Reference Values of Tissue Doppler Imaging and Pulsed Doppler Echocardiography for Analysis of Left Ventricular Diastolic Function in Healthy Adults

To determine reference values for tissue Doppler imaging (TDI) and pulsed Doppler echocardiography for left ventricular diastolic function analysis in a healthy Brazilian adult population. Observations were based on a randomly selected healthy population from the city of Vitória, Espírito Santo, Brazil. Healthy volunteers (n = 275, 61.7% women) without prior histories of cardiovascular disease underwent transthoracic echocardiography. We analyzed 175 individuals by TDI and evaluated mitral annulus E′‐ and A′‐waves from the septum (S) and lateral wall (L) to calculate E′/A′ ratios. Using pulsed Doppler echocardiography, we further analyzed the mitral E‐ and A‐waves, E/A ratios, isovolumetric relaxation times (IRTs), and deceleration times (DTs) of 275 individuals. Pulsed Doppler mitral inflow mean values for men were as follows: E‐wave: 71 ± 16 cm/sec, A‐wave: 68 ± 15 cm/sec, IRT: 74.8 ± 9.2 ms, DT: 206 ± 32.3 ms, E/A ratio: 1.1 ± 0.3. Pulsed Doppler mitral inflow mean values for women were as follows: E‐wave: 76 ± 17, A‐wave: 69 ± 14 cm/sec, IRT: 71.2 ± 10.5 ms, DT: 197 ± 33.3 ms, E/A ratio: 1.1 ± 0.3. IRT and DT values were higher in men than in women (P = 0.04 and P = 0.007, respectively). TDI values in men were as follows: E′S: 11± 3 cm/sec, A′S: 13 ± 2 cm/sec, E′S/A′S: 0.89 ± 0.2, E′L: 14 ± 3 cm/sec, A′L: 14 ± 2 cm/sec, E′L/A′L: 1.1± 0.4. E‐wave/ E′S ratio: 6.9 ± 2.2; E‐wave / E′L ratio: 4.9 ± 1.7. In this study, we determined pulsed Doppler and TDI derived parameters for left ventricular diastolic function in a large sample of healthy Brazilian adults. (Echocardiography 2010;27:777‐782)     

Tissue Doppler Combined with Pulsed‐Wave Doppler Echocardiography for Evaluating Ventricular Diastolic Function in Normal Children

Background: The ratio of the peak transmitral velocity during early diastole (E) to the peak mitral valve annular velocity during early diastole (E′) obtained by tissue Doppler imaging correlates with the left ventricular end‐diastolic pressure in adults. However, the E/E′ ratio has not been established in normal children. The purpose of this study was to assess the effect of age on the various tissue Doppler indices of ventricular diastolic function. Methods: The subjects in this study included 174 children with normal cardiac function. The left and right ventricular inflow velocities were recorded, and the peak of late diastolic flow velocities (A), E, and the ratio of E/A were determined. The following tissue Doppler indices were obtained: peak velocities of early and late diastolic mitral annulus in the left ventricular lateral wall (E’l and A’l) and in the interventricular septum (E’se and A’se) and those of the lateral tricuspid annulus in the right ventricle, E’r and A’r. Results: The E’l and the E’se increased with age up to 5 years after birth, after which they became constant. The E’r was constant after birth. The E’l/A’l and E’se/A’se increased with age up to 5 years after birth, after which they became constant. The E’r/A’r was constant after birth. The Em/E’se and Em/E’l decreased with age up to 5 years after birth, after which they became constant. The Et/E’r was constant after birth. Conclusion: The age‐related changes suggest age‐related alterations in left ventricular diastolic function. Right ventricular diastolic function is constant after birth. (Echocardiography 2011;28:93‐96)     

Tissue Doppler to Assess Diastolic Left Ventricular Function

Doppler indices of left ventricular (LV) filling have been used traditionally for the assessment of LV diastolic function. In many circumstances, however, the interpretation of these indices is difficult because they respond to alterations of different physiological variables such as preload, relaxation, and heart rate. A typical example of their limitation is seen in patients with abnormal LV relaxation and increased preload compensation, who often present a "pseudonormal" LV filling pattern. Thus, there is a need for noninvasive indices of diastolic function capable of discriminating the effects of relaxation and preload. Tissue Doppler echocardiography (TDE) is available in most modern cardiac ultrasound imaging systems. TDE can be used to obtain regional myocardial velocities during isovolumic relaxation, early filling, and atrial systole with high spatial and temporal resolution. This article discusses the complementary role, limitations, and future challenges of TDE in the study of diastolic function.     

Regional Diastolic Function in Microvascular Angina Studied by Pulsed-Wave Doppler Tissue Imaging

Objectives: Diastolic dysfunction is an early finding during myocardial ischemia. However, regional diastolic function has not been studied in patients with microvascular angina (MA). The purpose of this study was to assess the regional diastolic function in patients with MA through use of the new echocardiographic technique, pulsed-wave Doppler tissue imaging (DTI). Methods: Regional diastolic function was studied by DTI in 81 myocardial segments of seven patients with MA and in 54 segments of six healthy control subjects. Results: Myocardial segments in patients with MA had, in comparison with controls, an increased regional isovolumetric relaxation time (126 ± 34 vs 99 ± 34 msec, P < 0.0001), a higher e/a ratio (1.1 ± 0.7 vs 0.8 ± 0.3, P = 0.0048), and a lower peak velocity of the late diastolic wave a (6.9 ± 2.9 vs 8.4 ± 1.7 cm/msec, P = 0.0009). Moreover, peak velocity of systolic wave s was higher in patients with MA (5.8 ± 1.4 vs 5.3 ± 1.2 cm/msec, P = 0.0424). Conclusions: Patients with MA have an impaired regional diastolic function (an increased regional isovolumetric relaxation time and a lower a wave) and a higher velocity of the regional systolic wave s. These findings may have physiopathological implications .     

Systolic and Diastolic Ventricular Function Assessed by Tissue Doppler Imaging in Children with Chronic Kidney Disease

Chronic kidney disease (CKD) is associated with elevated cardiovascular risk even during childhood. Tissue Doppler is a sensitive technique for the assessment of ventricular dysfunction with relatively little data available in children with CKD. We report a prospective cross‐sectional echocardiographic study at a tertiary center. Forty‐nine patients with median (range) age 11.2 years (6.9–17.9), weight 39.6 kg (23.6–99.7) and height 146 cm (122–185). Thirty‐one patients were male. Median duration of follow‐up for CKD was 7.1 years (range 0.13–16.9). Patients were in CKD stage 3 (n = 37) or 4 (n = 12). Mitral valve E‐wave, A‐wave, and E/A ratio showed mean (SD) z‐scores of 0.08 (0.93), 0.12 (0.82) and ?0.13 (0.84), respectively. Tissue Doppler imaging (TDI) at the lateral mitral valve annulus showed e′, a′, s′, and E/e′ z‐scores mean (SD) ?1.10 (0.76), ?0.29 (0.92), ?1.2 (0.7), and 0.86 (1.1), respectively. There was a significant negative correlation of e′ and s′ z‐score with patient age. E/e′ ratio correlated positively with patient age. Blood pressure, left ventricular mass, and relative wall thickness did not correlate with tissue Doppler measurements. The e′ and s′ velocities correlated significantly with each other, suggesting an interaction of systolic and diastolic dysfunction. Children with CKD may have abnormalities of systolic and diastolic ventricular function on TDI, which are not evident on blood pool Doppler. The tissue Doppler results are consistent with worsening ventricular function in older patients.     

多普勒组织显像技术评价左室舒张功能的研究进展

左室舒张功能障碍在心血管疾病中很常见,二尖瓣血流频谱是评价左室舒张功能障碍的经典方法,但存在不足。多普勒组织显像技术是一项应用多普勒原理分析心肌组织运动的新技术,包括心肌速度显像、定量组织速度显像、组织追踪以及应变/应变率,这些方法为评价左室舒张功能提供更多、更有益的信息。     

彩色M型多普勒超声评价高血压病人的左室舒张功能

目的 应用彩色M型多普勒超声心动图测量舒张早期左室内血流传播速度(vp)，评价高血压病人的左室舒张功能。方法 高血压组195例(50岁以下者23例；50—70岁者101例；70岁以上者71例)。正常对照组136例(如岁以下者53例；50—70岁者50例；70岁以上者33例)。取心尖四腔或二腔心平面测量左室内血流传播速度(Vp)，二尖瓣和肺静脉血流曲线。结果 高血压病人的Vp值较正常人降低(P＜0．01)，血流形态异常。结论 应用彩色M型多普勒超声心动图测量舒张早期左室内血流传播速度，不受心脏负荷及年龄的影响，作为评价高血压病人左室舒张功能的指标有临床意义。     

Assessment of Right Ventricular Diastolic Function by Tissue Doppler Imaging in Patients with Acute Right Ventricular Myocardial Infarction

Background: It is known that right ventricular systolic parameters as assessed by color tissue Doppler imaging (TDI) are abnormal in patients with inferior wall ST elevation myocardial infarction (IWMI) with right ventricular myocardial infarction (RVMI). This study was undertaken to determine right ventricular diastolic function as assessed by TDI in patients with acute RVMI. Methods: Thirty‐five patients with first IWMI were studied and compared with 20 age‐matched healthy controls, and categorized into those with (14 patients) and without (21 patients) RVMI based on standard ECG criteria. Peak systolic, peak early and late diastolic velocities (Sm, Em, and Am), Em/Am ratio along with time to Sm (ECG Q‐Sm) and time to Em (ECG Q‐Em) were acquired from the apical 4‐chamber view at the lateral side of tricuspid annulus using TDI. Results: Sm, Em, and Em/Am ratio was reduced significantly in patients with RVMI as compared with those without RVMI and healthy individuals (Sm [11.1 ± 2.9] vs. [14 ± 1.9] and [14.5 ± 2.1] cm/sec, P < 0.01; Em [9.2 ± 3.5] vs. [12.9 ± 3] and [14.0 ± 2.0] cm/sec, P < 0.01; Em/Am ratio 0.53 ± 0.2 vs. 0.78 ± 0.19 and 0.8 ± 0.3 [P < 0.0001]). Among the intervals, there was significant prolongation of Q‐Em (558 ± 14.8 vs. 507 ± 16.2 and 480 ± 20 ms [P < 0.0001]) but Q‐Sm and Am were not statistically different between the groups. Conclusion: Right ventricular TDI diastolic parameters are abnormal in patients with RVMI. The method of recording the velocities and time intervals are simple and can be used to assess right ventricular diastolic function in patients with RVMI. (Echocardiography 2010;27:539‐543)     

运动负荷多谱勒超声心动图观察高血压病人的左室舒张功能

目的 :观察运动负荷状态下高血压病人和正常人左室舒张功能的改变及差别。方法 :高血压病人及正常对照各 15例 ,二组超声心动图 2 DE观察和 M型测量心内结构均正常 ,静息状态下左室收缩、舒张功能正常。进行卧位踏车运动 ,从心尖四腔图取二尖瓣血流频谱 ,观察 E峰流速 (VE)、A峰流速 (VA)、E峰流速时间总积分 (ETVI)、A峰流速时间总积分 (ATVI)、总流速积分(TTVI)、ATVI/ TTVI、VE/ A,于 70、80、90、10 0次 /分心率时分别测量 ,进行组内不同心率时及同一心率时二组间比较。结果 :组内比较 VE各心率组组内无差异。VA高血压组 80次/分开始加速 ,对照组 10 0次 /分显加速。ETVI高血压组 90次/分开始减小 ,对照组各心率组均无差异。 ATVI高血压组 90次 /分开始增大 ,对照组各心率组无差异。 ATVI/ TTVI高血压组 80次 /分开始增大 ,对照组 10 0次 /分开始增大。VE/ A高血压组 80次 /分开始下降 ,对照组 10 0次 /分开始下降。组间比较心率 80次 /分开始 VE/ A高血压组明显低于对照组 ,心率 90、10 0次 /分时高血压组较对照组 VA明显增快 ,ETVI减小 ,ATVI增大 ,ATVI/ TTVI增大。结论 :运动负荷状态下高血压病人较正常人舒张功能改变出现得早。运动负荷超声心动图是一种简便、无创的评价心脏代偿功能的方法     

Assessment of Left Ventricular Systolic Function Using Color-Coded Tissue Doppler Echocardiography

Tissue Doppler echocardiography can be used to measure myocardial velocity data by using the Doppler shift data of ultrasound waves. Two methods have recently been described to calculate velocity data: pulsed tissue Doppler and color-coded tissue Doppler. This article focuses on color-coded tissue Doppler data to evaluate left ventricular systolic function. Technical considerations and validation studies are reviewed. Potential clinical applications of color-coded tissue Doppler are presented, including dobutamine stress echocardiography, assessment of left ventricular ejection dynamics using mitral annular velocity, and tissue Doppler assessment of cardiac transplant rejection.     

The Role of Tissue Doppler Imaging in Predicting Left Ventricular Filling Pressures in Patients Undergoing Cardiac Surgery: An Intraoperative Study

Introduction: The perioperative management of patients undergoing cardiac surgery usually requires the accurate assessment of left ventricular filling pressures (LVFP). The gold standard for determining LVFP involves the use of pulmonary artery catheters (PAC). Using tissue Doppler indices (TDI) obtained by transthoracic echocardiography, the ratio of early transmitral filling velocity to the corresponding early mitral annular velocity (E/E′) has a strong correlation with pulmonary capillary wedge pressure (PCWP). Little is known, however, on whether this relationship between E/E′ and PCWP is valid intraoperatively using transesophageal echocardiography (TEE) during cardiac surgery. Objective: The objective of our study was to determine whether TDI obtained by intraoperative TEE during cardiac surgery can accurately estimate PCWP using PAC as the gold standard. Methods and Results: A total of 34 patients (26 males, mean age 64 ± 9 years) undergoing cardiac surgery were prospectively enrolled between 2010 and 2011 at a single tertiary care center. Conventional diastolic and tissue Doppler parameters were evaluated using intraoperative TEE with concurrent PAC monitoring before and after cardiopulmonary bypass (CPB) surgery. At both pre‐ and post‐CPB, there was no significant correlation between lateral, septal, and mean E/E′ obtained by TEE and PCWP. Conclusion: Intraoperative TEE was unable to accurately predict LVFP in patients undergoing cardiac surgery. PAC may continue to be the gold standard in the assessment of LVFP for this patient population.     

Aortic Upper Wall Tissue Doppler Image Velocity: Relation to Aortic Elasticity and Left Ventricular Diastolic Function

Background: Aortic stiffening contributes to the left ventricular (LV) afterload, hypertrophy, and substrate for diastolic dysfunction. It is also known that aortic elastic properties could be investigated with color tissue Doppler imaging (TDI) in aortic upper wall. The purpose of this study is to evaluate the relation of aortic upper wall TDI and aortic stiffness and other parameters of LV diastolic function. Methods: We examined aortic upper wall by TDI at the 3 cm above the aortic valves because of patient's chest discomfort or dyspnea. We excluded the patient with arterial hypertension or reduced left ventricular ejection fraction (LVEF) or significant valvular heart disease. So a total of 126 (mean age 53.8 ± 13.9 years, male 49.2%) patients were enrolled in this study and divided normal LV filling group (N = 31) and abnormal LV filling group (N = 95). Results: Aortic upper wall early systolic velocity and late diastolic velocity were not different between the two groups. Only aortic upper wall early diastolic velocity (AWEDV) was related to aortic stiffness index (r =−0.25, P = 0.008), distensibility (r = 0.28, P = 0.003), early diastolic (Em) (r = 0.45, P = 0.001), E/Em (r =−0.26, P = 0.003), and significantly reduced in abnormal LV filling group (6.19 ± 2.50 vs 8.18 ± 2.87, P = 0.001). Conclusions: AWEDV is decreased significantly in abnormal LV filling patients. It is statistically related to aortic stiffness, distensibility and parameters of abnormal LV filling, Em, E/Em. TDI velocity of the aortic upper wall can be a helpful tool for evaluating aortic stiffness, distensibility, and diastolic function.     

Tissue Doppler imaging in the evaluation of the regional diastolic function in chagas' disease.

AIMS: The main purpose of this study was to evaluate the regional diastolic function in Chagas' disease using tissue Doppler imaging (TDI). METHODS AND RESULTS: Seventy-seven patients were evaluated and divided into three groups: group 0, control; group 1, chagasic patients with normal ECG; and group 2, chagasic patients with abnormal ECG. The following parameters were evaluated: E and A waves, E/A ratio, deceleration time and the isovolumic relaxation time by pulsed wave Doppler and analysis of early (e') and late (a') filling waves by means of TDI, in basal segment of the septal, anterior, inferior, posterior and lateral walls of the left ventricle. The only index of the transmitral flow that presented a significant difference between the chagasic patients and the controls was the deceleration time. As regards the TDI, a significant difference occurred between the various groups in relation to the e' wave, especially in the septal, inferior and posterior walls of the left ventricle. CONCLUSION: TDI proved itself a more sensitive technique for the study of the diastolic function in Chagas' disease than conventional Doppler echocardiography, bringing to light regional abnormalities and allowing differentiation between normal and chagasic individuals with or without cardiomyopathy. TDI could be potentially useful in clinical work and in the stratification of risk of these patients.     

Tissue Doppler Echocardiography: Future Developments

The use of color-coded tissue Doppler echocardiography has resulted in rapid technological advances in the evaluation of cardiac function. This article describes some of these exciting new advances, including curved M-mode analysis and strain rate imaging. Data from studies in animals and humans are presented to demonstrate the potential clinical use of this new echocardiographic diagnostic tool.     

Comparison of Tissue Doppler Dynamics with Doppler Flow in Evaluating Left Atrial Appendage Function by Transesophageal Echocardiography in Prehypertensive and Hypertensive Patients

Increased blood pressure (BP) is associated with an increase in cardiovascular mortality and morbidity. We aimed to analyze the effect of increased BP onto the function of left atrial appendage (LAA) in early stages of hypertension. Transesophageal echocardiography (TEE) was prospectively performed to assess LAA functions in 120 patients with increased BP, and in 58 normotensive subjects without cardiovascular disease. Patients with increased BP were divided according to Joint National Committee VII (JNC VII) report: prehypertensive,stage‐1 hypertensive and stage‐2 hypertensive patients. During TEE, LAA late‐emptying velocities (LAAEV) were significantly reduced only in stage‐2 hypertensives as compared with control group (P < 0.001). In contrast, LAA late‐contracting velocity (LAA TDI‐D2) was significantly reduced in prehypertensive,stage‐1 hypertensive and stage‐2 hypertensive patients, when compared with control group (P < 0.05, P < 0.001, and P < 0.001, respectively). The LAA maximal areas were increased significantly only in stage‐2 hypertensive patients when compared with control group (P < 0.05). During TEE, left atrial spontaneous echocardiographic contrast was found in 2 of 36 patients in prehypertension group, in 7 of 40 patients in stage‐1 hypertension group, and in 10 of 44 patients in stage‐2 hypertension group. Left atrial thrombi were observed in 3 (6.8%) patients of stage‐2 hypertension group. In conclusion, in patients with untreated prehypertension and hypertension, elevation of afterload imposed on left atrium involved both left atrium and LAA, resulting in impairment of the LAA function. Tissue Doppler imaging (TDI) enables the detection of this functional impairment in early stages of hypertension, even in prehypertensive phase, when compared with conventional Doppler flow measurement of the LAA. Even in prehypertensive phase, BP should be decreased to normal levels to prevent the LAA dysfunction. (Echocardiography 2010;27:677‐686)     

Evaluation of Hemodynamic Determinants of Quantitative Tissue Doppler Echocardiography in the Assessment of Left Ventricular Function

The aim of the present study was to determine whether quantitative tissue Doppler echocardiography has a role in the assessment of left ventricular hemodynamics. Thirty patients with suspected or known heart disease, but no wall motion abnormalities, took part in the study. Quantitative tissue Doppler echocardiography was performed using new software for digital analysis of the tissue Doppler signal. Average systolic subendocardial (S1), subepicardial (S2), and transmural (S3) wall velocity data were obtained from the inferoposterior wall and compared with the hemodynamics, including high fidelity pressure readings. S1 and S3 rates were found to be most reliable, being directly related to the peak rate of left ventricular pressure rise (dP/dt_peak) and inversely to systemic vascular resistance (SVR) and resistance index (SVRI). The best correlation was between S1, dP/dt_peak, and SVRI (multiple regression analysis: r = 0.76, P < 0.0001; simple regression analysis relating S1 to dP/dt_peak/SVRI: r = 0.77, SEE = 0.25, P < 0.0001). Thus, wall velocity indices as defined in this study have promise to become helpful in guiding the therapeutic modulation of inotropy and afterload in patients with heart failure.     

Novel Application of Tissue Doppler Imaging

Tissue Doppler imaging was used with transthoracic and transesophageal echocardiography to determine its clinical usefulness beyond visualization of ventricular wall motion. Thirteen novel applications were found: acoustically difficult transthoracic studies, thrombus, mitral chordal motion, shunt detection using saline contrast, spontaneous echo contrast, intra-aortic balloon pump position and function, endocarditis (prosthetic and native), valve strands (prosthetic and native), mobile aortic atheroma, prosthetic valve motion, aortic valve motion in the presence of a calcified aortic annulus, systolic anterior motion of the mitral valve, and cardiac tumors. Tissue Doppler imaging directly affected the ability to make difficult diagnostic decisions with increased confidence and reduced the need for additional studies.     

组织多普勒技术评价扩张型心肌病左室心功能的临床价值

目的探讨组织多普勒技术(TDI)检测扩张型心肌病(DCM)左室心功能的临床价值。方法选择DCM病人和正常健康者各40例,用TDI于胸骨旁长轴检测室间隔及左室后壁中间段短轴方向心肌运动速度(MV),并计算心肌运动速度阶差(MVG);经心尖窗检测左室前壁、后壁、下壁、侧壁和前壁、后壁室间隔中间段长轴方向MV。结果DCM组病人出现4种MV频谱形态异常,长轴、短轴方向MV均明显低于正常对照组(P<0.05或P<0.01);DCM组MVG也明显低于正常对照组(P<0.05或P<0.01)。结论TDI可定量评价DCM病人左室心肌功能,丰富了DCM的超声诊断手段。