Impaired Myocardial Function in Hypertrophic Cardiomyopathy

Background: Tissue Doppler imaging (TDI) parameters of peak myocardial velocities (S′, E′, and A′) has been employed to assess the regional left ventricular myocardial function. The global function index (GFI) derived from TDI has been recently employed to distinguish the different etiologies of left ventricular hypertrophy. Objective: To analyze whether the GFI or individual TDI parameters of peak myocardial velocities (S′, E′, and A′) allows detecting different degrees of regional myocardial dysfunction in the most frequent forms of hypertrophic cardiomyopathy (HCM). Methods: GFI = (E/E′)/S′ (where E is the peak transmitral flow velocity, E′ is the early diastolic myocardial velocity, and S′ is the peak systolic myocardial velocity) and TDI peak myocardial velocities was measured in the septal and lateral mitral annulus in 101 patients with HCM (mean age 47.5 ± 14 years, 58 women) and in age‐matched group of 30 healthy controls (mean age 46 ± 6 years, 16 women). Results: Forty‐five patients had nonobstructive asymmetric septal HCM, 20 patients had a subaortic gradient ≥ 30 mm Hg, 21 p. had apical HCM, and 15 p. had other forms of HCM (midventricular, symmetric, and biventricular). All patients with HCM exhibited a decrease in early diastolic (E′) and systolic (S′) myocardial velocities, both in the lateral and septal‐mitral annulus border, but more pronounced in septal‐mitral annulus. Septal GFI was higher in HCM patients than in healthy subjects (1.8 (1.1–2.5) and (0.57 (0.31–0.92), respectively, P < 0.001), but no differences were seen when different forms of HCM were compared. Conclusions: In a selected population of patients with HCM and a preserved left ventricular(LV) systolic function, GFI and individual TDI parameters of peak velocity (S′, E′, and A′) and E/E′ ratio were similar in different forms of HCM, indicating that in all patients with HCM there is regional systolic and diastolic myocardial dysfunction, regardless of the location of hypertrophy. (ECHOCARDIOGRAPHY, Volume 26, July 2009)     

Echocardiographic measures of diastolic function in pediatric heart disease

PURPOSE OF REVIEW: The past year has seen a continued evolution in the echocardiographic assessment of diastolic function in children. This paper reviews published studies from the past year that have helped characterize diastolic function using echocardiography in children. RECENT FINDINGS: Characterization of diastolic function using Doppler and Doppler tissue imaging in the normal infant and child was a primary focus of pediatric echocardiographic investigation. These technologies appear to hold significant promise as tools to improve understanding of diastolic function in the normal child as the heart matures. Diastolic function in children with congenital heart disease has also been better characterized using these tools, specifically in patients with atrial septal defects, tetralogy of Fallot, single ventricle physiology, and following cardiac transplantation. Finally, diastolic function in acquired heart disease or with systemic disease in the child has been evaluated using echocardiography, with recent reports describing findings in children with dilated cardiomyopathy, chronic renal disease, obesity, type I diabetes, juvenile rheumatoid arthritis, obstructive sleep apnea, and after anthracycline exposure for childhood cancer. SUMMARY: Pediatric echocardiography has clearly become the primary tool for describing and characterizing diastolic function in infants and children both with and without heart disease. It is becoming an important noninvasive diastolic monitoring tool that allows serial assessment of pathologic diastolic disease in both primary myocardial and systemic disease states.     

Tissue Doppler imaging identifies myocardial dysfunction in adults with Marfan syndrome

BACKGROUND: Successful prevention of aortic complications has lead to improved survival of Marfan syndrome (MFS). With increasing age, however, ventricular arrhythmia and heart failure are emerging as life-threatening manifestations of myocardial dysfunction. HYPOTHESIS: We sought to investigate whether echocardiography with tissue Doppler imaging (TDI) identifies myocardial dysfunction in adults with MFS. METHODS: We performed two-dimensional (2-D) and Doppler echocardiography with TDI in 141 individuals with suspected MFS and competent heart valves, including 28 persons with MFS who had not undergone surgery and 86 healthy controls without inherited connective tissue disorders. RESULTS: Demographic profile, 2-D, mitral and pulmonary venous flow indices, and left ventricular ejection fractions were similar in both groups. Conversely, isovolumic relaxation time (p < 0.001) and deceleration time of E velocity (p = 0.005) were longer, and atrial reversal velocities (p = 0.02), and systolic and early diastolic TD velocities were slower in MFS than in controls (p = 0.01). Multiple linear regression analysis excluded association of reduced systolic and early diastolic TD velocities with mitral valve prolapse or other clinical or echocardiographic features of MFS. CONCLUSIONS: Our study identifies reduced systolic and early diastolic TD velocities in adults with MFS. Further studies are mandatory to elucidate whether TD velocities predict arrhythmia and heart failure in MFS.     

Tissue Doppler imaging detects early asymptomatic myocardial abnormalities in a dog model of Duchenne's cardiomyopathy.

AIMS: Early diagnosis of Duchenne's dilated cardiomyopathy remains a challenge for conventional echocardiography. We sought to determine whether tissue Doppler imaging (TDI) could detect early alteration in myocardial function in a dog model of Duchenne muscular dystrophy, i.e. the Golden Retriever Muscular Dystrophy (GRMD). METHODS AND RESULTS: Myocardial function was assessed by TDI in 20 dogs with normal conventional parameters of systolic function (eight controls and 12 GRMD, 25+/-11 weeks) without knowledge of the genotype. M-mode TDI was recorded from a short-axis view for measurement of endocardial and epicardial velocities and myocardial velocity gradient (MVG) within the posterior wall. Controls and GRMD dogs were comparable regarding left ventricular fractional shortening (37+/-2 vs 42+/-3%, p=ns). Conversely, TDI showed, in all GRMD dogs, a dramatic decrease in systolic MVG (0.8+/-0.1 vs 2.9+/-0.3 s(-1), p<0.0001) and early diastolic MVG (2.3+/-2.2 vs 10.8+/-1.1 s(-1), p<0.0001). This MVG alteration was related to a significant decrease in endocardial velocities in GRMD whereas epicardial velocities were comparable in the two groups. CONCLUSION: These results show that TDI is more sensitive than conventional echocardiography in detecting pre-clinical myocardial abnormalities before occurrence of left ventricular dilation and dysfunction. TDI should be part of the screening techniques for the early diagnosis of cardiomyopathy.     

Aktueller Stellenwert der parametrischen Echokardiographie beim Management von Kardiomyopathien

The assessment of myocardial velocities by tissue Doppler imaging (TDI) and deformation imaging by speckle tracking echocardiography (STE) has been proposed for objective quantitative assessment of myocardial function and sophisticated analysis of cardiac mechanics in a wide range of clinical and scientific applications. These techniques are a promising new diagnostic tool for the evaluation of global and regional cardiac function in cardiomyopathies as well as detection of fibrosis, scars and ischemia. These new techniques are of increasing clinical importance but their strengths and weaknesses must be taken into account for the interpretation of the acquired data. This document describes the principles of the assessment of myocardial velocities and deformation by TDI and STE of the echocardiographic work-up in cardiomyopathies. Moreover, the growing body of evidence as well as relevant information for the clinical application of these emerging techniques for the analysis of systolic and diastolic function as well as the differentiation of restrictive cardiomyopathy from constrictive cardiomyopathy and of hypertrophic cardiomyopathy from athlete??s heart are highlighted in this article.     

组织多普勒成像技术评价正常胎儿心脏纵轴功能

目的利用组织多普勒成像技术（TDI）测量正常胎儿心肌运动速度,观察其心脏纵轴功能及临床应用价值。方法应用组织多普勒技术测量152例孕龄21—39周的正常胎儿心脏进行测量,在心尖四腔切面将取样容积分别放置于右室游离壁、室间隔、左室侧壁与房室环交界处,测量收缩期Sm波、舒张早期Em波和舒张晚期Am波,计算Em／Am比值,进行统计分析和处理。结果右心室收缩期Sm及舒张早期Em测值明显大于左心室及室间隔处,左、右心室Sm、Em、Am、Era／Am均随孕周的增加而增加,呈正相关关系。左、右心室的Sm与左、右心室的心输出量有相关性,左：右心室Em／Am与E／A有相关性。结论利用TDI评价胎儿心脏纵轴运动是安全、准确、可行的。     

Stress Echocardiography: Abnormal Tissue Doppler Imaging in the Absence of Cardiac Allograft Vasculopathy in Heart Transplant Recipients

Background: The most significant predictor of long‐term survival in heart transplant patients is the development of accelerated cardiac allograft vasculopathy (CAV). Several studies have demonstrated the usefulness of dobutamine stress echocardiography (DSE) for screening CAV, by detecting regional wall motion abnormalities. Tissue Doppler imaging (TDI)‐derived indices during DSE allow for the early detection of ischemic heart disease (IHD), prior to a reduction in regional or global systolic function. These indices include a reduction in annular systolic velocity (S′), a decrease in early diastolic annular velocity (E′), and prolongation of time to E′. In cardiac transplant patients, the application of these TDI abnormalities during DSE remains unknown. Objective: The objective of this study was to evaluate the pattern of (TDI‐derived indices of systolic and diastolic function during DSE in cardiac transplant patients without evidence of CAV. Methods: A retrospective evaluation of 30 patients (mean age 54 ± 11 years) who had both DSE and coronary angiography was performed. The control group consisted of 15 patients referred to rule out coronary artery disease while the study group consisted of 15 cardiac transplant patients referred for routine annual follow‐up. During each stage of DSE, tissue Doppler measurements of systolic (S′), early (E′), and late (A′) diastolic velocities of the lateral annulus were taken. Results: All 30 patients had normal DSE based on systolic regional function and normal coronary angiograms with no stenosis >50%. There was no difference in hemodynamic parameters during the DSE at baseline and with stress. Despite normal coronaries, cardiac transplant patients demonstrated lower S′, E′, and A′ velocities at peak stress compared to the control patients. Conclusion: Dobutamine‐induced augmentation of TDI velocities of the lateral annulus, normally observed in the absence of ischemia in nontransplanted adults, is reduced in cardiac transplant recipients.     

Clinical Asthma Phenotypes: Is There an Impact on Myocardial Performance?

Background: Asthma is a systemic disease, which affects various body systems. We aimed to assess the impact of clinical asthma phenotypes on myocardial performance in asthmatic children using tissue Doppler imaging (TDI). Methods: We enrolled 58 children with moderate persistent asthma and 62 age‐ and sex‐matched healthy controls. Asthmatic children were classified according to clinical asthma phenotypes into shortness of breath group (n = 26) and wheezy group (n = 32). Pulmonary function tests, and conventional and TDI echocardiography were performed. Results: TDI echocardiography assessment of the studied groups showed that asthmatic children as a group had significant left and right ventricular dysfunction when compared with healthy controls. Children in the shortness of breath group had a significant diastolic dysfunction of both ventricles in the form of lower tricuspid and mitral annular early myocardial diastolic velocity (Em), early to late myocardial diastolic velocity (Em/Am) ratio, and prolonged isovolumetric relaxation time when compared with wheezy group (P < 0.001). In the shortness of breath group, TDI‐derived myocardial performance index (MPI) of both ventricles was significantly higher when compared with wheezy group (P < 0.001) reflecting global myocardial dysfunction. Conventional echocardiography of both ventricles showed RV diastolic dysfunction in the form of a significantly lower tricuspid E/A ratio in the shortness of breath group when compared with wheezy group. Conclusion: Clinical asthma phenotypes have an impact on myocardial function especially those presented with shortness of breath. Thus, measurement of MPI by TDI can detect subclinical changes in the cardiac performance in asthmatic children. (Echocardiography 2012;29:528‐534)     

Involvement of right ventricle in left ventricular hypertrophic cardiomyopathy: analysis by pulsed Doppler tissue imaging.

AIMS: This study uses pulsed Doppler tissue imaging to analyse right ventricular myocardial function and its interaction with left ventricle in hypertrophic cardiomyopathy involving ventricular septum. METHODS AND RESULTS: Thirty-four patients with septal hypertrophic cardiomyopathy and 30 normal subjects, comparable for sex, age, body mass index and heart rate, underwent complete standard Doppler echocardiography and pulsed Doppler tissue imaging of both posterior septum and right ventricular free wall, calculating myocardial velocities and both systolic and diastolic time intervals. Except for peak velocity A, the other Doppler tricuspid inflow measurements were significantly impaired in hypertrophic cardiomyopathy, without changes of tricuspid annular systolic excursion. Right ventricular Doppler tissue imaging showed longer right ventricular myocardial relaxation time in hypertrophic cardiomyopathy than in controls (P<0.00001), without a significant difference from other myocardial diastolic and systolic measurements. In the overall population, Doppler measurements of right and left ventricular inflow were not significantly associated, while (with the exception of myocardial deceleration time) all the other myocardial systolic and diastolic measurements derived by tissue imaging were directly related to the homologous septal myocardial indexes. In addition, a significant inverse relation was found between septal wall thickness and myocardial relaxation index (right-left myocardial relaxation time/right ventricular relaxation time x 100). CONCLUSIONS: This study shows the usefulness of pulsed Doppler tissue imaging to detect impairment of right ventricular myocardial function and to provide evidence about ventricular interaction in forms of hypertrophic cardiomyopathy which involve interventricular septum.     

Usefulness of tissue Doppler echocardiography for evaluating ventricular function in children without heart disease

Tissue Doppler echocardiographic imaging (TDI) is a novel method for accurately evaluating ventricular function. Currently, scant data are available on the distribution of tissue Doppler indexes in healthy children in the age range of 1 to 18 years. The aims of this study were to assess the distribution of tissue Doppler indexes of systolic and diastolic ventricular function in healthy children, to assess the influence of age on these indexes, and to compare them with conventional Doppler indexes. A total of 151 consecutive children aged 1 to 18 years were enrolled in the study. Nine different (7 diastolic and 2 systolic) TDI parameters were assessed. Peak velocities of systolic and diastolic excursions of the mitral and tricuspid annuli were obtained from the apical 4-chamber view. Mean velocities of early diastolic recoil of mitral and tricuspid annuli were measured from the apical 4-chamber view. The mean velocity of early diastolic relaxation of the left ventricular posterior wall was measured in the parasternal long-axis view. Results showed a statistically significant difference in some of the TDI indexes among the different pediatric age groups. Most of the TDI indexes showed a very weak correlation with age. There was no significant correlation (p >0.05) between peak velocities of the early diastolic mitral inflow Doppler pattern (E wave) and the corresponding TDI index. In contrast, there was a significant (p <0.001) correlation between the corresponding Doppler indexes in the tricuspid annulus. We conclude that TDI is a valuable tool for assessing ventricular function, particularly diastolic function. Establishment of normative data for TDI in the pediatric age group should broaden the clinical applicability of this useful modality for assessing ventricular function.     

Evaluation of left ventricular function in cardiomyopathic mice by tissue Doppler and color M-mode Doppler echocardiography

Tissue Doppler imaging (TDI) and color M-mode Doppler flow propagation velocity (Vp) are used to assess cardiac function in humans, but the feasibility and applicability of these measurements to murine cardiomyopathic models of heart failure remain unclear. Left ventricular (LV) function was measured by TDI and Vp among mice exhibiting severe dilated cardiomyopathy (TOT), pressure-overload hypertrophy (TAC), and normal controls (NTG). Transmitral flow pattern in TACs and TOTs showed a restrictive filling pattern, but early diastolic mitral annulus velocity was comparable among the three studied groups. Propagation velocity in an anesthetized state was comparable in all three groups. However, while Vp increased in all three groups in the conscious state, the increase in NTGs was statistically greater than in TACs and TOTs. Collectively, results indicate that color M-mode Doppler echocardiography can be used to assess LV function in mice. Furthermore, Vp is depressed by anesthesia, a complication that can lead to misinterpretation of LV function in normal hearts.     

Tissue Doppler imaging a new prognosticator for cardiovascular diseases.

Tissue Doppler imaging (TDI) is evolving as a useful echocardiographic tool for quantitative assessment of left ventricular (LV) systolic and diastolic function. Recent studies have explored the prognostic role of TDI-derived parameters in major cardiac diseases, such as heart failure, acute myocardial infarction, and hypertension. In these conditions, myocardial mitral annular or basal segmental (Sm) systolic and early diastolic (Ea or Em) velocities have been shown to predict mortality or cardiovascular events. In particular, those with reduced Sm or Em values of <3 cm/s have a very poor prognosis. In heart failure and after myocardial infarction, noninvasive assessment of LV diastolic pressure by transmitral to mitral annular early diastolic velocity ratio (E/Ea or E/Em) is a strong prognosticator, especially when E/Ea is > or =15. In addition, systolic intraventricular dyssynchrony measured by segmental analysis of myocardial velocities is another independent predictor of adverse clinical outcome in heart failure subjects, even when the QRS duration is normal. In heart failure patients who received cardiac resynchronization therapy, the presence of systolic dyssynchrony at baseline is associated with favorable LV remodeling, which in turn predicts a favorable long-term clinical outcome. Finally, TDI and derived deformation parameters improve prognostic assessment during dobutamine stress echocardiography. A high mean Sm value in the basal segments of patients with suspected coronary artery disease is associated with lower mortality rate or myocardial infarction and is superior to the wall motion score.     

Tissue Doppler imaging a new prognosticator for cardiovascular diseases

Tissue Doppler imaging (TDI) is evolving as a useful echocardiographic tool for quantitative assessment of left ventricular (LV) systolic and diastolic function. Recent studies have explored the prognostic role of TDI-derived parameters in major cardiac diseases, such as heart failure, acute myocardial infarction, and hypertension. In these conditions, myocardial mitral annular or basal segmental (Sm) systolic and early diastolic (Ea or Em) velocities have been shown to predict mortality or cardiovascular events. In particular, those with reduced Sm or Em values of <3 cm/s have a very poor prognosis. In heart failure and after myocardial infarction, noninvasive assessment of LV diastolic pressure by transmitral to mitral annular early diastolic velocity ratio (E/Ea or E/Em) is a strong prognosticator, especially when E/Ea is > or =15. In addition, systolic intraventricular dyssynchrony measured by segmental analysis of myocardial velocities is another independent predictor of adverse clinical outcome in heart failure subjects, even when the QRS duration is normal. In heart failure patients who received cardiac resynchronization therapy, the presence of systolic dyssynchrony at baseline is associated with favorable LV remodeling, which in turn predicts a favorable long-term clinical outcome. Finally, TDI and derived deformation parameters improve prognostic assessment during dobutamine stress echocardiography. A high mean Sm value in the basal segments of patients with suspected coronary artery disease is associated with lower mortality rate or myocardial infarction and is superior to the wall motion score.     

Adult definitions for dyssynchrony are inappropriate for pediatric patients

Background: Cardiac resynchronization therapy (CRT) is a promising approach to improve cardiac function in children in heart failure with cardiomyopathy. Cardiac timing measures in pediatrics are typically based on age and heart rate. However, pediatric CRT studies to date have used adult based timing cutoff values. We investigated the applicability of using these adult standards in pediatric patients with normal hearts. Methods: We studied 88 outpatients referred for cardiac evaluation who had a normal cardiac evaluation. Subjects had 12 lead EKG and normal echocardiogram. Patients with known heart disease or abnormal rhythms were excluded. 2D echo and Doppler including color tissue Doppler imaging (TDI, Vivid 7 GE Ultrasound, Norway) were obtained. TDI was performed on three standard apical views (four chamber, two chamber, and long axis). Longitudinal dyssynchrony was determined from (1) Yu index – standard deviation of differences in timing of peak TDI velocity of all 12 basal and mid LV wall segments, adult cutoff >32 ms and (2) opposing wall difference (OWD) in timing of peak TDI velocity of 12 LV wall segments, adult cutoff >65 ms. Radial dyssynchrony was determined from differences in timing of peak radial strain between anterior‐septal and posterior LV segments from speckle tracking of 2D LV views, adult cutoff >130 ms. Results: Median age was 11.5 years; median heart rate was 74.5. Longitudinal dyssynchrony was present in 40% of normals based on Yu index, and in 43% based on OWD. No child had Radial dyssynchrony. Conclusions: This pilot study of children with normal hearts suggests that current adult CRT dyssynchrony cutoff values are inappropriate in the pediatric population. (Echocardiography 2011;28:468‐474)     

Myocardial Velocity Gradient Assessed by a Tissue Doppler Imaging Technique

Although tissue Doppler imaging (TDI) is a promising technique for quantitative regional left ventricular wall motion analysis, Doppler angle of incidence and translational motion of the heart influence the velocity measurement by TDI because, in principle, TDI detects the velocity against the transducer. Myocardial velocity gradient (MVG) is derived from TDI as the slope of the regression line for a transmural velocity profile across the myocardial wall, which reflects regional wall thickening and thinning dynamics. Thus, regional diastolic and systolic function may be quantified by using MVG. MVG is also validated to be independent of the translational motion both theoretically and clinically. MVG may therefore be used as an indicator of regional wall motion even under such a condition that the translational motion of the heart cannot be neglected. Our preliminary experience suggests that the quantitative and objective nature of MVG enhances the diagnostic power of stress echocardiography. Further development of the automated, real time processing system and the algorithm for the apical approaches should be awaited for the practical approaches of MVG to be applied to daily clinical practice.     

Diastolic heart failure can be diagnosed by comprehensive two-dimensional and Doppler echocardiography.

There are many myocardial and non-myocardial conditions that cause heart failure with normal left ventricular ejection fraction (LVEF). Among them, diastolic heart failure (heart failure due to diastolic dysfunction) is the most common cause of heart failure with normal LVEF. Diastolic heart failure easily can be diagnosed by comprehensive two-dimensional and Doppler echocardiography, which can demonstrate abnormal myocardial relaxation, decreased compliance, and increased filling pressure in the setting of normal LV dimensions and preserved LVEF. Therefore, diastolic heart failure should always be considered when LVEF is normal on two-dimensional echocardiography in patients with clinical evidence of heart failure. The diagnosis can be confirmed if Doppler echocardiography and myocardial tissue imaging provide evidence for impaired myocardial relaxation (i.e., decreased longitudinal velocity of the mitral annulus during early diastole and decreased propagation velocity mitral inflow), decreased compliance (shortened mitral A-wave duration and mitral deceleration time), and increased filling pressure (shortened isovolumic relaxation time and an increased ratio between early diastolic mitral and mitral annular velocities). Early identification of diastolic dysfunction in asymptomatic patients by the use of echocardiography may provide an opportunity to manage the underlying etiology to prevent progression to diastolic heart failure.     

Diastolic heart failure can be diagnosed by comprehensive two-dimensional and Doppler echocardiography

There are many myocardial and non-myocardial conditions that cause heart failure with normal left ventricular ejection fraction (LVEF). Among them, diastolic heart failure (heart failure due to diastolic dysfunction) is the most common cause of heart failure with normal LVEF. Diastolic heart failure easily can be diagnosed by comprehensive two-dimensional and Doppler echocardiography, which can demonstrate abnormal myocardial relaxation, decreased compliance, and increased filling pressure in the setting of normal LV dimensions and preserved LVEF. Therefore, diastolic heart failure should always be considered when LVEF is normal on two-dimensional echocardiography in patients with clinical evidence of heart failure. The diagnosis can be confirmed if Doppler echocardiography and myocardial tissue imaging provide evidence for impaired myocardial relaxation (i.e., decreased longitudinal velocity of the mitral annulus during early diastole and decreased propagation velocity mitral inflow), decreased compliance (shortened mitral A-wave duration and mitral deceleration time), and increased filling pressure (shortened isovolumic relaxation time and an increased ratio between early diastolic mitral and mitral annular velocities). Early identification of diastolic dysfunction in asymptomatic patients by the use of echocardiography may provide an opportunity to manage the underlying etiology to prevent progression to diastolic heart failure.     

Application of tissue Doppler imaging in cardiology

Tissue Doppler imaging (TDI) is a new echocardiographic technique employing the Doppler principle to measure the velocity of myocardial segments and other cardiac structures. It is well suited for the measurement of long-axis ventricular function. Impairment of longitudinal myocardial fiber motion is a sensitive marker of early myocardial dysfunction and ischaemia, and TDI might therefore become an important tool in routine echocardiography. The technique allows truly quantitative measurement of regional myocardial function both at rest and during stress echocardiography. TDI has great potential in the diagnosis of diastolic left ventricular dysfunction, overcoming the load-dependence of conventional Doppler techniques. Right ventricular function, intracardiac and pulmonary artery pressures, transplant rejection and intraventricular dyssynchrony can also be assessed. This article reviews the current and evolving applications of TDI in cardiology.     

Cardiac dysfunction in acromegaly: evidence by pulsed wave tissue Doppler imaging

OBJECTIVE: To verify whether the accuracy of data on myocardial function provided by pulsed-wave tissue Doppler imaging (PWTDI), a new echocardiographic application that allows quantitative measurements of myocardial wall velocities, could help towards a better understanding of the natural history of acromegalic cardiomyopathy. DESIGN: Eighteen patients with active acromegaly (ten men and eight women; mean age 48.0+/-15.0 years) with no other detectable cause of heart disease underwent PWTDI. Thirteen healthy individuals matched for age and body mass index acted as a control group. METHODS: Ejection fraction (EF), transmitral early/late diastolic velocity (E/A) ratio and isovolumic relaxation time (IVRT) were measured by conventional echocardiography; systolic peak (Sv) and early (Ev) and late (Av) diastolic peak velocities, Ev/Av ratio and regional IVRT (IVRTs) were obtained by PWTDI. RESULTS: All patients showed appreciably abnormal left ventricular global diastolic function represented by prolongation of the IVRT (P<0.001). Using PWTDI we found a prolongation of IVRTs and inversion of the Ev/Av ratio. In addition, the Ev/Av ratio proved to be significantly negatively correlated with IVRT; this correlation was not present in the case of the E/A ratio. Furthermore, a decrease in Sv was detected in the basal segment of the lateral wall (P<0.01), which had the greatest degree of diastolic dysfunction. CONCLUSIONS: PWTDI confirmed the acknowledged diastolic dysfunction that accompanies acromegalic cardiomyopathy and highlighted the greater sensitivity of regional PWTDI with respect to global Doppler diastolic indexes. Furthermore, by revealing an impairment of regional systolic function in presence of a normal EF, the findings with PWTDI contradicted the largely accepted theory that systolic function remains normal for several years in patients affected by acromegalic cardiomyopathy.     

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

BACKGROUND: There is evidence that "inappropriate hypertrophy" of the single left ventricle, which occurs as a result of acute preload reduction, leads to adverse consequences on ventricular function. However, a systematic study of the capability of tissue Doppler imaging (TDI) to assess systolic and diastolic ventricular functions after the Fontan procedure is still missing. METHODS: Twenty-four postoperative patients aged 12-33 years were prospectively evaluated with two-dimensional echocardiography equipped with TDI capabilities. Nineteen age-matched normal subjects were selected as controls. Good-quality echoes for the measurement of ejection fractions were available in 21 patients. Ten patients (group 1) had systolic dysfunction (ejection fraction < 50%), and 11 patients (group 2) had normal systolic function. Peak systolic and diastolic wall velocities were acquired from the two-chamber view in the myocardia and mitral annulus. RESULTS: Compared with controls, the Fontan patients had a significantly reduced peak systolic velocity at wall and annulus sites. A linear correlation existed between ejection fraction and systolic myocardial velocity from the annular sites. Group 1 patients had lower wall velocities and lower annulus velocities both in systole and diastole. Group 2 patients had preserved systolic velocities but decreased regional and annular early diastolic velocities, suggesting impaired filling. Multiple correlation analysis showed a relation between peak early diastolic mitral velocity and ventricular ejection fraction, mean mitral annular motion at systole, mass/volume ratio, and the number of years post Fontan revision. CONCLUSIONS: Myocardial velocities recorded after the Fontan operation give insight into systolic and diastolic ventricular functions. The peak systolic mitral annular velocity correlated well with the ventricular ejection fraction. The peak early diastolic velocity and the ratio between the early and late diastolic mitral annular velocity are reduced and reflect diastolic dysfunction even in the presence of normal systolic ejection fraction.