A new method of haemodynamic assessment of mitral stenosis in atrial fibrillation: construction of a nomogram

Accurate haemodynamic assessment of mitral stenosis by hydraulic formulas requires measurement of the mean valve gradient and the cardiac output. The calculation is laborious, particularly in the presence of atrial fibrillation when averaged values obtained from multiple beat-to-beat determinations must be used. The relations between valve area, end diastolic gradient, and heart rate in 20 patients with mitral stenosis and atrial fibrillation were examined. In each patient the end diastolic pressure gradient for each cardiac cycle was related linearly to the RR interval of that cycle, and this relation was unchanged on exercise. The slope (S) and intercept (I) of this relation correlated with the degree of mitral stenosis as measured by the Gorlin valve area. The regression equations describing these relations were then used to construct a nomogram relating end diastolic pressure gradient to mitral valve area at different heart rates. When the nomogram was applied to catheterisation data from a further 30 patients the results correlated well with direct calculation of valve area by the Gorlin formula. The nomogram is simple to use, does not require measurement of cardiac output, and is independent of heart rate so that it is unnecessary for the patient to exercise during catheterisation.     

A new method of haemodynamic assessment of mitral stenosis in atrial fibrillation: construction of a nomogram.

Accurate haemodynamic assessment of mitral stenosis by hydraulic formulas requires measurement of the mean valve gradient and the cardiac output. The calculation is laborious, particularly in the presence of atrial fibrillation when averaged values obtained from multiple beat-to-beat determinations must be used. The relations between valve area, end diastolic gradient, and heart rate in 20 patients with mitral stenosis and atrial fibrillation were examined. In each patient the end diastolic pressure gradient for each cardiac cycle was related linearly to the RR interval of that cycle, and this relation was unchanged on exercise. The slope (S) and intercept (I) of this relation correlated with the degree of mitral stenosis as measured by the Gorlin valve area. The regression equations describing these relations were then used to construct a nomogram relating end diastolic pressure gradient to mitral valve area at different heart rates. When the nomogram was applied to catheterisation data from a further 30 patients the results correlated well with direct calculation of valve area by the Gorlin formula. The nomogram is simple to use, does not require measurement of cardiac output, and is independent of heart rate so that it is unnecessary for the patient to exercise during catheterisation.     

Exercise radionuclide angiography in patients with mitral stenosis: value of right ventricular response

We observed 26 patients with mitral stenosis and 19 normal volunteers with exercise gated radionuclide angiography. Although no differences were seen between normal subjects and patients with mitral stenosis at rest in left (LV) and right (RV) ventricular ejection fraction, significant differences were found for exercise change in ejection fraction for both ventricles, exercise time, exercise workload, and the percent change in LV end-diastolic, LV stroke, and RV end-systolic counts (ESC). Because nearly all of the normals (18/19) had a decrease in RVESC, patients with stenosis were divided into two groups according to whether RVESC increased or decreased. Significant differences were found between these two groups for age, New York Heart Association class, prevalence of atrial fibrillation, echocardiographic mitral valve area, and prognosis, that is, number undergoing catheterization and surgery. We conclude that exercise radionuclide angiography does yield information that has significant clinical and prognostic value in patients with mitral stenosis.     

Importance of the "atrial kick" in determining the effective mitral valve orifice area in mitral stenosis

Atrial fibrillation with a rapid ventricular response in patients with mitral stenosis (MS) is often accompanied by pulmonary congestion and reduced cardiac output owing to a diminished diastolic filling period and the loss of the end-diastolic left ventricular (LV) pressure increment. To test the hypothesis that loss of atrial contraction (atrial kick) also results in a decrease in effective mitral valve orifice area, 6 patients with pure, isolated MS were studied in sinus rhythm during atrial pacing and simultaneous atrioventricular pacing. Atrial pacing at 140 beats/min caused no significant change from baseline in cardiac output or mitral valve area, but there was a decrease in LV end-diastolic volume and ejection fraction as well as an increase in left atrial pressure and mean diastolic gradient. Simultaneous atrioventricular pacing (to eliminate atrial kick) induced a decrease in cardiac output (4.4 +/- 0.9 vs 5.2 +/- 0.8 liters/min at 110 beats/min, 4.2 +/- 0.9 vs 5.1 +/- 0.9 liters/min at 140 beats/min; p less than 0.05) and LV end-diastolic volume (77 +/- 27 vs 93 +/- 29 ml at 110 beats/min, 54 +/- 17 vs 65 +/- 19 ml at 140 beats/min; p less than 0.05), an increase in left atrial pressure (28 +/- 3 vs 20 +/- 5 mm Hg at 110 beats/min, 30 +/- 4 vs 25 +/- 5 mm Hg at 140 beats/min; p less than 0.05), and a decrease in mitral valve area (1.2 +/- 0.4 vs 1.4 +/- 0.5 cm2 at 110 beats/min, 1.2 +/- 0.4 vs 1.4 +/- 0.4 cm2 at 140 beats/min; p less than 0.05). Thus, loss of atrial kick may cause pulmonary congestion and reduced cardiac output in patients with MS, partly because of a decrease in effective mitral valve area.     

Non‐invasive assessment of left ventricular filling pressure

Dyspnoea is a presenting symptom for patients with heart failure. It is often due to elevated left ventricular (LV) filling pressure but can be due to pulmonary disease or other non‐cardiac reasons. While physical examination is useful, it has its limitations. Accordingly, non‐invasive imaging has an important role in the diagnostic evaluation of patients with known or suspected heart failure. Echocardiography is usually the first test obtained and is used to determine LV volumes, ejection fraction and mass as well as right ventricular size and function, left and right atrial volumes, valvular lesions, and pulmonary artery pressures. Additionally, LV filling pressure can be estimated. A recent algorithm was published that depends on clinical, two‐dimensional data and Doppler signals. The algorithm is accurate in patients with depressed and normal ejection fraction. There are other measurements that can be obtained as LV strain and diastolic strain rate and left atrial strain. These indices provide valuable insight into LV relaxation and filling pressure as well as left atrial function. Assessment of LV filling pressure has been evaluated most extensively in patients in sinus rhythm. However, it is also possible to assess LV filling and draw inferences about LV filling pressure in patients in atrial fibrillation, in patients with mitral valve disease and in patients with left ventricular assist devices. Left ventricular filling has been assessed by other imaging modalities, including cardiac computed tomography and cardiac magnetic resonance. While these other imaging modalities may be needed in some cases, echocardiography has the highest feasibility and validation, and the most practical application.     

Beat-to-beat left ventricular performance in atrial fibrillation: radionuclide assessment with the computerized nuclear probe

There is wide beat-to-beat variability in cycle length and left ventricular performance in patients with atrial fibrillation. In this study, left ventricular ejection fraction and relative left ventricular volumes were evaluated on a beat-to-beat basis with the computerized nuclear probe, an instrument with sufficiently high sensitivity to allow continuous evaluation of the radionuclide time-activity curve. Of 18 patients with atrial fibrillation, 5 had mitral stenosis, 6 had mitral regurgitation, and 7 had coronary artery disease. Fifty consecutive beats were analyzed in each patient. The mean left ventricular ejection fraction ranged from 17 to 51%. There was substantial beat-to-beat variation in cycle length and left ventricular ejection fraction in all patients, including those with marked left ventricular dysfunction. In 14 patients who also underwent multiple gated cardiac blood pool imaging, there was an excellent correlation between mean ejection fraction derived from the nuclear probe and gated ejection fraction obtained by gamma camera imaging (r = 0.90). Based on beat-to-beat analysis, left ventricular function was dependent on relative end-diastolic volume and multiple preceding cycle lengths, but not preceding end-systolic volumes. This study demonstrates that a single value for left ventricular ejection fraction does not adequately characterize left ventricular function in patients with atrial fibrillation. Furthermore, both the mean beat-to-beat and the gated ejection fraction may underestimate left ventricular performance at rest in such patients.     

A new formula for the measurement of diastolic mitral valve orifice area

This study evaluated the accuracy of a new formula for the calculation of mitral valve area. Fifty-two patients with mitral stenosis who underwent cardiac catheterization were evaluated by the standard Gorlin and the new formulas. The correlation between the two formulas was excellent (r = 0.89) for valve areas of 0–1.5 cm². When the new valve area formula yielded an area greater than 1.5 cm², there was no correlation with the Gorlin formula. However, the likelihood of the Gorlin mitral valve area being less than 1.0 cm² was low (10%). The results of the new formula do not appear to be affected by atrial fibrillation and are probably subject to the same limitations when used in the presence of a regurgitant lesion. Therefore, with moderate to severe mitral stenosis, this new formula shows a good correlation. However, with mild stenosis, further work is needed to determine the accuracy and limitations of the new formula.     

Left ventricular diastolic function and cardiac performance during exercise in patients with acromegaly

Exercise-induced impairment of left ventricular (LV) ejection fraction is common in patients with acromegaly and normal resting systolic function. This study aimed to clarify whether diastolic dysfunction plays a role in the abnormal adaptation to exercise in these patients. Forty-eight patients with active acromegaly underwent LV radionuclide angiography at rest and during exercise. Doppler echocardiography was also performed to assess LV mass index and diastolic function by combined analysis of mitral and pulmonary flow velocity curves. LV ejection fraction at peak exercise was related to rest ejection fraction (r = 0.78; P < 0.001), peak filling rate (r = 0.55; P < 0.01), LV mass index (r = -0.56; P < 0.001), and the difference between duration of diastolic reverse pulmonary vein flow and mitral flow at atrial contraction (Delta duration) (r = -0.54; P < 0.01). At stepwise regression analysis, rest ejection fraction and Delta duration were the only variables that independently influenced (P < 0.001) ejection fraction at peak exercise. Diastolic dysfunction is important in determining cardiac performance during exercise in patients with acromegaly and normal resting systolic function. Combined analysis of pulmonary vein and mitral flow velocity curves allows the identification of impaired LV diastolic function in such patients.     

Estimation of pulmonary wedge pressure by transmitral Doppler in patients with chronic heart failure and atrial fibrillation

Previous studies have demonstrated that left ventricular (LV) filling pressures can be estimated from transmitral Doppler recording in patients in sinus rhythm who have a broad spectrum of cardiac diseases. However, the correlation between pulmonary wedge pressure (PWP) and mitral Doppler profile has not yet been clearly defined in patients with atrial fibrillation, particularly in the presence of severe LV systolic dysfunction. The aim of this study was to evaluate the correlations between PWP and transmitral Doppler variables in patients with atrial fibrillation and chronic heart failure due to dilated cardiomyopathy. PWP and the mitral Doppler profile were simultaneously recorded in 35 consecutive heart failure patients (28 men, 7 women; mean age, 69 +/- 9 years) with severe LV dysfunction (mean ejection fraction 22% +/- 5%). Doppler measurements were averaged over 10 cardiac cycles. In addition, left atrial areas were derived from the apical 4-chamber view. Significant relations were observed between PWP and several parameters derived from the mitral flow: isovolumic relaxation time (r = -70), acceleration rate (r = 0.78), deceleration rate (r = 0.82), and deceleration time (r = -0.95). However, by stepwise multivariate analysis, deceleration time emerged as the sole independent predictor of PWP (r2 = 0.95, F = 590). The analysis led to the following equation: PWP = 51 - 0.26 (deceleration time). Our data suggest that mitral Doppler echocardiography is a useful tool for predicting PWP in heart failure patients with severe LV dysfunction even in the presence of atrial fibrillation.     

Left ventricular blood filling in patients with severe mitral stenosis: comparisons before and soon after percutaneous transluminal mitral commissurotomy]

To clarify the effects of mitral obstruction on left ventricular (LV) diastolic blood filling, 15 patients with tight mitral stenosis (each mitral valve area was less than 1.5 cm2) were studied. Each selected patient underwent successful percutaneous transluminal mitral commissurotomy (PTMC), which resulted in a 1.5 fold increase in each mitral valve area. LV pressure, left atrial (LA) pressure and cardiac output were measured before and immediately after PTMC. Left ventriculography was performed before and immediately after PTMC. The ventriculogram was traced frame by frame for one cardiac cycle. The LV volume curve was obtained from the traced image using a computer. The LV end-diastolic and end-systolic volumes (EDVI, ESVI), and ejection fraction in the subsequent cardiac cycle were calculated. The diastolic filling period was divided into 3 equal parts: namely, early, mid-, and late diastole. The blood volume entering the LV during early, mid-, and late diastole, which indicated the filling properties of each part, were calculated. After successful PTMC, both the mitral valve area (1.1 +/- 0.3 cm2 to 1.9 +/- 0.6 cm2, p < 0.01) and the cardiac index (3.2 +/- 0.8 l/min/m2 to 3.6 +/- 1.1 l/min/m2, p < 0.05) increased with the decreases in the mean diastolic pressure gradients between the LA and LV (13.4 +/- 4.5 mmHg to 5.9 +/- 2.6 mmHg, p < 0.01). The blood volume entering the LV during early diastole increased significantly without significant change in the blood volume entering the LV during mid- and late diastole.(ABSTRACT TRUNCATED AT 250 WORDS)     

Mitral Regurgitation Associated with Mitral Annular Dilation in Patients with Lone Atrial Fibrillation: An Echocardiographic Study

Background: Whether and how lone atrial fibrillation (AF) is associated with functional mitral regurgitation (MR) remain unclear. Method: We studied 12 lone AF patients without left ventricular (LV) dysfunction and/or dilatation, who underwent mitral valve annuloplasty for functional mitral regurgitation (MR). Ten lone AF patients without MR served as controls. Results: Lone AF Patients with MR had a greater mitral valve annular area and left atrial area than those without MR. There were no differences in LV volumes or LV ejection fraction. Conclusions: Therefore, we concluded that left atrial dilation and corresponding mitral annular dilation may cause MR in lone AF patients without LV dysfunction and/or dilatation.     

Comparison of pulsed Doppler echocardiography and radionuclide angiography in the assessment of left ventricular filling

To determine the relation between Doppler echocardiographic and radionuclide angiographic indexes of left ventricular (LV) filling, 42 patients were studied using both techniques. From Doppler mitral flow velocity profiles, the percent of LV filling due to atrial systole (percent atrial contribution) and at one-third of diastole (one-third filling fraction), the peak filling rate and the peak filling rate normalized for LV end-diastolic volume and the time from mitral valve opening to peak early velocity and from aortic valve closure to peak early velocity were determined. Good correlations were found between percent atrial contribution (r = 0.83) and one-third filling fraction (r = 0.67) using the 2 techniques. However, Doppler normalized peak filling rate correlated only weakly with radionuclide peak filling rate (r = 0.33, p less than 0.05). There was no significant correlation between Doppler peak filling rate and radionuclide peak filling rate. Neither Doppler time from mitral valve opening to peak early velocity nor Doppler time from aortic closure to peak early velocity correlated with radionuclide time to peak filling rate. Thus, Doppler echocardiography and radionuclide angiography agree on relative diastolic filling indexes but not on peak filling rates or useful diastolic time intervals. Relative filling indexes, such as percent atrial contribution and one-third filling fractions, therefore, may be the most reliable noninvasive indicators of diastolic function.     

Influence of age and sex on left ventricular filling at rest in subjects without clinical cardiac disease

Left ventricular (LV) filling at rest was studied by radionuclide ventriculography using alternate R-wave gating in 42 patients (29 men, 13 women) who had a low likelihood of cardiac disease. LV filling measurements differed little between men and women. Age was correlated positively with atrial filling duration (r = 0.55), atrial filling duration fraction (r = 0.52) and atrial filling fraction (r = 0.56) and negatively with rapid filling fraction (r = -0.58). Age was not correlated with peak filling rate, time to peak filling rate and first-half filling fraction. The heart rate at rest was significantly negatively correlated with rapid (r = -0.62), slow (r = -0.81) and atrial (r = -0.72) filling durations, but not with isovolumic duration. The heart rate at rest was weakly positively correlated with peak filling rate in end-diastolic volume per second (r = 0.36) and negatively correlated with first-half filling fraction (r = -0.35). Systolic pressure at rest influenced atrial filling duration. LV ejection fraction and end-diastolic volume index were not correlated significantly with LV filling in relatively normal subjects.     

Factors determining left atrial kinetic energy in patients with chronic mitral valve disease

BACKGROUND: Increased left atrial (LA) work is a major contributor to LA fatigue, LA failure and atrial fibrillation in patients with mitral stenosis (MS) and mitral valvular regurgitation (MVR). The present study was undertaken to define factors that determine LA work in patients with chronic mitral valve disease. PATIENTS AND METHODS: Peak left atrial kinetic energy (LAKE)was used as an index of LA work in 14 patients with MS, 14 with MVR, and 19 normal subjects matched for age and gender with MS and MVR patients. LA stroke volume and ejection fraction were measured from the biplane area-length method using echo techniques. Peak LAKE was obtained from the formula 1/2 mv2, where m = LA stroke volume x 1.06 (blood's specific gravity) and v = transmitral Doppler A-wave velocity. RESULTS: Stepwise regression analysis often clinical and echocardiographic parameters demonstrated that in MS, mitral valve area (r2 = 0.43) and LA maximal volume (r2 = 0.62), in MVR, only LA maximal volume (r2 = 0.42) contributed independently to LAKE. LAKE was greater in MS and MVR compared to control subjects while LA ejection fraction was similar in all groups.CONCLUSIONS: It is concluded that LA work is markedly increased in patients with chronic mitral valve disease. Increased LA work in chronic mitral valve disease may contribute to LA fatigue, LA failure, and atrial fibrillation.     

Left and right ventricular function during symptom-limited exercise in patients with isolated mitral stenosis

Ventricular function during exercise in patients with mitral stenosis has not been widely studied. Accordingly, 20 patients with isolated mitral stenosis were assessed during supine, symptom-limited equilibrium radionuclide ventriculographic studies. All patients had a normal left ventricular (LV) ejection fraction at rest (greater than or equal to 50 percent), and all were in sinus rhythm. Left ventricular ejection fraction rose (p less than 0.001) from 64 +/- 9 percent at rest to 74 +/- 11 percent during exercise. This normal response was due solely to a decrease (p less than 0.01) in exercise LV end-systolic volume. A significant (p less than 0.01) decrease in end-diastolic volume during exercise limited the increase in ejection fraction during exercise. The decrease in end-diastolic volume during exercise caused stroke volume to remain unchanged; cardiac output rose according to heart rate alone. Right ventricular (RV) ejection fraction did not rise with exercise due to an increase in end-systolic volume. With exercise, LV end-diastolic volume was smaller (p less than 0.05) with severe mitral stenosis compared to mild mitral stenosis. With exercise, RV ejection fraction was decreased (p less than 0.05) with severe compared to mild mitral stenosis. In conclusion, LV function during exercise is normal in patients with normal resting LV ejection fraction. A decrease in LV diastolic filling with exercise prevents a rise in stroke volume, and cardiac output increases by heart rate alone. With, exercise, RV ejection fraction does not rise, due to an increase in RV end-systolic volume.     

Natriuretic peptide levels in atrial fibrillation: a prospective hormonal and Doppler-echocardiographic study

OBJECTIVES: The objective was to determine the independent association between atrial fibrillation (A-Fib) and activation of natriuretic peptides. BACKGROUND: The association of A-Fib with activation of N-terminal atrial and brain natriuretic peptides (N-ANPs and BNPs, respectively) is uncertain but of great importance for the diagnostic utilization of natriuretic peptides. This uncertainty is related to the lack of appropriate controls, with left ventricular (LV) and atrial overload similar to A-Fib. METHODS: We prospectively measured N-terminal atrial and BNPs and endothelin-1 levels in 100 patients and 14 age- and gender-matched control subjects. The 32 patients with A-Fib were compared with 68 patients in sinus rhythm and similar LV and atrial overload (due to mitral regurgitation or LV dysfunction) measured simultaneously with hormonal levels with comprehensive Doppler echocardiography. RESULTS: Patients with A-Fib compared with those in sinus rhythm had similar symptoms, comorbid conditions, cardioactive medications, pulmonary pressure, left atrial volume, and LV ejection fraction and filling characteristics but demonstrated higher N-ANP levels (2,613 +/- 1,681 vs. 1,654 +/- 1,323 pg/ml, p = 0.007) even after adjustment for the underlying cardiac disease (p < 0.0001). Conversely, BNP levels were similar in both groups (165 +/- 163 vs. 160 +/- 269 pg/ml, p = 0.9). In multivariate analysis, a higher N-ANP level was associated with A-Fib (p = 0.0003), symptom class (p < 0.0001) and endothelin-1 level (p = 0.032) independently of left atrial volume and LV ejection fraction. Conversely, BNP showed no independent association with and was most strongly associated with LV ejection fraction (p < 0.0001). CONCLUSIONS: Atrial fibrillation is an independent determinant of higher N-ANP levels and blurs its association with LV dysfunction. Conversely, the BNP is not independently associated with A-Fib and is strongly determined by LV dysfunction, for which it is an independent marker.     

Increase in radionuclide left ventricular ejection fraction after cardioversion of chronic atrial fibrillation in idiopathic dilated cardiomyopathy.

To assess the potential improvement in left ventricular ejection fraction after cardioversion of chronic atrial fibrillation to sinus rhythm in idiopathic dilated cardiomyopathy, we studied prospectively 17 patients, aged 58 +/- 6 years, by radionuclide angiocardiography at rest. Left ventricular ejection fraction was determined before treatment and at a mean delay of 4.7 months after cardioversion. Return to sinus rhythm was obtained in 12 patients, pharmacologically or by electrical cardioversion. Five patients remained in atrial fibrillation. No clinical, echocardiographic or haemodynamic finding could predict the success of cardioversion. In chronic atrial fibrillation, the ejection fraction did not change significantly: 30.0 +/- 9.1% (19 to 44%) at the first evaluation and 29.5 +/- 8.3% (22 to 41%) after 4.7 months. After successful cardioversion, left ventricular ejection fraction improved from 32.1 +/- 5.3% (24 to 41%) to 52.9 +/- 9.7% (37 to 71%) (P less than 0.001). The difference was 20.8 +/- 11.3% and left ventricular ejection fraction was normalized in 50% (6/12) of the patients. There was a significant reduction in the cardiothoracic ratio on chest X-rays and of the left ventricular end-diastolic diameter on echocardiography; fractional shortening increased (27.7 +/- 4.3% vs 20.3 +/- 2.7%, P less than 0.01). A third evaluation was realized after a mean delay of 11.7 months in the patients with successful cardioversion. Sinus rhythm was present in 83% (10/12) of the patients: seven patients were reevaluated by radionuclide angiography. The improvement in left ventricular function observed at the 4.7 months evaluation was still present. In two patients with recurrence of atrial fibrillation, there was a severe deterioration of left ventricular systolic function.(ABSTRACT TRUNCATED AT 250 WORDS)     

Doppler left ventricular diastolic filling abnormalities in aortic stenosis and their relation to hemodynamic parameters

Doppler mitral flow indexes and their relation to invasively measured hemodynamic diastolic indexes were assessed in 13 patients with isolated aortic stenosis (AS), and compared to Doppler indexes in 10 normal subjects matched for age, heart rate, left ventricular (LV) ejection fraction and LV load. Patients with AS showed no difference in Doppler early filling (E) indexes, but demonstrated greater Doppler atrial filling (A) indexes in comparison to normal subjects: atrial velocity (89 +/- 31 vs 56 +/- 7 cm/s), atrial integral (11.4 +/- 4.8 vs 5.7 +/- 1.6 cm), A/E velocity (1.69 +/- 0.89 vs 1.06 +/- 0.26) and A/E integral (3.53 +/- 6.64 vs 0.81 +/- 0.27) (all p less than 0.05). Doppler indexes in patients with AS did not correlate with hemodynamic indexes of LV relaxation or chamber stiffness. Significant correlations were observed between Doppler and angiographic peak filling rates (r = 0.70) and between Doppler atrial filling velocity and LV end-diastolic volume (r = -0.66), LV end-diastolic pressure (r = -0.48) and LV ejection fraction (r = 0.53) (all p less than 0.05). These data indicate that, compared to matched normal subjects, most patients with AS have an increased atrial contribution to LV filling. However, in patients with decreased LV function, atrial function may also be depressed, as indicated by a decreased atrial contribution to LV filling, resulting in "normalization" of the Doppler mitral flow pattern.     

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

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) ≤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 ≤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.     

Atrial contraction after surgical isolation of the left atrial posterior wall concomitant with mitral valve replacement.

BACKGROUND: Surgical isolation of the left atrial posterior wall (LA-PW isolation) can terminate chronic atrial fibrillation associated with mitral valve disease. However, atrial contraction after LA-PW isolation has not been evaluated. METHODS AND RESULTS: The study group comprised 14 patients (mean age, 63+/-14 years) with mitral valve disease who recovered and maintained regular sinus rhythm after LA-PW isolation. Before the procedure, and 2-3 weeks and 1 year after the LA-PW isolation, the patients underwent an echocardiographic study. The left atrial (LA) diameter decreased after the LA-PW isolation and the change became significant 1 year later (before: 50.1+/-5.1 mm, after 2-3 weeks: 46.0+/-4.9 mm; p<0.05, after 1 year: 44.0+/-6.1 mm; p<0.05 vs before the operation). The left ventricular (LV) end-diastolic diameter, LV ejection fraction and LV fractional shortening did not change significantly from before the LA-PW isolation and after 1 year. The time - velocity integral of the atrial wave (Ai) and atrial filling fraction significantly increased (Ai: 4.5+/-2.1 cm vs 5.8+/-2.3 cm; p<0.05; atrial filling fraction: 15.4+/-7.7% to 19.2+/-8.3%; p<0.05) during the follow-up period. CONCLUSION: LA-PW isolation can benefit the restoration of regular sinus rhythm and, furthermore, the recovery of atrial contraction.