HTx patients was assessed in this study. Results This descriptive cross-sectional study included 39 HTx recipients who were candidates for endomyocardial biopsy as a part of their routine post-transplantation surveillance. Doppler transthoracic echocardiography was done before the procedure, and left heart catheterization was done during the endomyocardial biopsy. Thirty-nine patients (15 female, 24 male), with a mean age of 39.6 years (range 13–70), were enrolled. A strong relation was observed between lateral E / e ′ and LVEDP ( R = 0.64, P value < 0.001) and average E / e ′ and LVEDP ( R = 0.6, P value < 0.001). The best cutoff value for LVEDP prediction was the average E / e ′ ≥ 6.8 with a sensitivity of 96.15% and specificity of 68.5% for the prediction of LVEDP more than or equal to 20 mmHg. Two predictive models comprising age, gender, and lateral E / e ′ or average E / e ′ were also proposed. A significant relationship was also found between LVEDP and left ventricular global longitudinal strain ( R = − 0.31, P value < 0.01). Conclusions Lateral E / e ′ was the best predictor of LVEDP. The cutoff of average E / e ′ had the best validity for the estimation of LVEDP. Despite the strong observed association, echocardiographic parameters cannot be considered a surrogate for invasive LVEDP measurements when seeking information about left ventricle filling pressure on heart transplant recipients.

A Clinical Study of Cardiological Dysfunction in Non-Alcoholic Fatty Liver Disease in a Tertiary Care Hospital

Article

Nov 2023

Non-Alcoholic Fatty Liver Disease (NAFLD) is a term used to describe the accumulation of fat in the liver of people who drink little or no alcohol. Previous studies have shown a higher prevalence of left ventricular remodelling and diastolic dysfunction in patients with NAFLD but they all include patients with obesity, diabetes and/or hypertension, which are by themselves well known risk factors for cardiovascular dysfunction. Our aim was to find out the cardiological dysfunction in non alcoholic fatty liver disease patients without conventional cardiovascular risk factors as diabetes and hypertension. We performed a cross-sectional study in 70 non alcoholic fatty liver disease patients without hypertension, diabetes and 30 controls without NAFLD, with an aim to find out any cardiological dysfunction, its occurrence, nature and correlation, with simple and cost-effective means, such as echocardiography, electrocardiography and some relevant biochemical parameters. Cases and controls were subjected to detailed echocardiography examination, including tissue Doppler imaging. CRP, uric acid, lipid profile, liver function tests were done. Results were compared between cases and controls and suitable statistical analysis were done. Cases had higher waist circumference compared to controls, though BMI and body weight were not different. Blood pressure, blood sugar was similar between two groups. Serum triglyceride was more in NAFLD group. Though diabetes, hypertension was excluded,20 out of 70 patients met the criteria for metabolic syndrome. Left ventricular end diastolic diameter and left ventricular mass index were more in NAFLD group suggesting cardiac structural alteration. NAFLD patients also showed lower early diastolic velocity (E) and lower early to late diastolic flow (E/A), thus demonstrating diastolic dysfunction. Our study also showed a sensitive and specific cutoff value for LVMI, which can be very useful in Indian scenario. So, our study demonstrated cardiological structural and functional alteration in NAFLD patients independent of conventional risk factors of diabetes, hypertension and obesity in Indian perspective, where it is recently emerging as a booming epidemic. Key words: NAFLD, LVMI, Diastolic Dysfunction

K‐t PCA accelerated in‐plane balanced steady‐state free precession phase‐contrast (PC‐SSFP) for all‐in‐one diastolic function evaluation

Article

Full-text available

Nov 2023
MAGN RESON MED

Purpose Diastolic function evaluation requires estimates of early and late diastolic mitral filling velocities (E and A) and of mitral annulus tissue velocity (e′). We aimed to develop an MRI method for simultaneous all‐in‐one diastolic function evaluation in a single scan by generating a 2D phase‐contrast (PC) sequence with balanced steady‐state free precession (bSSFP) contrast (PC‐SSFP). E and A could then be measured with PC, and e′ estimated by valve tracking on the magnitude images, using an established deep learning framework. Methods Our PC‐SSFP used in‐plane flow‐encoding, with zeroth and first moment nulling over each TR. For further acceleration, different k‐t principal component analysis (PCA) methods were investigated with both retrospective and prospective undersampling. PC‐SSFP was compared to separate balanced SSFP cine and PC‐gradient echo acquisitions in phantoms and in 10 healthy subjects. Results Phantom experiments showed that PC‐SSFP measured accurate velocities compared to PC‐gradient echo (r = 0.98 for a range of pixel‐wise velocities −80 cm/s to 80 cm/s). In subjects, PC‐SSFP generated high SNR and myocardium‐blood contrast, and excellent agreement for E (limits of agreement [LOA] 0.8 ± 2.4 cm/s, r = 0.98), A (LOA 2.5 ± 4.1 cm/s, r = 0.97), and e′ (LOA 0.3 ± 2.6 cm/s, r = 1.00), versus the standard methods. The best k‐t PCA approach processed the complex difference data and substituted in raw k‐space data. With prospective k‐t PCA acceleration, higher frame rates were achieved (50 vs. 25 frames per second without k‐t PCA), yielding a 13% higher e′. Conclusion The proposed PC‐SSFP method achieved all‐in‐one diastolic function evaluation.

Relationship between Preoperative Echocardiographic Parameters and the Incidence of Postoperative Complications in Patients Undergoing Clipping of Unruptured Intracranial Aneurysms: A Retrospective Cohort Study

Article

Full-text available

Sep 2023

Background and Objectives: Preoperative echocardiography is widely performed in patients undergoing major surgeries to evaluate cardiac functions and detect structural abnormalities. However, studies on the clinical usefulness of preoperative echocardiography in patients undergoing cerebral aneurysm clipping are limited. Therefore, this study aimed to investigate the correlation between preoperative echocardiographic parameters and the incidence of postoperative complications in patients undergoing clipping of unruptured intracranial aneurysms. Materials and Methods: Electronic medical records of patients who underwent clipping of an unruptured intracranial aneurysm from September 2018 to April 2020 were retrospectively reviewed. Data on baseline characteristics, laboratory variables, echocardiographic parameters, postoperative complications, and hospital stays were obtained. Univariable and multivariable logistic regression analyses were performed to identify independent variables related to the occurrence of postoperative complications and prolonged hospital stay (≥8 d). Results: Among 531 patients included in the final analysis, 27 (5.1%) had postoperative complications. In multivariable logistic regression, the total amount of crystalloids infused (1.002 (1.001–1.003), p = 0.001) and E/e’ ratio (1.17 (1.01–1.35), p = 0.031) were significant independent factors associated with the occurrence of a postoperative complication. Additionally, the maximal diameter of a cerebral aneurysm (1.13 (1.02–1.25), p = 0.024), total amount of crystalloids infused (1.001 (1.000–1.002), p = 0.031), E/A ratio (0.22 (0.05–0.95), p = 0.042), and E/e’ ratio (1.16 (1.04–1.31), p = 0.011) were independent factors related to prolonged hospitalization. Conclusions: Echocardiographic parameters related to diastolic function might be associated with postoperative complications in patients undergoing clipping of unruptured intracranial aneurysms.

Personalized evaluation of the passive myocardium in ischemic cardiomyopathy via computational modeling using Bayesian optimization

Preprint

Full-text available

Apr 2024

Biomechanics-based patient-specific modeling is a promising approach that has proved invaluable for its clinical potential to assess the adversities caused by ischemic heart disease (IHD). In the present study, we propose a framework to find the passive material properties of the myocardium and the unloaded shape of cardiac ventricles simultaneously in patients diagnosed with ischemic cardiomyopathy (ICM). This was achieved by minimizing the difference between the simulated and target end-diastolic pressure-volume relationships (EDPVRs) using black-box Bayesian optimization, based on the finite element analysis (FEA). End-diastolic (ED) biventricular geometry and the location of the ischemia were determined from cardiac magnetic resonance (CMR) imaging. We employed our pipeline to model the cardiac ventricles of three patients aged between 57 and 66 years, with and without the inclusion of valves. An excellent agreement between the simulated and target EDPVRs has been reached. Our results revealed that the incorporation of valvular springs typically leads to lower hyperelastic parameters for both healthy and ischemic myocardium, as well as a higher fiber Green strain in the viable regions compared to models without valvular stiffness. Furthermore, the addition of valve-related effects did not result in significant changes in myofiber stress after optimization. We concluded that more accurate results could be obtained when cardiac valves were considered in modeling ventricles. The present novel and practical methodology paves the way for developing digital twins of ischemic cardiac ventricles, providing a non-invasive assessment for designing optimal personalized therapies in precision medicine.

Interpreting Diastolic Dynamics and Evaluation Through Echocardiography

Preprint

Full-text available

Mar 2024

In patients with heart failure, the evaluation of left ventricular (LV) diastolic function is vital, offering crucial insights into hemodynamic impact and prognostic accuracy. Echocardiography stands as the primary imaging modality for diastolic function assessment, and using it effectively requires a profound understanding of the underlying pathology. This review covers four main topics: first, the fundamental driving forces behind each phase of normal diastolic dynamics, along with the physiological basis of two widely used echocardiographic assessment parameters, E/e' and mitral annulus early diastolic velocity (e'); second, the intricate functional relationship between the left atrium and LV in patients with varying degrees of LV diastolic dysfunction (LVDD); third, the role of stress echocardiography in diagnosing LVDD and the significance of parameter changes in this context; and fourth, the clinical utility of evaluating diastolic function from echocardiography images across diverse cardiovascular care areas.

Interpreting Diastolic Dynamics and Evaluation Through Echocardiography

Preprint

Full-text available

May 2024

Prediction of recurrent heart failure hospitalizations and mortality using the echocardiographic Killip score

Article

Full-text available

Jun 2024
CLIN RES CARDIOL

Aim Examine the performance of a simple echocardiographic "Killip score" (eKillip) in predicting heart failure (HF) hospitalizations and mortality after index event of decompensated HF hospitalization. Methods HF patients hospitalized at our facility between 03/2019–03/2021 who underwent an echocardiography during their index admission were included in this retrospective analysis. The cohort was divided into 4 classes of eKillip according to: stroke volume index (SVI) < 35ml/m² > and E/E' ratio < 15 > . An eKillip Class I was defined as SVI ≥ 35ml/m² and E/E' ≤ 15 and was used as reference. Results Included 751 patients, median age 78.1 (IQR 69.3–86) years, 59% men, left ventricular ejection fraction 45 (IQR 30–60)%, brain natriuretic peptide levels 634 (IQR 331–1222)pg/ml. Compared with eKillip Class I, a graded increase in the combined endpoint of 30-day mortality and rehospitalizations rates was noted: (Class II: HR 1.77, CI 0.95–3.33, p = 0.07; Class III: HR 1.94, CI 1.05–3.6, p = 0.034; Class IV: HR 2.9, CI 1.64–5.13, p < 0.001 respectively), which overall persisted after correction for clinical (Class II: HR 1.682, CI 0.9–3.15, p = 0.105; Class III: HR 2.104, CI 1.13–3.9, p = 0.019; Class IV: HR 2.74, CI 1.54–4.85, p = 0.001 respectively) or echocardiographic parameters (Class II: HR 1.92, CI 1.02–3.63, p = 0.045; Class III: HR 1.54, CI 0.81–2.95, p = 0.189; Class IV: HR 2.04, CI 1.1–3.76, p = 0.023 respectively). Specifically, the eKillip Class IV group comprised one-third of the patient population and persistently showed increased risk of 30-day HF hospitalizations or mortality following multivariate analysis. Conclusion A simple echocardiographic score can assist identifying high-risk decompensated HF patients for recurrent hospitalizations and mortality.

Investigation of left atrial mechanical function and left ventricular systolic and diastolic parameters in athletes performing resistance exercise and combined exercise

Article

Full-text available

May 2024
BMC Cardiovasc Disord

Some individuals who go to fitness centers for various purposes perform resistance exercise (RE) alone, while others engage in combined exercise (CE) by including cardio exercises along with RE. Studying the effects of these two different training methods on left ventricular (LV) systolic and diastolic parameters and left atrial mechanical function is an important step toward understanding the effects of different types of exercise on cardiac function. This knowledge has significant implications for public health, as it can inform the development of targeted and effective exercise programs that prioritize cardiovascular health and reduce the risk of adverse outcomes. Therefore, the primary aim of this study is to comprehensively investigate the LV systolic and diastolic parameters of athletes who engage in RE and CE using ECHO, to contribute to the growing body of literature on the cardiovascular effects of different types of exercise. Forty-two amateur athletes aged between 17 and 52 were included in our study. The participants consisted of the RE (n = 26) group who did only resistance exercise during the weekly exercise period, and the CE group (n = 16) who also did cardio exercise with resistance exercises. After determining sports age (year), weekly exercise frequency (day), and training volume (min) in addition to demographic information of RE and CE groups, left ventricular systolic and diastolic parameters and left atrial functions were determined by ECHO. Findings from our study revealed that parameters including the left ventricular end-diastolic diameter (LVEDD) (p = .008), left ventricular end-diastolic volume (LVEDV) (p = .020), stroke volume index (SV-I) (p = .048), conduit volume (CV-I) (p = .001), and aortic strain (AS) (p = .017) were notably higher in the RE group compared to the CE group. Also left atrial active emptying volüme (LAAEV) of CE was higher than the RE group (p = .031). In conclusion, the cardiac parameters of the RE group showed more athlete’s heart characteristics than the CE group. These results may help to optimize the cardiovascular benefits of exercise routines while minimizing the potential risks associated with improper training. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-024-03908-w.

Personalized Evaluation of the Passive Myocardium in Ischemic Cardiomyopathy via Computational Modeling Using Bayesian Optimization

Preprint

Full-text available

Apr 2024

Biomechanics-based patient-specific modeling is a promising approach that has proved invaluable for its clinical potential to assess the adversities caused by ischemic heart disease (IDH). In the present study, we propose a framework to find the passive material properties of the myocardium and the unloaded shape of cardiac ventricles simultaneously in patients diagnosed with ischemic cardiomyopathy (ICM). This was achieved by minimizing the difference between the simulated and target end-diastolic pressure-volume relationships (EDPVRs) using black-box Bayesian optimization, based on the finite element analysis (FEA). End-diastolic (ED) biventricular geometry and the location of the ischemia were determined from cardiac magnetic resonance (CMR) imaging. We employed our pipeline to model the cardiac ventricles of three patients aged between 57 and 66 years, with and without the inclusion of valves. An excellent agreement between the simulated and target EDPVRs has been reached. Our results revealed that the incorporation of valvular springs typically leads to lower hyperelastic parameters for both healthy and ischemic myocardium, as well as a higher fiber Green strain in the viable regions compared to models without valvular stiffness. Furthermore, the addition of valve-related effects did not result in significant changes in myofiber stress after optimization. We concluded that more accurate results could be obtained when cardiac valves were considered in modeling ventricles. The present novel and practical methodology paves the way for developing digital twins of ischemic cardiac ventricles, providing a non-invasive assessment for designing optimal personalized therapies in precision medicine.

Correlation analysis between left ventricular global longitudinal strain and major adverse cardiovascular event occurrence in patients with end-stage renal disease

Article

Full-text available

Apr 2024
INT UROL NEPHROL

Objective To explore the correlation between left ventricular global longitudinal strain (LVGLS) and major adverse cardiovascular event (MACE) occurrence in patients with end-stage renal disease (ESRD). Methods From January 2019 to December 2023, ESRD patients undergoing maintenance dialysis and LVGLS measurement admitted to the First People’s Hospital of Lanzhou City were selected as subjects. They were followed up for 12 months to record the occurrence of MACEs, and divided into MACE group and non-MACE group according to MACE presence or absence. Results A total of 158 ESRD patients were included, with 32 patients in the MACE group and 126 patients in the non-MACE group. In the MACE group, high-sensitivity C-reactive protein (hs-CRP) level, peak troponin T (TNT) and the ratio of early diastolic mitral inflow velocity to early diastolic septal mitral annulus velocity (E/e’) were higher, while hemoglobin, left ventricular ejection fraction (LVEF) and absolute LVGLS were lower compared with the non-MACE group (P < 0.05). Multivariate COX regression analysis revealed that LVGLS (HR = 1.06, 95% CI 1.02–1.10) and hs-CRP (HR = 1.17, 95% CI 1.23–1.31) were independent predictors of MACE occurrence in ESRD patients (P < 0.05). The area under the ROC curve (AUC) for MACE occurrence within 12 months was 0.83 (95% CI 0.74–0.95), with a sensitivity of 89.9% and a specificity of 76.8%. The MACE-free survival rate in the high LVGLS group was higher compared to the low LVGLS group (P < 0.05). Conclusion Reduced LVGLS is an independent risk factor for MACE occurrence in ESRD patients within 12 months and a good prognostic indicator.

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

Article

Full-text available

Mar 2024
HEART FAIL REV

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.

2023Dimensional (2D) Echocardiography

Article

Full-text available

Mar 2024

Left Ventricular Diastolic Dysfunction Is Associated with Poor Functional Outcomes after Endovascular Thrombectomy

Article

Full-text available

Mar 2024

Introduction: With the advent of endovascular thrombectomy (ET), patients with acute ischaemic strokes (AIS) with large vessel occlusion (LVO) have seen vast improvements in treatment outcomes. Left ventricular diastolic dysfunction (LVDD) has been shown to herald poorer prognosis in conditions such as myocardial infarction. However, whether LVDD is related to functional recovery and outcomes in ischaemic stroke remains unclear. We studied LVDD for possible relation with clinical outcomes in patients with LVO AIS who underwent ET. Methods: We studied a retrospective cohort of 261 LVO AIS patients who had undergone ET at a single comprehensive stroke centre and correlated LVDD to short-term mortality (in-hospital death) as well as good functional recovery defined as modified Rankin Scale of 0–2 at 3 months. Results: The study population had a mean age of 65-years-old and were predominantly male (54.8%). All of the patients underwent ET with 206 (78.9%) achieving successful reperfusion. Despite this, 25 (9.6%) patients demised during the hospital admission and 149 (57.1%) did not have good function recovery at 3 months. LVDD was present in 82 (31.4%) patients and this finding indicated poorer outcomes in terms of functional recovery at 3 months (OR 2.18, 95% CI 1.04–4.54, p = 0.038) but was not associated with increased in-hospital mortality (OR 2.18, 95% CI 0.60–7.99, p = 0.240) after adjusting for various confounders. Conclusion: In addition to conventional echocardiographic indices such as left ventricular ejection fraction, LVDD may portend poorer outcomes after ET, and this relationship should be investigated further.

Significance of CHA2DS2-VASc-Hs score in the prediction of adverse in-hospital outcomes in patients with Non-St segment elevation myocardial infarction

Article

Jan 2024

Correlation between St segment elevation in the 12-lead ECG and the culprit coronary artery in patients with acute stemi undergoing primary PCI

Article

Jan 2024

The Probability of Multidetector Row Computed Tomography (MDCT) for Assessment of Transmitral Flow Velocities and Transannular flow Velocities in Comparison with 2-Dimensional (2D) Echocardiography

Article

Full-text available

Dec 2023

Two-Dimensions (2D) echocardiography using TDI has been used most commonly to evaluate diastolic LV function. Although the role of MDCT imaging for evaluation of coronary atherosclerosis has been explored extensively. Moreover, assessment of LV volumes and systolic function using MDCT were studied before and showing accurate myocardial border delineation despite its clinical significance use regarding radiation and contrast. The probability to evaluate diastolic function using MDCT has not been studied well yet. The present study was aimed to evaluate the probability of cardiac CT for assessment of diastolic function in a direct comparison with 2-dimensional (2D) echocardiography using combined assessment of transmitral velocity and transannular mitral velocity. One hundred and twenty patients’ consecutive patients who had been referred for 64-MDCT imaging were prospectively selected from our clinical registry. After exclusion criteria had been applied, forty patients who had undergone 64-MDCT and 2D echocardiography with TDI were enrolled. MDCT and 2D echocardiography were performed within the same day and no acute coronary events or worsening of angina occurred between the examinations and no changes in the use of medication occurred between both examinations. A good correlation was found for demonstrate the probability of multidetector row computed tomography (MDCT) for assessment of trans-mitral flow velocities and trans-annular flow velocities in comparison with 2-dimensional (2D) echocardiography using tissue Doppler imaging (TDI).

Dobutamine effects on systolic and diastolic left ventricular long-axis excursion and timing – significance for the interpretation of s′ and e′

Article

Full-text available

May 2023

Background Dobutamine effects on the relationships of the peak velocity of left ventricular (LV) long-axis systolic motion (s′) with systolic excursion (SExc), systolic duration (SDur) and heart rate, of LV long-axis early diastolic excursion (EDExc) with SExc, and of the peak velocity of LV long-axis early diastolic motion (e′) with EDExc, early diastolic duration (EDDur) and isovolumic relaxation time (IVRT') are unknown. Methods Two groups of adult subjects, one young and healthy (n = 10), and one with impaired LV long-axis function (n = 10), were studied, with the aim of identifying consistent findings for the two groups and for the septal and lateral walls. Dobutamine was infused at doses of 5 and 10 µg/kg/min. The relationships between tissue Doppler imaging (TDI) variables acquired before and during dobutamine infusion were analysed using mixed effect multivariate regression modelling. Results In both groups, heart rate increased and SDur decreased during dobutamine infusion, and there were independent inverse correlations of SDur with heart rate and dobutamine dose. In contrast, there was no change in EDDur during dobutamine infusion, and no consistent changes in IVRT' independent of heart rate. s′ was positively correlated with SExc and inversely correlated with SDur, and there were positive correlations between EDExc and SExc and between e′ and EDExc. Conclusion Dobutamine increases s′ due to effects on both systolic excursion and duration and it increases e′ due to the associated increases in systolic and early diastolic excursion. A lack of effect on diastolic times does not support the presence of a lusitropic effect of dobutamine.

Validation of Left Ventricular High Frame Rate Echo-Particle Image Velocimetry against 4D Flow MRI in Patients

Preprint

Full-text available

Nov 2023

Background: Accurately measuring blood flow patterns in the heart could provide insights in the pathophysiology of cardiac disease, and may provide additional diagnostic and prognostic information. This study aims to validate Echo-Particle Image Velocimetry (echoPIV) for in-vivo left ventricular intracardiac flow imaging by comparing it with 4D flow MRI. Methods: We acquired HFR contrast-enhanced ultrasound images from three standard apical views of 26 patients who required cardiac MRI. 4D flow MRI was obtained for each patient. Only echo image planes with sufficient quality and alignment with MRI were included for the validation. Regional velocity, kinetic energy and viscous energy loss were compared between modalities using normalized mean absolute error, cosine similarity and Bland-Altman analysis. Results: Among 24 included apical view acquisitions, we observed good correspondence between echoPIV and MRI regarding spatial flow patterns and vortex traces. The velocity profile at the cross-section at the base level (mitral valve) had cosine similarity of 0.92 ± 0.06 and normalized mean absolute error of 14 ± 5%. Peak of spatial mean velocity showed a difference of 3 ± 6 cm/s in systole and 6 ± 10 cm/s in diastole. The kinetic energy and rate of energy loss also revealed a high level of cosine similarity (0.89 ± 0.09 and 0.91 ± 0.06 ) with normalized mean absolute error of 23 ± 7% and 52 ± 16%. Conclusions: Given good B-mode image quality, echoPIV can provide a reliable estimation of left ventricular flow, as compared with 4D flow MRI, providing comparable spatial-temporal velocity distributions. There are advantages and disadvantages for both modalities. EchoPIV captured inter-beat variability and had higher temporal resolution, while MRI was more robust to patient BMI and anatomy.

The use of bedside echocardiography in the care of critically ill patients: a joint consensus document of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Medicina de Emergência and Sociedade Brasileira de Medicina Hospitalar. Part 2 - Technical aspects

Article

Full-text available

Sep 2023

Echocardiography in critically ill patients has become essential in the evaluation of patients in different settings, such as the hospital. However, unlike for other matters related to the care of these patients, there are still no recommendations from national medical societies on the subject. The objective of this document was to organize and make available expert consensus opinions that may help to better incorporate echocardiography in the evaluation of critically ill patients. Thus, the Associação de Medicina Intensiva Brasileira, the Associação Brasileira de Medicina de Emergência, and the Sociedade Brasileira de Medicina Hospitalar formed a group of 17 physicians to formulate questions relevant to the topic and discuss the possibility of consensus for each of them. All questions were prepared using a five-point Likert scale. Consensus was defined a priori as at least 80% of the responses between one and two or between four and five. The consideration of the issues involved two rounds of voting and debate among all participants. The 27 questions prepared make up the present document and are divided into 4 major assessment areas: left ventricular function, right ventricular function, diagnosis of shock, and hemodynamics. At the end of the process, there were 17 positive (agreement) and 3 negative (disagreement) consensuses; another 7 questions remained without consensus. Although areas of uncertainty persist, this document brings together consensus opinions on several issues related to echocardiography in critically ill patients and may enhance its development in the national scenario.

The correlation between Fischer’s ratio and the risk of cardiac dysfunction in Systolic Heart Failure

Preprint

Full-text available

Nov 2023

Backgrounds Due to the high mortality and hospitalization rate in chronic heart failure (HF), it is of great significance to study myocardial nutrition conditions. Amino acids (AAs) are essential nutrient metabolites for cell development and survival. This study aims to investigate the plasma branched-chain amino acid/aromatic amino acid ratio (Fischer’s ratio, FR) as a potential metabolic risk factor for the presence of chronic HF and left ventricular (LV) pressure filling. Methods The value of serum AAs was obtained from 441 cardiovascular subjects by liquid chromatography-tandem, and 213 systolic HF subjects were followed up for a mean year (11.74 ± 1.44 months). LV ejection fraction (EF) and the ratio of early diastolic mitral inflow to mitral annular tissue velocities (E/e’) were determined by two-dimensional echocardiography and Doppler flow imaging using standard biplane technique. Logistic regression analysis was conducted to measure the FR index and the risk of HF, and further confirmed by receiver-operating characteristic curves (ROC curve) analysis. The event-free HF endpoint was determined by Kaplan–Meier curves, and differences were assessed using log‐rank tests. Results FR index decreased gradually along with the control group, systolic HF with E/e’≤14 group, and systolic HF with E/e’>14 group (3.73 ± 1.20 vs. 3.45 ± 0.94 vs. 3.18 ± 0.83, respectively, P < 0.001). Low FR index was associated with systolic HF after full adjustment in all subjects [odds ratio (OR), 2.124; 95% confidence interval (CI): 1.595–2.829; P < 0.001] and the area under the curve (AUC) of ROC curve was 0.722 (sensitivity 62.91%, specificity 78.95%). Meanwhile, low FR index was the independent risk of E/e’>14 for systolic HF (OR: 1.525; 95% CI: 1.053–2.209; P = 0.025). The AUC of ROC curve for predicting abnormal E/e’ was 0.732 (sensitivity 61.39%, specificity 75.68%) by multivariate logistic regression. Furthermore, the decreased FR values indicated poor prognosis in systolic HF subjects (Log-rank P = 0.005). Conclusions In all subjects, low FR confers an increased risk for predicting systolic HF. Decreased FR levels could also indicate increased LV filling pressure in systolic HF. In addition, a lower FR value was associated with higher HF endpoint events. Thus, FR can be a valuable indicator of heart function.

The value of a dynamic echocardiographic approach to diastolic dysfunction in intensive care medicine

Article

Nov 2023
J CLIN ULTRASOUND

Diastolic dysfunction is an underestimated feature in the context of the critically ill setting and perioperative medicine. Advances in echocardiography, its noninvasive, safe and easy use, have allowed Doppler echocardiography to become a cornerstone for diagnosing diastolic dysfunction in clinical practice. The diagnosis of diastolic dysfunction and increased filling pressures is nevertheless complex. Using an echocardiographic assessment and the routine application of preload stress maneuvers during echocardiographic examination can help identify early stages of diastolic dysfunction leading to better management of patients at risk of acute heart decompensation in the perioperative period or during ICU stay.

Beta blockers therapy is associated with improved left ventricular systolic function and sustained exercise capacity in elderly patients with heart failure. CIBIS-ELD sub-study

Article

Jul 2013

Background: Exercise capacity is critical for therapy and prognosis in patients with heart failure (HF). Effect of beta-blockers (BB) on exercise capacity in elderly patients with HF remains unclear. Objectives: To assess contribution of BB to functional capacity and left ventricular (LV) function in the elderly with HF. Design: According to the protocol of CIBIS-ELD study group, elderly patients were treated with BB during 12 weeks. In CPET subgroup, an integral part of the CIBIS ELD study group, patients were performed Doppler echocardiography and cardiopulmonary exercise testing (CPET) before BB therapy and after 12 weeks. Setting: Randomized patients with HF beta blockers naïve. Participants: thirty patients with HF aged over 65 years were included in CPET subgroup, while 847 were incorporated in CIBIS ELD study group. Results: Heart rate (HR) and systolic blood pressure (SBP) after BB significantly decreased at rest (p<0.001) and during exercise (p<0.05), with sustained level of peak VO2. Observed changes of resting HR and peak HR were closely correlated (p<0.001). Significant improvement of LV ejection fraction after BB was obtained (p=0.003) and symptoms of breathlessness were reduced (p=0.001). Left ventricular diastolic dysfunction at rest significantly contributed to exercise capacity (p=0.019). Conclusions: Beta-blockers in elderly patients with HF are related to a significant decrease of HR and SBP, improvement of systolic LV function and sustained exercise tolerance. Resting LV diastolic dysfunction is strongly associated with lower exercise capacity.

Cardiac Dysfunction Rather Than Aortic Valve Stenosis Severity Drives Exercise Intolerance and Adverse Hemodynamics

Article

Oct 2023

Aims: To study the impact of heart failure with preserved ejection fraction (HFpEF) versus aortic stenosis (AS) lesion severity on left ventricular (LV) hypertrophy, diastolic dysfunction, left atrial (LA) dysfunction, hemodynamics, and exercise capacity. Methods and results: Patients (n = 206) with at least moderate AS (aortic valve area ≤0.85 cm/m2) and discordant symptoms underwent cardiopulmonary exercise testing with simultaneous echocardiography. The population was stratified according to the probability of underlying HFpEF by the H2FPEF score [0-5 (AS/HFpEF-) vs. 6-9 points (AS/HFpEF+)] and AS severity (Moderate vs. Severe). Mean age was 73 ± 10 years with 40% women. Twenty-eight patients had Severe AS/HFpEF + (14%), 111 Severe AS/HFpEF- (54%), 13 Moderate AS/HFpEF + (6%), and 54 Moderate AS/HFpEF- (26%). AS/HFpEF + versus AS/HFpEF- patients, irrespective of AS severity, had a lower LV global longitudinal strain, impaired diastolic function, reduced LV compliance, and more pronounced LA dysfunction. The pulmonary arterial pressure-cardiac output slope was significantly higher in AS/HFpEF + versus AS/HFpEF- (5.4 ± 3.1 vs. 3.9 ± 2.2 mmHg/L/min, respectively; p = 0.003), mainly driven by impaired cardiac output and chronotropic reserve, with signs of right ventricular-pulmonary arterial uncoupling. AS/HFpEF + versus AS/HFpEF- was associated with a lower peak aerobic capacity (11.5 ± 3.7 vs. 15.9 ± 5.9 mL/min/kg, respectively; p < 0.0001), but did not differ between Moderate and Severe AS (14.7 ± 5.5 vs. 15.2 ± 5.9 mL/min/kg, respectively; p = 0.6). Conclusions: A high H2FPEF score is associated with a reduced exercise capacity and adverse hemodynamics in patients with moderate to severe AS. Both exercise performance and hemodynamics correspond better with intrinsic cardiac dysfunction than AS severity.

Is Marfan Syndrome Associated with Primary Structural Changes in the Left Atrium?

Article

Full-text available

Oct 2023

Marfan syndrome (MFS) is an autosomal-dominant multisystem connective tissue disorder that is based on mutations in the FBN1 gene and variably affects different organs, including the heart. In this study, we investigated cardiac function with a focus on the left atrium (LA) in a relatively large cohort of patients with MFS. After screening of 1165 patients that had been examined in our center between 2016 and 2020, 231 adult MFS patients with and without aortic operation were included in our study and compared to a healthy control group (n = 106). Cardiac function was assessed by transthoracic echocardiography and NT-proBNP was used as a secretory marker. Most (94.8%) of the patients received genetic testing. Left ventricular function was within normal ranges and not impaired. Interestingly, we found that LA size and secretory activity were increased in MFS patients, despite normal left ventricular filling pressures. This finding was even more pronounced in MFS patients with prior aortic surgery. A correlation between LA size or NT-proBNP levels and the type of pathogenic FBN1 variant could not be identified. Right ventricular function and right atrial size were increased only in MFS patients that had undergone aortic surgery. In conclusion, these findings suggest that MFS leads to structural changes in the LA that are not solely resulting from left ventricular dysfunction, but probably can be considered a primary pathology of MFS.

The correlation between epicardial fat thickness and longitudinal left atrial reservoir strain in patients with type 2 diabetes mellitus and controls

Article

Full-text available

Sep 2023

Background Diabetes mellitus (DM) has been documented among the strongest risk factors for developing heart failure with preserved ejection fraction (HFpEF). The earliest imaging changes in patients with DM are the left atrial (LA) functional and volumetric changes. The aim of this study was to determine the correlation between epicardial fat thickness (EFT) and longitudinal LA reservoir strain (LARS) in patients with type 2 DM (T2DM), as compared with non-diabetic controls. Results The study samples in this case-control study comprised of consecutive patients with T2DM (n=64) and matched non-diabetic controls (n=30). An echocardiography was performed on all patients and EFT, volumetric and longitudinal LARS, left ventricular (LV) global longitudinal strain (LVGLS), pulsed-wave Doppler-derived transmitral early (E wave) and late (A wave) diastolic velocities, and tissue-Doppler-derived mitral annular early diastolic (e′) and peak systolic (s') velocities were obtained. The study results demonstrated that the patients with T2DM had thicker EFT (5.96±2.13 vs. 4.10±3.11 mm) and increased LA volume index (LAVI) (43.05± 44.40 vs. 29.10±11.34 ml/m²) in comparison with the non-diabetic ones (p-value: 0.005 and 0.022, respectively). On the other hand, a direct association was observed between EFT and the E/e′ ratio, and an inverse correlation was established between EFT and LARS in patients with T2DM (r=0.299, p-value=0.020 and r=− 0.256, p-value=0.043, respectively). However, regression analysis showed only LV mass index (LVMI) (β=0.012, 95% CI 0.006–0.019, p-value<0.001), LAVI (β=− 0.034, 95% CI − 0.05–0.017, p-value<0.001), and EFT (β=− 0.143, 95% CI − 0.264–− 0.021, p-value=0.021) were independently correlated with LARS. Conclusions LARS is considered as an important early marker of subclinical cardiac dysfunction. Thickened epicardial fat may be an independent risk factor for decreased LA reservoir strain. Diabetics are especially considered as a high risk group due to having an increased epicardial adipose tissue thickness.

The assessment of left ventricular diastolic function: guidance and recommendations from the British Society of Echocardiography

Article

Full-text available

Jun 2024

Impairment of left ventricular (LV) diastolic function is common amongst those with left heart disease and is associated with significant morbidity. Given that, in simple terms, the ventricle can only eject the volume with which it fills and that approximately one half of hospitalisations for heart failure (HF) are in those with normal/’preserved’ left ventricular ejection fraction (HFpEF) (Bianco et al. in JACC Cardiovasc Imaging. 13:258–271, 2020. 10.1016/j.jcmg.2018.12.035), where abnormalities of ventricular filling are the cause of symptoms, it is clear that the assessment of left ventricular diastolic function (LVDF) is crucial for understanding global cardiac function and for identifying the wider effects of disease processes. Invasive methods of measuring LV relaxation and filling pressures are considered the gold-standard for investigating diastolic function. However, the high temporal resolution of trans-thoracic echocardiography (TTE) with widely validated and reproducible measures available at the patient’s bedside and without the need for invasive procedures involving ionising radiation have established echocardiography as the primary imaging modality. The comprehensive assessment of LVDF is therefore a fundamental element of the standard TTE (Robinson et al. in Echo Res Pract7:G59–G93, 2020. 10.1530/ERP-20-0026). However, the echocardiographic assessment of diastolic function is complex. In the broadest and most basic terms, ventricular diastole comprises an early filling phase when blood is drawn, by suction, into the ventricle as it rapidly recoils and lengthens following the preceding systolic contraction and shortening. This is followed in late diastole by distension of the compliant LV when atrial contraction actively contributes to ventricular filling. When LVDF is normal, ventricular filling is achieved at low pressure both at rest and during exertion. However, this basic description merely summarises the complex physiology that enables the diastolic process and defines it according to the mechanical method by which the ventricles fill, overlooking the myocardial function, properties of chamber compliance and pressure differentials that determine the capacity for LV filling. Unlike ventricular systolic function where single parameters are utilised to define myocardial performance (LV ejection fraction (LVEF) and Global Longitudinal Strain (GLS)), the assessment of diastolic function relies on the interpretation of multiple myocardial and blood-flow velocity parameters, along with left atrial (LA) size and function, in order to diagnose the presence and degree of impairment. The echocardiographic assessment of diastolic function is therefore multifaceted and complex, requiring an algorithmic approach that incorporates parameters of myocardial relaxation/recoil, chamber compliance and function under variable loading conditions and the intra-cavity pressures under which these processes occur. This guideline outlines a structured approach to the assessment of diastolic function and includes recommendations for the assessment of LV relaxation and filling pressures. Non-routine echocardiographic measures are described alongside guidance for application in specific circumstances. Provocative methods for revealing increased filling pressure on exertion are described and novel and emerging modalities considered. For rapid access to the core recommendations of the diastolic guideline, a quick-reference guide (additional file 1) accompanies the main guideline document. This describes in very brief detail the diastolic investigation in each patient group and includes all algorithms and core reference tables. Supplementary Information The online version contains supplementary material available at 10.1186/s44156-024-00051-2.

Echocardiographic evaluation of mitral inflow e wave velocity-to-tissue Doppler e’ wave velocity ratio (E/e’) as a prognostic indicator in ST-elevation myocardial infarction

Article

May 2024

AIMS AND OBJECTIVES To study the clinical characteristics and to assess the usefulness of echocardiographic evaluation of mitral inflow E wave velocity-to-tissue Doppler e’ wave velocity ratio (E/e’) as a prognostic indicator in patients admitted with ST-elevation myocardial infarction (STEMI) with or without revascularization therapy to predict in-hospital mortality. BACKGROUND Myocardial infarction is a high-risk condition, especially when filling pressure is raised, and earlier reports have suggested that E/e’ is associated with poor outcome. However, whether E/e’ predicts risk better than left ventricular ejection fraction (LVEF), which is the current standard of practice, is not known. MATERIALS AND METHODS AND RESULTS The echocardiographic evaluation of mitral inflow E wave velocity-to-tissue Doppler e’ wave velocity ratio (E/e’) as a prognostic indicator in ST-elevation myocardial infarction” was carried out on 100 patients admitted in the Department of Cardiology of Fortis Escorts Heart Institute, Okhla, New Delhi, from November 2019 to March 2021. The mean age of the patients with ST-elevation myocardial infarction was 59.8 ± 11.3 years. In patients who had E/e’ >15, male predominance and higher age (mean 63.7 ± 7.7 years) were found. Out of common cardiovascular risk factors, smoking and diabetes mellitus were found to be statistically significant. 67.7% of patients were belonged to the Killip Class II or more. In patients who had E/e’ >15, 29 (93.5%) patients had LVEF ≤45%. Twenty-seven (87.1%) patients had deceleration time (DT) ≤140 ms. Moderate or severe mitral regurgitation (MR) was found in 19.4% of patients, while the mean values of LVEDD and LVESD were 50.4 ± 2.15 mm and 39.7 ± 3.3 mm, respectively. The mean velocity of E and A was 0.87 ± 0.12 m/s and 0.75 ± 0.11 m/s, respectively. The mean E/A ratio was 1.1 ± 0.22. The mean velocity of e’ was 5.02 ± 0.45 cm/s and E/e’ ratio was 17.48 ± 1.57. The association of various clinical features showed that male gender, higher age, smoking, and diabetes mellitus, cardiogenic shock, and Killip Class II or greater were significant factors associated with E/e’ >15. Echocardiographic findings showed that LVEF ≤45%, higher LVEDD and LVESD, higher peak E velocity, DT ≤140 ms, lower mitral annulus e’ velocity, higher E/e’ ratio, and moderate or severe MR were significantly associated with E/e’ >15. CONCLUSION The current study concluded that Doppler echocardiographic estimation of E/e’ ratio can be used as a marker of elevated left ventricular filling pressure and hence can be used as a prognostic marker in risk stratification of patients admitted in coronary care units. The E/e’ ratio is an independent and powerful predictor of the in-hospital mortality.

Left ventricular diastolic function in atrial fibrillation: Methodological implications and clinical considerations

Article

Full-text available

Apr 2024
ECHOCARDIOGR-J CARD

The assessment of LVDD is routinely included in echocardiographic evaluation because it correlates with cardiac disease progression and its prognostic value. Classic parameters used for assessing LV diastolic function correlate well with invasive measurements which remains the gold standard. Nevertheless, no one echocardiographic parameter alone can completely evaluate LVDD. LV diastolic function evaluation in atrial fibrillation is still challenging, since the E/A ratio, one of the most used parameters in echocardiographic evaluation, cannot be feasible. This is not a good reason to give up measurement. In this review, we analyze the different methods for estimating LV diastolic function in atrial fibrillation, including measurement not dependent on atrial systole and some novel methods that are promising, but not ever available during clinical practice highlighting that this assessment is mandatory for a complete clinical evaluation of the patients.

Abnormalities in the cardiac relaxation

Chapter

Jan 2024

Significance of Tissue Doppler Imaging in Evaluating Cardiac Function in Children

Article

Jan 2024

杰刘

Prognostic value of E/e' ratio and its change over time in ST-segment elevation myocardial infarction with preserved left ventricular ejection fraction in the reperfusion era

Article

Mar 2024

Hemodynamic Markers in the Progression from Hypertension to Heart Failure

Chapter

Mar 2024

It is of importance to better understand the pathophysiological mechanisms leading to left ventricular (LV) maladaptation and the timely identification and management of patients at risk of developing symptomatic heart failure (HF). High blood pressure is the major modifiable risk factor for overt HF. In patients with hypertension, the process of myocardial remodeling/dysfunction starts long before the onset of HF symptoms. The long-term increased afterload (high pressure) and, consequently, the chronically increased cardiac performance lead to LV concentric remodeling, decreased longitudinal systolic deformation (strain), diastolic dysfunction, and increased LV oxygen requirements. All these processes eventually result in symptomatic HF. Recent studies have revealed a high prevalence of asymptomatic (or subclinical) LV remodeling and systolic and diastolic dysfunction in the community. In this chapter, we discuss the various aspects of cardiac maladaptation to a chronically increased hemodynamic load. We also illustrate the complex interaction between the different components of blood pressure, arterial properties, and echocardiographic indexes reflecting LV function and structure.

Effect of Sevoflurane Anesthesia on Diastolic Function: A Prospective Observational Study

Article

Feb 2024

BACKGROUND The effect of sevoflurane on left ventricular diastolic function is not well understood. We hypothesized that parameters of diastolic function may improve under sevoflurane anesthesia in patients with preexisting diastolic dysfunction compared to patients with normal diastolic function. METHODS This observational study included 60 patients undergoing breast surgery or laparoscopic cholecystectomy. Patients were assigned to diastolic dysfunction (n = 34) or normal (n = 26) groups of septal e’ < 8 or ≥ 8.0 cm/s on the first thoracic echocardiography (TTE) performed before anesthesia. During anesthesia, sevoflurane was maintained at 1 to 2 minimum alveolar concentration (MAC) to maintain the bispectral index at 40 to 50. At the end of surgery, the second TTE was performed under 0.8 to 1 MAC of sevoflurane with the patient breathing spontaneously without ventilator support. Primary end point was the percentage change (Δ) of e’ on 2 TTEs (Δe’). Secondary end points were ΔE/e’, Δleft atrial volume index (ΔLAVI), and Δtricuspid regurgitation maximum velocity (ΔTR Vmax). These percentage changes (Δ) were compared between diastolic dysfunction and normal groups. RESULTS e’ (Δe’: 30 [6, 64] vs 0 [−18, 11]%; P < .001), mitral inflow E wave velocity (E), mitral inflow E/A ratio (E/A), and mitral E velocity deceleration time (DT) improved significantly in diastolic dysfunction group compared to normal group. LAVI decreased in diastolic dysfunction group but did not reach statistical significance between the 2 groups (ΔLAVI:−15 [−31, −3] vs −4 [−20, 10]%, P = .091). ΔE/e’ was not different between the 2 groups (11 [−16, 26] vs 12 [−9, 22]%, P = .853) (all: median [interquartile range, IQR]). TR was minimal in both groups. CONCLUSIONS In this study, echocardiographic parameters of diastolic function, including septal e’, E, E/A, and DT, improved with sevoflurane anesthesia in patients with preexisting diastolic dysfunction, but remained unchanged in patients with normal diastolic function.

The Ultrasound Hepato-Jugular Reflux: Measuring the Hepato-Jugular Reflux with Ultrasound with Comparison to Invasive Right Heart Catheterization

Article

Feb 2024
AM J MED

Left Atrial Peak Systolic Strain as an Indicator Pathway of Diastolic Dysfunction of the Left Ventricle

Article

Feb 2024

Background: Left atrial peak systolic strain (LA-PSS) imaging is an emerging index of LA function, and it was shown to be decreased in heart failure with preserved ejection fraction. We aimed to determine whether LA-PSS could be used as an additional diagnostic parameter to current existing guidelines for the presence of left ventricle diastolic dysfunction (LVDD). Materials and methods: A total of 190 consecutive adult patients with cardiovascular risk factors and normal LV ejection fraction with no prior history of heart failure were included in the study. Speckle tracking software was used to study ventricular parietal deformity, left ventricle global longitudinal systolic strain (LV-GLS), and LA-PSS. Results: The median LV-GLS was -19%, with a significant difference (p<0.001) between patients with normal diastolic function vs those with LVDD. The median LA-PSS was 33% (30 to 38%) (p<0.001). Most patients (61%) had grade 1 atrial dysfunction based on PSS (range 24% to 35%). The analysis of the area under the ROC curve of the LA-PSS as a potential indicator pathway of LVDD was 67% (95% CI 62-72), and 75% (95% CI 70-80), when the indeterminate pattern was included. The decreased LA-PSS made it possible to reclassify patients with an indeterminate pattern of diastolic function in 96% of cases. Conclusion: These results support the potential role of LA-PSS as an additional parameter for the diagnosis of LVDD in patients with normal ejection fraction, and may be integrated into the guidelines for routine evaluation of patients.

Role of Imaging in the Diagnosis, Evaluation, and Management of Hypertrophic Cardiomyopathy

Article

Feb 2024
AM J CARDIOL

Evaluation of left ventricular stiffness with echocardiography

Article

Jan 2024

Half of patients with heart failure are presented with preserved ejection fraction (HFpEF). The pathophysiology of these patients is complex, but increased left ventricular (LV) stiffness has been proven to play a key role. However, the application of this parameter is limited due to the requirement for invasive catheterization for its measurement. With advances in ultrasound technology, significant progress has been made in the noninvasive assessment of LV chamber or myocardial stiffness using echocardiography. Therefore, this review aims to summarize the pathophysiological mechanisms, correlations with invasive LV stiffness constants, applications in different populations, as well as the limitations of echocardiography‐derived indices for the assessment of both LV chamber and myocardial stiffness. Indices of LV chamber stiffness, such as the ratio of E/e' divided by left ventricular end‐diastolic volume (E/e'/LVEDV), the ratio of E/SRe (early diastolic strain rates)/LVEDV, and diastolic pressure‐volume quotient (DPVQ), are derived from the relationship between echocardiographic parameters of LV filling pressure (LVFP) and LV size. However, these methods are surrogate and lumped measurements, relying on E/e' or E/SRe for evaluating LVFP. The limitations of E/e' or E/SRe in the assessment of LVFP may contribute to the moderate correlation between E/e'/LVEDV or E/SRe/LVEDV and LV stiffness constants. Even the most validated measurement (DPVQ) is considered unreliable in individual patients. In comparison to E/e'/LVEDV and E/SRe/LVEDV, indices like time‐velocity integral (TVI) measurements of pulmonary venous and transmitral flows may demonstrate better performance in assessing LV chamber stiffness, as evidenced by their higher correlation with LV stiffness constants. However, only one study has been conducted on the exploration and application of TVI in the literature, and the accuracy of assessing LV chamber stiffness remains to be confirmed. Regarding echocardiographic indices for LV myocardial stiffness evaluation, parameters such as epicardial movement index (EMI)/ diastolic wall strain (DWS), intrinsic velocity propagation of myocardial stretch (iVP), and shear wave imaging (SWI) have been proposed. While the alteration of DWS and its predictive value for adverse outcomes in various populations have been widely validated, it has been found that DWS may be better considered as an overall marker of cardiac function performance rather than pure myocardial stiffness. Although the effectiveness of iVP and SWI in assessing left ventricular myocardial stiffness has been demonstrated in animal models and clinical studies, both indices have their limitations. Overall, it seems that currently no echocardiography‐derived indices can reliably and accurately assess LV stiffness, despite the development of several parameters. Therefore, a comprehensive evaluation of LV stiffness using all available parameters may be more accurate and enable earlier detection of alterations in LV stiffness.

Modifiers of the Association between E/e' Ratio and Survival among Subjects with No Apparent Structural or Functional Cardiac Abnormality

Article

Jan 2024

Study the relationship between left atrial (LA) volume and LV diastolic dysfunction and LV hypertrophy: Correlate LA volume with cardiovascular risk factors

Article

Jan 2024
DM-DIS MON

Heart failure (HF) with normal ejection fraction - the isolated diastolic heart failure, depicts increasing prevalence and health care burden in recent times. Having less mortality rate compared to systolic heart failure but high morbidity, it is evolving as a major cardiac concern. With increasing clinical use of Left atrial volume (LAV) quantitation in clinical settings, LAV has emerged as an important independent predictor of cardiovascular outcome in HF with normal ejection fraction. This article is intended to review the diastolic and systolic heart failure, their association with left atrial volume, in depth study of Left atrial function dynamics with determinants of various functional and structural changes.

Peripheral Venous Pressure Accurately Reflects Invasively Measured Resting and Exercise Fontan Pressures

Article

Jan 2024
AM J CARDIOL

Exploring the Connection Between Relaxed Myosin States and the Anrep Effect

Article

Jan 2024
CIRC RES

The Anrep effect is an adaptive response that increases left ventricular contractility following an acute rise in afterload. Although the mechanistic origin remains undefined, recent findings suggest a two-phase activation of resting myosin for contraction, involving strain-sensitive and posttranslational phases. We propose that this mobilization represents a transition among the relaxed states of myosin—specifically, from the super-relaxed (SRX) to the disordered-relaxed (DRX)—with DRX myosin ready to participate in force generation. This hypothesis offers a unified explanation that connects myosin’s SRX-DRX equilibrium and the Anrep effect as parts of a singular phenomenon. We underscore the significance of this equilibrium in modulating contractility, primarily studied in the context of hypertrophic cardiomyopathy, the most common inherited cardiomyopathy associated with diastolic dysfunction, hypercontractility, and left ventricular hypertrophy. As we posit that the cellular basis of the Anrep effect relies on a two-phased transition of myosin from the SRX to the contraction-ready DRX configuration, any dysregulation in this equilibrium may result in the pathological manifestation of the Anrep phenomenon. For instance, in hypertrophic cardiomyopathy, hypercontractility is linked to a considerable shift of myosin to the DRX state, implying a persistent activation of the Anrep effect. These valuable insights call for additional research to uncover a clinical Anrep fingerprint in pathological states. Here, we demonstrate through noninvasive echocardiographic pressure-volume measurements that this fingerprint is evident in 12 patients with hypertrophic obstructive cardiomyopathy before septal myocardial ablation. This unique signature is characterized by enhanced contractility, indicated by a leftward shift and steepening of the end-systolic pressure-volume relationship, and a prolonged systolic ejection time adjusted for heart rate, which reverses post-procedure. The clinical application of this concept has potential implications beyond hypertrophic cardiomyopathy, extending to other genetic cardiomyopathies and even noncongenital heart diseases with complex etiologies across a broad spectrum of left ventricular ejection fractions.

Unveiling the Hidden Chamber: Exploring the Importance of Left Atrial Function and Filling Pressure in Cardiovascular Health

Article

Nov 2023

The left atrium (LA) is a vital component of the cardiovascular system, playing a crucial role in cardiac function. It acts as a reservoir, conduit, and contractile chamber, contributing to optimal left ventricle (LV) filling and cardiac output. Abnormalities in LA function have been associated with various cardiovascular conditions, including heart failure, atrial fibrillation, valvular heart disease, and hypertension. Elevated left ventricular filling pressures resulting from impaired LA function can lead to diastolic dysfunction and increase the risk of adverse cardiovascular events. Understanding the relationship between LA function and LV filling pressures is crucial for comprehending the pathophysiology of cardiovascular diseases and guiding clinical management strategies. This article provides an overview of the anatomy and physiology of the LA, discusses the role of LA mechanics in maintaining normal cardiac function, highlights the clinical implications of elevated filling pressures, and explores diagnostic methods for assessing LA function and filling pressures. Furthermore, it discusses the prognostic implications and potential therapeutic approaches for managing patients with abnormal LA function and elevated filling pressure. Continued research and clinical focus on left atrial function are necessary to improve diagnostic accuracy, prognostic assessment, and treatment strategies in cardiovascular diseases. It will explore the importance of assessing LA function as a marker of cardiac performance and evaluate its implications for clinical practice. In accordance with rigorous scientific methodology, our search encompassed PubMed database. We selected articles deemed pertinent to our subject matter. Subsequently, we extracted and synthesized the salient contents, capturing the essence of each selected article.

Echocardiographic derived pulmonary artery wedge pressure is associated with mortality, heart hospitalizations, and functional capacity in chronic systolic heart failure: insights from the HF-ACTION trial

Article

Dec 2023

Heart Failure (HF) is associated with increased morbidity and mortality. Identification of patients at risk for adverse events could lead to improved outcomes. Few studies address the association of echocardiographic-derived PAWP with exercise capacity, readmissions, and mortality in HF. HF-ACTION enrolled 2331 outpatients with HF with reduced ejection fraction (HFrEF) who were randomized to aerobic exercise training versus usual care. All patients underwent baseline echocardiography. Echocardiographic-derived PAWP (ePAWP) was assessed using the Nagueh formula. We evaluated the relationship between ePAWP to clinical outcomes. Among the 2331 patients in the HF-ACTION trial, 2125 patients consented and completed follow-up with available data. 807 of these patients had complete echocardiographic data that allowed the calculation of ePAWP. Of this cohort, mean age (SD) was 58 years (12.7), and 255 (31.6%) were female. The median ePAWP was 14.06 mmHg. ePAWP was significantly associated with cardiovascular death or HF hospitalization (Hazard ratio [HR] 1.02, coefficient 0.016, CI 1.002–1.030, p = 0.022) and all-cause death or HF hospitalization (HR 1.01, coefficient 0.010, CI 1.001–1.020, p = 0.04). Increased ePAWP was also associated with decreased exercise capacity leading to lower peak VO2 (p = < 0.001), high Ve/VCO2 slope (p = < 0.001), lower exercise duration (p = < 0.001), oxygen uptake efficiency (p = < 0.001), and shorter 6-MWT distance (p = < 0.001). Among HFrEF patients, echocardiographic-derived PAWP was associated with increased mortality, reduced functional capacity and heart failure hospitalization. ePAWP may be a viable noninvasive marker to risk stratify HFrEF patients.

Influence of isometric versus isotonic exercise training on right ventricular morpho‐functional parameters in Olympic athletes

Article

Dec 2023

Background Cardiovascular adaptations in elite athletes involve both ventricular and atrial changes. Nowadays, limited research exists on right ventricular (RV) remodeling, particularly in female athletes and across different types of exercise training. Methods Our study evaluated 370 athletes (61% males) participated at 2020 Tokyo and 2022 Beijing Olympic Games. Athletes were categorized according to main type of exercise into isometric and isotonic. Comprehensive echocardiographic assessments were conducted to analyze RV morpho‐functional parameters, comparing genders and different sporting exercise. Results Significant differences in RV parameters were observed based on exercise type and gender. Isotonic athletes showed greater RV remodeling with larger RV outflow tract (15.1 ± 2.1 vs. 14.5 ± 1.7 mm, p < .0001) end‐diastolic and end‐systolic area (respectively, 24.6 ± 5.5 vs. 21.7 ± 5 mm, p < .000 and 11.7 ± 3.2 vs. 10.1 ± 2.8 mm, p < .0001) and right atrium size (11.7 ± 3.2 vs. 10.2 ± 2.3 mm ² , p = .0001). Functional parameters, such as TDI velocities, were similar between groups. Males showed larger RV area and right atrium size ( p < .0001) and lower RV TDI velocities with reduced E′ (15.4 ± 2.9 vs. 16.1 ± 3.2 m/s in females, p = .031), resulting in lower E′/A′ ratio (1.69 ± .6 vs. 1.84 ± .6 m/s, p = .021), while S′ was lower females (14.6 ± 2.3 vs. 14.1 ± 2.4 m/s, p = .041). RV TDI velocities were similar in isotonic and isometric both in male and females. Conclusions In elite athletes, RV morphological changes are influenced by exercise modality but do not translate into functional differences. Female athletes present distinct RV functional profiles, with lower S′ velocities and a higher E′/A′ ratio. Functional RV TDI parameters are not affected by the typology of exercise practiced.

Dynamic changes in echocardiographic parameters in acute decompensated heart failure: REALITY-ECHO

Article

Oct 2023
J Cardiol

POCUS in Monitoring: LV Diastolic Function and Filling Pressures

Chapter

Oct 2023

In the last decade, the study of left ventricular (LV) relaxation properties to define diastolic dysfunction and the consequent increase in LV filling pressure has gained increasing importance for the assessment of heart failure, particularly the evaluation of the fluid status of the patient. Therefore, a thorough evaluation of diastolic function could be pivotal also in emergency and critical care settings for diagnosis, monitoring and guiding treatment. Noninvasive estimation of LV filling pressures and diastolic function by POCUS should be fully integrated into non-invasive bedside assessment of haemodynamics. This chapter describes the main grades of diastolic dysfunction and their evaluation with POCUS, highlighting their usefulness and limitations in daily clinical practice.

Univentricular Support for the Left Ventricle

Chapter

Sep 2023

Basics of Tissue Doppler Revisited

Article

Jan 2017

Sita Ram Mittal

Tissue Doppler imaging (TDI) records velocities of myocardial tissue. Routinely longitudinal velocities of medial and lateral mitral annulus and lateral tricuspid annulus are evaluated in apical four chamber view. Commonly recorded waves include isovolumic contraction wave, systolic wave, isovolumic relaxation wave, early diastolic wave, and late diastolic wave. TDI is useful in detection of subclinical systolic dysfunction and early diastolic dysfunction. It is useful in differentiating athlete's heart from hypertrophic cardiomyopathy and pericardial constriction from restrictive cardiomyopathy.

Hemodynamic determinants of the time-course of fall in canine left ventricular pressure

Article

Full-text available

Oct 1976

The hemodynamic determinants of the time-course of fall in isovolumic left ventricular pressure were assessed in isolated canine left ventricular preparations. Pressure fall was studied in isovolumic beats or during prolonged isovolumic diastole after ejection. Pressure fall was studied in isovolumic relaxation for isovolumic and ejecting beats (r less than or equal to 0.98) and was therefore characterized by a time constant, T. Higher heart rates shortened T slightly from 52.6 +/- 4.5 ms at 110/min to 48.2 +/- 6.0 ms at 160/min (P less than 0.01, n = 8). Higher ventricular volumes under isovolumic conditions resulted in higher peak left ventricular pressure but no significant change in T. T did shorten from 67.1 +/- 5.0 ms in isovolumic beats to 45.8 +/- 2.9 ms in the ejecting beats (P less than 0.001, n = 14). In the ejecting beats, peak systolic pressure was lower, and end-systolic volume smaller. To differentiate the effects of systolic shortening during ejection from those of lower systolic pressure and smaller end-systolic volume, beats with large end-diastolic volumes were compared to beats with smaller end-diastolic volumes. The beats with smaller end-diastolic volumes exhibited less shortening but similar end-systolic volumes and peak systolic pressure. T again shortened to a greater extent in the beats with greater systolic shortening. Calcium chloride and acetylstrophanthidin resulted in no significant change in T, but norepinephrine, which accelerates active relaxation, resulted in a significant shortening of T (65.6 +/- 13.4 vs. 46.3 +/- 7.0 ms, P less than 0.02). During recovery from ischemia, T increased significantly from 59.3 +/- 9.6 to 76.8 +/- 13.1 ms when compared with the preischemic control beat (P less than 0.05). Thus, the present studies show that the time-course of isovolumic pressure fall subsequent to maximum negative dP/dt is exponential, independent of systolic stress and end-systolic fiber length, and minimally dependent on heart rate. T may be an index of the activity of the active cardiac relaxing system and appears dependent on systolic fiber shortening.

Differentiation of constrictive pericarditis from restrictive cardiomyopathy: assessment of left ventricular diastolic velocities in longitudinal axis by Doppler Tissue Imaging

Article

Full-text available

Feb 1996
J AM COLL CARDIOL

We sought to determine the utility of left ventricular expansion velocities in differentiating constrictive pericarditis from restrictive cardiomyopathy. Several studies have shown that left ventricular diastolic expansion is influenced by the elastic recoil forces of the myocardium. These forces are affected by intrinsic myocardial disease but should be preserved when diastole is impaired as a result of extrinsic causes. Using Doppler tissue imaging, we measured peak early velocity of longitudinal axis expansion (Ea) in 8 patients with constrictive pericarditis, 7 patients with restriction and 15 normal volunteers. Transmitral early (E) and late (A) Doppler flow velocities, left ventricular systolic and diastolic volumes, ejection fraction and mitral annular M-mode displacement were also compared between the groups. The Ea value was significantly higher in normal subjects (14.5 +/- 4.7 cm/s [mean +/- SD]) and in patients with constriction (14.8 +/- 4.8 cm/s) than in those with restriction (5.1 +/- 1.4 cm/s, p < 0.001 constriction vs. restriction). There was weak correlation between Ea and the extent of annular displacement (r = 0.55, p = 0.004) and the E/A ratio (r = 0.44, p = 0.03). There was no correlation between Ea and E (r = 0.33, p = 0.07) or ejection fraction (r = 0.21, p = 0.26). By multivariate analysis, Ea was the best variable for differentiating constriction from restriction. Our study indicates that longitudinal axis expansion velocities are markedly reduced in patients with restrictive cardiomyopathy. The poor correlation found with transvalvular flow velocities suggests that Ea may be relatively preload independent. The measurement of longitudinal axis expansion velocities provides a clinically useful distinction between constrictive pericarditis and restrictive cardiomyopathy and may prove to be valuable in the study of diastolic function.

Normal physiology of the cardiovascular system

Article

Schlant R.C.

Age and Gender Differences in Left Ventricular Function among Patients with Stable Angina and a Matched Control Group

Article

Jul 1996
CARDIOLOGY

To assess left ventricular systolic and diastolic function, M-mode (n = 675) and transmitral Doppler echocardiography (n = 358) were performed in patients with stable angina pectoris and compared with 50 matched healthy controls. Left ventricular fractional shortening (FS) was significantly lower in male than in female patients (32 ± 7 vs. 35 ± 7&percnt;, p < 0.001). A history of heart failure was as frequent in men (6&percnt;) as in women (6&percnt;), but left ventricular systolic dysfunction was more frequent in men than in women (25 vs. 12&percnt;, p < 0.005). The ratio of early/late diastolic peak flow velocity (E/A ratio) was significantly lower, indicating diastolic dysfunction, in female patients with clinical heart failure than in those without (0.79 ± 0.25 vs. 1.02 ± 0.3, p < 0.05). No such difference was found in male patients. Inverse relationships were found between age and E/A ratio in both controls (r = -0.45, p < 0.001) and angina patients (r = -0.44, p < 0.001). Thus, despite similar frequency of clinical heart failure, left ventricular systolic dysfunction was more common in men than in women with stable angina.Copyright © 1996 S. Karger AG, Basel

Determination of Left Ventricular Filling Pressure by Doppler Echocardiography in Patients With Coronary Artery Disease: Critical Role of Left Ventricular Systolic Function

Article

Jan 1998
J AM COLL CARDIOL

Objectives: This study was designed to determine the usefulness of transthoracic Doppler measurements in detecting increased left ventricular (LV) end-diastolic pressure in patients with coronary artery disease, specifically examining the influence of systolic function on the accuracy of these methods. Background: Studies that have correlated Doppler indexes with LV filling pressures primarily involved patients with LV systolic dysfunction. The reliability of Doppler indexes in estimating filling pressures in patients with coronary artery disease and preserved systolic function is unclear. Methods: Pulsed wave Doppler transmitral and pulmonary venous flow velocity curves and LV pressure were recorded in 83 patients with coronary artery disease. Results: Conventional Doppler indexes (deceleration time of mitral E wave velocity, ratio of peak mitral E to A wave velocities and pulmonary venous systolic fraction) correlated with LV filling pressure in patients with an ejection fraction (EF) < or = 50% but not in those with an EF > 50%. Previously published regression analysis for prediction of LV filling pressure was accurate in patients with an EF < or = 50% but not in those with an EF > 50%. The difference between flow duration with atrial contraction in the pulmonary veins and transmitral flow duration with atrial contraction correlated with LV filling pressure in both groups. Conclusions: Analysis of the early diastolic portion of the transmitral or pulmonary venous flow velocity curves can be used to predict LV filling pressures in patients with systolic dysfunction, but are inaccurate in patients with preserved systolic function. The combined analysis of both flow velocity curves at atrial contraction is a reliable, feasible predictor of increased LV filling pressure, irrespective of systolic function.

Estimation of left ventricular filling pressures using two-dimensional and Doppler echocardiography in adult patients with cardiac disease

Article

Dec 1993

Objectives. The purpose of this study was to determine whether left atrial size and ejection fraction are related to left ventricular filling pressures in patients with coronary artery disease.Background. In patients with coronary artery disease, left ventricular filling pressures can be estimated by using Doppler mitral and pulmonary venous flow velocity variables. However, because these flow velocities are age dependent, additional variables that indicate elevated left ventricular filling pressures are needed to increase diagnostic accuracy.Methods. Echocardiographic left atrial and Doppler mitral and pulmonary venous flow velocity variables were correlated with left ventricular filling pressures in 70 patients undergoing cardiac catheterization.Results. Left atrial sin and volumes were larger and left atrial ejection fractions were lower in patients with elevated left ventricular filling pressures. Mean pulmonary wedge pressure was related to mitral E/A wave velocity ratio (r = 0.72), left atrial minimal volume (r = 0.70), left atrial ejection fraction (r = −0.66) and atrial filling fraction (r = −0.66). Left ventricular end-diastolic and A wave pressures were related to the difierence in pulmonary venous and mitral A wave duration (both r = 0.77). By stepwise multilinear regression analysis, the ratio of mitral E to A wave velocity was the most important determinant of pulmonary wedge (r = 0.63) and left ventricular pre-A wave (r = 0.75) pressures, whereas the difference in pulmonary venous and mitral A wave duration was the most important variable for both left ventricular A wave (r = 0.75) and left ventricular end-diastolic (r = 0.80) pressures. The sensitivity of a left atrial minimal volume >40 cm3 for identifying a mean pulmonary wedge pressure >12 mm Hg was 82%, with a specificity of 98%.Conclusions. Left atrial size, left atrial ejection fraction and the difference between mitral and pulmonary venous flow duration at atrial contraction are independent determinants of left ventricular filling pressures in patients with coronary artery disease. The additive value of left atrial size and Doppler variables in estimating filling pressures and the possibility that left atrial size may be less age dependent than other mitral and pulmonary venous flow velocity variables merit further investigation.

Assessment of Mitral Annulus Velocity by Doppler Tissue Imaging in the Evaluation of Left Ventricular Diastolic Function

Article

Aug 1997
J AM COLL CARDIOL

Objectives: This study assessed the clinical utility of mitral annulus velocity in the evaluation of left ventricular diastolic function. Background: Mitral inflow velocity recorded by Doppler echocardiography has been widely used to evaluate left ventricular diastolic function but is affected by other factors. The mitral annulus velocity profile during diastole may provide additional information about left ventricular diastolic function. Methods: Mitral annulus velocity during diastole was measured by Doppler tissue imaging (DTI) 1) in 59 normal volunteers (group 1); 2) in 20 patients with a relaxation abnormality as assessed by Doppler mitral inflow variables (group 2) at baseline and after saline loading; 3) in 11 patients (group 3) with normal diastolic function before and after intravenous nitroglycerin infusion; and 4) in 38 consecutive patients (group 4) undergoing cardiac catheterization in whom mitral inflow velocity and tau as well as mitral annulus velocity were measured simultaneously. Results: In group 1, mean +/- SD peak early and late diastolic mitral annulus velocity was 10.0 +/- 1.3 and 9.5 +/- 1.5 cm/s, respectively. In group 2, mitral inflow velocity profile changed toward the pseudonormalization pattern with saline loading (deceleration time 311 +/- 84 ms before to 216 +/- 40 ms after intervention, p < 0.001), whereas peak early diastolic mitral annulus velocity did not change significantly (5.3 +/- 1.2 cm/s to 5.7 +/- 1.4 cm/s, p = NS). In group 3, despite a significant change in mitral inflow velocity profile after nitroglycerin, peak early diastolic mitral annulus velocity did not change significantly (9.5 +/- 2.2 cm/s to 9.2 +/- 1.7 cm/s, p = NS). In group 4, peak early diastolic mitral annulus velocity (r = -0.56, p < 0.01) and the early/late ratio (r = -0.46, p < 0.01) correlated with tau. When the combination of normal mitral inflow variables with prolonged tau (> or = 50 ms) was classified as pseudonormalization, peak early diastolic mitral annulus velocity < 8.5 cm/s and the early/late ratio < 1 could identify the pseudonormalization with a sensitivity of 88% and specificity of 67%. Conclusions: Mitral annulus velocity determined by DTI is a relatively preload-independent variable in evaluating diastolic function.

Left ventricular Volume from paired biplane two-dimensional echocardiography

Article

Oct 1979

To evaluate the applicability of two-dimensional echocardiography to left ventricular volume determination, 30 consecutive patients undergoing biplane left ventricular cineangiography were studied with a wide-angle (84 degrees), phased-array, two-dimensional echocardiographic system. Two echographic projections were used to obtain paired, biplane, tomographic images of the left ventricle. We used the short-axis view (from the precordial window) as an anolog of the left anterior oblique angiogram, and the long-axis, two-chamber view (from the apex impulse window) as a right anterior oblique angiographic equivalent. A modified Simpson's rule formula was used to calculate systolic and diastolic left ventricular volumes from the biplane echogram and the biplane angiogram. These methods correlated well for ejection fraction (r = 0.87) and systolic volume (r = 0.90), but only modestly for diastolic volume (r = 0.80). These correlations are noteworthy because 65% of the patients had significant segmental wall motion abnormalities. The volumes determined from the minor-axis dimensions of M-mode echograms in 23 of the same patients correlated poorly with angiography.

Doppler echocardiographic patterns of left ventricular in patients after acute myocardial infarction

Article

Oct 1992
AM J CARDIOL

Diastolic function is routinely assessed using Doppler-derived left ventricular (LV) filling patterns. Ratios between peak flow velocities during early filling and atrial contraction (E/A) of less than 1 are considered pathologic and diagnostic of impaired relaxation. Myocardial stiffness can normalize the E/A ratio, and thus, in some clinical settings, a normal E/A ratio may identify patients with high filling pressures. LV filling patterns were studied with Doppler echocardiography in 15 healthy subjects and 38 patients with recent acute myocardial infarction. The results were correlated with clinical and hemodynamic variables. E/A ratio less than 1 was found in 14 patients (37%) and in only 1 control subject; E/A ratio greater than 2 found in 5 patients (13%) and in only 1 control subject; 19 patients (50%) had an apparently normal E/A ratio. No correlation was found between LV filling pattern and ejection fraction or presence of diabetes or arterial hypertension. LV end-diastolic pressures were low to normal in patients with an E/A ratio less than 1 and were usually greater than 15 mm Hg in those with normal or abnormally increased (greater than 2) E/A ratios. Thus, an apparently normal E/A ratio in patients after myocardial infarction may identify those with more severe LV diastolic dysfunction and increased LV filling pressure.

Use of Valsalva maneuver to unmask LV diastolic function abnormalities by Doppler echocardiography in patients with coronary artery disease or systemic hypertension

Article

Sep 1991
AM J CARDIOL

It has been suggested that changes in left atrial pressure may mask or mimic left ventricular diastolic function abnormalities detected by Doppler echocardiography. The effect of the Valsalva maneuver on the transmitral flow velocity profile was therefore studied in 28 patients without evidence of coronary artery disease (group 1, mean age +/- standard deviation 50 +/- 8 years) and in 94 patients with evidence of coronary artery disease or systemic hypertension (group 2, mean age 54 +/- 10 years). At baseline, group 2 patients had higher peak late diastolic filling velocity (A), lower peak early (E) to late diastolic filling velocity (E/A) ratio and longer isovolumic relaxation time than group 1, whereas heart rate, E velocity and E deceleration time were similar in both groups. During Valsalva, both groups had similar increases in heart rate and similar decreases in E velocity but E/A ratio decreased significantly only in group 2 because of a lesser decrease in A velocity. The E/A ratio was greater than or equal to 1.0 both before and during Valsalva in all but 1 patient in group 1, whereas in group 2, 32 patients had E/A greater than or equal to 1.0 at rest and during Valsalva, 33 patients had E/A greater than or equal to 1.0 at rest but less than 1.0 both at rest and during Valsalva. Using group 1 as controls, prevalence, specificity and positive predictive value of E/A less than 1.0 in group 2 were 31, 100 and 100% at rest and 66, 96 and 98% during Valsalva.(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary venous flow patterns by transesophageal pulsed Doppler echocardiography: Relation to parameters of left ventricular systolic and diastolic function

Article

Jan 1992
AM HEART J

We have previously shown that the systolic and diastolic pulmonary venous flow (PVF) distribution is predictive of left atrial pressure. This study was designed to define the confounding influences of left atrial expansion, descent of the mitral anulus, and left ventricular contractile function on that relationship; to define normal PVF patterns; and to document the interaction of PVF with mitral inflow. Therefore we studied 27 consecutive intraoperative patients with coronary artery disease (22 men and 5 women, ages 35 to 78 years) using transesophageal echocardiography. A group of 12 normal subjects served as a control. Doppler and two-dimensional echocardiographic parameters were obtained simultaneously with monitoring pulmonary capillary wedge pressure (PCWP). We found that neither left atrial expansion nor the descent of the mitral anulus influenced the relationship between PVF and PCWP, but that left ventricular fractional shortening confounded this relationship. In normal subjects PVF was dominant in systole, whereas PVF in patients with elevated PCWP was dominant in diastole (systolic fraction of 68 +/- 6% [SD] in normals versus 42 +/- 15% in patients with PCWP greater than or equal to 15 mm Hg). PVF velocities interacted with transmitral flow velocities. Peak early diastolic mitral inflow velocities increased linearly with peak early diastolic PVF velocities (r = 0.62). We conclude that systolic and diastolic PVF distribution is mainly determined by the level of PCWP and to a lesser extent by left ventricular contraction, but not by left atrial expansion or by mitral anulus descent. Transesophageal pulsed Doppler echocardiography of PVF provides useful clinical information about the level of PCWP in intraoperative patients with coronary artery disease.

Relation of pulmonary vein to mitral flow velocities by transesophageal Doppler echocardiography. Effect of different loading conditions

Article

Jun 1990

It has previously been demonstrated that predictable changes occur in mitral flow velocities under different loading conditions. The purpose of this study was to relate changes in pulmonary venous and mitral flow velocities during different loading conditions as assessed by transesophageal echocardiography in the operating room. Nineteen patients had measurements of hemodynamics, that is, mitral and pulmonary vein flow velocities during the control situation, a decrease in preload by administration of nitroglycerin, an increase in preload by administration of fluids, and an increase in afterload by infusion of phenylephrine. There was a direct correlation between the changes in the mitral E velocity and the early peak diastolic velocity in the pulmonary vein curves (r = 0.61) as well as a direct correlation between the deceleration time of the mitral and pulmonary venous flow velocities in early diastole (r = 0.84). This indicates that diastolic flow velocity in the pulmonary vein is determined by the same factors that influence the mitral flow velocity curves. A decrease in preload caused a significant reduction in the initial E velocity and prolongation of deceleration time, and an increase in preload caused an increase in E velocity and shortening of deceleration time. An increase in afterload produced a variable effect on the initial E velocity and deceleration time and was dependent on the left ventricular filling pressure. The change in systolic forward flow velocity in the pulmonary vein was directly proportional to the change in cardiac output (r = 0.60). The pulmonary capillary wedge pressure correlated best with the flow velocity reversal in the pulmonary vein at atrial contraction (r = 0.81). Use of pulmonary vein velocities in conjunction with mitral flow velocities can help in understanding left ventricular filling.

Preload dependence of Doppler-derived indexes of left ventricular diastolic function in humans

Article

Nov 1987
J AM COLL CARDIOL

To determine the effect of filling pressure on the pattern of left ventricular filling in humans, the mitral flow velocity profile was measured by pulsed wave Doppler echocardiography during right and left heart catheterization in 11 patients before and during nitroglycerin infusion. Nitroglycerin reduced mean arterial pressure from 90 +/- 9 to 80 +/- 11 mm Hg (p less than 0.001) and mean pulmonary capillary wedge pressure from 9 +/- 4 to 4 +/- 2 mm Hg (p less than 0.001). Cardiac output fell from 6.6 +/- 1.5 to 5.5 +/- 1.4 liters/min (p less than 0.001) and heart rate increased from 60 +/- 13 to 65 +/- 14 beats/min (p less than 0.002). The time constant of isovolumic relaxation (TI.) decreased from 51 +/- 9 to 46 +/- 8 ms (p less than 0.01), indicating faster left ventricular relaxation. Nitroglycerin altered the Doppler characteristics of the early filling (E) wave but not those of the atrial contraction (A) wave. Peak velocity of the E wave decreased from 56 +/- 14 to 44 +/- 9 cm/s (p less than 0.001), peak velocity of the A wave did not change and the ratio of peak velocities of the E and A waves decreased from 0.97 +/- 0.33 to 0.77 +/- 0.20 (p less than 0.02). The deceleration of the E wave decreased from 289 +/- 138 to 186 +/- 71 cm/s2 (p less than 0.02). The ratio of velocity-time integral of the A wave to total velocity-time integral (that is, contribution of atrial contraction to total filling) increased from 0.31 +/- 0.09 to 0.36 +/- 0.08 (p less than 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)

Pulmonary venous flow pattern. Its relationship to cardiac dynamics. A pulsed Doppler echocardiographic study

Article

Jul 1985

We studied the physiology of pulmonary venous flow in 13 normal subjects and five patients with atrial rhythm disorders and atrioventricular conduction disturbances with pulsed Doppler and two-dimensional echocardiography. The left atrium, mitral valve, and pulmonary venous ostia were visualized through the apical four-chamber view. Mitral and pulmonary venous flows were obtained by placing the Doppler sample volume at the appropriate orifice. Pulmonary venous flow was biphasic: a rapid filling wave was observed during systole when the mitral valve was closed; a second wave was observed in diastole during the rapid ventricular filling phase of mitral flow, but was significantly delayed. In patients without atrial contraction (atrial fibrillation and sinoatrial standstill), the initial rapid filling was greatly diminished and only the second diastolic wave appeared to contribute to left atrial filling. In patients with high-grade atrioventricular block, each atrial contraction was followed by a surge in flow from the pulmonary veins. These results are consistent with data obtained from invasive measurements in both dogs and man, and confirm the validity of the use of pulsed Doppler echocardiography in the study of pulmonary venous flow. We suggest that pulmonary venous flow is influenced by dynamic changes in left atrial pressure created by contraction and relaxation of the atrium and ventricle. The initial peak in pulmonary venous flow occurs with atrial relaxation simultaneously with the reduction of left atrial pressure, and the second peak occurs with left ventricular relaxation and rapid transmitral filling of the ventricle.

A new color M-mode index of diastolic filling compared with radionuclide ventriculography

Article

Feb 1995
INT J CARDIOL

We correlated the new diastolic index 'delay of apical peak velocity', as measured by colour M-mode Doppler, with radionuclide ventriculographic indices of ventricular function. Thirty-seven patients with coronary artery disease participated in the prospective and blinded study, which included repeated acquisitions to determine the effect of realigning the Doppler sample beam. In multiple regression, neither peak filling rate, left ventricular phase histogram width nor ejection fraction were statistically significantly related to delay of apical peak velocity. The standard deviation of the differences between duplicate colour M-mode acquisitions corresponded to half the reference range of the index. We conclude that in this blinded investigation, the new Doppler index did not provide information about ventricular function equivalent to radionuclide ventriculography. The index may be significantly influenced by sample beam position.

Systolic and diastolic dysfunction in patients with clinical diagnosis of dilated cardiomyopathy. Relation to symptoms and prognosis

Article

Dec 1994

Dilated cardiomyopathy is an important cause of morbidity and mortality among patients with congestive heart failure. Hemodynamic and prognostic characterization are critical in guiding selection of medical and surgical therapies. A cohort of 102 patients with the clinical diagnosis of dilated cardiomyopathy who underwent echocardiographic examination between 1986 and 1990 was identified and followed up through July 1, 1991. Patients with moderate or severe symptoms had lower indices of systolic function and greater left atrial and right ventricular dilation. Mitral inflow Doppler signals were characterized by a restrictive left ventricular filling pattern. In multivariate logistic regression analysis, deceleration time, ejection fraction, and peak E velocity were independently associated with symptom status. Over a mean follow-up of 36 months, 35 patients died. Kaplan-Meier estimated survival at 1, 2, and 4 years was 84%, 73%, and 61%, respectively, and was significantly poorer than that of an age- and sex-matched population. The subgroup with an ejection fraction < 0.25 and deceleration time < 130 milliseconds had a 2-year survival of only 35%. The subgroup with ejection fraction < 0.25 and deceleration time > 130 milliseconds had an intermediate 2-year survival of 72%, whereas patients with an ejection fraction > or = 0.25 had 2-year survivals > or = 95% regardless of deceleration time. In multivariate analysis, ejection fraction and systolic blood pressure were independently predictive of subsequent mortality. Mitral deceleration time was significant in univariate analysis. In patients with the clinical diagnosis of dilated cardiomyopathy, markers of diastolic dysfunction correlated strongly with congestive symptoms, whereas variables of systolic function were the strongest predictors of survival. Consideration of both ejection fraction and deceleration time allowed identification of subgroups with divergent long-term prognoses.

Estimation of left ventricular diastolic pressures from precordial pulsed-Doppler analysis of pulmonary venous and mitral flow

Article

Sep 1994
AM HEART J

Because analysis of pulmonary venous flow (PVF) will be extensively used in comprehensive Doppler assessment of left ventricular diastolic function, this study was designed to (1) evaluate the feasibility of PVF measurement in 116 consecutive patients with various cardiac abnormalities by using precordial pulsed Doppler echocardiography; (2) Estimate mean pulmonary capillary pressure (MPCP) and left ventricular end-diastolic pressure (LVEDP) from Doppler variables of PVF and mitral inflow; and (3) evaluate the influence of clinical and hemodynamic variables on PVF Doppler patterns. We adequately recorded anterograde PVF in 96 (82.7%) patients and retrograde PVF in 45 (38.7%) patients. The strongest correlation between MPCP and Doppler variables of PVF was found with systolic fraction (the systolic velocity time integral expressed as a fraction of total anterograde PVF) (r = -0.88; p < 0.001). Age influenced this relation, with progressive increase of the systolic fraction in older patients. A good correlation (r = 0.72; p < 0.001) was found between LVEDP and the difference in duration of the reversal PVF and the mitral a wave. In conclusion, (1) PVF can be recorded adequately in most patients with precordial Doppler echocardiography; (2) left ventricular diastolic pressures can be estimated reliably by precordial Doppler echocardiography; and (3) the clinical meaning of Doppler-derived indexes of left ventricular diastolic performance is age-related.

Doppler-derived mitral deceleration time of early filling as a strong predictor of pulmonary capillary wedge pressure in postinfarction patients with left ventricular systolic dysfunction

Article

Jul 1994
J AM COLL CARDIOL

The aim of this study was to investigate the correlations between Doppler-derived transmitral flow velocity variables and pulmonary capillary wedge pressure in patients with severe left ventricular systolic dysfunction. Abnormal relaxation and increased chamber stiffness have opposing effects on the left ventricular filling pattern. When both abnormalities are present at the same time, as often occurs in patients with systolic dysfunction, the ability of Doppler recording to assess diastolic function and predict left ventricular filling pressure may be significantly compromised. Pulmonary capillary wedge pressure and Doppler transmitral flow velocity profile were simultaneously recorded in 140 postinfarction patients with ejection fraction < or = 35%. Correlation between the ratio of mitral peak flow velocity in early diastole to peak flow velocity in late diastole (E/A ratio) and pulmonary capillary wedge pressure was weak (r = 0.65). Although the specificity of E/A > or = 2 in predicting > or = 20 mm Hg in pulmonary capillary wedge pressure was high (99%), its sensitivity was low (43%). Conversely, a very close negative correlation was found between mitral deceleration time of early filling and pulmonary capillary wedge pressure (r = -0.90). Sensitivity and specificity of < or = 120 ms in deceleration time in predicting > or = 20 mm Hg in pulmonary capillary wedge pressure were 100% and 99%, respectively. Doppler-derived mitral deceleration time of early filling provides a simple and accurate means of estimating pulmonary capillary wedge pressure that is particularly useful in patients with a normal or normalized mitral flow velocity pattern.

Estimation of left ventricular filling pressures using two-dimensional and Doppler echocardiography in adult patients with cardiac disease. Additional value of analyzing left atrial size, left atrial ejection fraction and the difference in duration of pulmonary venous and mitral flow velocity at atrial contraction

Article

Jan 1994
J AM COLL CARDIOL

The purpose of this study was to determine whether left atrial size and ejection fraction are related to left ventricular filling pressures in patients with coronary artery disease. In patients with coronary artery disease, left ventricular filling pressures can be estimated by using Doppler mitral and pulmonary venous flow velocity variables. However, because these flow velocities are age dependent, additional variables that indicate elevated left ventricular filling pressures are needed to increase diagnostic accuracy. Echocardiographic left atrial and Doppler mitral and pulmonary venous flow velocity variables were correlated with left ventricular filling pressures in 70 patients undergoing cardiac catheterization. Left atrial size and volumes were larger and left atrial ejection fractions were lower in patients with elevated left ventricular filling pressures. Mean pulmonary wedge pressure was related to mitral E/A wave velocity ratio (r = 0.72), left atrial minimal volume (r = 0.70), left atrial ejection fraction (r = -0.66) and atrial filling fraction (r = -0.66). Left ventricular end-diastolic and A wave pressures were related to the difference in pulmonary venous and mitral A wave duration (both r = 0.77). By stepwise multilinear regression analysis, the ratio of mitral E to A wave velocity was the most important determinant of pulmonary wedge (r = 0.63) and left ventricular pre-A wave (r = 0.75) pressures, whereas the difference in pulmonary venous and mitral A wave duration was the most important variable for both left ventricular A wave (r = 0.75) and left ventricular end-diastolic (r = 0.80) pressures. The sensitivity of a left atrial minimal volume > 40 cm3 for identifying a mean pulmonary wedge pressure > 12 mm Hg was 82%, with a specificity of 98%. Left atrial size, left atrial ejection fraction and the difference between mitral and pulmonary venous flow duration at atrial contraction are independent determinants of left ventricular filling pressures in patients with coronary artery disease. The additive value of left atrial size and Doppler variables in estimating filling pressures and the possibility that left atrial size may be less age dependent than other mitral and pulmonary venous flow velocity variables merit further investigation.

Noninvasive measurement of rate of left ventricular relaxation by Doppler Echocardiography. Validation with simultaneous cardiac catheterization

Article

Aug 1993

The instantaneous pressure gradient between the left ventricle and left atrium during systole can be calculated from the mitral regurgitation Doppler velocity curve. The purpose of our study was to determine the accuracy of measuring the time constant of relaxation (TAU) derived from the Doppler mitral regurgitation signal by comparing it with simultaneous high-fidelity left ventricular pressure measurements in humans. Twenty-five patients had continuous-wave Doppler mitral regurgitation recordings performed with simultaneous high-fidelity left ventricular pressure measurements. Fifteen of these patients had measurements of six to eight beats at various RR intervals. Doppler velocity curves were converted to left ventricular pressure curves by different methods through application of the modified Bernoulli equation at 3-msec intervals. The correlation between catheter-derived and Doppler-derived TAU was best when a zero asymptote and knowledge of the left ventricular end-diastolic pressure were used. A less optimal but acceptable method used the addition of 20 mm Hg to the Doppler-derived ventriculoatrial gradient. Use of a nonzero asymptote for calculation of TAU yielded poor correlation between catheter and Doppler measurements. The correlation of percentage change in Doppler-derived TAU plotted against percentage change in catheter-derived TAU was poor. The descending limb of the Doppler-derived mitral regurgitation velocity signal can be used as a semiquantitative estimate of the rate of ventricular relaxation. This method requires knowledge of left atrial pressure and may not be sufficiently accurate for detecting small changes in the rate of relaxation on a beat-to-beat basis.

Pulmonary venous flow velocities recorded by transthoracic Doppler ultrasound: Relation to left ventricular diastolic pressures

Article

Jun 1993
J AM COLL CARDIOL

This study was conducted to investigate whether pulmonary venous flow variables measured by transthoracic Doppler ultrasound can help identify patients with elevated left ventricular end-diastolic or filling pressures, or both. A widened left atrial pressure A wave occurs when left ventricular end-diastolic pressure is increased. Increased duration of pulmonary venous flow reversal at atrial systole might therefore be a marker for elevated end-diastolic pressure. Decreased systolic pulmonary venous flow is shown to be related to increased left ventricular filling pressure in studies using transesophageal Doppler echocardiography. Left ventricular pressures at late diastole were measured by fluid-filled catheters in 50 consecutive patients undergoing diagnostic cardiac catheterization. Pulmonary venous and mitral flow velocities were recorded by transthoracic pulsed Doppler ultrasound. Adequate recordings were obtained in 45 patients. Pulmonary venous flow reversal exceeding the duration of the mitral A wave predicted left ventricular end-diastolic pressure > 15 mm Hg with a sensitivity of 0.85 and a specificity of 0.79. This difference in flow duration correlated well with the increase in ventricular pressure (r = 0.70, p < 0.001) at atrial systole and the end-diastolic pressure (r = 0.68, p < 0.001). The systolic fraction of pulmonary venous flow was markedly decreased (< 0.4) in all patients with a pre-A pressure (left ventricular pressure before atrial systole) > 18 mm Hg. Pulmonary venous flow reversal exceeding the duration of the mitral A wave indicates an exaggerated increase in left ventricular late diastolic pressure. Pulmonary venous systolic fraction < 0.4 suggests markedly increased ventricular filling pressure.

Mitral annular descent velocity by tissue Doppler echocardiography as index of global left ventricular function

Article

May 1996
AM J CARDIOL

Mitral annular descent has been described as an index of left ventricular (LV) systolic function, which is independent of endocardial definition. Echocardiographic tissue Doppler imaging is a new technique that calculates and displays color-coded cardiac tissue velocities on-line. To evaluate mitral annular descent velocity as a rapid index of global LV function, we performed tissue Doppler imaging studies in 55 patients, aged 56 +/-15 years, within 3 hours of radionuclide ventriculographic ejection fraction. Tissue Doppler M-mode studies were obtained from each of 6 mitral annular sites, as follows: inferoseptal and lateral from apical 4-chamber views, anterior and inferior from apical 2-chamber views, and anteroseptal and posterior from apical long-axis views. Only 1 patient with severe mitral annular calcification was excluded. The group mean 6-site average peak mitral annular descent velocity was 5.5 +/- 1.9 cm/s (range 2.4 to 10.5), and the group mean ejection fraction was 49 +/- 18% (range 17 to 80%). The 6-site average peak annular descent velocity correlated linearly with LV ejection fraction (r = 0.86, SEE = 1.02 cm/s): LV ejection fraction = 8.2 (average peak mitral annular descent velocity) + 3%. The 6-site peak mitral annular descent velocity average >5.4 cm/s was 88% sensitive and 97% specific for ejection fraction >50%. The peak mitral annular descent velocity from the apical 4-chamber view (average from inferoseptal and lateral sites) correlated most closely with the LV ejection fraction (r = 0.85) as an individual view. Peak mitral annular descent velocity by tissue Doppler imaging has the potential to estimate rapidly the global LV function.

Assessment of mean left atrial pressure from the left ventricular pressure tracing in patients with cardiomyopathies

Article

Aug 1996
AM J CARDIOL

The direct measurement of mean left atrial pressure is difficult and the ability to assess mean left atrial pressure from the left ventricular (LV) pressure tracing obtained at cardiac catheterization is clinically useful. The current study describes the limitations of using LV pre-a-wave pressure or LV end-diastolic pressure to estimate mean left atrial pressure and describe another index, mean LV diastolic pressure, which provides a better assessment of mean left atrial pressure.

Age and gender differences in left ventricular function among patients with stable angina and a matched control group. A report from the Angina Prognosis Study in Stockholm

Article

Jun 1996

To assess left ventricular systolic and diastolic function, M-mode (n = 675) and transmitral Doppler echocardiography (n = 358) were performed in patients with stable angina pectoris and compared with 50 matched healthy controls. Left ventricular fractional shortening (FS) was significantly lower in male than in female patients (32 +/- 7 vs. 35 +/- 7%, p < 0.001). A history of heart failure was as frequent in men (6%) as in women (6%), but left ventricular systolic dysfunction was more frequent in men than in women (25 vs. 12%, p < 0.005). The ratio of early/late diastolic peak flow velocity (E/A ratio) was significantly lower, indicating diastolic dysfunction, in female patients with clinical heart failure than in those without (0.79 +/- 0.25 vs. 1.02 +/- 0.3, p < 0.05). No such difference was found in male patients. Inverse relationships were found between age and E/A ratio in both controls (r = -0.45, p < 0.001) and angina patients (r = -0.44, p < 0.001). Thus, despite similar frequency of clinical heart failure, left ventricular systolic dysfunction was more common in men than in women with stable angina.

Myocardial wall velocity assessment by pulsed Doppler tissue imaging: Characteristic findings in normal subjects

Article

Oct 1996
AM HEART J

To validate the use of pulsed Doppler tissue imaging that measures myocardial wall velocities and to define the characteristics of these velocities in normal subjects, we obtained and compared the anteroseptal and posterior wall velocities in 24 volunteers with pulsed Doppler tissue imaging and digitized M-mode echocardiography. We also studied the relation between velocity components and hemodynamic events timed by standard Doppler flows. There was an excellent correlation between Doppler and M-mode-derived velocities (r = 0.95, p < 0.001), with higher reproducibility for Doppler (r = 0.99) than for M-mode (r = 0.95, p < 0.001). Biphasic velocities that were uniformly present during isovolumic contraction and relaxation were attributed to geometric changes due to asynchronous contraction and ventricular interdependence. We conclude that wall velocities obtained by pulsed Doppler tissue imaging are accurate and reproducible. This method may prove useful for studying the contractile and elastic properties of the myocardium.

Noninvasive Doppler echocardiographic evaluation of left ventricular filling pressures in patients with cardiomyopathies: A simultaneous Doppler echocardiographic and cardiac catherization study

Article

Dec 1996
J AM COLL CARDIOL

The purpose of this study was to examine the relation of the mitral flow velocity curves to left ventricular filling pressures in patients with two different types of myocardial problems: hypertrophic cardiomyopathy and severe left ventricular systolic dysfunction. Previous studies have suggested that assessment of Doppler-derived mitral flow velocity curves can be used to predict left ventricular filling pressures in specific disease entities. However, it is unclear whether information derived from specific mitral flow velocity curves obtained from one disease entity can be valid in other disease states. The study group consisted of 42 patients with left ventricular systolic dysfunction (group A) and 55 patients with hypertrophic cardiomyopathy (group B); both groups underwent simultaneous cardiac catheterization and were studied by Doppler echocardiography. High fidelity measures of left atrial and left ventricular pressures were obtained simultaneously with mitral flow velocity curves. There was a significant relation between the Doppler echocardiographic variables and mean left atrial pressure in group A patients. The left atrial pressure was directly related to the E/A ratio (r = 0.49, p = 0.004) and inversely related to the deceleration time (r = 0.73, p < 0.001). The sensitivity and specificity of the deceleration time, < 180 m/s, which indicated a mean left atrial pressure > or = 20 mm Hg, were both 100%. In group B patients, there was no significant relation between mean left atrial pressure and deceleration time. Doppler echocardiographic mitral flow velocity curves are useful in predicting and estimating left ventricular filling pressures in patients with left ventricular dysfunction. However, because of the complexity of the multiple interrelated factors that determine diastolic filling of the left ventricle, these flow velocity curves cannot be used in patients with other disease entities, such as hypertrophic cardiomyopathy. Future studies of different disease states are necessary to fully understand the role of Doppler echocardiography in the assessment of diastolic filling.

Quantitative Doppler tissue imaging as a correlate of left ventricular contractility

Article

Oct 1996

David S. Bach

Doppler tissue imaging is a new noninvasive imaging modality that allows quantitation of the low intensity, high amplitude Doppler shifts in the range of myocardial tissue motion. This study was performed to test the hypothesis that Doppler tissue imaging may provide unique information reflecting left ventricular systolic function, and to test the relationship between myocardial tissue velocity and noninvasive measures of ventricular contractility. Nine patients with mild or moderate mitral insufficiency and no regional wall motion abnormality were studied during dobutamine stress echocardiography. Left ventricular ejection fraction and peak systolic velocity of the sub-endocardial left ventricular posterior wall were quantified at baseline and at peak stress and compared with estimated peak dP/dt. During dobutamine infusion, ejection fraction increased from 41.7 +/- 22.2 (range 14 to 70) % to 56.6 +/- 27.9 (range 17 to 84)% (p = 0.001), peak systolic velocity increased from 22.7 +/- 4.2 (range 18 to 28) mm/sec to 35.3 +/- 10.1 (range 20 to 47) mm/sec (p = 0.004), and dP/dt increased from 1050 +/- 322 (range 613 to 1574) mm Hg/sec to 1766 +/- 768 (range 936 to 3000) mm Hg/sec (p = 0.01). Although there were good correlations between left ventricular dP/dt and both ejection fraction (R = 0.75) and peak systolic velocity (R = 0.81), the correlation between change in dP/dt and change in myocardial velocity (R = 0.75) was better than that between change in dP/dt and change in ejection fraction (R = 0.36). These data support the hypothesis that myocardial velocity determined with Doppler tissue imaging reflects myocardial contractility, and that catecholamine-induced alteration in contractility is better reflected by changes in myocardial velocity than by changes in ejection fraction.

Assessment of left ventricular end-diastolic pressure by Doppler echocardiography: Contribution of duration of pulmonary venous versus mitral flow velocity: Curves at atrial contraction

Article

Feb 1997
J AM SOC ECHOCARDIOG

The difference in the durations of flow with atrial contraction (A duration) at the pulmonary veins and mitral valve has been reported to detect the presence of elevated left ventricular end-diastolic pressure. It is postulated that with left ventricular filling during atrial contraction, reduced ventricular compliance results in the transmission of increased pressure into the left atrium, resulting in prolongation of the pulmonary venous flow with atrial contraction. However, the relationship between ventricular compliance during atrial contraction and the pulmonary venous and mitral A durations and their difference have not been carefully examined. We performed recordings of left ventricular pressure and complete Doppler analysis of pulmonary venous and transmitral flow in 87 patients. Operant ventricular compliance at atrial contraction was estimated by measuring the increase in ventricular pressure with atrial contraction (left ventricular a wave) and by using a compliance index, which incorporated an estimate of flow into the ventricle with atrial contraction from the Doppler transmitral a wave. The difference in pulmonary venous and mitral A durations correlated well with left ventricular end-diastolic pressure (r = 0.73, p < 0.01) and the pulmonary venous reversal duration exceeding the duration of the mitral A velocity curve provided high sensitivity (82%) and specificity (92%) for the detection of an end-diastolic pressure of 20 mm Hg or greater. The pulmonary venous A duration increased with a moderate decrease in ventricular compliance but was not increased further in patients with a severe decrease in compliance. In contrast, mitral A duration was not different in patients with moderate reduction in compliance, but was shorter in patients with severe decreases in ventricular compliance. Pulmonary venous and mitral A durations are related to ventricular compliance and they change in an opposite and progressive manner. Their difference is a sensitive method for the detection of the elevated end-diastolic pressure associated with reduction in ventricular compliance.

Tissue Doppler echocardiography: A new method of evaluating perfusion-dependent myocardial function during PTCA

Article

May 1997

The increasing demand for insight into the relationship between coronary perfusion and myocardial function stimulated the development of tissue Doppler echocardiography. This new technique was applied simultaneously with PTCA of a subtotal LAD lesion (single vessel disease, no collaterals) in a 68-year-old patient suffering from unstable angina pectoris. Prior to the conventional signs of ischaemia a decrease in myocardial tissue velocities and a loss of color-coded heart cycle intervals was observed. A myocardial velocity gradient calculated from the higher subendocardial and lower subepicardial velocity decreased from 3.3 to 1.3. This decrease was prevented by an active autohaemoperfusion device which supplied blood distally to an insufflated balloon (60 ml/min). Thus, contractility and viability might be maintained by preserving myocardial velocity gradients.

The noninvasive assessment of left ventricular diastolic function with two-dimensional and Doppler echocardiography

Article

May 1997
J AM SOC ECHOCARDIOG

Left ventricular diastolic filling can be determined reliably by Doppler-derived mitral and pulmonary venous flow velocities. Diastolic filling abnormalities are broadly classified at their extremes to impaired relaxation and restrictive physiology with many patterns in between. An impaired relaxation pattern identifies patients with early stages of heart disease, and appropriate therapy may avert progression and functional disability. Pseudonormalization is a transitional phase between abnormal relaxation and restrictive physiology and signifies increased filling pressure and decreased compliance. In this phase, reducing preload, optimizing afterload, and treating the underlying disease are clinically helpful. A restrictive physiology pattern identifies advanced, usually symptomatic disease with a poor prognosis. Therapeutic intervention is directed toward normalizing loading conditions and improving the restrictive filling pattern, although this may not be feasible in certain heart diseases. Finally, many patients have left ventricular filling patterns that appear indeterminate or mixed. In these cases, clinical information, left atrial and left ventricular size, pulmonary venous flow velocity, and alteration of preload help assess diastolic function and estimate diastolic filling pressures.

Evaluation of Diastolic Filling of Left Ventricle in Health and Disease: Doppler Echocardiography Is the Clinician’s Rosetta Stone

Article

Aug 1997
J AM COLL CARDIOL

Abnormalities of diastolic function have a major role in producing the signs and symptoms of heart failure. However, diastolic function of the heart is a complex sequence of multiple interrelated events, and it has been difficult to understand, diagnose and treat the various abnormalities of diastolic filling that occur in patients with heart disease. Recently, Doppler echocardiography has been used to examine the different diastolic filling patterns of the left ventricle in health and disease, but confusion about diagnosis and treatment options has arisen because of the misinterpretation of these flow velocity curves. This review presents a simplified approach to understanding the process of diastolic filling of the left ventricle and interpreting the Doppler flow velocity curves as they relate to this process. It has been hypothesized that transmitral flow velocity curves show a progression over time with diseases involving the myocardium. This concept can be applied clinically to estimate left ventricular filling pressures and to predict prognosis in selected groups of patients. Specific therapy for diastolic dysfunction based on Doppler flow velocity curves is discussed.

Utility of Preload Alteration in Assessment of Left Ventricular Filling Pressure by Doppler Echocardiography: A Simultaneous Catheterization and Doppler Echocardiographic Study

Article

Aug 1997
J AM COLL CARDIOL

The aim of this study was to demonstrate the usefulness of preload alterations in assessing left ventricular filling pressures with transmitral Doppler velocity curves. Doppler mitral inflow velocities, used to estimate left ventricular filling pressures noninvasively, are limited in predicting left ventricular filling pressures, especially in patients with normal systolic function and a "pseudonormal" mitral filling pattern. Forty-nine patients were studied in the cardiac catheterization laboratory with simultaneous Doppler echocardiography using high fidelity catheters to compare left ventricular diastolic filling pressures (pre-A wave left ventricular pressure) and Doppler mitral inflow at baseline and during reduction of preload during the strain phase of the Valsalva maneuver (n = 27) or sublingual nitroglycerin (n = 36), or both (n = 14). Doppler measurements consisted of E (initial peak velocity), A (velocity at atrial contraction), deceleration time (time from E velocity to deceleration of flow extrapolated to baseline) and absolute A wave velocity (A' [peak A wave velocity minus velocity at onset of atrial contraction]). In patients with high pre-A wave pressure (> or 15 mm Hg), there was a greater change in the E/A' ratio during the Valsalva maneuver than in patients with a normal pre-A wave pressure (-1.22 +/- 1.1 vs. -0.35 +/- 0.17; p = 0.02). A similar change was seen when comparing the change in the E/A' ratio after administration of nitroglycerin in patients with a high versus a normal pre-A wave pressure (0.81 +/- 0.49 vs. 0.18 +/- 0.17; p < 0.001). These differences were present in patients with a normal E/A ratio at baseline. Alterations in preload during assessment of Doppler echocardiographic indexes may be useful in noninvasively assessing left ventricular filling pressures.

Doppler Tissue Imaging: A Noninvasive Technique for Evaluation of Left Ventricular Relaxation and Estimation of Filling Pressures

Article

Nov 1997
J AM COLL CARDIOL

This investigation was designed 1) to assess whether the early diastolic velocity of the mitral annulus (Ea) obtained with Doppler tissue imaging (DTI) behaves as a preload-independent index of left ventricular (LV) relaxation; and 2) to evaluate the relation of the mitral E/Ea ratio to LV filling pressures. Recent observations suggest that Ea is an index of LV relaxation that is less influenced by LV filling pressures. One hundred twenty-five study subjects were classified into three groups according to mitral E/A ratio, LV ejection fraction (LVEF) and clinical symptoms: 34 asymptomatic subjects with a normal LVEF and an E/A ratio > or =1; 40 with a normal LVEF, an E/A ratio <1 and no heart failure symptoms (impaired relaxation [IR]); and 51 with heart failure symptoms and an E/A ratio >1 (pseudonormal [PN]). Ea was derived from the lateral border of the annulus. A subset of 60 patients had invasive measurement of pulmonary capillary wedge pressure (PCWP) simultaneous with Doppler echocardiographic DTI. Ea was reduced in the IR and PN groups compared with the group of normal subjects: 5.8 +/- 1.5 and 5.2 +/- 1.4 vs. 12 +/- 2.8 cm/s, respectively (p < 0.001). Mean PCWP (20 +/- 8 mm Hg) related weakly to mitral E (r = 0.68) but not to Ea. The E/Ea ratio related well to PCWP (r = 0.87; PCWP = 1.24 [E/Ea] + 1.9), with a difference between Doppler and catheter measurements of 0.1 +/- 3.8 mm Hg. Ea behaves as a preload-independent index of LV relaxation. Mitral E velocity, corrected for the influence of relaxation (i.e., the E/Ea ratio), relates well to mean PCWP and may be used to estimate LV filling pressures.

Application of color Doppler M-mode echocardiography in the assessment of ventricular diastolic function: Potential for quantitative analysis

Article

Jan 1997

Color Doppler M-mode echocardiography provides a spatiotemporal map of blood distribution (v(s,t)) within the heart, with a typical temporal resolution of 5 ms, a spatial resolution of 300 microns, and a velocity resolution of 3 cm/s. M-mode echocardiographic data can be obtained along a streamline from the mid-left atrium to the mid-left ventricle from either the apical transthoracic window or the basal transesophageal window. A key parameter of the color Doppler M-mode is the transmitral propagation velocity, the slope of the leading edge of the M-mode derived E-wave. This propagation velocity is significantly less than the velocities measured within the E-wave by pulsed Doppler echocardiography and appears to provide important independent information about left ventricular filling pressures and diastolic function. Furthermore, color M-mode velocities can be processed quantitatively by the Euler equation to yield estimates of the small (< 2 mmHg) pressure gradients between the base and apex during filling, the first time such gradients have been measured noninvasively.

Reversible Restrictive Left Ventricular Diastolic Filling With Optimized Oral Therapy Predicts a More Favorable Prognosis in Patients With Chronic Heart Failure

Article

Jul 1998
J AM COLL CARDIOL

We sought to assess whether in clinically stable patients with chronic heart failure (CHF) the prolongation (i.e., increase) of an initially short (< or = 125 ms) Doppler transmitral deceleration time (DT) of early filling obtained with long-term optimal oral therapy predicts a more favorable prognosis. It has been recently demonstrated that transmitral early DT is a powerful independent predictor of poor prognosis in patients with left ventricular dysfunction. However, DT may change over time according to loading conditions and medical treatment. One hundred forty-four patients with CHF and a short DT (< or = 125 ms) underwent repeat Doppler echocardiographic study 6 months after the initial examination, while clinically stable with optimal oral therapy, and were then followed up for a mean period of 26 +/- 7 months. After 6 months, DT had not changed in 80 patients (group 1), whereas it was significantly prolonged (> 125 ms) in the remaining 64 patients (group 2). Baseline Doppler echocardiographic features were similar in the two groups. No changes were found after 6 months in group 1, whereas group 2 showed a slight but significant (p < 0.01) reduction in end-systolic volume, an improvement in left ventricular ejection fraction (p < 0.01) and a decrease (p < 0.01) in the degree of tricuspid regurgitation. During follow-up, 37% of patients in group 1 experienced cardiac death versus 11% in group 2 (p < 0.0005). By Cox model analysis, prolongation of a short DT emerged as the single best predictor of survival (chi-square 15.70). The prolongation of an initially short DT obtained with long-term optimal oral therapy predicts a more favorable outcome in clinically stable patients with CHF.

Effect of loading conditions on myocardial relaxation velocities determined by Doppler tissue imaging in heart transplant recipients

Article

Aug 1998
J HEART LUNG TRANSPL

Cardiac allograft rejection is accompanied by cellular infiltration and tissue edema resulting in myocardial relaxation abnormalities. Doppler tissue imaging is capable of measuring myocardial relaxation velocities and is useful in the detection of heart rejection. However, the influence of ventricular loading conditions on myocardial relaxation velocities has not been studied. This study is performed to determine whether myocardial relaxation velocities are affected by left ventricular loading conditions. Twenty heart transplant recipients without evidence of rejection by endomyocardial biopsy underwent preload and afterload reduction with nitroglycerin. The pulmonary wedge pressure was reduced from 18.2+/-0.9 to 12.0+/-0.9 mm Hg 9 (p=0.001) and the mean blood pressure from 130.0+/-5.6 to 116.1+/-7.0 mm Hg (p=0.001). Pulsed-wave Doppler tissue imaging was performed before and after administration of nitroglycerin, and the peak myocardial relaxation velocities of the inferior wall were measured. Myocardial relaxation velocities did not change with the administration of nitroglycerin; 0.188+/-0.009 to 0.178+/- 0.006 m/sec (p=0.4) in spite of a significant reduction in pulmonary capillary wedge pressure. Furthermore, there was no correlation between pulmonary capillary wedge pressure, mean arterial pressure, wall stress, and myocardial relaxation velocities. Loading conditions on the left ventricle have no influence on myocardial relaxation velocities. Therefore in heart transplant recipients changes in myocardial relaxation velocities by Doppler tissue imaging may be useful in the diagnosis of rejection, in spite of diverse loading conditions.

Doppler Estimation of Left Ventricular Filling Pressure in Sinus Tachycardia: A New Application of Tissue Doppler Imaging

Article

Nov 1998

Doppler echocardiography is frequently used to predict filling pressures in normal sinus rhythm, but it is unknown whether it can be applied in sinus tachycardia, with merging of E and A velocities. Tissue Doppler imaging (TDI) can record the mitral annular velocity. The early diastolic velocity (Ea) behaves as a relative load-independent index of left ventricular relaxation, which corrects the influence of relaxation on the transmitral E velocity. We evaluated 100 patients 64+/-12 years old with simultaneous Doppler and invasive hemodynamics. Mitral inflow was classified into 3 patterns: complete merging of E and A velocities (pattern A), discernible velocities with A dominance (B), or E dominance (C). The Doppler data were analyzed at the mitral valve tips for E, acceleration and deceleration times of E, and isovolumic relaxation time. In patterns B and C, the A velocity, E/A ratio, and atrial filling fraction were derived. Pulmonary venous flow velocities were also measured, and TDI was used to acquire Ea and Aa. Weak significant relations were observed between pulmonary capillary wedge pressure (PCWP) and sole parameters of mitral flow, pulmonary venous flow, and annular measurements. These were better for patterns A and C. E/Ea ratio had the strongest relation to PCWP [r=0.86, PCWP=1.55+1.47(E/Ea)], irrespective of the pattern and ejection fraction. This equation was tested prospectively in 20 patients with sinus tachycardia. A strong relation was observed between catheter and Doppler PCWP (r=0.91), with a mean difference of 0.4+/-2.8 mm Hg. The ratio of transmitral E velocity to Ea can be used to estimate PCWP with reasonable accuracy in sinus tachycardia, even with complete merging of E and A velocities.

Doppler Estimation of Left Ventricular Filling Pressures in Patients With Hypertrophic Cardiomyopathy

Article

Jan 1999
CIRCULATION

Conventional Doppler parameters are unreliable for estimating left ventricular (LV) filling pressures in hypertrophic cardiomyopathy (HCM). This study was undertaken to evaluate flow propagation velocity by color M-mode and early diastolic annular velocity (Ea) by tissue Doppler 2 new indices of LV relaxation, combined with mitral E velocity for estimation of filling pressures in HCM. Thirty-five HCM patients (52+/-15 years) underwent LV catheterization simultaneously with 2-dimensional and Doppler echocardiography. Pulsed Doppler echocardiography of mitral and pulmonary venous flows was obtained along with flow propagation velocity and Ea. LV preA pressure had weak or no relations with mitral, pulmonary venous velocities and atrial volumes. In contrast, preA pressure related strongly to E velocity/flow propagation velocity (r=0.67; SEE=4) and E/Ea (r=0.76; SEE=3.4). In 17 patients with repeat measurements, preA pressure changes were well detected by measuring E velocity/flow propagation velocity (r=0.68; P=0.01) or E/Ea (r=0.8; P<0.001). PreA pressure estimation with these 2 methods was tested prospectively in 17 additional HCM patients with good results (E velocity/flow propagation velocity, r=0.76; E/Ea, r=0.82). LV filling pressures can be estimated with reasonable accuracy in HCM patients by measuring E velocity/flow propagation velocity or E/Ea. These ratios also track changes in filling pressures.

Cardiac catheterization Heart Disease: A Textbook of Cardiovascular Medicine

Jan 1997
177-203

Davidson Cj Fishman Rf
Bonow

Davidson CJ, Fishman RF, Bonow RO. Cardiac catheterization. In: Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine. 5th ed. Philadelphia, Pa: WB Saunders; 1997:177–203.

Heart Disease: A Textbook of Cardiovascular Medicine

Jan 1997
177-203

C J Davidson
R F Fishman
R O Bonow

Davidson CJ, Fishman RF, Bonow RO. Cardiac catheterization. In: Braunwald E, ed. Heart Disease: A Textbook of Cardiovascular Medicine. 5th ed. Philadelphia, Pa: WB Saunders; 1997:177-203.

Clinical Utility of Doppler Echocardiography and Tissue Doppler Imaging in the Estimation of Left Ventricular Filling Pressures : A Comparative Simultaneous Doppler-Catheterization Study

Abstract

No full-text available

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